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Anatomic Sciences Legend

Major Topic Arteries Blood Bone Cell Embryology Endocrine system Foramens Gastrointestinal system Abbreviation Art Bid Bn Cell Emb Endr S For GIS Hrt Jots LymS \ t is c. Major Topic ;\l uscles }\erves Nervous system Periodontal ligament/Gingiva Reproductive system Respiratory system Tissue Tooth Tooth histology Urinary system Veins Abbreviation Msl
l'lrv

NrvS PdVG Rpr S RspS Tis T Tlh Hist UrnS Vns

Heart
Joints Lymphatic system 1\Jiscellaoeous

( ANATOMlC SCIENCES

Lyms)

Which of the following structures leave each Individual lymph node at the hilus?

Afferent vessels Efferent vessels Tonsillar tissue Lymphatic ducts

(ANATOMIC SCIENCES

Lyms)

(
\..

All of the following statements concerning the lymphatic system arc true EXCEPT one. Which one Is the EXCEPTION?

The main function is to collect and transport tissue fluids from the intercellular spaces in all the tissues of the body back to the veins in the blood system Lymph is a transparent, usually slightly yellow, often opalescent liqwd found in the lymphatic vessels
It consists of the bone marrow, spleen, thymus gland, lymph nodes, tonsils. appendix,

!'eyer's patches, lymph, and lymphatic vessels Just like the circulatory system, the lymphatic system has a central 'heart-like' organ to pump lymph throughout the lymph vessels The chief characteristic common to all lymphatic organs is the presence of lymphocytes
2

1,2

Ccpynfbt 0 1009-2010 f"H11tal ~b

Effertnl

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Lymph nodes are small oval bodies enclosed in librou.< capsules. Lymph nodes contain phagocytic cortical tissue (reticular lis.nte) ad.1pled to filter lymph. Specialized billlds of connective tissue, called trabeculae. divide tho lymph node. Afferent lymph~tic vessels c.arry lymph into the node, where the lymph as circulated through the cortical sinuses. It is here in the sinuses that the lymph is cleansed by mncrophages. lymphocytes. and plasma cells. The filtered lymph leaves the node through the efferent lymphatic vessels, which melle through the roncave hUum and transpon the lymph into drerent collecting ves~els, which converge fnto larger vcs.els called lymph trunks (there 11re five "Uljor lymph tnmks m tire OOdy). These lympb tnutks. in turn, empty into either the thoracic duct or the r ight l)mphati< duct. Important: The thoracic duct drains most of the body and transports lymph to the Jell subclavian vein. The nght lymphatic duct drdms the right upper portion of the body und transports lymph to the right subclavian vein.

I Not..

I. The afferent lymphatic vessels enter on the convu surface of the node. 2. There are rcwer effcnont vessels than afferent vessels associated willt a node. 3. The spleen, thymus, palatine. aod pharyngeal tonsils do not have numerous aJTercnt vessel< entering them as d o lymph nodes.

.IU"iiiHHIht dllul.llllr) "~"'IIC'rn , llw l~mtJh.tlh: '~'lllll ha .. a nntral ur!!an lu pump h mph throu~huut Uu I~ 111Jlh "'''~.h

'ht.. arl - lil~t.. "

This is raise; unlike the circularory system. tbelymphatlc system dot's not have a pump (heort) to propel lymph throughout the lymph 'cssels. Instead. the lymphatic system

depends on the ronll'ac!lons of sktletal musclu, the presence or 'ah cs fn lymphatic vessels (similar 10 t/rose in veins), breathing, nncl simple gravity to move fluid throughout the body. Functiuus of the lympltntic system: Returns tb.sue fluid to the bloodstream ; when this fluid enters lymph cupillaries, it is called lymph Lymph is returned to the venous system via two large lymph duets - the tboradc duct and the rigbt lymphatic duct 1hrn.sports 1bsorbed fsts; within the vilb tn the small intesuoe, lymph copillanes. called lacteals, tr:snspon tbe products of fat absorption away from the Gl tract and eventually into the circulatory system - Provides Immunological derenses ugulnst disease-c:ausing "gents; lymph fillers through ly111ph node. which filter out 111icroorgunisms (such a,< hatter/a) and foreign
subs~1nces

I. Lymph contains a liquid portion that resembles blood plasma, us well 1lS No rea white blood cells (mostly lymphocytes) JDd a few n:d blood cells. 2. Lymph is absorbed from the tissue space,; by the lymphatic capillaries (which IS a I)'Sietrr of clostd tubes) and eventU3IIy returned to the venous cuculauon by the lymphatic' esscls, after lymph Oo~>s throUilb the filtering system (/ymplr IJ()(f~s). 3. In the up~r limb, a hallmark of lymphatic ,essels is that tbey follow the veins.

(ANATOMIC SCIENCES

Lyms)

\..

Which of the following develops immature T cells into immunocompetent T cells?

Spleen

Bone marrow
Thymus Lymph nodes

3
3
Cop)TiJbt 0 20092010 Dentli);l;s

( ANATOMIC SCIENCES

Lyms)

Which of the foiJowing lymph node ~:roups extend from the base of the skull to the root of the neck?

)
~

Facial nodes Occipital nodes Deep cervical nodes

Jugulodigastric nodes

4
Coprnjbl 0 2009-lOIO lkma1 Decls

'"rhe thy mus is a bilobed lymphoid orgun poSHioncd in the SU()(!rior rot'diastiown that has no l)'mpJunlcs. The m(lin function uJ'- the thymus l10 to dclfelop immature T cells into ir.nmun~ompclent T cells. The thyrnu.s ts- n.:hnivcly lingt iu newboml', corttimtes to grow until pubeny, and Uen rc~;rcsses in aduhs. Note: ln U1e adult !hymus. the hlou~ supply is lsolat~d from the pnrem:hyma (which Is the .frmatiauiug JNU'iion of the glnnd t~-5 di~tifiJ:tTffislwd from the cOft'1ecti\e ti.vsuu. or ,l(ffomu). This is so1.nelill1es rcfcmd to as, the bluucl thymus barrler. In lh.; child thymu;, the bloO<l upply 15 out as bolul<d from the l>arenQhyma, The spleen is formed by reticular and lymphlio tissue and I< tho lurgcst lymph orgn. Tile spleen lit$ in llu: l~ft bypocbondrlat! regiOil of the-abdominal c-avily between the fundUS-of'the.51.0!1'UIC'h $nd lhe diaphragm. The spleen ig purpJish io color and 'Vt.uie~ in site in difi<'rcm mdividualit. The !ipleen is 6ligbtly ovaJ in shape: W ith the. hilum on the lower mcdilll border. The amerior surH~ce is covered with peritoneum. U is enclosed in -a fibroe-lastic capsule. that dit)S inln the orgl\n. formlng trnboculne. Tho cellular material. con~i;tlntt or lymphot'}'tl:S ond moorQphagl\>, i> called >pleoic pulp, and il lies between the t.r;lbt.'Cl.ll<le, The >1>locn is the l"''l:""trngle moss oflymphpid Iissue in the body. The spl!l<'n c be oonsid~ liS two organs \o Olle: it filterS the blood and retuov~ oibnonnsl cells (sitcll a.\ n/J an. d defecrin 1't!Ji biiJotl cells), and it make~ dl~a~e-fighling components- or the. immune sy~lettl (/twlmJing muibodies arul lytllfllr"CJ''~J. T11 c body ur tho spleen ~PP"""' red a11d pulpy, >urroundcd by 11 tough cap~ule. 'fhe red pulp conSists of blood vessels- (.vphmk .vittu.wit\') inlcrwoveu with conneclivclis>-uc (splenic cor,/$). Tbe red pulp filtcl" ~1e blood'"'~ rtmoV<~ old and defective blood cells. It is the he of erythropoiesis (11/rmdjnrmrrlinn) 11111 fetus andi!ll Jnfanl The white pulp is insido the red pult>, and consists of lillie lump< of lymphoid tissue. Antibodies are nmdc inside the while pulp. Bone marrow cnntnins stem cells\ which may develop lnto any Clr SCN~rtl) di frt:I'Cfll ~ell typ~.;.S (r:nlled plur-lpOl(!l'lt} Some .sttm cells destined '() produce lnllllllllf: syslem cella serve us. sol~.rt:es for lympbucytes, whereas others develop into phugQcytes. Those tluu bocom~ lymphocytes arc ditr~,.~n:ntiatc-d to bccon1c either B ce-lls (K'Ilicll nwhu-e In 1/te bmw mm't'OW) or'f cells (''1/u'clltraveJ to tire Jhymv.t a11d mtUil'~ !here).

Ul't.'p C.' t.'n kal

111uk"'\

The deep C~:rvical lyo1ph nod<>""' lo<:med nlqng ~1e length of ~1e internal jugular vein on each side of the neck.. deep to the stemotletdnmnslmd nmsde.1l1e deep cervical nudes extend rr um 1hc bMe of1he skull to he root oft he n"ck. ~djP~ntlolho phar)'TL<, esophagus. and trachea. The deep cervicnl nodes arc f\uthcr cluli.~moo as to fuetr relationship 10 lhe sremocleidomastoid omsele -a~ being superior or inferior. The deep oervical lymph nodes are responslble f011he drainage of mos1 of he circular chail1 of nodes, and receive ciircot oft-.renL !Tum lhe salivary and thyroid glat\<1$, lh~ lOngue, he tousil, lhu nose, lhe pharynx. and lhe larynx. All !hose v~..,l~ join 1ogether t~ fo1111 the jugular lymph trunk. This v""sel tlruins [mo ejthe.r the thoracic duct onlh left the right lymphutk duct on <11e rigb,~ "' independently (!rain. into ~ither toe ihtem~l jugtil~r. subclavian. or brachtocephalic veios. Some regional groups of lymph nodes: Po rood lymph nod., - receive lymJih frum a strip of S<:!llp abo..: lhe parotid saJivlllY gllUld. fr<lln the nnledor wnll of the extemal otditory meatus. and from the latcml pJIJ'Is uf lite eyelids and middle car. Tho ciTcrcnL lymph \'OsS<:ls drain into the deep cerviool nod"' Submandibttlar lymph nodes - located between !he sub111andibular gl11ucl and lbc IUIIUdible;
receive lymph fnnn Ihe fronl of the -se:aJp, the no:..e, ond udjn... "Vnl cheek~ the upper lip and lower

lip (I!Xcepllltd c<'l!/4'1' fXIrl); the par.masal sinuses; the 111:1xillary and mondlbulor lo<tb lt<'Opt rile IIJQJU/ibttlar im.'iWJrs); the antt"rinr two.-thlr(ls or ch~ tongue (ttfCf!fJ( lite tip); Hie floor of the ll1uuth "'nd vestibule; ~1nd t11e-gingiva. 11 hc et'fhent lymph vessel~ {ltain inlo the de~p ccrvlcul
DO~ OS

Subne.ntal ly"'ph nodes ~ loca,ed behind lbe thin ru-1d on the mylohyoid muscle' receive lymph from the Up or the longue, the Ooor of the 11\0IItb b<'Jlcath ~e lip uf the tongue. lhc modibulsr incisor teeth and nssoclutt gioglvn. the ccmer Jl&lt uf tho lowe lip. ~nd lhc s.IJn over the chin. The effeJ'I'nl lymph vessels ~'"io into llw t ubmnndlbular ;mcl deep ccrvica.l node-!

( ANATOMIC SCIENCES

Lyms)

When antigen recognition occurs by a lymphocyte, B cells are activated and""D II" \.. migrate to which area of the lymph node?

Inner medullary region Medullary cords Medullary sinuses Germinal centers

5
Cop)rigbl 0 2009-2010 lknlal Oeekl

( ANATOMIC SCIENCES

Lyms)

The thoracic duct usually drains into the:

Left internal jugular vein Left subclavian vein Junction of the left internal jugular and subclavian veins

Superior vena cava

Junction of the right internal jugular aud subclavian veins

Lymph nodes art small, round specialized dilations of lymphatic tissue that are permeated by lymphatic channels. Their function Is primarily to act as filters. They help rtmove aud destroy antigens that circulate in the blood and lymph. for this purpose. lymph nodes con min a lot of macrophugcs. Lymphoid tissue in the nodes also produces antibodies and stores lymphocytes. Note: The nodes generally occur in clusters along the connecting lymphatic vessels particularly in the armpits, the groin, the lower abdomen, and the sides of the oeck. Each lymph node is enclosed in a flbrous capsule with internal trabeculae (connective twue) supponing lymphoid tissue and lymph sinuses. The node ~ns15ts of: Outer cortical region - comains separate masses of lymphoid tissue called ger minal centers (nodules) , which are a .source of lymphocytes. Also contains subscapular and cortical sinuses lnner medullary region - lymphoid ttssue here is arranged in medullary cords, which are a source of plasma ccUs (they secrete ani/bodies). Also conlllins medullary sinuses Lymph nodes can be classified as primary or secondary. Lymph from a particular region drains tnto a primary node or regional node. Primary nodes. m turn, drain into a secondary node or centrnl node.

Juncliun ulllnll'l.t inll'rnal

ju~ui.Jr

ami \uhd.l\1:111 \dm.

The thoracic duct is the main duct of the lymphatic system and is located in tbe posterior mediastinum. It begins below in the abdomen as a dilated sac, the cisterna cbyli (at the level o/ the Tl 2 vertebra) and ascends through the thoracic cavity on front of the spinal colwnn. It is the common trunk of all the lymphatic vessels of the body. and drains the lymph froon the majority of the body (legs. abdomen. 1~(1 side of loead, left arm. and leji rhoriiX). Note: The right lymphatic duct drains much less of the bt>dy lymph (only the ly mph [1-om the right arm, rig/of tloora.<. and right side of the head). Important: The thorncic duct empties into the junction of the len internal jUJtttlar and left subda ian tins (which is acwal~ tloe lx.ogimung ofthe left brachiocephtollc vein}.
~ I. Tho thoracic duct ascends throut~h the aortic opening in the diaphragm, on !'lotos the right side of the descending aorta. 2. The thorncic duct contains valves and ascends between the aortn and the azygos vein in the thorax.

The right lymphatlr duct is the right-sided cquivnlent of the thoracic duct and drains the right side of the head and neck, the right upper limb, and the right s ide ofthe thorax. The right lymphatic duct empties into the junction of the right internal jugular and right subdavlan veins (which is actually the beginning of the nght brachiocephalic 'ein).

(ANATOMIC SCIENCES

Lyms)

A 25-year-old car accident victim is bought into the emergency room complaining of severe abdominal pnin radiating into the left scapula. Low hematocrit, marked hypotension, and a grossly bloody peritoneal tap all Indicate a ruptured spleen. A splenectomy will be performed, and the surgeon must remove the spleen from:

The right inguinal region of the abdominal cavity The right hypochondrium of the abdominal cavity between the stomach and the diaphragm The left hypochondrium of the abdominal cavity between the stomach and the diaphragm The hypogastrium of the abdominal cavity just below the liver

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Cc.lp)-riih1 0 20092010 Den1al Ottli

(ANATOMIC SCIENCES

Lyms)
~

An 11-yca,...old girl presents to the pedlatrl<lan with high fever, sore throat, earache, and greenish sputum. Enlarged tonsils, areas of pus, and the inflammation Indicate tonsillitis. The girl also is breathing through ber mouth; the swelling of which tonsils (also known as adenoids when enlarged) caused 'the obstruction of the nasopharyngeal isthmus? ..J

Lingual tonsils Palatine tonsils Pharyngeal tonsils

7
Cop)ligbl c 20092010 Ekntal Decks

Tht: ll'ft h\puchunclrmm ul tlu. :1luJnnuna l C'l\il\ I WI\\l,n thl. .,ll,nl:l(h :111d lht
di;~ phra~m

The spleen os an 11\ood organ roug,llly til<> so.te of fill. The spleen contains white and red pulp. The white pulp contains compact onoes oflyn1phocyt.,; swroundiog bmnches of the splenic at1cry. The red pulp consi$t< of a network of blood-fil.Jd sinusoods, nlong with lymphocytes, macrophuges, pla.-ma cells. and monocytes (plwgoqtic w/oile bluod cc/Lv). There are tbree mujor flutotions o( the spleen, 111od these ure bandied by three different tissues wltbln lht spk"ln: Retlculotndotheli~llissuc: concerned with pluogocytosos of erythroc}'les Wtd cell dcbns tium the bloocbtR>Un This same tis:ruc muy produce foci of hemopoiesis when RBCs lll'c oo<ded Venous slnuroids: afons wilh the poW<...- of the $pleen to contrnct. provides a methQd for expeUlllg the conuun<d blood to ~ increned "'"'"latory ckm:onds W!oitt pulp: J'I'O'ides lymphocytes ll1ld a wurce of pi !ISm cells 8!ld hence atltibodio~ for rbe cellular ond humornl specific immune dcfenseq Blood enters tbe S)Jietn at the hilum through the splenic rtuy and L< drnlnd by the splenic vdu, wbich joio~~ the superior mescntoric vein to fonn the hepatic puo1al vein In the liver. ibe nerves to the spleen accompany the >picnic ~rtcry and are derived from tho cellae plos.us. Note: Like the thymus. the spleen pusocs::s only efferent lymphatic vessels. Rfmember: flle srleen does not develop from th< primitive gJll, . . rio the lung. liver, panclt!S, g:illblad~r. stomach, esophagus. ..nd inttincs. The spleen ck' elop.< from ooesentbymaJ cells uf the mesem<f) anacbed 10 the pnmirive >1oll1aCh.

The tonsils at tymphotic o~gans dn lie under the <urtloco lining of the mouth and throat They an: con;idcrro ptlt1 of the secondor) lmntune <)<If on. They sit in the Te>pir:nory and alimentary Inlets on po,.inon to he ~posed to wpm or ongesoed antigens from air or food. When sufficient antigen is preset~~, tbos ,\lmultes !he B cell< in the germinal wne of tile lymphood follicle to differentiate Jold product Dllhbodies. The too.<ils are mvolved In the production of mostly secretory lgA, which tmuponed to tho $urface, pt<wtdins local immune prutcclion. There nre three sets o( toullR, 11mcd accor\ling to their postlion. The phQ. ryngeaf ton! liS uro located crn the IIOStoriur waU of tho oasopharyru;. They 1\l't at their peak or Jcvelopment dllring childhood, oud wloeo elllargtd. lhey arc referred to as adenoids. fltey arc surrounded partly by ooul-"'ctl\c tissut und partly b) clllqted pseudo31Tatllled rolumnor epithelium (,...spfru/01,' pirhelium). They contwo no <.rypts. The palatine tontll! arc located on the posu:rolateral "'"lls oflhe tllroilt. one on tach side. They te~~ch thar maximom sae dunng e:orly childhood, but atler pub<t1y dammish considerably uo i7e. 11~ are lhe tonsils that arc: notocnbly erdaq;ed when person uffm from a "sore throt." They contain muoy crypts, lymphoid follicl.,., but nu slnusC!I. The palatine tonsils are surrounded pat1ly by coooec\tve hs.sue and partly by non-keratholtcd stratllll>d squamous eplthellum. l mportunt JIOint: The be~o wny 10 di$\lngui>h the palatuoe tonsil from the pharyngenl tonsil on the histologoc love! ~the type of epithelium aswclnted With it, The tinguul tonsils nrc smaller and mora tlltlltorQus. They arc: a colle~.'ticm of lymphoid follicle,; on the posteriur portion oftbt don>um ol'thc tongue. Each has song)e crypt. They surrounded by nonkerttinized oiTatifid squamous epithelium. Remember: Peyer's patches are similar in structure and t'unctioo to the toMtl< (Pt')tr'> patche form ~lntostinal tonsils"). ~t<d w \be 'mall intestine (.tp<'<'lfiCJJII}\ tbe Uoum/, th.ey serve to deJ.1ruy the abundiUit bacteria, whoeh \\Ollld olhorwiso tbnvc on the moi>1 environment of the ml<...,une. Note: Peyer's tontcbc~ anJ tonsils arc cons.dcred sulx'J'Ih<liol and non-encapulultd lymphoid tissues.

(ANATOMIC SCIENCES

"

In which oftbe foUowlng locations would one most likely lind ycUow bone marrow?

Head of long bones Center of long bones Ribs Cranial bones Venebrae

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Copyrisbt 0 20092010 Oen,al Dftb

(ANATOMIC SCIENCES

r
\..

Which leukocyte is the predominant cell type In pus, and is kno .. n as the hallmark of ac.u te inOammalion bocause of its fast immune response? ~

"I

Basophil Eosinophil

Monocyte Lymphocyte Neutrophil

10 Copynaht C 2009-2010 Deltal ~q

Ccnflr of lun:.,: IHHil''

*** YeUow bone ma rrow functions primarily as a site for fat storage and is found in the eenter of long bones.
The bones are not solid structures. Cavities in the cranial bones, venebrae, ribs, sternum, and the ends of long bones contain red bone marrow. This blood-Conning tissue pro duces erythrocytes. leukocytes. and thrombocytes within bones by a proceM called hemopoiesis.
I. Before birth, the formed elements are also produced in a number of other locations, including the liver, spleen, and lymph nodes. 2. Erythropoiesis refets specifically to the production of erythrocytes.

, Not

The red bone marrow contains precursor cells culled hemocytoblasts (pluripotem stem cells) that give rise to all of the formed elemems of ~1e blood. The bemocytoblnslS give rise to various committed progenitor cells, which give rise to the different types of formed elements. For example, the erythrocytes develop from procrythroblnsts; the platelets develop from large cells called megakaryocytes. When a child is 7 years or age, yellow marrow begins to appear in the disiJll bones of the limbs. This replacement of marrow gradually moves proximally, so that by the time the person becomes an adult, the red marrow is restricted to the bones of the skull, the vertebral column, the thoracic cage, the girdle bones, and the head of the humerus and femur.

'\lutrnphil

Formed Element El)'lbrocytes

Platelt1$
Leuko"lrt~\

Avg. NoJmm' Otscrlption

S million

Function
Transport oxyg<n
HemoStasis

Biconca\'e, enucleated cell

I S0.000-400.000 Small ocllulor frogm<:nos 10,000 S,400

275
3S

Cranuloc:ytes: .

Neutrophil~

Lobed hUCICU"', nne granules

lobed mlti<\IS, r<d or ~cllow gnonulcs

Part of the immune

system (phaxocyto.tls) May pllagoc:ytoze Af>.Ag
QOOlplcxcs

Eosmoplub
Basoplub

Ob!CuJ< nucleus. logl11 purple

gnonul<;

Release hi.sunune, heparin. and serooorun

Agnoauloc,1eo:

Monoc}'1c5 Lymphocyte

540
2,150

Kidncy-&hapcd nucleus
Round nucleus. lntlc cytoplasm

Phagocytosis Produce Ab, de.< troy specific target cells

(ANATOMIC SCIENCES

Under the microscope, erythrocytes (red blood cells) appear as:

Oval discs with multi-lobed nuclei Circular discs with centrally located nuclei Biconcave discs without nuclei Circular discs with several nuclei

11 Qlprri&bl 0 20092010 Dtntt.l Dttks

(ANATOMIC SCIENCES

Which leukocytes (white blood cells) are the least abundant?

Neutrophils Monocytes Eosinophils Basophils Lymphocytes

1Z
CopyncbtC
~0 10 Octll.aiOecb

IJiconl'a\'(' discs \\ithout nucl ei~- the~ alsn htck mitorhondria

Tbe process of erythrocyte production is called erythropoiesis. The hormone that stimulates erythropoiesis is called erythropoietin and is produced in the lddney. The average life span of a red blood cell is 120 days. Erythrocytes, or red blood cells, make up the largest population of blood cells, numbering from 4.5 million to 6 miJiion per cubic millimeter of blood. Their principal function is to transport oxygen and carbon dioxide. The hemoglobin molecules in erythrocytes combine with oxygen in the lungs to fOJm oxyhemoglobin. The oxygen is transponed in this state to the tissues of rhe body. lo the tissues, the oxygen is released to diffuse into the interstitial fluid. Within the tisues, carbon dioxide is combined with the hemoglobin molecules to form carbaminohcmoglobin, which is transponed to the lungs. Note: About 70% of carbon dioxide, however, is transported by the blood plasma as bicarbonate ions (HCOj ). Remember: (I) The proportion of erythrocyres in a sample of blood is called rhe hematocrit- usually around 46% for male.s and 40% for females. (2) The precursor cell found in the red bone marrow tltat gives rise to all of the formed elements of ibe blood is the bematocytoblast (these are pluripotenr stem cells). which gives rise to various committed progcoitor cells, which then give rise to the. different types of formed element$. Note: Granulocyte Colony-stimularing factor (G-CSF) is the hormone that stimulates precursor cells in the boue manow to differentiate into white blood cells (leukocytes).

Basophils

BLOO.D
8%ol'
body weighL 4 to 61iters

LEUKOCYTES

Temp= 38"C pli of 7.35 To 7.45

VOLUI\tF.
Plasma 55% Formed
Elem~nts

FORMED ELEMENTS (mtmber per cubic mm)

Leukocytes

45%

5.000-tO,OOO
Platelets 250.000-400.000 Erythrocytes 4.3-5.8 million

NeutrophUs 60-70% Lymphocytes 20-30% Mono<)'t<s 2-6% EosinophUs 1-4% Basophil 0-1%

Important: The mnemonic "Never Let Monkeys Eat Bananas'' identifies the order of abundance of the leukocytes.

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(ANATOMIC SCIENCES

I' GuillalnBnrre syndrome, myasthenia gravis, Wegener's granulomatosis, ""'I

and Goodpasture syndrome all have one treatment option in common. This involves taking whole blond and separating out the liquid portion and then returning this liquid portion back into blood circulation. The liquid portion \.. of the blood is called: ~

Formed elements Cerebrospinal nuid Plasma Lymph

u
Cop)Ti&ht 0 '20092010 Oen1aJ lkdt

(ANATOMIC SCIENCES

Platelets are best described as:

Giant, multinucleated cells Cytoplasmic fragments of cells Immature leukocytes Lymphoid cells

Cop)'n&ln C> ~010 o...., Do<b

,.

Plasm~ is approximately 9 I% water; the other ponion is made up of various materials (see char/ below). The portion of the blood that is not plasma consists of formed clements, which includes erythrocytes (red blood cells),lcukocytes (white blood cells), and cell fragmentS called platelets. Note: Senun =blood plasma without fibrinogen (after coagulation)

Bl..OOD PLASMA 8%of body weight 4 to 61iters Temp= 38'C pH of7.35 To 7.45
(WEIGHT)

VOL UME

---.

Plasma
55%

Proteins

{ {

AJbumins SS%

7% Water
91%

GlobuUns 38% Fibrinogen 7%

Formed Elements

Metabolic end produces Food materials

45%

Other Solutes 2.0%

Respiratory gases tlormones. etc:. Ions

Note: The treatment described on tlte front of the card is called plasmapheresis.

c~

toplasmic

lra~ment!'ri

of cells

Although platelets are often classified as blood cells, platelets are actually fragments oflarge bone marrow cells called mcgakaryocytes. Platelets are minute, irregularly shaped, disc-like cytoplasmic bodies found in blood plasma that promote blood clotting and have no definite nucleus. no DNA. and no hemoglobin. Normal blood contains 250,000 to 400,000 platelets per cubic mm. Their life span is 7-10 days; they are removed in the spleen and the liver. Note: Thrombopoictin (a glycoprotein hormone) is synthesized and secreted by the liver. Thrombopoietin stimulates precursor cells in the bone marrow to differentiate into megakaryocytes. Megak.aryocytcs give rise to platelets. Remember: Platelets stop blood loss by forming a platelet plug. They contain many secretory vcskles (granules), which contain chemicals that promote clotting. When platelets adhere to collagen, they release ADP and other chemicals from their secretory vesicles. Many of these chemicals, including ADP, induce changes in the platelet surface that cause the surface to become 'sticky.' As a result, additional platelets adhere to the original platelets and form a 'plug.' Important: Thromboxane A2 (TXA 2), produced by activated platelets, has prothrombotic propenies, stimulating activation of new platelets as well as increasing platelet aggregation.

(ANATOMIC SCIENCES

Jnts)

'A 61-year-old mole comes to the family physician complaining of sharp and a burning sensation in his hips and knees. The pain gradually gets worse threugbout the day, and although the knees seem enlarged, there is minimal inflammation. The physician notes slight grating and crackling sounds (crepitus) and diagnoses osteoarthritis. Tbe cause or tbe signs and symptoms or osteoarthritis Is the degradation or wb icb or the following structures io loadbearing joints:

ache~

Meniscus
Synovial membrane

Bursa
Anicular canilage

15 CoJ!>-riih1 0 20092010 Denta.l l~'kJ

( ANATOMIC SCIENCES

A synarthrosis Is a (an):

Joint permitting slight mobility Immovable joint Freely movable joint

S)110'ial JOints are frly movable (diardrrodial/. wllh onov<mcnt limited only by jomt ~urfa=. ligament;. muoclc:o. or tendons. They are chai"ICttrlzed by four features: 1. Articular <art:lla;e- a thin layer of hyaline can>logothot covOI'> tbe smooth onitulnr bone surfaces. lltis layer contain~ no blood vessels ur nerves. Note: The tcmporomandib\11Br jomt conlains fibrocantiA{Ic. nut hyaline cMilnl.(c. 2. J oint cavlry - m11ll Ouidfilled space >cparutllll! the ends of adjoining bones. 3. Artkulnr Qulnl) capsule - double-layered: outer loycr of fibrot"' connccuve tissue that enclose> the jo10t. 4, Synovial mcmbnoe produces synoYlal nutU. Found on both bursa and ruticulor QIMtlagc. ~ote: MOSI)OtniS ofth< body are syooial joint!. They nre clossifted funcuonally as dlarthroJes (metmsfru/y mO>'<Iblt). lu addition to lht feataun above. some synovial joinuo bave artl<ular discs (T/IU and <ltrn<>ela>mrlarjoinr/. The$e '"""" con<ist offibroeanilgc. They dJ\'ide the cavity into two separate cavities. Synovial Ould IS o clear. thick Ouid secreled by thoynovial mernbr.mc, whtch fills thcjoml capsule and lutmcatcs the articular cartilage at the end~ of the articulating bones. Supporting llgu"'cnts (cap..,u/UJ; e.timCttp.'illlm; tnld flllm,apm(ar ligaments) mnmtmn the nor mal positioo of tho bones. Ten percent of synovial JOtnls have a washer-like str\leture betwec:n bone ends called 1he meniscus. Its purpose is to absorb shock. to stabilize !he Joint, and to spread synovial Ouid. !'he menc< cus is made out of Jibi(ICanilage. but the m<'ntS<:US also has no blood supply. no nerves. and no lymphanc channel>. Diolog~eally. the mcnil.c:us ton'! heal itsdf. fhe knee metnSCU> b the n>O>t famous and mO>J. InJured meniscus in tbe body. Note: A bursa lS 1 fluidUC \hal is lined with a s)'novial membrane. The funcnon of a bursa a s 10 reduce fnction. for uample, a bursa may be locat<-d bc"\'ttfl a tendon and a bono to reduce the fric1ion of the tendon passing over lh.: bone when the tendon's muscle contracts. lnflamn\t'ltion of the lining of a bun1a t$ rcferr~d to a.s bursitis.

h nmm ahll juint

Articulations (jOltiiS) are the strucrures wb~re bones connecL There are three rn3tn class es of aruculations based on the amount or motion they allow: I. Syoarth rosh immovable joint (fibrous joint). Surures found bct\\e~n the Oat

bones of the skull are of this typt. Note: Gom11hosis is an example of a S)lllanhrosis. It is the joiot that bmds the teeth to the bony sockets (dental alveoli) in the mandible and maxilla. 2. Amp)llorthros\s - slightly movable joint (c'DI'Iilaglnnu.vjnint). One example is the symphysis pubis, where the two os coltu bones join anteriorly. 3. Diarthrosis freely movable join! (synovial joint).
Joints can also be classified based oo the type of associated conne<tivt tissue: Fibrous (joined byfibrous ~onnec:ti'f'tissue) two types: sutures (ofskull) and S)'D dumose (OOK f!f!lf rod/us and ulna) Cartilaginous (joined by jibrocurtrlage ur hyaline carrilage) - two types: S)lllchondroses, whtch are joined by hyaline cartil~ge (epiphyseal plates wirlt/n long lxmes), and symphyses, which are joined by a plote of fibrocartllage (pubic .tt'lltpity. vis) Synovilll (jolm capstile containing o synovial membrane 1/rat setrotw 11 srnoial j/uid) most joint~. ~uch as Ibe lemporomaudibulur join Is, are synovial

(ANATOMIC SCIENCES

An 18-mont h-old boy diagnosed with Crouzon's syndrome needs to have surgery to treat the prematurely fused cranial bones. The joints In the Oat bones of the fused cranium are classified as which of the following?

Sutures
Symphyses Synchondroses Syndesmoses

9,10
17 Copyripte 2009.:zoto Oentall)e(:b

(ANATOMIC SCIENCES

The paramedics arrive at the scene of a minor motor vehicle collision. One ~ driver dalms to ha,e experienced whiplash and is ha,1ng trouble shaking her head in a "NO~ motion. Sbc is line with nodding her head in a "YES" manner. Which of the following joints allows maximum rotational movement of tbe \, head about its vertical axis (say/11g "NO")? ~

Intervertebral joint Atlantoaxial joint Atlanto-occipital joint Costovertebral joint

JointS are places or union bcrween two or more bones. Joints are dass.ified on 1he bass of their slrUCrural feanues mto fibrous. canilaginous. and synovial types. Fibrous joints {.f)'nDnhroses): are barely mo,ablc or non-movable and are found in these fonns: Sutures arc connected by fibrous connecrive tissue and are found betWec11 the nat bones or the skull Syndcsn1ose.s ore eonnec1 ed by fibrou..~ connective tissue and occur as the inferior tibiofibular a.nd tympanostapedial syndesmoses Cartilaginous joints (amphiarthroses): Synchondroses (primary cartilaginous joi11U) are united by hyaline cartilage and pcnnit no movement but growth in the length of the bone. These include cpiphy=l canilage plates and the firSt rib and sternum Symph)ses (sw:mdary carti/agittOus joints) ore JOined by a plate of fibrocanilage and ore stighlly movable JOints. These ioclude the pubtc symphysis and the intervertebral dises Syno,ial joints (dlarthrodial joinrs): Permit a great degree of free movement. They are chametcrizcd by four feature>: joint (.<ynovia/) cavit-y, rtlcular cartllag~ synovial mtrnbrane. and articular capsule. Tlu;sc joints are classified according co axes of movement in1o: Gliding (platte): include those joints found in the cArpal bones of the wrist and the tarsal bones of the nnklc Hinge: the elbow and knee joints arc examples Phot: jomt such as is found between allo. (CI) and a.'is (C2) of the vertebral colwnn Elhpsotdal (condyloitf): found bet"ccn the diSUI surfaces of the forearm bones (rodi11s ond ulna) and the adjoccnt c:aipOI bone> Saddle: found where the melllcarpa.l of the thumb meetS lbe ttap<:ztum of the carpu.
(wrist)

Balland-Jocket: examples include the shoulder joint and the hip joint

.\ thln1n: n ial jnint

This joint is the synovial aniculation between the inferior aniculating facets of the atlas (first cervical errebra) and the superior articulating facets of the uls (second cervical vertebra).

*** Remember the movements of the head as in saying "NO."

Note: The lltlanto-occipital joint permits rocking or nodding movements of the head as in saying "YES." This joint is the synovial articulation between the superior articulating facets of the atlas (first cervical vertebra) and the occipilal condyles of the slruU.

GNATOMIC SCIENCES

Urns)
"

A 51-year-old male telemarketer has had a history of nephrolithiasis (kidney stones). A calcium oxalate buildup in the renal papilla would directly block filtrate now into the:

Major calyx Renal colwnns Minor calyx Ureter Renal pyramid

11
CopyriJ}It 0 2009-2010 Dnltal Dtcts

"

(ANATOMIC SCIENCES

Urns)

Name the following structures of the nephron in the order they are encountered from blood to urine:

Distal convoluted tubule Bowrnans capsule Collecting duct Glomerulus

Loop of Henle
Proximal convoluted tubule

12

\1innr cah' The kidn-ys an: lcxued at !he back of the abdomen. one 001 each side of !he spme, at !he level of !he lo"er ri~. They are a pair of reddi<h, bean-shaped organ> that are highly vasculariud and perfonn two essential functions of the urinary system: (I} fom1ing unnc

and (l) matnrnining homeostasis. Jhe lcJclney5 are located on eitber side of the lumbar spine, They lie rerroperltooenlly (exlema/ 111 tire peritonea/lining a} the a/xiomlnal C11Vity) in front of the muscle$ 111tached to the vencbral column. Internal features of kidney: Cortex - outer ltght-brown layer (glomentli and pro~imal and df<tal crJJtW>IIII<d ltthllles ar<! located h~re). Site of blood liltration Medulla - 1nner dark-brown layer. con tams cone-like structures called renal pyr:imids that arc 5cparntcd by renal columns Renal rulunu11 - cxren.~ions of renal CO!'I<!x Reool pelvis a hollow inner structure that join.< with the ureters (lhr tuber tltat conduct ur/ue ro the blaldder). Receive.< unne through Ute calyces Renal pnpiiiQ apex of pyramids, her< the collecting ducts pour into minor calyces Renal calyx extension of the renal pclv1~. Minor cnlyces unite to fomt mujor calyres. which urine is emptied into
1

t. The right kidney lies slightly IOt>er than the left kidney due to the large Nota tze of the right lobe of the hver. 2. Each k1dncy is surrounded by a Ohrous renal capsule and IS &upron<d by rbe adipose capsule. 3. tach k1dncy bas an indentauon, rht hilum, on the medial border, through whicl1 1he ureters. renal \'C:-!'~cls, and nerves enter or leave. 4. Each ktdncy rcceivos its blooo >upply from a rena l ortcry. a branch of the abdominnl aona.

<;tonu.:rulu' Um\nt:ln , ('tipml1. > Pru,inull . nn\ulutld tuhull" Oi,tal ('nH\ nlutt.d 1uhul1. -, Colll'CiinJ,! t..luct

>

l .un1 nf lh. nh.

Tbe Sllbunit of a k1dncy rruu punfics blood and ma1nta111! a qfe bslancc of .otu1es ml wa1cr" the! otphron: ttl& the fullcti011l untt of the bUmlln cM:rclory $Yslem. About one m111ion ntph!Oil$ are 1n t11e concx of c:J~Ch ltidney. and w:b one os 3 tong tubule with a dosed nd. cslled ~te Bo"man's capsule, Comp.u1~1t~ or the: ncrhron include:: Rcnl cnrpusele: which consists of ~lnmcrutus (11<11\'Qrk ofpllr<tltel cllpi/torlc..) and a double-wallud Clip. thu Bowman's capsule whtch surrounds the glomerulus tWd collects tilIrate. The nmul cotpuscl~ is the slte of tiltl't\tl\ln; tlus oom>ally produces protein-free nnd cellfree filtnu" th~t p~sses into the proximal eoovolured tUbltles. Tiae tubular portion: hns tour main reg1ons. Hhrtc from the Bowl'flo\n's <Up5Uic fil'11 passes into tht prol1nua1 tonvoluted tubule tn the (.'Ortex. Herr, glucose, am111o at1ds. m-ettlbo-lires. nJ electrolyts reabsoli>ed from fillnlte and re1Uf1led to ciroulatioo. ext, the filtrate Cllte15 the loop or l:lenlt, fu:<t 11\n,uatr it> dc><:aldong hmb aod thf<l throustt liS &>ndmg limb. Here. tho filtrate i$ COIIC<narated through eler~rolyte exchang_e and reabsOtJ>IIon ro produce a hwerosmolar fluid. This loop exltntls dec:p uuo the medulla. from there. Ou1d en1er, the distal cn..olutcd tubule, alw in 1he cortex. Hue, sodium is reabsorbe-d under the inftu enec of aldO>I<ruM. From lloe distal eonvohned tubule. tilrrate enters the oollectln~ duct, which is the dlst61 end of the nephron. l h1 s a tht ~lie of flno.l concenrmtou of flltn1fe, whtt:>h tlle11 empties into pupil lui)' ducts deep Within tho lltloollu. Aller filtration. Ouid in the noboolos of the nephrons undergoes two more proce,.es. both onvohing the peritubular e.~pillaties: tubular rrobsorptlon and tubulr srrretlou. Sotn< bloo<l 1S not liltered and p.....s Into the efferent "<=Is and pmtubular capillaries. Mru~y ubs1aoces that are filtered~ returned to 1h~ perirubular capo liMes from the tubules by r<al~on. often at hogh r.ues (eJ; nv:rttr. gluro$e, <oditun). Waste productl ftre aod etnj>!ied tnto a collecting tubule, whoch 1R discharged to the ~ttle111.

"'"""eel

GNATOMIC SCIENCES

Urns)

Name the foUowlng structure.~ or the urinary system in the order they are -.,. tneountered from systemic circulation to excretion from the body:

""' a
~

Urinary bladder Ureter Urethra Kidney

11
21 Cop)Tigh10 20092010 Dtnul Ott\.:

(ANATOMIC SCIENCES

Urns)

Which statement concerning urine is false? Adults pass about a quan and a half of urine each day, depending on the fluids and foods consumed The volume of urine formed at night is about half that formed in the daytime Norrnal urine is sterile. It contains fluids, salts, and waste products, but is free of bacteria, viruses, and fungi The tissues of the bladder are isolated from urine and toxic substances by a coating that discourages bacteria from attaching and growing on the bladder wall Urine forrnation is the result of three processes: glomerular filtration, tubular reabsorption, and tubular secretion The ureters regulate reabsorption and secretion, thus determining the composition of excreted urine

h.idlll' \ ~

h ' h.t ,

I nnn hi:Jdd<.' r

> t

r<.'thra

The urinary S)stern consists of the kidneys, the ureters, the urinary bladder, and the urethra. 1l1is system filters the blood and rruuntains tbe volume rutd chemical composition of the blood .

The kidneys are paired organs, which conmin extensive vascularity uod millions of nephron. within ll1e runul cortex and rtnal medulla. The kidneys filter blood und regulnte the volume and com posh ion of body 1lwd.s during the formation of unne.
The ureters are long, slender.libromusculutu~ that t.r.lJlspon urine from lhe pelvis of the kidney to !he bas.:. of the urinary bladder ~nuse the left kidney is htghcr than 1he right, the let\ ureter IS 11!\WJIIy sligbll} longer 1hru1 lho ngh~ The uretets are narrowest wbere lboy originate, at the renal pelvi~ (urererope/vl~ junction). Note: Filling of tbe bladder conslricts lhe ureter& 111 the ureteroYestcnl JUnction, where they enter tbe bladder. Peristaltic waves, oce11rring about one to five time ech minute, move urine through Ihe
ureters.

The urctbr11 is a fibromuscular tube that cun-ies urine liom the urinary blnddcr to tbe outside of the body. In males,lbeurelbrn carries semen as well as urine. Note: The portion of lhe motle urctb 1"3 lhat passes through the urogcnual diaphm~m is called lbe membranous uretbn. The urinary bladdu i~ a distensible sac that i~ suuoted in the pelvic eavity postenor tQ the symphyss puh.s. The unnary bladder .s sli{!htly tower in lbe female than tn the male. It conceotralcs und serves as a reservoir for urine, which the bladder recetves from the kidney lhrougb the ureters and discharges through lho urethra.

I hl' url'lt' n

ncui.Jil

n:ab-,c,rpliun

~ttut

wu~tiun.

thu' dLh.nmnint.: thl'

romtu"ilinn

ur l'\(rlllrlurilll.'

ThiS 15 faiJt; the kidneys r<gUiate reab.orpt1on and secretion. thw; det<rm'"'"ll the compositton of excre1ed unne. Urine Is conlinually produced by the kidneys and .tored m the bladd<:L When full, the blatl der sends a messegc to lhc reflex center'" the eMil pnn of the >pinal cord, where tl U'II!S""' 8 reflex contractiOn Of the muscle Of\be bladder OliO C(lllse8 the Ue<:k o( the bluddor 10 <elltll. This reflex ls surpressed untillhere is an opponunity to relieve the bladder. !'he u~inory system excretes the waste products of metabolism and mullllalus I he buluncc of water and electrolytes in the blood. The ~ystcm removes nitrogenous waste as urea from the blood. Urea Is produced when foods contniniu~; protem, such as meat. are broken down iuthe
body.

The kidne~s remove ur<a from the blood tluwJ!h tiny tilteriug uni;s called nephrOn>. U"' tOgether with water and other Waste <UbstatleeS. fonns the unnt BS it p:IS.~C$ through \he nephrous and down the renal tubul"" of the ktdncy. Remember : Pressure fTQrn the blood in tbe glomerulus cause.' fluid to tiller 11110 the Bowman's capsule. From there, tluid flows to the pro~lmal convoluted tubule, the loop or Henle, Jtllben to the distal convoluted tubule. Wlthin this system, wt~r. t;lttcosc, and sodium are renbsorbed Into the blood. Wn5tc produc1s are retained ~ntl emptied iuto a coUeding tubule, which Is discharged to the ureters. I. The urinary syatom is lined with lransltlonol epithelium. Nor.. 2. Th~ ~cnital nnd urinary system; 11n: supplied with parosympatbetk tibers from the pehlc splanebolt nrvos. 3. The ktdney<;, ureters, and urin.uy bladder are aU located rtlroperltonoally. nu, means !hey are located bfllind tbe ptritoneum, which tS the serous membr.me lining the: walls of the abdominal tnd pelvic cav1tics and enclosin1:1 the viscera.

(ANATOMIC SCIENCES

For)

r A 26-year~ld female has been previously diagnosed with McCune-Albright ""''

syndrome. There Is bony fibrous dysplasia of the anterior cranial base leading to the encasement and narrowing or the optic canal. Although her vision Is nor mal, there Is concern that there will be compression or the op!lc nene \.. and which of the following other stTucture(s)? ~

Ophthalmic nerve (CN V-1) CraniaI nerves Ill, IV, and VI Ophthalmic anery Ophthalmic veins

14
23
Cop)nt;bl 0 2009-2010 t)(m.aJ DL.

c A.t~ATOMIC SCIENCES

rA62-year~ld female visits the family physician with complain ts of right-sided

bearing loss, ringing in the right car (titrnitus), numbness over the right half of her face, and dizziness. The physician diagnoses her with an acoustic schwannoma that is occluding her right internal acoustic meatus. The Internal acoustic meatus pierces the posterior surface or the petrous part of the temporal bone. The internal acoustic meatus transmits which two structures?

Trigeminal nerve (CN V) Facial nerve (CN VII) Vestibulocochlear nerve (CN VIII) Vagus nerve (CN X)

The optic canal is located posteriorly in the lesser wing ofthesphenoid. ll communicates with the middle cranial fossa. It transmits the optic nerve and the ophthalmic artery. Bony Optnlng
Cnbrifonn plato wot~ foramina
fl)'JlOglossal caru.l

Location (Bone)
Ethmoid

Contents
OtfoctO<y ""rvcs
Hypoglo~sal

Occipi11

nerve

Carotid co.naJ
Lacrimal canol

Temporal
\tUJIIa and t><rimaJ Sph<no.t and maxilla Sphenoid

lnttmal c3rotid artery

N:u<>l><nmal (troT) duol
Jn(t'IOCbual and eygomaric nef\t:s from V2,

Inferior Olbttal G<<UTC

Smrior orbital fis:.urc

tnf'norbital

artery~ and

ophthalmtc. vein

Oculomotor. ttoehlcar, Bod obducent

ncr,. e,: lacrimal. frontal and niSO('ili31)' b11ncllos of 01>hlh>lm~< no."rVe (VI);

"!'htholmoe V<in; sympalheue fib= from

Q\~piCXU$

Optic canal and foratn<D

Slylomastoid roramen

Spbonotd bone

Ophc ner\'e Md ophtl\almtc ancry

Faclnl nerve

Tcmpoml

I acial nl'n t' (( \ 1//J -- mntnr and \ t,tihulm,:m:hh-.r ntn l' I( \ J 1//J

\t"n,nr~

rnn"

The vestlbulocochlear nerve enters the intemal acoustic meatus and remains within the temporal bone, to the cochlear duct (hearing). semicircular ducts, and maculae (balance). The facial nerve enters the internal acoustic meatus, the facial canal in the temporal bone, and emerges from the stylomastoid foramen. The stylomastoid foramen ties between tbe styloid and mastoid processes of the temporal bone. After the malo trunk of the facta! nerve exits from the stylomastoid foramen. it enters into the subsraoce of the parotid gland. It is here that it gtves off five main braocbes that will supply motor innervation to the muscles of facial expression.

,,...__, I. If you inadvenently deposit anesthetic solution in the parotid gland j Notf when giving a mandibular block, the patient will develop paralysis of the muscles of facial expression. 2. An acoustic neuroma is a tumor involving the ve.,tibulocochlear nerve as it exits the cnnial cavity. Because this tumor compresses surrounding structures or invades nearby tissues, in addition to hearing loss and equilibrium problems. a patient would most likely also demonstrate ipsilateral (same-sided) facial paralysis.

(ANATOMIC SCIENCES

A fourth-year dental student is getting to perform operative work on a ~ mandibular molar. He is ready to provide an inferior alveolar nerve block. Thinking of his old anatomy exam!, be remind! hlnuelf that this nerve enters the mandibular foramen. In relationship to the occlusal plane oftbe mandibular molars, the mandibular foramen is located:

At or slightly above the occlusal plane and anterior to the molars At or slightly below the occlusal plane and anterior to the molars At or slightly below the occlusal plane and posterior to the molars At or slightly above the occlusal plane and posterior to the molars

15
25
Copynaht C 20092010 Dcntai DKkJ

(ANATOMIC SCIENCES

(
\..

Which of the following allows for the exit of the spinal accessory nerve from the cranial cavity?

Foramen magnum
Jugular foramen Foramen rotundum

Foramen ovate

16,17

The mandibular foramen is located on the medial surface of the ramus of the mandible just below the llnguln, midway between the anterior and posterior borders of the ramus. The foramen lead into the mandibular canal, which opens on the lateral surface of the body of the mandible at the mental foramen. Note: The lingula is a tongue-shaped projection of bone that senes as the attachment for the sphenomandibular ligamenL hmnediately behind the incisor teeth is the incisive foramen. In this foramen are two lateral apertures, the openings of the incisive csmnls (foramina of Stenson). which transmit branches of the sphenopalatine artery, and the nasopalatine nerves. Occasionally, two additional canals are present in she incisive foramen; they are termed the fo ramina of Scarpa and are situated in the middle line; when presenL they transmit the nasopalatine nerves. Remember: The inferior alvrolar nerve (brnncll Q[ V-3), artery, and vein travel through the mandibular foramen. At the mental foramen, the inferior nlvcolar nerve ends by dividing into ( I) the mental nerve, which supplies the skin of the mental region and mucous membrane and (2) the incisove branch that supplies the pulp chambers of the anterior teeth and adjacent mucous membrane.

.lm.:ui,Jr turamtn

The jugular foramen lies between the lower border of the petrous part of the temporal bone and the condylar pan of the occipotal bone. The jugualr foramen transmits the following structures: the internal jugular vein. and the glossopharyngeal, vagus and spinal accessory nerves Bony Opening Location (Bm") Contents Maxillary ne-rve (V-2) Mandibular nerve (V-3) Spinal cord, vertebral arteries. nod spinal accessory nerve Middle meningeal nrtery MenUll nerve, anery, and vein Grunter palatine nerve, artery, and vesn Lesser pnlatine nerve, artery, and vein Nasopalatine nerve and brand1es of the sphenopalatine artery Internal jugular vein and glossopharynge31, vagus, W'ld spmal accessory nerves

Foramen rotundum Sphenoid

Foramen o\-.le
Foramen magnum

Sphenoid Occipital

Foromen spinosum Sphenoid

Mental foramen Greotcr patatioe Mandible Palatsne Pnlatlne Maxilla Occipital and temporal

foramen
Le>ser palatine foramen lncssive foramen Jugular

(ANATOMIC SCIENCES

For)

Tbe cranial nerves that supply motor innervation to tbe muscles tbat move the eyeball all enter the orbit througb tbc:

Supraorbital foramen Superior orbital fissure Infraorbital foramen Petrotympanic fissure

16,.17
27
Copyt~aht c

20092010 DemaJ D'LI

0ATOMIC SCIENCES

Rsps)

r During a baubaU game, a collision between the catcber and tbe runner into"""'
home plate resulted in fractures of the catcher's ribs, leading to a pneumothorax of tbe ldtlung. A pneumothorax is the presence of air into which space?

Cardiac notch

Hilum
Pleural cavity Lingula
Mediastinum

1~

The superior O<bual R<SUte IS located pO!>ICTior!y bclwe<n the !:Jellet and lc:s<cr wmgs or lhc sphenoid bont:. The )Upcrior orbital fissUI"e corrunurueateS \\ith lhe middle cranial fossa. It transmlls the: SUP"rior and inf.nor divisions of1he oculomolor nerve (CN 1111

crochlear nerve {CN IV) lacrimal, frontal. and nasociliory br11nches of lhe ophthalmic nerve (CN VI) abducent nene {CN VI) superior and inferior divisums of the oplnhalmic vein :,ynlpathctic fibers from the ttwemnu~ plexus

Bony Opening
P<trotympanie
fissure

Location (8o11e)
Temporal Sphenoid, oeeipilal. and 1empornl
Frontal

Contents
lnfenor alveolar nerve, 1111ery. tllld vtln C'hortla tymp.;;Jnerve Nerve of plel)'goid caoal (grdltr and deep Jlflmso/ nerl'.<). and artery ofplerygotd eunal

Mandibular foramen Mandible

foramen taccnam
Supraott>hl f~ramcn and canal

Suproo,bitaJ necve. artery, and vein

lnfraorbill!l toromcn Sphenoid and maxilla Jnftaarbital nme. artery. and V'tin aodcanal Pterygoid cnnal Internal ecoostic mcoiUS Sphenotd Temporal Temporal
Am~ nen es 3lld 'csscls

Foaal o.nd vestibulococblear ner\'OS

E>rtemJ acousuc
meatus

Opcntngco lympanic cavity

Pleuralt.':t\ 11\

A P"'cttation wO\IIld of lhe chest wall can I<Jid 10 o pncomolhonx (air in rht p/..,ro/ cavtryl or a hemothonut (blood In tht pl..,( crnil)1. In both of the>< siruations, dw: surfac:c <cnsloo dut binds the llmgs 10 the ches1 wall is eliminated, sod lht: lung W111 mscandy sbrinl< 10 lht: site ofa tcnnts ball. The lungs fillllle pleural divisioM of lhc thora<ic cavity: they """"'d from lhe root of <he neck to the diaphragm. 1be lungs are the main compOnent of lhe respintory sy~ they dasuibu1c atr and exchange gase~. Tbc: right and left lungs are sepora1cd by the mediastinum, which contams the

bean. blood vessels. and othermidline struc1urcs; nssurcs di\'ide each lung into lobt"S. Each primary
bronchus enters llS re~pecl"ive lung. at the hilus, an indentatiOr\ on lh mcdia:,tinal surf8cc. The bronchi and pulmonary blood vessels are bolll'l\ltogcther by connective tissue:- to fom1 the roo1 or

Ihe lung. The bJJt, the inferior surface of the lung. rest.~ on the diaphragm. The apex, lhc most superior portion of the lung. project~ above-the cla\tCie. Ri_gbt lung: Has lhrte lobH (.mperior, middle. and lnfrntJr) one! lhrte secondary (labor) bronrbl Cootains n bronchtal ses<n<niS (cort'OJIOfldmt to the rmiary bronchi) UsuaUy rteti\'CS onr bronchial arttry Has a $1lghlly 111'\lH eapacity !han lhe left lung Leftluo.g: Has rwn ICJbt!-J (S!Iperlor and in/f!rior) and IWO setQndary (lobar) bronthi Contains claM bronchial segments (con't?.'t:fX',diiiR to tl1e tertiary brr>11chJ) Contains a .:ardlac notch (on itS superior loht!), which is a.n indentation pruvid1na room rOr lbc bean Usually rece1ves t~o brontbial arteries Contains a Ungula, which is a tongue-shaped ponion of iiS superior lobe liult corresponds to lhe middle lobe of the right long
Each long is endostd in a double-layered plural tar. O..elaya is called lht: ,moral pleura; lhr olht:r iHalled llle parlelal pleura. Be<"=lht: two Iayen is lhe pleuralca>ity, which ts filled \\oilh strous Ouid.

( ANATOMIC SCIENCES

R sps)

The trachea bifurcates into right and left primary bronchi at the level of the:

First rib Seventl1 cervical venebra Xiphoid process Plane of the sternal angle Suprasternal (or jugular) notch

Copyttaht e 20092010 Dental Dc<b

..

( ANATOMIC SCIENCES

R sps)

~mphysema is a pulmonary disuse of the lung characterized by destruction o~

the s upporting structu res of the alveoli. This leads to increased elasticity of lung tissue and a pathologic Increase in the size of the air spaces. What final division or the bronchioles within the respiratory tree contains alveoli and first permits \. gaseous exchange with the blood? _J

Teniary bronchioles

Primary bronchioles
Respiratory bronchioles Terminal bronchioles

20
30

""""... 0 l009-l010 o....\ DoW

l'larw ur llw ,h.rnal angh.

The trachea is a metnbranous tube that begins below the cricoid canilage (otthe le1't!l of rhe 6th cuwcalertebro) of the larynx ami ends at the level of llle sternal ongle (the Jth thoracic ertebra). A series of C-sbapcd nngs of hyaline tartlla~e strengthen the lrnchea and pr~vcnt it from collapsing durmg Inspiration. The uachea is lined wath ciliated pscudostratlned columna r epithelium und murous-secrcting goblet cells, which trap inhaled debris. Ciliary action moves debris toward the pharynx for r~movul by coughing. The c~change of oxygen and carbon diol<ide between the air and the blood .x:curs in the lung.~. Air enters the moutb or nose and pas.'ICS inco the pharynx and the larynx, ~nd then illlo the traehca. A< th< trachea passes behind the arch of tbe uorta, the trachea bifurc.11"s or diVIdes into a ngbtaud left prilllary or maitt bronchus, which leads to the lung.~. Aller emering eoch lung. the trachea bifurcate 1010 right and left primary bronehi at the level of the two main hron~bl, which branch into the five lobar bronthl (se.:nnd(lry hmnr!ri). Not~: 11te rlg,ht main bronchus divides 11110 three lobar bronchi, ttnd the left main bronchus divides into two lobar bronchi. Eoch secondary or lobar lli'Onchus serves one of the five lobes of the two hiiii!S. Eacb lobar bronchus enters a lobe in each lullg (lwn lobe. Olltlte left, tltrcc lob<:s c111 the right). Withiu its lobe, each of the '"condllf)' bronchi (lobar bronchi) branch ioto tertiary bronchi (<egmenwl btvllchi). These tertiary bronchi continue to divid~ deeper in the IUUJ!b wto tiny bronchioles, which Mabdivide llllliiY times. fonn1ng ttnninal broocblolos. Each of these terminal bronehtoles gives rise to seveml respir~tory
broocbiol~.

Each resprrotory bronchiole subdivides into sever~! alveolar ducts, which end 10 clusters of small, thinwalled air 11aces called alve,lli. These clusters of alveoli are called ah<'()lor sacs und fonn the functional unit oftbe lung.

Condueting bronchioles are smaller extenston> of bronchi (little bronchi) ThQ.~ devoid of alveoli in their walls are nearer tbc lulwn of the lung. The.>e condueung passageways deliver atr to passageways that have alveoli. The hbt gcncrnltons of conducting bronchioles arc called terminal bronchinlr.s. Respiratory bronchioles, continuing fmm terminal bronchioles, branch nearer to the alveolar duct. nnd sncs nnd have occasional alvcolt in their walls. These bronchiole> capnble of respiring ure the flnt generation of possneeways of the rospirntury port iou oftbe bronchial tree. Broncltlolos arc churacteril"d by: A diameter of one millimeter or less An epithelium that progresses from cili~ted pseudosuatifil!d columnar tO simple cuboidal (rt!'lplrotory bronchioles) SnuU bronchioles have non-ciliated bronchiolar epithelial cells (Clara ulls) tbat secrete a surface-active lipoprotein Walls devoid of glands In the underlywg comtective tlssuc Woven bundles of smooth muscle to regulate th<> bronchiolar diametel Walls devoid of cnrtllt~ge (small cliClmcterttrovem.< them jitJm cflllatJSIIIJ: 111 ellfl o,(
expiratio11)

Note: Type 11 pncumoeytes are specialized cells within the alveoli of tile lunj;S that arc adapu.'d to produce ~urfactam. 'JYpe I pneun1ocytes are CJ<trt!Tllely thin epithelial cells lining the alveoli of the respirntory tree 1111d permit gaseou. diffusion with the capiUaries.

GNATOMIC SCIENCES

Rsps)

A clumsy dentist, while placing a crown, accidentally drops it into the patient's mouth. The patient aspirates the crown. A chest x-ray "111 most likely reveal the crown lodged in the:

Trachea

Right primary bronchus

Left primary bronchus
Pulmonary artery Pulmonary vein

19,_20
S1 CopynJbt 0
2~20 1 0 Dmtal

Dr<d.

(ANATOMIC SCIENCES

Rsp s)

Which statement concerning the respiratory system is false?

The lungs lie in the mediastinum Canilaginous rings are found in the main bronchi The left lung has u smaller capacity than the right lung Clusters of alveoli called alveolar saes form the functional unit of the lung
It has two major pans the conducting pan (a branching, tree-like set ofhollow tubes) and a respiratory pan (smallest tubes and thin-walled pouches in which

gas exchange takes place)

Ri;!ht 1lnma1 ~ hru1u. hn._.

lmporuol: When foN'ign objects are asporaoed 1010 the trnchea, they usually pass into the right primary bronchus because it os larger. straighter, and shoncr than the len. 11 is al~o in a more direct line with the tmchea (imponanl in a dental chair lwcausc if a parient swallow. an ol:>}ect it tends to lmlgc in tlo e right bronclotts), Each lung is shaped like~ cone. h hns a blunt apex, a conca\e base (tloc/1 sit.~ lin tire diaphragm), n convex costal surface, aod a concave mcdiasllnal surface. At the middle of the mediastinal surface, the hilum is lo;:atcd. which is a depr(ssioo on whoch the bronchi, Ve$Sels, and nerves that form the root enter and leave the lung The root or the lung contains the following strUctures: Primary bronchus: the right and len bronelu n~e from the trachea and carry nir to the hilum of the lung during inspiration and carry air ftom the Inns dunng exptrauon A pulmonary artery: enters lbe hllum <)f cnch lung carrying oxygen-poor blood Pulmonary vcln(s): a superior and inferior ptoir for each lung leave th~ hilum carrying oxygcnrlch blood
-. I. The <mall bronchial arteries (wloiclo nre hrnnciles of tloe desce11ding liOrln) "Not.. also enter the hilum of each lung nnd deUvcr oxygen-ncb blood to the tissues. The bronchial aneties tend to follow the bronchial troe to the resporatory bron chioles where the bronchial anetie. annstomose \\ith the pulmonary vessels. 2. Branch<:S of the vagus nerve also pa.s the hilum of each lung.

I hl' lunc'

ltl'

in flu. n11.di.1'1inum

... This is false; the thorncic cavuy is unuunckd by the ribs and c;best muscle$. It's subdivided mto the pleural cavities, each of whtcb contain a lung, and the medl asllnum. The mediastinum 1S further dovtded anto four Br<!S- Tho middle medtnsunum contains the bean ond pericardiol sac; the anterior, pusterior, and superior areas ~rc named accordJn,g to lheir positions relative to the m1ddle mediastinum. Tho respirutory S)'Steon con.<ists of the uppeo and lower ""'piratory uacts, tbc lungs. tmd the thoracic cu~e. The respiratory system i< des[gned to e~change the carbon dioxide occumulat cd in the blood for oxygen in the airways, whlcb entel'li the lungs as air from the surrounding atmosphere. Blood trnvel~ contonuously through two doncrent circulanons: the pulmonary and the sys temic circulotrotU. 'The hean pumps deoxygenated blood from the '"'ins of the $ystemie circulation into the arteries of the pulmonary circul:!tiOII. This blood is oxygenated by the lung$. and then 11ows back to the bean to be pumped 1nto the anerics of the systemic circulation. The strucnores or the upper respiratory trnct include the nose, mou01, nasopharynx. oropharynx, luryngopharynx, and larynx. Beside" warming and hooooidifymg Inhaled air, these structures provide for tnste. smell. and the chewing and swallowing of tood The low~r r~plratory trort struttures are the trnchca. bronchi, and lungs. Bmncho b1'111lCh into bronchioles. which in 1\lm branch into lobules. The lobule includes the termonnl bronchioles and alveoli. A muc<>us membrane contaonin& baor-like cilia lines the lower trnc1, functionally, the lower tract is subdovidcd into conducting ail'\\ a~ (lire lr<teht!# ami rlre primary. lobar. and "'8"'ental bronchi) and aheoll, the site< of !!'IS exchange.

(ANATOMIC SCIENCES

Rsps)

Which type of epithelium provides sensory innervation that tr avels on nerve bundles through the cribriform plate?

Olfactory epithelium Squamous ciliated epithelium without goblet cells Transitional epithelium with goblet cells

S3 Copynabl 0 2(1(19..2010 ()cnt;al Dh

( ANATOMiC SCIENCES

Rsps)

While ascending to 30,000 feet, the passengers on a commercial night experience the sensation of their ea rs "popping." The swallowing or yawning that triggers this equalizes the pressure of the middle ear with the surrounding atmosphere vla the eustachian (auditory) tube. The pharyngeal opening for this tube, along with the salpingopharyngeal fold, pharyngeal recess, and pharyngeal tonsils (adenoids) are all located in the:

Laryngopharynx Oropharynx Nasopharynx None of the above

23

Olrm. tnr~ crtithtliUitl .. 'JH~rialiJt..tl l'Hiumn:r l'(JiCh('lium

Air enters through tb~ nQStrils (extemulllares) !bat lend to the vestibules of tlte nose. The bony roof of lhe nosal cavi1y is funned by the cribnfonn plme of the ethmoid bone. The lattral walls bae bony projections calltd conchue (SUpt!rim; middle. and lnjtrior), whlch are also referred to as the nasal turbinates. These conchae lonn shelves !bat have spaces (or grrx!l'es) benllllth lbem called meatuses (.Wfk.'l'tor, middle. 011d inferior). The paired puranusal sinuses (ma.~tl/ary.frotual, ethmtJitilll, arrd sphetwttlal) drain into Ute nasal cavity by way of tbese mt:lltu>eS. The n""olacrlmal duct, wbieb drains tears from lhe surfact of the eyes. nlao empue.< mto the na>al cavity by way of lite inferior meatus. The floor is fonnl'<l by the bard palate. The nasal cavity opens po>teriorly mto the nasopharynx vie funnel-like openings enlled the c.hoanoc (posteriOI'/IQI't!S). 1I. The vestibule> arc lined with nnnl\eratlnlz~d stratifi~d !qunmous epitheli l"ot .. um. 2. Tb<: conchJe of lite na.al fossae are hntd with psrudo;tntlfied cillatl.'d colu mnar epithelium. ). Tite olfuctory epithelium is very prominent in the upp;:r medial portion of the ossa! cavity. 4. The oa.al cavity receives sensory innctvMion from the olfuctory nerve lor smdl and from lhe trigeminal nerve for other ;;ensations. The na.o;al cavity' blood ~"\Jpply is from branches oflhe ophthalmic and masJIIary arteries. S. The tickling sensation felt in the. nasal cavity just prior to a ~neeze is carried m the madllory division or the trigeutlnal nerve. 6. During a sinus auack, painful sensation from the ethmoid ceUs is carried in tbe naodlia.ry nerve. 7. All of the parana.o;al sinll6rs dnun into tbe middle me~tu~. except lhe sphenoid sinus, which drains almost directly down the lhroaL

The pharynx (rhe t/IITX/t) is a tube that serves a. a passageway for the re.piratory .md dig~tlve trncts. lt e~ tcnds from the mouth and nasal cavities 10 tbe lurynx and cost>phn gus. The pharyn.' is dividctl into three regions: . 1 Nasopharynt - 15 the most suptrior diYislon of the pharynx. h " lllfeno o lhe sphenotd booe and lies at the level of the sol\ palate. The plu!Jyn>. " lintd Will\ cihaled p.'>Cudostratified epitbehwn (respwotnry epit/Jflrillll). 111e nasophllrytLt ha.- four opettings: two audito1 y (ettSIIIt'itiall) tubes. euch opening 0111of n lnternl wnil and connecting W11h the middle car (tynrp(lnic c11vity) two orening:; of the posterior oms (<hoonae) The son rulate end uvula fonn the antenor waU of the nasopb~rynx. Note: The t~nsor veli palntini and the levator veli palothtl muscles pr~vcot food from entering the nasophnl')'IIX. 2. Oropharynx - the middle divis1!>n of the pharyu.t: is continuous with the posterior 01'111 cavity llltd i& lined wrth sltlltified !II}UIIInOW< epithelium. The ompltnrynx extend> inferiorly from the sol\ palate to the hyo[d bCJne. The opening 11110 1he oropharynx from lhe mouth is called the fouces. 11\c lingual tonsils protrude into 1he oroph~rynx from lh~ oral cavity 111 the base nl' Ihe tongue, The arucroiateral walls of the o1 '0phur ynx $1tppon the palatine Ions [b. It is a rood nud oir passage" ay. 3. Laryngophuryns is the mos1 infcnor diviSIOI\ of tile pharynx: the l3l)'tlgopMrynx extends from lho hyoid bone to the opening of the esophagus. lbe laryngopbliT ynx is lined" fth stnrufied squnmous epilhelium. extends from lhe nropharynx abo~e to the larynx aod e,<oph~gus. The laryngopharynx a lso serves as a tMssagcway li>r food nnd air. Alr entering the laryngophuryn.x goe. to the larynx while food goes to the esophagus. ote: Food entering the lal'}nx would be expelled by Vlolem cougbtng.

(ANATOMIC SCIENCES

R sps)

rA newborn In Ethiopia, whose mother has a human papillomavirus infection-:'

starts to grow warts on her larynx and respiratory tract. A tracheotomy Is performed in order to allow her to breathe. Which of the following structures is not at risk during the procedure?

Recurrent laryngeal branch of the vagus nerve Carotid artery Internal jugular vein
Vocal cords

Thyroid gland

35
Cop)Tight 0 20092010 Dtmal Dks

(ANATOMIC SCIENCES

Tbe external carotid artery terminates within the parotid gland, just behind the neck of the mandible, where the external carotid artery gives off and t h e - - -- - two linal branches, the

Superficial temporal artery Superior thyroid artery

Posterior auricular artery

Occipital artery

Mnillnl)' anel)'
Facial artery

,.
CopynptC 2009-2010 l)contal Dk.s

24

** The weal cords are above the incision area for tracheotomies and cricotbyrotomies.
Important: A cricothyrotomy is preferable to traclteostomy for non-surgeons in emergency respiratory obstntclions. In this procedure, an incision is made through the skin and cricothyroid membrane for the relief of acute respiratory obstmction. An emergency tracheotomy (tracheostomy) is most easily made by an incision through the median cricothyroid ligament. Titis ligament runs from the cricoid cartilage to the thyroid cani lage and is inferior tO the space between the vocal cords (rima gfollidis) where aspirated objects usually get lodged. The tracheotomy allows for air to pass between the lungs and the ourside air. Important: The space entered is called the cricothyroid space. Note: A tracheOtomy (tracheostomy) is rarely performed and is limited to patients with extensive laryngeal damage and infants with severe airway obstruction. Because of the presence of major vascular structures (carotid arteries and internal jugular ve.in), the thyroid gland, nerves (recurremlaryngeal branch of the vagus nen> e), the pleural cavities. and the esophagus, meticulous attention to anatomical detail bas to be obserVed.

Suprrtidal temporal
,).t\ill:.lr) .tl'lCI~

urtrr~

The external carotid artery supplies structures within the neck, face, and scalp, and also supplies the maxilla and rooguc. As with the internal carotid anery, the external carotid artery begins at the upper border of the thyroid cartilage (i.e.. at the tenninatirm of the common caroTid artery and the carotid sheath). The external carotid anery tenninates within U1e parotid gland, just behind the neck of the mandible, where the artery give;; off two final branches. the superficial temporal and the maxillary arteries. ~ote: At tts origin. where pulsations can be felt. the external carotid artery U cs within the carotid triangle. Branches of the external carotid: Superior thyroid artory - supplies thyroid gland, giws off a branch to the sternocleidomastoid muscle and superior laryngeal art~ry Lingual artery - supplies d1e tongue facial trtery - supplies the face, including lips aod tbe submandibular gland Ascending pharyngeal artery- supplic.' the pharyngeal wall Occipital art.c ry- supplies the pharynx and suboccipital triangle Posterior auricular artery - supplies bnckofthescalp Maxillary artery - tenninal branch of external carotid, it gives uil' branches to the mandJ"ble, and the middle meningeal artery before passing through tb<" pterygomaxiUary fissure to enter the pterygopalatine lbssa to supply the maxilla Superficial temporal artery - tenninal branch of external carotid, supplies skin over fronM and temporal regions of scalp Important: The external carotid artery and its branches supply the muscles of the neck and face, thyroid gland, salivary glands, sc-.Jlp, tongue, jaws, and teeth.

(ANATOMIC SCIENCES

A chiropractor performing a spinal adjustment quickly moved his patient's head from rest to tbe left. She immediately reported hemiplegia -- paralysis of half her body-and slurred speech. At the hospital, it was discovered that therapy caused an embolus to develop into a stroke. The clot arose from an atherosclerotic plaque located at the bifurcation of the common carotid artery. At what level does the common carotid artery bifurcate?

Cricoid cartilage Angle of the mandible Jugular notch Superior border of the thyroid canilagc

25
37
Co"p)rri.Jh1 0 2009-2010 Dctual Df.tks

GNATOMIC SCIENCES

Art)

ln carotid sinus syncope, the cardiac sinus is overly sensitive to manual stimulation and can lead to loss of consciousness. Given this, whic.h of the following statements is true?

It is stimulated by changes in blood pressure

1t functions as a chemoreceptor

It is innervated by the facial nerve

It is located at the tenninal end of the external carotid artery

It communicates freely with the cavernous sinus

26
38
Cop)Tigb1 0 20092010 Dcoral Dtet:s

~Upl rinr

hunh-r ut lht Ill\ ruid

c.1rti1.1~ 1.'

Blood is SUPJ>hed tO rl'te brain. face. and scalp viu two major seiS of vessels: lbc rl~:h and left common carotid arreries and lhe right and lrfl l'crtebrsl arteries. The nght tommon carotid arises from rhe bra.chiocephalic trunk, whrle rhe let\ common carotid anscs from lhe aortic arch directly. The common carotid lies wirhin rhe carorid shearh and runs upwards in lhe neck to the superior border ofrhe thyroid cartilage. liere it divides inro rwo puirs of blood vessels, U 1e exrcrnol ond inrernal carolid orreries. The external caroutl ar teries supply the face and scalp with blood, The Internal carotid orreries divide funber in lhe rniddle crnmal fossa inro the anterior and middle cerebral rtcries. which supply blood to the nntcrior three-fifths of cerebrum, except for pans of the temporal and occipital lubes. The vertebrobasUar anenes supply the posterror tw<>-fif\bs of the cerebrum, pan of tbc cerebellum. and the brain Slem. Remember: Four major anenes. lhe l\\O >'trlebnl and rhe mu carotid, supply the brain ,.;th oxygenated blood The two vertebral ancrie (which 11re branches of rJ~e subclminn.s) converge 10 become rhc basilar artery, which supplies the posterior brain. The circle of Willis (n/.w called the cerebmlartct1al circle) is formed by rho posterior cerebral (bnmclr of ha.vilar ortery), JIOStcrlor communicating (brOIIch q( intenwl carotid). Internal carotid, anterior cerebral, and 11nterior communicallJII\ (branch OJ Internal carotid) aneries. This circle of Willi~ forms an importanl me of collateral circulation rn rhe event of obstruction. The internal taJotid artery has no branches ou~ide the slcuU and enterS lbe skull through the carotid canal. Inside the skull. lhe internal carotid anery ghes off the ophlhalmic artery, which supplies the optic oerve, eye. orbit. and scalp. Tbe artery tcnumat<'S by pasing through rhe cavernous sinu to join the cirdc of Willis and supply the brain.

It h .. rimui:Jhd In di:Jil);!f.'' in hlond pn.'''lllt.'

The carotid sinos is a dilated poruon of the proximal pan of the internal caroud anery. near the btfun:arion of the common .:nrotid anery. This is usually at the le\cl of the superior border of the thyroid canilage. Cltang<-s 10 blood pressure stimulate vagal ner.e endings ill the wall oftbe carolid sinus 10 send signals along lhe vagus nen e to slow the heart rare; rhls response is referred to as the CJtrothl si nus reOex.
Important: The carolid sinus is itmervnrcd by rhe carorid sinus brnnch of the glossopharyngeal nerve and by a hl'anch of tl1c vagus nerve. Remember: The carotid body lies posterior lo the point ofbifurcntion of the common carotid artery. The carorid body is innervared by !he glossopharyngeal and \agus nerves and IS a chemoreceptor, being sensirive to CACe.5 carbon dioxide nnd reduced oxygen teoSJoo in the blood (this 'llaufd produu a rise 111 blood pre.<Srtn! 011d ht!an ratt!/. Carotid sinus syndrome is a temporary loss <)f consciousness that sometimes accompanies convulsive seizures because of d1e utlensity of the carotid sinus reflex when pressure builds in one or both carolid sinuses.

(ANATOMIC SCIENCES

Which of the following branches of the internal carotid artery Is most frequently lmpllcutcd in a stroke?

Ophthalmic ancry Anterior choroidal Middle cerebral Anterior cho,oidal

25
31 Cop)TigbtO 2009-2010 Dtntal Decb

(ANATOMIC SCIENCES

r
\..

All of the following statements arc true regarding hepatic sinusolds In ""'J comparison to capillaries EXCEPT one. Which one Is the EXCEPTION? ~

Sinusoids are smaller than capillaries Sinusoids have walls that consist mainly of phagocytic cells Sinusoids are n pan of the reticuloendothelial system Both s inusoids and capillaries are composed of endothelium

44 Copyrip. 0 2009-1010 ~~~ Derls

\ l iddlo cenhral

The middle cerebral artery is the largest branch of the internal carotid. The artery supplies a portion of the frontal lobe and the lateral surf.1ce of the temporal and parietal lobes, including the primary motor and sensory areas of the face, throat, hand, and arm and in the dominant hemisphere, the areas for speech. The middle cerebral artery is the artery most often occluded in stroke. Small, deep penetrating arteries known as the lenticuJostriate arteries branch from the middle cerebral artery. These arteries are often called the "arteries of stroke" because they are often involved in a Stroke (also called a cerebrovascular accident).

Stroke warning signs:

Sudden weakness, paralysis. or numbness of the face, arm, and leg on one or both sides of the body Loss of speech or difficulty speaking or understanding speech Dimness or loss of vision, particularly in only one eye Unexplained di7.ziness (especially wlten associated with other neurologic symptoms). unsteadiness, and sudden falls Sudden severe headache and loss of consciousness

Sinusoid\ an smalh.r than

c~1pillaries

A sinusoid is a small blood vessel similar to a capillary but with a discontinuous endothelium. Sinusoids are found in the liver, lymphoid tissue. endocrine organs, and hematopoietic organs such as tbe bone marrow and the spleen. Sinusoids are bigWy permeable, having larger inter-cellular clefts, fewer tight junctions, and discontinuous endothelial cells (meani11g that the individual endothelial cells do not overlap as in capillaries and are spread out). The level of permeability is such as to allow small- and medium-sized proteins such as albumin to enter and leave the bloodstream. Some spaces are large enough for blood cells to pass. Oxygen, carbon dioxide, nutrients, proteins, and wastes are exchanged througb the thin walls of the sinusoids. Sinusoids: Are 30 to 40 microns in diameter Are wlder and more irregular than capillaries Have walls that consist largely of phagocytic cells Form a pan of the reticuloeodothetial system, which is concerned chiefly with phagocytosis and antibody formation

cA.t.~ATOMIC SCIENCES
The most prominent fu nctional component in the tunica media of large arteries is the:

Skeletal muscle cells Elastic fibers Smooth muscle cells Collagen fibers

27
CopyrigtllC 20092010 Onltal ~ks

(ANATOMIC SCIENCES

(
\..
Arteries

No tunica media or adventitia is present In which type of blood vessel that exchanges subslanccs via diffusion?

Arterioles Capillaries Venules

Veins

Copynpt 0 20091010 Omtall>e<'b

 Key: If the question referred to small arteries, the answer would have been smooth muscle cells. Tbe walls of blood vessels are composed of the following tunics (layers): I. Tunica intima - iru~cnnost layer, consists of a layer of simple squamous epithelium (called endotheli11m) and a thin connective-tissue basement membrane. TI1e endothelium ofthis layer is the only layer present in vessels of all sizes. Note: Atherosclerosis is tbe emergence of plaque between the basement membmne and the endothelial ceUs of the tunica intima. 2. Tunica media - middle layer, is usually very thick in arteries, and consists of smooth muscle fibers mixed with elastic fibers. Increases or decreases lumen diameter; afl'ects blood pres.wre. 3. Thnica adventitia -an outer layer of connective tissue, containing elastic and collagenous tibers. The tunica adventitia of the larger vessels is iofiltmted with a system of tiny blood vessels called vasa vasorum ("vessels of the vessels 'J that nourish the more external tissues of the blood vessel wall. Blood is carried away from the heart in large vessels called arteries. These d[vide into smaller arteries, and the smaller arteries divide into arterioles. Arterioles divide into microscopic capillaries (the exchange area of the 'J''tem). The capillaries converge to form vessels called venulcs, which join to form stiU larger vessels called veins. Veins return the blood to the bean.

C:tpillarics

Blood is carried away f'l'Om the heart io large vessels called arteries. These divide imo smaller arteries, aod the smaller arteries divide into arterioles. Arterioles divide into microscopic capillaries (the exchange area of the system). The capillaries converge to form vessels called vcnnlcs, which join to form still larger vessels called veins. Veins return the blood to the heart. Through capillary walls, which consist of a single layer of endothelial cells, blood and tissue cells eJchange gases and metabolites. Capillaries are tiny blood ' 'essels wid1 extremely thin walls that consist of endothelium only; oo tunica media or adventitia is present. They join arterioles and veoules. These blood ves.~cls aocommodate erythrocytes one at a time. In certain structures (liver. spleen, bo11e man-ow. and certain glands). tbe arterioles. rather than connecting with capillaries, empty into blood vessels called sinusoids. They have very, very thin walls that conform to the space in which they are located (form imzgular tortuous tubes).

~Notes 2. A decrease in vessel diameter causes an increase in resistance to blood flow.

- - I. The velocity or blood flow is slowest in capillaries.

(ANATOMIC SCIENCES

Which artery supplies the liver with o:o:ygenated blood?

Common carotid artery Portal artery Hepatic artery Splanchnic artery

28
43
CopyrigbtiO 2009-2010 Dent~! Deck$

(ANATOMIC SCIENCES

A r t)

The greatest drop in blood pressure is seen at the transition from:

Arterioles to capillaries Arteries to arterioles Capillaries to venules Venules to veins

Copyrijbt 0 2009-2010 Dental Qe.cks

lllpatic arh.n - ad\1.'\ frum Ull' rumnwn ht'll.tlir. \\hich. in Iurn.

lhL rdi.u- tntnlo..

j,

a hr.uu.h n l

The hepatic artery brings oxygenated blood to the liver, wbile the hepatic portal vein brings food-laden blood from the abdominal viscera. Note: The hepatic porinl vein is formed by the union of the s uperior mesenteric vein and the splenic vein. Remember: All the blood supplied to the liver from the hepatic arteries and the portal vein eventually drains via the hepatic veins to the Inferior vena cava. Important: The most unusual aspect or hepatic circulation is that all the blood supplied to the liver from the hepatic anerics and the portal vein empties into the same siousoids (minute endotlrelial-lined passage...-ays In the liver lobules). wbicb therefore eonLain a mixture of arterial and venous blood. The sinusoids of each lobule empty into a common central win. The common central vein of each lobule then empties into one oftbrce hepatic veins. These veins all empty into the Inferior \'ena cava, which transportS the blood to the heart.

Important: The highest pressure of circulating blood is found in arteries. and gradually drops as the blood flows through the arterioles, capillaries, veoules, and veons (wh""' it is the lowest). The greatest drop in blood pressure occurs at the traositton from aneries to arterioles. Arterioles are one of the blood vessels of the smallest branch of the arterial circulation. Blood flowing from the heart is pumped by the lei\ ventricle to the aot1a (hugest nrte1y), which in tum branches into smaller arteries and (in ally into arterioles. The blood continues to flow through these arterioles into capillaries, venules, and fmally veins, which return the blood to the heart. Arterioles have a ery small diameter (<0.5 mm). a small lumen, and a relatively thick tunica medla that is composed almost entirely of s mooth muscle, with linle clastic tissue. Jhls smooth muscle constricts and dilates in response to neurochemical stimuli, wbicb in tum changes the diameter of the arterioles. This causes profound and rapid changes in peripheral r esistance. Tbis change in diumetcr of the arterioles regulates the flow or blood into the capillaries. Note: By affecting peripheral resistance, arterioles directly uffcct arterial blood pressure.

(ANATOMIC SCIENCES

Which of the following salivary glands does the facial artery supply?

Sublingual Submandibular Von Ebner's

Parotid

Copyrighl e 20092010 Dental Db

..

(ANATOMIC SCIENCES

'\..

Which arter y does not accompany tbc corresponding nerve throughout its course?

Inferior al veolar anery Posterior superior alveolar artery Lingual anery Infraorbital anery

46
Copyrijh! 0 20092010 Dental Oks

'\uhm anll i hu l.t r

The facial artery supplies blood to the face, tonsils. palate, labial glands, and muscles of the lips. The facial artery also supplies the s ubmandibular gland, the ala and dorsum of the nose, and the musdes or facial expression. The facial anery originates in the uternal rarotid anery and gives off branches that supply the neck and face. Branches of the facial artery (cenical and facial porrlofl) include: Cervical ponion: TonsiUar- to the tonsils Ascending pharyngeal - 1 0 tbe pharyngeal wall Glandular- to the submandibular gland Submental - to the area below the chin Facial portion: Inferior labial- to the lower lip Superior labial - to the upper hp and vestibule of nose Lateral nasal - to the lateral wall of the nose (outer side) Angular- to the medial stde of the eye. It is the tenminal branch of the facoal anery and can anastomose with the dorsal nasal branch of the ophthalmic anery. Remember: The two terminal branches of the external carotid artery are the ;uperficialtemporal anery and the maxillary artery.

I tn:.:ual artl'n

The lingual artery arises from the anterior surface of the external carotid artery, oppo site the rip of the greater cornu of the byotd bone. The lingual anery loops upward and then passes deep to the posterior border of the hyoglossus muscle 10 enter the submandibular region. The loop is crossed superficially by the hypoglossal nerve. The loop supplies blood to the tongue. suprahyood region. sublingual gland. palaune tonsils, and tloor of the mouth. Important: In the oral region, the lingual onery usually is found between tbe hyoglossus and genioglossus muscles.
Jtd Branches of the lingual artery include the suprahyoid, dorsal Iingual, sublingual, B deep lingual bmncbes.

Note: The Inferior alveolar vein, artery, nnd nerve along with the Ungual nerve are fom1d in the space between the medial pterygoid muscle and the ramus of the mandible (preT}gomUfldibular space). Important: The injection site for the Inferior alveolar oene block is probed with a cotton tip applicator at the depth of the pterygomandibular space on the medial surface of the ramus. The needle is inserted into the tissues of the pterygomandibular space until the mandible is contacted. The needle is withdrawn 1 mm from the tissues 10 protect the periosteum, and then the injection is administered.

( ANATOMIC SCIENCES

ln the KR, a car-accident victim who hit his face on the steering wheel arrives bleeding profusely from the mouth and nose. Upon examination, the physician discovers that along with avulsed teeth, his bard palate is fractured and the Incisive foramen is obliterated. Which artery emerges from the lncbive foramen?

Greater palatine nnery Descending palatine anery Nasopalatine anery Lesser palatine ancry

30
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Copyrigllt C 20092010 Dental l)tot:b

( ANATOMIC SCIENCES

Examination of a patient with an ulcerative carcinoma of the posterior third of the tongue revealed bleeding from the lesion and difficulty swallowing (dysphagia). The bleeding was seen to be arterial; which of the following arteries was involved?

Deep lingual artery Dorsal lingual anery Tonsillar anery Sublingual llncry

Copynpt Cl 2009-2010 Otftt.al Dks

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3J

'\;;.Pmpalatine

artr1-~

ln the pterygopalatine fossa, the maxillary artery gives rise to the descenrung palatine artery, which travels to the palate through the pterygopalatine canal, which then terminates in both the greater palatlne artery and lesser palatine artery by way of the greater and lesser palatine forrnamina to supply the bard and soft palates, respectively. The maxillary artery ends by becoming the sphenopalatine artery, which supplies the nasal cavity. The sphenopalatine artery gives rise to the posterior lateral nasal branches and septal branches, including a nasopalatine branch that accompanies the nasopala\ine nerve through the incisive foramen on lhe maxilla.
---. I . The greater palatine artery supplies the mucosa of lhe hard palate posteri1 Nut..

or to the maxillary canine. 2. Mucosa of the hard palate anterior to the maxillary canine is supplied by the nasopalatine artery. 3. The soft palate and tonsils are supplied by the lesser palatine artery.

***The dorsal Ungual artery runs on the superficial surface of the tongue it is a branch of the lingual artery that delivers blood to the posterior superficial tongue. So, this anery must be the source of the hemorrhage.

The tongue is supplied by the lingual anery, the tonsillar branch of the facial artery, and the ascending pharyngeal artery. The veins drain into the internal jugular vein. The lingual artery arises from the external carotid artery at the level of the tip of the greater hom of the hyoid bone in the carotid triangle. Branches include: dorsal lingual: supplies the base and body of the tongue (posterior superficial tongue) suprahyoid: supplies the suprahyoid mt1sdes sublingual: supplies d1e Jllylohyoid muscle, sublingual salivary gland, and mucous membrnnes of !he floor of the mouth deep Ungual (renninal branch): supplies the apex oftbe tongue Remember (infonnaJion about the rongue): I. Motor innervation is from the hypoglossal nerve (CN Xll). 2. Sensory innervation - lingual (branch of trigeminal CN V-3) supplies the anterior twolbitds, glossopharyngeal (CN JX) supplies the posterior one-third (including vallate papillae), vagus (CN X) tluoogh the Jnternal laryngeal nerve supplies the area near the c'Piglottis. 3. Taste- racial (CN VII) via chorda tympani supplies the anterior two-thirds: glos-<opharyngeal (CN IX) supplies the posterior one-third. I. The tonsiUar artery is a brnneh of the fucial anery that also supplies blond to the INot.. palatine tonsil. 2. The ascending pharyngeal artery is the smallest brnncb of the external carotid anel)'. Branches include the pharyngeal and meningeal arteries. 3. ne lingual anery and fucial artery often arise from a cotnmon trunk of!he external carotid artery.

(ANATOMIC

SCIE~CES

'

Which branch of the maxillary artery runs through the foramen splnosum ) lo. and is implicated in epidu ral hematomas? ~

Inferior alveolar artery

Middle meningeal artery

lnfraorbilal artery

Deep temporal artery

32
o
Copyrigbl C 201-1010 Dttnal r:>rctkt

(ANATOMIC SCIENCES

After a large Thanksgiving dinner, the traditional American family notices that they all arc drowsy. The "food coma" Is a res ult of oxygenated blood being restricted from tbe brain and being shunted to the stomach in order for digestion. All of the arteries that s upply arc derived directly or 1o. indirectly from the:

Splenic artery

Hepatic artery
Gastroduodenal artery

Celiac trunk (artery)

33
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Cop). c 2-2010 Dcmol "'"'"'

\liddll' 111l'llllll!l al :.trhn

The maxillary artery 1s the larger tennm.al branch of the eAtemal carotid artery h begins at the neck of the mandibular condyle within the parotid gland. The m::llulhuy artery runs betwoen the m;mdible and the sphenomandibular ligament anteriorly and superiorly through the infratemporal fossa. After traversing the infratemporal fossa, the ma>tillary artery enters the pterygopalatine fossa. Within the iufnuem poral and pterygopalatine fossae, the miL"IIury nrtcry gives off many branches. Branches in the blfratcmporul fos'"': Inferior ahl'Oinr artery: follows lhc inferior nlveolar nerve into tb mandibular canal and supplies tissues uf the chin and lower teeth Middle ownlngul art<l"): an importlllltanery that passes upwanl behind the mandibular ner\"e. The: ~ the sk\111 1hro11gh the foram:n spinosum. This artery supplits the meningl:$ within the skull. Note: Damage =Uts in an epidural bema.IOIJla. Small branches ~lllt supply the lining of the O.'le1nal auditory meatuS and the tympanic membrane Numerous small mu.<eular branches that supply the muscles of mastication Bnmcbcs in lhe ptcrygopalntlnc fossa: Posterior superior ah eolar artery: supplic.' th~ maxillary sinus aud the molar unll pre molar teeth Infraorbital ortcry: c'!lk'I"S the mbitnl cavity through the mfcrior otbitnl tissurc Grtattr p:tlatlne ortery: supplies the mucosa of the hard palate posterior to the ma.~tll

ary canine Pharyngeal broncb: supplies the mucou.~ mcmbr.u~e of the tool of the nawph:lrynx Sphenopalatine artery: supplies the mucous membrane of the nasal caVIty, It IS the tenrunal branch of the m8ltillary artery. Note: Damage results in cpist8ltis (noubletd) Note: The taterol pterygoid muscle dtvidetl tl!C maxillary artery into three sections: the mandibuiQr, pterygoid, and pterygopalatine.

All of the arteries that supply the stomacb are denved directly or indi~ctly from the celiac trunk (cellae artery~. The celiac artery takes its ongin from the abdominal aorta jtL<t below the diaphragm at about the le>el of the twelfth thorcic venebr:L It is the artt't)' that supplies the foreguL Tbe celiac artery is surrounded by the cellae plexus and lies behind the lc:.<~er sac ()(peritoneum. Tbe celiac llrtery has three terminul branches: the splenic, lef\ gust ric, and hepatic ancrics, Splenic artery -to the spleeu I. t..:ft gustrocplplolc: arises from ~-plemc nrtery at the hilum of the spleen to supply ihe greater curvuwre of stomacb. 2. Sbort gtlStr!cs: arise from we splenic artery at the hilwll of the. spleen lO supply the fundus of stomach. Lei! g11>'tric: artery -un~ from the celiac artery to supply the les,serL-urvature of stomach and the lower tlurd of the esopb<lgus. Hepatic artery - 10 the liver 1. Right hepatic artery - to right lobe of Uver. cystic urtery url_<es from right hepatic nnery to supply the gn11bl~ddcr.
2. l..en hepatic artery -- to left. lobe of liver. rtgbt gastric artery - arises from the hepatic artery a! the tipper borde-r or the pyloniS to supply the lesser curvature of stomach. gostroduodeuol artery - large brunch of hepatic artery that lillpplie> the p.1DCre:!S

and duodenum
rlgbt gostrocpiplnic artery: supplies gte.1ter curvature of the stomacb. sup<rlor pa.uc,..,.tiroduodcnal artery: supplies tbe upper half of the duodenum

(ANATOMIC SCIENCES

(
\.

The internal thoracic artery ends in the sixth intercostal space by dividing Into the:

Anterior and posterior intercostal aneries Subclavian and inferior epigastric aneries Superior epigastric and musculophrenic arteries

34
51
Copyright 0 20092010 Dtntal Decks

( ANATOMIC SCIENCES

( Tbe abdominal aorta terminates by dividing into the common iliac arteries"") \.. and the middle sacral artery at what vertebral level? ~

TIO

LS

The internal thoracic artery supplies the anterior "aU of the body from the clavicle to the umbilicus. his branch of the first part of the subclavtan anel)' io the neck. This artery descends venically oo the pleura behind ~lt costal cartilages, just lateral to the sternum, and ends in tho sixth intercostal space by dividing into !he sup~rlor eplgnstrlc and mnsculophrenlc artHies. Branche. of the internal thoracic artery tnclude: Two a.n terlor lntercu~tul arteries for the upper six intercostal spaces Perrorallng arteriH. whi~h accompany the tcrmianl branches of lbc corre,pondmg intercostal nerves The perlcardlaeophrenic artery. which accompanies the phrenic nerve and sup plies the ptrlcardtum Mediast;nal arteries to the contents of the anterior medlastinum, for example, the thymus gland Th~ superior CtlljlslStric artery, which eutcrs t.he rectus shealb and supplies the rectus muscle as f11r a~ the umbilicus 11 musculophrenic artery, which runs around tbe costal ruargiu oflhe diaphragm end supplic.~ 1he lower intercostal spaces and the diaphragm Note: The inferior epigastric artery, a branch oft.he eternal ilia~ artery, anastomoses with lhe supmor epigastric artery in the rectus sheath m lhe area of the umbilicus.

aorta a series of ves.el< th:lt convey the 10 li$sues or lbe body for th<ir nutrition. The :wna commences at the upper p.on of the !eli ventricle, aDd after a.c<nding for a shon cbSIBDCC. ar~hes bru:ltward and to the left s1de. O>tr the root of lbe left lung; the aona chen de;cend; wuhm the thorax on the left side of the ven.ebral column. passes into the abdominal Cllvlly through the aonic openns o{' the diaphragm in front of the twelfth thoracic venebm. The aorta descends behtnd lhe periconeum on the ancerior surface of the bodic.< nf the lumbnr vertebrae. Attbe level ~f che fourlb lwnbar vertebrn, the aona divides into the two eomnwu U1:1e arteries. Note: The ebaractcrlsllc future of the aorta is that it contn1ns a lot or elastic lib~rs In Its tunic media (middle Ioyer ofhloC<I esse/ wall). Anatomically, tbc aonu is craditionally dividtd into the ~~.<tending aonn, the aonie arch. and the descending aorta The descending aona is. m tum. Jubdivid<d into the thoracic OOrtll (rhut descends wirhm tl1e chesr) and the abdommal aono (rhar de.rcends within rht abdOIIItn/. Ascending aorta: a >bon 'esscllhat starts at the aortic opening of the left ventricle. Tbe ascending aorta's only bnmcbes are tbe right and leO coronary arteries. which supply the lleart mu.,.le. Aortit arch: g1ves rise to three arterial brunches: cbe bruchioccphallc, the lcfl common taroUd, and the left subclavian. TI1ese arteries fumish all of the bl~od to the hcntl, oi!Ck, and upper limb~. Descending norta: l'horclc portion: extends from T4 to Tl2 (lies in rhe posterior mNiia$1/num). All of the arterial branches (posterior mten:ostal. subco.ua/ arteries) from thiS 11art are small. They supply lbe lhora. and the cbaphrasm. Abdominal portion: extends from Tl2to L4. where the descending aON ttm>lnates by dl>idinc mto the two common tuac arteries and a small middle sacralnery. Arteries from thiS area supply tbe abdomen and pel vi~ N:gion as well as the lo-.er limbs.

GNATOMIC SCIENCES

As a result of curiosity, a 2-year-old boy decides to stick a sharp object up his nose and causes a nosebleed (epi.vraxls) of the anteroinferior portion of the nasal septum. This bleeding in volves the septal branches of the:

""''

Ophthalmic and occipital aneries Sphenopalatine and facial aneries Frontal and parietal arteries Pharyngeal and meningeal arteries

53 CopyrigbtC 2009-2010 Drntal Del:b

(ANATOMIC SCIENCES

Tbe upper half of the duodenum Is supplied by the , a bra nch of the gastroduodenal artery. The lower half of the duodenum is s upplied by the _ _ __ _, a branch of the superior mesenteric artery.

Superior pancreaticoduodenal anery; inferior pancreaticoduodenal ancry Inferior pancreaticoduodenal anery; superior pancrealicoduodenal anery Superior renal artery; inferior renal artery Inferior renal artery; superior renal artery

54

Cop)'n.&bt C :oo9.20 I0 Dm1.al Db

The anerial blood supply to lito nasal cavity is derived mainly from br.mches of the mulllry o.rtery. The most unponant btanch is the spbcnoralallnc artery, which enters tlte nasal cavity through the sphenop!tlati.ttc fommeu. The sphenopnlutlnc artery anastomoses with the septol brunch urlhe superior labial branch of the fnclul artery in the rcgioo of tbe vestibule, which i> a very common site of bkeding from the nose. Rrmtmber: The sphenop:tlntine an<ry IS the terminal braocb or the maxillary ortery. Other small 1111eries that upply blood to the nasal caVIty mel ode: The descenruog palollne bmnch of the maxillary artery The sup~rior labial brnnch oflhc facial anery The posterior ethrnnldal bmuch sud auterlor ethmoidal branch of the ophthnlmic uncry
Remember: I. The opbtbalmk art~ry is a branch of the internal carotid artery. 2 The nuuillary arter) is On< of the temunal an~nes of the external carotid. The other termina11111cry of the external Clln)tid as tbe s uperftciJI11mponl artery. 3. The prer)gopalaline fossa is o cone-shaped pnired d<pr.,;.<lon deep 10 tlte infra. temporal fossa. 11te ptcrygopalatioe fossa located between lite pterygoid process and the m~~>tiUary tuberosity, close to the apex of the orbit. This fossa coma ius Lbe moxillary arrery ~nd nerve and their branches ariSing ~ere. including the lnhorbitnl and sphenopolotme orteries, the mrutiUary division of the trigeminal nerve nud bl'llrlch.,., and the pterygopalaune ganglion The pterygopalatine fossa rollllllunlcte\ la1e111lly wtth the lnfratmtporal fc,.satluougb tbe pter) gumuillar~ lissu.re. medially with the MS.l cavity thcongb lh >llhruoplllaline foramen, superiorly with the ~kull tltrough the forooneu rotundunt, and anteriorly with tbe orbit through tbe lnl'erlor orblrnl

liNsurc.
Sulh.'l iur p:lncr~JihoclniHh.nu l arfcr); inlt.'IIUI panln."Hiicuduu<hm:II:Jrh.r)

The ortenal supply of the jejunum ;md ileum 15 from branches of the uprrior mesrnlerlt artery. The intesunal branches anse from the len side oftlt~ anery ond runm tbe mesentery to rench tbe gut They !lllastomose 1Vt1lt one another to limn series of orcndcs. The lowc~t purl of the ileum is alsu suppUed by the ileocolic IIJ'tery. Tite htrgc Intestine extcutls from the ileum to the UJiliS. The large um.'!lttne is divided into tbe cec11m. the appendix. the uscendiog colon. the tratJ.Werse colon. the dt'Seending colo~ nnd tbe stgmoid colon The blood su(tftly 10 wcse areas is "l> folloWl': Cecum: the arterial blood supply is from tltc arttenor and poterior cecal anerie.. wluch are bronches of the tleocolic artery, a branch of the supenor mesenteric artery Ap)lt!ndlt: tbe ancml supply is by means of the appendicular anery, a branch of the poMerior coC1lllll'1cry A~ccoding colon: the nrterial blood sap1ly is front the ileocolic mtd right colic bmuches of the "''Jlcrior mesenteric artery Transverse colon: the tlrterial blood supply of the proximal two-third~ is from llte middle colic artery. a br.tnch of the superior mesenteric artery. The dtstnllhiro is sllpplted by th~ left cuhc artery. 3 bmncn of the mfenor mesmteric anery Orscending colon: the ancri11l blood supply i' fmm the left cohc ami <i!mlOid bmncbc., of the inferior me.~enk'ric artery Sigmoid colon: llle anerin1 blood supply is from the sigmoid brunches of the infonor mesenteric artery Note: Tbe rtetial blood supply to the rectum is from the superior. middle, Ulld inferior recwl arteries. Tbe superior rectal artery is a dln.-ct continuation of the inferior mesenteric artery. rbe middle rectal artety is a &mall branch of the mtemal tlioc anery. The infenor rectal onery !< 3 branch oftbe internal pudendal artery in the perineum. Theartcnal blood sopplyto the ~nus (anal canalj is from the superior Md infenor rectal aneries.

(ANATOMIC SCIENCES

(
\..

The left subcla\'ian, left carotid, and brchiocepbalk artery arc branches of the:

External carotid artery Celiac artery Aortic arch Common iliac artery

55 Cop)Tif,ht 0 2009-2010 ~nul Otcb

cA.l~ATOMIC SCIENCES
(Anof the following statements concerning the common carotid arteries are tr.;:J
\_ EXCEPT one. Wbitb one is the EXCEPTION?

The common carotid arteries are the same in length The common carotid arteries differ in their mode of origin The right common carotid artery begins at the bifurcation of the innominate artery (brachiocepha/lc artery) behind the sternoclavicular joint and is confined tO the neck The left common carotid artery originates from the highest part of the arch of the aorta in the superior mediastinum and consists of a thoracic and a cervical portion

36
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58 201-2010 ,_..

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-\urtic an:-h

The arclJ or the aorta is a continuation or the a.<~eending aun.a. The aorttc arch lies behind the mrutubrium Slemi and an:bcs upward, backward. and to the leO on front of the trachea (its mam tlil'f!ction is bacAwarrl). lt then passes downward to the leO of t.he tra chea, and at tbe level of the sternal angle become continuous with tbe dese~:oding nona. Branches include: The brachloccphalic artery is an extremely shon nncry and is the first bronch from lbe aortic arch . Thts artery passes upward and to the rigbluf tho trachea and divides into the right common carotid and right !ubclavian arterie! behind the right sternoclavicular joinl Remember: There are two (right ami l~fi) bmcluocephalic vein$ but only one bmchiocephalic anery. The left com mon ca rotid artery arise! from the convex surface of the aonc arch on the left side of the brachiocephalic anery. The left common carotid artery runs upward and to the leO of the trachea und enters the neck behind the lei\ stcnllx:lavicular joint. The left subclavia n orlery arises from lhu aortic arch behind the ld\ common carotid artery. The left subclavian artery runs upward along dte left side of the trachea and the esophagus to enter the root of the neck. Titis artery lll'chcs over the upex of the left lung. lmporlant: I. The upper limbs on: supplied by tb~ subdavlao ar1eries (both right and left). 2. The head a nd neck nre supplied by lhe right nod lefl common carotid a rteries.

llh ~numuu

nsruthlarltrit~

are lhl ,uun 111 hu1,!1h

The major :utene> that supply the head and ne.:k are the common urotid and <uhctin arttriH. The on&in> from the bean of the rommU1'1 caroud and subclavtan anem-. thot i uppl} the beod and noc:k arc dtiTm:nt for the right and leO 01de! of the body For the right <ldt uf th< t..xly. the COilUl\on <arolid and sobclavtan ancnes are both branches from the bnachloc<phatk artrry. The brachioe<:phohc ane.y i< a direct brnnch ofthc Horta.
The common carocid arttry is branchless and trav..:l!t up Ihe neck. lalerolto the trachea ond lar)'1\>(, to the upper ltrdcr of the thyroid cartilage. The common carotid artory tra,el in o sheath deep lo the stemocleidomnstoid muscle. This shcnlh nl).o contains the intero:ll jugulor v~lll and the vagu51 11l'rve 1l1e common carotid arte1y cntl!' by dividing into the internal und external carotld art<rlts at about the level of the larynx. The lntornat torortd has no branches m the neck T~e internal carotid'sbronchc supply the structu~.s ln~ldt th~ cranial cavity. The intcmal carotid gaves rise to the ophthalmic artfl')~ the nta)or blood >upply of the orbit and c}c. that cnters the urbil fhmllgh the Opllt foramen (can.>/) "'tth abe op<ie nenc. The inl<'mal comlld ends by dividing onto the onrer1or and middle <erebral art<rie that eontrib<nc to the gno~~t ccrc:bntt circle (of lf!i/l~r). The <~ttmol carotid has eight branches thOI mainlY >UJ'PIY he;ut >tructures outside the c"'nial cavity. 'llte brunch<! arc as follow>: Anterior branehu: Posterior branches: I. Suporior thyroid llr1CI)' I. Ailcending pharyngcal urtcty 2. Lingual arkry 2. Occipital artery ) , Facial artery 1, Posterior auricular ancry 4. Maxillary artery 4. Superficial temporal artery

l'he subclavian oner) mcs latemlto the common caro1id anery. The subcla>tiJ\ 11'1<1') am:$ ofT branches 10 wpply both mu11creoiot al1<l exlr.lcruniJ >tructllr'eS, but its majot dcsuoauon is th<
uppef extm~~ny (~rm)

an~

Remtmbr: On d.. lft Ide of the body, the len cummon carotid and lefi suhclovaan artcnes from the erc:h of thf aorta m the supa{or n1cdhblinlll11.

(ANATOMIC SCIENCES

\,.

Which artery suppUes the muscles of mastication, the maxillary and mandibular teeth, the palate, and almost all of the nasal cavity?

Mandibular artery
Subclavian artery

Venebral anery Maxillary ancry

57
CopyriJVrl 0 2~2010 l)cnlal Ord:t

( ANATOMIC SCIENCES

a n)

'A

collision during a basketball game left the point guard seeing double. The"' on-cou rt physician determined that the paper-thin wall that holds up the eye had collapsed and the right eye now sat lower than it should hove, thus \..causing the diplopia. Name the proj ection of the ethmoid bone that collapsed:_,

Cribriform plate

Crista galli
Ethmoid sinus
Lamina papymcen

37,38

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~~It:.)

\ r hn.rl'nJ~ h

_ -

uftl11 \ 1,.\lll:.tr \ and

\bnd th ~r l:. r

l t-.:lh

............,

..., .... . .
.

Coon<

On nwtol bnoclld 6e1 bm pk.uft. to~ k fii.Ll.JI.

Alllmlr~ tlft!Oiat Mlllk!lc ~ 'collr Patitctlllt io~ipeotlra1,N!. Or'C1 nsc .. l brafteb that f~JW~ 01 mtad:ibwlar lf'th

I~trmor al\ eolu-

M"mllJ)ITftlll

A..-mor supcrlor ab'COiar

l~tr.I1KWbi~.al a11~

1\ rl~''' 11ftcr the mftaortll1;(1anny passes lhrou.gb the. rnftnl'f

octll lalli~~"' and

(orlh'- maxillary anery)

ill!O th< inhodliull canal S.MI!Iatld the n:enor l'ft'l.h

OtttfiHh v1111he' ah'eOillrcmul$ ;o surply pen orthc mull-

lney anlh
Svp(~ lH thCI max:illa1Y

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tr prf<4tec. antes t'r!!m tllc- iriiRorbiul arwry o( rbc nw:tllll')' cnay 11't<1 it pustSihNIIgh the mfcrinr orbital fiSJW.re U.S 111W

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lhc: CUll .,..,...... ..,. tht Ill\'COW caoals co supply llw "~ tltlw. aQd cbc: p~ ac die c:aaa:
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[ au.n ~ ialil~ $11dxe orb rAWIIII1JIIIIIIf k

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T.-nn.llft tmQ the mmta.1 *1MS ioctSi>.'e llOitllb a~ !lit !"t$1CJII s._pplloh &II or>bt maodibula: l<h

l11ffri(or al~lar ~'~'>'

lnfcrior aJV(OIIIf ll'l.r)'

Suprlld tbe lat'tlaf llQJI~ or the an.ltrlor k'tt.h

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ll.lp~ ral'l'a

Fitting together lO form a prote<:tive shell.lhe sk\tllos composed of paired bone> on each so de. ond unpaired bones running through it. modline. The seven unpaired bones are the front!. 1hmood. occipital, sphenoid, mandible, vomer. and hyoid bones. The 10 paired bones are the temporal bones, oncluding the tiny moddlc ..r bones (oulcl.s) of the malleus. incus- and suopes (hommPr on.-il. and stirrup). parietal, lacnmal. na$al. eygomatic, palatine, aud maxill:uy bones. The ttbmoid bone is exceedingly hgbt and sponl!). and cubical in shape: this bone ;, ituatcd at the anlaior pan of the base of the cranoum. betwc:en the two orbits. at the roof of tbe nose. and contributes to each of these ca'"ties. Tbe cthmood bone consists of four parts: a borlwntol or erlbriform plate, forming part of the base of the cronium; a perl"'ndicular plate, conslltutong part of the nasal ~tum; and two lateral msses or labyrinths. Cribriform plat@': C<mtaios many olroetory rommina. The otraolory ocrves pass lhrou"-h thc!le forumina. Note: Damage Co !Ius nrca typically rosulcs in cbe loss of sense ol' smell. icrpendicular p_ l att>: The trl.stu goUI is u nudllnc: projec1ion from the pcrpendiculnr l>ll'IIC that serves as an auachmcnt for chc falx cerebrl. Lateral masses (right and 1/1) prOJOCI downward from the cribrifom1 plate. They contnin the ctbmoid sinuses and the orbital plate Of the C lhmold bone (lamina pap)~D<'ea), The lamina popyracea form:. the paper-dun medial wall or the orboi. The 5Uperior and middle naul conchae are scroll-like projections that extend medially from the lacernl mass<: ioto ttl< o3>0I cavity.
I Each etbmoodal inus IS dtvoded onto anteriO<. middle, and posterior cthmotdal aor NorH cdls. 2 The superior wall or roof or the orbll is formed almost completely by the ort>otal plate or the frontal bone. POSienorly. the supenor wallos fanned by the lesM:r wing of the sphenoid bone.

(ANATOM IC SCIENCES

nn)

All siJitements concerning the sphenoid bo ne are true EXCEPT one. Which one is the EXCEPTION?

The greater wing of the sphenoid bone fonns the lateral wall of the orbit and the roof of the infratemporal fossa The lesser wing of the sphenoid bone contains the optic canal (optic foramen) and helps form the superior orbital fissure and roof of the orbit
The medial pterygoid plates of the sphenoid bone provide attachment sites for two

muscles of mastication Foramina within the greater wing of the sphenoid bone provide access to both the pterygopalatine and infratemporal fossa The body of the sphenoid bone contains the sella turcica and the sphenoidal sinuses
59 CopyriJllt o 2009-2010 Dtntl Db

39

( Al'IATOMIC SCIENCES

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)

Bone in the mandible develops by:

Endochondral ossification Subchondral ossification Intramembranous ossification Primary ossification

Thl' nu-<ti1 1l plln :,:nicJ piaU\ of lhl' 'Jlllt'ttnicl hnlll' pnt\ idl' allarhmlnt 'ih' fur t\\U mu'dl'' nf ma.. ri..'alinn

***This is falst. Rem ember: Tbe lateral pterygoid plate provides the origin for both lbe lutensl and the medial pterygoid muscles. The sphenoid bon e is situated at the base of the skull ht front of the tempornl nnd bosilor p~rt of the occlpirol bone. It somewhat resembles a bot wit.b its wings extended, ond is divided ioto n median portion or body, two great and two small win&> cxt.:nding outward ffom the sides of the body. and rwo pterygoid processes tbat project from the bone below. Hollow body: Conr.nns the sella turdc , which houses the pitui~ary gland and the sphenoidal sinus ... Greater " lngs: llelp tD fonn the lateral wall of the orbit aod the roof of the infratemporal fossa. Contain fo ra men rotundum : transmits maxillary nerve (V-1), fora men uvaJc: transmits mandibular nerve (V-J), and foram en spinosum: transmits the mlodlc meningeal vessels and nerves to Lhe tissues covering the brain. Lesser (.w~a/1) vings: Help to fot-m Ue roof of \he orbit and the superior Drbital fissure; cou\~iu the oplie canal {optic jilramen) that transmits the optic nerve (CN U) and ophthalmic artery. Pterygoid processts: One on either side. descend perpendicularly from the regions where tbe body and great wings unite. Each process con:<ists of a medial nnd o lateral plate, the upper parts of which are fused anteriorly; a enical sulcus. tile pterygopalatine !,'<OOve, descends on the front of the line of fusion.

l nlroJIII\' IIIhr.IIHHh

h"ificatiun

The first evidence of bone ossification (hone formation) occurs :uouod the e1ghth week of preoatal development. Bones de\'elop e1tht't' through endochondral osslnea!lon (going through 11 cartilat.>inous stage) or through intramembranous ossiOeatlon (foml ing difl!ct/y a.t botle). The distinction between endochondral and inlt3lllembranous formation rests on whether a C<Jrrilage model serns as the precursor of the bone (endoc/J0/1 dral oss!/lCalinJJ) or whet.ber the bone is formed by n simpler method, without the intervention of a cartllagc precursor (intramembra/lotL< wsificatlon).
Most boots are endoehondral, meaning that Jbey began as a hyaline carUJage model
before they ossify. This takes place within hyaline canilage. This type of ossification is

priocipslly responsible for tbe (ormatton of short und long bones. Bone replaces cartilage (ostcocy tes replace chondrocytes). 1hc bones of the extremities and those p:ms of the axial ~keleron that bear weight (e.g., ertcbroe) de>tlop by eodochondt31 ossification. The Oat bones of \he skull and face, tbe mandible, and the clnviclc develop by intTatnembrhnous ossiticnl"iou. It is so called becnu.' it takes place within membr-Jnes of connective tissue. Tho mandible and mxJJI" urc formed this way.Tltis process contributes to tbe growth of short bones and the thickening of long bones. Tbb process involves tbe tnlnsfomunion of osteoblasts tO ostcocytes. Remewb.r: Once bone is formed, 11 gro\\ S by appositional growtb (gro,..rh by aclclition ofnew layers 1>11 those previau.tly formed).

(ANATOMIC SCIENCES

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'During dlstalization of molars in bodily orthodontic movement, the alveolar"" bone distal to the tooth must resorb, and the alveolar bone mesial to the tooth must apposltlonally grow. In orthodontic movement, the alveolar bone Is being remodeled. This remodeling is a function of:

OsteoclasiS and osteoblasts Chondroblasts and osteoblasts Osteoblasts and osteocytes Choodrocytcs and osteocytes

81 CopynjbtO 2()(19.1010 Dmt.al Deck$

(ANATOMIC SCIENCES

B n)

(
\..

All are functions of the skeletal system EXCEPT one. Which one is the EXCEPTION?

Lymph filtration Mineral storage Suppon

Protection

Body movcmcm
Hemopoiesis

t2
Copynsf!tCI2009ZOIO Dmtel Db

OsteoclasiS are cells lhat brenk down and remove exhausted bone ussue. Osteoblasts bui ld new bone tissue tO replace this loss.
Osleobla~u are the princtpal bone-building cells; they synthesize coUagenous fibers and bone matrix. and promote mineralization during ossification. Once this has been accomplished. the osteoblasts. wbich are trapped in their own maui'l, develop mto ostrocytes that mainlllin lhe bone tissue.

I. Ostwblasts are derived from mesenchyme (fibroh/asts) and have a high

Nott RNA content nnd stoin intensely.

2. Osteoclasis (whlrh me derl\ed from srem ~ells in tile bone mam>w- the .rome ones that pl't)llllcc monocytes and macrophages) are large multinucleated cdls that contain lysosomcs and phagocytic vacuoles. Note: A llo,. sblp's lacuna is a small hoiiO\\ created on the bone surface by osteoclastic activity. 3. Osteoid is newly fonned organic bone matnx tbnt has not undergone calci fication. Important: Osteoid difTcrs from bone in that osteoid does not huvc a mineralized
matrix.

Remember: Bone is hard and resists compre;,sion because of !he mincrali7.ation of its extracellular mauix. When bone rnauix mineralizes, morganlc hydroxyapatite crystals (pr/manly calcium pho,tphare) an: deposited around the ~isting collagen fibrils. and the wa1er canteD! of the ntlltnX decreases. Bono deri'es its Oc>ttbility and tensile strength from its abundant collageu flbct1i.

I\ m11h t111r3liun

Functions of tbe skeleW system: Suppon: skeleton fonns a rigid framework to which are anacbed the soner tissue$ and organs or the body. rrotecllon: the skull :md vertebral column encloso the CNS; the rib cage protectS lito hean ,lungs, great vessel<, liver, and spleen; and the pelvic cavity supporrs the pelvlc

viseem.
Body movement: boo~ serve as anchoring att!Chment.s for most skeletal muscles. Ju Ibis capacity, the bones act as levers wilh the jomts functioning as pivots "hen muscles contract to cause body movement. Hemopoiesis: the 1\.-d bone tllJIITOW of an adult produces red blood cells, white blood cells, and platelets. Mineral storage: the inorgamc mauix of bone is composed primarily of the minerals calcoum and phosphorus. rhe-~c minerals giv~ bone its It!lidity and account for approximately two-thirds of the weight of bone. About 95% of the calcium and 900!. of th~ phosphorus within the body are deposited in the bcmes and teeth. Bone uists In two forms: Comraci(OI'JP"'II'>'tUasolld ma>s) and spongy ou::ont'<:llous bone. which consists of a brnnchong network of trnbeculac. lmponant: The initiation of bone monernlization involves the foUowing (I) I Joles or pores in collagen fibers. (2) Titc release of matrix vesicles by osteobla~ts. (3) Alkaline phosphatase activity in ostcoblosts and matrix vesicles. {4) The dcgrodGtion of matrix pyrophosphate to release an inorganic phosphate group. Fracture repair mvolves the following events: (1) Blood clot formation, (l) Bridging caUus formation, (3) Periosteal callus formation. and (4) New endocbondral bone fonnauon.

( ANATOMIC SCIENCES

so)

At the temporomandibular joint (TMJ), hinge movements occur between the: Condyle and anicular eminence Anicular disc and anicular eminence Condyle and articular disc Articular disc and articular cavity Condyle and aniculur cavity

&3 (op)'riibl 0 2009101 0 Denl&l Ocd:$

G NATOMIC SCI ENCES

B n)

'

A patient comes into tbe orthodontist's office as referred to by his general "' dentist. T he orthodontist notes tbe patient 's tongue thrusts and notes that early treatment could 11rcvent skeletal problems. Soft tissue development Is thought to encourage mandibular growth:

Upward and forward Upward and backward

Downward and forwa rd Downward and backward

( uiHh 1~: .md articular dJ"iC

The TMJ is a synovial joint with two nnicular ca' iti~-s. Each cavity is responsible for a dif ferent movement at the joinL An anicular dtsc sits between the condylar process of the mandible oo its inferior side and the mandibular fossa and anicular eminence oftbe temporal bone on the superior Side. ThiS disc dt' ides the joint into the two anicular caviues. Wlth one cavity acting as a hinge component and the other cavity senoing as a glidio~ component. The lo.-e.r pan of !he joint, between the condyle and the anicular disc. is the hinge component ofthe joint. Wben tbc joint moves, this hinge component of the joint mo'es tir5t, to initiate mandibular opening. The upper port of the joint, between the anicular disc and the mandibular fossa and anicular eminence of the temporal bone, creates the gliding com ponent. Owing joint movement, this gliding cavity moves after the binge component to tcr minate mandibular opening.
- I. The condyle of the mandible rests in the mandibular fossa (also calleclgleuoi<l Nott< fossa) of the temporal bone. The fossa articulates with the condyle of the mandible to fonn the TMJ. 2. The articular eminence fonns the antt rior boundary of the fossa and helps maintain th~ mandible in position. This area is the functional and anicular ponton oflheTh1J 3. Separaung the mandibular fO>Sa from the t)mpanic plate postcnorly t$ the squamotympanic !inure, tbrough the medial end of which (perrorympanlc fu Sllre) the chorda tympani cx.its from the tympanic cavity. 4. The concave area between the mandibular condyle and coronoid process IS the mandibular notch (nL<o known a.v rite coronoid norch). The mandibular notch
transmits arteries and nerves 10 the masseLer muscle.

5. .... lmport'nt: The posterior slope of this eminence is tined by fibrous con nctti\'e tissue.

The space between the jaws into which the teeth erupt is generally considered to be pro vided by g.rowth at the mandibulor cond) les (~-'peciolly rhe molars). The condyle ts a major site of growth. Many arguments have been made about condyle function m mandibular growth. Most authoritic:. agree tbnt soft-tissue denlopment cames the mandible fonvard and downward, wbile condylar growth fills in the resultant space to maintain contact with the base of the skull. The bone of the alveolar process u ists only to suppon the teeth.lfa tooth fails to erupt, alveolar bone never forms in that area; and if a tooth is extracted, the alveolus resorbs after the extraction until finally the alveolar ridge completely atrophies. Tbe position of the tooth, not the functional load placed on it, determines the shape of the alveolar ridge.

Note: The long axes of the mandibular condyles intersect at lite foramen uutgnum, which indicates that these 3XC!S are directed postcromcdially.

(ANATOMIC SCIENCES

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All of the following statements concerning the nasal cavity arc true EXCEPT one. Which one is the EXCEPTION?

T he latera l walls are formed primarily by the maxi lla, palatine (perpendicular plate), ethmoid, and nasal conchae (superior. middle. and inferior) The medial wall or nasal septum is formed entirely by the vomer bone The bridge of the nose is formed by the two nasal bones The roof is formed by the nasal, frontal, sphenoid (body), and ethmoid (cribriform plat~) bones The floor is formed by the palatine process of the maxilla and the horizontal plate of the palatine bone

40 41

,.

(;Qp)Tifht 0 20092010 Denial l)edt

~ATOMIC SCIENCES
(
A small, rounded process A prominent elevated ridge or border of a bone A large, rounded, roughened process A sharp, slender, projecting process A tuberde is:

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)

I lu. llh:tlktl n4::1ll ur na,ul

Wfltum

i\

fnrm~d 4.ntirt'l~ h~

th4. \OOh' r hunt

*** This

is false; the medial wall or nasal septum is formed by tbe perpendicular plate of the ethmoid bone, the vomer bone, and the septal cartilage. fhe rest of the framework of the nose consist' of sever.U plates of cartilage, specificnlly, dte lateral nasal caniloge and lbe greater and lesser alar cartilage. The cartilage is held together by fibrous coMective tissue.

The nasal cavity open~ on the face through the nostrils or nares and communicates with the nasopharynx through two posterior openiogs called the choanae. The area below each concha (.ruperior, middle. and inferior) is referred to as a meatus. 11tc nnsal cavity receives Innervation from the olfactory nerve (CN I) und branches of the trl&eminal nerve (CN Y). The nasal cavity's blood supply is mainly from tbe sphenopalatine branch of the muillary artery. The nasal cavity also receives blood from the anterior ethmoidal branch of the ophthalmic anery and the septal branch of the superior labial branch of the facial anery. Nole: 111e nasopalatine nerve is a para.<ympathetic and sensory nerve dmt 11rises in the pterygopalatine ganglion, passes through tht sphenopalatine foramen, across the roor of the nasal cavity to the nasal seprum. and obliquely downward to and through the lncbive canal, and itmervates the glands and mucosa of the nasal septum and the anterior pan of the baed palate. Important: The communocation bel\\l:t'n the pterygopalatine fossa and the nasal cavIty i~ the sphenopalatine foramen. The sphenopalatine anery and the nasopalatine nerve extend througb the sphenopalatine foramen.

Surfate Feato ret or Bone (et~large~~tenrs and processi!Jl): Prot~: the most gc:nenc term for bone projection that serves as a point for attach mcnt of mher structures. Erampte: Acromion process of Inc scapula, transverse proce.\s of venebrae. Epicondyle: a projection or swelling on a condyle (or above, in some cose1) Enmple: Medial and lateral epicoudylcs of femur. Spine: a sharp, slend<:r projecting process. t.xample: Spinous process of vcnebroe. spine of the scapula. Thberde: a small, rounded process. Example: Gn:ater and le..er tubet1:les of humerus. Tuberosity: a largo, rounded, roughened process. Example: Ischial tuberosity of the ischium. 'ltothanter: a large blunt proJection tor muscle attachments on OIC fcmW' Example: Greater and lesser trochanter.. of the femur. Crest: a prominenl ek'llted ridge or border of n bone. Example: Uiac cre9 of the ibum. Linea (line): a small usually somewhal1traighter than a cresl Example: linea aspera of femur. fhmUSl a major b11111ch or division or tbe miUn body Of a bone. Titi.' may have its own articulations or processes. Example: The coronoid and coudylar processes of the mandible are subdivisions of the ramus. Neck: a slight narrowing of the body of the bone that suppons the hesd Example: Necks of the humerus and femw. Lmioa: ~ ery thin byerofbooe. Example: The laminae of the venebrac.

(ANATOMIC SCIENCES

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The shaft of a long bone is capped on the end by spongy bone that Is surrounded by compact bone. This is called the:

Periosteum

Diaphysis Endosteum Epiphysis

42
87
Copyrijhl 0 2@..201 0 Onl1al ()(o(ks

(ANATOMIC SCIENCES

Bn)

Which cranial fossa houses the cerebellum, medulla, and pons? Anterior cranial fossa Middle cranial fossa Posterior cranial fossa

I ptph~'l"
Long bone& hove a tubular stmft. the dlaphyst.s, and w.ual1y an epiphysis at e:1ch end. During the arowing phase. the dillphysis is separated frOil\ the cpiphy~is. by an cplphyJeal eurUin~e. The- part of the diaphysis thttt he.s ad;accnr to lhe epiphyseal cartdagc ts called the metaphysis. The shaft heb u

c(ntral marrow cavhy cont3.ining bot'lc marrow. The outer pan o( tht: sba.ft h bone that is CO'\'Crtd b)'* coooo;th-.: IJJ:S:ue sheath. the: JWrfosttum.
A typir;allong boat includes the folio" lot "trucluru:

comro~ed o( c:ompa(;t

--

Stroc:'IUfe.
llt.phy~lf

Loc:ation and FuuC'tlon

Bone sh11 ft. cooai.Mi 11 f 11 ~~ indntal tub' 11( ~untbl~ oomp3Ct bot~.

lplph.v"

Caps d111pl~: cc.nsl!t1 o! 'POI'IIY boM urroul'\&d by wmp11c1 botiCI Wlins red bone~ fur the ptlllualan nf rnl blood eelll. \lo'luct blood: ;;c.Us. ... pl&l.ck~ Bdwca tk

""""""" ....- - o(bofto. \led~tllary t"aYii)' (\ontnU)' Jl'l.llltiOCird Jpaot V11lllln d~ipll)'lllf! oon.ta.i.ns fAtty )eiiOIN boflt
ffillmtW,

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.,.,s:a:r..W

~ .-,~ qaee oi l'!tUOCK ~"I)'

N~o~ltltn& f\nmcn

Opc.nlnauuC) diophysU; pro\l~lts t1l<: illf numcol vessel,~ to t:ri'CJ llf!d exit t~ malutlaty ~-... ily.

Artla1lor.r cwtlt.tt: Ceps ncb r:p1ph~,,. COlT!~ of~'lllnearnh~ iiciliwcJ '""'"

..........
Pcrlo.sttrutt
Con~cb..IDC.

-........
produce<l

l.ma; ~~'II),~ ofSIIJ"'*1t\~ ck1tsc: ctplar co.edlH' rissu<.

sile far Uaa.mml ~I lendltn-tnU5Cic atJD.;:ht11CN md n:spo~ub'e. (a,

Covcr.tlbt Nri'Ke- f'(bonc; CO'llSI:flt.of d~'flie "gular oorueaJvo lUIIIIC!

dlamtnlc bone~ 1tl kan1. ould I")'Cf of bcJm; DSStte: w-.m:d by per~ $CnQ (flf to taod!mcw oraM<to.. P'O'idcl PNtec'l.ol. aJ ~,.Q. .~unt~k *CWC"- tc
~ la)'C'f vfttc.t ~ mUcs U. booe liifl1t'1 n pM\'1 lks ~ fOt ~ Pw'lc l1'lltf'OW ~bc:rt- bloo4 otllt I'C'

Curlr.xlltoG

'""'_....,.,;

"fa:t ,. ..,...,,llmC'f

The mtemalurfau oflhe base oflbt kull const<tS Mthrce cntnial fOSSite.lbt anterior, muldlt, and posterior. They increase in sl~e and depth from ant<nor tn posterior. The anterior and mi~dle foo:sae an: 5Cpomted by the lesser wing of the >ph,-nod bone. and the tniddle and posterior ro,.,ae are seprotcd by the petrous part of the lelllpornl bone, The anterior cranial fossa is adapted for reception of the (ronlnl lobcs of the br111 D, and is tomted by portiom ofthc trootal, ethmoid. and sphenoKI bones. The <rl'llll galli, a midline process of the clhmoid bone, gtv<S anachment 10 the ntmor elld of th< fal ~bn- On each $Ide of the crista galli ore tbo grooved cribriform pLitts of the ethmod bone. providing numenlll'i orifices for lbt delicate olfactOry nerves from the """"' mucosa to >)'ltapse tn the olfactory bulb>. 111e ntidcllo Cnltual fossa is comJx"cd nf the body lind groat wings of the $1)h<noid bone, the <qUnDtou.~ and petrott< ports ofdte temporal bon"" and the frontal angles of the pnrtotal bones. ThiY fossa is tho "busiest" Oft he cranial fos ..e. 1 his fO$Sa tOJlt8tnJ laterally the tntporatlobcs oflhc brniD. This fc>s>a tiHl!Bins the optic chiasma, optic canal, sellatiiJcic:a. and tbe hypoph~i (a.sa that hoost$1he pllUJIAr)l glaud. Wtthm thts fossa, the supc:oor orbital fi;sun,. f0<11men rotundum. fonnnm 0"1lle, fommen b cerum, and foramen spinosum arc found. In tbe temporal bone, the hiatus for both tlle le>scr and gr"'1tcr petrosal nt'fVcs w-e found. On the anlcnur surface of the petfQUS portion or l.ht lempOr'dl bone IS the lrigemltlal tnlpteSSiOn1 which llclgt..'S the trigenunnl ganglion (~emlhmar ,,. gasserian) the. fifth ne-rve.

or

'11\e J)<)Sterlor crontal fossa, the dccpeM of lhe fossae. ho_,. the cereb<llum. medull, and pons. Antenorly, the posterior cnll\lal fossa e.,ll:ncls to lbt ape.< of lhc pctroos ttmpontl Posreriorly. 11 IS enclosed by the oc<tpual bone. Lat<n~lly. ponmns of Lbe .<qunmoU> temporal and maS1oid pan Of the temporal bone fomt its walls. It contains fO\If impol1nnt roramina, the intcmHI acoustic meatus (fn lhct petrou.t ptlrl of tlit> temporal lxJm!) 1 ihe jllgular rommen (betweetJ rf,t:t sphenoid and occipila/ bone.<), the hypoglt>Ssal cannl (/11 1/Je occipilal bone), and the fornntcn magnum (a largt median opening ill tile floor o( tile fi> w!tfl" th mw/111/.z oblooguta b colllin11ous "'ith. tltt rpfttol cord).

(ANATOMIC SCIENCES

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....._

Treachcr Collins syndrome is a rare genetic disorder that presents with many craniofacial deformities. One of the characteristic traits is downward slanting eyes, which is caused by underdevelopment of the bone that forms the substance or the cheek. Which bone is this that anchors the muscles of mastication and facial expression? \.

Ethmoid bone Zygomatic bone Occipital bone Sphenoid bone

43
6i CopyriabtO 20092010 {)(ntal Dks

cA.~ATOMIC SCIENCES

Bn)

Whith can be defined as a tube-like passage running through a bone?

Fovea
Meatus Fossa

Fissure

70
Copyngtlt c IOOJ.2010 Dental ~b

The zygomatic bone is siruated at the upper and Lteral pan of the face: this bone fonns the prominence of !he cheek. pan of !he lateral wall and floor of the orbit. and pans of the temporal and inrratemporal fossae. The 2ygomatic bone presents 3 ma13r and a temporal surface; four processes. the fromosphenoidal, orbital, maxillary, and temporal; and four borders. The zygomatic bone nrtlculates with four bones: the rrontnl, spbeuoidul. t~mporal (to fomt the :ygomlltlc orc/1), and maxilla. Above the zygomatic arch is the temporal fossa, which is filled with tbe temporalis musole. At13ched to the lower mw-gin of the zygomatic arch is the masseter muscle. 'lote: The tempora!is muscle p3SSes medial to the zygomatic a rch before the muscle insertS into the coronoid process of !he mllndible. The temporal rossa is a shallow depression on the side of !he Cl3niurn bounded by the temporal line~ and tcnrunating below !he level of the zygomatic arch The infratemporal crest of the greater wing of the sphenoid bone separates the temporal fossa !Tom the Infratemporal fossa below it. Important: I. The temporal imd infratcmporul fossae communicate with each other deep to the zygomatic arcil. 2. The pterygopalatine fossa communicates laterally wl!h the infratemporal foss3 through the pterygomulUary Hssu..., medtally with the nasal 1:avity through the sphenopalatine foramen, superiorly with the skull through the foramen rotuodum, and anteriorly with the orbit through the lofulor orbital fissure.

Sudace Fgah1Cf" o[ Bong

Depressions: Fissure (a sharp, dtep grO<we): a sharp, narrow, cleft-like opewng bel\\een the partS of a bone that allows for the passage of blood vessels and nerves Example: superior orbital fissure of the sphenoid. Sulcus (o grwve. but shallower and a less abr11pt cleft than 11 fissure): a shallow, wide groove on the surface of a bone that allows for the passage of blood vessels, nerves. nod tendons Example: Intertubercular sulcus of the humems, :tlternately known os the bicipital groove. Incisure (notch): a deep indentation on the border of a bone Example: greater sciatic incisure or notch of the os coxa Fovea: a small, very shallow depres:.ion Example: fovea capttis on the head of llte femur accepts a ligamenl from the bip socket or acetabulum. Fossa: a shallow depression. This rnoy or mny not be an articulattng surf.1ce Example (ofarticulating surface): Glenoid fossa of the scapula or nJttndibular fossa oflhe tcmpornl bone. Example (non-clrliculating Sll({ace): subscapular fossa. Openings: Foramen: an opening through which blood vessels, nerves. or ligaments pas. Example: Foramen magnum of the occtpttal bone, mental foramen of tbe mandible. Meatus (c.wwl): a lube-like passage runnmg through a bone Example: the acoustic meatus of the tempoml bone.

cA..~ATOMIC SCIENCES
Which fossa has no bony inferior or posterior boundary'/

Bn)

Pterygopalatine fossa Infratemporal fossa Temporal fossa

44
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Cop)Tighe 0 2009-2010 Dtn11l Decb

(ANATOMIC SCIENCES

sn)
J

,
All of the following are openings from the pterygopalatine fossa EXCEPT one. \.. Which one is the EXCEPTION? Sphenopalatine foramen Foramen rotuodum Foramen lacerum Pterygomaxillary fissure Inferior orbital fissure

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Cop,ris;ht 0 :1009-2010 O...al Dttb

lluundari~..

nf I m .. a~ of lhl 't..ull Ptt'T)"&npattd:ntTos,..

&oudaries

T~mporal

Fona
Uno

lnfntt.mportl Fossa

orrossu
Suptr'IOr
Attrior
rnt~al' wmpontl

Circ::uc-r wtnw or JpMnoid bone Inferior surf~c of tpbcrund bon~ body

~brlluylllb<loocy Mudbty~~

FIOOIOI.,......of
~boo<

Mt<llal
I.Aunl

Stirf"aoc C'l(lempc:nl bono

Latttal p1eryaold pll\lt

Mandibular MUTIIIJ lltJd
t)'SOmlrtic: arcll

ZYIIO"!.IUC =h

l'lcryg"""'iiLlly r........
~~aline' canal

...rtrtM
('Ofltrfnr

lnllll""'""''""' of
>Pb""'odbl(trfor IC'PlpomllliiCI
\lu~d'"'

'<obooybonln"
No bony botdtt
t'~\el<...

Jltcry'gou) pmt'C""-' ur Sphenoid bMC

Hluml \

:..ul 't'nt...., uf I n .....u.. uftlll 't..ull

Tt'mpora1 f'f)SSI
Mu.Jel ~

Infratemporal Fossa
l)cerygoid IU\ISC:Ies
~oid

Pter)goptlatine rosu

TemPUralis muscle AM blood vc:sach:

Blood vtSstb

plc.'us and tna.'(illary M"'ilb:) art)' (liWd ponlo.J and bnoncbos mc:h.dmg ioJr...IJ;ul told ""'Y (S<NN """""''""" braocbes mduchng middle -splroopabu!'lc *'1tnet> meningeala.rtery, mfcrior alvL-otaT art~ry. and t)OS-1eri()r
supe:rio\' al~yeollallt1~ry
Mmcbbuw ome lnocludiog tnferior ah eoollf and bnpal

NtntS

A.n,......

...,.,...

Pl>rys<>PO]otr..... glioft and l11.ilWy- <

J. ut amtn l.u. trum

The pterygopalatine fossa is a small Iriangular space behind and below the orbital cnvil)l. It communicates laterally with the infratemporal fossa through lhe pterygomaxillary fissure. medially wilh lhc nasal cavity through the sphenopalatine foramen, superiorly wilh the skull through tbe foramen rorundum, and an1triorly " i th the orbit through tb< Inferior orbital fissure. The plerygopalatine ganglion lies in the pterygopalatine fossa just below 1he maxillary nerve (V-2). The pterygopalatine ganglion receives preganglionic parasympathetic fibers from rbe facial nerve by way of 1be greater peuosal nerve. The pterygopalatine ganglion .ends post.gaoglionlc parasymparbetlc fibers to lhe lacrimal g!Jmd and glands in the pala1e and the nose. Note: 111e maxillary nerve (V-2) and the prerygopalaline portion of the ma~Uin11 itrtery pass 1luough the pterygopalatine fossa.
Bouy Open Inc
Sphenopalatine lof1\mcn

Locsdoo (Bon)
Sphenoid and palatine
Sph~Op:~ltuinc

Cootenn
artery 11nd vein. n8$0p:t.llllinC: nmc

P1<1)'oid canal
Plel)'gamaxdllr)

Sphenoid
Spbmood and owulla

Deep and &n:'ft.tU petto!!al net\'ei that ronn nCT"Ve o!

ptftygoid c:attal, llQ ~l.s

fi'-'"ure

Posterior 'uperior al\Jcolar \'tan, artery .and nene,. lflaxill:uy 11ncry

Ma.HIIlt)' nerve (V2)

f'onunen mtundum
lnftrior orbnal

Spllcr10id Spllenood and nwulla

Max1lla and palatine

n.wure

lafroorbolal and zygomaltc a<"<'. mliao<IMtal

arteJy. an4 orhthalmic \Cln

Pl<rygopllalmc conal
Pharyngeal canol

Greater and h:..ser palatine vcm,., anene~ e.nd nervesl'hw)n~l

i;pllcnoiAI and pal11irlc

broncbofV-2

(ANATOMIC SCIENCES

Bn)

Which of the following receives the 011enlng of the nasolacrimal duct?

Superior meatus Middle meatus Inferior meatus

40
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Cop)'rigbl 0 201-2010 DeniIDcl;t

(ANATOMIC SCIENCES

sn)

'

A prosthodontist designs his maxillary removable complete and partial ...,. dentures to engage the hamular notch behind the maxillary tuberosities. The hamulus Is a small slender hook, which extends from the medial pterygoid plate. The medial pterygoid plate is a component of the pterygoid process, which Is a \.. component of which bone? .tJ

Sphenoid bone Occipital bone Palatine bone Temporal bone

45
74 Copyn.S:.tCI10092010 Dmtl Dttks

fnf,riur

llll'alu~

The nasal conchae are three pairs of scroll-like, delicute shelves or projections. which bang into the nasal cavity from the lateral "ails. Tbest projecrioos assist in increasing the surface area \\~thin the nasal cavity for filtering, heating, and moistening the air. The superior und middle conchae are pan of the ethmoid bone; t11e Inferior conchae arc separate bone~ (also ,ailed the biferior rurblnares). The space below each concha is referred to as a meatus. Superior meatus: lies below and latcrnlto the superior concha. The superior measus =et,es the openings of the posterior ethmoidal sinuses. Middle meatus: lies l>t:low and lateral to the middle concha. Tlte middle meatus receives the openings of the frontal. maxmary. anterior, nod middle ethmoidal sinu.:.es. The middle elbmoidal smuscs drain omo the ethmoidal bulla (rounded prominence on the lateral wall of the middle meatu.<). The anterior ethmoidal siuuses drain into the infundibulum (/imnel-like srroctlll'e that empties info a gn>Q\'e called the hiatus semllrmaris on /he lateral wall of the middle meatus). The frontal siuuses drain into ~te inflllldibulum or directly into the middle meatus. The maxillary sinus drains directly into the hiatus scmilWlJI11S; its opening (ostium) is located near the top of the sinus. Inferior meatus: lies below and lateral to the inferior conchae. It receives the opening of the uasolttcrimal d uct. The nasolacritnul duct drains lacrimal Ouid ftom the surfnce of the eye into the meatus for evaporation during re;pirntion.

The l~n and right pterygoid processts proJC:C:I downward frt'tn near the junction of t3eh of the grc~urr Wings Within the body of the sphenoid bone. These proCCSM:S Nl\ along the poMtriOI' portion of lhC Msal passage tOward the palate. Each process consists oro nu!dhtl und a laterAl pterygoid plate. The lotrrol pterygoid plate provides the ori11111 for both lateral and medial ptctyl)oid mllllclc. The plate ai!IO fonns tile mecltal wall of the infrat<mporal fos.<a. The medial pttrygoid plate forms the pos.tcnor bnm oflbc: tatml wall of the nasal c;a\ity The mechal pla(e ends mfcnorl,) as a bamutus. a small. slender hook th&' acts b a pu11cy for lhc tensor \eli pala11n1 tendon 10 c:bangc its direction of pull from vcnic"l to horizomol, thereby tcosin& the soft palale
l~rot6Ses of Skull

.........
Prot~tal

,\h'COiu pnx:a'

C.........,proca.

Skull Booes
ManJLbk
~t...llt.o c~

Auodci:d Sll"l.I(Cura

.. ,~ar......t.~W't'tb

c-.-.of~-

Mmdihlr
t.4n~till

"""''oe of t'lllfmf
t umb rnffilal1nii-norbi'IOI rlm
Fom1' oni.CUOJ lll~tr.~l ~'lrl.'lk~l ...an

I''"""'' """"'' rrooes.s.

Lts~tWiftJ

a...... .....
M:uillaryp~

Zy~om11tic

Solo<-'

~-

........ """""' .. ~d -bo;ly

--.~ ......... ~box,._..,. (vf'Yif'llb~ or~ lbte.ctls

.......

r..._.t
Zyll')nlllti.c
MIL'lfllil

Fomn UllfiiOrbiU&I h ill "' J'llfUl'llt ur 111lti!nC!f latml <ftil:.l -.liTI

fll)m1) III IICniK lwrd P')Uc
"'"'~r.oT\U

''la!lllinc: proctu
~l&knold pt'OI."r'SSI

,..,....,...,... ,.,..._
Slylool.,......

T..._.l

C~~or~-a-~ta~~cr~~~~

T""J!J!'i
Ly""'"'n<

Sen""" b Utlld.;neni for ~b .. -..~ ll,gUDCCIL:

T"""""" """""

,,,,1.,,of X)'gofll.4t.c: rd
t.&1tml1o ocb{J

l~JO*Ilt P'OOC'.W. 't#)m.IJC.~

z,..,..me~

TF'ro11lfl

\t-.,,n,.

FO'fltt k~n~l portit! Olan.!I'IOd!'tU tm.

-~.,

..............

cA..~ATOMIC SCIE~CES
r

B n)

A young patient arrives In the physician's office with unexplained symptoms"' for a long time. The patient has had bloody nasal discharge and painful oral lesions. A chest x-ray reveals "coin lesions", and labs reveal kidney failure. Ultimately, the isolatlon or the ANCAs JgG antibodies yield a diagnosis of ~egener's granulomatosis. Tbe dentist "bo referred Ibis patient to the ph)siciar made a note or the necrotizing oral lesion that had perforated the hard palate 'into tbe nasal cavity. Tbe roof or the oral cavity is formed by the: ~

Ethmoid and palatine bones Maxilla and nasal bones

Maxilla and palatine bones Nasal and vomer bones

46
75
Copyright 0 20091010 Dtn111 Dtcb

( ANATOMIC SCIENCES

B n)

Most precisely, osteocytes are located In these spaces:

Canaliculi
Lacunae

Lamellae Trabeculae

47,48
Copyn~t C)

76 2(109.2010 Dtntal l>t<'lu

 Spectflcally, the poiAiine process of !he maxUia und the borltontal plates of the palatine bones.

The structure fonned by this union is D1e hard palute. The anterior m o-thlrds of the hard pnlme is formed by the p~latine processes of the maxilla, and the posterior unetbird is Conned by the horizontal plates of the pslatin~ bone~. The hard palate form~ not only !he roof of the oral cavity proper but also the Ooor of the nasl cavity. IJ IS covered with a mucotL~ mtmbrane and beuc:lth the muco..a ore pala1al !i:iliv>ry gland.<. The gre:uer (nmerior) palatine vein, artery, and nerve lrJvel uloJigtbe maxillary alveolar processes anteriorly where they join tlte nasopalatine ncrws and sphenopalatine artery and vein, exiting tbe nasal cavity from the Incisive foramen. The soft palate is con110uous with the hard palate pootenorly and IS "soli" becall5<' 11 does not huve ~ bony substrate bllt cootnin tough fibrous oonnective tissue shee~ the plllutaJ oponeurosis, and is covered wtth a mnoo>a. Salivary gi11J1d~ are found in the underlying connective tissue. f'osteriorly, the sofl palate suspended in the oropharyr~' ends tn the midliue uvula.
Remember : Most of lite palatal muscles receive motor innervation from the pharynanches l'rom geal plexuHof nerves. The tensor muscles uf the pnlnte receive motor b the mndlbular division ufthe trigeminal nerve (CN V-3). Sensory Innervation is provided by the maxillary dirulon of the tngeminal nerve (CN 1'-l). Anerial supply is from pan-3 (pterygopalatine portioll) of the ntA\illary rtery.

I anunu

There are two types of bone tissue: compact and SJIOn~y. The names imply tbat tile twu types of bone tissue differ in density. or how tightly the tissue is packed together. There are three types of cells that contribute to bone homeostasis. Osteoblasts are bone-forming cells. osteoclluts resort> or break down bone, and osteoc} lM are mnture bone cells. An cqwlibrium between osteoblasts and osteoclasts maintains bone tis5ue. Compact bone consists of closely packed osleons or lu.versiao systems. The haversian system consists of a central canlil C3lled the hnrshm canal, which is surround<:d by concentric rings (lamellae} of matrix. Between the nng,s of matrix. the bnne cells (O>Ieo cyres) are located in spaces called lacunne. Sm~ll channels (caua/icu/1) radiate from the lacunne tO the haversian canal to provtde passageways (hrough the hard marrix. In co n pact bone, the haversian systems are packed tightly togethet to form what appears to be a solid ma.o;s. Tbe haversian canals contain blood vessels that are parallel to the long axis of the bone. These blood vessels intm:onnecr. by way of perforating canals, with vessel$ on the surface of the bone. Spongy (cancel/ott.) boue is lighter and le~ dense than compact bone. Spongy bone conststS of plates (trtthecui<Je) and ban of bon<' adjacent to small. trregular cavities that contain ~d bone marrow. The canali~'Uii connect to the adjacent cavities, instead of a ceutral haversian canal, tu receive their blood supply. It rnay appear that the trabeculae are arranged in a haphazard maoucr, btll they arc O t"Sttnl7,od to provide maximum streugU1 similar to braces tbat are used 10 support a building. The trabeculae uf ~pongy bone follow the lines of stress and can realign if the dtrtttion of stress ch:mges.

(ANATOMIC SCIENCES

o n)

A 62-year-old female patient with osteoarthritis Is having bcr right hip ""' replaced. A titanium-ceramic prosthesis "ill act as the bead of her femur and a poly-ethylene cup will act as tbe socket in tbe blp bone. In a normal bip, tbis cup..haped cavity that receives the head of the femur is l'alled the:

Pubic tubercle
Obturator foramen

Acetabulum Pelvic girdle

n
Copynatnc 1009-loto Dcnw o..u

(ANATOMIC SCIENCES

A young couple looking to have a baby goes to a fertility clinic. The reason they are having trouble conceiving is because tbe man's sperm is incompetent and are relatively non-motile. In vitro fertilization l.s indicated and will most likely be successful. What is the long, whip-like organelle that \.. sperm use to move about? ..J

Centriole Aagellum Vacuole

Cilium

\t.ttahulum

Tbe os cox or hipbone is formed by the fusion of the ilium, ischium, and pubis on each side of the pelvis. The os coxa articulates \\ith the sacrum at the sacroiliac joint to form the pelvic gjrdle. The two hip bones articulate with one another anteriorly at the symphysis pubis. Tbe Ilium is the u;>pcr flattened part of the hip bone; the ilium possesses the lilac crest, which ends in front at the anterior superior iliac spine and behind at the post erior superior iliac spine. The ilium possesses a large notch called the greater sclotlc notc,h . The Ischium is Lshaped with an upper thicker part (body) and n lower thinner pun (ram11s). This part bears the weight of the body when a person is in an upright. seated poSition. Features include ischial spine and ischial tuberoshy. The obturator foramen is formed by the nmus of the ischium together witb the llUbis. The pubis is divided into a body, a superior ramus, nnd an Inferior ramus. Tite bodies of the two pubic bones articulate with each other in the midline anterior!) at the symphysis pubis. Medial to the symphysis is the pubie tubcrele. The inguinal ligament connects the pubic tubercle to the anterior superior iliac spine. Note: The acetabulum is a cup-shaped cavity on the lateral side of the hip bone lhut reeeives the bead of the femur. It is formed superiorly by the ilium, posteroinfcriorly by the ischium, and antcromedially by the pubis.

~ lagdlum

Flagella an: present in the human body o nly in the spermatozoa. Flasella are similar in structure to cilia but arc much longer. The action of the flagellum produces movement. The dUum is a short, hair-like projection from the cell membrane. The coordinated beat ing of many cilia produce orsanized movement. The baSIC struciure of nasclla and cilia is the same. They resemble centrioles in having n.ine sets of microtubules arranged in a cylinder. But unlike centriole,, each sei is a dou blet rather than a triplet or microtubulcs. and two singlets are present in the center of the cylinder. At the base of the cylinders of cilia and flagella. within the main portion of the cell, is a basal body. The basal body is es.~ential to the functioning of the cilia and nagella. From the basal body, fibers proJect into the eytoplnsm, possibly to anchor the busul body to the ceU.
Both cilia and flageUa u.~ually function either by moving tbe ceU or by moving hqu1ds or small particles across the surface of the cell . FlageUa move with an undulating snake-like motion. Cilia beat in coordinated waves. Both move by the contractiou of the tubular proteins contained within them.

( ANATOMIC SCIENCES

ceo)

The inactive X chromosome in a female cell is called the:

Pineal body
Lateral body Golgi body

Barr body

10 CopynalJtO 20092010 Oaltal DkJ

( ANATOMIC SCIENCES

In which cellular component are glycoproteins assembled for extracellular use?

The Golgi apparatus The endoplasmic reticulum The nucleus The nucleolus

Uarr hu(h -- alm ),ncm n :" fh<

\l'\

thrnmatin luuh

In the rem ale, the genetic activity of both X chromooomcs is essential only during the first

few weeks after concepcion. Later developmenr requires jusr one functional X chromosome. The other X chromosome is tmctivated and appears as a dense chromatin mass called the Barr body. Tilis Barr body is an.ached to the nuclear membmne in the cells of a normal female. In the cells of a normal male, who has only one functionral X chromosome, tbe Barr body Is absent. Important: The Barr body's preseoce is the basis of sex detenninari.on rests (for example. amniocentesis).
I. The sex of an embryo can be determined ar abour the eighrh week. :-ootH 2. Females have 4S active chromosomes and one inactive Barr body.

The funcrion of!he Golgi appararus i~ two-fold: First.rhe modification of lipids and pro Ieins; Second, the storuge and packaging of materials that wiU be exported from the cell. The Golgi apparatus is ofien called the 's hipping departme.n t" ofrhe cell. The vesicles that pinch off from the Golgi appar.llus move 10 the cell membrane, 3Jld the material in the vesicle is released 10 the outside of the cell. Some of these pincbedo()ffvesicles also become lysosomes. l mportant: The Golgi apparatus is where glycoprorelns are assem bled for extracellular use. The Golgi appararus (sometimes called the Golgi body) is similar 10 endoplasmic reric ulum (ER). h is composed of tlar. membranous sacs, or tistemae, arranged in Slllcks hke pancakes. These sracks have two poles- the cis face, which receives materials for pro cessing, and the Iran., face, through which substances are released for transport to orhcr partS of the cell . ....._ I. These cisremae are locared bcrween the nucleus and the secrerory surface of Notes a cell. 2. They package, store, and modify products that are secreted from the cell. 3. ProcoUagcn r.laments are fonncd here from amino cells. Lysosomts are cyroplasmic membrane-bound vesicles rhar cootain a wide variety of gly coprotein hydrolytic en~) mes thar st.'t'Ve to digest and destroy exogenous material, such as bacteria.

(ANATOMIC SCIENCES

' Which of the following is the distinctive array of mlcrotubules In the core o;' cilia and nagella composed of a central pair surrounded by a sheath of nine doublet mlcrotubules (cloaracteristic "9 + 2" patttrn)?

Centriole
Axoneme

Tubulin Malleolus

81 CopyrightC 2009-2010 Onu .al OU

GNATOMIC SCIENCES

Which organelle is known as the cell's ~power plant" and is maternally transmitted?

Peroxisomes

Ribosomes Centrosomes Mitochondria

\ \lllll'llll,_'

An uoneme is the core S<:alfold the eukaryotic cilia and nagella. whtch are projccuon> from the cell made up of mkrvtubul ... Thus. the axoneme scr-es as the "Sktletoo" of these orpneJies, both giving suppon to the strucrure and1 in most cases, causing 11 to bend. lbough dis-

or

tinctions of fw1ction and/or length may be mode between cilia and flagella. the mtemal :,tn1cturo
of the axoneme IS common to both.

The characteristje rcature of the axoneme is itS .. 9 + 2" a.rrangement of nut.Totubules and woeiat\:Cipnnelns.. as shotn in the 1magc below. Ntne pairs oP'doublet" mkrotubules. a component of the cellular cytoskeleton. fonn a ring around a oentral pair" or single mtcrotubul<" Ciliary dyueln arms, the mcuor comp1exe:. that allow the axoneme to bend, are anchored 10 these micro tubules.. The interaction~ between the ciliary dynt.ln proteins and outer doublet microtubulcs a:en .. erat< fO<Cc by stidmg the doublclS pamllelto each other, which bends the chum and enables it to
beat.

The ndial spokt, a protein complex important in regu1ahng Ihe motion of Ihe axoneme. IS also housed in the axoneme; it projeCts from each set of outer doublets townrd the central microtubules. The M:ldiol spoke is a multiunit protein Structure found in the MOnemes ()( eukaryot.ic tiha and nagella. The doublets and central sbcath> liie linked by prOtein> kno~<n as ot.rins.

= ~~~~"'
-..,..,.
the mitotic spindle,

~~
~

~~......
~ -~

't

Cross secrion of an uononoe

U111t" mt

4). .

Note: Centrioles arc cell orga.nc:llcs that con.stnute the ccntro~me and tbu.~, a.1d ia fonna1ion of

\1 ilut. hond ri.1 Mitochondria ore lhreadlikc structures within the cytoplasm that provide most of ~tc body's ATP, which fue ls many cellular activities.
( .fl 'lnldUH
1-u n\11~111"

Mtmlmoous
PIMnas ~t::IU~111r!C'
Serv~5 113 a bound.lty oflhCI cell. tn11Jn1tinina liS inlcgrity. pr<'IIC!n moleculn. embedded in plasma rncrnbrune pcrtOnu Y.~rious runcdCMIS~ for c-xamplr, IJlCIY S<f\'e as mnrkns tbat idcncif'Ytelts or each lndividual..... liXCJ'40f molccuJ~ ror c:tnam bonnonu o~nd 04bn moluln.. and as tran$pOn s:ocdw\i.im)

f.-plosmic mlculum Rl'bosomu attached 10 roup fiR S)"l~ pmcins lhlll~:~~'"c cells ~i.a.lbc Go1Ji oompl~:x: $.1'rl00th ER syndtei;17o- lipids. incorporated in ccll membnines.stcoroid honnor;e11. and ocnain curbobydta.tcs \l$ed to IOnn &ly(;opl"tHcins

Golgi appen&hl$

Synthesi1 orbobydrate. c-ombines il WLth proceio, aod p;x:~ ahe pOO\tll:t u sJ""""'ora~ A cell' ..d1~sti"-c sysltm

L).......,..
rerox~\('"\

ConlauJ cn;cym<es (hili dtlOXIr)' harmful sub)tAnc:c!l

C.ataboli.tm: ATP $)'1llhesiJ; a cell's 11po\l.tr plmnf'
~the amrtk.rodc, ._ tuch ia tum cbc:iMc:l: ~ Syadlc"lt.S, hrcby pll)l"IIA ascnaial rok: ta other 11 acttvmcs., rwntty. ce-ll tnn$p0rt.. maaboti:sm. and pG'Mh

MifOC:hoodtit

l'ludclio

Nonmcmbmnou)
Ribosom~
c~.v...

Site of protein syntbl.'$ls: 1 cell'~ "'protem f~tttOfi.. ~"

ActJ-. a tlamewod: klM~ppon !be cdl and 1ts ~tic$.; f~lOQ$ \n cdl ~ fonn:s WI tJ;tenSic:KI (~illi, cilia. flactll)

1\~.~tleoJUI

Play& an tssent1al role in lhc (ormation or nbofiomes

(ANATOMIC SCIENCES

KupfTer cells in tbe liver are a speelaliud type of:

Basophil

Plasma cell Mast cell Macrophage

83

Cofl>'lill't C 20092010 Demll D\1

(ANATOMIC SCIENCES

( Wbicb cell, known as tbe "mother cell," Is a part of the seminiferous tubule""' \.. and secretes hormones and proteins tbat facilitate spermatogenesis? ~

Interstitial cells Endothelial cells Senoli cells Clara cells

A macrophage u an} phagocytic cell den~ from a monoe~ te (a type ofblood .:.11). meludmg macrophagcs of lbe liver (Kupf!u ffi/j. spleen, and loose connective tissue (histiocwc).
Summar~
'

nf llifferenl Ctlls and llwir l'rima~ Funct ion l'rlmary Function Antibody synthesis

Cell
Plllsma Mast Schwann Senoli Leydig
Fibrobla~t

Mediator ofinna.mmation on contact with antigen

Fonns myelin sheath around a..ons of the PNS Produces w.;ucular fluid Produces testosterone Produces collagen and reticular fibers

Osteoblust Odontoblast Ameloblast

Forms bone mulrix, gives rise to osteocyaes

forms dentin

Forms enamel

T (l..ympltocyte<}
B (Lymplrocytts)

CeU-mediated immunity Differentiate into plasma cells Produces glucagon Produces insulin

Alpha (Pancreatic)
Beta (Pancrcoric}

Scrtoli nll\
'iummar~

uf Uifftnnl ( t. ll..-.. and I hl'ir

l,rimar~

l nratiun'

Cell
Sustcntaculor
Pyr.~mldn l Endoth el i ~ l

Prima ry Location Internal car (organ of Corti), taste buds, olfacoory epithelium
Cerebral conex (Ci!rebnuu) Lining blood nnd lymph ves.sels. endocardium (;nuer luycr)
Lining the brain tJCntricles nnd spinal cord

Ependymal
Sertoli Grulglionic
Globuw

Seminiferous tubules or the testis In a ganglion pcripheraloo lhe CNS Transitional eplllelium fkdn~y.
Stra:rum spioosum of ep1dennis

w"'"' bladder)

Pncldc
Fibrobla~

Most common c:cll of connective tissue

Clvomnffin Pud<injc Goblet lnt""t1tial Islet \1esencb)'mal

Adrenal medulla and paraganglia ofSNS Cerebellar corte (cercb<!llum)

Mucous membranes of respiratory and intestinal tr:Jcts Connective tissue of ova-')' and ccstis
Pancreas

Juxtag)omcrular Renal corpuscle of kidney Found between cc~cnn and endoderm or embtyos

(ANATOMIC SCIENCES

{iver spots are seen as a sign of aging and are actually lipofuscin granules pre~ en lin dermal cells. Lipofuscin is a yeUow-brown pigment that is produced as a result or lysosomal digestion. What is the coUecthe name given to lifeless substances, including lipofuscin granules, yolk, fat, and starch, \.. that may be stored in various parts of the cytoplasm? ~

Protoplasm Nucleoplasm Ectoplasm Metaplasm

Cop)'liJbl 0 2009-2010 DmtaJ DKU

(ANATOMIC SCIENCES

ceu)

In which phase of the interphase docs the DNA replicate in

preparation for mitosis?

S phase

M phase

Exam,J>Ies: Glycogen: carbohydrate storage gr.tnules in liver and muscle cells. Fat deposits Pigment granules: deposits of colored substances. I. Lipofuscin: yellowish-brown substance that increases in quantity as cells age. 2. Melanin: abundant in epidermis of the skin and retina. Protoplasm is a viseous, translucent, watery material that is the primary component of animal cells. It contains a large percentage of water, inorganic ions (porassirmz, calcium. magnesium, tmd sodium). and naturally occurring organic compowtds (.ruclz as proreins, lipids, and carbolzydrares). Nucleoplasm, the protoplasm of tbe cell nucleus, plays a part in reproduction. Cytoplasm, the protoplasm of the cell body that surrounds the nucleus. converts raw materials into energy. The cytoplasm is the site of most synthesizing activities ttnd contains cytosol (a viscot<v, semirransparenr fluid rlzar i.r 7()0,1, ta 90% warcr), organelles, and inclusions (meraplasm). A clear, thin lilm of protoplasm called the cell membrane always surrounds the cytoplasm. The outer pan of the cytoplasm is called the ectoplasm.

ph.tw

The odl cycle consists of Interphase (includmg grr:m1h and symhesis) and mitosis. CrO\o\'th is the increase in cellular mass as the resuh ofmeutbolism. Synthels is the replication of DNA in preparation for mitosis. Mltols is the splitting of the nucleus and cytOplasm that resultS in two diploid cells being formed. Tbe cell t)'cle ca.n be further dhided into: Interphase: the inu.-rval beiwcen successive cell divisions during which the cell is mecabol izing ond Ihe chromosome~ arc directing RNA syntltesis. It Includes: I. G 1 phase-- the finn growth phase 2. S phase - DNA synthesis 3. G, ph a..-- the second growth phase M phase: mito<tS (also co/It'd mryolriesls) is the diVISion or the nuclear pans or a cell 10 fonn 1wo diploid dnughtcr cells. Cy1oklnesis is the division of the cytoplasm, which accompnnies mitosis. r-------~~~-------,

C.II ~W

IIAC*ll.t!Ofi,Of

OJIA ~lttUon

Dft4 reoheett.oo en4 Cl'nfNUd OUOh to:U;n

(ANATOMIC SCIENCES

Cell)
)

Tbe plasma membrane (cell m~mbrane):

Surrounds the cell wall and serves to protect the cell from changes in osmotic pressure Is a polysaccbaride..:omaining structure that functions in anachmem to solid surfaces, preventing desiccation, and protection Is a non-permeable membr.me enclosing lhe cell wall Is a dynamic, selectively permeable membrane enclosing the cytoplasm

87
CopynJhl C 2~20 1 0 Denial Dlr.t

(ANATOMIC SClENCES

What type of cell in the dental papilla adjacent to the inner enamel epithelium differentiates into odontoblasts?

Myoepithelial cell Mesenchymal cell Macroglia cell Mast cell

The pJasmn membn~oe (cell memb.rtme) s a thtn clastic stroewre 7.) to 10 nanometers th1tk. It is located between the cell wall and the cytoplasm. Nonnal cell membrane function is essential (or passive nuuiall diffusion a.n and Out or the cell as well IS for a<:tivc ( i t . wquiring ~nerg)') transport acn>ss the membrane. The plasma membrane conSists ofa pbospboloptd btlayer contatn ing integral and peripherel proteins. This type of membrane is called a nuid ntoslc ;utd is found in both prokryotic and cukaryotic cells. The ull wall surround~ the plasma membrane and serves 10 protett the cc:ll from changes 1n osmotic pressure, anchor 11agella. maintain cell shape. and con1rol the lranSport of molecules into and O<tt of the cell. StructureS onterior to the cell wall tnclu.lo: the plasma membrane, the C)1oplasm, and cytoplasmic constituents such as DNA, n'bosomes, and inciU5tOOS. Remember: The mitochondrion is an uraancllc of the cell cytoplasm that cons1SIS of an Inner membrane nnd no outer mernbrane (as doe.:r rhe nudeus). Mitochondria c are the principal ener gy SOW'CC of the cell (major site ofATP production) and are involved in all oxidative process.:s.

They contoin cyclic OrN-' ' A...:;....- -- - - - --

- - - -- --,

These cells have the potential to proliferate and differentiate into diverse types of cells (fibroblasts, chondroblasts, odontoblas ts. and osteoblasts). )Aesenchymal cells form a loosely woven tissue called mesenchyme or embryonic connective tissue. Important: The mestncbymal cells tn the dental papilla adjacent to the inner enamel epithelium differentiate into odontoblasts, which produce predentin that calcifies tC> be<:<>mc dentin. Mesectoderm (also called ecsomese11chyme) is that pan of the mesenchyme derived from cctodenn, especially from tbe neural crest in the very young embryo. Neural crest tells give rise to spinal ganglia (dorsal root ganglia) and the ganglia of the autonomic nervous system. These cells also give rise to neurolemma cells (Scllw(lltn cells). cells of the meninges that cover the bmin and spinal cord, pigment cells {melanocytes), chromalfrn cells of the adrenal medulla, and several skele13i and muscular components of the bead.

(ANATOMIC SCIENCES

Cell )

rOn the playground at rettss, a young girl is stung by a bee and immediately"
breaks out In hives and starts gasping for air. The teacher grabs an epinephrine autoinjector from the first aid kit and is able to save the girl. What cells, when bound by lgE, are responsible for this anaphylactic reaction?

Mast cells Macropbages Platelets Kupffer cells

('.op)TIJIM C 2009-2010 Dcmll Ob

..

0NATOMIC SCIENCES

(\.

A ch romosome is maximally condensed chromatin wrapped around a protein base of primarily:

Hydroxyapatite Hyalurooan

Histones
Haploid

90

Qp)npt 0 2009-2010 Dmcal Dcd.~;

Mast cells are large cells with coarse metachromatic grunules containing heparin (anticoogulant), histamine (vasodilator), and other substances (I.e., chemotactic factors, such as eosinophil chemotacric factor of annphy/axi,f and neutrophil chemotactic factor). They occur in most loose connective tissue, especially along the

path of blood vessels. These cells act as mediators of inflammation on contact with
antigen.

Note: Normally, mast cells are not found in circulation. Both mast cells and basophils liberate heparin into the blood. lleparin can prevent blood coagulmion as well as speed the removal of fat panicles from ~tc blood after u fatly meal. They both also release histamine as well as smaller quantities of bradykinin Md serotonin, Note: It is mainly !he mast cells in inflamed tissues that release these substal)ces during inflammation. The ntust cells and bnsophUs play an exceedingly imponant role in some types of allergic reactions because the type of aotihody that causes allergic reactions (the lg type) has a special propensity to become attached to mast cells and basopbils. The reaction between antigen and antibody causes the nust cell or basophil to rupture and release exceedingly large quantities of histamine, bradykinin, serotonin, heparin, SRS-A (.<IOI\ reacting substance ofanaphylaxis). and a number of lysosomal cn:t)'IIICS. This, in mm, causes local vascular and tissue reactions tbal cause many, if not most, of !he allergtc manifestations.
4

Chromosomes arc maximally condensed forms of chromatin. Chromatin consists of strands of DNA wound around a protein base of primarily histoncs and looks like a beaded string under an eleetton microscope. Chromatin occurs in two forms: euchromatin (e:xtended) and heterochromatin (condtrL<ed). Wben a cell prepares to divide, the chromatin coils ullo compact chromosomes. Except in the gametes (germ cells), chromosomes appear in pairs. One chromosome from Mch pair comes from th<! male germ cell (sperm). the other from the female germ cell (ovu'"). NormJll human cells contain 23 pairs of chromosomes. which makes the diploid number 46. Tbe diploid number is tbe number of chromosomes of a normal cell, The huplold number is the number of chromosomes in a gamete. Usually, the diploid number is twice the haploid number. In these. cells. 22 pairs are called homologous chromosomes or autosomes. These setS con18Jn genetic information that controls the same cbaractensucs or functions. The 23rd pair are sex (X and Y) chromosomes. The composition of these chromosomes determines gender: XX produces a genetic fenude; XY, n genetic mule.

(ANATOMIC SCIENCES

A plasma cell:

Is a formative cell present in red bone marrow that gives rise to a specific specialized cell Is a mature B lymphocyte that is specialized for antibody production

Is a mature T lymphocyte that is specialized for cell-mediated immunity

Is any phagocytic cell of the reticuloendothelial system

Copyrigbt C 2009-201 0 lkntal l)c'(kJ

..

G NATOMIC SCIENCES

A chronic alcoholic is starling to show signs of cirrhosis and liver failure. Which of the following cell types will start to become ineffective In manufacturing albumin, Obrinogen, and the prothrombin group of clotting factors?

Fibroblasts Hepatocyte Kupffer cell Erythrocyte

92
CopynJM 0 2()09.2010 DcstQI Dedi.

Is a lll:llurc U I~ mphm~ tl' that i\ "i)H'daliJ(d fHr

anlihud~ llfUtlm:Cinll

Plasma cells are further differentiated 8 cells tbature very impoctnnt in the production of a ntibody. They arc rarely found in the peripheral blood. They comprise from 0.2% to 2.8" of the bone marrow white cell count. Mature plosma cells arc onen o,,l or ran sb~ped, measuring 8 to 15 11m. Their npperul!DOC (mz liglzr microscopy) is quite chorac teri~tic: they bnve basophil cytoplasm nnd on ecx;entric nucleus, in addition to a pale zone in the cytoplasm that (on eleclmn mitmrcopy) contains un el\tensive Golgi apparatus. They are tound mainly in bone marrow und connective tissue. They have a short lifetime of 5 to 10 days B cell (0 l)mphtx:yres. complele matz.rarion in lhe bone marrow): produce antibody mediated zmmunity. They account for 20% to 30% of circulating lymphocytes and like T lymphooytes become ussoci~ted wi~l lymphoid organs (lymph nodes. sple~11, elc.). As B lymphO<:ytes become sensitized to nn antigen, mature B cells develop into plaJma cells or become memory B ulls. Memory B cells are formed spitic to the antl~n(s) encountered dunng the primary immune response; able to live fot a long rime, these cells can respond quickly upon secnnd exposure to tbe anugen for which they are specific. T cells (T lymphocytes or thymusdrived lymphoc:yiM): produce cell-mediated immuni ty. They account for 700.4 to RO% of circulating lymph()(.'}'les and become associated wuh the lymph nodes. spleen, and other lymphoid tissues. Upon interacting with a specific antigen, T lymphocytes become sonsitized and differentiate into sevcz11ltypes of daugh ter cells. These includu memory T cells, which r~mam inactive unti I funzre exposure to the same antigen; killer T cells, which combine with antigen on the >urface of the for eign cells. causing lysis of the fon!ign cells and the release of cytoklne,; and different subsets of helpe.r T cells, which help ctivate otber T lymphocyte.,,

The liver's functional unit, the lobule, consists of plates of hepatic cells. or hepalocytcs, that eucircle a central vcm and radiate outward. Sepuntting the hepatocyte plates from each other are sinusoid.~, the liver's capllary system. lle-patoc:ytes make up ()()"It to 80% of the cytop\asmtc moss of the liver. These cells are involved in protein synthesis, protein storage and transformation of carbohydrates, syuthusts of cholesterol, bile salts and phospholipids. nn<l ~etoxinoatlon, modification, and excretion ofexogenous and cndollenous substances. rhc hepatO<:ytc elso initiates tbc fonnation and secretion or hile. HepatO<:ytes have abundant organelles tbnt perfonn their m1merous fuoctions. Smooth endoplusmlc reticulum produces bile snits and detoxifies poisons. l'eroxisomes also detoxify poisons. Rough endopln1mlc reticulum produces blood proteius. The Golgl apparatus packages btle and nthcr sccn:tory products of the cell. G\ycosom ~tore sugar. Finally, numerous mltoebondrla fuel cdl activtty. Kuprrer cells are reticuloendotbelinl mocropbage~, which line the sinu.<oitls. They function to remove oocteri~ and to:<ins that have entered the blood through the inteStin~l capillaries. These cells have definite cytologic chamctenstics such a:. clear vacuole.<, lysosomes, and granular endoplasmic reticulum.

GNATOMIC SCIENCES

Tbe following Is the s ite of synthesis of rRNA:

Endoplasmic reticulum Ribosomes

Golgi apparatus Nucleolus

Plasma membrane

t)

Cop)'figb'l C loot.lOIODtmal 0\t

G NATOMIC SCIENCES

( In which phase of mitosis does the chromatin condense into chromosomes """) \... and the nuclear envelope break down? ~

Interphase Prophase
Metaphase

Anaphase
Telophase

TI1c nucleolus is an oval body found inside the nucleus. The nucleolus consists uf RNA and protein and is not bounded by a limiting membrane. The nucleolus is the site of rR)ofA ynlhesis. Ribosomes are small 11articles consiSting of rRNA and protem. They are commonly called the " protein f3tlorics" of tbc cell. They arc responsible for the process of translation, or taking the information from ~1e DNA, encoding on RNA, and using it to crcoate the proteins needed by the ceU . The eudoplasmk reticulum IS 3 membmnous network through the cytoplasm. The endoplasmic reticulum is continuous with the cell and nuclear membmnes. TI1ere are two types of endoplasmic reticulum: I. Smooth (rlbqsomes nre absent) .. steroid syDlhesis; intercellt1lar tnmspo11; detoxification. 2. Rough (ribosomes are attached) - synthesis of proteins for use outside a cell (extruulllllar use).
I. The nucleus of n cell is S\lrTOtmded by two membranes nod tontains DNA. Notu 2. Active cells (fibroblasts, osleoblasts. etc.) are charncterize<i by an abundance of rough endoplasmic reticulum. 3. RNA and DNA can be distinguished from one another by the Feulgtn reaction.

Prnpho1't

Mitosis IS the process of nonnal cell dtvision. Mitosis occurs whenever body cells need to produce more cells for growth or for replacement and repair. The result of mitosis ,. two identical dughter ceUs wi1h the same chromosoml content as the parent cdl. MitoSIS is pan of the entire life span of the cell. al>O called !he cell cycle. This entire cycle consists of the following stages: Interphase: the interval between succesme cell dtvtslOns dunng which the cell tS metabolizing and the chromosomes are dire<:ting RNA sylllhesis. It includes: 1. G1 phase: the firstgrov.1h phase 2. S phose: DNA synthesis 3. G1 phase: the second groWlh phase Mitosis ean be divided mto ro11r principal stages: Prophase: The chromatin, diffuse in interphase. condenses into chromosomes. Each chromosome has duplicmed and now consist< of two sister chromatid<. At the end of propha.<e, the nuclear envelope breaks down into ve~icle Metaphase: The chromosomes align at tbe equatorial plate and are beid in pla<:e by microrubules attached to the mitotic spindle and to pan of the centron>c:re Anaphase: The centromeres divide. Sister chromatids separate and move toward the corresponding polos Telophase: Daughter chromosomes arrive at tho pole<, and the microtubules rusappear. The condensed chroiTilltin expands. and the nuclear cn'-elope reappears. The C)1oplasm divlCks (C}tokinesis), and tbe cell membrane pinches inward. ultimately producing two daugbter cells The turnover rate of the cell varies greatly from one ttssue to aoolbcr. For example, there is mpid turnover in the ephhelium of the alimentary canal and epidcnrus and slow turnover in the pancreas and thyroid.

( ANATOMIC SCIENCES

A specialized type of cell division that occurs In the formation of gametes such as egg and sperm is called:

Binary fusion Conjugation

Mitosis

Meiosis

eopyn,m 0

95 20()9..2010 iknl&l Db

( ANATOMIC SCIENCES

Gi s)

The preferred site for vitamin B12 absorption is the:

Duodenum Jejunum Ileum

Cecum

"' 52,53

Ahh ..IUh mciosts appears much murc eomphcuted than tnlt(')$h, ~iosis is rcaJiy just ""'O dhIIiOnl in ~equtnce, eacl\ on~ of whith hA!. ~rong, !1m1lanh~ to mitOS~ Mt.lorls 1, 1he lint of1hc two di'*tnn..c;, i~ oO.un callcod reduc.llon dh'i.sioo, 1t1nce II s here thKilhc chromosome comJ >Icmcnt is rc"<iuccd fm111 2N (dlplnid) 10 IN !ltaploid). lnterphll5c in meiosis is tdontkal to imcrplmso in mitosi Md there is no way, by simply ob..erving lhe ceiL to detemune wbat type or dtvl>ton the cell w1ll undergo whe~ il ~oes diVIde. M<icllic diYlSton "ill ouur only in coil lbes<>eisled "hh mole l)t f<Jnalc ,;ex organ. Prop bast I 1> virtuallt Idem teal to prophas..: in mHCISiS.. in,o1lfina the apl_')e""JI"'Jnce of the chromosomo. the develorment of the lipmdle appanttu~ . t~nd the hreakdO\\'Jl Of lill' nuch:!tr tn1..>tnbra.ne (e,wttlope). f<lcrc IS where the orllical diOercnct tXcurs between num\phase 1 il" rneiosis and mthtphase in mit~i> In the latter, al1lhc chmmo.<otncs lin4 up un \be metph!IS<' plate ut 110 p;IIIICUiat ur<lcr In mrtopltase I, the cllramosome pan ore li!!IJ<'(I on e1tlk1' >ide of lite ntc..,pltase plate. It is dunng tlnsolignmem thai chrmnarid arms 1nay overlap and h.!Jnpomrily f\bC (c/tia.rmatn}, resulting in crossovers. Ourina annpbnyo I the spindlu fiber.~ comruc~ pulling the homologous poir<llw:~y from each Qlh~r and h>wllfd each pol< uf the cell 1\ cleov~ fuiTOw lypn:ally forniS ot tlm point. folluvcd by ~ h..itJnt-dJ", btrt 1bc oucleu- mc."fl\bnmc UJ.ually 1~ not l"t':~romu:d .-nd lhe chtor\l()$()mn do nO\ dtsoppcar, At the end of teloph.,o I, ea<:h dauglttcr cell ho> "ngle set ui chrommoomc.,., half the tvtttlnumber in the origlta.l cell where tho chromosomes were present in p111r~. While, the on~inal cell wos diploid, the daughtor cell< ore now ho1>loid. Thl, " why mciol I is often ~ailed reduttlon division.

\ldosls II is qune '""pie m that 11 i imply 1tnlot1c dh'l>ton of C"'h of 1he haplotd O<!IL< produced in m~los-lt I. There is no lnlerphalt' between nrtCJ):I$ I and mclota~~: II. When me1o5is Ills complett. there will be a 1otul ur four dauJ.!hler Cl'llli, t."itu:h wttJ1 hnlr the tulal nmnber of ehromQSOmes ns the ortglnal oell In lhe c.ne of rDale <11\ICil!r<X. all four II$ will ev<ntually de\ tlop 1n10 typic\\1 Sp<rm cell. In the ca<t or f<male sti'UI.,.IrCS. throe of the cells will typt<ally boft. lcavmg a slogl< cell to ~lop 1n1o 3D ogg II thol '" uully mueb larger than a typical ,perm tell.

ll~ um

The fmU fnfe&tl.r1rr II the nu1111 Mt.! n( att)orpnon of digc:aiOO (ood. 11te .!iln.!tll inle!llrlC it sp~Xtalw:d for tht' W!npte:lion or the d!&CIIiOn proCC'SAC'\ 1'11111 tlw S\lb~ucnt att:.orpli_oo of the divested pi'O(h.ICbo. Th~ unaJI!llC'"; tme cotai_t;ts of tllr\.'C main scgmcntc; d.: Joodcf!IID,, J~junurn. and dcum_
ChncctriJrlc fdhi~ or dte. sm1U lntHtint. lndUdt; lntnUn1 \'Uil. Tbae -are fin,Cf-"ltkc f!tOJ~o'CltOib 1mo tbe 1WDL'TI (t'Off~hflny. ()j mrlc.r~ f1"'tlrri1Mtt Jrul mtiL'rl)i"S klmfna propria} .... 'rhc eplthf.ll\l m ltnlng the lumc-11 con~in~ (I( 1\ .:;imp!~: c~~fummr cp1tllclium With ~ubld cclb. ll1c 'olpi\Sll rurf"'-'C or the lbliOrpCiYC tphhc"a~ ~lb iW a '"IJriUb bardtr" b'eTit/li"Jl/IMI Q1, mr/et/J1.1'M1'1):C!'I'ftt"lf 1'} d6:Jel,. pVJ "fitrovfllt wltltlt mfol) numbt>r ~fwrul hudnd p. r absorp<i~ Ill 'Tbc awn t\mctiO'Jt of 1he m.kro''ill1 1a 10 inaeasc ~he NfactiJ\!:1 a\..&Jblc (Of ~10n The f2m,n propria of the 41lt11t1mesllnc 11 fom'led from IOQW' cunncctn'C 11\)Ut.:. 'nus wntams blood v~sM:1i1 Herv~. Olftd l(U}to lymphlltlc v~:-eb ('"~vi nfJ.mrpr/()u OJ llrdf). luh.'fUnlll gtAnds. These 8N Simple lUbUIAr &l~ndt 1hm Opi.l:ll 10 the: iUt..:StuwlluJl)C:1' bclWC...'n lh~ hll~ O( ~ll Vllh. Tilt mh.'1hMI gblncb arc 'iO.ne\imcr! caiiJ me. Cryptl tr Ut~bf.rkuhh. St...:Tetdry edJJ (Pofttfll cdlll w111! ~"' ~~todophili< .....,..1 .. .,. r.....t 1111t b>sc of 1ho ,.,...,.,.lgl<dld> r~~c filn<b<WI or 111< !ictretorY c:tll.11 ''sun not futl)' und.. ~ h4u" ... k~n Chat Chcy ~c lySt.V')~. wbk1t has anu..tw.c-lcnul proP'"7\ttJ.

Vlves or K('rckrluc. The lintn.g oftbc ~rrutll mtt~lmc h~s rt:I'IHI\neni lOlds knml/n It\ \ltl.l~o~c!. orKcrcloin.Y or pUt::.t d~u l 11n."f. These ~.ro !lWI\ 11romiuent en lhc. jrj~num. The:st folds, seen m~ros..:opcally .n rran .... vers.e sc~o."ttons, toMI$l of mucosa al1d subnl~

lmpon1nt:
1. T11C main di.!itif\J(IH!ihi"& r~;JlW'e or 'he dUOdt'IUJn'l ;, lhc fllC.!~Ct... "C or gland::. In lh). 'Uh!UUCO.Sij 1 h~ dUo-dcnnl 01 OrlJtiiU'-rstthiUlb rl'fldllt.!C 1\lkaline-~~tiun~ It) COliOI\.'tbO.:t illr.: ellbcllr or gil~\no;lt~.-"tdto tbat reach lhc d\M.ldl"flutn, 'These alandsl!iiSO prov1dC the net\.~saty allo,_.aJinc cn\ll.nn,r\enl for 1hc func:tiOUin.@. ord\t L'\t1Cn(IC
~ne sec~.ons.

2. The: mal"! dtstll'lf\U\hinr Cc:\1~ <'( ~ jej.aum 11 1ht pn. ....... ""nCC vf prvmincn1 \'ahu nr Ktt'C'krinc lp/iMt
e~t'Ctllnn>i).

l . 11\C Ileum il almMI de.vold or v&lves of Ktrda1ns, however llirge numu.ln.JIOIIY or lymphRIIC til_I,Ut'r bntil nodular and tlcntc. arc fOund in the lamina propn111. 111\.1.,: .:an Qf,cn be !!CCI' n,a~,.roooc'('lpreally as t1.1.rvc Vthite: pcatdloCS and -.re- (;"XnnlOIII;t knOWTI as Ptyt.r'$ p.atcht<J. r~ ilitu.m IS rite prdtmd &Jtt rDr- \ibt"'ln Btl bs.arptlon. Nolt"! Tlk ilo.un acphes a\\o 1be cecum 3\ 1he iltoe"tdt jua.. tion.

(ANATOMIC SCIENCES

Gis)

r A patient comes to the emergency room presenting with jaundice and intens;'l
pain in the upper abdominal and between the shoulder blades. The physician suspects choledocholithiasis that is caused by cholesterol stones formed in "bleb organ that stores and concentrates the bile.

Appendix Gallbladder

Pancreas
Spleen

54
t7 CopynahJ 0 2(109..2010 Dental Dk

(ANATOMIC SCIENCES

GIS)

Whleb comparison between the large intestine and small intestine is false?

The lumen of the large intestine is of a greater diameter than that of the small intestine The smooth muscle coat of the large intestine consists of three bands called taeniae coli that cause the colon to fonn pouches (called haustra). The smnll intestille lacks this characteristic The walls of tbe large intestine have more villi than the small intestine The cxtemal surface of the large intestine has small areas of fatlilled peritoneum called epiploic appendages. The small intestine lacks this characteristic The large intestine is about one-fourth the size of the small intestine

<.:lllhlnddl'l

11te gallblnctder i~ a sac-shaped orgnn I'Oughly 3 to 4 inches long. It is li1mly attached 10 tbe lower surface of the liver and lirll on 1he righl side Oflhe abdomcnjusl below tbe ribs ar We frool The gallbladder is joined by lht Cy>1ic duel tO tho! biliary duel$ O(the ll\tr. The comnton bile duel passes down through the hed oflhe pancreas 10 drain in1n !he duodenum m 1he duodcu:~l au111UIIa. Just before !he duel cnlcr.; Ibe duodeuwn. !he common bi lo duct is joined by lhe main duel of tbe paucrca~. Note: The gallbladd<r's lining is folded mlo rugae (similar to tlr<Me on tire YIOIIItJ<'hi. The middle layer consistS of ""'Otlth muscle fibers that con1rnc1 to ejtct bile Bile is conlmuously produced by the liver and dr:uns through the hepatic ducts and bile duct t~ Ihe duodenum. When rbe small intestine is empty of food. the sphincter (Otfdls sphincter) of the b~patopnntreatic om pull (ampulla of Vme11 conMrict~. and blle i6 forced up the cystic duct to the gallbladder for srorat;e. Importan t: Sccrerioo of the hormone choltcystokimo ufter a fauy meal stimulates gallbladder contr.Jcuon lllld rclaxatiorl uf Oddi's spbincter. and the bole mixes with the llhyme. I. 11te ~hincter (Oddi ~ spltl!t(l<!l) of the bepntOIIancreatic nmpullaris is a cir Nntl'O cult1t m113Gie llw~surround~ the bepalopall~reatio ampulla (ampulla ofVater). 2 The gli!Jbladdcr does ool c.on!ain a ubmucosa ns do 1he "Olnach and mte,. rines (both lar!ll! 1111d small). 3. Bile emu lsi ties neutral fats and absorbs !lmy acids. chole~lere>l, and cenuin vitwnins. 4. Tit~ gallbladder receives blood fi'om 1he ey~tlc ane11. n brn11ch of the nght hepatic ancry. The gallbladder is innervated by vagal fiber< from the cellae pleJus. n.e lymph ctraim imo a cyshc lympb node. then inlo 1hc hepatic nodes. und eventually lilt() the celiac nudes .

.. .._ Tb1s IK faiR; the ""all; of the larg~ mteiunc lack \i.lli.

'fhc large hncninc- coMisLS or lh\' C'oton and rmm Tbe ooll)u

iM eurnpc!led ar vari,\U\ J)ltU: tht ~um. asccudiuy colon, tr:wsvet $e ~J i an, dcs"-'<'Odinlt! t."'lon, 1md sigmoid t"(lll)tt, The IJ)jX'tldix ill nu~h<to the (~IQ. n,e r~tli.ITI ts the: ttt:eond 10 last pan. (I( thl: dlgeidve uactlnd leads. iuto the IIUt rxtrt. the atl.U" The lqe inwsnne la:ks fohb Of~tlli It is chlif'ICc.enKd b) marty hbltlu lnte-tdnal glands -.ith ~e n~ ben o(p>b'et ctlls. 'llui s: tOG\tl~ dcr.cnbed b J.:,t:and~o~lilr c.phtk:UtJm Tbt tv.,>e m~e is ilK 1rte ofWllet aMOrpb~ (~ofiJ rolumnor a,.<corpli\t t"'fillJ and ''also lbc ille. uf for mation O( Chi: ftceft, The.liCCfCtiOill oflhe gabl(l:l ttl~ provide lubnCaUiOn for lhe lumlolilllJfi'u~ AbtmdiUU lymphatic 1i.ll5Ut ~s eommon in lhe la:mina llroptiu (nwmg f(l tltL/urys INU'"II!rlil populotitJIIIfl tire:

h1me11 of tit(! full:~ inte.tthl6j

Wbertat the ~imrlar smooth musc-Le- layer 1~ wnwtuom. the-IOOJitudlnal.m\\.lOCb musde or tbt muscuiMt~ it in lhc ronn of tbra! tbac.k bMds. knc:K\'n as ue.olae t(Jf{ l'he anti ~.... Uit&ih the I"C'Sl or the II'Ji! m'tShM, ba-r a "l"fl~ oflon~inal foldJ. and the q')tthdnun
becomes 1 J\rl1if1ed squsnlOUII tptltchurn Tbr LII"Jttllniettlnt _b C~Hllt)oed or 'fhrrt Pllrtll:

I . Cct~uu: the ~ginnil'\i or lh~: large intc.mnc, bllg~like Mruc:tu~ tl'!il.t reCClvt:S lhU Ucuut of Lhc ~mi'U toteidnc I ~c ~erruUorm apptndlx i~ a ntrow. bHnd tube tl'lac ntt:nd-; downward- from t~ a~nL. It c:onlalll> I"'!" amount oflympOO!d Ul.>uc 2 Co1on: pam. of thr cotuit include lhc ts~niliog t'OfO.ft -the -shof'lest 'PAR or ttte lllf!C lntc:snuc: that Wen~ upward from lh<: t'\lffi o:t the ngbt pos.1erior ~ommal wall n.c, l rtnner,e tvlon CJttt:nd, lC:fOiiS the upper -abdou\cn whtn' thl.' co1on bends down.""an.! "long the letl P')'tartol' ~tbdomirllll Wfl.ll M the dt~nd ifl,g tolon.l..ow in Ibe: ibdmncn, Ihe COlon O:UrYC.t IUIO the. pelvis towunl the-midline 1\:J the
Sma~ Jdtmoltl s:oiQJJ, l. R~tum: extends: ft<Hn lhe '"!JmOid color! to the an\Js. h ~ 11tat~t and does no1 pou~ tbc tJetuat (011 IMI ~ J!fttc't\t in tbe l"t1JI of lh.l:' t.a~ .OlC)1ane. The rec:tum .:nd$ as dk aut anal f1 . 4 clff), ._.tucb opert.) lO thl;. t."{tenor throug,h the anus. The ltl\'1 cattal is surrouoded by the 1mernaland t"Xt~l .sphl.n..:k:f muiGleli lhat cQntrot he c:c.pulsion of coruuutt tl't()twtl mowtnrt'tll.~) Important: UnJik~ tloc: of che t"C$t nr chc OJ tral:!t., tong.nudinul muscles l.lo nt'' finm a cuntinuo\l~ lt'ycr uruund the larvt lntt<~unc. InStead thr babeb of lofl.Sinldl~l 111U!i:clc. ~lied t'.tCnlu ~:ull. ru:;1 lht ltr~cth of (b( (okJn. Codlnu:ti.aru P'htr ~ -;oton 16W ~ OidWtrfl) 1""'8 the: tub m: '"'pucltertd"' appeafl'11C(

(ANATOMIC SCIENCES

Gis)
~

j Name tbe glands found in the submucosa of the duodenum that secrete an alka-

1\..

line mucus to protect tbe walls of the mucosa.

Peyer's patches Glands of Kerckring Henwig's glands Brunner's glands Crypts of Lieberkuhn

S J
99

Coslrrltb( C 20092010 Ormal DKl.

( ANATOMIC SCIENCES

GIS)

,
\..

Heartburn or GERD Is a renux disease associated \\itb s ubsternal burning pain and e'en metaplasia where the acidic jukes of the stomach enter the muscular tube that connects tbe pharynx to the stomach. This tube is called the:

Ascending colon Duodenum Esophagus

Ureter

100

c.,yn... 0

2009-2010 Drrnal Oetlt

Urunne,.s giJiods (aLto cn/11'<1 duode11al glands or <ubm~rosol glaflds) arc small. bmnebtd. coiled tubular glands sotuatcd deeply on the submucosa t>fthc duod<'llum. These glands secrete an alkaline o uucus In protect tho wnlls of the mucosa fl'Oo n enzymes in the intestinal juice. :-lote: HostologicuUy, it is possible to distinguish lhc duodenum !Tom the Slom:u:b by the presence of these submucosal ~lands. Remember: I. The duodnum tS the lin;tpart of the smnll intestine ttnd mcn~urcs around 12 inches in length. The duodenum has a "C" shape, whb the curvnnore of the ''C" endrcllng the nead of tho pancreas. his the &honest but wodcst pan oftbe small intestine. 2. The ontcnor of the duodenum h;os fuldcd surface, which lncron>es the ovailablc surfncc UI'CII for ab~urption of sugars, fats, nnd aminu :ooids. 3. It is rerroperltoneat (lie behind rile perlm11com1). -4. It n:ceoves the common bile dutt and pancr~tk dut t at the duodt o l papilla (which i~ Q .mall, roomtled el~>ariQII ill the 1\'a/1 ofthe tlrmd1111111) 5. The .Juodcnum receives bloo<l from the superior llnercatlcodnodennl nrtory, a branch or the gastroduodenal artery, !111d the inferior poncreaticodnodeo l artery, a branch of the supcnor mesenteric artery. Importa nt : The sympt.othcli~ and parasympathetic divtsions of tbe autonomic nervou systctn control comruction of smourh muse Ius in the intc.,tinnl wall. (I) Sympatlletlc: The splancbnJc nerve p~es through the line plexu.. Postganglionic 6b<.'f!< innervate the snuU intt.<linc. Sytnpatheric stunulatioo slo" morlllty of tbe small intestine. t2) Pansyntpathetlc: Tbc vagu' ncne >llppltes a va.<l distribution of pli111Sympathl'IJO fibc.-s. Postganglionic libor~ from the celioc plexus ussociated with Ute vaguJ nen innervate the small mtestine. Parn. <oyrnpstbcuc <limulallon of lhc >mall intestonc causes oncreased motility. Note: The prcgangliomc paraympath<'tit neurons to the duodenum are located in the. dorsal motor ouclcus of the ''ogus uerve.

Tite e.~npbagus is a 10-lnch collopsiblo muscular tube 1.butlies dorsdlto the trlll:hea and ventral to the '1/Crtebru\ column. Th~ sopbogus is located behind the l!Uchcn in the lhOra.'<. Tioe esophagus extends fnun the oropharynx anoerior to ohe vertebral colllllUI. enters the mediastooum, leave.~ tbe tbon.x via the esoph~geal hlutns, and Jllln5 the stomach. The poilll whe.re the ~sophagu~ en(ls nnd the sto11mch begins is the esophugogutric j unction. The opening throu~h which the abdominal part of the o.wpbagus enters the cardiac portton of the stomatb is calltd the tsrdi c orifice. lmportan1: There is an abrupt chang<' in lbc type of surface epitbcloum ~~ the junction of the esophagus and StOtlllo ch- from 'lrntiiicd squamous to simple cnlurruwr. The esophu~:ea) wa ll comaios four layers. a> follows from the lumen omward: muCO!>n epitbc:hum, lamina propria. :md gland> .rubmucosa - connecuve tissue, blood vessels, and glands musculuris (11mldle layer) upper third, striated muscle; middle lbird. strintetlllnd smooth: loiVI!r third, smooth muscle adventitia conn~ctive llssuc that m~rges With connective tos~ue of suJTOunding structures The esophagus receive~ blood frotn the In ferior thyroid orter)', from branches of the d~scndlng thoracic aorta. and from brwoche" <lfthe left ~:asll'ic artery. ~cERO~ stands for gnstr()c!sophageal reflux disease, ond "Ball'ett'~ esopbogus'' is the metaplusia, or abnormnl change, in tho epilheliwn of the lower end of the esophagus thought to be caused hy Qhronic ~cid damage Remember: The esophagus T<'lves plll'Uyro pathetlc fiben. liom Ill~ e>ophgul branches of the vugus nerve. noe csopbagu~ receives motor Ober~ lrom the recurrent laryngeal branche. of the vugus nerve ;ond synJpothetic innervation from the esophageal plexus of nerves.

(ANATOMIC SCIENCES

GIS)

A newborn boy or J ewish ancestry has been vomiting frequently. Kis parents bring bim to the physician, who notes a narrowing (stenosis) or the opening from the stomach to the duodenum due to functional hypertrophy orthe s urrounding muscle. What is the name or the opening rron1 the stomach into the small intestines'/

Cardiac orifice Pyloric sphincter

Lesser omentum
Greater omentum

-
101 Copyn;ht 0 20092010 Dental Db

56

cA.l~ATOMJC SCIENCES
,

Gts)

All or the following statements concerning the liver are true EXCEPT one. """'

Wbicb one Is the EXCEPTION?

It receives blood from the hepatic anery and ponal vein It receives autonomic nerve fibers from the celiac plexus

Its function is to store and concentrate bile

It is the body's heaviest and most active internal organ

The caudate lobe of the liver is separated from the right lobe by the inferior vena cava and from the len lobe by the fissure for the ligamentum venosum The quadrate lobe of the liver is separated from the right lobe by the gal lbladder and from the len lobe by the fissure for the ligamentum teres
102 Copynlbl 0 l!DQ9.2010 0au1 Dfctt

57

'

Th~ stomaeh i a cullapsiblc. pOllt~hke srructurc ubout 10 tnth~s Jon~ and CUJKJblc ufholdmg 2

10 4 quans. Attact>ed 10 lbc lo"~ end of the e.<11>hagus, the stomch li<o unmedtatcly inferior to the doaphntgm and extend> 10 the duodenal p<>nton or the 5111111 mt.. tine Thc <lomach toes in the len upper quadrlll11 oftho,.Momonul cavil)'. Tho lmeral surface of doe swo nach i t-ailed the \II1:Atcr curvature: Ihe ou:dinllurtnce, tho lt.,er curvuture. The lt'fer om~otuRI llly<r uf the pcritoneu;n e'\h:nd.s around lllc .:~.lomath. and lht: Rrtaltromentum tt fOund along tbegn:at<r tuMtureoftbo llomoch. The tntcnorofUte \lomach 11 hned with rows of fold> oc wrinkltll. callod rug The stom;u:b has rour malo rt-ghma: t. Cardla: mmcdiutely ditlllto the ga<tt<>o,ophageal junction of the stomch and e.-<lpbOJl"' 2. fuodu.: C!!olory.-d portion distal to the cnrdia. tying ubove and to U.e ltll of the gasw~~1 <lpt11111!.

3. llod)': lbe middle or mam ponoon of the omch. distaltuthe fundus und tapennsm Bile,

4. l'ylorus: the lower p<>nion, betwL -cn the body and tho gn~trodundennl Jllllction. The liltnnach hilS 1hrct1aycrs ul Nmoolh mll'ioel .... L he ome.r lougitudh.al. thi.: middle dreulnr. and t.be: .nner oblique nu.tsefcs~ I. Th< llllXJmum capqclt) of tho stomach is 1\bout 3 to 4 Iuers. i\lit~ 2. The stomach re<>efv~ blood from all three br~nchcs of the eeli~c iir1cty. The lcrt gastric onery suppli~ the le:>ser cuovuture of Ihe fundus nnclthe body of the stoonoch. The right gutri< anery IS a loop llutt supplies the lesser curvature and then fomlS an onastomosi' with the let\ gamic antty. The ldt ond rlgbt gOJtro-omenllll anenes supply the greater c~~n<ature. Tbe rn~cosa 6 tho stomach contains many t:strk gland~ in the l;ommn proprio: Porietal /uxym'-'1 cells: located in fundu~ and body; ><'<rete HCI, Zymogtalc (o:lu~O cells: located in fundt"' und body; '"'"'' pepslno~en En~roendocrine cells: pn:.<enl duoughout tbe stomach: produce gutrin

lh luu ctwn h

In

''"n 'o uul

l'CUJcentrtrlh'

hil t:

This is false; the gallbladder ~iva bil<, Limctntrales it by absomin11 water aod snlls. and stores it until delivered to the dtoodt:num.
BUe IS produced Wid <ltereted by htpllllC)1es (/ll'f'ralfs), whlllh are !be most \m;atile ~lis in the bcldy. Bile is """'ed by the l"er into the roonmoo hep:liJc duct. A sh<>n <")">'lie duct lrom the gullb!llddcr joins the common hepotfc duct to fium h common bile duct, which llam;pons the blle lnlenorly to the duodcmno to help etn<~sily fin for digt!.1inn. Not~: Kutoffor tells IJne U~e sinusoid of the liver and function to filter bl!cl-ri and mm1l foreign l'llbciCll OUl of the bk>od. The liver is the hceviest and most active uuemal OIJl m the body. Many of the liver' fintetiuns are vital for life. NotTMlly n:ddish brown m color. the liv<-r ti .. under \he tover and pnote<:tion of the lower ribs on the rlghl side oft he ubdomcn. 'fhe liVer huN1 11111pp<.-r (dlaploragmatic) !Ro rfnce ond a lower (vircertJ/) surface; th<two surfuces III'C I!CJI'lfaled at UK: front by allhrup inft'rior borde~: The li,er isaJillcileclto the cliaphn8flt by the t'alci!onn, tmnf!lllar. and coroMt) llgomtnts. Tho li\-.:r 15 abo joined to the Aomachtnd duod<:num by the gastrohrpft!ic and bcpotoduodenalllgmtnts rt:$Joeotively. The vlscoral surfore of the liver 1s w t;onl~tl wnh the gallbluddc'<. ~Je right kidney, J)4llt l)f the duocknum. the esophllgu..... the stomach, nnd the hepotic flexure of the colon. '1M porta bepotb -the point where ,_., and ducts cuter Wid exit the li>-er- bcs on the venlnll <urface. fhe liver is divickd it)IO r\gl1l. kfl. raudalc, and quadrate lobes The quadrate and <::ltldate lube< are fUUC11(Hllllly pan oftheletllobe, nlthough they are separated li'om it by a f~ur on the Yi>cel'l11 side und by fue fq)cl fonn ligament on the disphmsmmic side. The liver ....:elves blood from two SO\oree>: the hepllti< urtory, which Stoppli,. the hver with OJ<Yb...,.ted blooJ from lbc aona, and the hepatic portal ,.cln. wlueh carries the products of d!p1011 to the for proot!o.<ing. This blood C\'mtUll\ly drain. via the hepatic veins into the interiQr vem cuvn, wbich ~<pMs thr blood uo the beart. ~emomber: The liver has di&cstive, metabolic, and re~ulatory fllDCIIOI1S. Its chief di~e<tive /Un(ltion is producing bile, which acts as fat emulsifier 1n the small mtestine.

u,..,.

( ANATOMIC SCIENCES

Gi s )

All of the following comparisons between the Ileum and jeju num are correct EXCEPT one. Which one is the EXCEPTION?

The mesentery of the ileum contains more fat The ileum has more plicae circulares (valves of Kerckring) and more villi They are both suspended by mesentery Less digestion and absorption of nutrients occur in the ileum

53
103

Copyn,ebl 0 2009-201 0 Dmtal Dll

( ANATOMIC SCIENCES

Gi s)

Peristalsl! for what organ is controlled by taeniae coli?

Esophagus Stomach Large intestine Small intestine

~-- 0 201)0.2010"""" O.Cb

..

53

1 IH ih.um h:.1' mun plir:ll' circui;Ut.'' (Will''' of had.,m::J anti uwn '1llt

nu< is false; tile jejunum has more plicae circulares (al-cs ofKerckrirrg) and mcm' vim. Note: Tho lower pan of the ileum has no plicae circularcs (WIIve. ofKercb1ng), Comparbon of the jejunum ond ileum: JejunllDI (mrddleponion ofsma/lmtestine): extends from duodenwn 10 \be ileum I. Thicker n1u<eutar wall for more active periStalsis. 2. Has a mucosal inner lining of greater diameter for absorption. 3 t las more (UIId larg0') plkae drculllre5 (vah'eS ofKRrc*ring) 3l1d more Yilli foc greater absorption. Ueum (distal portion of rile .<mall inresrine): extends fioot~ !he jejunum 10 the cecum L More mcscnlerle fa~ 2. \lor e lymphoid tissue (Peyer $parches). 3. Blood supply is morc complex. 4. More goblet eeUs. which secrete mucus.
Remember:

I. Valves or K.trckTinjt. The lining of !he sntoll intestine has penn:ment folds known as valves ofKerckring or plicae circulures. These arc most prominent in the jejunum. These folds, seen macroscopicully in tr.liiSversc S<!<:ltons, consiSt of muCOSll and submucosa. 2. Intestinal villi. These are fmger-like proJCCIIons into the lumen (ronsisrfng ofswface epithelium and under/yiuglamlno pmpria). The epithelium linlnt: the lumeo consist> of a simple columnar epithelium ";"'goblet coils. The apical surface oftbe absorptive epnhelial cells has a "bru~h border" (resulringfrom an orderly arro11gemem ofclo.u(\'-JXIC kcd mkrov/1/i, whidt may 1wmber several hum/red per ab.Jorpri>'f! cell). The rrotn functton of the microvilli i.s to increase the ~-urface area available for absorption.

Unlike those of the rest of Ote Gl trnct. longitudinal muscles do not form a continuous layer around the Jatt!e intestine. Instead, l.bree bands oflongirudinal muscle. called Utcolae coli, run the length of the colon. Contractions gather !he colon into bands (lwusrrn), giving the colon iL' "puckered'' appemancc.
The major funcuon of the Jatt!e lntesune (also called the colon) is !be removal of water from the material (chyme) entering it. Water is removed by absorption. Unlike !be small mteSune, !he large intestine does not secrete enzymes into its lunx:n. Histologic cbaractcristles: Epithelium: simple colu= with micro,;uns border to incrcllse surface area for absoqnion ofwater from the lwnen. Mucusseueted by goblet cells lubricates dehydrating fecal mass. Intestinal glands (CI)pt.' of Lieberltulm) invade lamina propria. 1l1c epilbeliwn lntks \1111. ~lusadaris externa: inner circle consisting of a smooth muscle layer. Contains the three bands oflongitudinal muscle, called taeniae col~ for pcri~1nlsis. Important; The vagus nerve supplies pat!ISyntpathetic fibers to the ascending and transerse colons, wh~e ~te descending and sigmoid colon along with the n.>Cntm and anus are supplied by the peMe splanchnic nerves.

(ANATOMIC SCIENCES

Gis)

( \.

Which cells, located In the crypts of Lieberkuhn, secrete an antibacterial ""' enzyme that maiotalns the gastrointestinal barrier?

Panelh cells Enteroendocrine cells

Sertoli cells

Absorptive cells

105 CopynJbl 0 2(1(19.2010

""'"'De<"

~NATOMIC SCIENCES
Which of the following Is not produced by tbe pancreas?

GI~

Lipase Trypsinogen Insulin

Cbolec:ystoltinio Glucagon

Amylase

58
~0

106 1009-2010 lkAtll Drtb

ChracteriJtic (Hht~ of the mll inrestlnt hu~lud~ ; lniHtioal ~nu. Tbt-sc. are fil1cr-Hkc. proJUunJ imo the lumen (coosuung vf n~r/r.C'C epulrtJiu, mm tmdtli)l,g lomr,a pmpritt).

The tpJOit-llum lining the lntnt::n ccU1SISt& ofn simph:~ t.'01Umnar t:p11hollum with goblet c~.:lhL 11\e p~<~l>11rface of rhe Absorpdve t'Pilhcllal cells ~.. "brush l><>rdtr" /t't'.wltfll!;[roiH un orderly ~~~g<'lrltnl qf closely-pack4!d Mlav'\illi 't'tltlch mo'' uwtbr Jt!''C'I'OI h~Jmi"'IQ ~r obsorpm~ ccfl) tbemam1Unc1ion oflbo nl<rv>tlli "10 lllCf<.,.lhc """""' areaa,.,lablc fonbsotpuon Tile lamia propria oftbt small int~tmc tS funned ftom 1(1(1~ oonnccmc: 11Ji:q,JC:. Thu. comalns blol)d ''"'"cis, nerves, and I4QIC lympharic v.,.Kcls (~fte u(<~b.wJI'PIIOn of/~111ft). " 1ntunnal g land~:. These. an:- shltple t'uhultar glands that open to the intestmnl lumen bt!!Wttfl the buc of lh< viUi. The inleslmal glands ""' somtrim<s c~llcd me crypl5 of LlcMrkdhn. Sc<n:<Ot)l cell> (Pdlld~ cells/ wi1h IIIIJ!< ac:l<lopbilie jp1tnu1<:s ""' tound th< blbt of lllc mlcstmal @lands Th<Jr runcnon 11 >1111 1101 fUlly Ul\d<1'5100d. bur II iJ; known !hal !hey <;ccr<lc ly$01.)'1nc, Wluch h3S anu..bacterial propcnies and helps mamtain che ~u.strointestiuul h~rrier. " Valves of K<'r('kring. The lining of the & mall hue~tln~e hiL!! pcnn11ncnl fbldK known :ti valvt::, Of
Kerckrittg or-plica' c1rcutaru. Th~ are mo~l pmminent 10 tht jejun11m. T11c:;~ folds. seen
IU2C~

IICO!lt<ally u> trOIII\<1'5<' section>. consi" orm... ._ ill1d subnlllcos8

Tbr IYP<> of l'jllthrllal tells line t~< micro' illl of lhc "brdsb budr": I. Cobld cellJ: SC\.Tt1t mucu..~, abundA nt ln lleun~. l Absorptlve tclb: pan-lei pate: 1n absocplion, simple cohunnur celts_ J. Entrr-oe.odoulne teJI.s: am.: entuo,gilitrOncs '"'rrtiJH 1/J~td rlwlet.)Jtc*l_,ild intO the
S:\(t":ml. Abundant In tbe dt.todtnum.

hltk~

lte.mem\u:n 1 Rrunner'l ghu1d! (also collt.rl dkocleual sltmds or subnmoosal g/Mu/.ld urc small, brtlnChcd.

coiled, rubular aJonds sillmleJ di:cply '"~.. aubmucosa or tht duodenum. 11\es<: glands >CCNIC an

eiJah,.. mll<ll> 10 proreot U.: wills oflhc Jnlt$1Uial ]wee. l. The Utum to11tams aggrepl<s ofme.mrenc lymph nod<:Ji callod l'e)tf"> pllcbcs, "hl<h imcrOtpl and d.,.,y bcei btfor< hey ~,. lolbed by O.e diao:srive l/'llci.

( hnlt>n \tn~ in in

The pancreas is an elonga1ed gland lying behind the s1omach and in fronl of th~ aorta and inferior veuu cuva. The 1t1rge bead ufthc pancreas is framed by the C-shapcd loop oflhe d~odenum. Ex1endio,~; to lhe left from 1he bead regon are the n<:dr, body, und tail or lbe pancrea$, respe<.'lively. The tail mee1~ lhe spleen on the left of abdonlcn. Pancreatic secretions are collected by lhe main pancreatic duel (and occe.ssol}' pnurre"''" tiltcl), which, logelhel' with the bile duel, en1ers lhC duodenum at 1he duodenal ampulla (ampulln of Var..r). Most of the digcs1ivc process takes place in lhc duodenum, due lo !be acuon or paucreauc enzymes. The e1ocrioc portion is fonned by sccre1ory cell' anangcd in small sacs cnUed (inl, which secNie digestive tnzymCj; callud pnncreaUc juice.t inlo rhe inlestinc, The endocrine portion consisiS of clusten. of cells called pancreulic Islets (islars of LangerlruiiS), wbich an: scanered am()n~ the acim. The:.e cells pr\lduce insulin 11nd ~lucagon, bortnones lhat promote the cellular uplake of glucose and Ill< btcakdown of glycogen. re,,pocrively. I. Endocrine portion (.rerreles lnw t.locdsrrwtm) tiJC following enzymes: paucrcatic Upa., amylase, e<~rboxypcptidase, ela.~a<c, and dt}'!OOirypsmogen. I< lets of Langerban (cell Qjpanctro:J): Alpha cell.: =rete glucagon. Which counters Ihe RL1ion or insulin Bela cell~ secrete insulin, which promoles uplakc and swruge of gluc<)Se 2. El<ocrine portion (.recn:re.v lhmugll tlucr inlo lltwdenum): ><:cretes lhe following enzymes: pancrea1ic lip~. amylase, carboxyp<!ptidase, ela<tose, ami cbymOil')'p;inogeo. Acinar cells produee en~ymes th111 digest proteJIIS, carbobydrotes, and faiS. Trypsinogen i8U1en converted to trypsin iJ11he small imestine Note: Cbolccystoklolo is produced by the duodenum and regulates pancreatic juice

tl

secr~tion.

( ANATOMIC SCIENCES

\,

Which muscle separates the anter ior cervical triangle from the posterior cervical triangle?

Trapezius

Omohyoid Mylohyoid
Sternocleidomastoid

......__
~

59,@,61
107
O:lp)'li.@bl 0 201-2010 Dttalal llr'b

( ANATOMIC SCIENCES

All of the longiludinal muscles of the pharyn are innervated by tbe vagus nene via the pha ryngeal plexus EXCEPT one. Which one is the EXCEPTION?

Stylopharyngeus
Palatopharyngeus

Salpingopharyngeus

Sllrnlll'llidllfll:t\lllid

The neck can be further divided into triangles, the two most import:lDt being the anterior and posterior cervical triangles. The anatomic borders of the antenor cervical triangle are the medial portion of the sternocleidomastoid muscle, lbe lower border of the mandible, and the midline of the neck. Imporwnt stJ11cttarcs within this triangle arc the carotid arteries and jugular veins, thyroid gland. esophagus, trachea. lai')'OX. and vagus nerve. The posterior cervical triangle's borders are the lateral edge of the sternocleidomastoid muscle, trapezius, and clavicle. Important structures within this region are the subclavian artery and vein, suprascapular artery, and brachial plexus. The posterior triangle of the neck can further be subdivided into: I. Occipital triangle lying above the inferior belly of the omohyoid muscle. Contents includes the spinal accessory nerve (CN XI) and the superficial cervical cutaneous brnnches of the cervical plexus. Part of the occipital and parts of the transverse cervical and suprascapular arteries are also found in tbe occipital triangle.

2. Subclavian triangle lying inferior 10 this muscle.

Contents includes the superior, middle, and Inferior trunks of the brachial pinus, suprascapular nerve, and artery, the subclavian artery and vein as well a.s the external jugular vein. Important: Muscles that usually appear in the floor of the posterior triangle include the medius scalene, splenius capitis, levator scapulae, nnd the anterior belly of the omohyoid.

The stylopharyngeus is innervated by the glossopharyngeal nerve.

I 1111\,!tludm31 \ln ..dt.-.. of lh' l'h.tf\11\

Musclr
Styloph"'Y"&<"-'

Origin

Insertion

Aetlon

Styloid PfCHX:6JI of tcrupOnil La!tral and posterior boa< rtwyngeal "-.lis

Posoerio< border or Ill< bani ~ond palole ond from lhe pohtin< 1h)'f0td cartilage:
aponeuro~&ll

Elevates the larynx and ~4/YOA durina swallowing

Pala...,...._

Pulls Ill< wall of !he rharyn< upward Actin& tO&ecbet.lhey pull lbe palatorharyngeal arcbc~ 1<>ward lhc midline

$31 pingopl\:ar)'ncut Lower pan of the eartil:age

or.... aoci<IO<Y '""'

hben. pus downw1rd Assists in cleonting the pbl.tyM. and bttod "lib tt.c pat...
IO(>horyugou> , _..

( ANATOMIC SCIENCES

The functional unit of a skeletal muscle is a :

Fiber Sarcolemma Myofibril

Filament
Sarcomere

62
109 CopynatJtO 2:0092010 Ottlu.l DkJ

( ANATOMIC SCIENCES

~ nervous dental student is performing local anesthesia for the first lime on oJ
of his peers. He has read his notes meticulously but is still very shaky. After the inferior alveolar nerve Injection, he gains confidence and performs the rest of the injections without a hitch. The nut day, the classmate whom he performed injections on is complaining of jaw pain and the Inability to open his mouth. Which muscle did the nervous student penetrate during the IAN injection, which, along with the masseter for ms a sling around the mandible?

Temporalis Medial pterygoid Lateral pterygoid

Buccinator
Posterior belly of the digastric

63 64

~Hn..'H111l'rl'

Each skeletal muscle fiber is SUJTounded by a membrane, the sorcolemma. In the muscle fiber's cytopi3Sm (sarcoplasm) are tiny myofibrils, arranged lengthwise. Each myofibril consists of two types of fi~r fibers called filoments (thick myosin filaments and thin actin filaments) . The filaments are stacked in compartments called sa.rcomeres, the functional units of skeletal muscle. During muscle contraction, the sarcomere shortens when tlllck and thin filaments slide over each other. The striated partem that is so cbaractcnstic of skeletal muscle directly results from tile strucwre of the contractile units of tile muscle. Each fiber of the muscle 15 striated and made up of many myofibrils, which are also striated in the same pattern of alternating dark and light bands called the A bands and I bands, respectively. In the center of each A band is a lighter zone called the H zone; in the center of each I band is a dark, tllin line called the Z line. The portion of a myofibril between two Z lines C{)nstitutes a single contmclile unit termed a sarcomere. Each sarcomere is composed of two sets of protein fLlaments. n1e thick myosin filaments are located in tile A band. n1e thin ucll n filaments nrc located primarily in the 1 bonds but extend Into the A bands. The overlap of the actin and myosin lilnments causes the dark coloration of the A bands.: actin's absence from the center of the A bands results in tbe lighter H zone of eacb A band.

\Jtcli,tl

phJ \

t!Uid

The angle of tbe mandible rests in this shng. The medial pterygo1d muscle arises from the medial surface oftlte lateral pterygoid plate and inserts on the me-dial surface of the angle and ramus of the mandible. Important: The medial pterygoid. ma..seter, and tempomlis (main/)' anterior portion) elevate the mandible during jaw closmg (brring and chl'wing).

r I. The superior origin of the Intern! pterygoid muscle is fiom the infratemporal /Notes crest of the greater \\1ng of the sphenoid bone, and the inferior origin is from the lateral sur face of the lateral pterygoid plate of sphenoid bone. Both bca~ insert at the articular disc of TMJ and neck of mandibular condyle. Remember : The mandible IS protruded by both the action of both lateral pterygoid mu.~cles One muscle causes lateral deviation of ~tc mandible (shifts mamlible to opposite side) 2. The masnter muscle originates from the lower border and medial surface of the zygomatic arch. The muscles fibers run downward and backward to be nnacbed to the lateral aspect of the ramus of the mandible. 3. All of tlte muscles of msticatlon are innervated by the mandibular division oflbe trigeminal nerve.

(ANATOMIC SCIENCES

The most minor manifestation of a cleft palate " ould result in a bifid:

Soft palate
Hard palate Uvula Glossopalatinc arch Pharyngopalatine arch

6
111 CopynjJtltC> 2009-2010 Dmtal ()(<lJ:

(ANATOMIC SCIENCES

Mst)

Which of the following musdes pulls the shoulder downward and forward?

Pectoralis major

Pectoralis minor Teres major

Teres minor
Deltoid

latissimus dorsi

66,6J,68
eo,.,... 0
112 ,..,.2010-.. O..b

+<:..

l 'ula

The palate is the roof of the oral cavity, oonsisting >tuenorly of the bony hard palate and posteriorly of ~ :.on palate. Transvene ridges, called palatal rugae, are located along ~ mucOU$ mcmbl'lllC$ of the hard palate, where they S<'rve as fricuon bonds agoinsl "hich the tongue ,. placed during swallowing. The uvuJa is suspended from the son palate. During swallowing. the soft pahuo and uvula arc drown upward~ closing the nasopharynx and prevcnling food and fluid from entering the nasal cavity. The neurovascular bundle or tJtc soft palate i:t the lesser palatine vein, artery, ond nerve. The pharyngeal plexus of 11<1'\es supplies the uwlar area. I. The apenure by which ~mouth communocates with the pharynx is called the b th Noteo' mus f~ucium. It is bouuded, atxwe. by the soO palate; below, by the dorsum of the tongue; and on ctthcr side, by the glossopalatinc il'()b, 2. The glossopalallne (palatoglossus) art.h (antfJio pi/laroffauces or anteriorfaucial plllar) on eilhcr side runs downward. laceralward, and forwaxd to the >ide of~ bose of the tongue, and IS formed by~ pr<>jection of the palatoglossus muscle with its eo><r &n_g m\JICOUS membrane. 3. The ph.aryngopalnrine (palatO[Jiwryngeal) arch (pa.sterior pilim<>,{ fa uces or paM< lor f aucial pillar) is larger and projects farther towurd the middle line than the aJJicri or; the pharyngopalatine arch runs downward, lateral, and backward to the side of the pbarytllL and is formed by the projccrion of ~ pal>tOplwyngeus muscle, covered by mucous membrenc. On eith.er sode, the two an:h.es are separnted below by a tnanaulor mterval. in wbieh 1he palatine tonsil is lodged. 3. The palatal sllvary glands aro fou nd beneoth the mucous mcmbrnncofllle hard and son palaCe. They arc mostly of the mucous type and contribute lo the ornl fl uid. 4. Bifid uvuJa results from lailurc of complete fusion of the palatine shelves. A unilllt <rally damaged pharyngeal plexus of nerves caU>e> th.e uvula to deviate to the oppo>tte S1dt. This is because the uwlar mu).tlc shonens the uvula when Jt contracts and the mus..cle on tbe intact side pulls the uvul~ toward that side.

Muse It

Ner\e supply

Actlon
Addu cit the ann and 1 '\Hate:'l it medially

Pectomi1S major \.fcdiaJ Md lateral pectoral

nerves (rom medial and latcral cords of

bnt<hial piCJ<IlS
Pectot1 h ~

mioor

~iedi1l

pecoral ner"\ e from media)

Pull~

the s-houlder downward and forward

cord o(bmchial pleXU.'i Latissimus dorsi Thoracodorsal ller\IC rroru poo~teri Qr

Extnd~ ad ducts, and mcdtalty
rula t~ lhe arm

cord ofbr.chil plexus

D<ltotd

Axillary nerve (C5 and C6)

Wuh tit< belp oftbo S\JJ)R>puuiUS mu~k. t abduru the upper limb tU the shoulder joint Mtdtlly rotates and Mdduc:t5 the -arm
LattraUy rota.l8 tht' t rm and stabi1 ~ lht-

Terei mjor
TettS minor

Lo\\'er subscapul ar nerve from po$tcnQt cord of brachial plcxu$

Bmocb of uillary nerve

houl<l<f joont

GNATOMIC SCIENCES

Ms~

All muscles of mastication are innervated by the:

Ophthalmic division (V-1) of trigeminal nerve Maxillary division (V-2) of trigeminal nerve Mandibular division (V-3) of trigeminal nerve Facial nerve {Vll)

6364
l1l CW>'nCIJI 0 1009-2010 Dttatal Ded.t

~ATOMIC SCIENCES

A 5-year~ld boy presents to the physician with tonsillitis. As part of her exam, the physician asks the patient to stick out his tongue and say "AAAH," in order to visualize the tonsils. Which muscle is responsible for the protraction of tongue?

Hyoglossus Styloglossus Palatoglossus Genioglossus

\ l:tndihular eli\ i'iun

(I-~~

nf lri~cmin:tl twn t.

Mastication is defined as the phystcal process of chewing food in preparation for swallowing and ultimately digestion. Four pairs of muscles in tl>e mandible make chewing possible. These muscles can be grouped imo two different functions. The first group includes three pairs of muscles that elevate the mandible to close the mouth. The second group includes one pair of muscles that works to depress the mandible (drop the jaw), translate the jaw from side to side, and protntde the mandible forward.

All are innervated by the mandibular division of the lrigeminal nerve ( V-3) - S~t! note below. They receive blood from the pterygoid portion of the maxillary artery.
Remember: I. The masseter, temporalis, and medial pterygoid - close the mouth (elemte the mandible) and hence account for the strength of the bite.

2. The lateral pterygoid -- opens, shifts (from side to side), and protrudes the mouth
(or mandible).

Note: There is one motor nucleus, a special visceral efferent (SVE) nucleus, associated with the lrigeminal nerve. It innervates the muscles of the first branchial arch, which consists mostly of the musdes or mutkation. They also include the ttnSOr tympani and several other small muscles. The nucleus is located in the mid pons nt the level of attachment of the trigeminal nerve to tbe brainstcm. fibers of the trigeminal motor nucleus emerge as a separate motor root.

Paired extrinsic muscles originate on structures away from the tongue and insert onto it, causing tongue movements dunng speaking, manipulating food, cleansing teeth, and swallowing.
\lu,.:lt, nf lht I nn:,:m

MuSt It

Origin
spine of mandible

tnse,rtion

Action

Innervation
Hypoglossal
n<T\'C

Genioalosa:us Supt-rior genial

Slyloglo-"'i Sl)llood!lfO$SOf 1emporal bone

01.)Bum of tol\aue Protrmlc,s apex of tons:ue lhrolljb mouth

IAI<t1ll.;de and

Draws W>c1gu< upwotd and

Oeprc:ms tooguc

Hypoglo<sal
nerve

dorsum oftcmguc backward

Hyogi<>Ssus

Body and greater Side of tonuc cornu of hyoid bone

Hypoalossal
O~J'\~

Palatogl.-..u. Pallone aponc:uro11is

Side of tongue

Pulls root of tongue upward Ph&l)'llj;cal and b11ckward, narrows plc-~tu5 orophal')'l\geal isthmU5

GNATOMIC SCIENCES

Most of the muscles tbat act on the shoulder girdle and upper limb joints arc supplied by branches of the brachial plexus. Which of the foUowing is not?

Levator scapulae Rhomboid major Rhomboid minor

Trapezius

Serratus anterior
Pectoralis minor

Subclavius
115 Copyrilh' 0 2009-:WJO fkma) D-b

6~

(ANATOMIC SCIENCES

,.

A !~year-old girl who is just about to have her junior prom comes crying Into the physician' s office, but is lacrimating onJy from her right eye. The left half of her face Is also par alyzed, and the physician diagnoses her with BeU's palsy. An oral exam reveals trauma to her buccal mucosa where her teeth have bitten her cheek. Which muscle, paralyzed in BeU's palsy, is responsible for keeping mucous membranes out of the plane of occlusion and food out of the \.. buccal ' 'estibule? ~

Medial pterygoid Lateral pterygoid

Buccinator
Masseter Temporalis

70,7J,72

\lmdh nf fht t\clunl <.irdlt

Mnsclt
Scrrotullo anterior

Acllon
Pulls scaruiB. forward and downward

luntn arlon

Lwtg thomcie nerve, which 3rise' from roob CS, fi, o.nd 7 of the bn<hill pt.,...
Mooial poc:oonl_,. from

POCUMah$ mmor

Pulls the $boulder dov.-nwMd and forv.1U'd Depresses the chtvic:lc and steadies this bone

medial tordorbrachi.aJ r1cxus Subclavius during movements oftbe shoulder gird1e

Tr::t.pntus

Nerve to 1hc :ittbclaviu.s from che UPf'<' INn~ of<he bnchaal piau>

Susptnds the h011lder ginllc from tbe skull and th Motor tibctl from the ).pn1at ve11ebml column. The upper fibers tlevatc the part of1he o~cessory ntf'\le and <en<Clt)l tlb<cs fmm lho dtinl scapula. The middle fibers pull the scapula medially. The lower fibers pull the medial bordtr ar.d fourth ~ervieat nnvts of tbc scapula downwanlso tbat !he glcoood oavtty factS upwmJ and forward

Lcv1th1r scapulile

Raises the medisl border of the 5Cilputa

Third n.nd founh ten'icul

oerv~s and from the tlor!ml
sa~pubr ncr>c

(CS)

Rbornoo!dmi,)Ot"

Wttb !he rhomboid minor and l...tor 5cap111,... it Donal s.;apulu """" cC5) elevates the mllal border of the scapula and pulls it medially

Rhomboid mlnur

With the rbombo1d major Md levalor sc-..a.pulae.. h Dorsal ;copulllr ncne (CS) elevates Ill< mc:dl border o f llt< =PU~ and pulls

itmtdi>lly

Hnnin:uur

The buccinator is one of the muscles of the cheeks and lips. On each side, the bucctnator has

a complex origin from:

Tbe maxllla along the alveolar process superior to alveolar mrugin horizontally ~ween the anterior border of the first and lhird molors The mandible along the oblique line of tht mandtble be1ween the first and third molars The pterygomandlbulor ligament The pterygomandlbulllr raphe: a thin, tlbrous band running from the hamulus of the medial pterygoid plate down to the mandible ltlnsens at OJbtcularis oris and skin a1 the angle of the mouth. It is trtlverscd by the parotid duct.

It is not a primury muscle of mastication - it docs not move the jaw - and this is reflect ed ln the buccinator's motor innervation from tbe facial nerve. However, proprioc<ptive fibers are den' cd from the buccal branch of the mandibular branch of the trigeminal nmc. The actions or the buccinator are tO: I. Move boluses of food out of the veslibule of the mouth and back towards 1he molar teelh. 2. Tense lhe checks during blowing and whistling. 3. Assist wilh closure of the mouth. --. I. The facial and maxillary arteries supply blood to buccinator mloS<:Ic. Not.. 2. Food accumulating in the vestibule might suggest tbat the buccinator is uot workil\8 properly. 3.1fthe point of a needle enters the parotid gland during an mferioralvcolar mJec lion and solution ts deposited ln the gland, the most likely result is pQni.lysls of Ihe butclnacor muscle. 4. Damage to tho facial nerve or its branches may cause weakness or paralysis of facial muscles called Bell's pals)'.

GNATOMIC SCIENCES

(
"'"

AU of the following statements concerning tile tcmporalis muscle are true ""' EXCEPT one. Which one is the EXCEPTION?

It is fan-shaped and originates from the bony floor of the temporal fossa and from the deep surface of the temporal fascia

The anterior and superior fibers elevate the mandible; the posterior fibers retract the mandible It inserts on the coronoid process of the mandible and the anterior border of the ramus of the mandible

It is innervated by the maxillary division of the trigeminal nerve (V-2)

It is considered to be one of the muscles of mastication

63 64
111 Copyngtu 0 2009-2010 Oo.al DcckJ

(ANATOMIC SCIENCES

Mst)

( All of the muscles of the soft palate participate in closing the nasopbaryru ""') \. du ring swallowing EXCEPT one. Which one is the EXCEPTION? ~

Uvular muscle Palatopharyngeus muscle Tensor veli palati muscle Palatoglossus muscle Levator veli palati muscle

118
~0

:101)9.2010"""" DKb

I t b~ illtll'natld In th~ ma\ill.ln di\ isiun uf thl' tri1!l'ntinal ll\'l"\\' ( I -!)

This is false; the ttmporatis muscle is innervated by the deep temporal nerves, which are bnmches of the mandibular division of the trigeminal nerve (V-3). The tempo ralls muscle is a broad. fan-shaped muscle of mastication on each side of the head that fills the temporal fossa. superior to the zygomatic arch. This muscle originates rrom the entire temporal fossa. The temporalis then passes medially (downward and deep) to the zygomatic arch as a tltick tendon before inse11ing on the coronoid process ---. 1. The primary function of the anterior portion (fibers) of the temporalis Not.. muscle is to elevate the mandible. 2. The posterior fibers retract tbc jaw and maintain the restiog position of closure of the mouth.

Five paired skeletal muscles of the soft palate: l. P alatoglossus muscle: puUs the root of the tongue up'vard and backward. Both muscles conttachng together eause the palatoglossal arches to approach the midline. and thus the opening (oropharyngeal isthmus) between the ornl pharynx and the mouth is narrowed. 2. Palatopharyngeus muscle: pulls the walls of the pharynx upward. Acting together, the muscles pull the palatopharyngeal arches toward the midline. 3. Uvator veli palali muscle: raises the soft palate. 4. Tensor veli palatl muscle: the two muscles tighten the soft palate so that it may be moved upward or downward as a tense sheet. This muscle curves around the pterygoid hamulus. Therefore, if lhe hamulus were fractured, the actions of this muscle would be affected. 5. 1Jvular muscle: raises (and shorte11s) the uvula to help seal oral from nasal pharynx.

Important: All the paired skeletal muscles of the soft palate are innervated by the pharyngeal plexus except the tensor veil palatl, which is innervated by a branch of the nerve to tbe medial pterygoid, which is a branch of the mandibular division of the trigeminal nerve (V-3) .__ I. The anterior zone of the pulatal submucosa contains fat, while the Notes posterior zone contains mucous glands. 2. The sahvary glands of the bard palate are located in the posterolateral zone. They arise from ectoderm and are separated by connective tissue septa.

GNATOMIC SCIENCES

\..

Which of tbe following travels with the esophagus through the esophageal opening in tbe diaphragm?

Aona

Thoracic duct
Azygos vein Vagus nerve

Right phrenic nerve

73 74
111 Cop)Tichl 0 20091010 Deo.tal lkds

GNATOMIC SCIENCES

Which of the following two sets of muscles raise the ribs during Inspiration?

External intercostal muscles

Internal intercostal muscles Innermost intercostals

Subcostal muscles

Transverse thoracic muscles

*** You can rememher this because the vAGUS travels with the esophA GUS.
The diaphragm is a flat muscle in a dome-like shape that separates the chest cavity from the abdominal cavity. 11te diapltragrn ~ pierced by several stnlerures lh." pass between the rwo cavities. The three largest of these Stmctures are the esophagus, the aorta, and the inferior vena cavn. 1'he central p11rt of the diaphragm is the centrnl tendon, whtch is fibrous rather than muscular. Tho undersurface of the diapl\ragm fonns the roof of the abdominal cavity, and Ucs over lhe stomach on th4e lefl ond the on the right. When the diaphragm contracts, it puUs down imo the abdomen, lhus creating a vacuum in lhe chest cavity that draws 3ir into the tun~. Exhaling is done by contracting the mus cles of the abdomen to force he diaphragm upward when it fs relaxed. Duri ug iusplrntion the dinphmgm move.~ dowo, increasing the volume in tbe dlmuctc cavity. During expi rA tion !he diaphragm moves up. decreasing the volume in the thmacic cavity. The upper surface is in contact with the hean and lungS: the lower ~urface cont!!CIS the liver. smmacb. and spleen. lmportsn t: The esophagus passes tb rnugh the diaphragm, while the OQI'\0, azygos vcm, and thorucic duct pal> posterior to it, The diaph ragm has th ree openings: I. Aortic opet~ing: transmits the aona, \he thorncic due~ and \he 8)gos vein. 2.. Esoph~gcal opening: transmits the esophagus and right and left 'agu.< nerves. 3. Cava l opening: transmits the inferior vena cava and the rlgbl phrenic nerve. Other rcs(llratory muscle> iucltod~ tlte external, intemaland innermost intercostals, sub costal, and 111lllsversus thoracis. These muscles an: all iunerva!ed by the iotrrcostal nerve while lhe diaplt ragm ;, Uln~ated by the phrenlr nerve. Not<: Tlle phrenic nerve travels ilirou~b the lhorax between the pericardium and the pleura.

Ji,.,.

l \hrn.ll lllll'fl'tt'lohtllnu\c..'lt>S

Suhcn,l.-tl mu' cll''

m~or touscle.s

Tbe thorax comains vital stmc!Urcs thnt enable such functions as brenching to occur. Its are the thoracic waU ancJ upper limb muscles as "ell 115 the diaphragm. Anterior thoracic waU nm!de$ Include: External inten:ostalmuscle.o;: eleven nn each side between the ribs. ~from rib to nb and run at righc angles to lite fibers of the internal and cnnrnnost muscle6. Continue toward sttmum us the internal intercustal membrane. They raise dJe ribs during insplraUoot. In ternal intercostal muscles: eleven on oach side between the ribs. 1 hey cooUDUA! toward the vertebrnl column as !he postenor intercostal membmue They d epress the ribs d uring espiration. In nermost intercostals: nm in !be !lame direction as internal httcrcostals but ure scpurnted from them by nerves and ves.els. Action unknown but probably thd srune us interuut inte~~;ostals. Subwstal muscles: originate on the inner surface of each rib ncar 1be cosllll!lllgle and insert on the inner surfuce of the first, second, or third rib below. They raise the rib~ du ring Inspiration. 'T'runsverse thoro1clc muscle.s: uttuch the pOsterior surface of tile lower sternum to the internal surface of coslal cartilages 2 lhrough 6. These mU>cles pull the ribs d o"n"nrd during explrution. lmportnnt: The.e muscles ~re all innervuted by !IJe corre;;ponding Intercostal nerves. Remember: The diaphragm is the lliJiin muscle n:pon,ible for quiet b realhlnll. The diaphnlg:m is innervated by the phrenic ncn-e.

G NATOMIC SCIENCES

Mst)

Name the molecule that lies along tbe surfare of F-actln and physically co\ers aetln binding sites during the resting state.

G-actin Tropomyosin Troponin Light meromyosin Heavy meromyosin

121 Cop)Tiihl 0 2009-1010 Drmal DL1

(ANATOMIC SCIENCES

j All of tbe muscles of the quadnceps group serve to extend or straighten the \ \... knee. Which one also Oexes the thigh on tbe pelvis?

Rectus femoris Vastus lateralis Vastus intermedius Vastus medius

76,7J,78
122
CopynF< 0 l009-:!010 Ocoul Docb

I ropnm~u, in

Tbe main contractile system of all muscular ttssue ts based on the uller<tcttoos of two proteins. actin and myosin . The system of these proteins is sometimes called the aclinmyosiD <Ontractilc system.
Actin filaments (tlrin mrofilaments, $-8 nm in diametet) ure composed of: Actin: globular aciin (0 -acrin) molecuks are tUTangcd into double helical chains called fibrous actin (F'-ac1ilr) Thopomyosin: long, thread-like molecules. lie alon11the surface off-actin strands and physically cover actin bindin& sites during lhe resting state Troponln: a small. oval-shaped molecule attached to each tropomyosin

Myosiu ntaments (Ihick myofilmueuls, I 2-I 8 11111 iJotliameler) are composed of: '1yosln, which has two componentS: I. Light meronl) O Sin (LMM) makes up the rod like bckbooe of myosin fila
mtnts.

2. Heavy meromyosin (ffMJ.t) fonns the shorter globular lateral cross-bridges. which link to the binding sites on the nctin molecules during cootruction. Skeletal muscle cootrcts when a stimulus from the nervous system exettcs the individual muscle fibers. This stans a series of events that lead to interactions between the myosin {tilickfi/amants) and nctin (1/rin.fi/aments) of the sarcomercs of the fibers

The tb1g.h ha~ htO djstiocl muscle comparln1tnts (unterior u"d fKJXterio') that nre ~eparettcd by connective t1s..~ue (deep /usda). Arisu~g from the upper two~thirdo~~ of 1he femur. the quadriceps ftmorl5 muscle fonns the major muselc mass of the (rom and outer s1de or the thigh (mrreriur compmtmcntl c:overin" most of the front and sides of the: ft.-mu.r. Tlw: qu.dnc<p$ femoris bas four parts - (ul/inMnored byf~... ,..I ,.<TW) Re<:tu femoris: extends Of strughtens the knee ond alS<> Ocx the thigh on th< pelvis Vastus lotcratis l Vastus intennedius ~ All exrcnd or stmlghtt n the knee Va"tu.s medialis t The: I~ is dtvided into thrte companmeuts, W1ih the a.attrlor oompar1ment conrnlning lhe mUS(les tba11110\C the fOOl upw>nl (!l<mfj/<xlhoolll<). The blenlconprlment oootlll\> ot,c fibWans lonp" and libulari brevi> muscles. which are respoohtbl< for tumong the sole of the fOOl outward (e\'tr$ltm) The pmftrlor romp3rtmenl or the leg conusins lht plar nor tlexors. 'rhe bamstring muscles. lie tn the posli.!rlur eompartment of the thigh,. The hutwnnng muscle _group consi.s~ oi three n\Usclc:$: Boceps f<mOris l Tlw: tumstring muscles 1\mcnon to utcnd the h1p JOint aQd 0 the: Ia>.., Semotcndinosu, IJoliU. All are 1Rn<l'V3tcd ~ the ttbial """"' exc:<pl die Shott bead or the .. Semin\tmbranosus l bi~ femoris. which s inocrvacod by the conuncm fibular nenr:. The pusterlor compltrtmcnt or the calf region contains numt."f'ous muscles. (lividcd into two groups: superfidai Bnd deep. The supcrOctaJ gnwp contlins the powerful g.astrocnc:mlu:s and soleus mU$CIC$. as well as th< plantaris m"""le, wbich ore eritteal to pushing off from he ground (p/IIJ1rorflalun ofth Qll/dJOII) during \\'3ll<Jns. running, ond jum)llng, and wben Slllnding 011 IO<S. The deep c,n>up contams. the popliteus, flexor dignorum Jon~. flexor hallucls longu.\, and the t.1b1alis poster1 or muscles. n1~ llu'8CSt of these, llcxor llallucis longus, i11 critical for pu~hmg olf f1'0m the big toe aurinx walking .Nott: All of the mu.~ les of the- posterior .:omprlment (JI4f'trficlal u11d tfn:p) of the calf n:glon m imlervatcd by the tibial o t i'>O.

one,

GNATOMlC SCIENCES

,.Which of the follo,.ing muscles of the anterior abdominal "all, when present," I I\.. is innervated by the twelfth thoracic nerve? .J
External oblique Internal oblique Transversus Rectus abdominis Pyramidalis

79,80,81
123 CopyrigblCI2.0(19.201 0 'l>ent.al Dks

0-NATOMIC SCIENCES

The middle pharyngeal constrictor muscle attaches anteriorly to the hyoid ""' bone and the stylohyoid ligament. Like the other pharyngeal constrictor muscles, this muscle inserts posteriorly into the:

Fibers of the buccinator muscle Posterior border of the thyroid cartilage Median pharyngeal raphe Palatopharyngeus muscle

SJ

I'~ ramicl:lli'

\Ju,dl' ullhl \niL"riut \hdonun.tl \\ olll

Muse!<
Extem.a1 obhquc

Action

lnnerv1tion

SUpporu: abdom1n&l c:ooseob. co~ abdomi- lower ,.,-A thorK1C nm-es naJ contents; usisu in flexing and rotation of trunk. and oliohypopslric and
Ass1s1s in forced expiration, micturition, dt!fccarion, iliotnguinal nervc:~~o (L I) panurition, and vomiting

lrurrool obloque

S.meuabon

S.m. .sabo~
Samt
IJ lb01't

f
1

Tratm--ersus

Comprc:s::sc:s abdominal contentS

column~3CCC3SOty

Rectus abdominis P)tamidolis

II(pmetl

Compresses abdominal content$ and flexes venebral Lowt1 six thoracic nerves mU$Cle o(upinttion
Ttl!,.. obc linculba
1\\clfth thoracic tltnt'

--,. I. As the spermatic cord (or round ligament of the uterus) passes under the
Not.. lower border oflhe internal oblique, the spcnnatic cord carries with it some

of the muscle fibers that ore c~llcd the cremaster muscle. 2. The posterior abdominal muscles include psoas major and minor (innervated by the lumbar plexus). quadratus lumborum (innervated by the lumbar plexus). and the iliacus (innerl'ated by the femoral nerve).

The constrictor muscles of the pharynx are involved in the digestive process. being responsible for moving food down to lhe esophagus~ The stylopharyngeus. along with the deeper muscles of the palatopharyngeus and the salpingopbaryngeus, are mvolved in elevating the larynx.
( 11 ~ ular

\lu,ch"' uf I he

J>h,tn 11\

")1uscle Superior constrictor

Middle

Origin Pterygoid plaoe of ilic splte..,id bone

lnser11on

Action uppcrplwynx

Median pharyng.eaJ naphe Constricts

constrictor
Inferior constrictor

<fteattr and lesser boms ofhyoid: stylobyoid ligaroen1

An:b of cricoid and obliquo line of lhyroid
eanila8<'

MO<b>n phuyngeat ,.phe Com1ncu lowtr pharynx

Medi3n pbatyngc:al raphe Cons1ric:ts lo~cr pharynx

1-. 1. AU of the circular muscles are innervated by the vagus nerve via tbe pharyn ' Not.. t:l plexus. 2. The stylopharyngeus. palatopharyngeus. and salpingopharyngeus are aU longitudinal muscles of the pharynx.

(ANATOMIC SCIENCES

r
I

\..

The connective tissue layer surrounding each indh,ldual muscle fiber is called the:

Perimysium Epimysium
Endomysium

125 CopyriJbl C> 20092010 rkn!#l. t>ecb

( ANATOMIC SCIENCES

r At a picnic, the klds aU decide to bang upside down on the monkey bars. One" daring kid decides that be will try to eat a grape "hlle hanging upside do" n and finds that he has no trouble doing this. Involuntary movements of internal organs such as peristalsis are produced by which type of muscle tissue?
~ ~

Voluntary muscle tissue Smooth muscle tissue Striated muscle tissue Skeletal muscle tissue Cardiac muscle tissue

Fndont\,iUnt

an organ, sl<olctol muscle consosiS of ~vera! nssue typeS. Skoletal muscle fibers :>re long, thread-hkc cells thnl compose skeletal (.<rrlllled) tis.ue. These cells have the ability to shonen their
As

length ur contract.
[)._--nse fibrous coMcctove tisruo (fascta) w03ves lhrou&h a skeletal muscle at S<Vetlll dorr<-n:ntlcvtls. The epimysium is the connective tis~ue layer that envelopes the entire skeletal muscle The per-imysium is: a con1inuation of this outer fascia, dividing the interior of lhe muscle into bwuiles of muscle cells. The bundle of cells sunounded by coch pcrimysoum is <&lied a fasclrulus The endomysium is a connective tissue layer surrounding cueh muscle tiber

Each of lh< thn..'t lc' els of fascia is interconnected. allowing vessels and ncn es 10 reach individ.W fibm. and cell.

(surrounds fasciculi)
{IUifOUndl

fibers)

(surrounds tr.tlre mu.sdt)

Cross section of skeletal muscle

~ote: The axon of a motor nnrron is hahty bta.lk:ht..'\1. I.I..Dd ont moror neuron Innervates num f'roLU musclt fiber1. When 3 motor oc.uron rr..nsmn.~ an implll~. all of the Obfrs it lnnenatf)

<ODITOCI Simulllln<OU$)y.

Snw ulh mu ..lll lls,tu.

Smooth muscle tissue is located throughout the body. panicularly "ithin the tunica (walls) of hollow internal O<glUlS. The smooth muscle firers are elongated and splodiNbaped with a single nucleus. The myofibrils lack transverse strlatlon.s. Titcy are responsible for involuntary movements of internal organs (,,g., peristalsis). Types or smooth muscle: >junctions (electrical synapsl's) between adjacent Slngl~>ounl1: have numerous gn1 fibers. These fibers contract spontaneously without nerve signal> Esamples Include: the muscular runica of the Gl tract. uterus. ureters, and unerioles. Mulri-unlt: lacks gap junction. and the individual fibers are nutonomicnlly inner vated. Examples include the ciliary muscle tu1d the smooth muscle of the iris, ductus dcfeten.S. and oneries Skeletal muscle tissue ullaches to the skeleton and is responsible for voluntary body mo,ement. It consistS of many longated, cylindrical ceiJJ, which are multinucleated and have distinC1 1Tansvtrse striations consisting primanly of actin and myosin l>rotelns. Remember: Each skeletul muscle fiber is innervated by an axon of o motor neuronal a motor end plate (w!Jich is a large and complex terminalfomlatioll by which u11 axon ofa motor neuron establishes synaptic contact nth a skeletal mllscle).

0ATOMIC SCIENCES

A surgeon performing a thyroidectomy accidentally transects a nerve. The patient then presents with hoarseness and difficulty breathing. There Is a loss or sensation below the vocal folds and loss of motor Innervation to all of the Intrinsic muscles of the larynx EXCEPT the:

Thyroarytenoid Posterior cricoarytenoid Transverse cricoarytenoid Cricothyroid Lateral cricoarytenoid

1%7

<Alp)'"ibl 0

2009-2010 Dema1 Dtd.J

(ANATOMIC SCIENCES

The axilla, or armJiil, is a localized region of the body between the upper humerus and thorax. It provides a passageway for the large, important arteries, nerves, veins, and lymph atics that ensure that the upper limb functions properly. Th e mustle that forms the bulk of the anterior axillary fold is the:

Latissimus dorsi
Pectoralis major Subscapularis

Teres minor
Teres major

ricuth~ rnill

The nerve that was transc:cted was the recurrent laryngeal nerve. ' ote: Damage to this nerve (as a res11lt ofs11rgery or disease) can result in hoarseness and difficulty breathing. I ntrinsic muscles of the larynx: Cricothyroid: stretches the vocal chords Posterior cricoarytenoid: maintains wide airways (for breothi11g} Thyroarytenoid: closes the vestibule Aryepiglottic: closes the vestibule Transvers cricoarytenoid: contracts to close the airway posteriorly for speech Lateral criroarytenoid: adducrs the vocal cords Thyroepiglotticus: helps close vestibule Vocal.is: shoncns vocal cords, is the antagonist of the cricothyrotd muscle The vagus nerve provides sensory and motor innervation to the larynx: I. The recurrent laryngeal nerve supplies all the intrinsic muscles except the cricothyroid. 2. The cricothyroid muscle is supplied by the external branch of the superior laryngeal nerve. 3. Sensation above the vocal folds is supplied by the Internal branch of the superior laryngeal nerve. 4. Sensation below the vocal folds is supplied by tho recurrent laryngeal nerve.

TI1e axilla can be visualized as having a noor, an apex, and four walls (medial. lateral. tmlerlor, and posterior). The apex is pointing toward the root of the neck. It is formed by the convergence of the clavicle (anterior). the scapula (posterior). and the first rib (medially). All the nerves and vessels of the upper limb pnss through this area. The anterior axillary fold is made up of the pectoralis major and minor muscles. The posterior axillary fold is made up of the latissimus dorsi and teru; major muscles. The base faces inferiorly and is formed by the skin and fascia of the concave ax11la (armpit). The m~dlal wall is formed by the upper four or five ribs and their intercostal muscles and the senatus unterior muscle. The lateral wall is formed by the humerus (specifically. the rora~obraclrialis and biceps miiScles In the bicipital groove of tire humerus). The posterior wall is formed by the sub~capularis, teres major, and latissimus dorsi muscles. The anterior wall is formed by the pectoralis major, minor. and subclavius muscles. Contents of the axilla: The axillary vessels Branches of the brachial plexus Both beads of the biceps brachii Coracobrachialis

(ANATOMIC SCIENCES

Msl)

Which muscle functions to turn the head side to side?

Digastric Mylohyoid Sternocleidomastoid Omohyoid

83
129 Copynabt 0 20092010 [)rental Dc..:kJ

ATOMIC SCIENCES

Mst)

The anterior and posterior pillars of the fauces enclose which area oflymphoid tissue?

Lingual tonsils Pharyngeal tonsils Palatine tonsils

6 ~
130
~"" 0 _,.,.""""' Do<b

~lt' riiHl'ltidum a\Cnid

,,_
o._,.

Oricho

Two 11'11.J~Iao actin SW:mockldomuaoid MU!IIhrilllfl s~Ctni 1DCI M.Jstoid ptOst.: o( 1nediJ.Ithin,l o( ciUVIdO tmp~ml bone 111.! oretpit:al IUJC'Ihct~ltll'fld hend lllld r~cct; cmc-

- _ ..... .. _
\lu'>h" nf ltH

,,,_.a..

Actio

laatnaliota

Sp.nal (WI
llc:fV(l

nw.tek ft'IQtQ; bead 10

nn:

C2 ond 3

or CICCCiOt)'

.......,,.ur

,,.~od

pcoctSs or

ttMipOilll bone

l~lllt' !(116M u bcld 1.0 hyoid b)ll~ by tillielal

txpre~

tbc m11!ldl

ra.c.sl rtmc
NC1VC 10 rey\OhylliJ

b~ Of dC\atc" t.l1t

AntmorbcU)'

"" , ..4

,_

111)' or maodiblc
\1)1oh,.o.l Gocoll>ody

''"'i

b)'(Md bone

r_..,_

~ ofhygtd Nrc ed

s- __ -- --0..~

Sty\oh)-otd

S'> lalld J)fOOe5$ or temporal boac:

Body of hyoid ~re

lllfttlor ft'lttltll spltle of OOI!y of h.y.,.d bort:

-bl< \1-..bm:un .s1crW ...

dt\iele

..,.,..... ........... ..,.,....._

I:.ICVI.Itl h)-oid bunt

~ Tn~tV)IGC'ft ~ ..tlilyoi6 bC* f~elal tlts'\'t"

........ -ot

Eknta hyoid bone-

f 111! ""'.olll)l;n'(
A.Mattn'tea~httC/.

- . .r... ,...Sboo<
Obliq~ Hnc tm

l)qlnooa .... ..,... booo

!.

gtfd3J An\11. tcrvicllhs tCJ, } -.IJ)

F1t11 mvic:IIII:I\'C"

S~h)'Jo\d

Manubrium s!Cm.i

Obl.qt~C lit!c oa a...

,...,

lan,itl3 of lh)'tlliiS0111.LaJc

IXpR:.s&ts tbe larynJt

1:-.-of-ot

C:.C"~t.)"ll"\

Omo!l)oid ln(enorbdl}'

Uppn margin or !'Clip-

lllllctmedl<IU: ttlldoclts bc:ld to clavic.lc ucl 1\nl n"b by

~btDy

[)qmt.StS tbt h)'O\If booo

Amac:crvcahs tCl, 1
(Iff(} J)

l,.o\l.er bor<.eT o( bod)" o(h,.o.l boa

"""'"""'

The fauces is a narrow passage from the mouth to the pharynx. situated between the soft pointe and the base of the tongue; this is also called the Isthmus of the fauces. On either Stde of the passage. two membranous folds. called the pillars oftbe fauces, enclose the palatine tonsils (consist ofprt!dominantly ~tmphoid tissue). The two arches fonned by the anterior nod posterior folds of mucous membrane nrc: I. The glossopalatine (palatoglossus) arch (anterior pillar offallt:eS or anterior faucial pillar) on either side runs downward. Iaten! ward, and forward to the side of the base of the tongue, and is fonned by the projection of the palatoglossus muscle with llS covering mucous membrane. 2. The pharyngopalatine (palatopharyngeal) arch (posterior pillar offauces or pas terior faucial pillar) is larger and proje<:ts fanber toward the middle line than the ante rior; it runs downward. lateral, and backward to the side of the phttrynx, and is formed by the projection of the palatopharyngeus muscle, covered by mucous membrane.

G~ATOMIC SCIENCES

Mst)
~

r All of the following statements concerning eardlac muscle Obers are true"J
\.. EXCEPT one. Which one Is the EXCEPTION?

Their characteristic feature is the presence of intercalated discs Cardiac muscle fibers have less mitochondria between myofibrils and are poorer in myoglobin than most skeletal muscle fibers Make up the thick, middle layer of the bean known as the myocardium Have larger T tubules and less developed sarcoplasmic reticula compared to skeletal muscle fibers In contrast to skeletal muscle fibers, cardiac muscle fibers are sbon, branched, and single or binucleated

t)t
Cop)TIPt 0 2(109.2010 Oen:l DetU

(ANATOMIC SCIENCES

Mst)

Which of the following statements concerning the tongue Is correct?

Protrusion of the tongue requires contraction of the genioglossus muscle The tongue receives its major blood supply from the internal carotid anery

AU extrinsic muscles are inuervatcd by cranial nerve XII (hypoglo.<sal)

General sensory innervation to the anterior two-thirds is provided by the glossopharyngeal nerve

84
1)2 Coclrn&htO l009-l010 DmtM Ocd.

C';~nlbu; nHI,t:ll- fihL'I, ha' l' ll''' mHorhundrh hLI\H'L'n 111~ nrihril\ :nul an putJnr m nn O!,!luhin lhan 111u-.t 'kl'll'l:tl mu'cll Ohlro;;

... This is false; actually, cardiac muscle fibe rs have more muochondria betwee n myofibrils and arc richer in myoglobin tbnu most s keletal muscles. Ltke skeletal muscle fibers, cardiac muscle fibers tontaln m yolilaments (contractile units) and nrc striated with actin and myosin. Cardiac muscle fibers contain large, oval centrally placed nuclei as well as strong. but thin. unions between fibers called intercalated discs. These intercalated discs provide low resistance for cuncnt flow, Important: Within tbe mtcrcalated discs, dcsmosomes anacb one cell to anolber v.;bile gop junction' allow electrical impulses to spread from cell to cell. Cardiac muscle fibe rs contract spontaneously without ony nerve stimulus. They respond to increased demand by increasing lbe si2e of the fiber; Ibis Is known as compensatol} hypertrophy. Note: Skeletal and cardiac muscle fibers couJoot mltotically divide, but certain s mooth muscle fibers can under bonnonal influences (e.g., dun'ng pregnancy, the smooth muscle fibers of the myometrium of rhe uterus i11cret<e in length, and IICII' cells are formed).

The extrinsic muscles (ge11ioglossus. hyoglossus, styloglossus, and pa/(lloglossus) anchor lbe tongue to !be skeleton (mandible. hyoid. and temparol bones). These muscles control lbe prouusioo (genioglosnts), relnlciiOn (styloglossus). depression (hyoglossus and genioglossus), and lateral movement (palaroglossu) of the tongue. Remember: All extrinsic muscles end in- glossus (to11gue) and bogln with their site of origin. Tbe intrinsic rouscJulie entirely wilbin the tongue itself. The fibers oflbcse muscles are named according to the three spatial planes in which they run: longitudinal, transverse, wtd vertical. When these fibers or muscles contract, they squeeze, fold. and curl the tongue. All of the muscles of the tongue, both intrinsic and extrinsic, except !be palatoglossus muscle, are innervated by tl1e hypoglossolnenc. Tile pnlatoglossus muscle is innervated by !be phnryngeul plexus. Note: The palatoglossus is a small extrinsic muscle nf dte tongue that ariseb from the soft palate and instJ1S in !be tongue. The palatoglossus acts to elevate the tongue. The tongue receives its major blood supply fmm the Ungual artery (which is a branch of the &rernol cororid arrery). ote: The tenninal pan of the lingual artery, the deep lingual artery, supplies !be tip of !be tongue. The veins drain into the internal jugular vein. Remember: The trigeminal nerve provides the sensory input to the anterior twothirds of the tongue: the glossophar yngenl, the posterior ponion.

(ANATOMIC SCIENCES

Ms~

All of the following statements are true concerning the triangle of auscultation EXCEPT one. Which one Is the EXCEPTION?

"' J

It is situated behind the scapula

It is bounded above by the trapezius muscle, below by the latissimus dorsi muscle. and laterally by the medial margin of the scapula The floor of the triangle is partly fonned by the s ternocleidomastoid muscle
It is a space on the back where the relatively thin musculature allows for respiratory sounds to he beard more clearly with a stethoscope

6,!)

( ANATOMIC SCIENCES

'A

nenous dental student is performing the inferior al\'eolllr nerve block for""'it the first time. His Injection passes the ramus, but he thinks depo~ition of the anesthetic will work. His patient complains that he can't "move his face" \. on the side of the Injection. Which gland did the dental student penetrate? ~

Sublingual gland Submandibular gland Parotid gland Von Ebner's glands

1 ht lluur uf tht trianclt h, parll~ lurnwd h~ tht \ltrnot:leiduma,lnid mthdt

This is false; the lloor is partly formed by tl1e rhomboideus majo r muscle. For purposes of description, the neck is divided into anterior and posterior triangles by the stemocleidomastotd muscle; the anterior triangle lies in front of the muscle and the posterior triangle lies behind it The antrrlor triangle is subdivided into smaller triangles by the anterior and posterior bellies of the digastric muscle and the superior belly of the omohyoid muscle. These smaller triangles include: Submental tr iangle: Boundaries: Anterior bellies of digastric and hyoid bone Floor: Mylohyoid Contents (main) : Submental lymph nodes, floor of mouth Digastric (or submandib11/ar) triangle: Boundaries: Anterior and posterior bellies of digastric and the latent! margin of the mandtble Floor: Mylohyoid and hyoglossus Contents (main) : Submandibular gland Carotid trlanglo: Boundaries: Sternocleidomastoid: posterior digastric and superior omohyoid Floor: Thyrohyoid. byoglosws, and pharyngeal constrictors Contents (main) : bifurcation of common carotid Muscular triangle: Boundaries: Superior omohyoid; >t<rnocleidomastoid and anterior margin of neck Floor: Sternohyoid and sternothyroid Contents (mairr): lnfrahyoid muscles. thyroid and parathyroid glands

If the needle misl>k<nly passes posr.riorly at th< IC\cl of the mandibular foramen,

me netdlc Wlll penetnuc the parotid ~land~ and the pauent may de\'t-lop paralysis of the musc::lc~ of facia1 expression. tfthc tip of the needle is resting well below the mandibular foramen, you will be penetrating the mtdlnl pterygoid musde.

--

Correct needle penetration into the pte.rygomandibular space durinv M

inferior alveolar block. lflhe needle is insenc:d too far ~tcriorly, it

nuy crttcr the p:uorid sali\"fY gland com,un.na me facial D<f'<. ing a c:omphation such b t:nrns1ent facial pa:rai)'St$.
C0\15-

GNATOMIC SCIENCES

Ms~

'
~

In an automobile acddent, an anatomy professor fracturu his humerus. "' He notices that he is unable to extend his forearm, but still is able to Oex the forearm. Which muscle oftbe upper arm primarily extends the forearm?
~

Biceps brachii Coracobrachialis Bracbialis Triceps brachii

85
135 Copynp"O 2()()9.2010 """'' De<O..

(ANATOMIC SCIENCES

Which muscles elevate the mandible and hence account for the strength of the bite?

Medial pterygoid, digastric both anterior and posterior belly, and lateral pterygoid Digastric both anterior and posterior belly, and lateral pterygoid Medial pterygoid, temporalis, and masseter Digastric both anterior and posterior belly, temporalis, and masseter

I rit:~ll' hralhti AI the shoulder. important muscles 1nvolved m th<: movement 1nclude lhc dcllol<l, wh1ch makes the rounded contour o' cr the upper surface of the ann and shoulder. At the elbow joint, importan1 muscles for flex1on mclude b1ceps brachii and brachialis. "bile the

mam extensor muscle is the lrccps.

.....

Sltnn h<'Od

Origin
Booy no...,,.......,-

~-lu;K-ulvcutanoou.'l

'lc:xct 11\e ann

"''"
o(elbo~ }Oint

Note: The radial nern~- is most c-ommonly inJwed in a mid ...humeral shin fracture. because

tbos nerve runs on the radoal (spiral) grooe of the humerus. The biceps braehii panocopates in Oexion at both the glenohumeral and bumcroulnar jomiS.

\lu'dl'' 111 \1:1\lll.".llmn

Muscle

insertion
c~~otmandiblc.

~ landlbular l\1o.. tmtnts

r.._w

..,......,
Mod<al~

Dt -~ .00 svpmor (,ben ~k~ale 11'1c n.ndible The l)\)i1efior fibers tt"lfiiC1 the ITI.'U'I(hble

.,,.,_""
.....

l.owu border arM& medial surr.:.ce

L.tlt'tll ~of lite DmUJof Radel (t~ltn) the llllftrJ.bk"' ... _Ole occ-t.ac tt.c ~ted~. iD muoc._

Tht supaikill bt~ anscs fiom \tedalSIIIface of !'he! ongk of As$~ 1n nisit~a (clnvm,ZJ tht the C1.1bcrosity of Ute maxilla. 1bcmll(ldible 1 tmnd1ble rtw: d t(')) bud ar\Jc~ from tbc n~ial surface of die literal piC<)..,;d pe...

~""" fi'WO~}

nc PP"' bftd . . - , ticn the Ollftt..._,.c-.,,.

li'C111ef v.ing o! lbc ~d

dibl d me artJ('\1181' dt.e of thf.T\U

F,_ til \be lied or~ .......

rhc lower bud llflcs (Mm the

'"'"" - ..,... lorcnol

bone.

l...-f1" ttrMis:: tJ,p. ~orchc f'l)lodible (durmgfi'l'l OJW!li"IJ

I""YJYod "'""

.,.,,,twit) IJ.cn . .~db;~ ofdw' ....,.,,Me

One II'IIU('It: IIUal de\'~lion of ~~~~ """-'NI1blc: fshifj llfdlldlb/' to

Important: The muscles of mastication are innervated by the trigeminal nerve (specif icolly. lhe mandibular division- V3).

GNATOMIC SCIENCES

A patient comes to the emergency room after boxing practice. He was hit "ith an uppercut sod heard a cnck in his jaw jolnL A cr scan shows a condylar fracture with damage to the articular disc. When the patient attempts protrusion, the mandible markedly deviates to the left. Which muscle is unable to contract?

Lei\ lateral pterygoid

Right lateral pterygoid Temporalis muscle

Buccinator

63,64
137

c..rnJI>I C> 2()()';.2010 D<mal O..b

( ANATOMIC SCIENCES

'A

46-year-old woman comes into the dentist's orncc for a cleaning. He notice~ that her tongue is slightly swollen, nery red, and smooth. lier diet history indicates that she bas had a loss ofappetile for quite some time and that she ha1 been feeling fatigued. A call to her physician indicates a history of iron deOeiency anemia and associated glossitis. In glossitis, the smooth nature Is caused by a lack of which papiUac that arc the most numerous and cover the \... anterior tv;o-thirds of the tongue? ~

Foliate Circumvallate Fungiform Filiform

86
138
Copyripi.O 1009~010 Ott.& Otoeb

The right and ldt pterygolds acting together are the pnme protractors of the mandtble. Wllen one muscle is oot funcuoning properly, the conlnllatcral muscle's action is uuop posed. nte lack of !he left lateral pterygoid trying to push the mandible to the right allows the right muscle to move the mandible to the leO. With this inJury, the mandible deviates toward the aiiected side. Similarly, because the muscle's insenion is disrupted (disconnected from the body of the mondlbl~) in the ease of a con d) lar fracturt, the mandible wiU also deviate toward the affected side. nte muscle Is tntact and can move the condyle when it contracts but not the body of the mandible because of the fracture. The unopposed right lateral pterygoid t:ben remains capable of displacing the mandible to the lei\. ltnportant: Jn addition to opening and promtding. the lateral pterygoid:; move the mandible from side to side. l'or right l leral excursive movmenls, the left lateral pterygoid mUJcle Is the prime mover ond vice versa Note: With a condylar neck fracture, muscle contractions might result in displnccmeut oflhe uyured condyle iolo the infratemporal fossa.

1-IIHorm

The dorsum of lite tongue is studded wilit pnpillae, of which ther;: are fottr types: Filiform - most numerous. sman cones arranged in "V"shaped rows paralleling the sui cus terminalis on the anter.or two-thirds of the tongue. They re characterized by the absence of tute buds and inc.relUed kerotlnizstion. Tbey serve to gnp food Fungiform- knob-like or mushroom-shaped projecllOJL<, they lire found on the tit> and sides ofU1e tongue. ntese t11sto buds are mncrvated by the facial norve (VII) Circumvnllate (vallate) lnrgest but fti\CSI in number, they are arranged in an invert ed "V..shaped row on the bock of the tongue. Associoted with tbe duel! of Von Ebner's glands. 11lese taSte buds rue innervMed by the glossopharyngeal net'\ (IX) FoUate - found on lateml margin.' as 3 to 4 vertical folds. These taste buds are tnnervat ud by both the facial nerve (VJJ a/liar/or papii/Cie) nntllhe glossopharyngeal nerve (IX - posterior papillae) The recept<K'$ for the sen.<e of taste (gustatiiJII) ""'located tn tlUte buds on the surface oftbe tongue. The tute buds are associated with peg-like proJe<:Uons on the ton~"'c mucosa called lingual papillae. A taste bud contains a cluster of 40 to 60 gustatory cells, as well a< many more supporting cells. Each gustatory cell is iMervated by n sensory neuron. The tongue and the roof of the mouth con tam mOS1 of the receptors for the taste nerve fibers in bnmches of the facial. glossopharynge-al, and vagus oenres. Located on taste cells in the taste buds, thest reuptors t\te stimulated by chemicals. T hey rt>5pond to four taste sensa
tions perceived by specinc nreas on the longue: sweet: on the tip bitter: ou the buck soOT: along the sides salt)~ on the up and sides

The underside of the tongue IS son and kept very moist by salivary gland .,ocretions. Beneath the tongue lie the openings of the ducts from the subUngual and submundibular gltiO<b. The l'i'enulum fonns the midline rldge on lite lower surface ul' thc tongue. The paired deep ancr ics and veins of the tongue he on each sid< of this ridge.

(ANATOMIC SCIENCES

Which type of muscle cell uniquely contains Intercalated discs?

Skeletal muscle cell Cardiac muscle cell Smooth muscle cell

139
CopynafltCI 20092010 Oerul Deck-~

(ANATOMIC SCIENCES

Mst)

Wbieb or the following r efers to the sarcoplasmic reticulum present In skeletal muscle?

Releases and stores phosphate ions during muscle contraction and relaxation Releases and stores glucose during muscle comraction and relaxation Releases and Stores calcium ions during muscle contraction and relaxation

140
""""'"" 0 2000-2010 Oaoul Docb

( ardiar nw,cle rl'll

Smooth nwscle fibers ore composed of unlnucl~ate, >piodle-sbaped cdls (filsiform oel/s). They are mucb smaller than skeletal muscle fibers. The nuclei are situated in the widest part of each liber. Tbey do not po~ess T tubules. and their sarcoplasmic reticulum is poorly developed. These muscle fibers do om possess regularly ordered myofibrils and are therefore not striated. Their cont111Ction process is slow ond not subject to voluntary control. Skeletal mu~le fibers are composed ofbuodl~ of very long. cylindric, o!Uitinucleattd cells that possess regularly ordered myufibrils that are responsible for the striated appearauce of the cell. The nuclei nre either slender ovoid or elongated and are situated peripherally. They do contain transverse tubules (7' tlllmles). and the sarcoplnsmic reticulum is very well-de\ eloped. Their contrnction is quick, forceful, and usually under voluntary control. Tbe myofibrils (actin am/ myo.<ill} ur~ the cootrncb1e element Remember: Cardioc muscle fibers contain centrally placed nuclei as well as int~rcalated discs (contain desmo.<ome.. a11d gttp jmiCtions), wlu.ch represent junctions between cardiac muscle cells.
I. rhe satellite cell is responsible fo1 slleletal muscle regeneration. Notto 2. 1'wo T tubules lie within a single skeletal muscle sarcomere. 3. In skeletal muscle, a triad refer< to aT tubule sandwiched between two dilated cisternae of the surcoplasmic reticulum. 4. Motor units consist of a motor neuron and all the muscle fibers It supplies. 5. The major regulatol') prottins in muscle tissue ore uoponin and tropomyosm.

Kcll'll""l'' :md 'tun, calcium ion~ durin).! musclt tuntracliuu .md rl'l."ation

It is a network of tubules a.ntl sacs In skeletal muscles. This network. is analogous. but not identicnl, to !.be srnootb endoplasmic rttlculum of other cells
Remember: The enttoplasmic reticulum is an extensive network of membraneenclosed 01bules in lhe cytoplasm of cells. This organelle is classified ns granular ur rough surfaced wben ribosomes :u-e attached to the surface of the membrane and a:. granulor or smooth surfaced when nbosomes are absent. The strUcture functions in tbe syntbesb of proteins and lipids and in the tmnsport of these metabolites witltiu Lit~> cell. The cytoplasm of muscle celb is called sarcoplasm. The sarcoplasm of each skeletal muscle fiber contams many parnll.,l, thread-like strUctures caUcd myofibrils. Each myofibril is composed of ~111ltller strands called rnyofilaments that contain the contmcliiC proteins, uclln and myosin. The rcgulars!l"tial org~ation oft.he commctile proteins within the myofibnls fonn.' the cross banding. A network of membranous channels. called the snrcoplasmie reticulum. extends throughout the sarcoplasm. Note: It is mainly a great increase in l.be numbers of additional myofibrils (which is caused by progresslw!(Y greater numbers of both acmn and myosin filamclll.r in tltc myofibnl.t) that causes muscle fibers to hypcnropby. Important: The number of muscle fibers does not increases.
incr~ase;

the size of each fiber

(ANATOMIC SCIENCES

~ During the fourth week of prenatal development, within the embryonic period, )
'tongue development begins as a triangular median swelling, called the:
~

Foramen cecum

Sulcus termioalis Tuberculum impar Epiglottic swell ing

,.,
Copyngllt 01009-2010 Dmtal [)r(-'b

87

GNATOMIC SCIENCES

Tbe cartilage in lbe s~ond branchial arch is called:

Meckel's cartilage Reichert's cartilage Thyroid cartilage Cricoid cartilage

8J

tuh~ n: ulum imvotr -- ur mLdian lunJ.!IH' hurl

Ttlc tubt'rt"ulum lmpar h: a ffia ngulilr mcdluo .swelling lht.n ill luc:utt:d in the midline. o.n the floor \'f the pnmihvc pharynx. in the embcyo"s coruotned ndS31 and oral c:t.Yifies.. Thh $.lructure g1vcs tftc firs1
indicauon nftongue ~dopmmt araboutllx fourth \\cclc oftmbt)onic lofc.Sooa. '"0 di.,.ltnn& u bulb (1atcralltngo.al :Nellmgs/ de.elop un each side of the mtdlon toogue bud. All of these antnior swcUin_gs Itt from he growth of mesenchyme oflhe fi~ bruntlual2uthes (or mnmflln, /ar tlldtes) and fuse to fom1 the anterior two-thirds or bot!)' of !he tOOb'UC. The: 1osterior onto-third Q f base Of the longue ls fom1ed by a pair of 'wellin~, the ropula ({fflm tlrr 111/rd M1d ports ()/ tltt' .fourih bnmchlol
arclles).

E'en fanbcr J>O>I<rior 10 the copula i$ the pi'OJ<Cil<>n of a third m<dlan s"'cllmJ!,tbe tplglotti< '"tiling. winch deelops from the .,...,.byrne ofthe po>to:noc pans of the fnurth branch~al """"' Thisswclllli
maik$ the dcvel()pmml of Ihe most postenor t'e810D of th.:--ton~uc flnd of dle fu ture epiglottis.

Remtntber: The. hr:.tntlti_.l

(plwryng~ol) arches are

stacked biiAterlll $\'il'IHn~,ts ofci.ssue that :~ppt11r

jnfrr ior to Ihe $l.omodcum durin& lhc founh week of embryonic development The~ bnmcbia1 arche\ are sb: pa_lrs of V-sbaped ban wnh a oore rntsencbymt.. r,,m~-d by nrunl rttst cells that mlgnte ro tile neck rCJion, Th< branch11l ""'""' are covered e<l<mally b)' :lodtml and toned tntanally b)' eododtrm. These ar~hcs )l.lppon the hu~l wa1l' of the pnnuthc pharynx.

1. Rlfld tOngue ~~ che ~sult ofhu:k of rusivn of the diliUtllonguc buJs (Or lmo:ral .r~'f!lli,J/.S). Note; Thl') $terns to be common in South American iltfiuu~. 2. The Cifth br.nchill archs a~ so rudimc:ntary thai they arc -ub~m in buman~ or- a.rc

intlu<led wirb lh< fourth bnincb>allllthcs Be<\\..., the 1lxth and <ighlh ,..eeks of pm~atal <kvclopmcn~ the rhtcc maJor ..II VIII)' gl:ulds bt~m a
q-titheUt~l prohfen~tions, or bud,, from the lodctmallioing uf the pnmith e rn"uth (Mmnmltmffl) The rol,llldcd tcnnm~tl t.-nd.<t or the~ tpithcliat buds JVOW into tJ1u underlyiug mesenchyme, pro,hu;in_ the secretory ccll5, or gJaodular fti!Jnl. and the duc:ulJ ;;ystQll. The:. pawuthJ g,lanru apJ)....-.tr early Ul the: snth week and Art the firS( to form. lllc submandibular glands appear late in the sixth w-tt\.. aad the Jubllngul ~lnlb appear on the eighth wttl

Each f13tred branchial arch bas its own developing cartilage, nerve, vascular, uod muscular components within each mesodennnl core. TI1ese elements 11re of neural crest origin.
Derivothes of the branchial arch cartilages: First arch canUage (Meckel 's cartilage) - is closely related 10 the developtng middlo ear; becomes ossified to fonn the mullens and incus of ohe middle enr, sphenomandibular Ugament. and po>rtions of the sphenoid bone.
Note: \1ost of this cartilage disappe3rs as lhe bony mandible fonns by intramembran-

ous ossification IIS1cral to and in close association with 11, yet only some of~eckel's cartilage makes a contribution to it. Its fate is said 10 be dissolnlion with minor
contributions to ossiOcntioo. Second arcb cartilage (Ref~hert s ~artiiQge) - ts also tloscly ~lated to the developing middle car; become; ossified to fonn the stapes of the middle ear, !he styloid pmce-ss of the temporal bone, the stylohyoid ligament. the lesser comu of the hyoid bone, and the upper ponion of the body of hyoid bone. Third arch cartilage (llllllamcd cartilage) - ossifies to fonn p3rt of tbc byold bont. Fourth through s inh arch curtllttges (wmamurl cmri/age) -- ruse io form the

laryog.,..il cartilages.

G NATOMIC SCIENCES

During the fourth week of prenatal development, the upper lip Is formed when eaoh ruses with eaeh as a result of the underlying growth of the mesenchyme.

Frontooasal process; lateral nasal process Maxillary process; medial nasal process Lateral nasal process; medial nasal process Maxillary process; lateral nasal process

89,90 91,92
1<13
~~ C ~2010DmWDeda

G NATOMIC SCIENCES

During the fourth week of embryonic development, the first branchial arch divides to form:

The two medial nasal processes The mandibular and maxillary process The rwo lateral nasal processes The lateral and medial nasal process

88,90

Thm. the"'' '(IIJry proc.Hus oomnlMJte: to the stdc( of lhe urrcr hp. and lhe tf\o mcd11l na.sa.l Jlr'f<<>e. conmbuu: ro the middle ofrll< upper lip. ~osron ofrhc:J<C proec:.sc ro form rhe upper hp 1~ \,':Offiplncd t1uring tbc S~th week orrrenatal tie\'elopmcn~ When tht g:roo'VCS bctWe-t:n the ptiK:C..IiSf;i; ~"' oblircrnred. The ~t~lllury procosm on tach sl~c nrrhc developing fntc paniotly fUM: 1\irh rhc mndlbular iircb to fonn the labi-a! con\rni15u~. orcorDl'!fl. or the tnoulh. .\ fler fonnoll011 Oftht ltOmod<um (tht primitii'P /hDIIIh} buunll \\ilhin rJic founl> bulges oru~ue aprenr H\fctior to 1he primuivc mouth. the t"o la r-~:.e mnndibulor proccner tll the fU'SI hnmt.hial MOh, n1~ mondlhll" fOrnlS o..o~~ o result of the fi1sioo of the riMiu and lei~ mnndibuJnr prtwcsscs. ne mrmdible i rhe f11St pMion of rht ll<>t ro fonn nfl<r the cr.uuon oftl>C wmodcwn. ' Ole: Th~ mndlbl< (r.'l!pl]nr the CVIII~~es) ond rh~ mO>ill are mo..ty ll>mcd by branoo.s o,slfication. l11c mad II 1s fturoe:d primttrily by mcrgin,g or the 1wo smnller lllR.~IIIRry processell or the first brancbial n,:h. These mxillary ptwe>S<:$ also turm rhe upptr check rcgioo> and most or the upper lir Ounn& thelounh \\'ed<. ~ r.,otonanl proust {fHwtn.,te</lso fonm.ll bulge oftt<$UC in th< upper mclnl ata, at the "'"" <ephallc <nd uf rho cmbi)'O, nnd is the emmaI boundury )f the ttomodewn In Ihe future, the froniOnf\Snl proce!l~ ~.t&vc~ r(:-c h> the Up(14!r face:. whit;h lncludcs the forehead. btidg< of ll05<, ptirrutry palate. MS3l:1Cptllm. and all tmcrures tdotcd ro the nc<lial na,-.t

wed<,""'

larrm-

o<-

rroces>CS
Tlle 11A.ul placodn fonn In Lhe antcnor portion of1ht fronwnual prQC4.)..JUlll supenur to 'be sto-

modeum, durrns 1he founh Wt"ck. l'lu:sc two button like lllruC{UJ'('$ fom1 a.ll" bilutcml ccrodennnl duckeoing,< thnl lartr develop into olfoctory cells fur the ~en>arion ol' smell. I he middle p<mron of rlle rit<Ut !!JfiWIOB IIIOOJ\<Jihc nasal placocfn aprdn I' twO Crt>CCOI<haped SW<Ihnt:S ill1d art .:Oiled the mrdjaJ na,.a1 pf"'fti.'<tl. which fu.(Oe tU form d1e mtddle portion o(liu~ 0C'$e from 1he fOOl to the ape-M tll'ld ~he cemer ponion of 1 he t.ippcr lip nml atso the philtrum rcg1 un On the uutcrponiun nrthc nasal placodcs, there are also two ulhercrc~e:llt-~hi1pcd <;:welllngs, the t:ucrttl oaJMIJirocesses. which will

fonn rhc oloe. or sidClS of tM no<e. fu>1on of!he lat<r>l """'!. moxllry, and medial nasal processes fomiS ~ nJtes, or nv>tril<. :-.ote: Loteral rlrf\in~ or th lip "'wit from rhc f>ilorc of dte maxillary and mediol na;;al processes to f\110.

f h1. m111111ihuhtr ;.tnd mo.t\ilh1n pro""''' - otb:o "allttl prmu iutn Ct''

ma\ill:t~

and rnaudihular

The bronchi~! (plrm)'llgea/) urches arc smc~erl hilaierul sweUings of tissU< thor appear nferior to the sromodeum dunng t:h<: rounh wctk of ~mb.ryomc ~c.... clopment . The;e branchial arches are sl~ pain of U-ihlll~d bars with 11 core m eonchym e ll>trMrl by neural crest tell that mi!!r31 e to lhe neck region. The bt'lluchi.al urchl'& arc C<lVere<.l cxrernally by ectoderm and lined rntemnlly by endoderm. The ectodcm1 between the areb"' fom1 clefts (grooves) called bnmchial (pfwryitgealj dens (l:roo'oes). Ute arches lll'l! bordered medially by the pharynx, which IS lined by endodenu. Medially each uflh~ branchial nrcl1~s is separated by a pharyn~el pouch, The~" pouches approach the corresponding brancbinl cleil The uppruximationofthe cctodenu of the pharyngeal cleft ""th rbe endodenn of the ph8l)'llgeal PllUCh forms the pburyngcal membrnne. The groove and pouches arc named (llfl/llbCfl<il) the sanrt as 1he preceding arch After formAtion oflhe stomodeum (ihr pruuilt<e mnmlll but still wi!h10 Ute tourth wee!.. rwo bulges of tissue 3rJle<lr infen()f" to Urc pnmitive moutb, the tWO large mandibular processes of !he tlrsr branchial ureh. Important: The mandible fonns osa result uf rhe fusion of rbe Utesc two largomnudibu-

lnr processes.
Note: The mandibular sympbysi is a lil1n1 ndgc in the midline on !he surf~ce of rhe bony mandible whore the rnlll1d1ble is fom1ed by the fu>ion of tl10 mandibular p1'0cesscs. The two smaUcr mu lllal")' processes of 1bo first l>rurrchtal ar~h torm the mnx.illa. th lrppet check region.. aud mo~l of 1he upper lip.

(ANATOMIC SCIENCES

(
\.
First

Which pharyngeal pouch gives rise to the inferior parathyroid and the thymus gland?

~:)and

Second Third Fourth

,
~~

Cl 2(109..2010 DmlaJ t>U

..

88

(\NATOMIC SCIENCES

The primitive mouth, or stomodeum , initially appears a s a shallow depression in the embryonic surface at the cephalic end before the fourth week of prenatal development.

Ectoderm Endoderm Mesoderm

90

lourlh

Four well-defined pairs of pharyngeal pouches develop as endodermal e,aginations from lhe lateral walls lining lhe pharynx. The pouches develop as balloon-like structures in a craniocaudal sequence between the branchial arches. Note: The fifth pharyngeal pouches are absent or rudimentary.
Pharyngeal Pouch
~irst gro<J1;~).

Structures Derived From

Contributes to the fonnation or the tympanic membrane (wilhfirst brtmchiaf auditory tube. tympanic cavity. mastoid antrum
Palatine tonsils

Sec<>Dd

Third and founb

Pnmthyroid and thymus gland<

l.ctu(kf 111

The oral cavity (primirive mowlt or stomodeum) appears as a shallow depression in the embryonic surface ectoderm. At this time (befort' rhe fourth wee/c). Ibis stomodeum is limited in depth by the oropharyngeal membrane ((buccopharyugeal membrtme). This temporary membrane, consisting of external ectoderm overlying endodcnn. was fonned during the third week of prenatal developmenl The membrane also separates the stomodeum from the primitive pharynx. The primitive pharynx is the cranial portion of the foregut, the beginning of the future digestive tract. The first event in the development of the face, during the fourth week of prenatal development. is disintegration of the oropharyngeal membrane. With this disintegration of the membrane, the stomodeum is increased in depth, enlarging it. In the future. the stomodeum will give rise to the oral caviry, which is lined by oral epithcllum, derived from ectoderm as a result of embryonic folding. The oral epithelium and underlying tissues will give rise 10 the teeth and associated structures. Note: A plane passing th.rough the right and left anterior pillars marks the separation between the oral cavity and oropharynx in the adult.

G.NATOMIC SCIENCES

T he palate, both hard and sort, begins fo rmation in the:

Third week of prenatal development, within the embryonic period Founb week of prenatal development, within the embryonic period Fifth week of prenatal development, within the embryonic period Sixth week of prenatal development, within the embryonic period

93 94
107 Cclp)1'iiln 0 '2009-1010 ~rual ~lr.t

G NATOMIC SCIENCES

Which cranial nerve supplies the muscles derived from the first pair of branchial arches?

Oculomotor

Facial
Trigeminal Glossopharyngeal
Vagus

Hl'lh \H'l'k ul pnrwt;tl tiL\elnpmeut. \\ilhin fh(' cmhQnnic pt'riml

The palate is Conned from two separate embryomc srructures: the pnmary palate and the secondary palate. The palate is then completed during tl1e 12th week of prenatal development. The palate is developed m three consecutive stages: The fonnation of the primary p3late The fonnation of the secondary palate The completion of the palate Primary palate formation: During the fit\h week. the intermaxillary segment arises as a result of fusion of the two medial nasal processes within the embryo. The intermaxillary segment gives rise to the primary palate. The primary palate will form the premaxillary portion of the moxilla (the anterioronctilird ofthejinal palate). This small portion is anterior to the incisive foramen and will contain the maxillary incisors. Secondary palate formation: During the sixth week. the bilateral maillary processes give rise to two palatal shelves, Or lateral pnlatine processes. n 1ese tWO palatal shelves elongate and move medially toward eacb other. fusing to form the secondary palate. The secondary palate will give rise to the posterior two-thirds of the hard palate. \\hich will contain the maxillary canines and posterior teeth, posterior to the inctsive foramen. The secondary palate also gives rise to the son palate and its uvula. Completion ofthe palate: To complete the palate. the secondary palate meets the posterior port1on of the primary palate. and fuses together. These three processes are completely fused, forming the final palate, botl1 hard and sot\ portions. during the 12th week of pre natal development.

I ri:::t.lnin:tl
B1 amhi.tl \n:tu. ' ' .uullkri\ ,tti\l' 'lru"rnn\

Ar<.hes
Fust arc:hewo (ffwmdibtllur)

Future Ntrns and Musdes

Trigarunal nO"\re-, mUK1 of
tmsot \-th palatine ~td

Future Sktlttal Struttort's and Ugamtnts

'1aUtut~ nd tnctt" of mlddJc- e&(.

mctudmg. a.ntC':nCM' ha:o.meat masticatiOI'I, mylbbyod and a.n\erior of the ma11Cu5..apl!cnoJt3Udbu1ar Uanmtm, ld poo.l~n of belly of dip~uic:, enwr tymJ'IMi. 'he~oid b(ll'leFao.al IICI'-t~ $CalpCdNs mo:k-, muscles or r.e;al P'f"C$\Oft. pooeriol' belly of the dJ~Irie musclt.llt)'lohyoid ml.b4:1e
G~gal ""'..

Seoaad .......

r">oiD!

Stapes IDd portJO..- ofmalkus and '~ ofm:s4<tlt car. ~~Cylohyoid lig.ameflt. StYloid PfOC$ afll'l~ tempunr.l bone. tcs;.cr eomu of hyoid hooe, upptt poninn of bOO)' or b~'Oid

Thildan:ba

"""' Gra.n-comliloflr)'O'd bone.lawu port100: ufbod)

(!lf(be'

h) Old bone ~am-tc Fourth lh<oo' Superior lal')1lg~1 brnn(h tnd l..larynl:i~al CAfli1oaet tixlb urdlat ~nt ltryn.&ea.l branch orva@US rteNe, kwtOt pal#ti.nc ~lr$.
pfw)Qie.l ~ Ultnnsit

nqcles or diC: taryax

GNATOMIC SCIENCES

The nasal cavllles are formed from which embryonic structure?

Stomodeum Frontonasal process lntennaxillary segment Nasal pits

$
{;op)-n&h1 20092010 Ot:ntall:)r.('ks

(ANATOMIC SCIENCES

\..

Tbe ooronary sinus receives most of the \'Cnous blood from the heart and empties into the:

Right ventricle
Left ventricle

Right atrium
Left atrium

9596
150
C~ e1G09-ZOIO o-.1 Dccb

'\la~ial

pil\
I min' !!Ill\ llt' 1 lufiiiU 111 ul llu I .n'

E1nbryonk StruttUre
!\tomodoun

-.-or..-,_.
INM lhh

Ma.nc!OOim ttl\ (Jim hr'ottriJJ~I u~~~

~Wii!Uy """"'( ..)

~~~-

Orl&ln
Onlc:t\ic) ~

fiurure 'rh~u L-,

1!:(14dcrr.ulilqwN101t C1tlar!ed by

fu!oOd tr\IID6ib..Uv ~~ 111:16 neur:'ll crest tell

L.uwer I!Jf, l(t'ftf f'att, mand.iblr wr~b i610Cf.llo.l fltfr'IICI

Miclfi. t ppcr 1 .. tidcs.. dsU. ~ paiiM.:. p.lllenut
~ ofuw.l.tl.a I!Jl CU"Iilled fblkS..~IC ~

S\JI)Criot uc& ~ swtt1i:ftc (s)

kne...a

rromomu.'lJfOC'n'
"-!pits McclitllM&I pro..::nt{_tsl
h1ICII'I'IUiJIIII')' 11(~111
t.ani;l11.8111~(a\

""'""" I!C"'OOamal

purnoe of~l bcJots;

.~1~aJ and '-'m1 ri&AI pnn~ro~MU~
N1.'dlca~

t~UUC lnd Clt:lm!l Cft~l

.. .., pi""""

..

f~ ~IIX'dsal
~

BO-'

N.toidk oC-- f'H11Nm n':JI"'\ II"'CtiiP.i'Jb? llpiCilll

r~tCed mcdW nutltlfOI.'Csses F~~ lrllml.o,GIJI&i

~.asolc;rttuiiJ OOfd

...

ft,l'lli..-.r p011ki11ul mn.xilll "'lUI .;~\.Oitl(!i ~od tmUII!t. J'fitl'W'}' poil.ol>

Nuol.mmllfOO''e

--

i.N:nmatl sat, IIQIII~al dllct

ltichl alnum

When viewed from lhe back (posterior view), Ihe most obvious struciUI'C lying in I he coronary sulcus is the coronary sinus. This sinus receiv~s most of 1be venous blood from the heart lllld empties inlo lh" righ1atrium. Its tributaries are the small cardiac ,eln, n1lddle cardia< vein. and the grealer <ardlac \tin. Thete is a <mall \tin that arises along I he tel\ side of lhc left atrium just beneath the tower Jell pulmonary artery (called tllu ohliquc elu). This ve1111S a n.m nant of the embryonic left superior vena cava. The great cardlac vtin: opens into lhe left ew~mity ofthe coronary sinus. Thi~ '1!in receives tributaries from 1be lei\ atrium and bolh ventricle<: one. lhc left marginal \'ein. IS of considerable site. nnd asecnds along the let\ margin of the heart. The small cardiac vein: opens into the right extretnily of the coronary sinus. This vein re<:cives blood frocn 1he back of the right atrium and ventricle; the right marginal 'ein ascends along lhe right margin of the hean and joins the >mall car<hac in the coronary sinus. or opens directly into the nghl atrium. The mtddle cardiac vein: encb in the coronary sinus near its rigJll extremity. Tbe obUque nin: ends in lhc coronary sinus"""' ilslef\ extremity; this 1S continuous above wilh !he ligament of the left -ena cava. The following cardiac veins do no I cod in lhe coronary sinus: The anterior cardiac veins: comprising three or four small vess<ls which collect blood from the front oflhe right ventricle and open inlo the ngbt atrium: the right marl(inal vein frcqucnlly opens 1010 the right atrium, and is 1berefore sometimes regarded as belonging to this group. The ~moUcst cardiac veins: consisting of n number of minute veins which nrise in lhe muscular wall oflhe bean,; lhe majority open inlo the atria. but a few end in lhe \entricles. Note: n., anterior Interventricular artery (left amerior descendmg arr~ry1. a bronch ofthc left coronury anery. accompanies Ihe great cardiac ' 'cin. The posltlrlor (or descending) inlerventrlcular artery, a branch of the right ~'Oronary urtery. accotnp:mies the middle cardia( vein.

'"in

in

(ANATOMIC SCIENCES

\..

All of the following s tatements concerning curdiac muscle arc true EXCEPT one. Which one is the EXCEPTION!

It makes up the muscular component of the heart known as the myocardium Cardiae muscle cells are faintly striated, branching cells, which connect by means of intercalated discs to form a functional network It contracts voluntari ly Its fibers are separate cellular units, wbicb (unlike other striated muscle fibers) don't contain many nuclei It responds to increased demands by increasing the size of its fiber; this is known as compensatory hypertrophy
151
Copyrt~bl

9 J

C 20()9.2010 OC'n1aJ t>cd,_f

(ANATOMIC SCIENCES

I' When the SA node fails, or the SA node impulse is blocked, "bleb structure""'iII
\.. must take over as the pacemaker for the heart?
~

Sinoatnal node Atriovent:ricular bundle Purkinje fibers Atrioventricular node

97
152
Cop)'nllll 1'009-2010 Drr1CU ()c(b

It t.'ontr:u:h \nlunt~1dl~

.,. ThLS IS (liS(_: it C(NilmClS in\ oluntarily. The !'ltrtngth and freqUt.-ncy or tbr h.ear1 beal arc eomrollcd by 1hc ouaonomie nCI'ous I)Sictn. Dmh porS.<)'mpaahetic and >ympslhtdc pons of th' autoncunic- nervous ~ylttem are nwolved in thu control or the hcun. The h<mrt 1$ al,o hll.S an internal n~.,-vo"' syslem mode up of Ihe SA (s/ooMrial llt!de) nnd lh" AV (alriO\~IIlrinlior) node fhc AV bundk (Hu) leav<:lhe AV node near Ihe lll"er f""' uflhe mll'Tl\lnal J'IUm and sploiS O\'er the upptrl""" of lhe onlctVCDlnCUitr ,<plum mlo a lefi bundle branch 1ond a ril!)u bundle b~<tnch. The cardouc muscle i; Ihen supploed by branche> uf the 1wo hundll-s. Speciulh:cd cardiac.: muscle C:l!IIS in the woll oflbe: heArt rup1dly imtit1h: or conduct an cleclm:nl fm.. pullie lbroughoullhc myU<ordium. fhc lil!lllll ;, inolmtcd b)' lhe>lnoatrlal (SA) node (f'<JC<'Iflaicer) ond $p<1:0dJ 10 \he n:st of tile rigbtalr'lal lll)ocardoum dir<clly. to Ihe let\ atnol myocatd1um by -.ay of bundle of mtcralrial conduetins fibers. ~nd lo Ihe atriovemncular (A ~J node by woy of three
lntl.-modttl bundles. 'rlle AV node theumiuntes a $ignnl that IS conducted thruugh the \1C I1irtcu1nr tl'IYtx:ardiwn hy wuy oflho alriovenui<uiJir bundl~ (bu11JI uflhl and Purltinjc flb<n, lmponant: The 'louatrlol nod, located at JllOCtoon of the >Up<nor nnu th< righl eurlcle, lillie mns1 rapdly ~c-polanttn cardiac muscle hssue of lhe h""n Tbis os 11hy the .SA 11ode IJ\ refe~d 11.1 as the .. ,.ac~: ma k er"' of the hum't

.-.""and

J lememl}er: lhe conducting $y:,tcm

und not rttf'\ICS.

or

the

h~rt

b all mtxlifled

~oanliac

muscle fibern

1'1lc 'l mpolhttic fib<.-. ~""" from J!Incnts T2-T4 of the oponol cord ond 41\! Ji~lnbuacd ~H>>ugh Hoc middl< cervical ~nd ccrvico-ahomcc (or rellu~e) gan~lin and 1hc fi~l r,,.., Q;lngli;o uf Ihe lho r.-cic syrupnl.hctic ch"in. The l'yntiWlhc1iG libcrs puss luto the cardiac p1cxug :md frottlthcre to th ~ SA notle 1nd the ciiTdiut: rnll>CI< The dfL'<I of lhc ~ympalhellenm es at thu SA node inn 'ncrea"' an heart rote The efrect on llle mllSCie ~ an mcreuc in rise of pn:>~ure "nhon the 1~'llln<le. Ulll>
lnl'l'Ca.li:ln stroke voiUint.:.

The vagu; nerve provides pQrosyrnpatbotie control to ahe heurt. Th~ effect oflhc VUGUS nerve at the SA node is lh~ opposite of abe symP"theti< n<rves; it dcc=seslhc hun rate. TI1e vagw nerve abo decreases the excitah1li1y of lhc juncuonal ttsloUC around the /IV node, and this resuiiS in slow..- transmi&SIOn. Note: Slr<lng va,;nl snmulaaiun here may pmduce 1111 /IV block.

\trio' \'lit riruhJ r nucll

Tbe bean contains musses of uodul tis><~<. cxcilable tl&~ue that c<mduc\5 unpulses aud stimulates the hc'llrtbellt intrinsocolly Tlu conduction YMem signals !he heart ttl beat independently. II does not requtrc any e~temaltnfluencc.<. The impulse to stimul31c the he~nbeal passes through the ~onduction system stmcturcs in thos order; SA node - AV nodc- AV hundle- l'urkinje Obers. rhe S.\ node" in the wall oftbe rigbt trlunt. ncar the entrance of the ~upcraor vena cava. The SA nooc 1ypic!llly tlcpol;1rizes ~ron1nneously utlhe tJte 60 10 100 tnlles per minute, cuusiug the utr1a lo contrncl. Impulses from the SA node pa. 10 the alraovcntric ular oooc (A V node/. otriovemriculnr bundk (A V hundle, nr ht)nc/le o{His). ;;md finally 10 the condUcttOn myofibets (P11rk111je fihen) within the vemriculor walls. Sumuhtlion of tlto conduction myofobers C3ot,es Ihe veouicles 10 conuucl simull~ncnusly.

,,r

Nota

1. Tite r.ue ofthe discharge of the SA nod sets the rhythm of the enure heart. 2. The rllythm originates from the SA node because the SA node derolariz"" more frcqueo uly (60-trl(l bear. pt!r mfnule) thnn the AV 1 10de (~0-6() he11ts per min me) and ventricular conducting systeln (30-40 heaL< per mimi/e) ~o the AV node and ventricular conducting sy,tem are "capwred" by the ~onu' IJl)puJ~ and dnvco 01 60-100 beats per minme. 3. In sinus rhylhm, every P-wavc 15 followed by a QRS complex. the RR in terval is reguL1r, and the P-R interval ts les;, than 0.2 SCC<>nds. A r..t $Inns rhythm, r,~<ter tbao 100 beats a minute, is IJtown as sinu t<hycurdla whil" a slnw rhythm, slower than 60 ben~~ min11t<, is known a.> sln u! brnll,yrardlu.

(ANATOMIC SCIENCES

The apex of the heart is located at the level of the:

Third left intercostal space

Fourth left intercostal space Fifth left intercostal space Sixth left intercostal space

98
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(ANATOMIC SCIENCES

In the fetal hea rt, the permits blood flow from tbe right atrium to the left atrium.

Fossa ovalis

Fommen ovale
Foramen roiUildum

Ductus aneriosus Ductus venosus

J be apex of the hean is fonncd by lhe tip of the left vemricle and is located at the level
or the firtb len Intercostal space. The ventricles are larger and thicker walled than the atria. The right ventricle pumps blood to and from the lungs. Tho l~tl ventricle, larg~r und thinker walled than tltc ,; ght. pumps blood through all other vessels of tha body. Note: The ventricles receive blood frorn the atria. Important: The left ventricle enlarges brieOy in respon.~e to coarctation (coustrlctum) of tbe aorlll.
Remember: The hean functions as a double pwnp. The right side (right atrium) receives deoxygenated blood from the systemic circuit via the superior aud wfc:rior venae cavae as wellllS the coronary sinus. The blood then goes from the right atnum to the right ventricle via the rigbt AV valve. The right ventricle then pumps blood into tbe pulmonary circuit (\~a the p ulmonary semilunar tofv~. which allows blood lo flow Into
the ptllmMary arteries).

Note: Resistance to pulmollliry blood now iu the lungs cnusts o strain on tl1e tight vemride nod result in ventricular hypertrophy.

The le1 side (lejl arrium) receics o~genated blood from the lungs by way of 1he pulmonary veins. This blood then Oows through the left AV valve mto the lefl ventncle" f rom the left ventricle, blood passes through the aortic valve and cmcrs the arch of the aonn. which will deliver the blood to the body's systemic circuiu..

Fur:.tntl'n H\ alt

Remember: In the fetal bcart, tbe foramen ovate permits blood to Oow from the right a trhtm to the left atrium. The blood will tl>en pass to the left ventricle and the aorta, thereby bypasstng the noofuncuonal fetal pulmonary circuiL Eventual!), the foramen ovale becom~ pennanently closM with fibrous connective tissue and becomes tbe fossa ovalis in the adulL The fossa ova lis is situated at the tower pan of the aerial septum, above and to the ten of the orifice ofthe inferior vena cava. The annulis ovIIJ fonns the upper marg>n ofthe fossa. The atrial portion of the heart bll$ relat ively thin IVttiiS and is divided by tbe atrial septum into the right and ten ~tria. 'f hc vemricular portion of the heart bas thick walls and divided by tlte ventricular septum tntO right and left "eutriclcs. Note: The liga mentum arWriosum is a rc1 nnant !If the ductu~ arteriosus in tbe fetus. The ductus artenosus is a nonnal fetal structure. a llowing blood tO bypass circulation to tbe lungs (blood is shunted from the p11/monory artery to the uortic arm). Since the fetus does not use hts or her lungs (oxyge~ (\ pmt'ided thvugil rill! motlter splacenta), Oow from the right ventricle needs nn outlet. The ductus provides this, sht1ming now from the left pulmonary artery to lite aorta just beyond tho origin of the anery to the left subclavian artery. The high levels of oxygen that the ducms is exposed 10 aner binb causes the ductus to clo>c 10 most cases within 24 hours. When it doesn't clo!>e, 11 is tenned a patent ducrus ortcriosus. After binh, lbe ductus aneri<>sus become.' the ligamentum artcriosum, which conuecL~ the arch of the norta to the toO pulrnonnry artery.

GNATOMIC SCIENCES

A worker in the meat-processing Industr y comes down with an illness, presenting with symptoms offever, headache, and sore throat. A few days later, he feels chest pain and has pink, frothy sputum. His physician states that the worker bas a viral infection caused by coxsackie B. This patient has Inflammation or which layer or the heart {the thickest and tire workhors<!)?

Epicardium Myocardium

Endocardium

1SS Capyngbt 0 2009-2010 Dttll.liDtd;i

GNATOMIC SCIENCES

The left atrium and left ventricle are supplied by the:

Anterior interventricular branch of the left coronary ancry Circumflex brnnch of the left coronary artery
Marginal branch of the right coronary artery

Posterior interventricular brnnch of the right coronary artery

\1~ o~~Jnlium

Lavers or Lbe heart: i. lntcrnnl or endocardium - Homologous with the tunica intima of blood vessels. Lones the surface of lhe he:ut chambers with a simple squamous endOihelium and underlying loose connective u.~sue containing smnU blood vesseb.

2. Myocardium .. Homologous wilh lhe tunu:a media of blood ves~ls. Fonns the bulk oflhe heart mass and eonsosts predominantly of cardiac muscle cells arran~;ed in a !;pi ral configuration. This spiral arrangement allow~ the heart to "wring the blood from !he ventricles toward !he aortic and pulmonruy semilunar valves.
J. Pericnrdlum - is the set of membrnnes around the bean (ills act11ally compo.<ed of three loyen ofmembra11e.<). The innermost is the 'isceral pericardium. the middle os !he parietal pericardium. and the outer ooe tS the extra one. called the fibrous pencardium. The inner two (vi.vceml mul parietal) arc rather thin tmd ddicutc. The uuter one, the librous JX'ricardium. os tough. Important: The major sen.-.ory nef\1~ to the p:sn etal pericardium i~ from branches oftlo phrenic ntr\'e (C3-1;5).
l utp()rlant: The bean and its pericardium make up the contents of the middle medl a~tinum. TI1o left and right phrenic nef\~s and tl1eir adjacent artcnes lie to lhc left nod nght oftbe pericardium and anterior to 1he r()(IIS of t11~ lun[!.S.

ircumn~ ' hr:.~.ud1

ut thl' 1 \'ft cornnan

tif"h."r)

The anerial biQQd supply of1hc hcan IS prov1d,'tl b~ ~ right and Jell coronaryarten~s. which nn>< from the aorut iUIIDCdiately aOO\c the JNII< ""he Th..") and thctr maJOr branch<> ore dl5tributcd
m ~the sur race of lhe 1\ea.n l}lni wnh1n &,UbtTicardlnl connecci' c tissue. Tile rlgbr coronary ur1\ry arises from the ~lntt"nor'30rtic s1nus oftl1e ~ending uortn and rUn) fOr ward betwc'Cn the pulmonar) trunl. and the right euncle. Th1> anery I!JV<S ri"" to an tm[IOIUnt brunch immtdtately aner leavtna the 8.)tlding aut1a This as the anterior righ suriaJ bntnch. whit.:h gwcs nl)e lo t.hc 1 mpor1nm uodalartN)'. 1111:,. nnery ftupphes the SA node ur pucernl\kcr of lho heart. Ole right comoary llltcry conunues in t(le coronary sulcus, givina oil' noorgtoal bronch. u. htch supplies the ri!lht ventricle Finlly.the ngbt cM>oary anery gl\ me to th< t>Ostuior In tenen1rltular branch (posll!rfor fles~ttlldln.g at"-''''), whic;h ~upphe" buth vcmrlclt!s. aml lhtn
a.no..,tomoscs wilh lhe l.'lrtwuOcx
art~:ry

from t11e let\ coronary 1 1 rtery.

The left coronary artory, wbich os usually larger than the ri&Jit comrntry llt!Cf)'. ons~ fn>m the lcR pcKterior 30<11< slnU.> or the ascending aorta rorwaod bel ween the pulmonary 11'111\k and the left aur1 cle. This arte-ry dh11dcs into un anterior fotcrventrlcuJar brnuch (lt!fl anlerlur ,/e~ uc"ding urlery), which rupplics the right and tel\ vcnh'icla and the intCNI!ntricular \(;ptum, onO a cln:wnftt\ bnonch, whicll.upphes the left auiunt and the left '""tnclo. Important: nu: ruuerlot interv<:ntriculor artery ts 1 he one 1 nost u!'tl.'tl lnvo h~~ 1R coronary ocC'ha&auns :ind IS often the une that is bypassed in hypnss cardiac surgery. "'"' OM four Rts or '"'''es that keq> the biQQd OOWtng in the proper dnrtuon lhmul!h thee hom-

and""""''

"""of lho h<-ar1:

Rigbl nnd lfl trloventrlculor valv<s (AI' V<l/1~~)- ore located bctw<en the atria and the 'entnclc. TI1c valve on the n&h is callc'Cithe tricuspid ' olvt; on the !eli h is called the bicuspid {ttfhra/1 \ah These ,.l,es preC1'1t baciJlow ofbiQQd onto the atna during ventriCillar con lr:sctum. Sentllunar vslves -the pulnoonary semilunar valveilo.:nted on the pro.,unll c'Od of the pulmC>Mry trunk. The aortic umllunar 'ahe is located in the pmximol end of 1he orta. lllce vatvcs prevent return ofbtuud 10 tl1e ''-'n1ricles lfnm the ~!Jr1n ancJ pUI InOo(~ry (runk ~tfkrcon
rractioo

G NATOMIC SCIENCES

Which group of structures empties directly into the right atrium?

Superior \ena cava. coron81)' sinus, and hemiazygos \tin Coronary sinus and pulmonary vein Pulmonary and bronchial veins Superior and inferior venae cavae and coronary sinus Coronary sinus and azygos vein

157
Cop)rigln C 20092010 Drntal Dkl

G NATOMIC SCIENCES

,
A patient "ilh a " heart-\atve problem" comes into the dental clinic for periodontal therapy. Sbe sa)'S that her old I>Crlodontist always gave her antlbiotlcs before trcntmcnt, and Insisting that the dentist bear the problem, she places the stethoscope in the left fifth intercostal space n1cdialto the \.. nipple line. Which heart valve Is best beard over the apex oft he heart? ~

Tricuspid valve Mitral valve Pulmonary valve

Aortic valve

100101

Sulllrinr ancl inftrior H'ltlH' l':t\ ar ami rurnnar~ \inu'

The coronary sin us lies in the posterior part of the coronary sulcus (atrioventricular grooe) and opc11S in the right atrium between the operung of the inferior ''e03 cava nnd tl1e roglll atrioventricular orifice, ils opening being guarded by a semiluntlr valve (T/rcbesitm valve). The superior vena cava opens into the upper pan of the right atrium. The superior vena cava returns the blood from the upper half of lhe body. The Inferior vena cava (larg~r than the .<rt(Jerior mna C'Qva) opens into the lower part of the rigbl atrium, The inlcrior vena cava returns the blood from the lower half of the body. flow or the blood through the heart: I. Entering the right atrlum are the coronary sinus and the superior and inferior venae cavae canying rlco:<ygenated blood from the systemic circuli. 2. Upon contraction oftl1c rlgbtatriutn, blood passes through the rightAV valve to the right ventricle. 3. Upon contraction of the right ventricle, blood leaves to pass to the right and left lungs via the pulmonary arteries. 4. Blood gases are exchanged in the lung. and oxygenated blood rotums 11a pulmonary veins to the left atrium. 5. Upon contraction orthe len atrium, blood passes through the len /\V val'e to lhe left l'entricle. 6. Upon contracUon or the left ventricle, olygenoted blood pnsses through lite aortic valve to the systemic circuit via the aona and its branches.

\t11r.tl 'ah l' (/11, "'piJ 'alt't'l

The four vahes of the hean ure designed 10 allow one-way now only or blood. Their function is to J>rcvent backllow into tl1e releasing chamber. The four ltean valves work in pairs in tandem: During entrlcular s~stole, the cmricles of the bean contract. and the pulmona11 a nd a ortic vahes open lo allow blood to be pumped into the pulmonary 811d general cii'Clllatory systems, respectively, whi le the mitral nnd tricuspid valves remnitt closed. Dunng ventricular diastole, the aon1c and pulmonary valves close, while the atri oventricular valves (th~ mitral and trirrupid a lves) open to allow blood to pass from Lhe atria to tle ventricles. 1. The. atrioventricular valves- the mitral und 1ricuspid vnlvcs- separtne the Notes atrium and ventricle on the lefltmd right sides oftbe heart respectively. 2. The aortic and pulmonary vah e.< are said to be semilunar valves. be.:ause each consists of three half-moon-shaped valve cusps Lhat are nuachcd to the in side wall of the aonic and pulmonary anerie.~. 3. The apex of the heart lies in tlte left fifth intercostal space medial to the nipple line. about9 em from tbc midline. Tlus location is useful for detcnnining the left border of the bean and for auscultation of the mitral (bicuspid/ valve. 4. The tricuspid vah'e is best heard over the right half of the lower end of the body or the sternum. S. The. pulmonary ' 'alve is best heard over the second left intercostal space. 6. The aortic vahe is best beard over the second right intercostal space.

GNATOMIC SCIENCES

A 10-year-old eirl comes into the physician with complications from Group A streptotocc:al infection, namely rheumatic fever. She Is presenting with aortic valve stenosis, which Is causing her di:a.iness and syncopal episodes. In the healthy heart, during diastole, the aortic valve:

Prevents reflux of blood into the right ventricle Prevents reflux of blood into the right atrium Prevents reflux of blood into the left atrium Prevents reflux of blood into the lefl ventricle

100,101
159 Cop)TiC}n 0 20092010 Onltall>tc:k

GNATOMIC SCIENCES

,
The pectinate muscles are prominent ridges of the atrial myocardium located on the inner surfaces of much of the: Right atrium Right ventricle Left atrium Lefl ventricle

lrr\rnh rl'llu\ tf hloud intu llu left Hnlridl There are four vahes that keep blood flowing in one dirc!Ction through !he heart: The right and left atrio,cntrlrular ' '"lvcs -- separate the atrium and ventricle on the leO and right sides of the heart, respectively. - Trlcu<pid valve or right AV valve - guards !he right atrioventricular orifice; consists of three cusps. Thi!. valve controls lhe flow of blood through !he right AV opening. Nott: TI1in but str ong fibrous cords of the chorda~ tcndlneac nnach the cusps of this valve to lhe papillary ntuRies oflhe right ventricle. Tbe mitral vahe or left AV valve - guards the lei\ atrioventricular orifice; conststs of two cusps. Chordae te ndineac anach these cusps 10 papillary muscles of lhe left ventricle. Important: Overdistension of the valves of the atrioveutricular orifices of lhe heart is prevented by tbe ppillary muscles and the trabeculae carncae (nucle ridges and bulges lining lire righl\'enlric/e Q(llre lreart). The semilunar valves: - Pulmona.r y nlve- guards the pulmonary orifice (berween tire nghr erflricle and rhe pulmonary llrii'IJ'): consislll of three semilunar cusps. -Aortic vtlve - guards the aortic orifice; consists of three semilunar cusps. Not~: When these valves are closed it prevents backflow of blood into the left ventricle. ... Important: There are no chordae tendlncue or papillary muscles associated wirb these valve cusps. Papillary muscles are found only in the ventricles of the henn.

Ril,!hl al rium

The pectinate muscles are promincut ridges of attial myocardJum located on the inner surfaces of much of the right atrium and of both auricles (whrdr are small eanical

pouches projecting/ram the upper anterior portion of~ach atrium).

The crista terminnlis is a vertical mtr:s<:u\ar ridge that runs alons the right atrial wall from the opening of the superior vena cava ro lhe rnferior vena cava. The crista tenninahs provides the origin for the pectionte muscles. Note: The crista terminalis represents the junction between the sinus veno>'US and the
heart in the developing embryo. h "represented on lhe extemal5urface of the heart by

a vertical groove called the sulcus terrninalis. lmportant: The SA node is located in the crista ternrioalis near the opening of the superior vena cava. Remember: PapiUury muscles arc cone-shaped mu:s<:les that rcnninnte in the tendinous cords (choroae tendin~ae) that attach 10 the cusps of the atrioventricular \'ah-es (rricrupitl and nurra/'(JIoe). P&pillary mu.~cles are round only in the \'entritles of the heart. nte papillary muscles do not help the valves to close. Instead, these muscles prevenllhe cusps from being everted (or being blown out) back into the atrium during ventricular conuaction.

GNATOMIC SCIENCES

In a cardiac tamponade caused by trauma, tbe pericardia] sac nus up with nuid. The Increased pressure on the heart prevents the pumping chambers from nmng up properly and in turn causes inadcq uate pumping of blood. The pumping chambers of the heart are anatomically known as:

Vena cavae
Ventricles

Nodes
Atria

161 Cop)naJ!1 0 20092010 OcDoal Dtd.

GNATOMIC SCIENCES

r Which gland Is sometimes called the " master" gland of the endocrine system, ~
\.. because this gland controls the functions of the other endocrine glands? ...iJ

Punc:reas

Thymus gland
Parathyroid glands
Pituitary gland

\ l'tllril'lt>\

The aduh heat~ ;_.. n hollow. four-chambered muscular U'I!Jin that is about the St7e of a dosed flsLAbout two-thuds oflhe hcan'smass is to the left orthc body midlit>e. 1'11e heart and tt> peri cardium make up the contentS ofthe middle media.s11num.11 prricardlunt IS a tough doublrvnllcd fibrous membranous sac Otat surrounds the heart. 11to outer wall of the sac is culled the parietal pcricurdium: Ute inner wall of the ""cis csUcd the visceral pericardium (etli cardium). T11e ponetal and ''isceral p<:ricardia are continuou. T11ts coOiinuhy take> place at the pOints where the maJor blood vessels ente< and lone the hcllrt. In betweettthe"' walls IS tbe perlcardial cavity, whtch con~11ns serous Ould that minimize. friction 01; the heart bents. The anterior surraoe of the hean 1s ttlw known ns 'he sternocu~-ral surf1tce. The anterior sur~ fnce shows p:lrtS or each of the four cltambers of the heart. Right atrium (RJ\) } are sman and located toward the superior regton ortbe heart and Left atrium (LA) are sepnralod by the thin. muscular interatrial S<ptum. Right vemrtclc (RV)} arc lnrger and are located at the apex of tlle heart and arc sepa l.eti entriclc (LVI rated by 1be thick. muscular intervenu'iculat sepmm.
l 'hrte borden or the heart: Risbt border: mude up of the roght ~tnuon Inferior border: made up of right au'iurn. right ventricle. nod left entricle Lcfl border: made up of the ldl entricle The left and n~:ht 'en Irides make up the dlaphragmatlc surface of the bean. This part rcsu on tl\C tlbrous pllrt ufthe ilinphrogon. Thc lrt atrium mnkcs up the ~o-cnlted l.>asc of the heart. When the body ts in the supine tM>sition (lying 011 It !tack). the hcrt ~Is on ItS base, and the I""' of the heart (th up of the left l'f'ntride) piOJe<:IS up and to tbc ldi and lib into a depression on the diaphragm.

Th~> pimitary

ghmd 1s no larger than a pea (weighs onll' 0.5 gnu11). and rests ln the sella turcica. a depression io tl1c .1phenoldal heme at Lbe buse of the hratn. The pituitary connects witil th hypothalomu.~ via the infundibulum. through which this gland recehes che.-nicaland neural sumuh. The pituitary gland is often referred tO ns the "master rndocrinc gland" bccau~e it conli'C))S SO many oliler glands. It dOt:S thl~ through the action of tropic bormoncs -hormones that affect the aollvity of tiDOther endocrine gland. For this reason. the piluitary gland b 'I tal to life.

The pituitary develops from two different sources: an upgrowth from the ectoderm of
tbc stomodeum and a dowu~;rowth from the neurocctodcnu or tbe dicncepbnlon, in other words, an upgrowth from the roof of the mouth and a down growth from the Door of the brain. This double nl'igln explains wlty the pituitary gland IS composed or two cOil'tllletcly different types or tissue. The adenohypophysis (glmrdulnr pllrtiOII) arlsC:i from the oral ectodenn, and the neurohypophysis (lltr>'Ous JH)rtion) urijpnates from the neuroectoderm. During the developmental stage (about rllree weeks), a dierticulum coiled Rathke's poueb arhc. from the roof of the stomodeum (primitil't! momll) and grows toward the bmin As this flO\tCh approaches the developing neurobypophysi~ {po.<l<rior lobe}, its attachment with the mouth is lost. The pouch then goc~ on to form the port ion of tho nin1itary glund known a, the adenohypophysis (anterior lobe).

GNATOMIC SCIENCES

E ndr s)

,
Diabetes insipidus Is characterized by the secretion of large amounts of dilute urine because of a deficiency in antidiuretic hormone. Antidiuretic hormone is secreted from the: Anterior piruitary Posterior pituitary Adrenal medulla Adrenal conex Thyroid

113
Ccp)'n&bl c 2009-2010 DmlaJ Db

( A1"1ATOM1C

SCIE~CES

Endrs)

,
A SO-year-()ld female was diagnosed with anaplastic thyroid cancer and underwent aggressive surgery to remove most of the thyroid. Unfortunately, """' the surgeon also excised tbe parathyroid glands. Which of the following could result from !be excision ofthe parathyroid gland!? Strengthening of muscles Weakening of bones Muscle convulsions Decalcification of bones

Tbt puuitary hns IWO mrun regions. The l~rger region. the anterior potuitary (odenohypophJ'Sls), produces at least six hormones: Mnentonlc - CPA B-FLAT GH, ,Croluctin rrom Alpha cel.ls. Retn cells: fSII, Ul, ACTH,ISH. I. Growth hormone (GH)- promotes growth in general, panicularly the skeletal sy~
lcm.

2. Corticotropin (ACTII)-- controls the secretion of adrenoconical hormones, wboch in tum affect Uoe membollsm of glucose. proteins, and fat. 3. T hyroid-stimulating hormone (T.S'H) -controls secretion of thyroxine by the thyrood. 4. Prolactin - promotes mammary gland development and milk production. S. FoiHde-sllmulating hormones (FSH)- stimulates growth ofGraniian follicle.< in the ovary and promotes spermatogenesis in the mate. 6. Luteinizing hormone (L/1) - stimulates secretion of sex hormones by the ovary and .,-tis.
The posterior pituitary, whtch makes up ubou\25% of the gland, serves as a sto..age area for: I AOB (onrufluretoc hon11one or n.~opres>ill) - conrrols the rate of water cxcreuon onto the urine. 2. Oxytocin -- helps to deliver milk froiJitJte glands of the breast to the nipples during nursing. Note: ADH anti oxytocin are produced in the hypothalamus and tntnsponed on axons to the posterior lube of !he hypophysis ior storage and secretion.

A deficiency of I'TII """lead to tetany. muscle weakncs$ due to a lack of available cal cium in the blond. The body'ssmallest l:nown endocrioegland>. the parathyroid glands an: small. pea-like organs embedded beneath the postcnor surface of tht th)TOid gland. Most peOple ha~e four of thom. Working 10gether as t1 single gland, the porathyroid glands produce parathyroid honnone. l'ar:rthyroid bonnone is the most important regulator of calcium and phOSilhorus cone<:ntration in extracellular fluod It finds tts major target cells in bone and kidney. r~~esc glands are esRntlal forlifc. Each parathyrotd gland has u fibrous tissue caJ)l'Ule and t"o types of cell~: Chief cells- produce parnthyroid honnone, whoch acts to raise the concentration of calchnn in the blood and reduce tbc concentration of pbosphate ions Oxyphil tell< - function is undeu:muned fhey receive onner\'ation from the postganglio"ic sympatbcuc fibers of the superior conic! ganglion. The superior palr receives its blood supply frum 1he superior thyroid artery (from cxremal carotid) and the inferior pair froon the infcri6r tltyrold llrtcry (from thymcr~vlcal
/rUIIk).

ott: Tbe lh) roctrvltallrunk is shon and duck and arise. from tbe fU"St ponion of the sul>clavian anery close to tbe medial horderofthe scalenus anterior. Thostnmk dovides almost ommediately into the followmg thoee branches: inferior thyroid. supra~<Cnpulnr, nnd 1ranswrsc cervical (or srlfoerjicial cervical) lll'lerles. I. These glands develop from w third and fourth pharyng<:al pouches. 'lot.,. 2. The tlny pineal ~tlnd lies at the back of the third \ entricle of the brain. This gland produces the hormone n1clntonin. This hormone is thouhtlo play a ntlmbcr of roles in humans, uocluding the regulation of the sleep-wake cycl.,, body temperatUre regulation. and appetite.

(ANATOMIC SCIENCES

E ndr s)
~

Which hormone is the most plentiful a nterior pituitary hormone and is also ) \. controvers ial for use in athletic sports and body building? ~

Foll icle stimulating honnonc (FSH) Luteinizing hormone (l..H) Prolactin Growth hormone (GH) Thyroid-stimulating honnone (TSH) Adrenocorticotropic hom>one (ACTH)

165 Copyn&t!t . 2009-2010 Dental Dl.~

( ANATOMIC SCIENCES

E ndr s)

,
When trying to locate the parotid d uct, a freshmen dental student in anatomy """' class would consider each of the following relationships EXCEPT one. Which one Is the EXCEPTION? Its opening can be seen in the vestibule of the mouth opposite the maxillary second molar tooth It extends from the anterior border of the parotid gland
It can be palpated as it crosses the faoe, superficial to the masseter muscle

It is superior to the zygomatic arch

104 :>

Remember: The anterior pituitary gland mak~s four tropic bormon~s FSH. LH, ACTH, and TSH . This gland also makes two regular hormones - GH and prolactin. G rowtb hormone (also called somatotropin) targets most body cells, especially those in the bones and muscles. It accelerateS body growth, stimulates cellular uptake of amino acids and protein synthesis, and stimulate.< carbohydrate and fa t breakdown. Prolactin promotes breast development and stimulates milk development. Prolactin release is triggered by rising levels of estrogen.

It

j,

'upuiur ro

thl'/~~onutlir

nrch- if i~ ;~cfuall~ inft:.rior In

thlt~J.!nmalk

arch

The parotid gland is the largest of the .alivary glands and is a purely serous glond. It is situated below the external auditory meatus and lies in a deep hollow behind the ramus of the mandible and in front of the sternocleidomastoid. This gland is divided into deep and superficial lobes (which enclose tire facial nen't!). Therefore, a ponion of the parotid lies superficial to the mandibular ramus, and another portion lies deep. The parotid gland is drnined by Stensen's duct, which crosses the masseter muscle and pierces the buccinator muscle to open into the vestibule or the mouth opposite the maxillary secon d molar. Parasympathetic secretomotor fibers from the inferior salivary nucleus of the glossopharyngtal nerve supply the parotid gland. The nerve fibers pass to the otic ganglion via the tympanic branch of the glossopharyngeal nerve and the lesser t'Ctrosal nerve. Postganglionic parasympathetic fibers reach the parotid gland via the auriculotemporal nerve (bra11ch of V-J), which lies in contact with the deep surface of the gland. The u temal carotid artery and its terminal branches v.'itbin the gland, namely the superficial temporal and the ma.xiUary arteries, supply the parotid gland. The lymphatic vessels drain into the parotid lymph nodes and the dtt>p cervical lymph nodes.

( ANATOMIC SCIENCES

Endr s)

,
T he part of a developing salivary gland destined to become responsible for its functioning Is called the: Nephron Follicle
Adenomere

Lobule

167
{:orl)ns!ll 0 20092010 Den!1l D~

( ANATOMIC SCIENCES

E ndr s)

,
A death-row inmate who was notorious for aggressive and hyperactive

behavior is complaining of abdominall>aln. Hospital tests reveal bilateral tumors that are secreting excessive catecbolamines. The pheochromocytomas are located on which endocrine gland?

Anterior pituitary Pancreatic islets (l.Angerhans)

Adrenal medulla

Paratbyroids
Adrenal conex

,\th.nollll'l"i' it i' IIH' hmctii)ll~tl unil in 'alhar~ :,!l:uul\ Exocrine glands...., stnK:turaUy and functionally subdhidtd by sepia. platelike mvagmauoos oftheir connecme tis;uc capsules 1111> ammgement app!Jes mninly 10 the pancreas ond sali vary glands. I. Lobu nee the largcSI oft be subunits and ore separutcd by connCCii>< ris:me sept. 2. Lobules ate subunits oflhe lobes aod an: ~par.ued by thin extens1on' of tbe !iCJl'3. Adenomeres are secretory subunits oflobules. Adcnomeres con:;'" of all !he ~retory cells lhat release their products into o single imralobular duct. 4. Ado! (m(J/Ieoli) ore smaller secretory subunits. Each acinus is a ;phcric colle<:tion of secretory etlls sw-rounding tbe bhnd-eoded tenninatiun ol a ~wglc JOtCfcaLttd duct.

An adenomen is COn1p6Sed or:

lntertalnted ducts transpnn saliva to lnrgcr ducts S triated ducts contain a lot or ntitochondrin respo~!!iible for elcctmlylo and "ater transpon during Sretion. Simple.low colutnnarepitbehum lh~<: tho.: duelS Clandulor ull$ - synthesize &lycoprotein> Types of sull''"l')' glands: Major I. Paro1id gland- pwcly StrOllS gland 2. Subm3ndibular (11rbmaxlllao1 gland - mhed serous and mucou~ gland 3. Sublingual glnno - purely mucous ~:land Minor are located on the; I. Lip> 2. Cheolc. 3. Tongue von l::bntr's j:lllnds are n>S~ciuted wi01 cfrcumollnte papill" 4. Hord palate

\dn:n:1l nll-rlulla

Stinutlatiun of the adrenal medullA cuu.o;es th~ 1\'lca.<e of large quantitic> ofcpl nepbrlne and norepinephrine. The same effects are also cau.ed by din:ct sympathetic stimulation, ~ C<!ptlhe errcc~ last longer when llle medulla src:tes tlle honnones. Wuh (If withOut one or the other (medulla or .vympatlretlc 11enes), the oljlans would still be stimulat<d. In other words.lhc medulla functions in a manner shnilr to postgunglionic sympathetic cells. The two adrenal gtonds (ulso C(JI/ed suprarennl glands) arc nauened. >Umcwhal trinngularh:lped endocrine glands resting upon the supCf10r poles of each loom:y at the baclc of llle abdomen. Each gland h3S an outer pnn. the cortex, and a core, the medulla. The adrenal cortex produces three main t>'JlC" of hormones: Glucocorticuids: which arc produced and released under Ute control of adrcnoconlcotrophic hOflllUIIC (ACTH) from tbe pituitary. influeuccs the metabolism offal, protein. and carbohydrate>, promotmg the breakdown of protem and the release of fat and sugars into the bloodstream Minerolocorticolds : stimulate tho relea.-.e of sodiWll in the kidneys

Sex ~t<rolds
The adrrnal mtdulla contains many modified nerve cells, which produce the homtoncs ep lnephrinc and norepinephrine ((1{/rena/ine nnd noi'Oifrenal/ne). 11te~c bormoncs ~re re leased in bursts during emergency situations or accompanying intelt'IC emotion. They act to mcreasc llle strength and rate of hear1 contractions, r.usc the blood sugor le,cl, elc,ate the blood pressure, and mcreasc breathing. Important: The adrenal medulla develops F rom ucuroeetodcrm, while the adrenal cortex ucvclops from mesoderm. 'iote: Nturotoderm is a special~ group of tell; lhat di ffcrcnuate from the ectoderm. lloeurul crest cells arc a specialized group of cells developed front neuroectoderm that migrate from the crests of the neural folds and disperse to sp~ifio sites wilhln the mes nc h)m c. They also inOuencc a speeJali)1Je ofmcenchyme, the Cclo mescncbyme.to fom1 dental tbi.ues.

G.NATOMIC SCIENCES

Endrs)

(\.
Par.; nervosa Infundibulum

The portion of the pituitary gland that arises from an outgr owth or the hypothalamus is the:

Adenohypophysis Neurohypophysis

Cop)'Tiaht 01009-2010 DentaiDcd.s

(ANATOMIC SCIENCES

Endrs)

(
\..

Exocr ine glands indude all or the rono.,ing EXCEPT one. Whjch one is the EXCEPTION?

Sweat glands
The prostate gland Bile-producing glands of the liver The pituitary gland Lacrimal glands

Gastric glands

170
c~

2009-2010Dr:alal0ed.J

Remember: The posterior lobe fonns from on outgrowlh of !he hypolhalrunus and conUiins axons from the neurosecretory ceUs of the hypothalamus, along with neuroglialike cells (piwlcytes). n>e anterior lobe (aduuohypophysi<) is fonncd from an invagination of the pharyngeal epilhelium (Rathke's pouch)- thus, the epithelial nature of its cells Important: I. The anterior pilultary or ndenohypophysis is a classical glaud composed pedominantly of' cells that secrete protein hormones. 2. The posterior pituitary or neurohypophysiS is not really an organ bU1 an extension of!he bypolhalamus. It is composed largely of the axons ofbypotl>alamic neurons that extend downward as a large bundle behind the ante ior pituitary. It also forms the socalled pituitary st~lk, which appears to suspend the anterior gland from the hypothalamus. The tropic hormones (F'Slf, LH. ACTH. and TSIT) arc hormones that affect the uctility nr another endocrine gland. Releasing or inhibiting hormones produced by the hypothalamus control these hormones of lbe anterior pituitary. Prolaelin and growth hormont (GH) also made ie the anterior pituitary are not cons1dered 10 be tropic
hormone.~.

Secretory cells of the anterior pituitury are categorized anto two g -oups. according to their staintog properties. Addophils (acrdil' <lai11): secrete Gil, and prolactin Bsso11hils (basic stain): secrete TSH. FSll. LH. and ACTH

I h('

pitUif.lr~ ~l.uul

F.xncrine glands are glands whose secretions pa~s into a system of ducts that lead ultimate!) tn the exterinr of the body. So the inner surface of the glands ond the ducts that drain them ore topologically cnnllnuous with the ex>erior of the bod) ( the din/. Endocrine Rltnds. in contmst. place their seen:tions into the imemal en\ irnomcnt - the blood. Classification of exocrine gland>: Type M secretion l.M ocous (secnuc mums= mter~ mucin)- buccal glands, glond.< of the o;ophagw.. cardiac aod p) loric glands of the stnmach 2.Ser<>Ui (en;yme.t)- parotid gland, pancreas and uterine glands 3. Mued (nmCOIIN tmd somtiS) -- submnndibular nnd sublingual sallvory glands. glands of the nasal ca,ity, paranasal sinuses, nosopbarynx,laryn.\,trachea. and bronclu ~lode ofse<:rttlon J. Merocrine -- only cell secretory product rcle.1Sed from membrnne bOlmd secretory granules - pancreatic acinar celb 2.Apocrine - secretion of product plus small ponion of cytoplasm - fat droplet secretion by ruiiJ1lmary glands 3. Uolocrine -- entire cell with secretory product - sebaceous ~;lands of skin and

uosc
Structu re or dU<I !)'Stem I. Unbnanebed - ''simple~ glands- sweat glands 2. Dranched - ~compound" glonds - pancreas ShnJIC or secretory unit I . Tubular - cylindrical lumen surrounded by secretory cells -- sweat glo.nds 2. Ad nar (al-.:olar) - dilated sac-like secretory unit - sebaceous and mammary glands 3. Tubulnochta r (tubu/ooilrolar) -- intermediate in shape or having both tubular and alveolar secretory units - n1ajor saUvar') ~:lands

GNATOMIC SClENCES

Endrs)

I'

A young girl Jlrcscnts to the physician with a large, round face, a "buffalo hump," and central obesity. She also bas a history of hypertension and insulin resistance as a result of increased cortisol from Cushing's syndrome. Which anterior pituitary hormone controls the production and secretion of glucorticoids such as cortJsol?

Follicle-stimulating bonnone (FSH) Luteinizing hom>one (J.JI) Adrenocorticotropic hortnone (ACTH) Thyroid-stimulating hortnone (TSH)

171 Cop)'n,ah1 C 2009-2010 l'kntal DU

(ANATOMIC SCIE~CES

Endrs)
~

A pancreatic CJtncer patient bas a tumor that presses on the ampulla ofVater.
~

This has been causing him GIJ>roblcms because the tumor obstructs the \.. common bile duct and the main excretory duel of the pancreas known as:

V.'hanon 's duct The duct of Wirsung Bartholin's duct Woltlinn duct

58
172 ~ ,.. l(JC)9.l010 Ortol De<:b

Adrenocorticotropic hormone. as ils name omphes, sumulates the adrenal conex. Moce ~pocifically. this hormone stimulates secreuon of glucoconicoids such as corfuol, and has litlle comrol over sccreriou ofuldosterone, the other major steroid hormone from the adrenal conex. ACTH is secreted from the anterior pituuary 1n response to corticotTOpln-reiU$Ing hormone from the hypothulnrnus. Conocotropinreleasing hormone is secreted in response to many types of stress. which makes sense in view of the ''stress ouuongement'' 1\onctions of glucocorticoid.~. Conicotropinrcleasing hormone itself is inhibited by glucoconicoids. Folticle-slhnulating hormone (FSH): ln females, FSlt initiates ovanRn follicle development and secoetion of estrogcas in the ovaries In moles, FSH stimulates sperm production in the t<Stes (spcrn1<1toge11esrs) l .uteiniLiog hormone (LH): In femAles, LH stimulates secretion of estrogen by ovarian cells 10 rcsul1 111 ovt1la lion and stimnlalcs fonnatiou of the corpus luteum and secretion of progesterone In males, LH S1imulates the onterstitial cells of the testes to sccrtle testrn.tcrooe Thyroidstlmulatinl: homtone (fSif) !gul3tes thyrood gland nctivities, uptake of iodine, and synthesis and release of thyroid honnones.

I hlthu:luf \\ ir,un)!

The pancreas is a retroperitoneal organ located posterior to the stomach on the posterior nbdominal wall. The poncreas's large head 1s frumed by the Cshapetlloop of the duooenum. while the tail touches the spleen. The patl<'re-.os riY> >1 role in both the d1gtsll\ e and endocrine sy:>~ems. The panereas l> co\ ered '" a tissue capsule tha panotions the gland into lobule.. The erodocrine function of the pancreas is concemed with both foodslloll'release dunng fa>t ong and foodstuff storage after meals. fhc h\O parocreallc hormonu responSible for~ functions are glucagon and Insulin, respectively. These two hormones nre produced in spc cial cell types willtfn many tiny spherical clumps of pancreatic tissue. which are known as the pancreatic islets or the Islets of Langerhans. Withm the i~lets of L.111j1<rhsos, the alpha cells secrete glucagon, "boch elevate. blood sugar; beta ctUs secrete insulin, \\bich affects the melabolisrn of fats. proteins, and carbohydrates: and della cells S<:<:rcte somatost:ltln, '"bich can inhibit I he release of both glucugon and Insulin. Two ducts that may be associated with the pancreas: I. The main pancreatic duct (duct of ff!inrmg) - begins a< the tail and joms ohe common bile duct 10 fonn the hepaloJiancreatic ampulla (umpulla of J111er) before opening lnto ~1c duodeount. This ampulla discharges bile and puncreatic enzymes into ohe descending ponion (second port) of the duodenum. 1. 1 he accessor) panerutie duct {Sontorln/S duel} - when P'"'cnt opens >eparatel} into 1he duodenwu . .., I. Bartholin's duct is tile major sublingual duct (ll'hen presem) that drains the Nolet' sublingual salivary gland and opens on the sublingual papilla in doe floor of the
mouth.

2. Wotman duct (ol<u mlled til~ mesonephlc clucr) l an embryonic duel that develops w d1e male into the deferent duct in the female, II ~ obliter:oted.

G NATOMIC SCIENCES

Endr s)

On a patient's panoramic radiograph, the dentist notices a small, well-defined radiolucency that sits Inferior to the mandibular canal. 1 he dentist performs a sialogram that rules out a true cyst and makes the "orking diagnosis a static bone cavity (Stafne bone cyst). Which of the following salivary glands creates the de11ression in bone that radiographically gives the above ftllpearance'!

Sublingual gland Von Ebner's glands Submandibular gland Parotid gland

,.,
CopynaJ'It 0 2Q09..20 I0 l>eolal Dt..

104

G NATOMIC SCIENCES

Endrs)

Tht major gland(s) ofthe immune system is:

The thyroid gland

The adrenal glands

The pineal gland

The thymus gland

"""'"P ., 100'>-lOIO De-' Ocds

Snhm.Jmlihul.lr cl:1nd The ubmandibular slnd We!Jibs balfllle \\eithl oflh< Jl'lfOIOd. Tht<glond "often rcf<rred to as 1he >Ubmoxillal)' glnnl. This glnnd lies m !he sutnnndlbulor triIP formed by the unltrior !IIId

posu:riC\r J-.cllics of the dil;aslnt' muscle t'l"d lhc inrt:fiOf llUir~m or the IMOndibh:. The gland 18 poSliiOii<d med1al nd tnfenOr 10 lbe mandibUlar IUJ!IU.< f'31'll) ~'nor an.t panly inf<'110f IO I~ bast oflhe poolenor half oflhe mandible. The glond forms 'C" oround !he unlcrior mOl'!\In oflhe m~luhyold muscle. which d1vide.< the submond1 bular ~lond inlo 11 supc:rtimnl and deep lobe. The deep lobe compdliCH the majurlly pf the ~land. Tho ~landulru clements rue n miAIUrC of <trollS 1mostlrt and mucou> acini ~>llh wcne S<:rou< demilune< 11.< "1he case w1th lbc paroud 5land.lbe JO.u.-nn~ndlbultu gland i; investcJ in 1lS own capsule, "'htch to; a1w conhnumn with the ~uperficia1 lnyer of deep C'C"'Ic:nl fa.."icia. lmport:unt: The mnq.;lnlll 1113Udlbular l)rllnch of the rnciut nerve <~ur><> superliclllco the >uhmandibular 81and nd deep to Ibe placysm The submandibular duct (11"/~nrton. duct/ ari>C> JTom he deep portion or 1M gland and crosse the hn~ual M"C In the reg10n of chc sublinJ!Ual gl11nd to ICTiliiiiDie. on I he ubliugunl CMimtlc (f'Uf'lll<i! ndjacent1o tl1e h11>o uf the sublingual f enulum. When Ihe subhn&ual due< (811rlhuli11 ~
Juc/1 LS rr~l!flt. 1l Ul!.uQIJy tcnnln:lto. On Or ncar lhC li!Ubmaf\dibulnr canu14.JC also. lrnpor1anr. The lingual nent "'1111 MkJ:nd \Vhwton's duct. 1an1ng lih.1'1ll.md t.-nd1ng meditJl co the due~. while CN XII (lilt il,l-p<gluS<il ,.,w) l~""llel s clw >ubmandbulor duQl nmningJul

mfcmor 10 it
Blood ppl~: The blood supply is ftum the sublln~ual btoncb of th<! lln~ual all<"')' ami from d~r >ubmtnlal hnnth oflhc fotlal rtcry. The fllt1alaney tonn.< ~ groo>C m ched<:Cp pan uflhc gland, ~nd lhcn curve up :u-ound llw inferinr mill'gn M1hc mandible to ourply the lilcc. vcu1> drum mtu lhc lbclol ond lilll!unl veins. rh< Lvmph "'''-'ICls drain mlo the uhmandit.llur and deep cenl, ..llymph mldcs l nnen'atlun: Pansyrnpllt.htllt' )C'(.'TCtomotor- fibe.,.... lnrm the ~u~nor .s.ah~Qry nucleus nr the rulal nerve. The nt."rvc Obcr11 p21ss l() 1hc -.ubnnandlhuhu nnnglion vln the ehurda 1yrnpnni ur und lhc liqgual nervt. Pa>lgon:Piulll< por.u~ mpatbrllc fobeM> IJ'l.S ID the @lond ia the lingual nrrw. PO>tganglionc )mpllhrric r~~><t, rt"a.:h Ill< 1ill>d as a plc.us of"''""' arou..t the J~cal ond lingual ar1c110>.

n,.

llw

th~ nHI'

c,l.md

Tlte thymus gluud is a duetle~s gland II>Cnted clecp 10 the Sl~ruum a1 1d is sitUnlcd in the superior m cd hutinum. At birth. the cb~miiS ~cigb~ about a half of no ow>ee. ancl funber CJ1Iatge5tO oboul ,cn IIUDCI.' b)' rubcrt). l'ollo11i11g puherl)' lh~ lhytnU> >brink> 10 a fully fibrou rcmuanl, weighing nbout a ltnlf of an mmco. While 1he thymus is pl111 of Jhe endCicrine system. the 1hyruus'< prunary funcuon i that <lf a l!ffllpb organ. Th~ thymus IS the eentnll corurol nrgan for the unmune S)'>trm. l~mphocyll."$ onglnn~r from uemocytOblusls (slcm cell>) in red bonu mnrrow. Those ilitn enter tbe tb.ymus mature und develop into acuvn1cu T lympbooytel> (I.e.. able 111 respoml to <lniiR<"IIS en("OUIIIetl!<l elsewltere In the body) They then diide imo two groups: "Thos~ lhn1 r<-t"lller 1he blood: lhese urt' transponed 10 dc,elopm); second:uy lymphoid tt..<ues, such as lymph tlodcs :Jnd Hplccn. Tbuse that remain in the thymus gland aod are the wuree ul'ftuure gcn<t:~tions ufT lymphocyte<. Muny n111ricn1s function us imp(lrtonr cofactors in the manufncllJre, .<ooretion, and function of 1hymlc honnones. Zinc. vitamin Bt., and VItamin C ore ~rhJp~ tbe mu~l en heal. Zinc is perhaps the mo>1 cnucal mcnel':ll involv.:d m thymus gland fun~ion ancl thyJnus hotmune oction. Zinc is uwulved in vutually ever y apcct or immunity. 1. The lhymu; hns no afferent lymphmics or lytnpiU1hc nodules. "'"'"' 2. Olh~r lymphoid O'l!ans ongioatc ~oxclusidy from mesenchyme, wh<N.ons the 1hymus has n double embryolo~lc origin. Th~ lymphocyt~~ are denvcd from hematopoietic stem cells (me.-e~uJhym~!. while Hussall"s corpllscles fepitirelium) arc derived from endoderm of th third phaJYugcal pouch. 3. The at1eries >Upplyiog lbe 1hymwc nre tlt-n\'ed from the inter nal mammary, upertor lhyrold, ;md Inferior thy roid rtcries. h is innurvatcJ by 1he va ~ u~ nerve.

( ANATOMIC SCIENCES

Endrs)

An aggressive duodenal ulcer has the potential to perforate the small intestine and Involve other organs. A posteriorly penetrating ulcer has the potential to adhere to this organ, which is both an exocrine and endocrine organ.

Thymus gland
Pancreas

Thyroid gland Parathyroid glands

175

Co!>Y"'!!> C> 2oe-201o """" Du

G NATOMIC SCIE~CES

Endr~

A patient with DiGeorge syndrome can present with cleR palate,

autism, heart defects, and a hypoplastic:

Thyroid gland Thymus gland Pituitary gland

Pancreas

19:,6

The pancreas is a retroperitoneal organ located po~terior to ~ stomach on the posterior abdominal woiL The pancreas's large head is framed by the C-shaped loop of the duodenum, whi le the tail totches the ~plccn. The pancreas plnys a role in holh the digestive and endocrine system.,. The pancreas is covered in a tissue capsule that partitions the gland into lobules Endocrine ponion (I.<let of/..ongcrlwns endocrine cell.<ofpaiii:NJfl,f): Alpha cells- secr~te glucagon, wluch counters ~le action of insulin. Beta cells - secre1e insulin, which helps carbohydralc metaboliSm. Oelta cells - secrete somatosutin, whtcb ac1S locally within the tslciS of Lange mans themselves to depress the secretion of both insulin and glucagon. Important: The degeneration of the islets ofl..1111gcrhans leads to diabetes mellitns. Exocrine portion: Acinar cells (poncreatlc e-wcnne cells)- these cell~ are filled with secretory granules coutainiog the digestive enzymes (mainly tryp.in, chymotrypsin, 1Hmcrealic lipase. and amylase) that an: secreted into the lumen of the acinus. Remember: Pancrenuc secretions contain bicarbonate tons and are alkaline in order to neutralize dte acidic chyme that the stomach chums out.

I h\1111h t:land

Defects in cbrotnosome 22 (rrmso nfmost case" oj'DIOeorge syndmme) muy cause a baby's thymus gland tn be smaller than normnl (hypoplastic). tn some cases. children wilh DiGeorge 5YIIdronte don't ba' e a thymus gland a1 alL Remembrr: The primary fwtcnon of the thymus is the processiug aud maturation of special lymphocytes (willie blood cells) eaUcd T lymphocytes or T cells. which are as,,ociated with antibody production. T lymphocytes migrate from the bone mnrrow to the thymns. where they marure and differentiate until activated. Wh1le in the lhymtts. the lyntpboc)'!es do not re.pond to pathogens and foreign agents. After the lymphocytes have matured, they enter the blood and go to other lymphatic organs. where the lymphocytes help provide defense against disease. The lhymus also produces a honnonc, thymosln, which Slimulates !he matunnion of lymphocytes in other lymphatic organs. Note: The thymus glnnd also produces thymic lymphopoietic fnctor (TI.F/, which confers immunological compc1cnce on thymus-dependent cells and induces lymphopoiesis. The lhymus gland is u primary lymphoid organ (alollg wlt/t the spleen, toosils, lymph nodes, alld Peycr's patches) that consists of 1wo )(l bcs surrounded by a thin layer of coonecuve !issue. The thymus &lund is located deep 10 1he sternum in the superior ntediastinum. This glond consists of an outer cortex tbnt is primarily lymphocytes. The Inner medulla also comains lymphocytes and Bassall's corpuscles. These corpuscles are tbougbt to be vestiges of epithelium; their function is unknown Important: Tlus organ appt:ars to be the ntlUier organ in immunngenesis in the young and is beheved by some (bur llOt all) 10 monitor tlte total lymphod system throughout life.

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All of the following contain mucus-secreting cells EXCEPT one. Which one is the EXCEPTION'r

Submandibular glands Sublingual glands Parotid glands Glands of the esophagus Mucosa of the trachea

n
Copyns:llt 0 2009-2010 Omtal Ocd;j

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E ndr s)

The thyroid gland can be examined In which of the following triangles of the neck?

Submental Glandular Carotid Submandibular (or digastric) Muscular (or visceral)

107

 Rtml"lnber:

l'he.~ glands are ct~mp ltl ~l}

.;erous.

Both ol>e major and mmor ~lionry aiiJlds an: c:ornpo<c:d of boch tpUbeUuno and conoecU.c oinue. lprtlldl3l celt; bvlh hn< obe duco <y>l<1n and produce o~e.ah_.. Con=me oi.,uc surrounch !he "J)H~tlium. prou~cnns

uncl suppOrtlni the gland, 1lte connective us~tu: of the glond

i~ divided

mm the

C8J)~U1L 1

which &urr('IUndS the outer p011lon of the entire olnnd. and 5t.ptu. Each !lt:ptum hdpo divide the iMer ponion of the gland into larger lob..-. and smaller lobule>. ~rndr<lial <>ell> ohal produre s:dtva ""' calltcJ so<:"IOr) ccltl. !'be IWO IJip<' uf t:creoory c<ll< are
as ettbcr otU<!Ott> or serous cells. Sc~tttory cel1~ ltn: (ound in 11 gJlJUp, or ado u.s fJtfl,rol.

C'las~dicd

udni). whtch rescnlhlcs a clusoer of srnres. 11<11 ocinu.< COII~il or. single IY'f ,,f cuboidlll cells,

ephlu:lhtl cells SOJTOtlndi"S a luru<'n a cemrol O J )tning where tJle $tlltva is dcpusl11:d aller hcir1g produced by'"" ,..,.,<tory cells n.~ lh~ ionm ofacini arc classofic:d ,. orh oype or cpnhelial <:ell rn:.ettland lhe produ<~ heing produced.

t"""'

,,,.,,.oury

Serodsl\~lni:

COmJX'S.Cd

or ~..cou.s cells producint: 0 !OCM~t."t secretory JJI'Oduct: BN ~'tncro.lly~'phcriclll with

a t~arrow lu.mcu
Serow cell coooain W!; amouoos orrlR, IT ribo>omc$. prommcn1 Gol&i eomple~. and ODfnl:rolll J"'l<tA-cith. mtmbnme-botmd VCSi<IOS called ..ccrc1~ry !lf'lll\lfts. In ctlf<ohal f>I'O duce dig~:-t.tivt enZ)'llltSJ the..1le vesicJcs are called Z)'llh'&cn gmnules .Mucous Adni: Con>po>od of onu<oos eclls producn111 moco\IS >relory product. arc U>llltlly mO<c rubular wilh a ..-ider hllll<.:n Most rnUC'OUS cells cone am latge n\lmbcrs f'f mucanogctuc grnnul~ an their ap1cal ~.-ytopla5m ~ lle<l Acini: tlave both mUC:(l\,1!; cell$ surrounding. the lumen and 11 'i4'I'OIJII d~ilun t or cap of .!U!rotJII ttll"> '1uperiic:ial w the group of mucons 5ecrecory fls These caps. or serou, dtmUunt>. "'-'a1:1< mlv Ill<: h1~.hly c:onohuod moerccllular .-pace, between the mucous cells. Th~y .arc- UJ\'Ic-Jat.ed wuh the mi~cd ac~n1 of the suhlinaua' and sttbnumdibulnr glond; well as the ~Iandi oo f tfu, tsophnsu ~nd oroch11

\lll'~cular

tor ,.,,nru/)

Remember: 11tc neck is arbitrarily subdivided inrotwo oriongiL-s by thu sternocleldl)mustoid mu~cJc: the aniHior nod posterior triW1glos. l11e ""terior lrinngle is then sub divoded into the s ubmental, s ubmandibular, musculur (oJr voul!rol), and tbe urolld triangles. The po.oetior triangle is then subdl\ ide4 min the ocdpiLal ~nd supradaicu lar (umod011culorl lriangles. 11tc largest ot'lhc endocrin~ glands. the thyroid gllliitl conslsls of1wo lobes, U te right nnd left. whicb are jo'"cd across by a thiu balld t111led tb< i<lhntu s. T~e lhyroid glnnd is on " H"sbaped struclU"' localed anterior to the upper pan ot Ute 1rochet1 near its JUIICIIOn wnh the larynx . Thyroid epithelial cells-- Ill< cells respon~ible for synthesis or'thyroid Mnnonc .. are tli'I'Dnged in spherts c<~llcd tuyrold follideJ~, These follicles are filled with colloid. Colloid is composed oflbyroglobulm nnd 1odinc nnd is the "'Ofllge form of the thyroid bormon"" T3 o.od T4. Note: Thyroid hormone IS cQ<npO>ed of 1wo diff~rcn1 subsonnces: thyroxine (also called T4, ot rerraiodotltymnine) and trilodolh)'ron lnu (TJ). Thyroid homoooe has severnl funclinns, the main one being In rletennine the metabolic rot< ofb<ldy hs~ues. Important: The production or thyroid hormone is under th" t()Q!rol of th~roid~llmu latlng hormone (1'SH), which is released from rbe piluioary gland. In ltddltlon '" lhyroid epithelial cells. the o hyroid glnn<l houses ouo no her ionporlunt eo d~rine cell. Nt."'lled in spaces betweon tbyroid foll icles arc para follicular or C rolls, which 5rete the hormone calcitonin. Calcilooin acts to reduce blood calcium. OJlP').,ing the effects of pan~thyroid bl)rmone (PT/1), Note: Tbe thyroglossal duel is n narrow canal thol coouecL< the thyroid glnud U> t~ tongue d~rins dcvcloprneut. This duct diStipJI'-ars soon uftcr develop men I of the sluttd. Jn the adull lhe proximal end oflbe duct Jl"rsists as Ihe ror11men ctcu nt of the longue.

GNATOMIC SCIENCES

Endrs)

~ Hospital tests on a patient identify a tumor In the hypophysis that Is excessively secreting growth hormone. Given that the patient Is a 4-year-<lld male, what is the expected outcome if no trcatntcnt is performed ?

Pituitary giantism

Acromegaly

Pituitary dwarfism
Achondroplasia

178

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In which .wnc of the adrenal gland a rc mlneralocorticoids secreted from?

Medulla Zona glomerulosn Zona fasciculata Zona reticularis

105

The amount or growth hormone secreted by the anterior pituillll)' gland cau have a dramatic effect on bone development: Pituita ry gint- twnor prior to adolescence, excessive GH delays ossftcation of ep1physeal camlage (nun-fiion of epiphyses) . Acromegaly -rumor after adolescence, excess GH secreted after ep1physeal cart; Iages have been replac-ed by bone (fitsion ofepiphyses), , Pituitary dwarf -- GH deficiency =uhing in early replaccmem of ep1physcal can.lages by bone. Tmport1 tnt point : TI1e deciding factor in whether giga.ulism or acromegaly wi ll occur wbeo there is oversecrction of growth hormone by the pituuruy gland is whether the cplp b )$CS or the long bones ha,e fused with the shaft or not, 1\vo lobes of the pituitary J!land (hypophys/,r cercbrl): 1. Posterior lobe- Wlmyelinatcd nerve fibers, secretes AOH and oxytocin, 2. Anterior lobe Alpha cells (acidophl/,r: stain strrmgly with acid dyes) 1. Somnlotropes - secrete GH 2 Lactotropes- secrete proloctin Pa rs d lstalis Beta cells (basupllil, v; .<lain .rtrongly with basic dvc,r) I, Corticotropes -- secrere ACTH 2. Gooudotropes - secrete FSII and LH 3, Tbyrottopcs - ,o:crcte TSH *** The pars in termedla and tuberalis have no proven function in mammals.

.lun.t t.:lomuulo\a

The two adrcnol glands (11/so called sr<prcmmal glands) are flattened. somewhat triangular-<haped endocrine glands restmg upon the superior poles of eaeh kidney ur the back of the abdomen. Each glond has an outer pan, the corte~, and a core, the medulla, The adrenal cortex is composed of three layers, or zones (endocrine tells 111'1! organized into these tlrree ar~as), 1. Zona glomrrulosa - thin layer composed of clusters ofcell< beneath 1he conneelive tissue capsule. Cells secrete tltc mineralocorticoid,, primarily aldosterone, which :rn: involved witlt the maintenance of electrolyte and wnter balance. 2. Zona rasclcula.ta -a thick middle layer, the cells are arranged in parallel columns that run at right angles to ~te surface of the glnd. Cells secrete tlte glurocorllcolds, primarily cortisol, Small nmounts of estrogenic- and androgenic- like substances are also produced, 3, Zona reti<ularis- mner layer of cortex, cells arc arranged in a network of interconnecting cords, Secretes small amounts of cortisol and dchydroepiandrosterooc
(DHEA),

Remember: The meduU of the adrenal gl3nd really is modi tied nervous tissue and functions in :t manner similar to po~tgllnAiionlc sympathetic ceUs --stimulation of the adrenal mcdulln causes the release of large quantities ofe11inepbrine nnd norepinpb rine, The same eO'eelS arc also caused by direct sympathetic stimulation, ucept the effects III.St longer when the medulla secretes the honnones, With or without one or the other (medulla ur sympatltetic nerves), the organs would still be stimulated.

cA.~ATOMIC SCIENCES

Endrs)

Meibomian glands (or tarsal gla11ds) are sebaceous glands located nt the rim of the eyelid that function to protect the eyes (rom drying out. Meibomian glands, which release the entire secretory cell witb the sebum secretion, are thls type of gland.

Merocrine
Apocrine Holocrine

Copyrisbt 0 20091010 Dm~l Oecli

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GNATOMIC SCIENCES

Which salivary gland can have either numerous small ducts that open onto the noor of the mouth or a single main excretory duct (Bartlwli11 s d11ct) that empties at the sublingual caruncle?

Submandibular gland Parotid gland Sublingual gland

112
CqJ)-nJh1 0 20092010 rknll Db

llulucritw

Exocrioo gl1nd have a Ju..1 chrou11 wluch lhm produce (sweat. ..a/h.,, dige.r/1\'e PIIJYI!Itl, etc.) IS rei~ F..xc>enno glands wichio lhc incc:gumcnlllt)l sy<l<m incJu~e sebaccouo vl<lnch I> h/ch "" uss~dated n rlh Jrarr fo//ic/1 and Ol'l! donc't!d .from eclnd.rm), s\\ eal glands. and mnntmary
glands. Wi1h111 lhe di.:cst.ivc sys1em. exocrine glands mcludt 'hu salivary glands.. g:lstrte glands

Mthin the stomnch, and ~he exocrine por1ion orlht JXIn'-TCas.

s,,rctur~

Ch,siticatinn ul' 1'\m'rim. (;lands

Example> SaliviU)' ...d rrun;rube slond. .:crmin S'\\eat g:l.a..n&b
MlltUDe!l' glaocb., ,"efta,iq w.tol &ll!llds

Type
~{erucnftl:

Description
1be lland ceJI'{ produce their STdiOCU ud rtlense !hem enco lhc clucc, cau:siug no cboma,ce lo lhc cell

Apoamo

The ICCr'C'UOM a('(:Wtlulate in one pan of1he ecU, collod doc ap!Cil regJOII Thcs part b<caks ofl fmm che rut or lh~ ceU ~long "''ith soote oytopJasm. rcleastng ltJ. pmduct inlo lhe <!ucc
and n::htMt the. "+bc.1t: ceU h'll(l Ote du~t. 'This Jestroys the c.cll, which ih rq>laced by a oew growth <:ell.

H(IWc:r111e Ac:cumul:nc lheJr secretions-ir1 each ceii'K t.')'tuphmn

S~h:tceo"-~ gJt mds nft:ktn

Endo( riot glands ;CCII.'IC !heir products (lwn11oner) 11110 lhc cnlermotoul flue~ sum>undong lhe SIXTetory cells front w~coh !hey diffuse 1n10 c~pillanc>IO be carried away by tho blood l:nrlotrine glands constilule the <nducnn~ system and inc:luJ<: lbc puuuary, lhyrocd, JIMIIh)nliJ. odrel\lll, ai\J pineal glands as "ell 11> che gonad> and lhc i>lc11 of Ungcrhans fexucrilc~ <Y:II.< (!( lh< pGnrrr<U/. The major ullt ry gl1nd tpumlld. "'INnanJi/Julur. und scrM/ngua/) are cbsolficd compound cubwoaheolor ~;lands. lhcy delier chetr iall\ncy secretion> into lhc moulh by "oy of l:orge ~--:<.:reory ducts (Srenft11 :r, Whor't(m \, amltlr~ numtrotts small Rh;,u.-. S Jurl.f) rcspecthcl)'. 1'\ote: TI>e pornlld gland and von Ebner's gla nd nr tho only adull salivary slunds chat arc purely serous.

..

Suhlin::.:,m1l t,:l:lml

The sublcngunl gland cs the smallest oftb~ thrtc main salivary gland>. It cootnm.< hotn serou~ and murous (witlt .<em11s demilunr.J acme, the lat1er predommatcng. II b locmed beneath the oral mucosa in the floor of the lll()Uih bcc\\ccn rbe rnillldible on one srde rued the gcnmglo..sus and hyoglossus muscles on tlce ocbor side. The sublingual gland sils on lbe mylohyoid muscle. UnUk~ the submnndcbulur gland. which drsirus via 011e lnrgc duco, the sublingual glnnc.l dmins via approxim~c~ly 1220 small duets (RM11u.: ducts) al11ng the sublinb'tl~l fold along the floor of the mouth. Tbe subhngunl glfinrl is iunervated by pnrnsymJlathetlc secrctoml)tor tlbers from superior sulivnoy nucleus of cbe facial nerve. Tbe nerve fibers p3ss co the submandlbular gtlnglinn via lhe chorda 1)111Jranl nerve and lhc Ungual nerve. Postganglionic parasympathetic fibers pass 10 the gland \'ia the lln(tual nerve. Postgangliomc symr;~chetic liben; "'ach the gland as a plexus of nel'\<es around lhe facial and lin(!Wll anenes, fhe blood supply ~ from the sublingual branch of che lingual anery and from the submental branch ufche fadal artery. lmporla nt: T11e veins clrain inco U te facial and liogunl ''~Ins. The lymph ve$Sds tlncin in111the subcnnndibulnr and deep cervical lymph node. Sometimes che numerous su~bllngual ducts (12 IIJ 2/J ;, numbel) JOin 1 11 form u single main excretory duel {Banltoli11 i; duel} chat usual I~ em plies on co the submandibular duct Note: Yon Ebner's el:~nds are located around the drcumvallau: papclla uf the IUilf,'Ue. Their main funcuon ts co rinse lhe food a"ay from the papilla aJlo:r lbe foocl has~ IBSted by the ta.<tc buds. Those gland are purely serous.

(At"iATOMIC SCIENCES

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The portal venous system occurs when one capillary bed drains into another capillary bed through veins. There are three portal systems In the human body: the hepatic portal system, the renal portal system, and a portal system involving which endocrine gland?

Pancreas

Thyroid gland Pituitary gland

Adrenal gland

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(ANATOMIC

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~

A pathologist receives a salivary tissue biopsy of what the dentist believes is pleomorphic adenoma. Howe,er, the dentis t f~rgot to mention the site or the biopsy. The pnthologlst identifies certain histological structures that would indicate that this sample is not from the parotid gland. What structures can be seen in histologic examination of the submandibular and sublingual glands but not In the adult parotid gland?

Myoepitbelial cells Serous cells Intercalated ducts Serous demilunes Striated ducts

http://dentalbooks-drbassam.blogspot.com
PituitaQ J.!l:md

A ponal venous system occ~ when a capillary bed dratDS into another captllary bed thtough vcms. Both captllnry beds aod the blood vessels that connect lite beds arc con sidered pan of the portnl venous system. They ar~ relatively uncommon as the maJOrity of capillary beds drain mto the hean, not imo nnother capillary bed Portal veoous systems arc considered venous because t.ltc blood vessels thnt join the two capillary hcds nrc either veins or venule;. Examples of such ~ystcms include the hepatic portal system. the hypophyseal portal system, and d:te. renal portuJ system Blood supply to lh~ pituitary gland is from the right and lett superior hypophyseal arteries and fmm the right aud lelllnftrlor b) pophyseal aneries. which are branches of the internal carottd anery. These fonn the nch va.,cular hypophyseal por121 system. Thts system of blood vessels links the hypothalamus and the anterior pituitary. This system allows eudocnne communte:ttion between the t\\10 structures. The veins dmin into the in tercavemous $i11uses. lmt>ortant: The neurohypophysis contains abuudnnt axons whose cell bodi~s (trc lo cated mainly in the suprnoptic and paraventricular nuclei of the hypothalamus.
SUIIIIII:tr~

or Ori;:in and Trrminulu~:~ ul Pituilar~ Gland

AdenobypophJ sil (gltmlur poriiOil/
Neurobypoph~ols

Oral ectodtnn (from roofo(ttolll<Hieum)

.Keuroe<'todeml

Pars disralis Pmmberalis Pan tnt<mnedta

Pao;nerv\l58 lnfimdtblllum

} Antcnor lobe } Posterior lobe

lftum}loor uftltenuplulltml

(nerve portion)

Important: Se<retory cells are found in a group. or acinus (plurol. ocim). which resem-

bles a cluster of grapes. There are three forms of acmi. serous, mucous. :tnd mtxed.
Mixed arinl: these glands bave both serow and mucous cells. The mucous <ells form tubules. butthetr end arc capped by serous cells that secrete berween the tnncou. celt~ intercellular >pace. These serous caps on mucous cells are called scrou demilunes. Appl'Oximmely I0% of submandibuJur glands contaiu serous demilun~s. hut these glands are predominantly serous acini, which constitute 90% of the gland. The sublingual gland contains !Serous demilunes amid iL~ predominant mucous cell population. Serous cells are present cxclusivdy un demilun<! or mucc)US tubules. Note: Tbe key potnt is that the paroud gland and the vou Ebner's glands are pun!ly serous and do not contam any mucous or mi1ed acuu. These demilune cells secrete mucus that contains the enzyme lysozyme th>t degrades !l!c cell walls of bacterin. Jn this way, lysozyme confers antimicrol>ial acuvity to mucus.
Rcmemb~r: All of the major salivary gland~ (parotfd, .w bmandlhtllflr. allfl subllllgual} are classified as compou nd tubulo:Uwolar gluds. This m~ans that their ducts branch repeatedly (comtXJtmd) and their secretory ponions arc tubular and compose.! of small sacs called ulveoll or acini.

( ANATOMIC SCIENCES

Endr s)

Follicular "colloid" is a protein substance that stores:

Thyroglobulin Triiodothyronine Thyrotropin

Thyroxine

CopynJ}It 01009-2010 DenQI Ol.t

'"

( ANATOMIC SCIENCES

Endr0

1 The small, pea-shaped pituitary gland (h)popllysis) is J""ated on the inferior"""~

"surface of the brain. This gland is positioned In the:
~

Infratemporal fossa of the sphenoid bone Sella turcica of the sphenoid bone Crista galli of the ethmoid bone Cribriform plate of the ethmoid bone

rh, roclnhulm
Thyroid epilhehal cells (folficulor cells) -- the cells responsible for synthesiS of thyroid hormone-- are am~ng<d in spheres called thyroid follitle5. Th~sc follicles nre filled wi1h colloid. Collotd I> composed of thyroglobulin nnd iodine illld is the storage fonn of the thyroid honnones T3 (iod01hyronine) and T4 (tltymxinc ar rctraiodotll.wrminc). When the pltulluty j\l~nd secretes thyrotropin, the colloi.d becOme$ uctlvc, ond thyroglobulin molecules arc released nnd token bock into the folliculnr cells by endocytosis. where the tnoleculcs ate broken down into thyroid bormoucs, tbyroxmc (T4) and triiodothyronine (TJ). :-lote: The T3 Blld T4 .1re collecti~ely referred to 11.\ the thyroid hormones. This hormone then passes out of lhe follicular cell< snd enter.; the blood5trc~m. Wnhin the bloodstrerun, almost all of the thyroid bonnones ate bound to pla.<ma proteins such llS thyroid-binding globulin (TBO). The thyroid normally produces aboutlO% T3 and 90% T4. In tht! tissu<"s, howeveo, much of the T4 1~ converted to T3, which is the major active form of tbe tbyroid hormones I the cellular level. Follicular cells remain inactive at timus ol' low thyroid hormon~ need and can he activated when it is necessary for tlle mubdi7JUion of colloid found wilhtn t11e thyroid follicle. :Sole: MetabnUcally inactive follicular colloid will stain ~cidopbtlic (stu/Its Jtrongly ...lth oc1d stains) wbile metabolically acthe folli~ular collmd Will stain bas1c stams). basophilic (stairu strong/!'

,.,,h

Se-lla

turd~o.u

ur lhl 'JIIU.'OUid buill..'

The sdl turcica (literal/; ThrkisJ sttddle) ~a suddlesbaped depte;;sion tn the sphenoid bone at lhc base of the skull. The seat of the saddle is known ns the bypo(>hyseal fossa, wlticb holds the pituitary gland (hypophysis t~rrbri). l.oeated anterior!) to the hypophyseal fossa is tile tuberculum sellae. Complettng the fonnation of the saddle WJtc>norly is the domom sellae. The dorsum sellae ts terminated laterally by Ute pu.ottrlor clinoid processes. 1 1. n1c crista gn lli is a sharp upw!U'd proJection of the ethmoid bone in Lhc midNot., line, for the nttachnent of the fillx ccocbri. 2. The cribriform plate consists of perfurotcd areas on either ide of the crista galll. h trunsmits olfactory nerve bundles. 3. The infratemporal fossa ties inferior to the temporol fossa ond the onfrutem por.al crest on 1he greater wing of the sphenoid bone. 4. The noor of the sella run:ica L< also the roor of the spbenuod smus. Important points to remember concerning the pituitary gland : I. Blood supply 1s from tbe right :t11d left superior hypophyseal al'1cnc; .ond from tlo e right and lei\ Inferior hypophyseal aneries, whttll are branches oftbc ontcm;tl carotid artery. These fl)rt\1 the rich vascular hypophyscai i>Ortol system_ 2. Tho nlltetloo 11llultnry or adenohypophysis is a classical gland composed prcd(lminantly of cells that sectl!te protein honnone;. 3. The posterior pituitary or neurobyJ!OPhysos is not reaUy an organ butttn e~tension of the hypothalamus. The posterior pituitary IS composed largely or the axon~ of hypothalamic neurons that extend downward a.~ a large bundle b.:hind the antenor pituitary. The posterior pilllltaty also forms the \0-(:0IIed pituitary stalk- whtch nppc:ars to suspend tloe :>oocrior gland from lh" hypothalamus.

GNATOMIC SCIENCES

Endrs)

Oxytocin and vasopressin arc synthesized in the hypoyhalamus and are transported to the pituilary gland for storage by ""Yof:

Myeli nated nerve fibers Both myelinated and unmyelinated neNe fibers Unmyelinated neNe fibers

t87
CopyTia}lt 0 20092010 Dm~l Ob

GNATOMIC SCIENCES

,
\.
Conicospinal tract Rubrospinal tract Vestibulospinal tract Reticulospinal tract

A fighter pilot in W\VJJ gets shot down during a mission. Miraculously, he survives but arrives at the hospital unable to perform fine motor movements such as writing his name or buttoning his shirt. Which descending tract of the spinal cord would be damaged In this case?

""'

108

l 'tun~ l'linah:cl m:n l' tilwr'

As oppos~d to the anterior lobe (odenohypophysis) , \Vhich prc.entS epithelial characteristics, th~ posterior lobe (neuroll,pophysls) comists of about I00.000 unmyelinated nxons of secretory nerve cells, the cell bndics of which are housed in lhe supraoptic and paravcntriculur nuclei of the hypo~talumus. The secretory products (oxytocin ond vosopressfn IADHll are transponed down the axons and stored in the axon terminals of these neurons in the neurohYJlOphysis. ~se products are released into t~ bloodstream when needed. Thus, oxytocin and vasopcessin are syn thesized In the hY ilothulamus tlnd stored In and released by the neurohypophysis (specifically, rlre
pars JJen.'Osa).

Important: The hypotbalamo-bypopbyseal portal tnct refers to the way in which secreuons by the anterior pituitary are controllc.d by honnones called bypotbalamie releasing and Inhibiting factors. These fnctors are secreted within the hypollmlnnms itself nnd then conducted to the anterior pituirory through the rich vnscular hypophyseal portal system. rhis system of blood vessels links the hypotbalamU> :md the :mterior pituitary. This system allows endocrine commuoicauon between !he two structures. Remember: The pituitary glund is an endocrine gland located in the sella t\lfcica of the sphenoid bone, attached to the hypothalamus by a stalk (infundibulum). Through the infundibulum pass impona11t ncrw tracts and substances that act upon the pituitary.

( ntlu.o\,pin.lllr.H."I
l'rucl~ d.~t~ndmJ: IOthe spmal cord :~re con~ml!d Wllh volonlory motor fum.:uon, mu:;clc tone.. rc:ilexes

and equ1hbnum1 vrsccrnl innervation, and moduhatlon or asccndmg s~nsory signab. UnivtrsaUy rt!;u.n.led \1)' lhc single most i .mponant li1Cll'Onccmed "ith ltd volUDtiU')' acthiry.lhc:: cortlcospinallract origUlOin rrom pyramicloshap<d Its tn d)., pn:mOCOC', pnmOI)' moiQC', and primal)' seno,QC')' oomx

''"I

\131' lh"<tndln:.,: I r.Hh orlht '111n.ll urd

Name:

Funetl01 1

LocaiiOI:I

Orl~io

Ttrrnfnadr:m

Ll'etal oonaoospin.al
(or~P>TUMJ.to/1

Voluntary mo"cmcot. eontract.on or individual Of .....0-ofmusoleo, panlr:v.latly those movinJ hands. finsm. fert, and toes ofopposilo.side
$3me. U II I.C'taJ coctiClX(Mfttll

lAtetill whtlC Motor attu or

columof

wtbral ronc' oppos:ite ~ from Uilet Jocallon 1 o cord

"'"'"""

......... ,.,
t..l=lor

AnttriiK corticoo;:p!nsl
t-/irct:l11}~1 14/J
L~tl~oo"'"f l ret~eulo&rhnl*l

ANmo.

""'""' .....t y - of
""""std< M3inly (acalhotory influcnc:c on molOr neurons to skdct~l
m~lt1

-.hitc

"'"""""

Motor C()C\(_'( but on lar..-nJ Of -~ nk .. toe&I ton in cord column,.

_,.)

LtuemJ y, hjte Retlculw fonnntla11, L.ucrol '"' eolwrub midbrain, ponll. !lnd untc:rlot 8nt)
medulla

cotuum;,.

\1t.!..t~...,

MWy anbobitooy ..n._ on motor nturoas tO ske.lctal muscles

""'""'" ... bite

column..

Rrocular fonnalion. J.ooml or medulla m"udy anlcru'lf" j:fl)'

columns
Yttt~alar

Rub~plnal

Coonlmotlon of body D0\1Cmtllt and poslm=

l..au:rnl wbltf Red nucleus cot1111111:1 (oj midbraml

~teriJ \\-hilt

IDtcriUf ~(mY

V anhlolospnlll

Medi.tlcs tile ooOu..- or the

..cstibtdar end organ and lhc t<:tcbcllum upon exti!OSor muscle tone

c:olumm,

L:stmJ \c:Wibultr nudeus. (4th vtnfric/tJ

"' """""or Latc:ool

!lmenor Kfi!IY column\

(ANATOMIC SCIENCES

A 56-year-old male Jlatlent with type JJ diubcte comes into the emergency room with a painful blistering skin rash localized over the left side of his forehead. The unilateral nature Indicates a herpes zoster (sllingles) infection. A localiLCd a rea of skin tbat has its sensation via a single nerve from a single nerve root of the spinal cord, and which is isolated In s hingles, is <ailed a:

Fasciculus Dermatome Spindle

Bundle

188
Copyrigbt 0 2009-1010 Dmtal ()h

(ANATOMIC SCIENCES

Which cerebral lobe is the visual processing center of the human brain?

Parietal lobe Occipital lobe

Temporal lobe

Frontal lobe

110, Ill , 112

11)0

C.O.'riabl c 20092010 ""'"' O.Cb

Oerma1omts ~ 1be aru-. of <kin $l1Jlplicd by a smalc spmal nct.,.e, bowc>tt. lhcre 1> 11>-..ally <om< ""erlap ~- odj~~CC~~I dnmatomcs. Eaob of lhe 31 sc~'m<nts uf 1hc <pinal cord giVe< n: 10 opour
flf spinal nt:I'C$. whtC'h cany messages into and ou1 of the CKS. These spinal ncl"\'t.S bnnch huo snd

service particular areas of the body. Ultimately, c1'!eh nt-rvc ends up innervating a differen1 rrt~ion of the ~kin, called n c1c:rmtomt'.. with the exception of ~pinnl ne:rve Cl, which d('CS 1 \0l ploy a role in
dl!fl])atomes.

Pt'!riphetal n ~r"vt inncrvl,lion of the skin (t'Uimtvml:~ lnnenYJtitm' n.sually forms ;1 ditfcl'<!nt pBttem lro111 spinal nerve ~"'in mnc.'f\'IUion (dermrttome) because the ventral primary divh;ion.; ur ,pir,~l nerves form pluuse.s. Thb allows multiple spinal nM~.) lo cons.titute 3 penphernl nerve. For example-.. the museui(J<;llbni:OO$ nerve" oompaoed of,..,.tral pnmory dt,.Stons of <pinal n<r>cs CS. C'6.111d C7. \Vhcn 1he <Ul.UI<OU> poruon of lh< ncne r<acho:$ 1llc ...,,n of 1hc l&lttal foranl<tl, lilt bnmcht> from eac!> of1he S{Nnl """'"' su1111lY 1hrir rapccthe<ltnn>141'ne$ Kt) J>')in11o ro~mb<rr: Thep3nomor dislribwon of 1hc: pcnpherolnm c ('IISCOIOC'IllanNIUJ) 1$ dtffOftiU from 1ht dtn113Hl1n< pollem Important: Crani~l nCI'\'( dt.:rmaLOmcs do ru;t hi''"C 1ny o\eri3Jl (aiY not tnnl!'t,o:ucd by molY! than one nt::n!e) whcrca; "f"nal nerve <k-muuomes onrl.ap c:.1c.h other by SO"rGas instmJncc aga.tN.1 aoe-:tht-eiia or a dermatome. The lO~!i uf the ovcrh1p reqUires lht: lus:s of i nnervation 10 tbree adjacent

in !he middle dermatome. For e:rampl e~ aJI thr~e of 1he dursal TS, and 'l'6 W()Uid ha\le 10 l:'le sew:ccd or durnu~-:d to creme anesthesia in dcnntuome 'I'S. Severing a. pet;ph!!ml n~rve produces a different l'attcm of anesthe!iia Of! the $kio. 'iOii: This i"' di~gnosed by the ncurolugJS1 to detenninc if the' le. .o1ion ls '" Mt.pm~tl ncn1t' or pc:dphtral m:rvt. R emt.f"'tMr: Rrferml p:un is c~uscd when the knsory fi~ frOD\ an internal otpn rotc:r the <pirPJ cord in the same rooc a, m)trs froo1 a de:rmal.OI'I1t. The br1tn ~ poor at inlcTJirrll"-i vur.~t pam JfKi imlead 1Ditt'fl'<l$ 11 '"' pain from 1he somobc ore& of tb< dnmatom<. So pam m 1hc: IIQtl IS often inltrpl'tiM .,. J'&ln in 1ht left orm or shoulder. pam tn the dtophmgm i ini<I'J>f'ltd 1011!1 the lfi da,~c1e md neck. and the 'ssilch in your "Side you sc.nnc-umts feel when runnmM: is p:uo 10 1hc liver as ns vessels vasocon ~t ri ct.

de.rmatome~ m produce ;mctilhi!Sia ruol't ur in1erco~t.11l nerves T4,

or

Ocdpilal JuiH.'

The cerebrum or contx (rhe extensn.vtomer I.Ji tr of gray matrer ofllll! urebral hcmuphereJ)

is the hugest pan of the human brain, associDted \\1th higher brain function >u<:h a;; thougbl and act1on. The ccn:bralconcx is divided 1010 four <eenons. called "lobes": tb< frontal lobe. parietal lobe, uccptallobe, and temporal lobe Note: (I) 11le limbic sys1em, ofieu n:ferred to as the "emotional brnln," is found buried wuhin lhe em:brum. (2) Basal nuclei are I!I"Y mal ter structures deep wnbin each cerebral hcm15pl1ero th.11 help 10 control skeletal muscle activity.
;\rca nf Ctrebrnl Cortex

Function
lsasSO'ilited wnh n:asonmg. mo1or sk:ilb, lu~bcrl...-~~:1 cuv.nitiun., and a.~tV< lanpge

Frontallobt

rrcrronlalat'ta or frl'lflgl
i'n<tlll,..l~:tru>

Coocemcd Wllh lhc t:ontrol or social bebavtar, mohvatMMt. and

pbnntlll! Primary moltr trn
~of ianp1lOJ;<"

<ffn>n1al lob<

Btwa'sara
Pori"allob<

Is assoc;iau)IJ w.lh proct"Ssing UCiilt s.eru;ory mrl'lmall~>n RKh 1ti

presSUI"\'., \OUCh., lnd f)JI Ul

. . .

l'mrce:nlrtliO"'' Mp!tnetaJ lobe Primary ur\fory .Ntor bQUl}nt or IJU!iletnlral ~, Pr1mary IJI!ItCl area So uw.tolltll.~OI')' ~(')rh.~ Is esscntioiiOIJ1e:. procestiQ! of the body'! .st'~
le~hr.

.,.t'l,

Oc:dpltaJ

Prtm11ry wl~u~t l arn

Primary auditory torttx. ~hldl is importa.nl tOr iDICJJ'TWn.g !10tlnd11Dd the tangu~~ ~C' heat. Primary olfactO') ana

Ttmptnu lot~

(...ell).

Rlppocampus

Msoc:iatcd lh lbt (ormanon of memories

G NATOMIC SCIENCES

Which structural component of a neuron sends Impulses away from the cell body?

Neuroglial cell Perikaryon Dendrite Axon

113
191
Copyrigln C 2009-2010 l)mlal Db

( ANATOMIC SCIENCES

,
'

A 14-year-old female patient presents to the physician with hypeq1igmented lesions (cafc-au-lait spots), hamartomas of the iris (Lisch IIOdllles), and auxiliary freckling (Crowe's sig11). The patient had previously been diagnosed with neurofibromatosis, but is now complaining of generalized pain and tingling. The physician discovers mulliple neurolemmomas, classifying the dbcase as a form of neurofibromatosis. Neurolemmomas are a sarcoma of which cells that are responsible for myelin formalion In the peripheral nervous S)Stem?

Astrocyte Oligodendrocyte

Scbwann cell
Microglial cell Satellite cell
112
Copyritbl 0 1()09. 20 I0 Dm!al Ded.$-

ll3

\\nn

Nervous tissue is composed of two types of cells: I. ~eurons -ttallSmit nerve impulses. 2. :oleuroglial cdls (glial cells) are non-ducung suwon cells"' of nervous tissue. ElUII11ples include astrocytes, anacbed to the outside of a capillary blood vc>sel in the brain, phagocytic microglial cells, and ciliated ependymal cells that form sheath that usunUy lines Ouid cavities in the brain. SITuctore of a neuron: Cell body (perikaryon) .. contain~ the nucleus and most of the cytoplasm Locmed mostly in the central nervous system as clusters called nuclei, some found in U1e peripbcral nervous system as groups called ganglia. Dendrites - neuronal procc.~scs thm send the impulse toward the ceU body. There may be one or many dendrites per cell. Some neurons lack dendrites. Axon (nerve fiber) .. neuronal process that sends the impulse a\Vay from the cell body. If lhe axon is covered \Vith a fatty substance called myelin. the axon is refem:d tons o myelinated fiber. lflhere is no myelinated cover, then the axon is referred to us an unmyellnated fiber. Neurons are classified according to structure (based on the nwnber afproresse.f that extend from tM cell body): bipolar, unipolar, or mulnpolar (most common). They are also classified according to function: motor (~ffel'l!nl), <Cn$ory (afferent), or interneuron
(which lie between sensol) and moturnermm.v in the CNS). Note: Whether or not someone feels different <rimuli (pain. temperature. pN.>SIIrc. vt<.)

is detennined by the specific nerve fiber stimulated.

SdnH1nn cd l - also calll'd

n curnll'nlmoc~ tc

nr neurolem ma cell

Sch\Vann cells in the peripheral nervnll' syMem serve as supponive. nutrithe, and service facilities for neurons. The gaps m the m:elin sheath lhat occur between adpccnt Schwann cells are called nodes of Ran,1er, and serve as points along tbe newon for generating a signal. Signals jumpmg from node to node travel hundreds of time> foster than sig11als traeling along the surface of 1he a.on (lrnoH'n as StdlotOI)' cmrdll(:tion). This aUows your brain to communicate Mth your toes in a few thousandths of a second. 'iote: There are no Scb\1 ann cells m the CNS (central nen-ous .fptem); ll1c myelin sheath (In the CNS) is fonned by the processes of tle oligodendrocytes. Remember: The neural cest is a buncl or neuroectodermal cells that lie dorsolateral to tl developing spinal cord, wher-e they separate into clusters of cells (neural crest f)el/s) tho develop into dorsal root gnnglfon cells, autonomic ganglion cells, chromornn cells of the adrenal medulla, neurolemma cells (Schwmur cell.<), int~~tumentary pigment cells (me/anocytes), and U1c meningeal covering of the brain and spinal cord. Importan t: Microglial ceUs lire the resident immune ceUs of the cent!"'.al nervous ~ystem. Their function resembles thnt of tissue macrophages.

( ANATOMIC SCIE~CES

i\..

Which of the following a scending tracts of the spinal cord function to carr y pain and temperature sensory information to the thalamus?

"''D
~

Lateral spinothalamic uact Anterior spinothalamic uact Fasciculi gracilis Cuneatus

Spinocerebellar tract

,
G NATOMIC SCIENCES

Copyright () 2()09.2010 0tn1al Otd:s

..

108

N rvs)

Which of the following spinal nerve structures is exclusively composed of sensory fibers?

Ventral root

Dorsal root
Ventral rami

Dorsal rami

114

I :Jltral \(linnth:tlamil- tr.Jct

The white mancr of Lhe spinal ron! oonwns tracts that ~r.~vel up and down the cord. Mlllly of these ~roe~s tra\elto and from the brain 10 provide sensory input 10 the brain. or bring motor sllmuli from the brain to oomrol effectors. Aft"Jldlng tracts, those !hal troveltoward tbc hrnin are sensory, desrendln~ tructs are motor.
\1!1j tlr
\<.HOdlll~!

II :wh ul I h1 'tiiiHII ( u rd

Nn~

Fmtttlon

Loau.llln a>l&ltnM
..,...enorw~ra:

Origin

La1ml

......,.,.

!!ftno~h~!

mu"'

OMIO"ht sa-

Pa1n. tc:mpcrlllun:.l\l!\i tnldc touc.b Li!tral W~ti.C

l'nod<-~ad ........

Pe-ttenot _gray (Olumu

oppositr side:
~rcnor pay roWmo opposile'$4c

''ulMS

...s...-...

~U~L

~~""""-~md~J'~ itCf~ aJ'Id tWOpoin\

~lllmftt

r~-- \j,bue. Sp;ool _ , . ""'" ....

- ..
Th.al.lnnAS
\t.....U.

'tel'mlniUion

d.ic:nminaciUfl, also COCUCJ(I;Is

ttnc~.h~ts:ia

Anln'lor ;tt111 ptxltri Unc:unsl'ious kineslhc:si.a qm!Oftbcllc

bi.OIOI whu,e
I.'Ohmlnll

Anterior or posccrlcn
gray ool\unn

t:debtllwu

Note: For mosttructs. tbe nnme will indicate If it is n motor or sensory tmct. Must sen sory tracts names ~gin with spino, indicating urigiu in the spinal cord, and their names

end witl1tbe part ofthe brain where the ll:lct leads. For example, the <~ino~halamlc ll'ICI travels lfomthe spinal cord to the lhalamus. Tracts whose names ~&lD wuh 3 pan ofthe

brain art motor. for example, the comcospiiWitroct begms with fibers leavmg the c:=bral conex and tnwels down toward IJ'Oior neurons in the cord.

Uon.tl rnut

Tbt sprnal c:ord

JJ

(motor) palh11o"l)'> forrno5t oftheOOdybdo" lh<h<>d andn...:k. The spinal cd bcglmatlh< bram<~em lnd ends at bou.t the a.ccond IU11100r~cncbra.. T'hc \tlbt"f)', motor, Bltd inlcmeutoll) ~found m11ific patb of the tptn&f cord3nd nt-01rby SU'OC'UltCS Stn~~l') ne-uron~ hl\'e lheir ce.U bodies tn Ihe. ~pma1 (r/Qr $ul mm) ganghon. TheJrtxQI'lS tr'8\'GI through the dorsal root in1o the gray maner nf1he cord \Vithm the gray mauer a~ 1l'lteme\il'(1ns wnh which tbe ~en"'JY ncun,ns may co'tlncct Also Joe; led ~o the w:ray lrtJ1rt;;.r Jre the motor n~uror~s whose s.xons Ui\'tl out the cord lllnn.~gb the nontrl'l root. The whue nuu

the. connuon c:c-nttc for lht ~oc::'(~ as well as the afferent (stnJui'Y) ond effert"nt

or

1er 'S\Irroundll the gray nliHtC'r, It contains tJie splnoltr.'IC'L\ rhru ascend ;uul descend Ihe. :splnul curd. At J I placc~~o t~IOD,Q the .spmnl curd, Ihe dorsal and vcn1t:~l Mlll$ come 1ngc~her to fonn lifhntl ner"t$. Spinal nl.'fVC.~ coob'lin both Rcnsory -and moto1 fibers, .:~ ''~'most nerves. SpinnJ ncnclf nrc uiven 1\Uil'~.. rhattnJicotc the: portion or the vct~cbral coluo111 m whrch the ncnt$ arise. 1llere nr< ~ ctn lUI (CI llllloro<ic (T/112), s lumblr (llI.J). 5 ....., (St.S5), ill1d 1 COC<)g. .J ...... t'ocrvc C"l !.ttlsts bt.C~ttn dtt Cnlniun\ an.,l 3t1i1J (/~t &tt'\iical 'ff~bnzl. ilnd Ci ames bet\WCil the 7d ettY1"11nd a '>I fhorac1c wnc:btl A111hc other.; arise: below rhc re"-pcctn-e \t:ffcbra or fomJtr vct1cf'q 10 lltc n.sc of

c.,).

ranu. ptbltnotly.

thtsacrum. Srrnal n<rv<'l di\ld< mto b<an<h<s <aile.! .-.mi. Vr:rrlr.l pnmary ramr exit interiorly. an~ dorsal prtmary

A nerve plr-t.UJi IS a 1'\t'lworl:- or adjac.ent Spinal nerves dut JUfn togelht..T. Tbe name of t~ch plcX.lh de ~bcs. the urea its ncncs supply. 'fbe major nerve pfexu..,cs ttnd areas r.bcy supply :u~: ctrvicat: htlld, ,eck, shoulders, dinphr.agm brachial: upper limbJ and some neck -and should~r musck"S lumbar: p8.11 O( lht abdominal wall, luwet limbs:, und cXIt."rtllt1 maJe gt."flhah;~ satrtll: penncum. buttocks, and most uflhc lo~Ac:r hmbs pudendal: cJtle:mal female gtnitalta Sensory impub.:$ rn"laloog the5CUS"'Y (oj]cnnL w sudillgJ ncur;l parbWllys to the l<ll>Ory <or tu in the pon.,.llobo of the brarn wbeft they m rnl"'l'fctcd. Moror uopolses ,,.,..1r,.., the b<aon to toe 11111SCICS aloo& the moe (tfJ'"tn~ or d<$C'<ndlllt;) pothWll)> Thcsc impuls<s on~,na~ rn the motor conex ofthe front~ I lobo ancltra\'d along ppr:r rnoror ncuton' to the peripheral nOf'ous >)'litem t;pl"" motor nn:roM una10acc '" lht bram and front MO major 'Y5"1.;m.s. thr pyramJd.Jll ""d rxtrapyran1idal syn ems.

(ANATOMIC SCIENCES

A student dozing orr in class is unexpectedly called on by the professor to a nswer a question. Not knowing the answer, the hair on the back of the student's neck stands up, his pupils dilate, and his heart starts to race. This ligbt-orOigbt response is controlled by tbe:

Somatic nervous system

Autonomic nervous system

Skeletal division Sensory nervous system

1 5
185
Cql)Tiihl 0 20091010 ~tl Dks

(ANATOMIC SCIENCES

Nrvs)

Which meningeal layer Is fibrous and forms the falx cerebri and falx ccrcbelli?

Dwamater Arachnoid mater (membrane)

Pia mater

,..
Copynabl c 200..2010 DtmaJ Decb

116

The cenrnl n<nous S)'lit<m includes the bnun and spmal cord. The peripheral off" ous S) tm consiSL< of all body""""" Motor neuron pathways are of two typ<">" >Otni lit l.<kel~tol) and utonomic (>mnotll mr<,cle. cardiac mu.<tle. and glmuls). '111< autonomo~ ~ystem i~ subdivided into \he wympathetlc and parasympnlhctic systems. Tho I'NS coot, ists of all nervous St!\ >C(UJ"eS located outside the CNS. The PNS includes the cronial nurvet).lln~tng J1'(1ollthe infbrior<tspoct oft he bmin. nod the s~inal nerves, nrisiug li-om tbe spinal cord. '11tc ~NS ls divided fitncti<>nally into ercnt (.ven.,ory) and ~ffcnut (molr~r) di visions. The offert no dlvl<lon of the PNS includes sornRiic sensory neurons which curry ompulses 10 the CNS ti-om the skin, t'>scia. and JOool"- alon~: with 'isce1111l ><n> ol')- neurons. which carry ompul~ from obe vi_, of the body (lmngn- pangs. blood Jll"i!...Wf"t) to th CNS l'be cfTC r<nt dl>ilioo ufthe PXS is divided mto the sumo lie (\'olomtnry~ lind auronumi< (m-olulltary) ocrvuu~ system
( umpuri,un nt lhl Sumalir :nul \ulnnumk
:\enuu~ S~\h.'lll"i

Fenluf'e
r. ff <Cto~

Somatic
Sltete~al noUS<le

Autonomic
Glands. t~moo th musc::le. cardJ .c- rruL&CIC

Control
E.fforcuoP"thW11ys

csuany volunlllr)'

Uwally nwolonwy

O..e nerve fiber rrom CNS Two""""' m.... from O.S 10 effecror,

to efTector. no l!J.Dl!lia

Nc:\.l.roU'IJun,,nm

Acrl)'k:bolm< (Ach)

~- ... S3'1gl""' Ach and nxqllnc:pilnne INE/

E.<C1t110 ooy or inlubooocy

E!fcooon t8f8tL cdl!; Always excttablc

Effector ~ <11m Arion Flaccid pa;alys~>

Dcn.:rvation hyper!;ensltlv,ty

Uur:1 rnahr

The mcrunges m three concentric protect!\~ membranes surrounding the brain and spmal cord (rhe CNS). 1. Dora mater -the outennost tough fibrous layerthot lines \he skull and fonns folds. or rct]ecuons. that ~csccnd into the brnoo's fissures and provide staboluy. T he dural folds nrc the following: Falx ccn:brl He< in the longitudinal fissure nud separates the cerebral hemispheres Tentorium ccrcbelll- separates do c ccrebnun and the cerebelhom F11lx ccrchclll separates the two lobes of the ccrebeUom 2. Arachnoid noembrane -- is a fragile network of collagen and elastin fibers with a cobweb-like appearnnce. The arachnoid r.nembrdne has moderate vusculuri ty and ltes between the dura mater and the pin mater. 3. l'ia mater -- iruoermQSt membrane. it is ao et.remely thin membrnne made up ofcollagen and clasue fibers containing many blo<ld vessels. The pia mater adh~ closely to the braon and spinal cord. These arc the structures invohed in mcrungous, an inflammation of the meninges, Which, if severe, may become encephal o tis. an Inflammation of the bra on. 11te ~ubaraehnold space, filled With cercbroSllinal Ould, separates the aruchnoid membran" and the piu ntntcr. 1n addition, the meningenl area has two potemial spnccs: pldural5J>ucc- over the dura mater; becomes a real space in the prcscnc0 of pathology. s~ch o~ accumulation of blood from n tom meningeal artery (ul! epidur11/
hematoma)

Subdural spat e- a clus<dspace with no egn:ss between the dura mater and the arochnoid membrane; often the >itc ofbemormage after head trauma ;.lote: In the ventricles of \he brain. the pta mater and ependymal cells contribute to the formation of rhe chcoroill ple.{US~s. It is these plexuses that regulate the tntrnvemricular pressure by seere11on and absorption of cerebrospinal ftuod.

cA.~ATOMIC SCIENCES
A patient in the dental clinic hates getting alginate impressions taken on him because he is a "gagger." Which or the following is the most inferior portion of the brainstcm and controls renex activities such as coughing, gagging, and vomiting?

Midbrain Pons Cerebrum Medulla

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Which of the following meningeal structures Is a ring-shaped fold that allo"'s the passage of the infundibulum of the pituitary gland?

Tentorium cerebclli Falx cerebri

Falx cerebclli
Diaphragma sellae

\I Nlulln The broln ~lcm, which is continuous whh 1he spinal cord below. consists of the mid broin, pons, ~tud medulla. P:l!l!ting through the brain stem are ascending pathways cnrrying smsory information from the spmnl cord to the brnio. and descending palhW'a)'S. carrying motor command down to the spinal cord. Centers in tile bnun stem regulate many vital functions. including beartbeut, respirdtion.and blood pressure. The mldbraln connects dor.;ally wi1h the cercl>ellum. The midbrain relays motor sig uals from the cerebral eor1ex to ll1e pons. and sensory 1r:1nsmission in the opposite direction, from the spinal cord co the thalamus. Tbe oculomotor (CN 1/1) and II'OCWear (CN IV) nerves arise in the midbmin. The s ubstantia nigr~ in the m1dbrain helps 10 conltol movement. lesonns of the aubsll1nti3 oau>c Porkin.sun 's diseuse. Tbe pons Ues below 1he midhmin uud connects the cerebellum wolltthc cerebmm. The pons also links the midbrain 10 1he medulla oblonpUI. It is involved with motor activity of the body and o~1ns. In addition 10 hou.<ing one of1he brain's respomtory centers, 1bc pons acts as pathway for conduction tmct~ between bnun centcrs and the spinal cord, and serves as the oKit point for cranial nerves V, VI, VU, and VII I. The me!! nil oblongBia is the most inferior portion the brain stem and is a small, coneshnpcd structure thai joins the spinal rurd al the levd of the foramen mag)lum. The medulla oblongata functions primarily os a rday s1a1ion for the cro.S111g ofmotor tram between the spinal cord and the brain. The medulla oblongata also contains mcchanisms for controlling rcfleK activitie> such as coughing. gagging, swollowing, and vomiting. It's the site oforigin for cranial ocrvt'1> IX, X, Xl. and Xll. The mcdullaoblonaa1n also cooHains a central core ofgry maner called the rctlco~ar formaUon. This area 1~ in~olved in regulaung lccp and arou><\1, and io pain pcm!J>Iioo, and tncludes Vllal centers that regulate breathing and he;on acu,;ry,

or

The dura mater is the omerumst toush l1brous layer thai lines lbe skull ~nd fonns fold., or reflections, that descend into tbe bnun, tls,ures und provtdesH1b1l ity. Tbe dw'a nl~ier is composed of two lnycr~. The endoteullo~er dheros tightly to the inner swfb llftlte cranium, and the meolngeollayer fonn.' pnrmion~ (folcls or rrjlectimu) cbatdesc<'tld into the bram's fissures and provtde stability. The duro I folds are the following: Two vertical folds: Falx cerebri -- lies in the IQngitudinal lissure and sepnrnres the cerebral hemispheres. Contam< Inferior t1nd superior uglttlll sinus.,. FIr tere~rlli - separates the two lobes of the cerebellum Conmi"" occipital sinus. A horlzoutlll fold: Tentorium cercbelll separa1~s the cerebnun and me cerebellum. Concnins 1he straight, transvene. aud suptrlor petrosal sinuSC'!.
The dural veoou~ sioust>S are spaces between tbe endosteal and meningea11aycl'li of ~1e dm o. TI1c sinuse~ ~'Onlaiu venous blood Ihat onginu!es for the ntost pan from the bmi1 or cranial cavity. The sinuses contain an cndoohcli~llining t11 u1 IS contillUOtls 1111 0 t11e ve1ns Ihot arc connected to the aiuu<cs. There are no valves in the simo.es or in tl1c veins that are connectcd In the sinll'>tS. The \'ll'it majoril) of tbe 'emlll'> blood tu the sinus drains froon the cranlwn via 1be intemal JUgular vein.

Note: The diapbragma sellae. is a ring~~uped folu of dum m. nu..,. covering the sella n1r cica, ~nd containing an U!lerture lor passage of 1be iufuucJibt~um ol'the ricuitary gland.

(ANATOMIC SCIENCES

~rvs)
)

(
Basal nuclei
Diencephalon

The hypothalamus Is part of the:

Cerebrum
Cerebellum

18
Cqt)right C 2(1()C).l(IJ0 DtMall>tch

'"

~ATOMIC SCIENCES
Which type of neuroglial cells form myelin in the CNS?

Astnx:ytcs Oligodendrocytes Microglia Ependymal cells

http://dentalbooks-drbassam.blogspot.com
COfl>-naM 0
200 4:0092010 Ocmal DJr.s

lliLnnph:lln

The brain lies within tbe cranial cavity of the skull and is mnde up of billions of nerve cells (neurons) and supporting cells (glia). Neuronal cell bodies group together"-' gray matter, 31\d their processes group together a. wbire matter. The brain can be divided mto four main pans: the cerebrum, diencephalon. bmin stem. and cerebellum, The cerebrum is the largest part of the brain ami consbiS of the five paired lobes with the two cerebral hemispheres, connected by a mass of white matter called the corpus callosum. The cerebrum accounts for about 80% of the bruin's mas> and,. concerned with higher functions. including perception of sensory rmpulses. instigation of voluntary movement, memory, thought, and rea;oning. There arc two layers of the
cerebrum:

- The cerebral corte< is the thin, wrinkled gray mauer covering each hemisphere -The cerebral medulla is a thicker ~ore of white maner The diencephalon hes beneath the cerebral hemispheres and bas two main structures -the thalamus ami the hypothalamus. Tbe walnut-sized thalamus is a large mas~ of gray matter that lies on either sidt: of the third venmclc. The thalamus is a great relny station on the aiTerenl sensory pathway 10 the cerebral cortex. The uny hypothalamus fonns the lower part of the lateral wall and floor of the third ventricle. The bypothala mus exerts an inDuencc oo a wide range ofb.>dy functions. Remember - Each portion of the braJJI cow;isL<; bastcally of three areas: I. C ray matter -- composed primorily of unrnyellouted nerve cell bodies 2. While matter- tom posed basic.ally of myellnoted nerve fiber.. 3. Ventricles-- spaces filled with cerebrospinal nuid The cerebellu m is auacbed to tltc bratn and feantres a higllly fold'd ~urfuce. It is 1111 porumt in the control of movement and balance.

Oli!!Udlndrnc~

ll''

;o.;euroglial cells. tho; uther major cell type in neural tissue. provide structural integrity 10 the nervollS system and ftLnctional support that enables neurons to perfonn. Neurogliu dt> not typically have synapS<:.\ nttheir surface. Classically neuroglial cells arc described as existing only in the central nervous system (bral11 md ~pined cord). Cells in the PNS that suppon neurons include Schwann cells and satcllitt cells. !\'ott: With the uceptlon or llli<fOllli. which denvc from mesod~rm , all neuro~lla derive from l'<'toderm
Cell

Strutcurc
M1ny ~ aawbed 1o th<:ir

Function
Pro"destr\laurai""J'POC'
f'nnn m.yeUn .!halhr ruvund axon& 111

CNS
"-'ITOcyl<
oh,odenc~rocy~A:,

.
.

11 bod)'
~mi\Ocr edl bodies than Mrrot:ytcs and relntlve1y fewer processes teav;nt; ll\e cc11 txxty

1 1>c CNS
~loin phagoc)tlc c<IIAnd :uuig<n p.....,ring <tlb 10 lilt CNS

MletO&U

Smallest cell bodic 1mong. tM ncurosJia

C'<>lllllUUt cells "''~' Cllintod f=
Sllrfoc~

Ependymal <ttb
Ch~r~idal tolls

Line m ostoft.h~ "cntrieulM<S)'Sicmof

thcCNS
Form the inner 1 -aytr of lJ1L' choro1d

Modified cpcndymlll cc:lls

plexus. Stcrete tfN.'br~ pin lll fluid anto lbe wntriclo.

S.iellue celli Schwrum lis

P'S

Small, flanened cells

Flattcntd celts am1na:;cd in seri6
~L'{QOS

Sut11mrt ct"-U bodi~s In yanglia Wllhtn the rNS

Form Jn)'tlin With en the P~S

GNATOMIC SCIENCES

As a general rule, parasympathetic preganglionic neurons synapse with postganglionic axons in ganglia:

Near the thoracolumbar region

At the cranial nerves

gans Near or within 1nrgel or Of the paravenebrni chain

201 Copyrlgllt 0 liJ09.2010 Dental Dtt\s

(ANATOMIC SCIENCES

The tbird ventricle of the brain communicates with the fourth ventricle by the:

The two foramina of Luschka The intervenlrieular foramen The cerebral aqueduct The foramen of Magendie

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Cop)Tigllt 0 20091010 OC'ftQI Dttb:

111e aulonumit ntr,ous system nut.S bodl1y functiont~ Withoul our awareness or rontrol. 111!:1 the. mo1 or ~ySicm to visceral orgnnll. It rs divided iniO IWu systt:ms; Sympathetic (lhdruco-Jumbar) di\lMon:
"Fighl frigb~ or Oig~r Deri\c~ from lhool<rcand lumbar '1'111&1n~(TI-L2) Preganglionic nturons (mrduwltd); rclw-cty sbon Cell bodoos an: located anllle ontcm><daobter.tl gray column oflll(Jfaeic and lumbar ,cncl>rn< - Prcgan(lhonic ucuums c1ut ""n~ra.l root .... into while l"l'nn.u commumCAIIUllS - ,.ynL'Ipse w11h

postgang1iomc axon in periphcm.l p.o.ngliqnat the .snmc l"wcl or another level - Ncurolransrnincr is acttyl~hl)linc Postganglionic uoos {Wtml-tllnat~dj rdarivcly lortll . Cell bodoc>"' jl<riph<nl Jloi!ISI"' cxu:nd ro visceral Ol'gilll>

Omnbuuon as wadc>p<d
Neuro1r2nsmmer is nort'pinephnnc Parasympalhttlc (rraniai&OC'I'OI) diVIMOn' -"(ood or StX" . Dcrivod lrt>m <r3nlnl and $Ueml ncrw - Dl Ill. Vll. IX, >n<l X; Sl-S4 PregangUunlc neurons (mytllllillti.l) . relali\e-ly lon& .. Synapse with P\l'Slgan.,ghomc axonoc m pnglia close 10 organs ~auorransmittcr is aeetyk:hohnc r ..~gngllonlc nons (umwrdmaltdl: !1:1amdy shon .. .NeurotmnQniUc:r is accrylcholinc: - 01stnbuuon i~ more spec:cfic nnd lc~s d(ffuse lh::tn Jtymrathcric Sympathetic ''S. Pnnasympafllelk Most organ..; bnvt < hlHil11nc:rva6on In generaJ, the actions of one system oppoo;c ahosc of the ot~r Bolh dav1sion:t r\! toopersth m sall\vy @larKb Predomtnant&one ts parasymp:~tbttlt tn most <Kgan) Symporhcuc tone exists solei.\ an ~nal medulla. swear glonds. pilo<:r<eror mu~cle< ofskill. and

many blood \'C~<11

Sympathetic J1.,1 nbU110n \ends tube 1111m! difruse whereas parn..;ympathetic i' mvrt spedtic

There ZIJ'e four \tnlf'ides an <he bram. They connect wath tl!Cit other.lhc cmral canal oflbe spinal cord, and the lnlbarathnoid sp3ce >Um>unding the brntu and spinaloord. The entrklos contain ccrcbro~pinol nuid, which act> ns a shock absorber. cu$hioning 11te bmin from mechanical tbrces. I he right and lei\ lalfral nntrlcles are in the ri&ht and lcll e<:rebral henusphcres. respec tavely. The \eotricles communacure "ith tbe nmow third ventricle an lh< dicncepholon through a small opening, the intenentricutar foramen (/(>ramen ofMmtl"()). l'bc third ''en tricle is continuous with the fourth ventricle \ia the cerebral aqueduct (ul>o called tlw aqueduct ofSylvius) that rraverses tbc midbrain. The l'ounh ventricle is located dor.;alto tlw pons und medulla. and ventrnl tu Ute cerebellum. A single median a pertu rl! (foramen ofMa gemlie) lltld n pair ortolcral apertures (foramen oj'Luschka) provide communication betw.:cu the founb vcntncle and the subarachnoid sp:u:e.

Cerebrospinal fluid is produced tnainly by a Slnlcture called the choroid pie> us in the lar cral, thir<l and founh ventncle.. CSF flows from lho lnlernl ventricle to tho third venrrtclc through rhe Interventricular forame n (aL'o called thefarnmen ofMomV). The rhird ventra cle and the fourih vent riel~ arc connected <o each other by rhe cerebral aqueduct (also culled t/oe aqueduc1 ofSyMru). CSF then Oows into the subarachnoid space ihrouglt the foramina or Luschka (Ihere ore two ofthe.<el and the foramen of Mogeodie (only one ofthese). Nolo: Absorption oftbe CSF into the bloodmeam takes place in the superior sagittal sinu; through SU'Uclures called arachnoid 'lUi. When the CSF pressure is grearer than the venous pressure, CSF will now into the bloodstream. Bowcver, the arachnoid villi acl as one way valves"- if the CSF pressure is less than the venous pressure. the arJchtHtitl vlli will NOT let blood pass into the ventricular system.

(ANATOMIC

SCIE~CES

A 23-yearold male medical student is experiencing diplopia and goes to get ""' an MRI done. The scan shows non-descript pcrivcntricular lesions, and so a spinal tap Is done to determine wbetber the patient has multiple sclerosis. Which space is entered when a spinal tap is performed?

Conus medullaris
Subarachnoid space Arachnoid space Central canal

203
Copyrigbt 0 2009-2010 Dmtal Db

( ANATOMIC SCIENCES

:'lleuron ceU bodies are located in:

White matter of the spinal cord

Meninges
Gray matter of the spinal cord

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Th< 1pioal cord ends 10 the adult around L1 (l.i lo L2). The dura aod amchnoid, bowe\er. conhnue down to levd S2, where the arachnoid fuses wnb the filum terminale. Tims, a needle inserted between the spines at L2 and L3 will enter the subarchnold lllQce, which is filled with cerebrospin~J nuid, without injunng the spinal cord. Cerebruspinl nuid (CSF) is a colorless, thin nuid found in the veuuicles <>C the bruin, the subaraenootd space, and the centml canal of the spinal cord. CSF is produced I!Ulinly by a structure called the choroid pleJus in lhe lateral, third and fourth ventricles. CS~ escapes the veutncular system of the bram through the tbrre forrumna of the fourth ventricle and so enters tlle s ubarachnoid space. CSF now circulates both upward over the surfaces of lhe cerebral bcmi"f'heres and downward around the spinal cord. The subaraGbnotd space extends down a; far as the second sacral \ertcbra. Evenmally, tlle nuid enters the bloodstream by passiug toto the arachnoid villi and difTusins through their walls. I.Tlte choroid 1 lexuses regulate the intruvcntricular pressure by secretion und Not<s absorption of cerebrospinal fluid. 2. The cerebrospinal fluld, along with the bony and ligamentou; walls of the vcrtebml canal, protects the spinal cord from injury. 3. Ependymal <ells are cells that ll\llke up the lining membrnnc of tbe ventricles of the brain and of the central canal oftlte spinal cord. The)' are also present to the choroid plcu of tbe centrnl non ous system and partiC1pate in the production of cerebrospmal flutd.

V.'ithin lhe pinal rd. the H-~ ma:s.s of PI> maucr "' dhlded inao ~ "l:uth c-on:s.1'R I'Mtft)y vf DhU"''t1al ec:U bocha and u in1mnediacc tone Pot-lt-rlor (IIM'IOI) horns: Are .spt"Cia.hztd tu ptl"C\"\) ~'OJ)' inronnaliOO M~ch as IO\II:h. f'IJM, and joint kJ15-Illinn. and to relay this iofonnalltm 'o HI( br.1m Antcrlur ('>-"1Ural) horns: comaiu .mutor ncun.Wi. wluch uausmil messages out 10 lh rnlt'ie1~ vla spmal nnvc11 An inrerm(':dllllt 10ttt: COIII<tln$11Ul11Y intemcurons that UN in \Jolvc~t in linkin iucomtnM ~t:nwry ncuroM wilh outgoing mutOt ncuruus to brint; about 111110nm1N (r~fltxJ rtsponk51hal do not l1 wulvt: d1( bnun. \Vbit:t matter SUI'f\)IJUdlll~ the: OUICf J'l3Il u( tho.c hom-e COI\fiS') Of myelin~ ltd 11CJ\C Jibrh gt'UoUp~tl functi'lloaJiy m vcnical c:olunuu., Of tracts. lmportani: 1be cd1 bodi~ ('flOe sontari..: motor ~)ISttm lte ""ithin lhc aottrior or \tntr.J hom. 1 he cell bodies of the 50f"ft3lx: st:n'Df') ~tern lie wuhan the P'G"trlor or t.kmal hom 'The nct'\es that Uc "11hln tbr sptnaJ cord a.re u.p~r mo1or ntui"'Dt (UA.fNtJ, 100 \heir rurkuon 11 so rany 1.be mcsS&~"C:S bxlt and (onh from tlk bm.in tot~ spu\11 ncn~ 1lang lhc Sf!'lnil tract. The Ipfnal ntn H lbat brMch out ho1u 'he o;pinsl rord to lbc: blhcf parts of the body art calk"d lo~rr oJolor nt'urons (l.AINr). lh.ese spmal nC'J"oc:s exttn:nd enkr a1 e.ach 'mcbrat lc\ d and CO'Inmunkutc lf>ith spcciric ll'tt!S of the body. J'he sensory porU,,ns or01e LMN cany m~~gcs about SC1,~tlon l:t.Jm the skm aud Olh~r body p3m and

'"""'111! throu!lh lite ..,eb<ot <3mlt

The spinal cord cxt.cnck rmm chc: ba.w ortht ~l;ulllfl J

PQtrtl ~bo-te

two-thirds oftht o;,ay dov., '~ Mck.,

organ!' 10 tlte brain The motor portions orlht LMN send 11\CM'It!(t.S rrom tl~e Imtin \0 lll" vtmou.s body rarL't \o 1nitintc action..~ Mith 11.!1 niUSCit! movement. Important: S)'mJUithl'Ht prtJtllngllonlc: ntlJrfin ntuh.'S Preganglionic oturonr may du un~ or three Lhlng'i: L Enter lhe paru\'c:nebml gat~.g.lioo at the. srunc: 1U\tcl \ril the \rohi-tl.! ramtt:s c:otnmllnt~~ns ~a.n..J syn:~pse
tbtt-e. 2. Entcr lbe prllrl\enct>ntl g>DSE.., artd cillteJ .....00 ot ckfcen<lto aoomcr levcll<l '>"'I" a1 that

!e-el J. Pass Lhroufb the p1ra~mebntl gal'l@hon via the \\<hue nmus. commuru~ and cyrnq~ m ' melml i111&lion.

pr~

cAl~ATOMIC SCIENCES
In the peripheral nervous system, which fibers carry impulses to skeletal muscle?

Somatic sensory (afferent) fibers Visceral sensory (afferent) fibers Somatic motor (efferent) fibers Visceral motor (efferent) fibers

20$ Copyright Cl 2009-2010 Dent1 Dtcb

(ANATOMIC SCIENCES

The ciliary, pterygopalatine, submandibular, and otic ganglia arc all:

Sympathetic ganglia Parasympalhetic ganglia Bolh sympathetic and parasympathetic ganglia Neither sympathetic nor parasympathetic ganglia

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2M Cop)tn&bt c 2()09.2010 Dental Dceb

Soma tk mulnr (,.jj ntntJ fihrf' Functionally. the fibi.'f't of pt"ripberaJ net'\e~ may Cllhtr be somafit or ' lsttr111 and abo e1thc:r 't:nsor) (ojftTI'JU) or molor lcfforrnl). Tbt.re are rour lypts of fibers: I. Somatic stosory (n(for-ent) liben carry impulses from tutaneaus t nd propriocq>ll\e rectptor:.. 2. Vis('eral senttory (qfft!"nt) fibers can)' irnpu111!e$ from the viscera. 3. Soma lie motor (effernu) fibers carry impulse~ tn $\t:Cietal musde. 4. Vlseeral ruotor (ejfC!rem) fibers carry impulse~ to smooth Rnd cardiac muscle und to ghmds. Somatic motor"' vl,c.eral mol or-: Somatic: mol or nt.:urons arc din.-ctcd from con"ollevelA tu skelc:tl!l muscles and m volunu1ry. Visceral motor nruronJ are din:cted (rom tht hypodualamus and midbrain and 11ft \ olunto.ry. hut ha\'C input from the cone:..'\ .and thalamus. Somatic lo"tr mocor neurons at"C" in cbc ventral hom or pay mattcr and the ncurotl'lnsmltl at skd<Utl muscle IS trctytcboline. VtsraJ moror nt urons cumc: from f:f'IDla) ntf\"t"S ot tbe mtennediolau:rn1 gr2y hom, mvol\c rwo neurons, and the neurotransmitter is. either acetylcholmc: or norepinephrine al ctther tardioc muscle. imootb muscle. or ilands.
C'umpun,un nl fhL' S~mp.ltiH.'hl' :tnd Pttt.t\\lllfl:IChelic Uhhiun'

Ftoturf
t)n&ln In t;NS
\..aaut~n ul

Sympotbcttc

l'ar..ympattwtlc
C.:rnntc_,-1 (Cl' lli.VII. IX.
nd X: S2-S4)

Thorncolwnbar (T ILl)
Plmt\crtclJral p.nJbS ldjxtni CO

gql1a

Tcnnical ganglia r.earor w.thln

Jpioal column and I'"" cncb<al pn_Jlia ammor to 1 t

f lbcr I=Jih

Sbon pr<ganglloru.: l.ong poogaogllonc

--

Sbori post&anJiionc
Minim:~ I (tbout1 .2)

Lo"' -gl;ooM:

.Ntturonlll dl\trgcnoc Extenswe (abolu l

F.tfcct5 on J)IStcnt

n)

Otlen \\idespttad and t:nrr.ll

MQre local ami o;;pccific

Parasympacheuc pnghJ are the !lltonomsc f:lliJ.h3 ot lhe J'MU}'mparhctic ncnous ))SU."'JJ Most are small lenniMl poaJII 0< mlrJmaral g2:1gliL > IWIItd !hey be ncar or wilhm the c>tpns they
inner\ ate. Parasympalhttl< gonglla: C~ lll Cilia.-,. Rnxlioo- eye CN VII Pttr')~upalatine and submaodlbulafw_"ngllun- eye and nasaJ DlUC~a CN LX Olic ~:ngllotl -parotid .salivary glam1

b'""

CN X To ~:mgl1a on em:h organ S2-s4 To lafC intestine, rectum, gt:nitalia, urttun. lmd urinary bladder Neurotran~mltter 1.~ acttyleholine al pre-- and po~tg.QngJionlc synapse!! S)mp11lhetic. SCAngli: organized lnto two c:bain.s that run JXtmllclto and oo either side oftl\c spimal cord. Para"t rttbral J.tn,aha; lie: un each .side oft be- ve-rtebrae and areeonntcted lo fonn the symp:alhc.."tie<ham or uunk. Th<'f1: .., ll<ually21 or 2) P'IJl'S ofll1<"' pn&Jia: ) in thetnVtcal n:giOO. t 2 1 n !he d~ racu: rcsi""- J Ill 111<: tumbot region, 4 ., the soct'll ~:ion. and a stngte. uupw-ed pn~hon tymg m fron o f the -.:yx ealkd the g2:1glion impar. Ct"ftll g.&ll&lia- superior; middle Of ioftr1or ct.n Jtal ganglioa Tboradc. lumbar and scrat ganglia Prt\'t th:bral (or pYr!oortlc) ganglia: pmvide uons tht!.l are dis:tribuled with 1hc three mUJOr gas~ rroinLt::,tlnal art~ncs arising from the.aona "CeUac g11nKiiun Supetior ltnd Inferior mesenteric gangliofl tnftrior bypoga~tric ganglion ** Neurotnmnlllftrl' norepinephrine (NE), ~:tttqt on adtenal mtdufla wbert il i1 actl)'lcholint.
Whitt ramus and J,trA) r:~muJ tommuo.Juos: ~\bile nmuJ comm~nictn.s; All sympalbttic. prqan~llonk neurons eolcr che parncnc:bfll pnghon cbatn v, the "'hue ramus communicaas. They art white btc:aus the nnv~ are m)t:liMttd. Gray nmus cotnmuniC'aa.s carry llDI:n)'thnatcd poslganst)Jonjc sympatbeti(" ocn ei tn peripheral organs.. They aregroy bcn.Uk they are onm)tlinaltd.

~ATOMIC SCIENCES
I\..
Endoderm Mesoderm Ectoderm

Which of the foUowiog embryonic tissue types gives rise to the central nervous system?

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GNATOMIC SCIENCES

An endodontist is performing root canal therapy on his anxious dental patient. His anesthesia has been successful throughout the access preparation, cleaning, and shaping. Just before he starts to obdurate, he sticks a paper point in the first canal to dry it out. The patient jumps up in pain from the stimulus. Which type of primary afferent fiber carries information related to sharp pain and temperature?

A-alpha fibers
A-beta fibers

A-delta fibers

C-nervc fibers

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Fctnderrn

During the laner part of the third wtck ofprenatal development. the ceniilll nervous system begin~ to develop in the embryo. Many steps oecur during this wt\Ok to fonn the heginning of the ; pinul cord and brain. First. a speciaUzed group of cells differentautes from the ectoderm. These cells nre the neuroectoderm, nnd they ore localized to the neural plnte of U te embryo. The neUI-al plate is a band of cells that extends the length ofthe embryo, from the cephalic end to a he caudal end. This plate undergoes further growth and thickening, wb.icb cause tbe plate to deepen and htvuginate centrally. fomtiog the neural groove. Near the end of the third week. the neural groove deepens further and is surrounded by the neural folds. As nan her growth oftbe oeuroectodenn occurs. the neural folds nteef superior to Ute neural groo' e, and a neural tube i~ fonned during the fourth "eek. Theneurnlrube undergoes fusion at its most supenor ponion and forms the future spinal cord as well as other oeurnl ussues. Important: Dunng l11e third week. 3lJOUJer specialized group of cells, ahe neurxl crest e.ells, develop from the ncuroc.-toderm. These cells magraa e from the crests of tlte neural folds and disperse within the mesenchyme. These mib >rated cells nrc involved iu the development of uuny face ~nd neck stncnares. such as the branchinl arches. Note: These ncuraal cre5t cells are essential in the development or the face. neck. and oral tissues. Remember: The growth of neural fusue during the fourth week of prenatal dc~elop meru causes folding of the embryonic disc into an embryo. establishing for abe tim time the human axis and placing tissues in their p10per poSiuoos for further tmbyonic de>elopmenl.

PriuaMy arre...,ot a~ons ore the nerve fibers connected 10 the different types of receptors in the slM, muscle. and internal OI'Jl1IOS. These primary afferent nxons come Ul different diameters and can be davided into different groups based on tbetr size. Here, an order of decreasing size, arc the different nene fiber groups: A-alpba, A-beta, A-delta, and Cnerve fibers. Aalpb. A-bell!, nod A-della nerve Ober.; are insulated watb myelin, Cnerve fibers are unmyelinated. The thickness of lite nerve fiber is correlated hl the speed with which informntion travels in ia -- the thicker the nerve fiber, the faster inftrrmol!ull travels in it. lmpurtunt: A-alpha nerve fibers curry information rclnted to proprioception (muscle .tenre) Abcta nef\t fibers carry information rcluted to touch A-delta ~r\e fibers curry informntion ~lnaed to pain and temperature C-ner,c (jbers eM!')' mfonnation relatetlto pain, tempel"!ltu...,. and itch Autonomic neurotransmitters: All autonomic preganglionic synapse> bnve Ach ns the neurotransmitter (nlcnrinll
receptor.<)

All (tostgun~llonlc parasympathetic synapse~ have Ach as the neurotrtmsmuter (mrLtcorinhJ'CCOf i/Or s) ' Most poslf(augllonic sympathetic synapses have NE as the neurotransmiuer (adrenergic rt!L'e{Jtor.<J

Sympathetic preganglionic neurotrnnmallcr at adrenal medulla as Aeh (nkorimr fl!ceptor) --release of epinephrine and nortpnlephrine (80/]0) Sympathetic poslgllllglionic neurotmn,nutter at S"'eal glands is Arh (maucnrintc rercpton)

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A gag rencx overcomes your patient as you lightly swab an area of the oropharynx. What nerve carries the sensory fibers of this rcnex?

Trigeminal nerve (CN V) Facial nerve (CN VII) Glossopharyngeal nerve (CN lX)
Vagus nerve (CN X)

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,
Masseteric nerve
Auriculotempornl nerve Facial nerve (CN VII)

Trochlear nerve (CN IV)

The glossopharyngeal nerve is a mixed nen e {mowr and sensary), whicb origmates from the anterior ~urfucc of the medulla oblongata nlong with the 'agu.~ nerve (CN X) and spinal acccs.~ry nerve (CN XI). The gh>ssophtryngeal nerve passes laterally in the posterior cra nial fossa and leaves tlte sk'\tll through the jugular foramen to supply sensation to the pharynx and posterior third or tho tongue. The ~ell bodies of these sensory neurons are located iu the superior und Inferior ganglia of this n~rvc. The glossopharyngeal nerve then descends through the upper part of the neck along with the internal jugular vein and internal carotid artery tQ reach the posterior border or the stylopharyngeus muscle of the pharynx to which the nerve supplies somatic mo10r fibers. :"'ote: Th< glossopharyngeal nerve carries prim3ry afferent neurons to the gag re0es (the g/at.<aphtlf)'ngea/ nene innt!I"'YJtt.r the IPII/l'OII$ lllt!mbrane;; ofthe fauces}. The otic ganglion i~ a small parasyutpathetlc ganglion that is funcuonally a>soeiated uith the glossopharyngeal nerve. The ouc gani:lion >S located immediately below the foram~n ovalc in the iniTatemporal fossa. The otic ganglion is one or fottr parasymputhclic ganglia of the bead and Mtk, (lite orJrers are rlw .mbmlllldilwlar ganglion, ptl!l)'gOpolatine ganglion. <Inti cili111'' ganglion). The tympanic and lesser petrosal branches or the glossophuryngcnl nerve supply preganglionic parasympathetic secretomotor fibers to the otic ganglion. Here the fibers synnpse, and the postganglionic fibers leave the ga nglion nnd join lbe auriculotemporal nme. As the auriculotcmpornl nerve passes the p:uoud gland, postganglionies leave the ner\c to enter the sub>tance of the gland. Important: Terminal ganglia recetvc prcgangh~>nic fibers liom the para>ymJlllthctic division. The followmg cranial nerves also contnm preganglionic lr>ympathctlr fibers: oculomotor (ciliary ganglion/, radlll (ploygopalatille and sllbmandlb11/ar gnnglin), and vngus (small terminal gang/it//.

\uriculnhmpnnlnln

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The auriculotemporal nene aris.:s frt>rn the postcnor division of the mandibular nme (V-3}. The aunculou:mpornl nerve suppli~' the poscerlor portion of the TMJ. The nerve to the masseter (masseteric lletW). obo o branch ofV-3, carries a fc\\ sensory libers to the :out~rlor portion of the TMJ. The deep temporal nerves (anter/(lr, mtddle, and pwueriur /)tatcllcs) Innervate the tempomlis muscle and carry a few fibers to the anterior ponion of the TMJ as well. I. P3iu ill\pulses from a patient's rructured condylar neck arc tamed by the au nculotcmporol nerve. 2. Pam (TMJ patient) is transmtUed in the capsule and periphery of the disc by the auriculotemporal n<'TVe. 3. The auriculocempotal nerve carrtCS oome secretory fibers from the otir ganglion to the parotid salivary gland. 4. The TMJ, as is the case with all joints, receives uo motor innorvnuon. The muscles tbnt move the joint receive L he motor innervation. 5. Its urterinl blood supply is provided l>y the superficial tmporul und maxillary br-Jnches of the external caruHd artery.

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When walking to his car late at night, a poofessor hears footsteps behind him. His sympathet.ic response (fright-or-flight) results In dilated pupils, a dry mouth, and constriction of blood vessel$ in his face that makes him look ashen. Which ganglia, located at the level or the Ct.C2 vertebrae, house the cell bodies that cause the sympathetic response in the bead?

Superior cervical ganglion Middle cervical ganglion Inferior cervical ganglion

Ganglion impar

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A 62-ycar-old woman complains of an "excruciating, stabbing pain" on the "'

right side of her face on her check, lip, and nose. She complains that this is the worst pain she has felt in her life. The pain is triggered by light contact, chewing, or even drafts of cold air. T he working diagnosis is a neuralgia of 'what cranial nerve (the principal se11sory nerve to the head and face)? ~

Facial nerve (CN Vl/) Abducens nerve (CN VI) Glossopharyngeal nerve (CN IX) Trigeminal nerve (CN V)

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Suprrim Ct.' I"\ ical J!aiiJ,!Iiun

Paravertebral sympathetic ganglia lie on each side of the venebrac and are connected to fonn the sympalbclk chain or trunk. There are usually 21 or 23 pairs of these gan glia: 3 in lbe cervical r<g.on, 12 in the thoracic reg.on, 4 in the lumbar region. 4 in the sacral rtgton, and a single, unpaired ganglion lying in front of the cO<:Gyx called the gan glion irnpnr. Three cervical ganglia: 1. Suprlor cervical ganglion: the uppennost aod lorgest, St:tching from the level ofCito the level ofC2 or CJ. This ganglion lies between the internal carotid artery and tbe lntHnul j ugular vcin. The supcri(lr cervical ganglion innervates viscera of the bcud. 2. Middle cervical ganglion: small, located at tl1e level of the cricolcl cartilage. 11lrs ganglion is rdated 10 the loop of the inferior thyroid ancry. lnnervates \iscero of the neck. thora.' (i.e.. the bro11chi ond het~rt). and upper limb 3. IJtfcrior cenical ganglion: occurs at the C7 ertebrallcel Mo~t commonly i> fused 10 the lirst thorncrc sympathetic ganglion to fonn u stellate ganglion. Innervates viscera of the neck. thorax (i.e., the lm mt:"hi and heart). oml upp~r limb. lmpnrtant: The I:""Y r.unl connect the symp.,thetic trUnk to every spinal nen c. The " bit rami are limited to the spinal cord SC!,'ITl<Pts bet"ecn n and U The cell boclies of the v!scer111 efferent t1hcn in visceral nrnnches or rhc sympatltetio trunk arc located in the inlcrrnediol:tiHnl cell column (or lateral hol'll) of the spinal cord; the cell bodies of ' lscenl afferent flbers are located in the dorsal root ganglia

Th.: trigtmlnal nen r eMislhe infeml~:m:mlllO'b a,. a scowl')' ;md motor l'('l()t, The t.ng~r lt'tt trtory

roat cnlcrs cbe trigeminal (:;tmilrmnr. guxxrrlcmt ganglion in \he middle c1nmul fu),sa. l11 c: llil'ce sensory ()ivisions or tile nerve arise front 1hc ganglion 11nd le-ave 1 he cnuuol cavily 1 hrouHh [\lramiTUl rrtlhc spbenoi~ bone. The smaller motor ruot pos""s under the Qlln21ion Md JOitb the lnaJxbbular division as 11 cxu~ through the fonmeu fnaJt. Tile mand1bular diuSJon lnnC-f\:ttc~

eighl 01u:lt:. Somatic sensory cell bodlcs of the ~olliiOn 's sensory nbcrs enter tbc: Ophthalmic division (fl-1) to S\tJlJ>Iy general SCll>alion lo the orbit and skin of fnce above
eyes

Maxillary division (Vl) to supply go:ner.>.l scn.salton to the no.>;&l cavity, ona..ill3l)' teeth. palate. and skin "'.,. n10xilta ~londlhular division (V-3) to supply g<:noral sensuon ro tho mandrblc. TMJ. 0\ilnJibular
teeth. floor of mouth, tongue, lind skin ofm:mdihle n u: UXOIL,. of the neuron,; cnh:r the pon!i thrOuMh tile sensory rout and lcmlinuu; in onC' ofdh! lhrec llUcle( o( tlu: tngcminal ;c~nsory nuclear t01t1pleX:. ~lutncrpbalit nuclt us m<ditcs proprioccpuon (ex mt.-<;kspinJ/e) C.hld or pontin~ nutltut mrdiau. "S d1scrimmativc ~cn~11un (a (tght tou,h) SpinA l nuclcu, (med/ut<S pout onJ tcmpcrutllre.{IYJm the lt<ad mtd IlCeA) eun be dtvided mlo llueu rewons along. us lcmath : lhe r~giOil o los~~t to thu mnuOl Is culled Mahruu:ltus ora II~. 1 hc mteldlo region i!t culled subnurh1oll) inlrrpnlaris. auJ the rcgitm c.:.lO!te~t to the: tail iM cnllcd subnuclt u.s uudoli~. The p::ain fibcrllii oecualty syn~tpe an \ubnucleu.~ cnud3lb.. Noto: PR>pnocCp<ie libcr> from muse~ and the T\IJ an: found only tn the mandibular dilimn The cell bodit>S or J)I'Uflrioceph'-e G .rst urdcr neurons arc found tn the 11lCJencrl> lntlk nucleu...., not

the tngenunsl ganglion. Br2nchlomerlc (lhf!armrR deri1~djfom em(>tycmic hranchlr1/ nrdte.~J motor Obcr.!l innervate 1he tcmporoli>. mos.<etcr. mc:d:ll and latcrl pterygoid. ru11crior belly uf the dtj;>Stnc. mylohyoul.
tensor tympani, and t~I\.\Or wli
p:~l~ttoi (p.llari)

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Tbc pterygopalatine ganglion contains l>reganglionic parasympathetic axons from which cranial nerve?

Oculomotor (CN Ill) Facial (CN VII) Trigeminal (CN V) Glossopharyngeal (CN IX) Vagus (CN X)

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~ A patient wlfh uncontrolled diabetes comes into the clinic for some periodontal work. You notice that her right eyelid Is now drooping, which II was not doing a year ago at her last appointment. From class, you recognize that nerve damage can be the result of chronle high blood sugar. Au upper eyelid that droops (ptosis) may be caused by damage to the:

Trochlear nerve (CN IV) Abducens nerve (CN VI) Oculomotor nerve (CN Ill) Optic nerve (CN II)

Copyright Cll009-2010 Dental Dttb

Fada I / ( \ I //I
These lburf'1'red PJ11ha "'''M' all prasympadl<uo ~otK"' "> lh< h<ad aod n<d<. Tb<y IRlh< <oh>ty puglion, poetyi<>!'Oiaronc: pujlhO"- submandibular pnghon, and rhe ouc ganglion. Each bas lhree roou rnlenna lhe ganglion and 1. ,'Jriablo num~ of e..'iting brn:ochcs. The motor root Clt'l'l'tS prH) naplic para.sympalh~th: n.;r.e fibers that tennina:t rn thc ganglion b)W'fiiPS

ing; the poslsynapne fibers travel to wge1 organs The sympathetic: ruot c~mitt p~stsyoaptic sympat11etlc fibers thot tmvcrse the ganalion whhl)ut synapsing The senwry ruoc cames general stnsory li~ that nlso do not synttpse in the ganglion

- Some ganglia also eflny speeial sensory fibers lbr t:.:ne

P.1n1"' 111fMihc1u ( lnt!ll.

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, . , . . _ . . .,.nu.-.padtfdc: ftk:n &or,) dw t'C~ hCtW' h$cp1tJ...k ,.,.af)....,.,_lrlt:dc: IJbes: b\~ ~. th= lbor'l cil..ry l)tn t4 S)'tllp~~t.htek nbr:n from tbc: 1t1W"r'MJ Cll\>lid rAh
l"r?CoaJIGAic HC"rttWUOoLttr Obt-r cue ia ibc. l.cnmal twe lru~ of tl!e
r.nal~c

Pt~tme.

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plct)'I.OPIJJihlle f"M6a

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Po:.canall4*1c panilympatbetk !'ibers reach the muMIIIII) nerve b)

one ror '" P"'lk-nlc branei1Cl1 - lhCiile f'Cilcb 1.1te lncrinul jll llod; othcfl. Nil u11hc; p;,IAiitlC nnd nn.-111 nts'IIC I<' lbe pa~linc lnd nllt.allli..!Mlt SywnptJ1t!ffe nt~otN ~eb the png!um viJ.I.h,e humwl t:orocl'd ~\l e!CUS
l'rt~nJlklnlt p;~nt:ymplh~!t-

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ntH:n mM:b tbe ptt~Uon trum ll'lc

sopm.r ~ll.h\atJ ruxkus of thr &.:tal nc'f\'C viii &be choNI t)tf'C)Anl eN
P~~kparu)WJIQI!ht1kfikn~ * ~

p . l lrt'Wtloch; lfoey-lft tt<itiOii)A)c. Ocher-~Wta.cBpbtlo)

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rrttOat:f9ttk prat)"lllpatlllftk fiben Qn_f."tmle ID 1bt

1r'lrmur uln.ry r1uelru' oftfle glo$iopl'wyn_ia) fK"1"1't
.aurwulotnnr.onl l\ef'\~ fi~

mcd~al ~ ll~e m~~ndiboln

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l"MtV'l.i:lkttl1c parafyl'npttbt'tic tibers Jeavc: 1M ilniJitoR lltldJOin lhl" m ~omotor to 1M pUO(hl j!,IAnd

Oculomnlu r nl'fh' I( \ 11/J

The oculomotor nerve supplies the followmg extraocular muscles: medial. superror, and inferior rccli; inferior oblique; and levalor palpebru su ptrlori s. The oculomotor nerve sends preganglionic parasympathetic (ibers to lhe ciliary ganglion, The postganglionic fibers lea\e the ganglion in lhe short dliry nerves to supply the sphincter pupillae and the crliary muscle. Note: In most ca>es, pto~is is caused by either a weakness of the levator muscle (muscle that rai.ves tire lid). or a problem wilb 1hc oculomotor nerve. Remember: The trochlear nerve (CN IV) supplies lhe superior oblltJUe muscle (the ml4scfe that wrn$ the eyeball illferlarly and laterally), and lhe abducens nerve (CN VI) supplies the lateral rectus or I he e) e. The oculomotor nerve (CN Ill), !Tocblear nerve (CN IV), and abducens nc.- e (CN VI) all exit tbe cranium through the superior orbital fissure, They iDllervale the extrln.sic ocular muscles, resull ing in movements of the eyeball. Note: The trochl ear nerve is the smallesl ernnlal nerve and the only cranial nerve that emerges from the dorsal (back) a s jJCCI of I be bralnsteru.

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The splanchnic nerves (greater, lesser, tmd least) arise from the:

Cervical sympathetic ganglion (chain) Thoracic sympathetic ganglion (chain)

Lumbar sympathetic ganglion (chain)

Sacral sympathetic ganglion {chain)

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A 34-year-old female patient complains to her physician of hoarseness. The physician notes drastically enlarged lymph nodes in the aorticopulmonary window and suspects involvement of the recurrent laryngeal nerve. The path of the recurrent laryngeal differs on the Left and right sides of the body. Which one (right or left) loops posteriorly around the aortic arch and ascends through the superior mediastinum to enter the groove between the esophagus and trachea?
~

Right recurrent laryngeal nerve Left recurrent laryngeal nerve

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llwraru: '~ mp:tlhLIic J.!OIIIJ.:Iiun tdwin}

Remember: Para,ertebral S)mpathetic gangli11 lie on each side of the vertebrae and are connected to fonn the sympathetic chain or tru nk. These nerves arise from tbornclc ~nnglia (TS - T/2). Note: They all pass through the diaphragm. The 1>rcganglionic sympathetic fiber.; may pass through the ganglia on lbe tbomcic part of the sympatbetic trunk wnbout syru~psing. These myelinated fibers form the splanchnic nerves. of which tbcre are three: 1. Greater- formed from sympathetic fibers from TS- T9. The nerve passes through tll< crum of the diaphragm to end in the celiac gmJglion, 2. L~sscr- formed from sympathetic fibers from T 10 T11. The nerve pass through the diaphragm with the ireatcr to end in the aorticorenal ganglion. 3. Least- arises from the last thoracic ganglion. and. piercing the dwphmgm, ends in lbe renal plexus. l mponant: Thoracic splanchnic nerves (specifically the greater splanchnic nen e) to the celiac plexus consist primarily of preganglionic visceral efferent fibers. The postganglionic ftbers arise !rom the excitor cells in the celiac plexus nod are distributed to Ute smooth muscle and glands of the viscera.

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H'\.'UITl.'OI hu-~

n!.!l'.IIIH.'n l'

The let't \'&.g us gives nse to tbe Jet't ~urnnt laryngeal nene. The right ~current laryngeal nene spins from the right vagus befo re entering the superior mediastinum at the level of the right subclavian artery. The nerve books pOSteriorly around the subclavian m1ery and also ascends in ~tc groove between tbe esophagus and trachea.
Bo~> re<:urrenr laryngeal nerves pass deep to the lower margin of the inferior con.~trictor muscle to innervate the Intrinsic muscles or the larynx respOnsible for controlling the movements of the vocal folds.

The right recurrent laryngeal nerve innervates: All of the muscles of the larynx. except the cricothyroid, which is supplied by the external laryngeal branch olthe superior laryngeal nerve The mucous membrane of the larynx below the vocal fold-' The mucous membraue of the upper part of the truchca Note: Thi< nerve comes in contact with lbc thyroid gland and come5 into close relationship with the inlerior thyroid artery The Jert recurrent lazyngeal nerve innervates: The same muscles and mucous membranes as the right recurrent laryngeal, except on the left side Remember: A few cardiac brunches arise from ~1e vngu$ and enter the cardiac plexus. TI1C$t are preganglionic parasympathetic nerves that synapse with pOStganglionic parasympathetic nerves in the hean. They innervate the hean muscle and conducting system (SA node. etc.).

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All or the following statements concerning the hypoglossal nerve (CN XJI) are true EXCEPT one. Which one Is the EXCEPTION?

It is a motor nerve supplying all of the intrinsic and extrinsic muscles of the tongue.

except the palatoglossus. which is supplied by the vagus nerve

It leaves the skull through the jugular foramen medial to the carotid cnnal

It passes above the hyoid bone on the lateral surface of the hyoglossus muscle deep to the mylohyoid muscle
It loops around the occipital ancry and passes between the external carotid artery and internal jugular vein

Soon after it leaves the skull through the hypoglossal cana~ it is joined by C I fibers from the cervical plexus
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One method or the inferior alveolar nerve block, where tbe target is tbe mandibular foramen, encourages remo,al or the needle about halfway and deposition of approximately one-third or a carpule of anesthetic. This method is meant to anesthetize the nerve, which carries general sensation from the anterior two-thirds of the tongue. T his ner ve is the:

Hypoglossal nerve (CN Xll) Chorda tympani Recurrent laryngeal nerve Lingual nerve Glossopharyngeal nerve (CN IX)

218
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lhl 'kUII thrnUJ.!h lht. ju~ul;.tr [nr: H11l'll nlldialto lh(' C':lrlltid

('~ln:ll

***This is false; it leaves the skull through the hypoglossal canal medial to the carotid canal and jugular foramen. Note: The jugular foramen allows for the exit or the spinal accessory nerve from tbe crnninl cavity. Important: The hypoglossal nerve travels from the carotid triangle into the submandibular triangle of the neck. LesionJ or the bypoglosul nerve: Unilateral lesions of the hypoglossal nerYe result m the deviation of the protruded tongue toward the affected side. This is due to the lack of function of the genioglossus muscle on the diseased side Injury of the hypoglossal nerve eventually produces paralysis and atlophy of the tongue on the affected side with tbe tongue deviated to the affected side. Dysarthria (inability to articulate) may also be found Important: lftbe genioglossus muscle is paral)"Led, the tongue has a tendency to fitll back and obstruct the oropharyngeal airway with risk of suffocation.

in~.:ual

n.:ne

The lingual nerve is a branch of the mandibular dh is ion (V-3) of the trigeminal nerve. It supplies general sensauon for the anterior rno-thirds of the tongue, the floor of the mouth. nnd mandibular lingual gingiva. "!ole: The submandibular duel has an intimate relation with the lingual nerve, which crosses it twice. The lingual nerve descends deep tO the lateral pterygoid muscle, when: the nerve is JOined by the chorda tympani {branch of the facial 11ene), which conveys the preganglloni< parasympath etic fibers to the submandibular ganglion and taste fibers from the anterior ho-thirds of the tongue. Important: If you cut the lingual nerve after itS junction with the chord tympani, the tougue would have a loss or taste and tactile sense to the anterior two-third~.

Norts

I. The chorda tympani emerges from a small canal in the posterior wall of the tympanic cavity (petrotympanic fiSSure) after crossing the medial surface of the tympanic membrane. h joins the lingual ne~e in the infratemporal fossa. 2. The chorda tympani nerve conveys general visceral efferent fibers (motor jiber.r) of the parasympathetic division of the autonomic nervous system. lt carries special visceral atTerent fibers for taste. 3. Parasympathetic n~n~es are general visceral efferent fibers.

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T he glossopharyngeal nerve (CN IX) Innervates all of the followlnj: EXCEPT one. Wbicb one is the EXCEPTION?

Stylopharyngeus muscle

Parotid gland Taste to the anterior two-thirds of tlte tongue Taste to the posterior one-third of the tongue Carotid ~inus

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All of the following statements concerning the cervical plexus and its branches are true EXCEPT one. Which one is tbe EXCEPTION?

The motor nerves for most of the infrahyoid muscles are bran<:hes of the ansa cervicalis (/()()p formed by C 1. C1, and C3) Cervical nerves CS-C8 contnl>ute 11>01or fibers to the cervical plexus
It is positioned deep on the side of tbe neck, lateral to the first four cervical venebme An important brtlnch of each cervical plexus is the phrenic nerve that supplies the

diaphragm The supraclavicular nerves innervate the skin over the shoulder The transverse cervical nerve provides sensory innervation to the anterior and lateral pans of the neck

129, (30,13 1

Ta\h' lo lh~ .ulhriur hu,..thirdo;; nf tht: IOJ11!Ut'

The glossopb3r)'ngeal ntf\'e innervates the st~ lop baryngeus muscle Ma the Hlll<ettfar brandt). h Is lbe only mu.ele lbat is supplied by this nef\e. This muscle is 3 l3ndmark fQr locating the glossopharyngeal ncf'le because llS the nme ent<TS lbt pharynscal wall, it CUf'les postcnorly nround tbe lateral margin of this muscle. lt1 addition to the somn1lc motor inncrvnlion nf the stylopharyngeus, the glossopb-

aryngcal nerve supplies preganglionic parasyrnJtnlhctlc mutur fibers to the otic gnn~llon. n.ese fibers synar<e with lhe postgan~:~lionic fiber~ in the g:mglioo to supply the parotid gland. The pregAnglionic ncnes leave the glossopharyngeal nerve a~ the tympanic nene. which enters lbe middle ..,. caity and panicipatos 111 lht formation uf the tympanic pie~us. The tympanic nerYe reform> u the les""r petros.! nerv<. lc:avc. the Cfllllia.l cavily through the foramen ovale. and tnters the otic ganglinn Post,ganglionic;.r; are tanied by lhe aurietdotcmpa!lll nene fVJ) to the p..-otid VIsceral seru~ory hr nches of the glossopha ryn ~eal ntnc: Lingual branches- nre two in number; one supplies the va.llrue papillae and the mucous membr' Jn~ cover111g the bose of the tongue; the other supplies the mucous membrnne an~ folliculur glands of the posurior onc-thirrluf the longtte, and commU tliClltes wlth the
lingual uerv~ Also COI'rles .fome ucretomowr jilwr.v l<ltlw l(lumlv Pharyngeal distributed to the mucous mc10brune of the pharynx. Is the sensory limb
of the gag n:.Oex Carolid lou< ner. to c;ttotid >illll:l (l>ororw:qlwr) and carotid body (<hmo-

receptor) Remember: The lingual nene (hranoh of VJ) descends deep to the lateral plerygoid mu.<cle. where the liogul ntf'le is joined by lhc <bordu tympani (branch o/tlie/aclulllt!M'<'), whtch

conveys the (tregnn~llonlc pamsympathelic Obers to the sobmaodibuln rgAngllon nnd taste fibers frmn the anterior h\'tHhlrds of the tongnc.

( tn ical llt'l " ' ' ( ~-C H l'Hnlrihufl' mulor lilnr'

In lht Cl'n kal

plc\1"

*** This is false; C I - C4 contribute motor fibers to th~ cervical plexus.

Tite fo ur m ain pairs of nerve plexu.<cs tbal are formed by the mixing :utd bnmching oftht ventral rarul the spinal nerves: I. Cervic.al (llexu~ (C l-C4)-- provide> culaneous innervation to the ~km of1he nt'Ck, shoulder. and upper :utterior chest wall tts well a< motor innervation to the mfmhyod (strap) muscles and geuiohyold muscle. n1c phrenic nerve (C3-C5) is the motor

or

nerve to Ihe skeletal muscle of the diaplmtgm. 2. Brachial plexus (CS.C8 and Tl)- fomocd in the posterior lriaoglc of the neck, the brachial plexu.< ex lends into the axilla. supplying nerves to the uppcr limb. It has lhr cords: posterlo~ axillary and radial ore main branches lateral - musculocutaneou.~ nene is mam brnnch mcdilll - ulnar nen e is main branch ~ole: ll1e median ner.-e fonns its two head.' (me<flal and lnreral) fnom the medinl nnd lateral cords.

"'-rv""

3. Lumbor pies us (LI IA) - formed in tbe llSOas muscle, th<! lumbar plexus suppUc,< the lower abdomen 1111d parts or lb~ lower limb. Maiu branches ate the femorul nnd

obturator nerves. 4. Sacral plclU S (l-1-LS and Sl -s4) - It~ in the posterior J>l'lvic wall in front of lhe ptrifonns muscle. The sacr:l) plelllJS ~uppltes the low~ oock, pelviS, and part> of the thigh, leg, and foot. 111e main branch t< the sdatlc (largest IJI?T\'C m rM body).

GNATOMIC SCIENCES

Nrv)

Wblcb divblon of the trigeminal nerve exits the cranial ca,;l) through the ation to the midfaee foramen rotundum and provides sensory innen (lower I!Jelid to tire upper clreek), palate, and paranasal sinuses?

Ophthalmic division (V-1) Maxillary division (V-2) Mandibular division (V-3)

221
Copyn.&ht C1 2~2010 DmtaJ I>~

126,127,132 J33

G NATOMIC SCIENCES

,
\..
T he mylohyoid nerve is derived from the Inferior alveolar nerve just before it enters the mandibular foramen. The mylohyoid nerve descends In a groove on the deep surface of the ramus of the mandible, to the supply tbe: Anterior and posterior belly of the digastric muscle Mylohyoid and anterior belly of the digastric muscles Stylohyoid and posterior belly of the digastric muscles Geniohyoid and stylohyoid muscles

The ophthalmic division {V-1) enters the orbll through the superior orbital nssure and provides s~osory lnnervalion to the eyeball. up of lhe nose, .~kin over lhe upper and Lower eyelid, and sktn of the face above lhe eye. Branches include the lacrimal. fromal, nasociliary, supraorbital, supratrocblem, iJJfmtrochlear, and e)(temal nasal nerves. Nole: During u sinus attack, painfi.1 l sensation from t.he ethmoid cells is curiccl in !he nasociliary nerve. The maxillary dh'l.slon (V-1) passes lhn)ugh lhe foramen rotundum and provides sensory innen allon to lhe midface (IH!Iow the eye and above the upper lip), p:tl:tle, parana.al sinuses. and the maxillary teelh. 'lotc: The tickling sensation felt in the nasal cavity JUSI pnor to a sneeze is canied by the maxillary divis1on of trigeminal. Branches include lhe Infraorbital, zygomaticofacial, 3lld 1.ygomaticotemporal nervto. Sensory innervntlon of mandibular dlvhinn (V-3) c~ to lhe sk.in of the cheek. the skin of the mandible, and the lnwer Up and Side of the head. Sensory innervation ulso includes the TMJ, mandibular teeth, the mucous mcmbrnncs of the cheek, the fioor oflhe mouth. and the anterior part of the tongue. Branches include the mcneal. buccal, and auriculotempo1'111 nerves. Important: 111e trigeminal nerve contams no parllJympathelic component at it> origin. The ner"cs hranches are used by rhe oculomotor. faciaL and giO>;.opharyngcal nerves to distribute their preganglionic para') mpathelics to the parasympstltctic head ganglia.

.,,. The mylohyoid nerve arises from the mferior aleolar nerve. a l>mncb of the mandibular division ( Y-J) of the rrigemmal nerve {VJ Function of mylohyoid: eJe,ates hyord bone. base of tongue. and Ooor of n~oulh. The mylohyoid Une, which gives origin to the m)lobyoid, is found on lhc body of tne mandible. The sublmgual gland is located 'upcrior to tlte mylohyoid muscle. When nln1 is placed for u periapical \-lew of the mantlrbulnr molar.s, it is the mylohyoid muscle that gets in the wny if it is nor relaxed. Important: Swelling atlhe angle of t.hc rn~ndiblc and the lateral neck is nften the result of detlection of cxudnres by the mylohyoid muscle. Suprab)'Oid muscles: -Digastric musdcs -Anterior belly: innervated by nerve 10 the mylobyoul. which tS a br4nch of the mandtbular dh "ion of the trigeminal nerve - Posterior hclly: tnner.'&ted by the factal nerve - ;\1ylohyold muscle: innervated by nerve to lhc mylohyoid, which is a branch oflhe mandibular division of the trigeminal nerve - Geniohyoid muscle: lnncrva!ed by the first ccrvlc.11 nerve through the hypoglossal nerve - Stylohyuld: innervated by the facial nerve Tnfnthyold mu~clcs: - Omollyoid muscle: innervated by llllSll cervicalis - C 1, 2, and J -Sternohyoid nru<cle: innervated by unsa ce" icalis- C 1. 1, nod 3 - Ste.rnolb) rold muscle: inne"ated by ansa cervical is - Cl. 2. and 3 - Tb~toh) oid muscle: inne"-ated by the fir.st cervical nene. "hich accompanre& the hypoglossal nerve to the suprahyood regton, 411d then bmnches from 11 to reach lhe thyrohyoid OlU>Cie

Gl'IATOMJC SCIENCES

Nrv)

,
Whi<h of the following nerves carries parasympathetic Obers in addition to motor innervation? Optic (CN 11) Olfactory (CN I) Oculomotor (CN Ill) Trochlear (CN IV)

136,137.,138 139
223 Copyn,ahl C 2(1()1)..2010 Den111 Dt<U

(ANATOMIC SCIE~CES

Nrv)

,
The extended eour>" of the abducens nene from the bralnstem to the eye makes it \'Ulnerable to injury. In blunt force trauma to the htad, an individual's petrous temporal bone is fractured, leading to the injury of the right abducens nerve. Which of the following would be a sign of that injury?

IUght ptosis Loss of light reflexes on the right side Inability to adduct the right eye Medial deviauon of the right eye Loss of corneal reflex on the right side

Oculnmulur (( \ 11/J
Nme
Ol[li<IOiy

SHe or E11t from Skull Cribriform plate of ethmoid hoM Optic for1rnen

Compontal
Spetbl &f:n..or)' (GpitJI4f/]#r'tlltJ
Spcdal 3tnsor)'

funtdon
Sense of smell

!CNI)
Optic

(CN //)

(sptol.,ffirtm)

Conveys \'isu:.l i.nronrulli<m from the re~jna

OculomotOr Superior orbiLal ti~.;ure ICN J/1)

Som1lle notor Supplies four of the six cx1rooeul11r (g~1eral Jomurlc ejfrrettt) muscle$ of the: eye arw.t I he IC'\o'l'llor palpeb~ $Uf)tfioris mu!!Cie o( tht upper eyelid

VhoctniJnot.,.
(~~ ~ fi"(J/ t'/JnwttJ

irochkar

Supmor orb1111 fiuurc

Somatic motor
(g01UOI1/(),.lDiit: t>ff~ll)

Paras)'n:lpa!Jitelie IMtf\'" l bOn ofthe pupdlat ond nbaoy -Ia tnnm~es tbt 5Upmor oblique

!CN IV)

muscle

The four extraocular muscles that the oculomotor nerve innervates arc the: Superior rectus muscle Middle rectus muscle Inferior rectus muscle Inferior oblique muscle

\1cdial

dt'\

ialinn uf the ri::!ht

t~ l'

Remember: The abducens (CN VJ) oen c inncf\ ates the lateral rectus muscle of the eye. The lateral rectus muscle is responsible for lateral gaze (ilS contrac/1011 causes rhe eye robe abductt-d). A lesion of this nerve results'" mt>dial strabismus (~ross-eyed) and diplopia (double 1isio11).
Nerve Sire of Exit rrom Skull Component Trigeminal: (CN I') Bnnthll l motor
V-1 Ophl.babnlc
Y2 M<lllillty

Fune1ion

Superior orbital fissure

Fonuntn rotundum
Foramen ova!e

V-3 Ma.xlibu.l.v

(special ''(SCf'rol dferenr) mastication: Masseter Temporali.s

. . . . . . .

lnne:rvotcs the mu!leles of

Me<bat t*'Ya<>1CI Lacmt pl<t)JOlCI

Ankrio<dtTcmor tympan Tensor veli palatine

Also illncfvalcs: Mylobyoid

Ccnrrl ttn~ry

General scnsndon to the

(gMttral .)'Qmatic affire.m) major part of the he'd

Abduocns (CN VII

Superior orbital fissun:

Somatic motor lrmervatcs the lalel'll rCUS (gtntro.l somatic t./ftnitl) RIU!C!C

(ANATOMIC

SCIE~CES

Nrv)

The principal types of nerves found In the dental pulp are:

Parasympathetic and efferent fibers Sympathetic and afferent fibers Sympathetic and efferent fibers Parasympathetic and afferent fibers

225
Copyngl\1 C 2000-2010 l)('ntlll Drclc.s

( ANATOMIC SCIENCES

Nrv)

Which cranial nerve (which technically does not arise from tire brain) Is the only nerve to start in the cranium and extend below to tbc head, and innervates the viscera?

Trigeminal (CN I?
Facial (CN VII)

Vagus (CN X)
Hypoglossal (CN Xll)

124
22t
Copyngbt Cl 2(1()9.2010 ~~~ Dttb

s~ llljlilllnlh,: :tlltl :tiTl'rt.'lll fihl11'"i

The sensory nerve fibers in the dentnl pulp originate in the trigeminal ganglion and are

categorized. from smaUcst 1o largest dirunetcr, into C-fibers. A-della. and some A-beta
fibers. On the other hand, postgnngllonic sympathetic nerve fibers onginale in lhe superior cervical ganglion. A-della fibers are myelinated low-threshold mechano-rcc~ntors and nre responsible for the so-called "first pain signal~. C-fibers ane unmyelinated. highthn:<hold fibers They are termed poly-ncxllll because they respond to several types of stimuli such as mechanical, chemical or thermal stimulation of the pulp. C-fibers most likely mediate Ute senS<ltiot of "second pain". Note: The pulp contains both myelinAted and unmyelinated nerve libel's. Tooth rmlp consi.s~< of a loose type of conn~'Ciive tis~11e. '"main components are thin col13gen fibers 8l111nged asymmerncally plus a ground subMan~e comaiUlUI! glycosaminoglycons. Tooth pulpts" highly innervated and vosctdarizcd ss~e. Numerous fibroblsts arc present. Surounding the pulp and ~cparuti11g it fro.n the denrin arc the odontoblasts. lmportsnt: l'ruo originates In the pulp due to fre~ nerve endings fuf}c~mfibers). which arc the only type of nerve ending found in the pulp and ate specific receptors for p~in. Regardless of the source of stimulation (heal. tl1id, Jlres81tl'('), the only response '~ill be nain. Note: Vasomotor sympathetic Obers are thc)ught to end on blood vessels. Functions of tile pulp: l . ~utritive- \Cty rich blood supply that surrouuds the odont<>blas~~2. Formative -- periphel'ullayer of pulp cells gives rise 10 tl1e odontoblasts thnt form dentin. 3. Sensory - free nerve endings that make conmct with the odontoblasts.

The vagus ncr. ~~a mi~e~ nerve thai lc:o\'0\ dte brnin from the 1m:dullo 3nd ptlSS<s out of the cranial cavity lhmugh the jugu1l1r foramen. rhr '"gus nerve descen~> In the neck In the cnrmld sbcolh behmd the Hllcmal and con1100n ...r~td anerics and Ihe internal jugut.u- vein Both right nd left vgat 1runl.< ~""" lhrough the posltrtor mediastinum on lhc <><'!'hagus and enter the ahdorrunol caVIty wth the <>Opha&1JS- The 'apus nerves suppl) '""' vi>ccro or the nc'<k.. thor:u., 11n~ abdomen to 1he lefi colic (.\pleukJ fle:wre of Ute large inu:sune. l11e vngus llervc consH!IS nf
fi\IU

f:Qmpootents:
\ <J~U\ - - (

fO.IIUa l

'\ , n,~

Component
Unll\thlal t'llOCor

Fuuenon
SUJ)plies lhe ~ohmtury musde~<'rthc pharynx aud moKI of&hc huynlC, nli
Pa~Uy11lpllh<CIC \llll<f'~hOO

;,~'-''"' vsscernl t'lfcn:lll) \Wills lhc: palatoglc!.Su:i muscle o(thc tongue

\'bunl moior
Vl\l'trllU..n!iOI'Y

tgmwo.l 'istTIYll t ffenru) ('b1U)'11x.

or chc: -Ch muscle and glands or \he l1!ynx. and\,...,.. oflhethoru and bdomtet
1

PnwiJcs viseerut scnSttty infonmuiun from 1he IMynJt

~sophagus.

tntchcB,

(S:tntnil vi.~reml a{Tf!l'i,'M) lind ubdommat artd lhun~etc visccru. 15 welt u.s the ttNtGh n:ccptors uftht: aoruc 1rth iDd. cbcmor~cepton or tht aortic bodlcs
Cmtnl.itttWf')
(~'f:rrrrct romazr. ~p~tll

I'IJJj!n!m)

Prvvldtii gc:mnl 5tniCM')' fnfonnalioo lfvm \be skin of the bxk 01 rhe ear and fJtkrnal audiiOI')' meatUS. ~ru. of 1he e.\.tanal .surface ur the 1)'mpanic mcmbrnnc. and lhc J lhnrynx

<<.'UJOry

lf"<iola.fftrcn/1

A "crt minor COHtp\'lnetu of eN X. ProvldCila5.1tscn~tion from tht: tp&toctk ret;ton

~1\l"plicd

I. The abdominal vtsccra below the left colic nexure am.l the ('K'Ivlc andgemtu.lia arc with 1)1.\l'lh)'nlpalhetic prcyungllonics from tht flCIVic SphU\Chnio ncrY(.11, 2~ M10: phqryngt~lll,l~xus of nerves <:Otllttins both n1010rand sen'iC:lry componenb. The

motor nerves~ behC\.ctl tocon:t~ from the "111US n<r\'c

G NATOMIC SCIENCES

N rv)

,
The only part of the retina that does not contain photoreceptors, and lro.contains tbe axons of ganglion cells that form the optic nene, is known as the~ Photo spot Optic chiasm
Lens

Oculomotor nerve (CN Ill) Optic disc

227
Cop)'rljjhl 0 20092010 ~~~~I Dh

GNATOMIC SCIENCES

Which of lhe following receives fibers from the motor, sensory, and parasympathetic components of the facial nerve and sends fibers that will innervate tbe lacrimal, submandibular, and sublingual glands?

Semilunar ganglion Geniculate ganglion

The otic ganglion The ciliary ganglion

221
C~t

e 2009-2010 DtmaJ Dtds

The Optic dbc (ttlsu clllled the optic p<1plll11!is tile small hlind spot on the surface of the retina, locatedaboul 3 mm to the n3sal side ofbe ma~ula. The oplit disc is the only pan of the I'Citna that contains no phOIOn:<:<"J'IOTS (rods m <orrcs). The disc consist5 of a.xons of ganglion cell~ exning the retina to fonn the optic nerve. The;e a>~ons are accompamed by the cemrnl artery and vein of tho t'Ctinu. The optic nene luis only a special sensory compon<nt Spcctal sen<Ory oooveys vhual ioformRtlon from the rellna (special ttf!erelll). Viual mfonna1i0n ent<'T!> the eye mthe fonn of photons of light thut are convened to electric~! signnls w !he retina, These signals nre cUJTied vin the optic nerves, chiasma, and trnct to the lateral gc.nicuiMe nucleus or cn~h tbalumus ami then 10 the visual centers of the brain ll>r interpretntior\. Remember: After e>.iltnl! the eye at the opuc di,;c, the mn Optic nerves (une fmm each ntect ut the optic chlosma. IL lS here Ihat the axnns from the m<<hal (nas<tl) half of each retina cross to the opposite s id,, while those from the late111l half of \lach reti1111 r.:maiu on the 5ame side. From the opttc cbia.<roa. a~ons that perceive ~~~ l~n v~~ual {icld form the right optic tract. These opti<: tract tibers ynnp<e in lh~ lat"TOI geniculate nuclct "'1th gerucnlocalcarine fib(rs (optic rtu//(1/loraJ !hot tenninatc on tbe banks of the calcanne sulcus in the primnry visual con~x (BIYidnrann ,; 01-ea 17) of Ihe ocdpital lobc. n ms, lhc right visual field is interpreted m the leO beuliophere of tl>e braln ond vice
ey e)

verso..
.'\ole: The centnll artery nr the retina, br.lllch of the opbtbalnuc ancry, pirc:es the opnc nerve ond gaiM access co the renna b) emergwg from tbe center of the opnc dtsc

I Ill' l!l' UH: nl:~h: g.m 1:lmu

The- a;e:ntt'Uiatc ganglion 1 .s an [...shaped t<'ll(.'('tton. t. tihm und se.ntOJ1' nf.."Umns nfdll! faeiel ntr,c localcd iu lhe I Bcial catla1 C\f lhChe-ad. The ~t."IU C\tlu1c. gi1tl,.U.hon receive), llbL'rt. fr..,m lhe moloa, Jil~u .sQty. uml I)OI".tsympa1 hcuc cumpon1tnt.\ or th~: r~cud nerve n11d Mend\ fibers that \VillttU '\cJ'\181 c lhc

lacnmnl glunlli. submandibulAr g lands ubhnj,'\JUI gtaud,, IOnJ1U< ramtrwr nolhil'l/$), J'.llit< phai)'DJ<, t\l<ml a1Jd1IO<)' rnerus.. Sla!"'dus I'O'Ienor ~~~~or lhe di~';l$lll' musclo, "Yidb)ord nlllsclc, and ntuscle; of fGA:tolexp,.,.>IOO\.

Sensory t nd v~rasympalhetk lnpu t~ ii~ ~:'imt"d tn(n the gcnlcttlu'e .,;aJl.HhUn Vln lhc ~f"\1. In

tennedms. Motor fiber:; ()J'C c.amcd vm lhc f~tctnJ n~l"'\ e pruJ )Cr. The grentt1r petrC)o;QI nrrve, winch
c:trries St1\)tJry O ber$ n~ well a" prcg!il1t_(llonle pnn)yntiH\thetl..: fibers, emerges f[t)m lhe tUUe:-

rior llSp<'Ct or the gangliuu.

Important bnncbe;, of the fntrapetrou' pa rt of tfrr tad I nrn i.': f'he grtattr petrosal nene ati~ (TUnt lhe facial ncn.e tl 1ht gemculatc: Ja.ng.lion. Til.: nt"f'\C' rontam" prcgangti.,mc p.:tl'\'liYmpathchc liben; Ihat puss tu tho pterygnp.thUt"e pnglitln t1nd ore thcol'C n:luyed dunugb the zygomatic and tucrim~tl n~rv~ tOIhe la.crimr1l ~lnnd~ ot11er polotgan~
glionic flbcr!W l'ilS.!i lhrough the na.snl nntl]\llh1\ine nerves (U lhc glands onh~.. fU\.tC0\1$ mernbrune

of the nose: and ~ltttc: the nenc also aJntums many 1 u.,1u fibers from the mucow m..:mbrane. of the Pillu:. 'l'be Dl'TV\: enteq,ocs on sutfac<: or the I"""""' part or !he temp<lrat bone 1111d "'"' furwl!l'd ro enrer lh< fonmen locenmJ. It is here JOined by lh< ~eep prtro'"l nen e from 0 >ympatheuc plcxtL<on the 1 ntcml earolid artety and ti>rms th< urve to the ptrl ~oid camtl. ThiHpus. ~~ rorwttrd and eutcrs tJle pterygopolnum: f()ss:L Wht,:lt! I( ends in the pttrr)' gO(!ahlllne ~angUon. The ntrve to Ibe stap<llh" ari,.., frvm the facial ner.c 10 <oppl~ thc >tlpedu.,. muscle Tb< t honl I) mpanl """" from the facial " c JUst above tbe sl) lollliSiotd fornn"-"' The nCr>e lca\ts the tympnn1 c cavrty lhroo~h the J"'II'OtympodiC ftsSore ami cntoi'OI the rnfrarempoml rossn, where the nerve joins the Hngunl oenc. l11 c chorda tympn.n1contofns many tasfc Oben from the mucous mc&nbrnnc covering the :anterior tw(Hhil\ls of d1L' wngoe, nnd t.he tloor t>r1hc: mouth Tl\c ncrveai!ID contains preganglionic parasymputhetic ~e<'ntunwtor tibc111hill rc:tch the wbmandibulor gllll@lioo and are then: n:la~cd to 1~c ;ubmandtbulu JnJ sublin!;U!Il >alivruy

the'"""'"()<

glnd<.

(ANATOMIC SCIENCES

,
\.. Expansion of the 11ituitary gland by a tumor can put pressure on the crossing-over fibers at this X-shaped structure formed by the meeting of the two optic nerves. The name or tbls structure is:
~

Optic tract Lateral geniculate body Optic chinsma Medial geniculate body

137
229
Copyngbl

e 20092010 ~ma1 Decks

(ANATOMIC SCIENCES

Nrv)

Which statement concerning the left ' 'agus nene is false?

It can be cut on the lower part of the esophagus to reduce gastric secretion (termed a

vagotomy)
It fonns the anterior vagal trunk at the lower part of the esophagus

It passes in front of the left subclavian artery as it enters the thorax

It contains parasympathetic postganglionic fibers It contributes to the anterior esophageal plexus

The optic oerc (CN II) arises from a.<ODS of gangllo? cell~ _of the ~~ina. which converge at lhe optic disc. The optic nerve leaves Ihe orbnal cavny by Jll'SSII'Ig lhrough the optic foramen (also called optic canal) of lhe sphent>id bone with the ophthalmic artcrv and then cmers 1he cranial cavity. 1l1e nerves on t>olh si<lcs join nne un01her to fonn ;be optic chiasma. Here, lhe nerve fil>ers 1hnt arise from tl1e mcdiul (lltl$111} balr of eacb retina cross llac midline and enter U 1c optic n-oel ofthe opposi1e side; Ihe fil>ers from the lalel"dl (remporal) half of each re1ina pa.,s (lOSieriorly in lbe optic l!acl of the sarne side. The optic tract emerges from the posterolalcral angle of the optic chiasma and passes backward around the lateral side of the midbr:1io to reach the lateral geniculate body. Remember: The optic nerves cany impulses associa1cd .-ilh vision. Like the olfactory nerves. the optic nerves are entirely sensory. The optic nerves are aciUally br:1an tr3cts rather than true nerves, since the optic nerves nre formed from oulgmMhs of the embryonic diencephalon.

It

cont:..~in"'

p :ll',t"'\mp:Jihl'fic po\l!,!OIHCiionk

Jihlr<~

- This IS fa be; the vagus Dtn e cam~ parasympathtiiC preganglionic nbcn; 10 the tbo<acic and abdommal viscera. The Jell agu5 ntnt enters lhe tbOI'al< m front ofthe ltfl subcla\iaa artery aod behand the left brarhioccphall< eln. The nerve then cros;cs ahelef\ sade oflhe aortic arch und i< its<lf crossed by the kfl phrenic nerve. The loft vagus nerve pns.<cs behind the root of the left lung. forms the pulmonary plexus. and cominucs to form the esophageal plexus. Tl1o left vagus nerve enters lhe abdomen in front of the esophagus ahrough the esophageal lalla Ius of the diaphragm as the anterior vagal trunk (I"COc/h.'.S the mtte.rior surfut:e oftlte stomnchj, .'Vole: The vagus nerves lose their identity in the esophageal plexus. At the lower end of the esophagtL<. brunches of the plexus reunue to form an anterior vagal trunk (allleri<>r gasrric nene), which can be CUI (\agotomy) to reduce i!lbtric secretion. The right vagus ntn t crosses the anterior surface of1he ril(btsubcla ian artery and enters lht thonu posterior lo the right brachiocepholle ein, laternl to the tnch<a, and Just posterior 10 tbc arch of the azygos vein. The nerve passes posterior to the root of ahe right lung. conlributmg to the pulmonary plexus. The nerve also contributes to the esophageal plexus. The Dl:l'\t en1ers the abdomen behind the esophagus through the esophageal hiatus of the diaphrogn1 ns the posterior vagol ll'lank (rellches the posterior sw:fnce <Jj tile stomach). The agus nerve (CN <XJ: General t'unclions Molor to and scn.~ory from tbe l;uynx Motor to all of the muscles of the pharyn.. eccpt the stylopharyngeus Q"mm CN XI) and all muscles <>fthc soft palate exeept the lens<>r >eli palatini (from maJidibularcl~>lrioJr ojC.V

J?

Communacates lllSie from area around epiglotll> Sensory from e"emal auditory meatus 1\fferen1 from vi.<c:era above lei\ (splenic) colic flexure Parasympa1he11c to the lungs. heart, stomal!h. and myenaerlc plexus

cA..~ATOMIC SCIENCES
EXCEPT one. Which one is the EXCEPTIOIV'?

Nrv)
~
M

r All or the J~ryngeal muscles are innervated by the recurrent laryngeal nerve~
~

Posterior cricoarytenoid Thyroarytenoid Cricothyroid Transverse arytenoid Lateral cricoarytenoid

124
231

Copyrigbt ~ 2009-2010 l>mtf.l ~l;J

c ANATOMIC SCIENCES

The semilunar ganglion is a large, Oattened, sensory ganglion ol' the , lying close to the cavernous sinus in the middle cranial fossa.

Hypoglossal nerve (CN Xll) Facial nerve (CN VII) Oculomotor nerve (CN Ill) Trigeminal nerve (CN V)

m
Copyripa 0 2()09..2010 ~~~ [)cocb:

ri~urh~

rmd

mu~lt.

The \lgu.s nerve posses;es '"" sonsury ganJ!Iia: i. Superior ganglion - lies on nerve within the ju~:war foramen 2. Inferior ganglion - lk> on ncrvcjusl belnw the Jtlllular foramen Bnmchcs that ttrise from the superior ganglion: Meningeal- supplies dura mater Aurfcoin- supphes auricle, oxternal audiiOI') meatus Branches that arise from the lnrerlor ganglion: Pharyngeal fonn pharynReal plexus, suppliel' oil of the mu>cl<.' ut the pharyn. e1eep1 th~ stylopharyngeus muscle (innenntNI ~~ glo<S"f>h<>ry.'<~ge<l n<W) ond all of the muscles of tile soft palntc, csetpt rlte tensor vcU pulultni rilltreure.l b)' nuurrliiJ11111r nmw:. V-J). It joins branches from the glossopharyngeul nerve nnd thesyo npathctk tmnk, to fbrm the pharyngeal pie~ us.
Superior laryngeal - d1\ides: imo;

Interns! 11') ngtal trnvels with superior lor) ngeaJ artrl') and pierces the thyrohyoid ncembrane. SuppJicj mucous membrane> ofthlarynx abo' e tht ,out folds. - Ellernal !at) ngeal - travels with sup<rlor thyroid arkry and upplics the cricothyroid nousde. The right recurrent laryngeal nerve aris.:s front tho vug11s, as the nerve cnls;es the first pan of the subclavian artery. The nerve supplies sll oftbc muscles oftht larynx etce(lt the cricoi.hyroul, whieh Is supplied by the cxccmallaryngeHJ brunch of the superior larynllenl nerve. The nerve nisoupplies th~ mucou:1 membr.uce of the laryn hetow the 'ocl folds. ond the mu' cotos mcmbmne of the upper part of the trachea. The len roc:urrent lryngeal none anses from the \1lgusas the nene cro~ aile an:b of the uona in the th<>rax. The nene supplies abe same mu.cles and mucous onemhnmes B.< abe right rccurrcnt lnryngeol nerve. except on tbe lefl ;ide.

llte tngeminal n~rw. or CN v, IS the m~t HtiUtnlllOUS of an ofthe cr;uual nerves. ran of the first branchial ~rch '"mandibular arch, tbe tngeminal nerve is scnsonal for tho fadol regions and mo101 for tho masticatory mu:.cle>. The trigeminal nerve exit~ tbe infcrol~teral pon; ns u sensory and motot roo1. The laeger sensory rootontcr~ tbe ttlgeminal r~emilumw w Oa.<<erj gungllon in the middle cr-n ial fossu. The three sensory divisions of the nerve arise !rom the ~unglion '"'cl leave the cramnl cavity through foramina in tile spllenoill bone. Tbe $tnaller motor root passes u.~~der the ganglion and jon~ the mandibular division 11.' it exits UtMugh the foramen oale. Tbe llllUidibular division mnervates eaghl muscle>. Remember: The genirulntc ganglion is an Lshapo.'d eollecuou of tillers and senSllry neurons of the facial nerv located on the facial canol of the he.ad. The ganalion rcecives tibcrs fMm ~tc motor, set\Slii'Y und parasynt(lntlaetlc cornpoMnts or the rudal nenc nlld sends fibers lbul will innervate the lacriannl glands, subonnndlhulnr glands, sublingual gland<, tongue (antel'im two-tl tln'/.,), palate, plt~ryu.~. external auditory meatus, stapedius. postenor belly of the dig11.<lnc muscle. stylohyoad muscle. and muscle~ of facial expresston. TI1c greater petrosal nerve (brtmth of th~ jacllll nen"e) ans<s from the gentculal< ganglton. This nerve as the paras) mpathctlr root of the pttrygopalatine ;:augUon. fl nms through tltc fact~! C&lllll and groove on the petrous portion of the tcmpornl bone be<ide the fornmen lncentm through the pterygoid canal to reuch the plorygopalathtc ganglion. lmportunt: This nerve o.~rrics preganglionic t (j'or the /aalm~/ gltlnd> as well plltuympathetic fibers to tbc pterygopalatine googlioa cU glands of the p<rlare utttlllaralrovily). I. Taste fibers to the posttrior ooe-tblrd or the tongue are from the glosso'lot.. pharyngeal nerve. 2. Loss of lacnmation (dry e.~e) ean be dur 10 an injury tu the III'C.1h!r petrosal nerve.

(ANATOMIC

SCIE~CES

Nrv)

Which cranial nerve supplies the derivatives of the second branchial arch?

Glossopharyngeal (CN IX) Trigeminal (CN Jl)

Vagus (CN X)
Facial (CN VJI)

2U Copynabt 0 2009-2010 Dtn1 11.1OK-l:s

(ANATOMIC SCIENCES

Nrv)

,
I

'

A lesion of the facial nerve just after II exitS from stylomastoid foramen would result in:

An ipsilateml (same .ride) loss of taSte to lhe anterior tongue A decrease in saliva production in tbe floor of the mouth A sensory loss to the tongue
An ipsilateral (same side) paralysis of facial muscles

A contralateral (opposile side) paralysis of facial muscles

CownJtn 0 2009-2010 IXrl~l Decl:J

...

141,142

Furia! (C

II)

th :llh:IH.II \rdtl'' .uul lkrn ;~tiu 'tnu.:tun...-.

,.,_
'""""'

Arc.brt

Future Nrnf':l and Muscles

future Skc&etal Strutturrs and ligaments

(mandibu/lliJ

ltota11ew;anJ ~o(tmddk ar. in.:ludO:J ~I.C'rioc bgamen-t Tripn!Aal tWf\ r. mu.scles o( nas:tica:uon. rnytobyoid ud an.tcriOf af me maneu~. spbcthlmsru:fibubr hltOment, tiod pan ions of lhC' srhenofd flol)t bdly ofd1Slll1ric:, u:n:sor lympam. lt"nSOr vtli pai.Aiu~ mu!Kie$
Faci~ ft<T'r~. JQPtdlus rnusck. nmsdts or rxYJ c.~FftSS!OO. """"""lodly o(lbc: dip-

s-od""""
l1ut\l MC:hCIIi
FOUrth d.ltOU$:h

">"*>""' ' - JlyloOd- ollbc: ....,...J bono. tt'$$CI' C'Cic'U ofhyt'ld bofte, ~ J)C'Wtl\ln ofbodyofb:rotd
bone
Gttfil~rrOOnm

Sf.Jpg. llilld portJOn' ornulfeu.:. and toto. or mlddlr- ear,

musck. ~y~d mo.~lt

Gk>~$0rharyntnl nt1'e. C~ylopfw)1Jgt:tl mus.:lt

of hyoid bqc~ loWtl' portiou ofbady Mthe

h)'oidtue

.R<Io-*'

m:urmn ~~ bracb of VIJU IIO'Yt. lC\"UUf palame musc:k:s. phar'yilinl ~ors, intnmte

~... ~-and

l.u}11galll>loJ"

musclC!i or lhe lirynx

Note: The lrigemiual, facial, glossopharyngeal, and vagus ncrv<!s are said tu be branchiomeric (nmrsomltic) in origin because tbey originate from the brunchial arch<>.

The facial nerve is the nerve of facial expr~slon. The facial nerve is a mixed nerve

containing both sensory and motor comj)QnentS. h emerges fiom tbe brain>tem between the pons nod the medulla. and controls the muscles of facial expression, nnd taste to 1he anterior two-thirds or the tongue. The facial nerve's main function is motor control of mOSl of the f>Kral muscles and muscles of the inner car. This nerve also supplies parasympathetic fibers to dte submandibular gland and sublingual glands via the chorda cympunl nerve and the
ln addition, the nerve receives taste sensations
I ada I

submandibular ganglion. and to the lacrimal gland via 1he pterygopuhlline ganglion. from 1he anterior two-thirds of the tongue. The facial nerve has four components with distinct functions:
( uuual

,.,.rH \ 11
Fun<'tlou

CnmJonent Brand,llal mocor

~a/ \-&c.-..rtJ/ ~m:.nl)

Supplies the muscles cf facial expresstOn: posterior hell) of di&BStrit mwcle: saylob)-Otd. and aped~"'

.,..,.,..

\'bcual moiGr

Puasympalbet1t lnnet'\'11ion of the lacnmal, subm:md1buiM, and. su.bhngual

(g""'"'''"cfm/ effr:mrl) a lands:, as ~ell u mucous membmnt1 of 1he nasoph~nx and che hard and ~ft palate

Ce.ntnl

~nsol')

{grlu:hll -tUI'nan~c ajftr-n~t)

<kncral sensation from the skin or1bc concha of the auricle and from a small area b<hlnd !he ear
PnMdes taslc $<115aliOn fiom lbc &Dierior awo-lhirds or lbc IOilgUe; lwd and sofl pala1t'S

Sptdat StDWr)~
(Sf"'rlal a{f.,..nl)

Key point: Branehaal molar fibers conSlllule the largest poruon of Ibe fac1ul nerve. The remaining tluee comj)QnenJS are bound in a distiocl fascial shc:alh lrom the bmnchinl motor fibers. Colle<:t,.ely, these lbree componenls are referred to as the nervus intcrmedjus.

(ANATOMIC SCIENCES

Nrv)

The trapezius and sternocleidomastoid muscles receive motor innervation from the:

Glossopbaryngeal nerve (CN IX)

Vagus nerve (CN X)

Accessory nerve (CN XI)

Hypoglossal nerve (CN Xll)

143144
235
Cop)Tight 40 20092010 Dtn~l Oc<:h

GNATOMIC SCIENCES

Misc.)

~ All or the following organs are intraperitoneal (peritonealiud organs having a 'meselllery) EXCEPT one. Which one is the EXCEPTION/ ~

Stomach

Jejunum
lleum
Transverse colon Kidneys

Liver
Gallbladder

145

Ncn 't
O"""plwyog<ol /CV/Xi

Sltt or E1:i1 from Skull

JllJt.~lu foramen

CompCJntmt
Rr..ttdal m<ltDr
r~ tlcrrT.II/ (/fUPitll

f"nncrlon
S~ii~Ph the li)>l""'l"r)'ltJIC\11 lfllllfdt'

c.,.,..

\lKtnl_,fiCCnl dk.nul.t

,....,... . llllllm---o(I

DKkD!Jtnk of-.c~llr'Yf!1'.. aid -~oftM Chen ... aflrlbncl

SJDOCIIII

V\M'tral M"n$01')'
fitfll~m( vlscrful 11ff~rlll

Carn.u ,;~1

Sle'll.o.'Y lnfam\adon rom

d~ csrod>l S.n.d 11rt.l Mll1

CttlfNII ttMI')'
(~lfC"''dl $()111NllJ~-olflfr*"ll

"""".....,. ..........
plw)m

Pnw~~t ~iol' llnfomwloa trufttktkirto(lhfc-.awnRIOI!r.ler.lal .r.ccormt"'-..-..:~

__ ...~-

_..

Sprtbl ttftSOI)

ll"<ib' <!tli',..,ri
4CSKII)'
A~auJar r~tn

Provides w:c 5ro54bOfl fWinl JStt'rior \li!O--th!RI oflhc tOng~~r

lnner.-alC$ mute:kl of1bo llll')'tiX at~d

tCNXJJ

81'111dtbll nt61 _.f'-4':,1LIIhll ...,,

~~~"" H~eroi ~f,

lf)1!tlgtOSSII

fi.YJHlt~l WJal

lnct.bl .,.,. t91DM

...... wck-"

l!IICt't ..ccs tbt lni'U* -

.........cih

lf't'l"f.J. dc.VJWl ,ff~

(~t'fll-"m1 jl).ll!t.!tJC' ~jll'f'ti!IJ

S.cuGtk motur

!CNXlQ

lnncr.--.tes .t.ll oru.e llll!ln.u: and tnOSl or the t:\ttilbit mu.'<l< c.r the \Ofllj;\l< ~t11tO,'om.t. 11J'II1g/~ 'S, Qttt/ >\J~t.a.m.u"""~t'/nl

Vttail.docoet.'ICNI!IIJ)

1111~ kOWIICi tnQSid

l;;:pediii.M'bOf)

fiJ"' -4/ ,zfftrnUJ

Tolhrll!"pD l1fCoru l.w ketlroa To die scmirirt'Ular c:uult f\>f blanoe

Abdominal ca"il): the major part of the abdom:r.opeh1< <anry. bounded by the lllonococ doaphragm and the pelvic: l:nJi:,_ The abdominal cavity meludes both tht> pcritont:~l t':&\11y and the rtrropcritoneal space. Peritonul cnlty: that part ofllu; ;t\xtomen :;urroundcd by peritoneum. nus IS 11 potential space be

lwccn the paricml and viscc:raJ layers of peritoneum

Rciruperhonul space: the area bchmd (f>b$Jbfot roJ the peritoneum. Rctro~ruoocal organs AI'\! located in this ~pace
Abdominal coottiUJ:

Peritoneum: a chin. serous membrane hning &he wall\ ~r the abdominal and pel\ic cavities and tlothing the abdommal and pelvic v1sccra. The peritoneum can be regarded a.~o 11"'balloon.. inro which o.rgans are pressed into from the outl!ldc. The peritoneum has ''isceral and p,.rletal layers,just like
the pleurul c;~vity P:nielal ptrhontun}: Jines the walls of the abdommJ.Iand pel\ic e3vides Visceral ptrltoneum: CO\'ers the orpns .--H Tbc potentiAl space between lhe rwo layers.. which is m cfTect the- mside space of the balloon. b called the prrJtonut ta\il).

The perhone.l ca\hy can be divided into l\\O pans: Greater nc: is llle main component of che peritoneal cavity and eXtl-ndS from the diaphr-.tgm down to the pelvi, Lesser sac: I.S smaller and lies bch1nd the sromath The lVo'O $1CS 11rc in free communkation ~ith one ftnocber through :m oval "tndow c-.allcd tht' optnin.g of lht 16str .sac, or the tpiplok for3mtn The lertns intraptrhonHI and rtlroperhoneal are U$Cd to dtscnbe the relatlOm.hlp o(\"llliOU$ organs to tbe ptritonea.l ccwenng. An ocpn is saJd to be lntrap-er-itontal when it is abn<htiOially covered w1th \'1$CCra) petltOncum, The rollowing Of'8:i.ll1.; O.re Considered to be lntraperitontal: the SI011'U1Ch, jejunum. tlcum. !ipJocn. tmnwerse colon. liver. 1tnd gnllbladder. ltetroptrlfcmel\1organs arc chose 1 hatlie behind the peritoncurn ond are only partially covc:red witb visceral periloneutn. The followmg organs or :;true~ rurcs are consideced to be rttroperhont t1; the aorta, inferior vena c-ava. kidneys, adrenal ghmds. pan~ CTeas. urcten., and the 154:ending and desccnchng pans of lhc. colon.. 'lott: \ftst-nttr1u are two-layered fold\ or puitoncum conneenng pans of the anh:~uncs 10 the posterior Abdominal wall These folds pcnnt blood.l)mpb. \esscb. lnd nerves to reach !.he viscera.

(ANATOMIC SCIENCES

Mise)

A 47-ycar-old patient with pancreatic cancer Is put on multiple chemotherapeutic drugs. Unfortunately, us a side effect of the drugs, his kidneys start shutting down, and this leads to hypervolemia, or excess extracellular fluid. Extracellular fluid:

Is composed mainly of transcellular fluids Makes up the major proportion of total body water Has a higher sodium/potassium ratio than intracellular Ouid Contains less glucose than intracellular Ouid

237 Copyn!Vtt Cl 2(1(2010 Dtntllkd:s

(ANATOMIC SCIENCES

Mise)

A 15-yeal'-old patient comes into the emergency room with diffuse

abdominal pain, loss of appetite, and a fever. On palpation of the lower right nbdomen he feels pain, and even greater rebound pain when the pressure is released. The diagnosis is appendicitis. Which of the nine regions of the abdomen contains tbe appendix?

Umbilical Epigastric HypOgastric Lumbar Hypochondriac

iliac

146

11~1"1 :t

hi!!hlr ~odium 1pnt:l"'\iUIII ratio than inlr:trdlular fluid

/42. K' 4) ,.,, lntrocellular fluid (Na' 10. K 140) The body's water is effectively compa1tmentalized into several major divisions.

*** ExtraceUular fluid (Na'.

Intracellular fluid (/CF) comprises two-tblrdsofthe body's water - If your body has 60% water, lCF is about 40% of your weight. The ICF is primarily a solution of potaSsium and organic anions. proteins, etc.
(Cellular Soup!)

The cell membranes and cellular metabolism control the constituents of this ICF. . TCF is not homogeneous in the body. ICF represent.~ a conglomeration of fluids from ulllhc differeot cells. Extracellular nuid (ECF) is the remaining on(\..thlrd of the body's water ECF is about 20% of your weight. The ECF is primarily a NaCI and NaHCOJ solution. -The ECF is further 'ubdivided into three s ubcomparmtents: Interstitial Fluid (ISF) surrounds lhe cells. but does not ctreulatc It comprises about lhree-quaners of the ECF Plasma circulates as the extracellular component of blood. It makes up about one-quaner of the ECF 'l'ronscellular nuld is a set of fluids tbat are ouiside of the nonnnl companmcntS. These l-2 liters of fluid make up the CSF, digestive juices. mucus, etc. Note: Theepidemlis of the skin obtains nourishment by diffusion ofti:.suc Ouid from capillary beds located in the dermts. This tissue Oujd (a/so called inrerstitiofj/utd) contains a small percentage of plasma proteins of low molecular weight thai pass through the cap illnry walls as a consequence of the bydrostauc pressure of the blood. This fluid bathes tbc cells.

llhu;

The abdomen

IS dt\1ded Into nine regtons b) four Imaginary plancs " like a tl<-tactoe bnard". I. Umbilical .. around the umbilicus: mcludes ponions of the smnll and large intestines, inferior vena cava. and abdominal aona.

2. Rlght and left lumbar -- lateml to umbilical region; contains portions of the small and large intestines nod ponions of the right and left kidneys. 3. Eplgam1c - immediately below the diaphragm and supenor to lhe wnbilicnl region; contains ponions of the pancreas aud most of the stomach and the liver ' inferior ''ena cava. abdominal aona, and duodenum. 4. Right and left hypoehondl'iac -- lateral to Ihe epigastric region. Contains ponions of the diaphragm, kidneys, and stomach, the spleen. and pan of the pancreas.
5. B) pogastric (puboc} - mfenor to the umbilical region; contaans the bladder, ureteJS, and portions of the stgmoid colon and small intestine.

6 Rl~hl and leO lilac (ingllinol) .. lateral to the hypogastric region; contains ponions of the small and large o nlestincs.

(ANATOMIC SCIENCES

Mise)

r In an elderly tulult, the thymus is mostly atro1>hied, and the remains lie In the~
superior mediastinum. In a pubescent boy, the thymus is at its largest, with an average mass of3S grams. When it is Ibis size, the thymus will be present in whitb other division or the mediastinum?

Anterior mediastinum Middle mediastinum

Posterior mediastinum

23g
('q!)'n&ln 0 20091010 Dtn,al Oteks

(ANATOMIC SCIENCES

Mise)

rA college professor has taken a week off with a bad upper respiratory Infection ~
that will not resolve. At the end of the week, he has an earache iu his left ear, and his bearin~: Is slightly muffied. How would an infection spread from the nasopharynx to the middle ear?

Vestibular apparatus Auditory tube Extcmal acoustic (auditory) meatus Acoustic apparatus

148

\nft'f iur IUl'clia,tlnnm

The thoracic cavity is surrounded by the ribs aod cbe't muscles. lt"s subdiided into the plewul cavities. ench of whieb contain.' a lung, and the mediasrinum. whteb oonwins the hc.-ut, large vessels oflhe heart. trachea, esophagus, thymus. lymph nodes. and other blood vessels and nerves. fhe medlosrinnm is further divided mto four areas. Lfted below are some oflhe major struclures contmncd within the differeot regions. ({/ n nnruith111tlre ,\tOpe nfthe!!e car-ds Ia li<l o/1 o[tlil'l<Jnlorls of the nr<'drortirra). 'lote: Some stnrctltres overlaJ!rnto differ<'llt areas. Superior medlaslinum -arch or the ortn, left sud nght subcl~vian artcrle> snd veins, rigb! nnd left common carotid arterie.<. right and Iell internal jugular vein, l'igbt and left brachiocephalic veins, bmthioocphalic artery. upper hal{ of the superior vena ca'a. right and left pnmory bronchu.~. trachea, esopbagu.<, thoracic duet. thymu&, the phremc nerves. vagus nerves, cardiac plcxu$ of nerves. and left recurreut laryngeal nerve Inferior mediastinum - reg ron directly below the superior oncdiostinum This is 'ubdtvrded into three regions: anterior, truddle. and posterior 1. Anterior mediastinum - lymph undes, br:mth~s of intemal tbomcic artery; in cbildren, coot~itts the inferior part of the thymus gland. 1. Middle mediastinum pericimliwn, heart and atljacent great w:;sel5. the phrenic nchcs, and the main bronchi. 3. Posterior mediastinum -thoracic n(lfUI. thoracic duct. esopha~o'IJS. rracbca, right and left main hroncbus, bracbioccphalic an~ry. left common carotid Hrtery, left ~lib clavian artery, arch of aor1n, esophageal rlexus (bmrrcltes oj vagts und sp/am-lmfc 11erve.t), sympQihetic chatn ganglia. azygo and bemrrv.ygos ~cins. and many lymph

nodes.

The auditor)' tube cquulizcs arr wcssurc un either side ot the tympanic membrane. The middle enr commumcutcs rostel'lurly with the mastoid "ir cell; und the nmstold nnuum thr~ugl the adhus ad antrum.
Tbe en con>bts of: El.lernal ear - consistS
~r th~ auricle (I'"'"") and the external uditory Thrs pan l'~"Cc..iVcs sound waves. The ltU ricJe e:onsbts C.flrlllft~lt10Uc; tl:ntihcllx. C I'UX of the hell>,., lobule.,. tro~u.s. and condua.. The exttrii:AI ltUdUory unal i~ a narrow chamber n,eu..,unng_

or

=I.

about I inch long Thi> c~~nol connectlo the uricle with the 1ymponrc ntembnonc m the middle eru-.
Middle cor <atiry)- an o&rlillcd cavity withm the pctrous nrt of the temporal bone. Tho middle ear '"'ontains lhrec small hones or us:slcles, the mallus (hammer)~ ).tlap(ls ('rimrp), and lr1tu (om//) that transmit sound. Lined with mucosa, the muldle ear i> bound ed latcrnll) by the tymponte membr.\11<: and mediolly by the &)val and round windo"; Also contains rn o IDU<<Ies -the supcdiuJ must! e. which rs the <mallest of the sktletnl muscles n U1e body, und the ten.<or t) rnpnni muscle. T11e tyrnpnlc membrane, con;ishnlJ of lnycrs nf skrn. fibrous tissue, aud OlUCO\IS mcmbusnc, tran~nuts 'lound vibnal1011~ to !he (JHcmal c:nr. Inner ear - .:onsistll urctoscd. tluid-fillcd Sp;IQeil within the tcrnponrl booc. The Inner car i> a bony lib) rlnth, wb1ch mcluclcs lhnlc connected ruct~ - the >tilibul, the ~emi c:lrc.ular canals, and the cochlea. These .structures t\re lin(d witlt a ~rous mcmhrnnc that fl>rm.< tl1e m~rnbranou tubynnth. A fluid en lied perilymph fills ihc ~p11c< between tho bony labyrmth and the membranous lubyrlnth. Note: Within the cochlc lies the co<: blear duo~ a triangular, mernbronollS ~\rUctll!C howuog the organ of Carli. The receptor organ lor hCl!P injl. the organ of Coni tr~lbmrt$ sound 10 the cochlear brunch of the OCOilstic (CV 1'1/J) nerve.

(fl""'"'";"

Cli niul con1lderotiooo: Middle car

nd the !Uiiopharyru<.

infection~ (olills m~dlql ~....,quite

prevalent 3Jid may

become cxtcnstvc due to t.:~o.mncctions between I he tympanic ClWity and bvth the ma.'ttokllur cell"

( ANATOMIC SCIENCES

Mise)

\.

Which structure divides the anterior (vemral) body cavity into an up11cr thoracic ca\1ty and a lower abdominopelvic cavity?

Liver
Diaphragm Stomnch Lungs

149
C<>pyti&ht

c 20091010 lkntal Db

GNATOMIC SCIENCES

Rprs)

,
A young woman with no secondary sexual cha racteristics, short stature, and webbed neck walks into the physician's office. Her medical history indicates a karyotype labeled 4S,X. This woman, diagnosed with Turner's syndrome, is unable to conceive children, one reason potentially being that the sire of oogenesis is non-functional. What is tbe site of oogenesis in a healthy female?

Ovary Ovum Oocyte Oviduct

Ovarian

lacun~
:U2 CoyricJu 0 20091010 Dmul D<d.J

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Hiaplu :tl!lll

Body cavitie< are spacc8 within the body thot contaiu the hllcmnl organs. The dorsal (pf>.~fe rior) 1111d ventul (anJerior) caviuos are the two major closed cavities. Donal ra,ity is subdl\ided into t>u '--aviti~ I. Cranial cil)' (skull} - et1<<1SeS the bram 2. Verlebrol covity (also ~oiled rhcl !>mal or \'Crlehro/ <aua/) --is formed by portions of tho bon<-. (lerrei>n,,J that form the spine. It encle>scs the >1Jinal co1-d. These cwu c:willt$ commurucare 1hrough the foramen magnum. These c:a~ides nre lined by meni11gcs. The fluid in tllese C1>1lits is called cerebroplnal nuid. Ventral~' it)1: is !liUbdivided imo two cavities l. The thoTatlc cavity. is surrounded by the ribs and cheS1 muscles. The thoracic cnvtl)' i~ subdiv1ded into: Pleural uvlt.les (light and ltj/) -each of which contain.~ a lunl! and tbe m~dlast lnum, \lohich conwins the hean. large,.._...,,, of the heat'l. trachea. csophagUil. thymus, lymph nodes. &nd other blood vessel> and nerve<. Remember: The mediastinum ,. funbc-r divUied mto four areas: the tn>ddle, tbllllnt erior, posterior. and M.lpl"rior arens . Pericardia! CliVI!)' - between the VISCtrnlund parietal layer!< or the srou rerlcnrdium. contain< u thin film of fluid 2. Abdominopelvk nlty, wtuch ll3s tWQ regions Abdominal rail)' -- contatn< the stomach. inteS1mes, spl<etl. ltv<..: Wid olbcr tnt emal organs Pelvic ta,iry .... inferior to the-abdominal cavi1y. contains bladdt:r. )Qme reproduct ive structures (see he/ow), and the rectum. In the male - the paired dt~<:tus deferens and semU131 vesicle ami the unl'alt<d prostate. In lbe reml - tlle pmred ovaries and the unp:nn:d utents. ***The two cavities (rhoruclc aod ol><lul/ll/lopeM~) corrununtcate lhtou~h an operung in the diapbragm called the ltluhJS.

fh a n

Jk fjurt...,.. eniptital O<gllns, snuatcd LillSC to the sid< wlls of tho: pelVIS, and an- supponed by the brua.d llg11ment of thr ull!r'Us:. All the- OVJI)I\ hii,'Od llllll lymph:uic ves~ct~. ont.l ner\'elO enter lit 1he hilum. Oe11c11th its surface ef')llhclium 1 s -u. ti)I''U.~ that encloses the m~dulla 111 lUI em. The bulk or tht ov:try I!J the supponin :nrucmre called the nTonu.. Nutt: The m01ln fuucuon of lht O\li.\n(.'' u 10 prodUtt mtturr o<va. The corto tOII.tains O't a Jl \hrfcmn stage"> of ck"Vc1c>pmenL The ova b<gin as prtmordW (I'K',1n, f\U"-

rounded by a layer offlatccU' called grauuiMa reU~ At puberty. the gr11nulo.. C<il> begm to muluply
and fom11hc multilayered the['a inrern th111 ~ecn:~c.s ~strogen~: chc 1\Urfl\tindln Slf'Otnal edt~ nmn the

thec:-a exttrnM. A spJit appcan: in the 1h~'C.'t ioltttKt ttnd expands: ID form a nuid-fillc.-d l'ilvity th:u plhhts the. oocyte ro OIIC' side. the rolhclc i5 now. c.-..fian roiUde. 0\ lllation takc:'ll place Jb the m""dte ofn.tb cncnsm.J:ll t )'clt'- a Or.wfia.n rollicJe Ol('fllr(S to ~lease h.s U\!Utn, which cmcrs the urtrlnt lube. ne empty fllllicle lillt wtlh hliKKI and f\'8,rcs.~~'S an10 a cnrpus lut'eum. If the ovum i!) frrttll:zt~tJ, the corpu!) IUtt'll.lm wlll pt.-rsl~t 11nd co1uinue st.'trcllng ,,rogt!~tertwe tO maiultlln f'reguancy. Jf not. th.: corpilS lutcum <lhnnkll intO 1.1 mAll ma.t;.... of coll01~t:nous tissue - tbt cor
pus 11hlcan~:.

s .. ,. Lhat

I 0411:ottia (&'"R'Jt~r oogoniuntl an: " a n celb that g,,.t n~c to th~ lil'etime ~upply ofuocyce1 lltt: present lrt th~ remale's UVIU'ie!i b)' the rime !t-he I~ bom. Notr~ The UN:)'ICS ~in to d.:gcncnue. and tht proec:ss conhnue' throvghout aduh life. 1'be~c. an: calh:d "tn:tic folll('le~. 2. rrlmfJtdillotlleleJ cumain ill,& primary oocyl~ 111 1he ~e1(ually mature. uv11ry11rc stimul11tcd 10 devetor by s~c:rct1on of FSH fmrn the antmor lube or the pttuitary. Pnmary roll ide" (1ft fh~

)11,, ~Miotic 4/J~Jsum' ~come "-tcondary follic:t.:) with the (otnL:Ji10t'l or 1he antrum lcovw' Fully n~arure Graafian folhcles tonQinlng >ond..r) OOC)'1<S (1)1 '~' sYind 11trioll< ih11>i1>11l rtlea~ the egg nno 1he abdoounal ca\ II)' un4.trthc mOoc:ncc ofW to~ sv.qn inlu the ns1ium of the falloptM 1'\abll (t4fC.I'ine ruhc, r)l.'idurl) to be ttn1 li?cd and ~ubscqucntly in1planted in tht morus ordi,.,anlcd 1rnoC ICrtiUzO<I.
3. Dllnng m.liturah''" of the ega. fQur duus,tner <ltll!. Grt produced. unc of' \\hich Is the 1af};c. r~rciliublt uvu m. \\htle ~ otbns life ~It rudimentary cells nlleJ pot:~r bodlts Pr
potll<)1es.

(ANATOMIC SCIENCES

Rprs)
~

Consider the following three tubes [1. epit/11/ymis 1. oviduct 3. ejaculatory ductj.
When a man and a woman are participating in sexuaJ intercourse,

name the path the sperm travels upon ejaculation .

1,3,2
3,1,2

2.1,3

2,3, I

152 153
2A3
C'op)TislJt C> 20092010 Dcontal Dkll

GNATOMIC SCIENCES

Rpr s)

Cooper 's ligaments - fibrous bands attached to the musculature- support:

Each testis Each ovary Each body of the epididymis Each breast

CopynJbl Cll<M-2010 OtoW ()e.cb

...

Spum i> formed in lhe l fi!OS and !hen p.ICS along 1he ductus d~ferus, which JUIDS chc d ur l oft be seminal ' eslcleto form the ejacula wry dueL During ej~<tulahou, the S])l'l11\ rom bines with sern:oons from ll1il prostate gland and stmlnol \'esicles ro fonn I he seminal Ould. The testes are IWO oval organs conl~ined in <he scrolum; <he rigb1 one is u.uully h<gher !han the left by oeurly" half inch. The lcsris is oap1><d by 1 he epididymis. Thtt el)ldldymls ls n tortuoll.5, C.shnJX:d, cord-like lull<! aboul 20 feel long localcd in tho !iCI'O IUJll. Tbe tubo emerges from lhe IRiltls lht ductus (vas) defer ens. The ductus defcreos and ils surroundina vessels and nerves form !he spermatic curd, which ruus upward tn the levl of ll1e pubic tubercle of the pUbtc bone. JX,;scs through lhe in~tulnol canal, nnd tb<:n turns sruarply ro en<er

the pelvic C8VIIy. The dUCTliS deftn:ns then heado IO,.ard !he back of the pi'OSI81C ,land. where the ducrus deferens e'pands into llllampulla ond joins the ducr oftbe scn11nal 'e<icle to form chc ejatularory durt. The ejarulatory ducr pcne1rates lhe prosllltc gland 10 upcn inro the prostatic urrrhra. Afier leaving !he prostaTe ~tlnnd, 1he urethra runs lhroul:}llhe muscles of the urogcnnal diaphragm, and en1ers the pcnio. I. fhc ejaculatory duct is one of the 1wo pasSllgeways tllat carry semen from the Nn<;o proslutc gland 1 0 the nre<hrn. The uvlducl ((flllopicm mbe) is one of n pair of ducts opcnin nl one end into the menlb und 111 Ihe other end into the perironenl cavity. over ll1c ovary. Each rube serves us n pt,.suge throug~ which an ovum i> carried w tht Ultrus and through which spermatozoa move out toward the ovary. 2. Stcre~llia are long~ nonmoule nlttO\'tlli that cover the rree surfaces of some of lht p:.l'Udcb'II'Dhficd rolumnsr epithchurn !hal lmes lhc in.<ide of lhc epidJdymis. Ste!'e()l.~li ''''"'" to fac:ililate lhe I>:ISUIIt uf nutnents from che cp11hclium 10 The sperm b) ln..Teasing the epithelium'~ ' '"f""e are..'1/ote: Srcr~'<JC1ha iltC aL.o present In the durms (v</ deferens. wh1th ~~ ~l>o lined wilh pscudostrduficd columnar ephhellutn.

The mammor)' glands (brensls) an: lncated on ei~1er side of the :HItenor chesl wall over tbe greater pecrorul and the wrlcnor srnrus muscJeq. Th!Se glands are specialized acces.<ory glands 1!1&1 >ecrele miU.. They are formed frQm many smsU tubule' grouped uno lobule. Severnllobul~~ coi\St\ttne a lobe. each of which bas liD lnlrrlobuler duct. Many ofrltesc duel< c:cmbfue tO fann a lctlferous duct, which lennfnat"'l atlhe mpple. The nipple IS prescn1 Qll euch brast and J'rescms as a centraUy located pltnemcd area of erectile tissue ringed hy au aruolu thnt 's darker 1hnn lbe adjiltelllli;,~uc. The arterial supply of the breast~~ fr01 11 perromllng branches of the lnternul thoracic artery and the lntorcostnl arteries. The nxillary artery nlso suppli"'l the gland vtn tiS lat cr~l thvrucic oud thorMcoacromial br~nchcs. Several c~Ail\5 of lymph uodt>s drnio ditTcrem area.' of the b~st aod 3Jttlla. n1e nodo chains and I he areas they drain are as foUows: pe.::toral mo,t of the bren.t and nntcrior cbe.r brachutl- mos1 of the ann subscaput r- poslcrior 'hest wall and pan of lho ann minaxiUary- pecton~l, brachial and subscopulnr nodes iuteynalmnmmnry node'< m:unmary lnbes I. Breast <~lnccr ca<Les dimpling of the ove!lying skin and uippl~ reunctlon. Not.. 2. fhe suspensory lfgamenls (Coopers 1/f!,umenl.t) are strung. librous processes that run from lhc dennis of Lbe sk<n to the d<ep l~yer of superficial faociu thru11gh the breas1. 3. Important: Mammary. sweat,laTimnl. and salivary glands ron~,in a specal type of smoo1h muscle ccll called myorpltheliaJ cells (star-shaped). Tbese cells hove processes thar >piral urowtd ~e of the secretol) cells of theie glnnds. llle conlra<'lion of the!.c flX~!t:S force& the <eerelion of lhc glands toward !he duel~.

(ANATOMIC SCIENCES

Rpss)

\..

The Inguinal canal is an oblique passage through tbe lower part or the anterior abdominal wall and Is present in:

Males only

Females only

Both sexes

145
Copyright 0 2()09.2010 Dmtti !Xc\:f

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,
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ANATOMIC SCIENCES

Rpr s)
~

The most common type of urinary tract infection (UTI) Is an infection of the urinary bladder called cystitis. Women more commonly get UTls because what passageway between the urinary bladder a nd outside of the body is shorter in females than In males?

Ureter

Urethra

Ductus deferens Theca internn

154J 55
1<14
Copyni#Jt

c 1()09.2010 Oml&llkd:i

llulh "il'\C\

Tbc Inguinal ~on1l allows stnJcturesofthe spermatic cord 10 P"""' to tutti from tbe letis to tltc abdomell in tbe male. In the female, the sm:tlltr canal penni IS Ihe passage of the round ligament of the uterus from the uterus 10 lhc lab1um maj us. ;-lote: In bout S~"l<<S, the canal also tran$mits the Ilioinguinal nerve. The pcrmulic cord L~ a collection of stnJciUrC.< that 1mverse tl1c ingu1nal canal and Jl'lSS to and from tltl.' testis The spcnnaric cord is covored Wllb three cunccnlric layen. of fasCia derived ftom the layers of the antenor nbdominal wall, and begi~ at the de~p In guinal ring latcrnllo the mferior cpigas1ric anery <tutl end~ nt the testis. Struclun:s oftbe spermat)c cord: Ductus (WJS) d~fcren> .. 11 is a cordlik~ 5\r\lctUTC. II conve) S sperm lrom the epididymis 10 the ejaculatory duct, whocb is a pasl;ageway fanned by the union of lite defereut duct (ms d~{i!rf!ll>') amlthc e>crelor)' duct of the seminal \'csiclc. Tbc eJacu latory duct opens into 1he prosiJitlc urethra. Tes tlculor ortfry' brJJJch of !he abdominal aona: supplies mamly the tes1is and lbe epididymos Tesliculur veins an xlensive venous plexus. the pampinlform plexus, leaws the postcl'ior border of 1be 1es1i~. As the plexus nscends. it becomes reduced in size into n single testiculnr vein. This runs up on1l1e JXI'Itdrior abdominal wall und drains mlo the lei\ renal wm on the lei\ sodc. and inlo 1he inferior vena cava on the right stde. Testicular lt mph vessels - ascend lhrougb the onguinal cMnal and pass up over the posterior abdominal wall 10 reach the lumbnr lymph nodes on lht fdc of lhc aona at the level ur tlle firstlumbnr venebr!L Autonomic nerves ~ympa1hetic fibers run with the 1esticular artery &om the renal or aortic sympalhetic ple.,u>es. Afferent o;ensory nerves accompany 1he effen:nl sympalhetic fibers.

l nthra
TI1< 11re1bra is olio be that convey~ urine from lhe unnary hh\Utlcr 10 the oul<idt Oflhe body.lho wall

oJ' th.; u.rcthm 1:!. It ned wilh mlleous mcmbraue~ 1 "'d ~ontain ;~ 1' rei:Ui\lely dm:llaycr uf amnmh m1,1..r clc liss:ue. It 6150 CQntain!; numcrou' mucous plitnds, called .. urtthnal gltruh.- that .:-tttt'tc mo~u.~
ioiO the \lrtlhnl c:anal

subjects the ft:male to more ftequtf\1bladder mr~ctioos. 13ecuuse 1he male mcl.hm l m .. ~;ls 10 the penis, tbe rn;itc llrethm 15 loup,er tbun the tcmulo urt:(hru. This r..:qutn:K an Jl\\latlini orguni:un to tr.tvel u ~l'l:3ter di!rlance to g;aifl ilCCCS$ 1 0 the urio::uy hhtd<kr t:lim1n.al~Jli urine: by the rnalc tt:ncb 10 n\~h the umhra before n uwadill!! O<g.1DI51ll ~ rco<h lhc urinary hi odder I. The ftmale u~hra open inlo the "''''bule between the clil<lns and the vagi011. WMtt" 2. lo l1\c male, th~: melltra B (SI.) convey~ M:mctn fi'om the rt'pfrn.luch\'e orgun.s during c:Jn~ula tioo. 111c male utt!.thnt i:~ dlvid<:d iuto tJl 'tt parts: - pronatlc: il is-lhc widt):t ~md m~t ,l!l:atable pnnion or~ urtthru . mtrobraoo-us: "I he. ibo{k'SI, and lea.,u diltuabk:: fi0'\100 oru~ uretht-.t P<nllt: il i> the lon!l<$1 and 1\Atmwtl!l pmtion; bulboumhrnl glolil> open omo 11 3, The un.-1cr i!'l a pcured l'll'\St\ge'f\oy lhat t.r:~n.:~p<trts the urine fuun the 1\1 dney to the unnary

The urc1hra beong shorter i11tht rrmale (pbout f

em fo11g}

ll1011 it is in dt< tns1e (obuut :n '"' /0/Jg)

bladder forconcentration und storsge until the Ul'int! is vnided.

lmportanr: The IICc:.eS.~)ry gland-4. which produce most Of the scmc:n, include th-e: Th.: tmtoal >tsi<les an: pr.tt't"d""" a1 <be: base of the bladd<r. Til< bulb<>ufflbNI1 glands (C"ot'P"' :r glori!IJ/. al<o p3orcd. ate located tnfcrior to tlte prot41e Kland. The prosh.Cc gland 1s l'hllfled like iln invened pyrunud and Ues undt.:r the hludder, with the poin11ng downword llmcrgtnE lhlm the neck of the bladder. the urdh!U """' <noc.Uy thro<.8)t lbe prosllt<: glal14. and <xtb just on !font of the aP< 11>< pro>lltc gl;nd

pc

I>RS lowO major groups of gltn<ls:

periur~tflrttl gJands: t~rc in the ccmrol 1ont sutrOund i n~ the urethra
rnaf11 ghwdJ: -ate In the peripheral ~oo~

All th~ alnods Optl\ into lht p~ll!lhC urelhra -and se<:n:te lbc-entymc: atld phospht l. alie._ fib-nooly,ln, lnd .orne proteins. PI"'SQilC ...~on makes u.. 3botJ,t 15~"- ur ~C'D.

cA.t~ATOMIC SCIENCES

Rprs)

( '

Tuballl~atlon

is the permanent sterilization of women in which this structure, where fertilization occurs, is severed and scaled.

Ovaries
Uterine tubes Uterus

Labia majorn

156,157
247 Copynjbt Cl 2012010 Dental Db

GNATOMIC SCIENCES

Rprs)

,
A 17-year-old male patient who has no history of vaccinations comes into the physician's office with bilateral swelling of the parotid glands, fever, headache, and orchitis. Orchitis is the ;1alnful swelling of what organ, which produces male gametes? Prostate gland Ductus deferens
Testes

Scrotum

Penis

152153

( Jrc ~ n' uf lht 1-tnJ:Jk Uqu udut "' t'

""'',It_ m

Organ (s)
Ovaries
P'f'odu~ o"a

Funct1on
{ft:nulle gum cells) and female JCJC h()t'n\()1\es (c:Jtrogt'IIS (md progc:Jtft'Otle)
Rcteivc the ovum from the <WMY Md provide silt wheft fertil~ion of the O\'U.IU t:an take p~cc. The tubes sme as a conduit alona whieh the lpCTlll8toz:oo travel co reach the O\-,nl
Sc~

Uterine tubes {follopitm tJtlw-~)

v...,.
labia majora

U!CruS

a.s a site for lhe rcccption. retention, tnd nutrhion of the fertilized o...-um

NOt Oftl)' is tbc- female~ canal buc allo tcn"tS as the or:ererory dues rot the mcftSil'\Jal now and forms pll1 of the birth c::anal form tnU'IJftS ofpudcod:aJ dcfl cnclote lnCI pcokd ocbu cxtemalocpodw:b"c orpns

Labuammano
Cbtoru

form mare,inJ ohescJ'buk: pro4et1 opcnaap of , ..,Jil'll .S Ul'dtn

Provit: feding of pleas\.lrt: cfuriQa JtunuJadcn Secrete lubricacing fluid into the vesubulc and VlgJnaJ opening during coirus Product flnd secrete milk for nourlllhmC'I\1 of an infMI

Vt$1jbu)ar vt.and&
MammaT)' glM<b

ll'\h''

(Jr :,.:.n' ofl hl' \bit' l.f:qnutltufl\ t

'''f('nl

Orgn (f)
T es1<0(1)

f uactioa

Procktce Spc:ml and 1$0Sltrone (malr .fe:t h<>rm0111:)

l!nc loses and protU testes

S<ro<wn
Epididymis (})
~atc &l.and

J)ortion of the seminal duet in whieh sperm maturt aod are stored

Ouetu.\ (wzs) dcrmn, (1) Transport sperm d~ng ~IL(ulation upwn.rd inside the spcmuuic cord to the urethfll

Produces semen, the fluid that ciLI"fics spcnn; Lhis fluid helps protccc spcnn rrom the vagiMs acidity during cjac:ulatKln

Serrunal "es5cln

n pGir)

Stcrtte me majority o(lhc flwd (alkaUn~ Gild ncA lnfiwtos~J ID sc:mrn

Bull>o=thralalando

Scemt Ouid thai lubricates ld'Cetn and md or pct~i$

Recei\.-e spenn and addlb\U to poduce sc-miNI Ovid: run tbn;K1,gb !he proscc and open 11'110 tbt umbra
Mtle saua.l organ that pbSCI bolh urine and &penn

I Ejacnbmry docu {1J

Pcms

GI'IATOMIC SCIENCES

Rprs)

( \.

A new alien species is discovered that reproduces in a unique manner without gonads. This would mean that the species did not have:

The uterus in females and the epididymis in males The vagina in females and the ductus deferens in males The ovaries in females and the testes in males The uterine tubes in females and the ejaculatory duelS in males

248

Copyngtll ~ 10092010 1Xn1 allkcts

(ANATOMIC SCIENCES

Pdi / G)

Surrounding the root of each tooth is a specialized epithelium known as:

Connective tissue attachment

Periodontal ligament auachment Junctional epithelium Nasmyth"s membrane

250

CopyrialJ c 20(19..2010 Om..l ()c(!b

The 1l\ nies arc elhptlcal Qrgons. silllllted clo~- to the side walls of lhe pelvis, and arc supponed by the hroad lig~ment or the <II eros. All ofth~ ovary's blood and lymphatic vessels. and nerves ontcr ut the hilnm. Beneath its surface epithelium is a cortex thnt enclose. the medulhtat its cotc. Tite bulk of the ovary is the supponmg Sll\ICI\Ire called the strotn3. Not~: The main fimction of th~ ovaries tS to produce mature ova. The ovatiC$ also prcxltJce steroid honnones estrogen ami progesterone. Estrogen -promote the development ond maimeotu1ce of female o:.xual chamcrer istics and the l>ropcr sequence of evenll! 111 the femole rcproducrive cycle (me11strua/
Cl'c/t').

; l'rogesterone - mamtains (alo11g wllil <Utrogett) the linmg of the uterus ncccs<asy for <uccessful pn:gnancy. R~member: Ovulation takes place in the middle of ench menstnllll cycle a Gmnuan follicle rupllll'/:.1 to release its C > vwn, whicb enters thr uterine tube. l1c emptY follicle till~ with blOod ond reg= mto a tO'llUS luceum. lfth~ o\'\lm is fcrtlll~ed. the corpu< lotoltlm wtll pcr.;t and conuuue secreting progesterone to main rom pre!lJ1ancy. If not the corpus luteum shrinks into a small mas< 11fcoUagenuus tissue the corpus olblcns.
'C pnired SlrtiChores that are suspended wiU 1in the scorw11 fhc testes (Jingu/a": testis) a1 m the rn.Ue. They produce spenoatozoa and sex hormones (andmge,>). Sperm ore produt<d in the 5emlniferous tubules and stoted outsule the resu~ m the epididymis until ejaculated. Attdrogcns. the ruosl impartllnt one l>eiog testosterone, nr~ synthe~i>.ed ami secreted mto the bloodstream by interstitial cellc (of L...tlg) found 111 the intorstitium of the t"''tis between the seminithous tubules. Testosterone is re,;pl>nsible for gro" th and tn31ntenance of mal~ st'f.unl ch11ntctensucs 1111d for sperm produ~tion

Junclinn~lll'ftiiiH

liun\

l1lr dentojunclional cpilbclluon is th~ juncriou between the h]nlh surfac~ and the gingival tissues. Togother, the sulculr epithelium and junctional "llllhclium form the dcntnglugival junctional ti\Snc. ntey art composed Qf nonkcroliniud stratilielf squamous epithelium. Sultular cpltltellurn (a/su m/led t:t"f!tlcular epitltclium) .. wu1ds wy Jiom the looth. creating tt ginglvul sulcus, or $pace that is filled with gingival Ouid or crevicular Ouill. Junct.ional epithelium -a deeper extension of the !mlcular epithelium. the JIIOCt tonal epithelium l>cgins at1lte base of the sulcus. This epithelium ts a collru ltke band of stratified ~quamous ep>thelium that is flnnly ~twched to the toodt sutfuce by way of an epithelial uttachmcnt. At the epithelium's be1,<inniug, iL ts approximately 15 to 30 ccU layers thick. and at ito apical end, the epitbcliwn os only a tcw ceU lllyc:n~thi<:k. The junctional epithelium consists ur two layers: a basal layer oud suprabasalla) er. Important: Tho superficial, C>r stlprab:ssul, epithelial cells of the junctional epithelium provide tbe hernldesmosomcs a11d an Internal basal lamina ~>at create l>lthellal attachment. The epithelial nuuchmem is '"'Y strong m a beai~Y ~tate. acung ._, o type of -.:al bet\\e.:tl the SOfi gtngovol US!<UCS and th< bard lt~'U< surface. u In ideal gingival hellh, the jwltttottal epithelium i locnced entirely on cnumel ubove the cemcnlocnnmel Jtmction. Note: Hlstologlcally, the be" way to diStinguish thu free ging1vn (row the epttheli!ll attachment is the fact that the epithelium uftlte epithcloal a!lachmcnt does not contain rete pegs or conne.:live lis~ue popllltoe and the free gingiva docs. Rete pr~:s are epithelial proJccrious that extend into the gingival connective tissue. CnMctlvc tissue P"llllle are connective tissue projections th~t extend inm th<t overlying epithelium.

u,.,

GNATOMIC SCIENCES

Which fiber subgroup of the glnghal fiber group (gingiva/ligament) inserts in tbc cementum on the root, apical to the epithelial attachment, and extends into the lamina propria of the marginal gingiva?

Circular ligament Dentogiogival ligament Alveologiogival ligament Deotoperiosteal ligament

251 Q)pynalll 0 20092010 Oen;1l Db

(A.'iATOMIC SCIENCES

All of the following are lined by keratinized mucosa EXCEPT one. Which one is the EXCPTI0IV!

Dorsum of the tongue

Soft palate

Hard palate Gingival tissues

lh.nln'2inch allil;!~fnrnt

Gongival fibers are collagen libers that support only the margin:ol gingival tissue.' to mainoain their rclation<hip to the tooth. Tbe gingivnl Obcr group (also mlled tire gmgi,.,/ /igam~m) is the name gh en to separate but adjacent fiber groups that are found wilhm the lamina propria of the marginal gingiva. Norc: Some hisrologists consider the gingival ligament to be part oflhe principal fiber> (n/so called tire alnwlogingioulligllnr~nt) of the POL. Gingi,al Ugament (ur gingival fiber gmup): Circular ligament . this fiber subgroup of the gtngival fiber group is located in the lamina propria of the matg~nal gingiva. The circular ligament encircles the tooth and helps mrunwin gingival inrcgriry. Ocntoglngivallignment -this fiber subgroup of the gingival fiber group on~rts in tbe cementum on the rooL aptcal to rhe epithelial attachment, and ~tends into the lamina propria of the margutal gingova. Thus, this ligament has only one mineralized uuacbment to the comentum. The dcntogingival ligruncnt works wirh the circular ligament to maintain gingival integrity. Ahealoglngivalllgamt nl -this tiber subgroup of the gingival fiber group extends from the alveolar crest of the alveolar bone proper and rodiatcs corona tty into tloc overlying lamina propria of the marginal gingiva. These tibers may possibly help to anach tbc gingiva to lhe alveolar bone because of lheir one mineraliled anachmentto boue. Dcntopcriosteal llgament --th:is fiber subgroup of the gingh-al fiber group course; from lhe cem.,tum. near tiJe cementoenamel junction. across the alveolar crcsL Titese fibers possibly anchor the rootb to the bone and protect the deeper periodontal ligament

~of1 p:tluh: The oraJ mucosa Is a mucou.'i m(lmbnme t~ t ~O"'-~ JJI -.~am uude tbe ural eavity ('<cert tbe tth.. Til< 0011 mii<Oft V>ria 10 color rram pin).'" lorom;to 1""1'1= drrcohll cmanwln-.do.tt'lkin colO< The rlf\.lCU.tre oflhc' oral mu~l va.Mefl dcpettdin' (If\ It! k1<11ton tn the OQI U\tlty tnd the function orlhlll trt'3.

I\ 1... uf (lr:t.l 'luC0\9

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Ltftm
MMIJI!iiQf)'
tliii~IIA

R<tloo

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A,._.rar:t:

WMnS,tb~k
flpclnlllt't

611""1 m~ kobllll IMI~, 11IVO!IIM SOIIc:r lc.du~. "101

~niX'!'

!OIIp

-- """"-_..._
lm c"ffva. ,..IIC!kiJ gm@lvn,
~....,eawor-.

--'-\011..-..
..

\If' ~~~. ''"'~

.l!rl'--. ....hl!lli......
trrid' . .ec ......

. . . . . ana.w,

...

Tinn IIOI!tJi.t'n :IJ !rt'ft

W11bG.d

"{wt!IIWI

~"'*~ OlicJ ...... I'"r'"'l

pcp.lbk' ........,....,.
!nUl)' !tiC

II!Wid~u.l p !, 1'l'lo fwd petltt-1116

RIIN!c:ry 11ollt~ !CI'll\liCI 1m.\ ""'''ICIIC)', wrntlo ..

,_~

Kf'nt.llni:rtll epilhlt!lun.

' """liP'&-

pitpll'--

.........,,.

\I""'J~ 'J't~t.l fk filil'CIIltlCif\II!IMildr 1!"1'"1~

~l'lfx>cl bill*

p!IIJl- .... aotl.a~~>t~~

J T'bt-l.irno& ora bt a h> ~ 11 canlposcd or a oqk<nUniad epchehat ~ Y.itb lht rttt ptr;t. The pre.\m of rtte pegs, is lndle:arin of th~ prcsmcc of inJ1amma1ion. 3. The junction qftke lining. m1com wilh the nmsliculOry mucus:a tllthe mueQ l:lnglvat jtmctloo. ' l' h t Orl.) Jt'I UCUS1i iJ COIPpMtd oft"' U l.a)rn: I Str clntd squ m&us rpitbttium, 'hic.h may be non\;.era.t.mlcd. par.akeratiradcd. or onhokmUnized dq?Cnd.ng UfiOU tts locatton. 2. L1nllo11 propria ( COrfntt:tl\t> U;uutt), whi.ch tUJ)pl)rts the tpilhclhun Suhdivided into two l1yers (papt/lo" anJ ,,..~). h may be aua.:hed 10 the palOSt<wn or '"" olYCOtu bone or Ul~ 0\<f the Jubmuto1a (liw Jt1bmW:Wt1 COftflliM {{laNds. blood 1'(Ssds. onJI flrnT.J) Nott: A bt t.ment nlt hlbtam It tocalcd belWn""r! lhc ural cpilhelium and the eonnooU\'C ussuc rhe ~emcnl membrane i.11 compostd O l two l a)tr~ balaJ UDd rctiC:I.II3t lanuna.
e ...

Rt mc.mbu. I. The t rcvlcutar (SI,Jt:t,/ol') epithelium ;md a:mgival t:ol ore "!Joktractub.t!d &:h'lglvalll'!'tei

(ANATOMIC SCIENCES

Pdl /G )

Scaling and root planning are periodontal treatments that can remove calculus and also stimulate the gingiva. Usually, a periodontist waits rour to six weeks after a scaling and root planning procedure ror re-evaluation or therapy. "!"his allows healing or the connective tissue by what main cellular component ohbe gingival connective tissue?

Osteoblast Odontoblast Fibroblast Ameloblast

253
Copyn&hl C1200SI2010 Delllll DtcU

(ANATOMIC SCIENCES

Pdl / G)

Similar to the alveolar bone, the POL Is derived rrom the:

Dental papilla Dental sac Stratum reticulum Stellate reticulum

15' Copyripl 01009-2010 Dmtal Dreck

Fihrnhl:prd All forms of epithelium. whether associutcd with linwg. masticatory. or specialized mu cosa. have a lamina propria deep to the basement membrane. The lamina propria. hkc all forms of connective tissue proper. has 1\\.o layers: p:l!lillacy and dense. The lamina propria is densely collagenom. with a system of oollagen fiber bundles called the ginglvnl fibers (gingivalligamanl). These fibers brace the marginal gingiva against the toolb. provide the rigidicy necessary to withstund the mechanical insults of mastication, and unite the free marginal gingiva wuh the cementum of the root nnd adjacent attached gingiva. These fibers are continuou~ With the periodontal ligament. The PDL is also considered to be connective tissue. It surrounds the root and connects it with the alveolar bone by its principnlfibers (alveolodemal/igamem). which are ulso collagenous fibers. The mo~t common cell an the lamina propria, like all types of connective tissue proper, ;., the fibroblast. The fibroblast is responsible for lbc synthesis and secretion of collagen as well OS other proteins. Therefore. fibrobla<ts are rest>Onsible for healing of the gingtva lvllowins surgecy or disease processes. Other ctll$ present in the lamina propria in smaller nutnbers are the white blood cells sucb as PM Ns. mast cells, macrophagcs. nod lymphocytes. Remember: The collagen fibers of the gingiva are c3lled the gingi>'al fiber group or gingival llgament, which consists or five ligaments or groups: the ~ircular ligament, deotogingival ligrunent. dentoperiosteulligament. and nlvcologingivul ligamenL Note: The gingival apparatus is u term used to d=ribe the glngh'al ligament (or group.t) and the epithelial attachment.

The periodontal ligameotts that pan of the periodontiUm that provides for the attachment of the teeth tOthe surmunding alveolar bone hy way of the cementum. The l'DL app(ars as the pcrlodoutal s pace of0.4to I.S mm on radiogmphs, u radiolucent area between the radiopaque lamina duro or the alveolar bone proper nod the radiopaque cementum. The POL IS an organ1led fibl'()us conne<:rhe tissue th~t also maintains the gingJva n proper relationship to the teeth. In addttiou, lbe POL transmits occluS<tl forces from the reetb to the bone. allowing for a small umount of m<rvement and acting as a shock ab sorber for the soft tissue structures around the teeth, such as the nerves and blood vessels.
1. The POL becomes very thin and IQSeS the r~Jsr arrangement of its liber when a tooth loses its function (lr)pafunctwn). This also occurs in aTeas of tension as opposed to areas of compression. Teeth io bypcl'funclion ha>'e lUI Increased PDI. widUt. 2. Unlike other connective tissue> of the periodo~tiWll.the POL does not show the chang., related to aging, although the POL can undtrgo drostic changes as a result of periodontal disease. 3. Reutnnnts of Henwig's epithelial root shenth found in the POL of fu~ctio_nal tooth are called epithelial rests or Malasse.. These groups of epttbehal cells lti3Y become located m the mature periodontal ligament (called

t:enrentides).

cA.~ATOMIC SCIENCES

Which of the following fiber groups of the alveolodental ligament is the most '\. numerous of the fiber groups and covers the a pical two-thirds or the root? .tJ

Alveolar crest gJOup Horizontal SJOUP Apical group Jnterradiculnr group Oblique group

255
Copynghl 0 2009-201 0 OC'ml Dtcks

(ANATOMIC SCIENCES

, I "

The periodontal ligament space Is vital to the functional life of the tooth because this space:

Contains nervous and vascular elements Allows for physiologic movement of the tOOih Provides a cellular soun:e for new cementum and bone All of the above

Obh ~fU l' !,!nJU{I

The ponc:opol fibcn of th< POL ""' pr;...rily >mpc<d of bundles oi IJ p< I rollogtn fibtllt These fibers con.necl 1he: ccn1cntum to the ;dvtolar bone. The main rnnci)la.l fiber group 11 the ahtolodtntal Ug~mt.at, WhiCh COfiSIStl orn,e fiber ,b'l'OUps; Alnolodentalllgamtnt: The h"eolar crnt grou1, of the alvt..-olodental ligllnH:nt.; ongimnes an the alvco1nr c:n:~~ot of the

ufvco1t1r bone proper Bnd f&.ns ou11o inl-trt Into lht: r.f.'rvitall'emcnnun at nriuus angles. 111c funcllon of thi~ group is 10 ~t-it 1illing, Jnlru...qvc, e:ttrulilvc. ond rouuionl forces. l,e aplc:n.l croup Q( Ihe ;JIYC\Jlodcm~l li~~ment: radittr~s from Lho! upit-.1.! n:ion of 1hc cc:rucnrum 10 insertlntu the: surround1ng alvwlur bone propct lhe fun-cliQn of thl$ group I! to R:l!ISI C'"n&sfvc foo:es. wluch try lo pull the tooth outward. and rot.ni~nal for\."<:< Tht obliqu groop ofoh< alveoloderualligilrtl<onL the most nutmfous ofthe fibto (!lOOp< anu com th< apiCal twotblld> of Ill< root. n,;, tuoup orieonau:s In th< alvcolu bon< p<op<r ond nrcnds aptcally to 111.~ mono apieally into th< C<!JK'Iltwn on an Pbli~~VC tmi1Uief. The funct.,o ofth l;JI>Ilp

Tht borlzootal e.up nr the alvcolo<lcnlol IJgamn Otigti\Oie< m \he alveolar bon< proper apiCal
10 irs 111\'~l "r crc-;t and inserts into lhe c.emeJ\ltinl h.Jruuntally. (he: function of 1h111 croup 111 lu rcsisi

1.i to ~1St

inlnuwe forces. whicb try to ptah the IOOih lftWilrd. as \\'~U b Mlttu.mttl r\)tl:a

tiltmg forces. wbtch work to fQree th:.: tip dth4.:r m~:.sially, dtsudly, lingually, or f<\Cil\11)'. lind 10 rc-slsl romtlon::tl r..,rce,s, 1'be ltuerrudlcuiGr ~:roup of 1 hc d\'eolodeulu1 hpnmcnt: found ooly m 1nullirOUI~ H!~lh. Ttns !;tour J!t in.;~'ffcd on Ihe e-cmcnrum or\'"~ ru4.1t to 1M cecnennun ofd\e othcr r(l(l' tm rouiJ) ~upcrfi('13.l to lhc mt.crrlldtculnr $tpt\lm ud thus h:IS no bony ltll\chmern.. The function or 1h1s {!.NU(11J hJ work logdhcr w1th the alvrohn -=rest and apical JP'O"P" 1 0 NS1SI ;nmmve, ~tr\1$1\-C-. ulling. and roftUjonal
forttt.

'>ott: Another pr~n<:~J'<Il foba 01hcr man lh< alvcoi.U<noal hc>mall is the irlltrdeotollfganlrnl. or lr&niStptal ti.gmul. n.., fiba" puur (txJ/lt .l tl\l'l.uqtc~l flhrr$} insa1S mcs:Wiy ot mladcm.~Jiy tnlo tl>c <<nil:al oemcnl\Un ofn<1gl\boring teeth over the ol\ .olor crest of the alveobir bone proper Thus..lh<
fibers travel from 01.-mentum to ccme:ntwn wnh'-"'' ~my bony :machment. The funcuon ofth1-t group is lO rcs1st rouuionu.t rorccs and thw bold the: te.elh m mt~roxnmtl con! act. Important; Th ~ t.nd.i the pnncipat ~. \\'hltb dl'e emhc:dded into tht ccmL"QUIID BJ1d ftlventar

or

bone, are callt.'<l Shupey's flben.,

\II ulllll' :1huH

Flrnclions of the POL;

Support: ptQ\ ides auacbment of the tNth tQ th~ alvoolar bone Formative: con111ins cells re<;ponibl for formation of the periodonhum ~utrilive: contains a vHScular net\\Orlc pro' i<hng nutri~nts co its cc:lb Sensory: conusins afferent nerve fiber. ~sponsibl< for paiu, prw;ure, ood propm>ceptlon llemodcllttll: comains cells responsible for remudel1ng of the pedo<lonlltttn Import aut: Orlhodontic treatment is possible because U1c PDL conlinuously rcspunds and Cl\a!lges liS the II:SU\1 Of \be 1\lnctional M:\l\lttomcn\s \mpo>od upon tho rOL by externally applied forces. Contents of the POL: Fibroblasts: like all conn~tive tissues, they are the moSt conunon cell Cementoblasts and .ementotlasts
OsteoblastJ and osteorlasts l\1acropbages, masl cells, and eosinophlls Uodiffercntluted mesenchymal cells Ground substance: proteog\ycaus. glycosnminoglyctins, glycoprotein~, and water The PDL bas a va~culor s upply (arises from tile max/110/y urle1y). lymphatics ( drafn ''' the submandibulurlyntpll nodes), and a nerve supply. which enter che apical furumen of the tooth to supply 1he pulp. Two types of nerves are found within the PDL: I. One type is arrercnl, or sensory, w~ch is myelinated and ttan-'>mits sensacion. 2. The other rypc is autooomit sympathetic, which regulates the blood vessels. Two 1ypes of nene endings are found in the POL: I. Frtt nerve ending$: roovey pain. 1. EncapsuiRted oerve endings; convey pre-sure.

(ANATOMIC SCIENCES

'

Which type of epithelium, characterized by multiple layers that can contract und expand, would be found lining the urinary bladder?

Simple squamous epithelium Stratified columnar epithelium Stratified cuboidal Transitional epithelium

1 8
2$7

Copyri,gbt Cl 20092010 Dcr.Utl Decks

(ANATOMIC SCIENCES

Tis)
~

Upon returning from a two-week trip tO Mayan ruins in Mexico, a Harvard archeologist keeps getting compliments on his tan. Melanin is produced by melanocytes, which are located In which layer of the epidermis~

Stratum corneum Stratum lucidum Stratum granulosum Stratum spinosum of stratum genninativum Stratwn basale of stratum germinativum

Cop)ri&:hll C 20092010 Dtnul DoeU

...

159

Simple squamout rphbtllum .. single laytt of tlun. Ott celb.; fitncrions in g.u rxchan~ hna: blood ,cssrls and variou1 me1nbra1ter.; Endulhtlrum linmsthc t-~~rdiov.ascular system Epithelium limna the ~he.oU In luo.gs Mesothelium Uning body cavities and c-oat~ organl'- ('I( theM! cavnies Slmplt cuboidal ...pHhcllum .... :,ingle ID,ycr of cubc~!h npcd t'ells; canies on se-l:reuuu aml1sbsorpuon: Es>ithdhuu linin c:tll1'-'i!ling: ducts. prodmnl, and disml rubules of tlle kidney Epi1hcliu111 lining thyroid follicles Simple column11r tpllhtllum- dong;ucd cells; functlOI\.'i in pro1ecuon. secretion and ab:torptlon: Lining of \he rnoll and l.rge intestine, the jSallbi.Jdcf. and the Slorn>oh

Utennc qntbclium Salivary &land """'"" ducts lclcmallimna of the 1113Jorit:y of the mholat ga<lnlimestimolUOCI Stratified squomous rplthrllum - eo.nposed of nwty la)m of t:<lls: protooiS und<:rl)'\1\i c:clls from
enW'Urunental nuctulltons: Epidennts nflhc .ktn (kem,;~,t;ed}

Lining. of the esophagus (usually ,rot ktratlnl:cd) Stratified cuboidAl epit h~lium composed of mauy layers of tube.-i;harOO tt! ll~: Ducts or the sweu1 gland~ Stralificd colurun~r tpllhelhun -l'Ofllposed of numy laytni uftlongmcd cell$:
large due~ o( ~ll hVIIf)' glands

Male urcduu Speciallztd epithelium:

. Pstudostrlintd cotuouatr tpllhdlutn. tkK\ltatcd cclll lop one :~.nothtr \\'ilh n\ldCt toca\Cd ;u Jno(li ~Wlltun "lb; may IDH:! c1h1 dul Nnct1nn ta move fluids~ tbe cctls Luling of the urper respiratory """ Un:~ . Trtnslllonal r:1,lthtliurn - ~peciaH1.cd 10 undefll!n di~1cnsion; hdps prcw;ul urlruuy nuids from
two or more

diffusing outwards ~

Bladdor

Lining or Jmri-" uf the mule reproductwe fiYslc:m

Slr;tlum ha\.lh. ul \lr.llum

~ermintJih

um

The epidermis is the outer, thinner ponton of the: 'kin. The epiclennis ts av~cular. h develops from embryonic ectoderm. The epidemn.> <onst,L of four layers. From Innermost to ourtrmosl they are: I. Stratum germlnath um - conmons the: only cells of the epidemus that rct\C nutrition, cells m constantly Wldergoing division 11nd betng pushed up to the body surface. Two subdivisions Lnclude:

Stratmn basnle deepest layer; cuboidal to colmuuar cells; site of continuous cellu lor reproduction. \1elanocytes, wbich produce melfouiu, are located here Strorum spino5um- oext deepest layer; contains cells called Langcrhaus cells; con tain.s nerve cells The twu subdivisions together are somcllmes called the malpigltian layer. 2. Stratum g.ronulosum - three to five rows of flat cells; site of leratin prodUC1tl)n 3 Stratum luddum -only in the thick sktn uf the palms and soles: const$15 of clear, flat, dead cells 4. Stratum corneum outennost layer of cpodemus; 2S to 30 rows oflla~ dead cells rtUed with kerurin: conhnuously shed and replaced Note: Tho bottom l~ycr of the stratum genn inativum, the strut'um bnsnle, has cells tlout are shaped like columns. In this layer, the cells divide and push already fonned cells imo his hcr layer.;, As the cells move into the rugbcr layers. tho cells Ou~en and eventually die. The top layer ofthe epidermts, the stratum curneum, is madt of dead, flat skin cells that shed abom every two week>, Important: There are three rypes of spcciahzed cells in the cpidenms. The melon~) tt produces pigment (mela11in), the Langorhans ctll ts the front tine defense of the tmmune system in the slun. end the l<orlinoq 1< produces kcraun (a protecme protem), They are the most common cell type on the epidt:mlis of the ski~ No1e: Tonofibrils (fihrill11r srmcfllral proteins) and desmosomes are espectally well developed jn kernrinocytes.

GNATOMIC SCIENCES

The oral epithelium Is covered by a layer or:

Stratified cuboidal epithelium Stratified squamous epithelium Stratified columnar epithelium Pseudostratified columnar epithelium

259

Copyri,gb1 C 2009-2010 Dcn1aJ Dtd:s

GNATOMIC SCIENCES

Tis)

Which type of collagen is unique to basement membranes?

Type I Type n Type Ill Type IV

2tO

Cop]."rip. 0 20092010 Omtal Oceb

Slnllifh:d "luamnlh t.pithdium This strnt"iOcd squamou' epithelium ucts os a mechanJcnl bnrricr and protects the uoderlyms tissues There arc three IYI>O< foulld within the oral c:lvoty: I. Nookt>ratiniztd (nun1 common)- sclecu-..t barrier. atrs as s cushton. Cells do not conll1n keraun l'i as.~iated ~ uh hmng muco"a (/.~.. buQI 011J lohia/ muroso. mr~eosa lining llrt floor of tltt mouth, erolrtrl .rurfac-e oftlte torogr,., cmd the .IU/1 pa/me) 2. Orthokerfttini:z.ed (leu.Sf commUJI) - nssociated with masticatory mucosn {I.e hnrd palate a1uJ the u/lached gl.,g!lw, also the. lirl}lual papillae"" lito dorsa/ surfor. of the to11gue) 3. Parnkeratinized - a..societed with mas11catory mu<Osa (I.e auach~d glgit'IJ, ;,, higher lewis than ortllo/watml!ottoo. and the tmtgue~ dorsal tifa~J Note: The main diffen:ncc between paraktrallnit..td cpithchwn and orthoker:ulnized epnhehun1

is in tho cells of the k""'"" layer. In parakerotinizod epithelium, the superficial layer is slill being
shed or lost. but these. ce-lls olthe keralinluycrcontain not on I) keratin but also nuclei, unlike those of orthokerntinizod <:pithcl[unt. Other ctlltyp<s (other than keratinOC}'t<S) found in the oral epithelium: l:plthtllal <11$- form a cohesh< sbCCI that restS'$ phystcd forces and serv., as a batric1 to tnfcetion
1\telunocytes - synthesize melanin

Langcrhans cells - antigcrt pl'l!S<)nling cells. pari or immune system

Gran~rtln l!tUs -antigen ('lr f!Senting cells., port of immune system ~lrrkel coli$ -II.>SOCIMod with scru;ory nc:nc eodin!!'> Wblte blood cells- PMNs are the mo>t commonly occurring All fonns or epithelium(\, lletht!r associarad ~ uh lmhrg, mastit'fii(W)1, or ~pecla/f:etf mrtNJ.WJI h:ave a lamina proprio (''Oiilll!CIIIIt' tissue pruper) dct."P to the l)asemcm mernhrtmc. It suppons the cpuhehtun 11nd is subdivided into two layers !papillary 11ml tlcnse). It ntay be anathod to the p<;."riosttum of the alvt.-olar bone or interposed ova the submucosa (the subHtutMa con1a1tu glands, blood teJjels, and roenu).

l'iote: A basement m~bune is locattd between the ontl 'Pulleltum ana the oonnecnve nssue.
Till! ba)entt..m' membrane IS composed or 1"n l11~ers -- OOsal ttnd reticular lami11a.

hI"' I\

... 90"!. of the collagen ln the body is in types I. II. Ill, and IV. Typ~ I is associated wilh (bONE). Type II is associated with cunilage (carTII'OI/age). Type Ill is associated with reticular fibers (reTifREEiculm:J. T}'f>e IV is associated with the noor (FOUR) or the basement membrane. The basemtnl membrane is a thin. actllular slnlcture I ways located between any fonn of epithelium and its underlying connective tissue. The basement membrane consists of two layers: The basal lam inn (pmduced by the epithelial cell.): superficial ponion of the b;)semenl membrane. Consists of two layers microscopically: The lamina Iucida: clear layer, closer to the: epithelium The lamina deosa: dense layer, closer to the connective tissue The reticular lamina: this layerts a thin layer composed of type IV collagen (which is unlqrte 1(1 ba.semerttmembraftes) lihcrs as well as reticular fibers produced and secreted by the underlying connective tissue. Altachmut mechanisms are also pan of the basement membrane. TbeSt: imol\e hemldesmosomcs wilh their auachment plaque, tonofilnmenis from the epithelium, and the anchoring collagen fibers rrom 1he connective tissue.

G~ATOMIC SCIENCES

T is)

\.

The human body contains four basic types of tissue. Which type is classiOed according to the number of cell layers and the shape or the cells on Its surface?

Nervous tissue

Muscle tissue Connective tissue

Epithelial tissue

l&l
Copyright Cl 201-201 0 Dem11 Dec:b

(ANATOMIC SCIENCES

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Which or the following epithelium functions in the secretion and propulsion of mucous by cilia?

Simple epithelium Stratified epithelium Pseudostratified epithelium

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tpilheliallh'Ul' Simple: single layer of cells Squamous e pithelium is a single layer of Oat eells; lines an:as in whtch substances such as gases need to cross readily Cuboidal epithelium is a single layer of cells of equal height and width; lines areas involved with secretion and absorption Colunuuor <llllh<lium is a single layer of cells ta ller than wide; I inc' areas of absorp-

tion Stratified: multiple layers of cells

SquamouJ epithelium lines areas necdin11 protection C uboidal eplthtlium lines areas ofmd-siLed dun Columnar epithelium lines large ducts Specialized tpithelium: specialized to undergo diSTension PseudostratiOed eolumna.r epithelium is specialized for S<:<:rction and mo\ement along luminal surfaces (multiple la)'ers oft'ells) Transitional epithelium lines areas that accommodate increase in luminal a rea by changes in cell shape (also has low permeability) -- is a stratified cpithcl ium Conn ective tissue -- tYJles: Solid soft: connective tissue proper, specialized (adipose, fibrous, e/a,uic, reticular) Solid lirm: cnni1age SoUd rigid: bone Fluid: blood.lympb t\1uscle - types: l nvoluntry: smooth and cardiac Yoluntuy: skeletal

Ntne -- typeS:
Afferent: sensory Efferent: ll'IOtor

Slratilil'<l t:pifhdium

Simple epithelium has only a single layer of cells, all contacting the basal lamina.

Stratified epithelium has two or more layers, with only the dccpct layer contacting the basal lamina, PseudostntiOed epllhelium appears multilayered, but is actually only a single layer with aU of lhe cells touching the basal lamina. The positioning of the nuclei witbin tbe individual columnar cells causes this illusion.
Summar~

uf Uilhnnt I ~Pl'' ut l.pilhelium

EpitheUum
Simple

Cell$
Squamous
Cuboidal

Function (s)

DiffUsion and filtralloo Secretion or ib<o<pt1oo

Ab<oq>tioo and secretiOCI
Prolccuon. pre'e:nl.) "''Iter kKs

Columnar
Stratified

Squamous Cuboidal Columnar

Varie.~ between cuboid~ I and ~~quamous Columnar cells atop one another with nuclei located at two or mo~ level~

Procection and secretion

Prolection

Speciali<ed:

Transitional Pscudostra,ilitd

Specialized to undergo di,tcn~ion

May bave cili~ tlmt function to move

within ce Its

fluids past the cells

(ANATOMIC SCIENCES

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T~ndons ,

ligaments, cartilage, and bone are considered which type or human body ti~sue, which supports and binds other tissues?

Epithelium Muscle tissue

Nerve tjssue
Conneccive tissue

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Simple squamous epithelium Is most likely round lining the:

Upper respiratory tract

Urinary bladder
Vasculature

Esophagus

Princip:1l l,iuch uf l tlri'IH'' TypH

Ep,.hohl tissues Ot:sc.riplion nd Funcdon

Tw<E>ampl<>

May be .,..(.,"'!~t)or ,....,., (sffYfrif/td) loym thl<k, Two types. lower .surfac.-c bound La 3: $U[tp0nl\ e basemen! Covtring nd Urttng c:phhc:bun1 membntnc; mllfii~CA~ Ily t'ICliv.: tibuc: awscular; eover d1e ('()vm d.c out11ide of the body turl3(:e ofltw body nd lffic !he viUiou.'l body c:avitie:s. aud line~ tnu:n1~tl organs d~.s.. and vcsscl1 Gl:andubr quthdNm

Coucw'~
USSUtS

OMiidtrabJe Ul.lette:JI~;tlar mamx: mn.oucaUy 9Cii' t

liS.Suc: used rur JUM)Ort (bonu tmd e<u'f'lla.~J. for
aUachmcnt or Other U!iSUCS (umd01U, IJgmmmis, OJifi fascia~). or for ocJtct specialktd runoetions ($uch us b/Q6</)

lh&bly - (urqxjw CDTtJ/,.); .......

Teudoos ud b~-"' eoni1ogc od booc. :adipore ltsiUC. bklod

Typ~ ol'e<mncttiH~

. .

!Issue propel ~

. . .'-4ipo.c

Molar 0en,'4C ("'*ular) Elastic Rru<ulu

Musct~llir

dlRs'UC.'J

Limited mitollc: Mtivny; composed ofj!pC'Cializ:ed ccU! 'Thfrelypc:o thai Art Cllp;;~bh~ of oomraeti.nM lind thrreby dtt.TCll'i.n'li In Smoolh length; these 11'-SUt'B mO'I'' t the skeleton. propcllhc: blood Coroioc thn>o;!Jout Ill< body. al1d ai4 ill dill"'""' b)' moin~ rood Slcd""l d'li'OUgb the dlpti\ t Ind.

w.....

N~OIII

Umik:d llllaobC .atvily; uanmut mesuges: throughout 1be body

Fam1 brant. spm1 con!. .and ntn (~, consm lar~cl ) hf' reUs (IWIroJf J
wicb lmig pl"(uoplsgn'tc c.v;tensions.

\ .1 .. \ulaiiH t'

Epithelial tissue! can be clo~sified into rno m:lin calegQne~ on lht' basis of lhc1r arrangement mto layers or cells: I. Slm11lo: cons isis of a single layer of cpilhelial e<lls. The further classtficaliun u( tissue In volv<5 di1Ten:n1 types of epithelial cells accordtng 10 >h:lpc: they can be: Slmpl squamout epithelium : con.<i<l$ or Oattcn<.-d. platelike eptlh<lial cells.. lines blood and lymph:ltic ve:.scl'- beon, and s.-rou< CO\itics and hoes the air 5<1CJ (al-eoli) oflhc lunJIS Simple cuboidal epithelium: consests of cubc~shapcd cells thallene the ducts ofvanous glands, such as certain portions of Ihe salivill)' gland ducts. Simple columnar epithelium : consisiS ofrectan&ltlor or tall cells, such as in the hnin of olhersalivary ducts, as well as the 10ncrenamel cpitheliun. whose cells become am<lobls<~s 2. Strotifted: CODSL<I$ of lwo or"""" la~c:rs of eel!;, wtth only lbe loWI'r level conlliCttng lbe basement membnsne. Only the Shope ofll~e surl'ace Ioyer 1S used to dctcmunc lbe classification ofsiJ"tifled epithelium. Slratlfied squomo1u epithelium: most ofd>e opithclinl tissues irt the body are of this type, which include the superficial portion of the skin and oral mucosa. Can be kertiru<cd oc nonkeratinized Stratifted epithelium can also be: cuboidal or columnar or a eombmntion oft~.
Eipithellaltissue can nlso bo cla.<Sified ns ps<udostratified pllbeliutn. Tit is epilhclium faLM:Iy appears US 11\Uiti(')Je layers IJt."C3USe the Cells' nuclei appear at dlffcrent(Cycls. 1'his type Of ~.:pithtlium lines tJH! upper respirator) rract, includin,a the nasal uvhy and paranaulslnuses. This type or opithelialltssue may be dilated or noucUiated 31 tbe tissue surf~. i\'ote l'>c:udosuatific-d cthaled columnar epnh<lial cells belp trap and transpon particles brought in throuah 1be nasal pa>;a&cs and lungs. Remember: Transit-icuml epithelium, which lines the urinAry bladder, ureters, and pt'tr1 o(thc urethra. makes up specinlizcd tissue that allows for the eAp~msion of -an organ with only minlnMl resistance from the tissue.

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A Obrous connective tissue sheath containing blood vessels that surrounds most cartilage is called the:

Pericardium Perichondrium Periostewn

Pericranium

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Tbe formation or osseous tissue, which Is responsible for tbe increase in the length or long bones a nd the healing of bone fractures, occurs due to:

Endochondral ossification

Heterotopic ossification
Intramembranous ossification

2M

Cop)Tiah1

c 20092010 Oenul Dt<:ks

Pcnchundrium

Cartilage is type of dense, fibrous connect{\ e us;uc, which supports and shape< vanous t>tru<:tuteS- It also cu>hon1 ond absorbs shock. Caniblge i comrose<f of cells called ehondro<)'1e~ lhat arc dispersed In 0 fll1ll, SCI-like ground subslllnce, <Oiled the matrix. nteso cell> re>idc in dcpn.."Ssions in the mnlnx, ca11cd h\ruoaP. CartHage contains no blood n~ssel5~ and nuuic::~u~ nrc diffused through the mntri~. Canllage is found in tlc joints. the rib cage, the car, the no>c, nd the throat and between ntcrvonchMtl discs. Note: Tbc only blood supply to cortllac is pmvukd by blood vessels tltat enter the conilagc through the pcnchcmtlrium. Important: n,e cxc1'1ion to the rule tltat cun.lla~c is always covered by a pcrlchondrltllll i< the artitlllir earlllo~c at syno.-lol]oint. There arc: three oubtyprs b"'d on thccompu<noon Clfthe matrix: I. R;taline canola~e- bas a high proponwn uf malriA and lin< collgc:notos lib<rs Tbro<tghuut chddhoocl ond odolesccnc:e, h) aline <3nllagc plays an tmponam emn n the wowth io LtnJ:Ilt of1011~ bonc.s (t'fiiPh.ll<t!lll p/nii!JI are rompn<tJl ofhy,lm<' cortilagc). Covers the arucular urfilwof nearly ~II $)'00\ ial joints. h is mtapable of repair when fl'ltctul"\:d Note: Type II collngcn noukcs up40% ~fthis cartilage's dry weight . 2. FI1Jrocartlh1ge - hHs a large nwllbcr of collaJ;Cn fol)Crs embedded 111 a small amoum of nnlnx. Filli'OCIIrtilugc Ls found In the discs withm joint<(U.JI., 1/1e 1MJ. stem udmmllarjolnl, tmd lrJwe;omt) nnd on th< anicular surfacC> ofth< clnvclc and nUUidible. 3. Elo5tit curtiln~c - similar to hyaline cartilage. CJ(<'<pt tlasric c;tt1ilage pos~csses lorae numbers ofciii.Stoc libc~ embcdd;.'d in the matrix. Elasr.ic canilage is ""'Y Oe.lble anti Is found on the auncle oflh< car. the cxt<mill auditory mcattl.'l, the auditory tube. and the cptalotu.s I. Cl\lltlot;c is a proewsor to endochondml boot:. '~t.. 2. The mnlriA is mainly composed of protrog!)cans, a special type or glyc:osammoglycans. The moSt conunon tyres ""' cltondroltlu utfate and keratan >ulfte.
3. TI1c
~rlt.hnndrlum

is \'ery 1mponant 1n 1 he gro'Wlh of cani1agc~

4. No cnldum salu ttre pre~t and, 1ht!rcrore, canilage dOC .out appem em x-mys.

Endochondral ossification begins Wllh J")tnts tn the cartilage calk-d " primal) onlfiu.Uon center.." They mostly app<ardunnJ! fetal development. thou~>b a few shon bones begin thetr primary ossificariou after btnb They at"< responsible for the formation of the diapb) ses of long bones, sbon bones, and cenain pans of uregulnr bones. ~~ccondary ossJncation" QOOUTS after bin h. anti fomts the epiphyses oflong bones and tho ox~milic.' of irregular aod flat bones. The doaphyses and the epiphy>~s M long bones remain separated by a growing zone of osrlllage (the metupbysls) until the child reaches aduiUtood (18 rQ 2j y ('!Jrs oft~ge), whereupon the cartilage ossifies. fitsing the two together. Note: Heterotopic ossllicauon is the formation of booe outs1de the skekiOn and is seen in diseasecS such os myositis ossificans. Long bones tncr<n>e in length during srowtb and development. The tpipb)SUI plat~ (drsc) is n " 'edge of hyaline canlfage account in& forth" increase. Thts plate is fowtd between the "l'pby>is (bu/{>O"r end) and diuphy<tS (wbular shajl) at <ach end of tht bone. The cartilage cells of the epiphyseal plate form layers of compact bone ti~sue, adding to the lcng1h of the bone (irrtemitial grr;wtlt). Tlus di:.c becomes inactive w mo~t indtvidu als by the late teen~ nr early twenties. Remember: Bone formalion or developtncnt occurs hy two method$: I. lntrumetubranous os.,ificatiou mainly occurs during fonnation of the ORI bones of the skull: t~c bone is formed from mesenchyme tissue. 2. Endocltortdflll ossification occurs in lon11 bones. ~uch as limbs; tbe bone is formed from cortilge.

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A patient in tbc dental clinic states in his medical history thnt he has heart disease and occasionally takes nitroglycerin for his pain. During treatment, the patient clutches biJ chest and frantically points to his jacket pocket. The dentist obtains the nitroglycerin bottle from his jacket, remoYes one tablet, and places it:

On tbe soft palate On the gingiva Sublingually

On the buccal tissue

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Cor>-nJhl 0 20092010 Dcnlll ~kJ

G NATOMIC SCIENCES

Tis)

What structures act as "molecular sponges" and hold water in the extracellular matrix of cartilage?

Glyco58Jllinoglycans

Giycoproteins
Oxytalans

Elaunins

Suhliugualh In general, the permeabilities of the oral mucQ5a decrease in the order of sublingual greater than buccnl and buccal greater thou palautl. Tins rank order is based on the relative thickness and degree of kcratinizarlon of those tissues, with the sublmgual mucosa being relntivdy thin aJtd nonkeratinizcd. the buccal ~1icker and nonkeratinl:red, and the palatal intennediate in thickness but keratinized. Important point: The oral cavity is higbl)' acceptable for systemic drug deltvcry. The mucosa is relatively penneable with a rich blood supply. and the virtual lack of Langerbans cells makes tbe mucosa tolernnt of potential allergens . This route nlso bypasses the First pass et'fect and avoids presystemlc elimination in the G l tract. Example: Nitroglycerin tablets are given subtingually for rapid absorption. Rem ember: The oral mucosa is composed of an outermost layer of stratified squamous epithelium. Below ~lis lies a basement membr.me, a la111ina propria (connective tissue JliTJf>Cr} foUowed in most cases by tbe ubmucosa as the innermost layer. The composition of the epithelium varies depending on the site tn tbe oral cavity. The mucQ5a of aJUS subject to mecbartical stress (the girrgia ami hard palate) is keratini:r.ed (specifically. orthokeratinized). The mucosa of tbe soft palate. the sublingual, and the buccal regions, bowcve1. Is not keratinized. Note: Alveolar mucosa is very simi tar to sublingual mucosa in thst tt. roo. appears red due to the numerous blood vessels and the thin epithelial covenng.

Cartilage matrix is a homogeneous material principally composed of protcoglycans, macromolecule.~ with a proteinaceous backbonr, to which is nuached complex carbohydrates (the.<e carb<Jirydrates art! "glycosaminoglycans. IISI/ally abbreimcd GAGs). The GAGs radiale from the protein core like the bri>"'les of bcute brush. The principal GAGs of caailagc are chondroitin sulfate and keratun sulfate. Another mutrix component is llyalurontr acid, a gelatinous mucopolysaccharide. The hyaluronic acid aciS as a sort of cement to bind the proteoglycans together into large aggNgates. l mportllnt: Because of the chemicalnarure and orgauilation of the glycosammogly cans. the ground substance can readily hmd aud hold water, which allows the ussue to assume a gelntinous nan1re that crut resist compression and penni! some degree of diffusion through the matrix Note: Chondroc)1es produce all the componentS of canilage: the matrut material nnd the fibers as well. Hyaline cartilage fonns nearly all of the fell!I skeleton. ln the adult, the remuanls ure: Articular ear!Uage- smooth and shpp..-ry, it lines movable joints Costlll cartilages- al the sternal ends of the ribs Respiratory cartilages - movable external nose nnd septum. larynx, trachea. and bronchial wolls Audltory cartilages -external auditory meatus and pharyngotympanic tube

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At the gymnastics center, a 22-year-old male doing nips on the trampoline lands incorrectly on his ankle and dislocates lt. In the emergency room, the physician must provide traction to replace the ankle, and the procedure is without Incident. The patient is told that although there are no fractures the bands or fibrous connective tissue that connect bone to bone are almost definitely tom. T hese bands are called:

Tendons

Bursae
Ligaments

Menisci

Copynaln o 2009-2010 tXo~al ~>~

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(Al"ATOMIC SCIENCES

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~~Which type or connective tissue, seen in ligaments and tendons, is composed""''l

\.. of closely packed collagenous fibers arranged in a consistent patlern?

Loose connective tissue Deose irregular connective tissue

Dense regular connective tissue Elastic connective tissue

i~HIII l' UI\

ligaments are dense. strong. flexible bands offibrou.' connecuve tis.ue that he bones to other bones. Ltgaments that connect thejoint ends ofboncs either limn or facilitate movement Ligaments also provide stability. l 'endons are strong, nexible bands of fibrous connective tissue that ntlllch muscle~ t9 the fibrous membrane that covers bones (perio;tcum). Tendons move bones when kcletal muscles contratt. Important: When a tendon or ligament is auached to the bone, the atwching fibers are called Sharpey's nber5. They are periosteal collagen fibers that penetrat~ the bone matrix, binding the periosteum to the bone. R cmemher: The periodontal ligament contains collagen fibers that are insencd on one side in the cementum and on the other side in alveolar bone. The ends of these collagen fibers are Sharpey'~ nbers. BursA e nre smnll. synovial, fluid-filled S<ICS located around joints at friction pomts between tendous.lignments. and hon~s. Bursae aetas cushions. t. A fasciculus is a botmd group of individual muscle fibers. The fas<:lcull are Not..- the bundles of 11llll>cle fibers composing a muscle. In tum, each muscle ts surrounded by a connective tissue culled fascia. 2. The fascia secures tl1e muscle to a tendon. 3. An :1poneurosis is a sheetlike tendon. 4. M"niscl are CRSCcnt-sbaped interradicular fibrocartilagcs m ccnam jornts. including the knee.

Connective tissue derives from mcs<nchyme (meso.lem). Compared with epithcli\1111, conne<:tive tissue is usuaUy composed of fewer cells spaced funher upan and contntning larK amounts of matrix between the cells lettepr ill aJ1pose conntcti>'" tissue). The mosr common cell LS the fibrobi~JL Other cells found in connecti>e nssuc include migrated whne blood cells such as macrophages. basophtls (mast cells). lyn1phocytcs (including 111amut teJI.,), and neutrophils (PMNs). Connective tissue includes bone, canilage, mtd odipose t.fatty) tissue. Connecuve tis<uc serves "connerong" funcnon. It &upports and binds other tissues. ~nlike cpuhelial tissue, connecrive tissue typically has cells ,;cauered throughout an extmcellular matrix. One method of classofying conneclive tissue is :tccordin~ to tc.cme, which I> either: Soft: include~ those tissues found in the deeper luycrs of tile skin nnd oral mucosa Fim.: conststs of different types of conilage Rigid: COO>UIS of bone Fluid: consisL< ofblood wtth all its components and lymph Soft connective tissue can be classified as: Loose (llrt!Oiatj: consislll predominantly of cells or matri~ in an ttn:gular or loose: nrrn 0ge.. ment. ServtsM paddin~; for the deeper pon1ons oflhe bod) Dtnse: whtch provides >true rural :rupp<>n. has greater fiber (protem) conccolnltion. and os tightly packed. Dense is further subdavided into: Pense regular connective lissue: has n regular arrangemt:Dt of tightly packed, strong, parallel collasen libers with few fibrobllll-1 cells. This tissue includes tendons. ligaments. and aponeuroses. ~e i r~ular connective tissue: has rightly packed. strong. parallel C(ollagcn fibers arranged in an lncouslstcnr or irregutnr pattcm. This tissue b found in o be tlennis. Sllbmucosa of the GltraCt. Organ cup~lll,.., and deep (._,cia.

GNATOMIC SCIENCES

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A 71-year-old woman presents to the dentist wilh multiple blisters on the oral mucosa. She states that the physician has diagnosed bcr with bullous pemphigoid (BP), an autoimmune disease in which the body targets certain intercellular junctions. In BP, the junctions Ihal are targeted are those tbat anchor the basal cells of the epithelia to the underlying basal lamina, causing the epidermis to dNach. Which junctions are affected In BP?

Desmosomes Hemidesmosomes Adhereos junctions

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Copyript 0 20(19.2.010 Dtnl.ll DU

GNATOMIC SCIENCES

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Proteinaceous lubes that connect adjacent cells are called:

Tight junctions
Hemidesmosomes

Gap junctions Adherens junctions

l-1 t mifll""IIIO,IIIO(' Bricks in 11 building must he stuck together and ~l'lc1 tied sornehow to the fi'undruion~ Similarly, cc:lls within tiMUe< and organs mu).l be anchored to one aoother and att;~.chtd to compof1C111S: ufibe extnacc:l lular molnl<. Cdl h;m: deeloped liC\'naJI}"Jl<' oflnttrullular )unctioas to sem: 01<'<C fnct;om. and in each case,an.oonn~ protcnlllext<nd througb IM pti<m m<rnbrano mlink <Y'"'kdml proltins

cell to C)'tOJikelrtal prote&ns in ncigbbonng cdl5 a~ well a5 tn proreuu., il'\ lht e"tracc:Uular mam:t.

ill"'"'

,Junction
Ilesmo:;A>n)C>

Cytoskeletal Anchor 'l'ransrucmbnUtl\ Linker Ties Cell To:

lntcnneduue filamentS
Cadhmn
Ochttcell<

HemtdestTK-somes

lntermedlale !iltmml$

lnregrins
Cadherins
lntegrlns

EC matrix

Adht:rcns JUnDiiO!\> Act1n filmcnts

Oth<-rcells
EC matrix

An intercdlu1arjuncrioo bct\\oceo cens i:S. de..~mosome. The desmosome ~r.J co ht disc-sbapcd IDd can be hkCIIcd loa "spol "ckl." Another type of intercellular Juncnon is a hen1idesmosomt. whittt mvotvcs an altachmenr of1 celltn an acljilCtn1 noncellu1dr ,urfacc. hupodanj! J11is type tlf uttac:hmcnt is JlN!Cnt w1tJ1 t.he iMV1Hll epirhcllum lh!tl allaches 10 lhe tooth surftLCC (ca lled lf;t jumHnnnl "'plrJJt!lltuu of tire upilht.litll mtiJCiutttrtO M well as In Ihue which occllr5 hc:twecn rualls and Nil I beds. Nott : The: chnteal condu$on known a.s bullou1 pt1nphl,::old lnvolns l~ disrupu.on of htmdamoloOmd and c:omequen sepan1oon oflbe cpi1helli1Jll fl\lm the ba"llamma Ano1ho- type of fr\l~rccllulou junction ts ''hat is ca.llrd 811 adhtrem; juuclion (aliHJ t'UIIed ~mwlu tul Jtt-,+elu). n,es.; juncrioa; thflrc the characteristic of anclmring ccllr. 1 hcuugh their ~:ytoplnsmic :t.Ctln tjl .. amcuts, Tbc:re IS cons1tlerub1e morphologic divcrsiry among t~dh~rcns JUOCUUIIIf. 01ose that tic cells 10 ~ne a.nolber are seen as isolat4.-d strtotks or spuiJ.. ura\ bands th:al compltteiy c:ncm:le the cell The: band rype o( adhcmJs j1111<1ion> IS &.'"'"""ted ,.,111 bu!l<ll<S Of .<lin fila111""1s lflal alsO CIICfrclc lht cell JUSI below the plasma nu:mbroiiC. Spot-Ilk< dht~n< juncnons help cells adheretu tile crncellular ""''"' Adhen:ns junctions art lhoughl tu pan"k1pate 10 foldmg and hendlng nf ~:pilhcllal cell )hccts.

Gap junrtlons are pro1eiuaceous rubes some 1.5 10 2 run in diameter. l11ese tubes allow material to pass from one cell to the next without having to pa.'s 1hrough the plasma membranes of the cells. Dissolved substances sucb. tiS ions or glucose can pass through the gap JUnctions. They are fonned by transmembrane prole ins called connexlru. Gap junctions are scpanote from the componeniS of the junctional complexes. gap junctions facilitate cclllo-cell communication. :-lotc: Because Ions can Oow through gap junctions, they pernUt changes in the membrane potentiallo pass (rom cell to cell.
Funrllonally, there an: three groups of cell jwtcoons: J OcdudingjunrtioM - whiehjoln the plasma membr:mes of adjacem cells tightly

together. 2. Anchoring junctions which physically connect adjacnt cells and !heir cylu sk.elcton.s, but leaven spHcc scpamtingthe plasma membranes. 3. Communicting junctions- which pem1it lbc p;>ssag~ of chemical and electrical signals betwen the JOined cells. Gap JIIPCtioos belong lo this group. Such spcc:alized celt junctions are fow\11 in many tissues throughout the hody, but arc especially abundant in epithelial tissuu, where some cell junctions nrc organized into groups called juoctlonnl complexc~. Three disriuct components of a jnnctionnl complex: A tight junction An Intermediate junction A desmosome A 11 of whfch ar~ A$SOcialed with the plasma membranes of adjncem cells

GNATOMIC SCIENCES

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What type of cartilage is found in the auricle of the ear, the enemal auditory meatus, the auditory tube, and the epiglotris?

Hyaline cartilage Fibrocartilage

Elastic cartilage

m
Copynabt Cl 201-2010 Dttl~aiDtd,,

GNATOMIC SCIENCES

Tis)

Which layer of skin is mainly composed of areolar connective tissue and adipose tissue?

Epidermis Hypodermis

Dermis

.-

1 9

ElasliL ' l">t r liht~l'

Remember: Elastic cartilage is similar tO hyaline cartilage, except elastic cartilage pos" sesses large numbers of elastic fibers embedded in matrix. Elastic cartilag~ is very ncxible and is found in !he auricle oftbe ear. the external auditory meatus, the auditory tube, and the epiglottis. Ca rtilage can develop or grow rn size in two different ways: 1. I nterstitial growth is growth from deep within the tissue by the mitosis of each chondrocyte, producing a large number of daughter cells within a single lacuna, each of which secretes more matrix. thus expanding !he ussue. 2. Appositional growth- is layered growth on the ou1side oftbe u.~suc from an outer layer ofchondroblasts within perichondrium. Growth of bone: Apposlriool growth or layered formation of bone along its periphery, is accomplished by the osteobJasts, which later become entruppcd as osteocytes. Because of its rigid structure, interstitial growth is not possible. ** po not confuse bone growth \vitl1 bone formation or development. Bone fotms by either endochondnl ossiOcaUon or intramembranous ossifkatlon.

The integumentary S)Sttm consists of the skm and its many derivatives (hafr. glmrds. rrarl.< , tmd sensory r-eceplors), 11te skin is composed of many tissues stmcrurally joined tor specific ftancrions. Strucrure of skin: The outer epidtnnls: which cons1Sls of stratified 5qu:unous epithelium. h de\ el"!l' !Tom embryonic ectoderm. l11e outer dennis t> avascular. The principal cell of the epidrnm IS called n keratlnocyrc. The outer dermis consists of f<>ur layers. From Innermost to outermost. they are: the strnnun germi.ontivum (wlriclr lws t\''0 .'wbdfviJ10II.t~ tire sl,.tuum basale and stratum spillo~,m), stratum grunulosum, stratum lucidum, and s1ratum corneum The inner dermis: thicl:er portion of rhe skin: composed of COMecnve t1ssue wtth col-

lagenous and elasllc fiber< for lOUgbness. The inner denn" develops !Tom embryonic m~ dcrm and contains blood ''essels, nerves. &lands, and hair follicles. It IS a strong, strt:tchable layer that essentially holds the body together. The inner dermis has tWo main regions: pplllary layer: upper dennal region reticular layer: dccpest skin layer The subdermis (lrypodtnnis) is the la}er of tissue du..aly underneath the dennis. l'lle ;;ubdennos is mainly composed of arwlar (loos~) connective ri~suc and adipose tissue. Tite >ubdemtis's physiological function> include insulation, the storage of energy. and aid in the anchoring of the skin. The subdermis also cushions the underlying body for extra protection against trauma_ The skoo also contams several other relevant struc.twt!>. 111Cluding tho following: Basement membra ne: collagenous membrane between the epidemn> and dermi that holds them mgethcr Meissner's corpuscle: oval body in thu J ermis. thought to participate in tactilesenstion Ruffini's corpuscle: oval capsule containing the ends of !ltnsory fibers in the dermal papillae

GNATOMIC SCIENCES

Tis)

Which layer of the dermis contains blood vessels, nerves, and other cells?

Papillary layer Reticular layer

1??
275 Cop)'li&h1 0 2009-2010 Dt:ntal Otc.kl

( ANATOMIC SCIENCES

Cementum is the closest in composition to which ofthe following?

Bone

Enamel
Dentin

Dental pulp

276 Cooynpl lOI-2010"""" Do<b

lhfkul.u

Ia~ l' l

The dermis is the thicker pOrtion of the skin. The derm1s is compo5ed of connecuve tiSsue with collagenous aod elastic fib<:rs for toughness. The dermis develops from embryonic mesoderm and contains blood vessels, nerves. glands. and hair follicles. The dermi.~ is a strong, strctchnble layer that essentially holds the body together. The dermis bus cwo

main regions:
1 Pa pillary Ioyer - thin and less fi brous; has projections (papillae) that extend up toward the epidermal layer. This tayer contains the blood vessels thai supply the overlying epide1mis. The layer contains fibroblasts. mu.>r cells. and mncrophagcs. 2. R eticular layer -- 1hick and fibrous. and is continuous with the hypodecmis. Blood vessels from the hYJ'Odermis pass through this layer. lt conlllin.< more reticular fibers and fewer cells than the papillary layer.
Cburacteristics of the subdermls (hypodm11is) that connects the denn 1 s with we underlying fascia of muscles: CompOSed primarily of loose (areolar) connective ussue !\laj or site or fa t depo>itlon (500A> of body far} l ias good blood supply

Umh

Cementum is the bone-like mineralized ti~sue covenng the anatomical roots of teeth. The primary function of cementum is to nllnch Sharpey's fibers. It has tbe l'ollowing

characteristie:s:

Slightly soner and lighter in color (r~llowJ than dentin Fonnod by oementoblasts from the POL. as opp<>sed to denim, whicb I fonnod from odootoblasrs of the pulp. It develop; from the dental sac Most closely resembles bone (more so than dentin). e<cept there aro no haversian system.< or blood vessels it is avll5cular Mature cementum is b) ,.eight 65% mineralized or morganie matenal (mom/) , a /cium hydroX)'DfJOtite), 23% organic material, and 12% water The orgonlc ponion is primarily compOsed of collngen and protcrn

llns no nerve innervation.

Thickest at the tootll"s apex and tbinnes1 at the CEJ at the c.orviJc of the lOOib Important in onhodomics. Cemen1Um is more rtshtlan to resorption than alveolar bone, pem111ting orthodontic movemeu1 of teeth withnut root resorption Two types of cementum (fmrctlotrully t!rcre Is no difference): I Acellular (sometimes called primury cenrenrum) - consists of the first layers of cementum dt'l'OSited at the DCJ: aecllulnr cementum IS fanned at 3 ~low rtc and coottuns no embedded cementoeyt es, usually predominate on lhe coronal two-th1rds nf the root Thhmcst at the CEJ. 2. CeUular (sometime.< called secorrdary cememum) - consists uf the last layers of cementum deposited over the acellular cementum: cellular cementum is fonned at a faster rate tllan acellular cementum and contains embedded cemtnloblast>. Cdlalar cementwn occurs more frequently on the aplclll tblrd of the root . Cellular cementum is usuaU y the thickest to cmnpensatc for ocdusaJ/Iudsal . , ,1ear und passive eruption of the toolh. Note: The com position or bo ne is roughl) )0% inorganic, 25~. collagen. and 2s water.

(ANATOMIC SCIENCES

When using a high-speed handpiece to remove caries from o tooth, the dentist must drill past the enamel into dentin. The first layer of dentin (atth~ DEJ) is called:

Imratubuiar dentin Intertubular dentin

MantJe dentin
Circumpulpal dentin Interglobular dentin

2n
Cop)'n&lll 0 20092010 Dmtal Okt

(~ATOMIC SCIENCES
r
The ner.e plexus of Raschkow is located in .-bich zone or the dental pulp?

Cell-rich zone Cell-free zone (zone of Wei/) Odontoblastic layer

\l:111tlr lhntin

Montie dt rHfn l:i the firsl predeuhn thnt forms and matures Within the tooth. Man1 le dent'".
shows a difren:nce in 1he direction of the mineralized collngcn fibers compared with the rc-sl ol dcntiD.t wlth the libcrs pcrpcndiculur to the: DEJ. MantJc dentin also has more pcntubular dentin lhnnlbc inner porllOII> oflhc dcn1on and lh"" has higher lt,ols of mineraluolion The layer of denlln around lbe OUiu polpal wall is called <lraunpulpal dondo. All circum~pal

dOJiun ;, form.:d sod ma1ure. Rcr ol81llle den lin. Tl~ collag<n fibers of tlrc,unr>ulpal denun are nJDo nly parallcl10 1he DEJ compared w1th 1hooe of ID!lollt dcolin. Circumpulpnl demin mukc-. up I he bulk Of tho dc111in Ill a IOOih.

,.,_""'... ........
1)1)<
~~~~m

~tt~~lbe: tlolblllcs

I \IW"Ilf lhuhn

Locatloa/Chronology

DesutpUoe
HiP>leakir..d

lll$'-b c:&)gfied
f lrt"l denllft f,:,mJtld
l>c1 1!.in tbrmed 11~n- w.hllk 1 lcnlln
~Lied lt.u kUDII.v) ~~~~aa

Mtm!('dmtm

();d~II)'Cf

Clf\.'\IIIJJ~ dOnun l.a.)lcr DI'O\IDIS OUICf' pulpul wnTI

Prtnwy Jtnt..n

FcxmaJ bdfoo!'CI ~nioft of apl..::~t ~muncm Fbtme'd "'art ta{'ldl)'; "mort

~odontoblast.

F""""'al\<7""""'""''r..-~

.....

Fnn:nred J">Wcc....d tflcM

.........,

rct1wy cJrnu11 hwJ\IJIIOP'IIlcm l a.~~~1n fl'lf1nC!d u. ~ "' lljttl)' .. (Tomes ' fiber) of OJ\ Re member: Etleh dcnhual tubule coru.un.s lhc cytop11sstmc cell process

hiiJJOrtant: Odonloblasts secrcu: the organic compuucn1s of the denhn malrlx The fibro~ n\atrix is mostly t)'pt: I collagtu. Noe: Dead lrl<ls <onsisl or group~ of empty lubules due: IO the dealh of the od<>nJoblast:. whose proccs><:S fonner1y filled Ill< luhulr< These traCt. na.e been annbuled 10 the asi1111 ~rocess of lhe denlinal lis.<ue. They may -lsu be oaused by caries, L'nmon, ca. ily preparation. ot odontobl:J.stic crowding,

( l'llfnt'

IUOl' (:. onc

o(Jit'ifl

The pulp IS the ID.llc:nnosltssue of the tooth The pulp IS formed from the central cells ofthe dental papilla. Anatomy of the 1 1ulp: Coronal pulp- located in the pulp chamber und form.~ pulp homs Radicular pulp -- located in the pulp canals (root portion oftvoth) Apical foramen - oommunic~les With the POL *" A~cessory canals may also be associau:d with the jlUip. Remember: These form when ll~nwig's epilbeliBI roo1 sheail encoumers a blood ve<scl duriug root fonnation, Root structure 1hen fonns around 1he vessel, fonnintt lhe accessory canaL The central 1.one or pulp proper contains large nerves and blood vcscls. This area IS lined peripherally by a specialized odontogenic area thai has the following zones
(from the outenno<t zone closest to tlrf' detrtin to tire lnncmwst zone oftM pulp); Odontobla!llc layer: lines tl1c outer pulpal wall and consists of' the cell bodies of

odonloblasts. Cell bodies oflhc afl"creUl axons from 1he dentinal 1uuules are located between cell bodies of the odontoblliStS. Cell-free zone or zone of Well: contains fewer cells !han the odomoblastic layer. The capillnry and nerve plexus (plexus of Rcuchkow) are located here Ce!l-rlcb Ulne: con1ains an iocrea.<ed density of cells compared with tbe cellfree zone aod also bas a more extensive vascular system. Co01a10s fibroblasts and odomoblast progenitor cells. Pulpal core: located in the center of the pulp chamber; consist~ of rnany cells and an extensive vascular supply. Excep1 for the loca1ion. the pulpal core is very similar to the cell-rich lone.

(ANATOMIC SCIENCES

Amelogenesis (the f ormation of enamel) begins at the :

Cementoenamel junction (CEJ) Dentinoenamel junction (DEJ) Cementodentinal junction (CDJ) Mucogingival junction (MGJ)

279
Cf)fl)'l'iJhl 0 2009-2010 lktual OeekJ

GNATOMIC SCIENCES

Pulpal involvement of a carious lesion in a young child much more likely because:

i~

Caries progress faster in primary teeth Caries can enter primary teeth from the enlarged apical foramen The pulp chamber is larger in primary teeth compared to permanent teeth Reparative dentin is not as functional in primary teeth as it is in permanent teeth

Ot:nlin u ~o. n.uud

junc tinn ff>l-.))

Amtlogenesl> is the proeess of enamel mauix formation tbot oecun during the >ppositional ~tage or 1001h development. Enamel matrix is produced by omeloblast cells. These cells are columnllf cells that wlferontiatc dunng the apposition stage 111 the crown area. The enamel matrix L< secreted from each ameloblast from its Tomes' process. Tomes' process is the secretory surface of tlJe ameloblast that faces tbe dentlnoen:unel j unction (De}) . Enamel matnx is first formed in the incisal/occlusal portion of tbe fUture crown neAr the forming OEJ. Important: The OEJ is tbe iuterfaco between the dentin and enamel. The D6J IS the remnant of the onset of enamel fonnauon Dur1nJl amelogenesis, a melohlnts enter their first formative state fler the first layer of dentin is rormed. They secrete enmnel matrix as they retre'.lt away from the DEI. Ibis matri>. then minerallus. Remember: enamel ts produced in a rhythmte fa~hion. Important: The odnnloblasts begin dentin fomtation (deminoge11esi.) lmmNJiqt~ly before enamel formntion by the ameloblasts. Dentinogenesis begins with the odontoblaSts laying down a dcnlfn lltO trix or predentin. moving from !he DEJ inward toward the pulp. 'fhe mOM! rccemly fon11ed layer of dellt ln is nlw~ys adjacent to the pulpal surlacc. Note: Predentin or dcnri n matrix is a mesenohynml llfOducr consisting of 11onmlncrnlized collagen fiber;. These odootoblasts are induced by the newly formed ameloblasts to produce predentin tn layers. moving away from the DEJ.
I. The DI:J i$ also the area at which rAit lnration of tooth beguu !'lot.. 2. The morphology of the DEJ is determined at the bell stage. 3. The olde5t enoDI~I in a fully erupted molar is located at the L>EJ underlying
a tu!op.

4. Research has shown 1hnt in order for amcloblasts 1he M ru.tum inl ermedium must be presem.

10

fonu enumcl, tolls from

I hf. pull' t.: humlu.r h l:tq.~tT in pl'inwn h.tlh l'CJ111pan.tllo pcrmancnl llclh

The dental pulp tS a connecuve tissue. and thw. ha. all of the components of such a riJ!S\Ie: interceUular S\tb>tnn~c. ussue fluid, cells. lymphatic<. \'ll$CUiar s~.,em. nerves. and fillets (lfloillly C()l/ogcn und some retiCillarfibers). Cells found in the pulp: Fibroblasts: mo>t numerous Odontoblats: only cell bodies are loentetl in the pulp UntlJITorentlnted m""enchymal ceU s
WBCs nnd RDCs

'IWo ryves of uer ve< are ~ssociated with the pulp: Myelinated nerve.: re llte <lXotts of senwry or nlferent neurons O tatan: located in lhe dentinal tubuJ.:s in detllm The usocioteJ n<rw cell bodies a"' located bet" eel\ the odon tobla.<IS' cell bodies in the odontoblastic layer of the pulp UomyeUnatNI ntrvh: are assoc:iated wnh the blood vessels In addition tO being the fonnative organ of the dcntm, the pulp also hOI$ the folio" tog functions; Nut rlthe - tho pulp keeps the orgalllt cornpontn\$ or rhe surroundmg rnnlcr:llizcd tissue supphed With moisture and nutnents Sensory ... extre!llc-S in temperature. pressure. or trauma to the- U enun or l'ulp arc
l'rOl<tlivc tbc formation or reparative or secondary dentin (/Jy rite odomnhlot.<t>) linpor tunt cli nical Information : l'ulp C'.lpping is more succes.sful in young teet.h because: The apical fommen of a young pulp is large The youn~ pulp contains more cells (odonrobltJJt/cJ The young pulp tS very vaseular The youn~ pulp ba.< f<wer fibrous elemcnl~ The youns pulp bas more tissue Ouid ** Tho young pulp Jacks collat~rl cireulntion
p~rccivcd us p:11n

GNATOMIC SCIENCES

The main function of eementum is to provide rough surface anchorage for attachment of:

Transseptal fibers Sharpey's fibers Oblique fibers Alveolar crest fibers

281

COJJ)'n$b1 C 2009-2010 Dtnlal t>b

(ANATOMIC SCIENCES

Tootb sensitivity to cold, bot, or p~.ssure stimuli is usually caused by exposure of wbicb oral tissues?

Dentin
Cementum

Pulp

Enamel

Sh:upL ~

\, lilll'n:

Cemenmm is composed of u mineralized fibrous matrix and cells (cementocytts). The fibrous matrix consists of both Sborpey's fibers and intrinsic oonpenosteal fibers. Sharpey's fibers are the tenninal portions of the principal fibers of the POL (alveolodentallfgllment) tlwt are each partially inserted into the outel' part of the cementum at 90 degrees. or a right angle, to the cementa! surface, as well as the alveolar bone on their other end. Remember: Cementum is the bone-like mmeralized tissue covering the anatomical roots of teeth. The two basic types are acellular and cellular. Other functions of cementum include the following: Compensates for the loss of tooth surface due to occlusal wear by apical deposit ooo of cementum throughout life l'rotects the root surface from resorption dunng vertical eruption and tooth movement I. Histologically, cementum differs from enamel in the following ways: Not.. Cementum has collagen fibers Cementum bas cellular components in the mature tissue 2. Cementoid is the peripheral layer of developing cementum that is laid down by cemenloblasts undergoing c~mentogenesis. Cementoid is uncalcified or Immature. 3. When the cementoid reaches the full thickness needed. the cementood surrounding the ccmentocytes becomes calcified or matured and is then considered cementum. 4. Ccntentocytes are ccmentoblasts entrapped by the cementum they produce.

lhutin
Cnmpari~rr;un nf

Clu. l>entalllnnl I ilrri"i.\lf'

Ctmeotum

[a.amcl

Otntln

Alveolsr Bone
\1 """'"""

Embi)'Otogicat
bnci<g,ound

Erusmel orpn Epithelial

96~

Denuol papttlo
Conn .ecuvc tisli-Ut:

D<:ntol papma

'fnoe of tissue
lnoopnic '""<Ls lncremcnuol hn<l

Conne<.:tivt tissue Connective tiuue

701'.

65'CcmmlObla~ts. ~m<ntodasu

60'.
Arte~ t aod rc"c11a I
hne11 Osteocyto

Lines of Retzius Amoloblasts

Imbrication h.nts of A.rrnt and re' cr~ von Ebllcr sa' lines

Form.-.ti,,-e cells
RC>OC'pli\tcello

Odomobl..,.

Odontoclast:S

Odonloct.ns

O.troc:tasts
25% organic ~nd 15%
wi<T

Organic and wnICr levels

Tt.~~ formation oncr eruption

1%organic ond ZO% o1ganic and lO'A, watrr 3%water Nooe

POS:Sible None:
Pr<Sa>l

23% organic and

12%wao...
Poo>abl<

""'""!
!lrtscnl
l'r<'letll

Vnsculanty
Innervation

None
None

'None

None

GNATOMIC SCIENCES

Generally, as the dental pulp ages, the number or cells _ _ __, and the number or collagen fibers

Decreases; decreases
Decreases; increases Increases; decreases
Increases; increases

213
C'Of')>ngllt

c 20092010 rkml DeckJ

(ANATOMIC SCIENCES

Topical application of nuoridc and more recently amorphous calcium phosphate (ACP) are both treatments to remincralize the hydroxyapatite in which tissue- the hardest calcified tiss ue In the human body?

Bone

Dentin
Enamel

Cementum

l )rcnot\l'\ : incrca\l''

Important: As the dental pulp ages, lhe following chattges take place: Decreased: - intercellular suhstance. water, 1111d cells *** Mnjor decrease in lhe number ofundiflerentiated mesenchymal cell< - size of the pulp cavity due to the adduion of secondary or teniary dentin

Increased: - number of collngcn fibers -calcifications withio lhe pulp (called dcntides or pulp stone.<) Important point: As the pulp ages. 11 becomes more fibrotic. leading to a reduction in the regenerative capacity of the pulp.
Remembtr: I. The only ty pe of nerve endmg found tn the polp tS the fret orne ending, which is a specific receptor for pain. These prun receptotS are located 10 the plexus of Rascbkow. Regardless of tbe source of stimulation (heal, cold, pressure). the only rcspoo sc will be pain. 2. The pulp conlatns both m~elinated (mostly) and unmyelinated nerve fiber>. They are afferent and sympatbeuc. 3. The myelinated fibers are the a.xons of sensory or afferent neurons that are located in the dentinal tubules in dentin. 4. The unmyelinoted 11hers are sympathCtlC and associated "llh the blood vessels. Note: Proprioceptors (which respond tn .wmuli regarding movement) arc nut found In the pu lp.

t n:tmd

Enamel is the hardest calciOcd tlssnc .n the human body and tho richest in c"tciwn. Enamel is highly mineruliJ!ed and is totally acellular. h consists of approximately 96% tnorganic material (primari(l' calciw" and plwsphon~t o.v hydro:ry11putite), 1% organic material, and 3% water. Enamel is of ectodermal origin. The o rgnnic matrix consists mainly of protein. wldch is rich In proline. The fundamenllll morphologic unit of enamel is the enamel rod or prism - bound together by an mterprismatic substance (interrod substance). Each IS fonned in mcrerucnts by a single cnamelfonniog cell. the ameloblast. Most enamel rods extend the width of the enamel from the DEJ to tbe outer enamel surface. Consequently. each enamel rod is oriented somewhat perpendicular to the OEJ aod the outer eoamel surface. The specific shape of tbe enamel rod is dictated by the Tomes' process of the nmeloblust. In most cases, each enamel rod is <:ylilldrical in the longitudinal ~ectioo. In most urens ofcname~ the enamel rod is about 4 micrometers in diameter. Note: The o!dest enamel in a fully erupted tooth is located at the OEJ underlying a cusp or cmgulum. Other important facts about enamel: It bas no powtr of regeneration - the nmeloblasts lose the~r functional ability "ben the crown of the tooth has been completed It has no power of metaboltsm lt has no means of combating bacterial mvasioo - the susceptibility o f the mineral component to dissolution [nan acid environment is the basis for dental decay h has no nene supply It is a good U1ennal insulator The ucld solubility of the surface enamel is reduced by nuondc {this is the basis for /he topical application offluorides In dental caries prewmtlon)

(ANATOMIC SCIENCES

What percent of mature enamel is not inorganic hydroxyapatite?

4%
10% 16%

25%

215
Cop)'n,ab1 C 2009-2010 DtmaJ Dk:t

( ANATOMIC SCIENCES

Which of the following is the line found in all deciduous teeth and in the larger cusps of the permanent first molars that marks the division between enamel formed before birth and enamel formed after birth?

Hunter-Schreger bands Lines of Retzius

Perikymata

Neonatal line

Enamel is a highly mineralized sttucture containing approximately 96% ino rganic material. This inorganic component consists of mainly (909S%) calcium hydroxyapatite with the chemical fommla ofCato(P0,)6(0H)2 Other minerals. such as carl>onate,tnagnesium, potassium, !iOdium, and nuoride. arc also present in smaller amounts. Note: Due to the high inorganic content, enamel appears opticaUy clear on a histologic section of the human tooth. Enamel also consists of nn organic matrix (/%)and ~>ater (3%). Tbas organic matriK and water content decreases as enamel marures. At the same time, the inorganic content mcreases. Enamel is semitranslucent and rums various shades of yellow-wbite because of the underlying dentin. The enamel on primary teeth has li more opaquu crystalline form and thus appears whiter than on permanent teeth. Note: Enamel is a selectively permeable membrane, allowing water and certain ions to pass via osmosis.

Enamel fonnation begins at the future cusp and spreads down the cusp slope. As the ameloblasts retreat in incremental steps. the ameloblasts create an ani fact ln the enamel called the lines of Rcltiu~. Where these lines terminate at th~ tooth surface they create tiny valley> on the tooth surface that travel circumfcrentially around the crown known ns perikymata or imbtitatlon tines of Pickerill. One of the lines of RelllUS is accentuated and is more obvious than the others. It,. the noonatalline that marks the division bet\Vten enamel formed before binh and that which is produced after birth this neonatal liue is found ilt ull deciduous teeth and in the larger cusps of the permanent lim molars. Enamel lufts ate fan-shaped, hypocalciftcd suuctur"" or enamel roo thai Notu project from the dentinocnamcl junction into the enamel proper. They uc found an the inner one..,h{rd of enamel and represent areas of less mtnerali-union. Emnncl tufts are an anontaly of cryslllllizatioo and seem iO have no dinical importance. Enamel 5phtdlcs represent short dentinal tubules near tlie OEJ. They result nom odontoblasts that crossed the basement membrane befor~ it mtnernlized inao the OEJ. These dentinal tubules become trapped during the apposition of enamel morrix. and enamel becomes mineralized around them. They may serve as pain
recep1ors.

Enamel lamellae are partially calcilied vertical defects in the enamel resembling cracks or lracrures that traverse the entire length nfthc crown frum the surface to the DEJ. They are narrower and longer than enamel tufts. Enamel lamellae are an anomaly of crystallization and seem to have no clinical importance. The tenn Hunter-Schrc~er bands tofers to the altcntnung light aud dark lines seen in dental enamel that be11in at the DEJ and end before they reach the enamel surface. They represent areas of enamel rods cut in cross~section dispersed bet\\ecn areas of rods cut looguudanally.

(ANATOMIC SCIENCES

Where would you expect to see the incremental lines of von Ebner?

Alveolar bone Eoamcl

Dentin
Cemenlum

217
Copyn,aht 0 2(11.2010 Dcnta.IDb

GNATOMIC SCIENCES

The organic component of dentin primarily consists of:

Collagen fibers Elastic fibers Odontoblasts Amcloblas!S

l>c. nlin

The Incremental (or imbrication) lines of von Ebner in dentin can be likened to the growth rin~ or incremental lines of Retzius in en3Jt1el. The incremental lines of von Ebner show the incremental na!Ure of dentin appositton and run at right angle to the dentinal tubules. The contour lines of Owen are a number of adjoining purallel imbricmion lines tha( are present in stained dentin . These comour lines demonstrate a disturbance in body metabolism that aftects the odontoblasts by altering their fonnntion efforts. These contour lines appear together as a senes of dark bands. The mo!.l pronounced comour line is the neonatal line that occurs during the t:rauma of birth. Otlter contour lines occur with tetracycline staining of the teeth. in which the nn tibiotic becomes pcnnaoently and chemically bound to the dentin. Tomes' granular layer is most often found in the peripheral portion of the dentin beneath tbe root's cementum adjacent to the DCJ (dentinocememaljuroctiofl). This area only looks granular because of its spotty microscopic appearance. The cause of the change in this region of dentin is tmkoown.

( oll.tcc.n filwr-..

Dentin is the specialized connective tissue that makes up the bulk of the tooth, extending for almost its entire length. Dentin is hard. elastic, 70% inorganic, 20% organic, and I0% water. The Inorganic component consists of mainly calcium hydroxyapatite with the chemical fonnula of Catr,(P04 MOH)z. This calcium hydroxyapatite b similar to that found in higher percentages in enamel and in lower percentages in bone and cementum. Smaller amounts of other minerals. such as carbonate and Ouoride. are also present. rl. Unllke cnmtl, which is acellular, dentin has a cellular compQneot that N otu is retained allcr it~ fonnation by odontoblasts. 2. Dentin and pulp tissue arc both formed by the dtntal papilla. Pulp tissue is a loose, very vascular, and non-calcified connective tissue while dentin is ava scular and a calcified tissue. 3. The main cell type in dentin is the odontoblast, which is derived from cctomcscnchymt. 4. Dentin is much softer than enamel but harder than bone. Dentin is more nexiblc (lower modulus of elasticity) tltan enamel. Dentin's compressi\e strength is much higher than its tensile strength. 5. Dentin is more ruioerulizcd than cementum or bone but less mioerall~ed than enamel. Morphologically and chemically, dentin bas many characteristics in common with bone. 6. The major organic component of dentin is type I collagen fibers (91% to
92%).

GNATOMIC SCIENCES

In orthodontic tooth movement, bone remodeling Is forced. Tbe bands, wires, or appUanccs 11ut pressure on one side of the tooth and adjacent alveolar bone, creating a zone of In the PDL. This leads to bone . On the opposite side of the tooth and bone, a zone develops In the PDL and causes the or bone.

Tension; deposition; compression; resorption Compression: resorption; tension: deposition Compression; deposition; tension; resorption

Tension; resorption~ compression; deposition

2a9 Copyn,aht Cl 2009-2010 Dtn~al l)e(ks

GNATOMIC SCIENCES

I\..

Apical absNsses of which teeth bave a marked tendency to produce cervical spread of infection most rapidly?

Mandibular ccntml and lateral incisors Mandibular canine and first premolar Maxillary first and second molars Mandibular second and third molars

OnbOOontic movement of teeth always causes remodeling oftbe alveolar bone proper to accommodnce movement of the teeth. Important: The new alveolar bone deposited during orthodontic trencment is best described as lntrn111 cmbranous.

Remember:
Ostcoblasts (dem-edfrom mesMchyme. f.e.jibrob/tlSIS) are bone-fom1ing cells that secrete tbe collagen nnd minerals needed to lay down new booe in c.heir vicinity. OsteoblaslS that have been trapped in the osteoid produced by otbcr S\UTOunding osteoblasts are called oste<Kyle5. Osteocytes maintain bones. play a role in controlling the extracellular concentration of calciwn and phosphate, and arc dtrectly ~lHoulatcd by calchonio and inhibited by PTH (poratltymid ltonllone). OstcOciMts (wlliclr are tlerll'ed ji'Om stem cells /11 rite bone marrow -- tile same o11es that produce monOC) res and macrophages) are bone-resorbmg cells. They are essential panners for bone modeling and remodeling. Their res<>l'fltive activity allows the pcnnnnenl renewing of bone and regulates calcium homeostasis. l. A similar situation is the alleroate loosen1ng and tightening of a deciduous !'.o1..- tooth before 11 is lost. This 15 caused by the alternate resorption (umcmoclasiS. osteoclasiS) and apposition (cememoblasts. ostcoblasts) of cementum and bone. 2. During active tooth eruption, there ts apposition of bone on aU surfaces of the alveolar crest and on all walls of the bony socket. Remember: Pennanem teeth move occlusally and buccally when erupting.

\lantlihul.1r rwcuntl aud lhh-d runb,...,

Cenain anatomic features determine 10 a lar~e extent the acnml direction thai infection may take. The atlacltmcul of muscles may decmnine the roule that :Ill infection will take. channehng the infec11on into cenam tissue SJ!'Ice<.
ll'l'lh
~I lid

lim.::ll'n.~elllltliun

or \h\lt'""\'\ and .... lul.ll'

Cllnlc"l Prtsenttllm of l.tt:~n

Ma:Q.UII)' 'oi:SIIbWe

rcttb MMt Conunonlylnvoh(d

Muilt..y ~and IA....C mcisoc Ma.ullary ur~ine. (ifroN IJ 1Jwrt and in/MCH' ltllf'WJMr -m&JIIi oris) Maxillary pn:anolm Max.illat)' molars (IJ'INul roo!) art ~~~on .md Jlf{trl()r to /N;.criftalu~")

~'-'floc<

MatU.,y central t.nttw

Maxi liar)' canine (ifroot u ltmg flnd .wtpuftutv ln-a/01' tiiiJ.:.rlfi oris) MaxiJJuy l~rerul in<:i~
Mofj]J.uy pmnolm (linpDI ,_)

Nasolabial ddn n.'gK)o

Pai.Me

MwU"Y .,.,..,. (pdlo141 roJ

Perforatl(ln 10to aw:Uiitf)'

Maxilll'tly molart (Jfbt~Cet~l rf>Ols ar~ lmtll)

~UJI.lry

fiinU.'!

Bu<W !lido wrf~~:

Man~ .. 'ICSI.Ibu.le

molln (i/buca.l roou au ~tprrW {() bw<aOD'->1}

Mmd.ibu.Lir ittcisors (if1'0011 M~t.dwn atJ snptrinr., W~t:r~laltsJ Mandibul eanines and pre:molaC'i I ifroou ar-t sMn ur~J ('U{'<'rior ro dlprtruors) Mandibul~~r rtrs1 and te<:Ond molar$ (ifroots ore slon umltUJit'rior '" I'HtccmatorJ
Mand ibu1u i.Deison (ifrotJI.f o" ltmg unJ ucforior to Mftflalb)
Mmdh:d fi~ molar (if flft!IIO/ f'l)fJJf b mort tmd nqNrlt;r IQ m.rloiryo1dl Mandlbul.lr ~nd molar tifm~gW~IIllf)llt shorl and .ruptrior ra 'fJ).foll>'f!ld)

Subrrv:nt:al lun ~&ior'

Sablmpal teJioo
Sbbnmn(liblll~r'Skin (c~on

Mandibulur scoond 010l:u (if lt~'1l(.J[ rot>~ Is lung and /Jifrr!Qr 10 m)luhhmiJ MandibuLar dl:ird molln (I/nJ()IS art m/D~ toiW)'Io-'11 t,tkl}

c A.~ATOMIC SCIENCES
The lamina dura is the hard layer of bone surrounding tbe periodontal ligament along the roots of teeth. T he lamina dura is a component of wbicb of the following?

Alveolar bone proper Supporting alveolar bone

Alveolar crest

Cortical plate

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G NATOMIC SCIENCES

A delicate membrane covering the crown of a newly erupted tooth Is called:

Perikymata
The primary enamel cuticle

Henwig 's root sheath Plasmalemma

~2

Copyri&ht 0 ZQ.lOIO Dmtt.llkd:s

\h rnl3 r hmh.' p rttpl'r

111e alveolar process is thai pan of 1he maxilla and mundil)le that forms und suppom !he socke1s of the teeth. Like all bone, ma1urc nlveolar bone IS by weight60'Yo minernlizcd, or in organic- rruuerial. 2S% orgolnic material. and lS% water. The inorganic compcment consist'\ of mainly caldum hydroxyapatht with 1he chemical formula of CBtofPOtl.\(OH)2. This ealcium hydro\yopallle is similar to thai found in higher percentages in enamel ;md dtnbn and is most similar 10 1bat of cementum. The aheolar pmcess consists OfhO main pans: l. Alvtolr bone proper .. is u Oun layer of compact bone that is a SJXI\:Iolizcd continua cion of the cnrticul 1>lnte wtd fmms the tooth socket ur alveolus. Note: The lnminu duralo 11 horseshoe-shaped whnc line oo a dent;!] radiogroph !hat ruughlycorrespands 10 the alveolar bone proper. The lamma dum ""-' minute openinl!S thai provide paSsnges for vascular and nerve: componems. ltts compo>e<l of compact bonr, but is sometimes called bundle boot due to 1he presence of bundles of perfQf'3tinl! Sharpe~s fibers. 2. SupporlinA 1\'toiRr bone --tho! buoe that surrounds lh< alveolar bone proper and gives suppon lo the ~ocker. h consists of: CortJcal plnte - Structurally. 1he cunicl plalc " compu._d ol' lingual and facial plates of compact bone, The eortical plate is dense in nature and proides streng1h and protection nnd IICIS as theaiUlchm<nt for skclcml nul<4'1es. The mandibular cortical plate is more d,-nse !han the maxilbcry cortical plate aod bu fewer perf0r.1uons for the paSSlll,!e of nerve. and blood vessels. Note: The ulvcolnr crest is the highest point of 1he alveolar ridge nnd ,joins the fucial and Jingunl conical plales. Spongy bone (mucel/ou.r bon)- tills in the nrcd hctweon conical pltc>llnd alveolar bone proper. This typ< of bone 1< not presetll in !he anrcnor r<gion of !he m"uth: here the cortical plate is fitsed 10 the alveolar bone proper. Th1~ is also~ o er the radicu!M buc cal booc of the mnllillary ~tenOI$ Note: The alvolar bono proper tS tbe only essential 11ort of the bone sock~!. The su1> poniug alveolnr ~one is not alwnys ]>rosen~

I h\' prima r~

\'llUIU\'1 t:ulidc

Also called Nasmylh's m~mbrane. It is produced by the ameloblast cellallerit produces the enamel rods. 11te primary <numtl cuticle consists of two extremely thin layers (tire Inner ana clear /Jnd .vlriiCIIIreles.<. tile ower one cellulat1. coverin~: the entire crown of newly eruptM teeth and ~ubsequcntly abraded by mastication; the culicle is evident mi croscopicaUy as an amorphous material between the nuachment epitbeli~m and the tooth. This cuticle IS wom away by masttcation 8rtd cleaning. Nasmyth 's membrane is replaced by an organic dtpostt called the pellicle, wbicb is fonned by salivary proteins. It is this pellicle that is invaded by bacteria 10 form bacterial plaque lha~ if not remo\ed, will cause

den\a\ caries And peri()dontal disease.

Remember: Enamel is incapable of repairing lbclr once it is destroyed (wrlike tlenti11), After the ameloblnsts are finished with bolh enamel apposition and maturation. they be come part of the rtduced enamel epllbellum, atoog with the other portions of the com pressed enamel organ. The reduced enamel epithelium fuses \vith tho t>ml mucos:t, creating n c:tnalto allow the enamel cusp tip lo erupt through the oral muc'<ISa into tho Qrn[ cuvity. 'Unrortunatcly, llo ameloblasts are lost fore,er as the 1\sed tiosutiS disintegrate during tOOth eruptiou, preventing aoy further enamQI apposition.

(ANATOMIC SCIENCES

A physician determines that a patlcnt with acromegaly will develop a skeletal class Ill occlusion due to excessive growth of the mandible. What causes the formation of resting lines as seen in the cortical bone of the mandible?

Growth of the mandible by appositional growth Grov.'lh of the mandible by interstitial gro~~o'lh Growth of the mandible by both interstitial and appositional growth

29l
Copyrigllt 0 2009-2010 Dml;all)t();s

( ANATOMIC SCIENCES

(\.
Triacctate fiber Tomes' fiber Tag fiber Korff's fiber

Dentin is considered a living tissue because of odontoblastic cell processes known as:

Remember: 1. Bone apposition is the deposition of suocessive layers of bone on those already pres
ent. 2. Due to its rigid structure, bone can grow only by appositional growth. However.

cartilage can grow by both appositionnl and interstitial growth. Remember also that both the maxilla and mandible develop from tissues of the first branchial arch, or mandibular arch. The maxilla forms within the ma.,illary process, and the mandible forms within the fused mandibular processes of the mandibular arch. Both bones start a.~ small centers of intramembranous ossifiCAtion.

lunu,. tihtr

These odontoblastic processes (Tomes 'fibers) occupy the dentinal tubules. The~ is one per odontoblast. It jq because of these odontoblastic cell processes \bat dentin Is
roosidered a living tissue, with the capability to ~act to different stimuli and produce secondary, sclerotic. and!or reparative dentin. Dentin sensitivity is not \\ell understood. One theory is that Tomes' fibers are receptors and transmit an impulse to pulpal nerves. The preferred theory is thatlluid movemeot within tltc !lobules, in response to a stimulus. triggers the pulpal nerves. Remember: The odontoblasts begin dentin formation (dentinogenesis) immedhotely before enamel formation by the nrneloblasts. Dentinogenesis begins with the odontoblasts laying down a dentin matrix or predentin, moving from the DEJ inward toward the pulp. The most rccen!ly formed layer of dentin is always adjacent to the pulpal surface. Note: Predentin or dentin matrix is a mesenchymal product consisting of nonmineralized collagen fibers. Remember: Amcloguesis is the proces of enamel matrix formation that occurs during the appositional stage of tooth development. Enamel matrix is produced by ameloblast cells. These cells are columnar cells that differentiate during the apposition ~lllge in the crown area. The enamel matrix is secreted from each ameloblast from its Tomes' process. The Tomes' process is the secretory surface of the ameloblast that faces the deotlnoenamel junction (DE.!).

I. The cell body of the odontoblast lies in tbe pulp cavity.

2. The dentinal tubules are S.Shaped (curmturF) in the ero" n due to overcrowding of odontoblasts. This curvature of the tubules decreases In root
dentin.

GNATOMIC SCIENCES

( \..

Which of the following is p roduced In reaction to various stimuli such as attr ition, caries, or a restorative dental procedure?

Primary dentin Secondary dentin Reparative dent in

Mantle dentin

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G NATOMIC SCIENCES

Tth

H is 0

( \..
Cemen1um

All of the following arise from the dental sac EXCEPT one. Which one is the EXCEPTION?

Alveolar bone proper

Periodontal ligament Dental pulp

160

Rrparolll\l' <hnlin

Reparative dentin or tertiary dentin is dentin formed 'ery rapidly in locali7ed regions in response to a localized injury to exposed dentin. The mjury could be caries. ca'iry preparation, attrition, or recession. Odontoblasts 111 the area of the affected tubules might die because of the mjury, but neighboring undifl'etentinted mesenchymal cells of the pulp move and become odontoblasiS. Tertiary dentin tries to seal off the injured arcu. thus tbe tenn reparatjve dcn1in. Primary dentin is the dentin formed in a tooth before the completion of the apical foramen of the root. Primary dentin is characterized by a regular panem of tubules. Secondary dentin is the dentin that is formed after completion of the apical foramen. Secondary dentin is formed at a slower rate than primary dentin and is less mmerahzed. Secondary dennn IS a regular and somewhat uniform layer of dentin around the pulp eavity. Secondary dentin is made by the odontoblastic layer that lines the demin-pulp interface. ~ote: Tbc junction berween primary and secondary dentin is c.hamcterized by a sharp change in the direction of dentinal tubules. When dentin Is dumagcd, usnally by the chronic injury of caries, odontoblastic processes die or retmct, leaving empty dentinal tubules. Areas witb empty dentinal tubules are called dead tracts and appear as dark areas in gound sections ofto01h With time, these dead tracts can become completely filled with mineral. This region is called blind tracts and appears white in sections of @tound tooth. A certain type of tcniary dentin eaUed sclerotic dentin fills the blind tracts. The adaptive advantage ofbhnd traCts i.~ the sealing off of the dentinal tubules to prevent bacteria from entering the pulp cavity. Clinically, this sclerotic dentin appears dark. smooth. and shiny.

Dental pulp

Perip.heral cells of the dental papilla dtft'erentiate into odomoblasts that produce predentin tlut Clllcifies and becomes dentm. The center of the dental papilla will become the d ental pulp. Cementoblasts differentiate from the inner layer nf mesenchyme of the dental sac. adjacent to tlte tooth t'OOI. Cemcntoblasts are cells that form cementum. Tbe dental sac will also form the per iodontal Ugament and the a lveolar bone proper. Cells from the Inner enamel epitbelium of the enamel organ differentiate into ameloblas ts thnt produce enamel. The inner a nd outer enamel epithelia of the enamel organ come together in the neck region and form ller twig's epithelial root sheath.

(MATOMIC SCIENCES

Tth

His0

The dental lamina, a thickening of the oral epithelium that produces the swellings of the enamel organs, Is nrst seen histologically:

Second week in utero Sixth week in utero Tenth week in utero Fourth month in utero

16~162
zt7
Copynght C 2009-201 0 Dcn~tl ll"l.t

~ATOMIC SCIENCES
Tb~ reduced

Tth

His 0

enAmel epithelium forms a s the collapse of what structure?

Cervical loop Hertwig's epithelial sheath Enamel organ

Dental lamina

163 164

By the third week al\cr conception, the primitive mouth (11omodettm) has formed. Over the next few weeks. the tongue, jaws. and palate develop. During the sixth week, formation of the teeth commences. and by eight weeks, all of the pnmary (decrduou) incisors, canines, and molars are discemable. Tooth development appears to be initiated by the mesenchyme's induct1v~ influence on the overlying ectodenn. Early in the sixth week, there appears to be a thickening of the oral ep1thelium (which is o deriva1i1e ofrhe surface <>ctodenn). These thickenings or Usbaped l:>ands are called the dentallomlna and follow the curve of the primitivejaws. At certain points on the dental lamina, the ectodermal cells proliferate and produce swellings that become the enamel organ. Inside the depression of the enamel organ, an area of condensed mesenchyme becomes the dental papilla. Surrounding both the enamel organ and dental papilla is a capsule-like structure of mesenchyme called the dental sac. Note: The enamel organ separates from the dental lamina after the first layer of dentin is deposited. Remember: Each tooth is the product of two tis.~ues that intemct during tooth development, the oral epithelium and the w1derlying ectomesenchyme. The omt epithelium grows down into the underlying ectomesenchyme and fom1s small areas of condensed mesenchyme. which become tooth germs.

I namd nrc,an

Following the formation of tbe crown. the enamel organ (the inner and outer erwmel epithelium. sltatum inlcrmedium. and srcllare reticulum) collapses to form the reduced enamel cpilheUum that covers the tooth through emption. The reduced cnamfl epithelium coosiSis of the maturelprotecu e ameloblasts and remnants of the outer la~ers of the enamel organ. Numerous capillaries, which had formed to supply oxygen and nutrients to the ameloblasts following dentin fonnation, surround the reduced enamel epithelium. The reduced enamel epithelium IS 1mponant in the fonnation of the dentogingh al junctlon, whieb is an area where the enamel and oral epithelium come together as the tooth erupts into the mouth. This forms the initial junctional cp1Lhelium (or epithelial ollachmenl), which later migrates down the tooth to assume its normal position. Remember: The junctional epithelium (or epithelial a/lochmem) altacbes the gingival tissues to the tooth usmg bemldesmosomes. The apical extent of the junctional epithelium is usually the cementoenamel junction.

(ANATOMIC SCIENCES

Tth

His 0
~

\..

Which structure functions to shape the root (or root.!) and induce dentin formation In the root area so that It Is continuous with coronal dentin'!

Dental papilla Dental lamina Dental sac Hertwig's sheath Enamel

2111 CoPYTiabt 0 2()09.2010 Dtn~allkcl:s

(ANATOMIC SCIENCES

Tth

His 0

Listed below are the usual events In the histogenesis of a tooth. Place them in their correct sequence (from what happe11s first to what happens lllst).

Deposition of the first layer of dentin Differentiation of odootoblasts Deposition of the first layer of enamel Elongation of inner enamel epithelial cells

The structure responsible for root development is Ute cervical loop. The cervical loop is the me5t cervical portion of the enamel organ. a bilayer rim that consists of only inner a nd outer enamel epithelium of the eoamel organ. The cervical loop be&Jns to grow deeper into the surrounding mesenchyme of the dental sac, elongating and moving away from the newly completed crown area to enclose more of the dental papilla tissue and fonn Hertwig's C J>lthelial root sheath (HERS). H.trtwlg's sheath is an epithelial diaphragm tbat is derived from the Inner and outer enamel epithelium of the enamel organ. After cro" n formation. the root sheath gro"s down and shapes the root of the tooth and induces fommtion of root dentin. Uniform gro\VIb of this sheath will result in the formation of a single-rooted tooth, while medial outgrowths or evaginatlons of this sheath will produce multi-rooted teeth. After the first root dentin is deposited, the cervical ponion ofHenwig's epithelial root sheath breaks down, and this new dentin comes in contact with the dental sac. Thts communication stinaulates cells to differentiate into cemcntobl~sts that produce cementum. This process is called cementogcnesis. Note: Accessory root canals arc fonned by a break or perforation in the root ~heath before the root dentin is deposited.

I. Flun~~tion of lh\' inner rnaml'l l'pilhelial n.'lh of thl l'tnlml'l or:.:,an: thi

inllmnt.'\'' nlt.'\l'IICh~ mal .:l'll\ on lhl' att intu mlontohhl\h (#] bdoll') 2. J)itftn.ntiatiun nf juluntnhla'h

I'J('fiphtT~

uf lhl dlOta11H11Jilla IO difflnnfi-

.l. lltJ)tl,ilinn of fhl' n.-.... la~t.'r nr tllntin .... llqm ... itiun of tlu. lir<rol la~lr nr l'n:und

Tooth development is dependent on a series of sequential cellular interactions between epithelial and mesenchymal components of the tooth germ. Once the ectomesenchyme influences the oral epithelium to grow down into the ectomcsenchyme and become a tooth genn. tbe above eventS occur. I. Some texts include lbe deposition of root dentin and cementum as #5 in Notts the histogeuesis of a tooth. 2. Korff's tlbcrs is a name given to tbe rope-like grouping of fibers ill the periphery of the pulp that seem to have something to do with the formation of dentin matrix. Remember: Histogenesis means the formation and development of the tissues of the body, in this case the tooth.

GNATOMIC SCIENCES

Tth

His0

\..

Identify the following areas of a developing tooth bud on tbe schematic drawing below.

Oral epithelium Dental lamina Enamel organ Dental sac Dental papilla

301
('op)'l'lfht 0 2009-2010 !Xntal [)r(:b

( ANATOMIC SCIE~CES

The four distinct layers of tbe enamel organ include all of the folio,. log EXCEPT one. Wbitb one is the EXCEPTION?

Outer enamel epithelium Inner enamel epithelium Stratum granulosum Stratum iotermedium Stellate reticulum

Oral tpilbelium

Dental lamina----,

Dental papilla Dental

Four layers of the enumel organ: l. Outer enamel epithelium (OEE) . lhe outer cellular layer of lhe enamel organ (very thin). This layer outlines the shape of the fulure developing enamel organ. 2. Inner enamel epithelium (fEE) . 1he innermost cellular la~er oflhe enamel organ (very thin). The cells in this layer will become ameloblasts and produce enamel. This layer Is essential for lite initiation of dentin formation once enamel is formed. 3. Stratum lntermcdlum - this area lies immediately lateral to the inner enamel epithelium {thidcer than both the OEE and lEE). This layer of cells seems to be essential to enamel formation (prepares mthiems for the ameloblasts of the lEE). 4. Stellate reticulum this area is the central core and fills the bulk of the enamel organ. This layer conlains a lot of Intercellular Ould (mucust)pefluid rich in albumin) that is loSt jusl before enamel deposition. Remember: After enamel formation is completed. all of the above struclurcs of the enamel organ become one and form the reduced enamel epithelium. This is imponant in the formation of the dentogingiv;ol junctlon, which is an area where the enamel and epithelium eome together as the tooth erupts into the mouth. This forms the initial junctional epithelium (or epithelial al/achmenl), which later migrates down the tooth to assume its normal posilion.

(ANATOMIC SCIENCES

Tth

His0
"'

,.
A young girl presents to the dentist with yellow, thin, chalky enamel, but sound dentin. The diagnosis Is amelogenesis lmllCrfecta and is a genetic disorder with malformed enamel. In amelogenesis imperfccta, there Is an error in what stage in the nrc cycle or a tooth?
Initiation

Bud stage
Cap stage

Bell stage
Apposition Calcification

Eruption
Attrition
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166

GNATOMIC SCIENCES

Tth

His0

,.
A cementicle Is a spherical, calcified body that lies in the periodontal ligamen t or fused to the cementum of a tooth. The remnants or the epithelial \.. root sheath that then become calcltled to form a cementicle are called: ~ Accessory root canals The epithelial rests of Malassez The dentinoenamel junction (DEJ) The ccmcntoenamcl j unction (CEJ)

165

I. Initiation (sixth tose>'t'tlllrweeks)- Ectoderm lining stomodeum gives rise to oral cpithehwn and then tO dental lamina. adjacent tO deeper I.'Ctomesenchyme, which is influenced by the newal crest cells. lnduollon os the maon process involved. Congenitalab sence of teeth (anodontia) and supernumerary teem result from an interruphon m thts phase. 2. Bud stage (eighth wk) Growth of dental lamina into bud that penetrates growing ectomesenchyme. ProlifHation is tbe mam process invohed. 3. Cap stage (nimh In tell/It weeks) Enamel organ fonns into a cap. surrounding the mn.~s of the de mal papilla from the e<:tomesenchyme and surrounded by the mass of the dental sac also from the ectomesencbyme, thus forming the tooth germ. ProUfcrotlon, differentiation, and morphogenesis ore the mnin processes involved. Dens in demc. geminauou, fusion, and tubercle fon11ation occur during this phase. 4. Dell stage (eleventh to rweljlh week.1) final shaping of[l)()th. cells differentiate into specific tissue fonning cells (omeloblasu. odonlt!blasrs. cememoblusrs. und fibruh/asu) in the enamel organ. Histodifferentla tlon and morphodifferentiation are the main processes invol~ed. Macrodontialmicrodontin occur during this stage. 5. Appo.drion (varies per tooth) ceU that were differentiated into specific ussue-fonn ing cells begin to deposit the specific dcntaltL'>S\Its (enamel, dentin, cememum, tmd pulp). Enamel dysplasia, concrescence. and the fonnJJUOn of enamel pearls occur during thts Stage. 6. Calcilkation (varies JNr rooth) minerali1.ation 7. Eruption (aries per tooth) 8. Attrition (varies per tooth) Note: Dentinogenesis irupcrfecta :md nmeloglncsis impcrfeda occur during hostO differentiation (Bell stage).

The epithelial rests ofMalass<:L are remua.ms of Henwig's epithelial root s heath ,.,I() e01
be found as groups uf epithelial cells 10 the periodontal ligament Some rests dcgenernte: others become calcified (fonn cemcnticlc.t). Rt.member: Th purpose or Henwig's epnhehal root sheath os to shape of the root (or roots) and indu~e Mntin formation (b)' stimulating the diffrrentiallon ofodolllobla.tL<) in the root area so that it is continuous woth coronal denrin. After tllis root dentin ~~ deposited, the cervical portion of the root sheath breaks down, and thi~ new dentin comes in contact with the dental sac. This contoct stimulates cells From we dental sn~ tO differentiate into cells that will produce cementum, the PDL, and tlte alveolar bone proper. Important: The continuity of Hcrtwig's epithelial root sheath must be broken ill order for cementum to be deposited during tOOth development (cememogen~sir). llertwig's epithelial root sbearb is characreri2ed by: The formation of ceU rests (resiJ ofMalosse:) uo the PDL when the sheaths timet rons have been aceomplished The bsence of a stellate reticulum and a stnuwn intennedium Remember: The structure responsible for root develOpment is the cervical loop, wbicb ts the most cervical pomon of the enamel organ.

GNATOMIC SCIENCES

Tth

His0

Histologically, the dentin or the root is distinguished from the dentin of tbe crown by the presence of:

Incremental lines of Rctzius Rete pegs Tomes granular layer Sharpcy's fi bers

S05 Cop)-nJh1 0 20092010 DcnuiOh

(ANATOMIC SCIENCES

Tth

His 0

The tooth germ is composed of all oftbc follo"ing EXCEPT one. Which one is the EXCEPTIOJV!

Enamel organ Dental sue Dental pulp Dental papilla

Tomr\ cnmul.tr I<J~ l'r luf,a 'allcd rh, ~rmmlar lara oj Tium"'J Important: Histologically, the dentin of the root is distinguished readily from the dentin of the crown by lhe presence of Tomes' granular layer. Tomes' granular layer is most ofien found in the peripheral ponion of the dentin beneath the root's cementum, adjacent to the dcntinocementaljunction (0CJ).11lis area only looks grnnu lar because of its spotty microscopic appearance. Tbe cause of lhe change in this region of dentin is unknown. It muy be due to less calcified areas of dentin similar to interglobular dentin or loops of the terminal portions of braocbing dentinal tubules found near the DCJ similar to lhat of the DEJ. lnterglobul:tr dentin diffcn from Tomes' grnnul3f layer in that interglobular dentin usually occurs a sbon distance inside the DEl. Remember: Enamel formation begins at the future cusp and spreads do"o the cusp slope. As the amdoblasts retreat in incremental steps, lhe ameloblasts create an anifact in the enamel called the llncs of Retzius. Whtre these lines terminate at the tOOth surface, they create tiny valleys on the tooth surface that travel circumfcrcntially around the Ct'Own known us perikymata or im brication lines of Pickco lll. O ne of the lines of Retzius is accenmmed and i~ more obvious than the others. It is the neonata l line that marks the division between enamel formed before birth and that which is produced aner btrth - this neonatal line is found in all deciduous teeth und in the larger cusps of the permanent first molars. I. Globular dentin: refers to areas of both primary and secondary moneraliza-

1\ota rion 1n dentin.

2. loterglol>ular dentin: refers to areas in dentin where only primary mineralization has occurred 'vithin the predentin. Interglobular dentin is slightly less minernlized than globular dentin. Interglobular dentin is especially evident in coronul dentin and near the DEJ.

Ul'ntal pulp

Componenu of the tooth germ: l. Enamel organ, whicb is formed from orol epitheliu~ wbicb is denved from ectoderm. The cn:trnel organ bas four di<llntt cell layers: I. Outer enamel epitheliwn 2. loner enBmel epitheliwn 3. Strntwn intermedium 4. Stellate reticulum The enamel organ will give rise 10 enamel and will eventuully form Hertwig's epithelial root sheath (HERS).
2. Dental sac. which is formed from mesenchyme (eetomesenchym~). which is denved from neural crest cells. The dental sac surrounds the de\'cloping tooth germ and will give rise to the cementum, tbe POL, and the al\eolar bone IJrOper.

3. Dental papilla, whlc.il is also fonned from mesenchyme (ectomesendoymc), which is derived tlom neural crest cells. The dcntol papilla will give rise to the tlcntln and dental pulp. Note: The outer layers of cells difTerentiate into th.e odontoblasts (defltin-fnrming cells).

(ANATOMIC SCIENCES

Vn~

The portal vein is about 2 inches long and is formed behind the neck of the pancreas by the union of the:

Left gastric and the left colic veins Appendicular and the inferior mesenteric veins Superior mesenteric and the splenic veins Right gastric and the right colic veins

167
307

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(ANATOMIC SCIENCES

Vn~

Mos t posterior in tercostal veins empty Into the which In turn empties Into the at the fourth thoracic vertebra.

Femoral vein; inferior vena cava

Subclavian vein; brachiocephalic vein Azygos venous system; superior vena cava Splenic vein; hepatic ponal system

168
308 Copyricht 0 1CJ09.2010 Oct:lt&l Offi.s

The porto I vdn (mwt commo11/y rejim'l!tllo us tire hep!lllc portal H'in) l~ n major vein that drains blOC<! from the obdominal pan oflhe gaStrouttcsiiMI tract from the tower third ufthe e'ophag~ 10 h~lflllay down the anal canal. the ponal vem also drain< blood from the spl<et\, panea., and gallbladder. The portal vein enters the hv.,. and break up mto >inu.<oids, from which blood piiSses into the h~patic veins thKijoitlthc mfenor vena cnva. ll1e portal vein is form<d beltind the nc~k of the panoreus by ihe union of the uperlor nttscntcric and the splenk veins. The portl vein o;;ccnd to the righ~ bchi11d 01c tlrst part of the duodenum. and enters tbe l.,..,r omcnt11m The pon:ll vein then runs upward m fron1 of the opening imo the le;ser &ac to the porta hepolh, where u dtvides intO nghr ond lei\ brancho, before enrenng
the liver.

Almost all of the blood coming from tho digestive Sysrcm drains into u spocoal vcnou dt<:ulnrion called rhe portal tlrculutlon. Th{s b becou>< it contams ull ~ nutrients and roxins that ha>e been absorbc<l along rhe digestive ltllct frnm mgested food. llefore these tbsorl>ed ublitances can It" m10 lhe r>emie clrculutrOI~ rhe portal con.,dariou musr be filr...ed lirM to remove or "dermMy" !hom. This tilteting lind dcto"fi""'""' nre funchtt< or tllo liver. The tribuumes of the ponal vein are I he: Splonlr vein: joiJl.'l the 'uperior ~1\<nt vein to form the ponl \'etn Inferior moteric -rln: is joined by the splenic \eon. whoch dnun$1he accesS(\<) dr gesuve OlltiUJS or tile pancreas aod spJ.~n. liS well ns pan Of the stom"ch Suplrlor n1eseuterh: vein: joins tho spll."nic vein to fonn1he ponu1 vein Cusrrlc vein, wboch drains the urper pan M the stomach. aud l.bc cytlc veins. which drnio the gollblndder, ulso dTBin iniO the ponal eio Not.: Onee bi<JOd cklivcred by the hcp.,uc porull sys1em Ius filtertd through lbe liver. rhe blood Is terumed to the hean "in rb< Inferior ' 'ena ca,a. lnopor1nnl: The pol'l~l vein tarries h\itt as much blood ns tlo~ hepatic nr~ery.

V\ t:n'

\ t nuu~ "~'It'll! , 'upcriur \ t n11 ~r. .:n 11

The lrtttrnftljugular and ubcla\1ian ><Ins of eacb >ode join at the firsr intcrc01aol cnrtllo&o to fom1 the superior v0no cnvft. Anmtercnsml vuin runs ulo>lgside each i111crcosral urtcry. Each side has clewu posteriorimercost"l veins and uno suhcoslal vein. Mosr potennr intercostal veins '-"mP'Y intn the ft:t.)'gOs vcnOU5 sy~tem, wbich in tUrn em11ties mto the $Up~rtor ,eoa cava at rbe four01 thomcic venct>... The til:) CO> veins COtiM>ts ur!he main 8l)IIOS vem, 1hc Inferior bentiALy~os vein, and the superior hemiaeygos v.:m. They dram blqod from the po.'\terlor pans of lhe mten:osUll spnceo, tlo posterior obdonnnol wall. the ptricardium1 Uoc diophragm. the bronchi. and the csopbugus, The unaon of rbe aty~;o< 'eln is 'anahle h b otltn fonnod by the umon of tbc rlgbl asCt'ndin{llumbar vem IIllO the rlgbtsubeostal ein. n1c ~Lygos vdn osnds thmugh the .our ric opening in 1be dwpbrogm on !he ci!lht si~e of the ui'IK to the level nf 1hc fifth rhomcic vertcbl'ft. 1-lcre the vein urches forwurd above d1e roor oflhe righ11Ung to er\lpty in10 the pos terior 1urface of'rhe superior nna cav. "'ute: n,e 117YI!O> v<in leave5 ou impression on the nghr hma us the "''" arche;, ow the root Tbe li7Y!l< vein has numeroU> tributnries 11\al inolllde the d~tht lower lntei"(OJIIal vem.<, rh.: rigbtsoptrior lnoen:ol~l ve111.1he superior ond inferior hemiaeygos veon. and num<wu orediastinol vems. The supCI'IOr vena cnv11 i.!t one of the tWo mAin vein~ (rite mlrcr hein,g the fu/&tio,~ "enu c :uwr) bringing dooxygennrcd blood from the body to lho belli~ Vcms fiom the head and upp.:r bady feed onto the supenor vcnu cava, which empties intu the nght atrium or the hc:!tl. '\olf: The infenor veno uava carnes blood bac~ to lhe right atrilUll from the lower pan or rhe body. Remember: At the 1'0()1 of the neck, rbolntornal ju.gulr veiu joiM rho sulk:lovian ' 'cin to fonn the large brachiocepltalic "cin. This O<!ctii'S un bnth Rid"" of the Muk, and rhc twn brachlocCJihUc veins tillite in lhe suporior medhtstinum to font) the 1uperior en11 cava (tht <IZII80S vein uiJO /olru tltcpostermr aspect ofthe rx:rior vena CD\'0 Justlwfo,Y! 11 pw~tes
the pertcanfium).

(ANATOMIC SCIENCES

Each subclavian vein Is a continuation of the-:-:-----.,. and runs from the outer border of the nrst rib to the medial border of the scalenus anterior muscle.

Brachial vein Brachiocepbalic vein Internal jugular vein

Axilla.ry vein

309

c:opyn,bl c 2009-2010 Dmtal Dtcb

~ATOMIC SCIENCES
Oxygenated blood leaves the placenta and enters the fetus through the:

Foramen ovale
Ductus venosus
Umbilical aneries
Ductus arteriosum

Umbilical vein

The subclavian veins are two large veins. one on either side of the body. Each subclavian vein begins at the Oilier border of the l11'$t rib as a eonnnuation or the axillary vein. At the medial border of the scalenus anterior, the vein joins !he Internal jugular vein to ronn the brnchlocephalic vein. lmporhmt: Tbe subclavian vein crosses the first rib anterior to the scalenus anterior muscle. The uternal jugular nin lies in the superficial fascia deep to the platysma. The vein passes downward from the region or the angle of the mandible to the middle of the clavicle. This vein perforntus the deep fascia just above the clavicle and drains onto the subclavian vein. ~ 1. The subclavian vein follows the s ubclavian nrtery and tS separnted posterNoc.S iorly by the insettion of scalenus anterior muscle. 2 . The thoraric duct usually dmins into !he junction of the left internal jugular and subclavian veins. 3. BradtloJ vtin - drains venous blood !Tom deep antebrachial regions and brachial regions into the axillary vein. 4. Cephalic vein - drains venous blood from the radial side to tl1e autebrachtum and brJchiwn into the axillary vein. 5. Brothlocepbalie vein - eitber of two vecns (right ami left) formed by tbe union of the internal jugular and subclavian veins. 6. Suptrior vena CA\'a - a large vecn formed by the union of che l"o hrachlocephalic veins; this vein bas no valves. It receives blood from the head. neck, upper limbs, and chest and empties into the right atrium of U1c heart. 7. The Inferior ' 'en a cava (larger tl111n the superior wma cam) opens into the lower pa" of !he right atrium: !he cnferior vena ca,.., is guarded by a rudimentary, non-functioning valve. The cnferior veon cava rerums blood 10 the heart from lbc lower half of the body.

Blood leaves the placenta and enters the fcn1 s chrough che ucnbilical vein. It is the only fetal vessel to carry blood lhal is rich In oxygen and outrio11ts. All of the other vessels carry a mixture of anerinl and enous blood. Aiter circulaun; in the fetus. the blood returns tu the placenta through the uonbltleal art<r1H.
Strutrure
UrtlbilfcaJ vein

lAcallon

Func.Lion

F'u~ In the .Newtwrn

CaMects lht pl11ecnis tOthe 'rr~n.'tJ)QCU flut.ntnHich f0m1:t. the. rouru.l Ug~nt ful:so ltVCTj f(lrms I rNjor portion a( 0\)gl:'QI.ted blood (rom ~~~ u th~ ligtu~te~Hmrt h.'7'U)

Ill< ....bill<al """'

DuCU'\oCOOSIU

the pbi:cclu
Tl'llhpons t>xy~nted

oflhc h'tr

Vmous ~Wit \lolllun the laver lo connect with the inferior

\'Cna tJVU

blood directly lncoche

mltrior veoo Cl\\1'11

f(l(ntj t.ht lqcamttuum vmu!'um, n fibrous COrti in the lhcr

Ct.>oc> 11 bonb and bcccmes lh<
fossa ovaltt. ' ckprc:s.l;tan1n etw: immwl iq)lum

f~mco

Ofll.t

Opcruns 'bel"- lh< riil> a.<~ A 1hun1 to ~ tllt left al'lia p.il~ bKu.try
Between lht pulmonary trunk aud the aonic nrch

Du~o:tuslll1rriostml

A i.IJuut w bypaA.S th~ putmon-:uy cin:ui t;ry

CIOS($ st1unty utter binh. 3.110pi'IICJ.. 3M become& the

llgamcnt'-lm tutcnosum

Untnhc:al arlcoo Arise from ll'&cma1 iltK: mcnes; ASIQC\!Ucd wnh tM: umbilicat <:ord

T-bl<>o.!f""" Atrophy co '->me lhc tcml \be f~ h.ti.M piiC"tutl wnblhtllllitamerus

(ANATOMIC SCIENCES

Vn~

Exchange of gases in the tissue occurs in:

Aneries
Capillaries

Veins

311
Ccp)rigbl 0 20092010

Dt'"' ~kj

(ANATOMIC SCIENCES

Vn~

\..

All of the following nenes are embedded in the lateral wall of the cavernous sinuses EXCEPT one. Which one is the EXCEPT/ON?

Trocblear nerve (CN I V)

Ophthalmic nerve ( CN V-1) Oculomotor nerve (CN Ill) Maxillary nerve (CN V-2) Mandibular nerve (CN V-3)

~0
312 Ccp)-nJbl 0 201)9.2010 Dmal DKU

Unlike the ancne:. ond ew.. capillaries arc: very thin and fngile. Tbe aplllanes an: actually only one epithelial celt thick. They are so thin that blood cells can only pass tbrough !hem in single lite. The exchange of o~ygen and carl>on d10Kide ~akes place through thctllin capillary wall. Arteries nnd veiM run parallel throughout d1e body with a 11 eb-likc networi< ofcopillnrics, embedded 111 tissue, connecting them. The ortcrlcs pass their oxygcnrich blc>od I<> lhe capillaries, which nllow the exchange of gu.<os whhin the th-, -ue. The capillaries then pass their ~e-rich blood to the veins for lml1SJXlrt back to the heart.
( 'wn1101ri,nn of\ cin,, \rtlril'' ~uul
Art<rl..

< apillaril'"'
Vt.Jns

Crillaries
J\zfb arrent:~ to ...c:ans

lllood du'CCii<111

Fmmhean

To bean
Tnm eLasnc
l'reSC111

Mu1c.le la)'t'f

lbick elastJc None

Nune Nune

Semilunar valve$
.Prussure

lligh ";th pul"" Less., no J'llllc'ic

Vory low with pulse

O,.)gt..on concemnnion Oxygrnd Mixture 0co'<)'~enatcd Differences io blood pressure are reOected 111 vcssel Structure: Arteries -thick. muscular walls to accommodate the flow of blood at ht~h speech and
pressures Anerioles - tlunnrr walls WI coru.'1rict or dilate as~ to control blood flow to the capillaries Capillar ies - .-ails composed of only smgl< Ioyer of entlothellal cells Venules - rece1ve blood from capnlaries; 11UIIs thmner than those of arterioles

Veins - thiuuer walls but larger diametm than aneries: maintain low blood l)re:ssure re quired for rchu11 lu hean
\1andihuhu mnl'

f( \

I -3)

The two cavernous sinuses are large ~em> lying within the skull ca"ity. immcd1ately behind eaeh eye ~Cicet ~nd ou either >1de (If the pituitary gland. They connect with the veins of the face and those of the brain. Thes< sinuses empty by way of the superior petros al sinuses into the transverse siouses that continue as the sigmoid sinuses. The sigmoid sinuses end at the jugulor forum en by becoming tbe ioterual)ugular veins. These sinuses are nlso emptied by the Inferior pctl"osal sinuses that dmin into !he internal Jugular veins. Because the veins of the hC<ld do not have valves, blood from the cavernous siou.es eon t1lso drain anteriorly into the ophrhlrulc ''eh1s. The cavernous sinus is an important structure been us~ ofits location 011d its contents. This sinus carries in its lateral w91l the third crantal (oculommor) nerve, the fourtb cronial (trodtlelJr) nerve, and pano I (the ophthtJ/mic 11cn-e) and 2 (the maxillary flene) of the fifth cmnial (trigeminal) tlerw. Remember: The Internal earotid artery and the abdu~cn' nene (CN VI) pass through tbe sinus.
l. A en vernon$ sinus thrombosis is a blood ciOl within the cuvemous sinus. ole.< This clot causes the cavernouN s inus syndrome. 2. The covemous sinus syndrome is chnrsc1 c1 i zed by edema of the eyelids nnd the conjuncuvao of the eyes and puralysls of the crnnial ntl'ves tim course through the cavernous sinus. 3. The ortlltal cavity is drained by the sul'er lor and inferior opblbalntle veios. The uperior ophtbahni< vein communicates m front with the racial vein. Tbe inferior ophthalmic vein communicates through the inferior orbital ti<Sure with the pterygoid venous plexU> B01h veins pass backward through the superior orbital fissure and drain into the cavl'rllous sinus.

GNATOMIC SCIENCES

The veins of the brain are direct tributaries of the:

Internal jugular vein Dural sinuses Diploic veins

Emissary veins Pterygoid venous plexus

313

CO())'n.hc C 20092010 Dot1al Dtct.s

(ANATOMIC SCIENCES

The pterygoid venous plexus Is a venous nehork associated with the pterygoid muscles. It reeelves Yeins tbat correspond to branches of the maxillary artery, a nd the network's posterior end is drained by the:

Facial vein
Maxillary vein

Brachiocephalic vein
Retromandibular vein

169

llur .11

'illU\t'\

faJ,o t ul/,tl' t'lt'hral \lllll"f'' or.,;,""'-" of tlura mntcr)

The dum! sinuses are large. endolhelium-lined venous channels siiUated between !he two l~yers of dura mater. the endoslcal and the rneningCJtllayers. Tite dural sinuses are devoid of valves and are part of 1be vonOIL' system of llte dura mater. Major cranial sin use-' include a postero-superior group, at the upper and back part of the skull (sue II as superior sagl11al. inferior sagittal, straight, transerse. and occipital) and an nntero-inferior group, at the bas!: of!he skull (s11ch as cavernott. petrosal and basilar plexus). Important: The cins of the brain are direcl.lribuu~ncs of the dural venou.. sinuses. I. The emissary tins, which are valveless. connect the dural venous sinuses Not with the veins of ll1e scalp. 2. An emissary vein. found in the foramen ovnlc, is a means of communication between the pterygoid plexus and lhe cavernous sinus. 3. The iliploic veins lie in channels in the dtploe of the skull and communicate with tbe dural sinuses. the veiru of tbe scalp, and Ute menlng~~l veins. 4. The intfrual jugular I'Cin begins in the jugular fora.men liS a continuation of the sigmoid sinus. Tbts vein descends m the carotid sbeath and ends io the braebiocephallc vein. II receives blood from the brain. face. and the neck. 5. Generally. th~ vems of the head and neck do not have valves.

\l.1\ll1.1n \dn

Veins conesponding to all branches of the muillary artery drain into the pterygoid pitXUS O( \'tinS. This pleltUS occupies the mfratemporal fossa and is ituoto:<l ""'w=n tbo tcmporolis and lateral pterygoid muscles. It is a venous network associated with the pterygoid muscles. Its posterior end is druined by the maxillary vein. The network communicates with the racial vein tllrougllthe deep facial vein. Importan t: The following venous channels have direct connections with the pterygoid venous plexus - the ma.~illary. deep fucial, infraorbital, and posterior superior alveolar veins. The maxillary win is a shon vessel that drains the posterior end of !he plerygod venous plexus. This vein runs backward with the maxillary anery on the medial slde of the neck of the mandible and joins the supcrfklal temporal ' 'ein within the purorld gland, 10 fonn the retromandibular vein. Tite fa<lal vein is foaned 111 the medial llllgle of tJoc eye by union of the ~upraorbital and supratrochlear veins. This vein auastomoscs with the retromondlbolar vei n (anterior brandt) below the border of the mandible. The facial vein ends by draining into the main venous SIJ\lcture in the neck, the Internal jugula r ein. Remember: The internal jugular vein descends througll the neck within the carotid ~heath and unites behind tbe sternoclavicular joint with lhe subclavian vein to form the bracblocepbalic vein. The braeblocepbalic ehts (right and left) unite 111 the superior mediastimtrn to fonn the superior vena cava, which returns blood to the right atrium of tb.e beart.

( ANATOMIC SCIENCES

Which of the following are considered to be primary resistance vessels?

Large arteries
Arterioles Capillaries

Large veins

315
Copynabt Cl 2009-2010 Den1ILI Dccb

( ANATOMIC SCIENCES

The great veins of the neck are all derivatives from the:

External jugular vein Internal jugular vein Retromandibular vein Superior vena cava

311 Copynsbt 0 20091010 Dmtal D:L$

\rH rwh'
I' .IIIII\" 11f 1\lwul \ Aorta Nun'lbcr U.ra. t Arltril''l'
AJ'tU'iftlt.'
l '\t I\

(.'plflriu
fn1biiiHm
lm.c~

U r~

V.tr"

YtniH" C.vat

On<

Scvnl hwl\1* llulr. m111l(ll!l

I"'"'

Sc,ml h1111dlt'll t\lru

Wall WL"kflnt
INtmaiMli
SpodOI-

FunCliOfl~

2""' IE em

Thxk,dip

.... 7'

20 wnietOI:'IIdft'S
J0 U1ia01111tttn

.s ....
.San

I Smm

l~""~

1<"'

llli.l:qt lbil;l>-.

<4 wtJk..sm&U,.
d~ribul:ion o ( Q:nJI.c \,KIIpul

1\.lk!r.l ._..,.. ... aos.r

lot'l;ttoolllol.n:a
JI'IICSAIId
n~t:abolu rto:

..........

Re'-ivcl)' ..... Po.ihk - ~

~P'JY ti"om bean IO

tis$~

prt$51'"' mervalr

Pti.tntuy IUI.$-IIm UloJOd aad tissue hsllllttwa)' 1 0 l~~:~n from ussucs; \CSSd$: dclemnnt oc:n ~ ~xd1:lngt: biQOd tkt\'thr
fi"IM arrmoi~~:C to
VC11\Ikt

I. Veins have tbinnu walls than arteries but ha>e larger diamettrs because of the Notfl low blood p.-.ssurcs requored for vc:uou., return to the bean. 2. Valves in the '"tons of the neek, anns, and leg.' prevent venous back now. 3. Important: With the exception of ~ t>ulmonary vessels and certain fetal vessels, arteries tnmsport oygenated blood, und veins uanspolt deoxygenated blood. 4. Venules continue from capillaries nnd merge to form veins.

The two hugest'"""" in the body arc the superior and Inferior,.,.,. cavae. wboch clnlio mto the hCM fioom above and belo.,... rcspccu\ely. The gre11 of the neck arc all dawativel. from the superior ,en a ca,a. The superior vena cava i~ a laJiC:. yet $hon vein that carTit.."S deoxygenated blood from the upper half of tho body to the hean's right atrium. The superior vcM cnvo is formed by the left and right brachlocephalic veins, There are three main veins in tlw m'tk. .. the e~ternal.
autcrlor, and Internal jugular veins.

fhe txt<roaljugular vctn originat<"S from just behond the mandible"s angle. and is fonned b) the unification of the posterior auric-ular 'ltCtn and lhe posterior di\lsion or chc retromandfbular vein. Note: The rttromandibular <in ttself i Conned wnhtn the paroud gland. This vein's fonnation ~from the unifocatioo of the suprfitialtemponl and the ma.d lfa ry Hins.

The Internal jugular vein, which drains the head and brnin,joins the subchH IAn vc1 n to form the bracblocepbalic vein. The hrrt and rlgM brathloccphalic veins join to form the superior vcnn cnva, which drains into the hcn.n. The anterior jugular vein arises below lht chin from th..: vein.c;; droining. U 1c chin and lower lip, plUSeS dOwn the front Of the neck SUpcrficially, and tcnninaU.S in the C.'temal JUguJor Vein at the lateral bo~r or the 40ttnor srnlene muscle. I. The bnchla~ baslli<. and rep hall< vcms clnlin the uppec hmbs: lbcsc eon> drain into Not the nltJary vein. "'htch becomes the subclavian vem. 2. The IZ)'gos vein. which drainS! Lhe lhomdc cl\vity,joins the superior \'tna c.ava1just before il enters the heart. 3. The femorul vein droins the lower 1imb, becoming the external ill or vein as il ente~ the lnmk, where the vein is joined by the intc.rnnllllat vein from the pelvis to become the common iliac vein. 4. The two c:ommoo mac veins join to form tbt inferior vena"' a, whic:h passes up ilic posterior abclominol wall. whet< the inferior vena cava is joined by >-cins from the kidnoys. pads, Ji,-u. nnd baek region. The iof<nor 'ena cava passes through the doaphragm and .... """ th< bean.

GNATOMIC SCIENCES

Vn~
~

Which venous sinus of the cra nial cavity turns forward and then downward through the posterior part or the jugular foramen, to become continuous with the superior bulb of the internal j ugular vein?

Sigmoid sinus

Superior sagittal sinus

Transverse sinus
Straight sinus

~)'nil"

318 C 2009-2010 De:lltal Oetl s

(ANATOMIC SCIENCES

Vn~

Wbi<h vein communicates "ith tbe superior ophthalmic vein and thus "ith the cavernous sinus, allo\\ing a route of infection from the face to the cranial dural sinus?

Occipital vein Facial vein Lingual vein

Posterior auricular vein

.
317
~

1009-2010 [bql [)c(b

Si~nuud 'IIIII '

The du~l H no11ulnu..,. ""'spaces betw<en the ~~~hnd mcntngc:tllaym ofIll< dura. The>< <inusc:s c::omain vc:oout b1oocllhl.t Ofiginates for the most p.tt fnm, tht' bntin or cnunal avny. 'The: 1iinuses contain an mdolhc1iaJ 1inin,g that is continuous mto the ''cuu that :.rc connected to the smusc:s. 'lbt'ff are no \'ah es in the :.inu.scs or tn the veins that are connecled tu 1 ht: sinuses. fhc vast majority 'rthe venQu~ blood in the smuse~ drams fmm the c:ranium via the: fnltrnlll j ugular v~in , The .superior sa gittal ~in us is found in the upper bord<.-r ufth.: falx Ct:rtbri Bnd begins Itt the: cnMD galli. The J-1tpi'nur ~ashtul sums i.s fed by blood frorn the !Hipenur ccrdnnt veins and cnd.'i 81 thu COt\Hucn<:e:

of sinuse.'i near the lntc.:nml occipital protubc-r.t.ncc. The Tnre.rlor <~agithll sinus is IOC3ted in the lower free bnf..ter t,r th(: fat~ ccrcbn bl:twccn the two cerebnd hemi.;;phe.~. This s1.nus beg-..ns anteriorly and end~ w1th its JUnction wnh the 5tral!!,ht s1n\t.:'l The srni$thl sinu' orlcJn,a:rts with the uni"'n ofd'lc peat ('t'rcbnl \"Ctn and infenor t.agntalltinu~. 'The &trlligbt sinus lUllS f'l'<l<rlorly in ohe)\RlC1ion between !he flx ..,.belli and 1ct\Ulrium emb<:lh 10 hecolne
<Qntinll<>U> wtlll one ll'1liSVme Sinuses (trtml N>tnlfU>ftl)' thtl~ji) The ronrnou lnu!ts ""'found oo eith<r side ofd>< body oflht rh-id !>one on 1l!1ddlc mn,.l fossae:. TheK ~IUUI!r<.t.. ~c1\'e blood from tbe sphenopant1a1 \muse:, tha1 are located Wldmtt'lllh the fn:"c edges uf tht Jem.r wmgs of the ~phenoid bnne. B1~ also dm1ns mto the eavemou~ sinuses v1111he 5\1~ perior and inferiOr ilphtbAlmk Vtill~. The ct\\'('fll UUS SIOUSC$ dram pos!t"riorly tbrt,Ugh the SUpCl inr Hnrl inferior pe1rosnl sinu.st:s Md infenorly through the pterygoid f)k~u~ uf veins. The ~uptrlor IJetrosal sinuses life located In the t:dltC or Ihe tentorium certbeJit on th ~ rid"!.! uf lht pctrons part of the tempumllxu.e. Thi$C' sinust!i dr:.in mto lhe tra.uven:esifl~c:s The Inferior pttro,.l slnuns arlO fo\Uld aI!lie bMt O(\he ptltQUS part of the lttuporol bone m the nostcriorcranial f0553C when: these sinUses empty lnto the mu:maiJugular \Ctn. The baJUt.r iJtiU} inCA:ttonnects ...,ith infmor pt"trOS&I sinu$cs and thr inu::m.d vencbr.l pius. Tbc lnf\f\trM sinuKS ~'\mod latt:caUy from the connuen..:c or)imJSC5 in the! lenronum c:cTCbclli The U'UIS\'ttSC: SlnUK! tnnel \'t'n&ral()' \0 btaxM tM SlltnC)ld SIRU~ o( C3Cb Side.

or'""

n.t: sigmoid .-ln uit'!i bend mlo an S-sha.ped cune &nd tononue mto the truemaJ j~ulcr \Cm lhtough
the jugulAr tOrarncn rbc occipital s1nu~ is toea led ln the pOslerlf.'r tt.Adted border of the falx ccrebelll. Thut !IIIIU~ t'Uitununie:ateS sup~.:ric..tly with the connucnce ofsumsc.:1 ..:~nd lnfenorly witb the lmr:mul vc:n~hf'nl plexus.

hu:i:.~l H ' ln

The fad l vemts fonned at the medial angle oflhe eye by the union of the supraorbital and upral rocblea r vein.<. The facial \ein is connec1<d to Ihe superior opbtbalmit 1em directly 1hrough the supraorbita l 1 ein. By me..ns of the superior oph1halm1C, lhe facial vein is connecled IO the ca~ernons sious. TI1e facial vein descends behmd the facial artery to the lower margin of lhe body of lhe mandible. The fooial vcm crosses superficial to the oubmandibular gland and is joined by 01e anterior division of the retromandlbular vein. The facial vein ends by drnlning into the internal jugulnr vein. l mportnn h Oanl!t r tria ngle of the face- o lrianglo exists O un approximulely covers the nose nod maxilla ond goes up to the region bc1wcen ih< eyes_ This is an area in which superficial veins communicate with tbe dural sinuse~ The facial vein has no valves, and a backOo11 can cause an infection to getln1 o Ibe dural sin usu. lhrough the deep f.aclal eln (vin pi<'IJ'f:Od p/e.~u} and superior ophthalmic ein (via cavernous sinus). Anastomoses 10 remember: I. Deep facial vein is a communication between 1he facial vein and the plerygoid plexus. 2. Superior ophlhuhnic vein is a conun unlcution b~lween Lite facial vein :md 1he cavernous sh1tn .

( ANATOMIC SCIENCES

Vn~
...J I

I\..

I" All of the following characterislics are true concerning veins EXCEPT one. ' ' \
Wbicb one is the EXCEPTIO!V!

Thick tunica media with a lot of muscle fibers Thick tunica adventitia with little elastic tissue Larger lumen and thinner walls than the aneries they accompany Some contain valves and vasa vasorum

31t Cop)'liatn 0 2009-2010 Dtn111Dttts

*** Veins have a thin tunica media with few muscle fibers.
Vessel
Arttrles:

Characteristics

Large (t'I<Utic arteries) Very thkk tunica media that oontains a lot of t.la~tlc fibt.rs and some smooth mtl9Ck
fibers
Small (mU$~flfar urteril!s) Tunica media consiSt$ oral~ entirely smooth mustlt. eelb with few clastic fibers Small ves.sels (diamett'T < .5 Min), small lumen, thicker tunkll me<Ha with a lot of smooth musde fibers

Arteriolt.s CapiDarles Venulq

.()I diqmet{'r), walls hne endothdlal layer only Small ve$$C:I$ (Q

Small vessels; walls have e:ndochelium and ~-ery thin tunica adventitia; larger vcnuks ba~c thick" tunica advmtitia Thin hllllea media with few smooth muscle fibers: thick tunka advudtla with liule elastic tissue; largn lumen and thinner walls than tbc arteries the)' aeoompan)'; some contain valve$ and vasa vasorum (mdrlenr bkxxl \'(eSS('l$ lfral supply 11/e walls of
/Qtgt: wins)

Vtins

Biochemistry/Physiology Legend
Major Topic Blood Carbohydrates Central nervous system Circulatory system Disorders/Diseases ON A/RNA Enzymes Gastrointestinal system Heart Hormones Kidneys Lipids Liver Abbreviation Bid Carb CNS Clrc S Disord/Dis DNA/RNA Enz GIS Hrt Hrm Kid Lipids Liv Major Topic Membranes Metabolism Minerals/Vitamins Miscellaneous Muscles Nerves pH Proteins/Amino acids Reproductive system Respiratory system Special sense organs Substances Tooth/Mouth Abbreviation Mbr Metab Min/Vit Misc. Msl
Nnr

pH Pro/AA RprS Rsp s

sso
Sub Tth/Mth

(siOCHEMISTRY I PHYSIOLOGY

Sugars that contJI.in aldehyde groups that a r e - - - -- - to carboxylic acids are classified as sugars:

Oxidized, non-reducing Oxidized, reducing Reduced, non-reducing Reducing, oxidizing

(smcHEMISTRY I PHYSIOLOGY

\.._

Which of the folio" lng glycosaminoglycans can be found functioning in syno'ial fluid?

Heparin sulfate Keratan sulfate Hyaluronic acid Dermatan sulfate Chondroitin sulfate

2 Copyn,p'll 0 20092010 Otmal DttU

(hiditt'll. reducing

*"*Examples In clude: !acrose, maltose, glucose, galactose, and fructose. Reducing sugars contain a free anomeric carbon (oxygen 011 C/ mom is ttVailablefor redox reacllou) that can be o:<idized. lf the oxygen on the anomeric carbon (the carbonyl group) of a sugar is not attached to any other structure, thnr sugar is a reducing sugar. A reducing sugar can react with chemical reagents (see note # I belmv) and reduce the reactive component. Note: The anomcric carbon itself becomes oxidized. Important point: This reaction is the basis of a reduciog-sugnr test. whicll was classically used by clinical laboratories to screen for d iabetes (presence of excess free glucose In the blood) and other inbom errors involving the inability to metabolize other reducing suga~. Important: Most current clinical tests for blood g lucose utilize glucose o.<idase linked reactions. Because the reducing groups of both glucose and fructose are involved io the glycosidic bond, sucrose is not a reducing sugar. lo otlter words, sucrose contains no

free anomcric carbon.

I. Common test reJigents are Benedict's reagent (CuS01 lcilrllle) and 'Notes FeWiog's reagent (CuS0 /tartrate). They are classified as reducing sugars 4 since they reduce the Cu' to c u , which forms as a red precipttate, copper (I) ox ide. 2. Glucosuria, the presence of glucose in the urine, can be caused by low insulin levels, high blood sugar levels, impaired tubular reabsorption, or a high glomorular fil tration rate.

tl ~

uluronic 3cid

The must abundant bctcropulysaccharides in the body are tbe glycosuminogly<-ans (GAGs). These molecules are long w1brancbed polysaccharides containing a repeating disaccharide unit. The disaccharide units contain either of two modified sugars N.. acE"tyJ ..ga.lattosamine (GaiNAc) or N-acet)'t-glucosaminc (GicNAc) and a uronic acid such 1lS glucuronate or iduronate. GAGs are bighly negatively charged molecules, with extended conformation thai imparts bigb viscosity to the solution. GAGs are located primarily on the surlace of cells or in the extracellular mairix (ECM). Along with the high viscosity of GAGs comes low compressibility. which makes these molecules ideal for a lobricatiog Ouid in the joims. At the same rime, their rigidity provides stntcmral integrity w cells and provides passageways between cells, allowing for cell migrntion. The sped fie GAGs of physiological significance

are hyaluronic acid, demunan sulfate, chondroi"tin sulfate, heparin. hepariu sulfate, and
k.ertatt sulfate.
( h.truchn<;llcs ul (, \{ .,

GAG
Hyslut'OfUl.l~

l .ocallr.~llnn

Commt-nl.l

S_ynot.'iat fluid. vitreoU$ humor, ecM nf loose C'OI IJle(tiv~ 1jssue

C-anita_ge, bone, heJSn vah~
Basemen! membranes, oompnncrus of

Lf)tge potyn1cn. ~ Qbsorbjug

M(l.)'l Ab,lrtil;lnl

Chondmirin lilllfate

OAG

H~nn sulfo.Jc:
llc;pllrin

Ct:mtain$ hi,sbet 3Cdylnted ah.eu.<~:~~mine

th3tl.hepa.rio

cell sutfacc.-s

Componc:nt ufimracellulu.r granules or Serves 11$ nn t:nticotlgulbnt. nlOre" 11ulfntrd mest .:ell$lininl? the IUlcne:s-of the than hepilrin sulfutt: lungs, livc:r.ltnd skin Slon. blood \'essds, hean valves
t'oml-a. bone. c.aniWgc 11ggre-g-n1ed Wltb

Dcmatao sulmtc Kemlin $lllrMe

Mosr hel01'1et10\L\ GAG

ctlondroilin !Sull'lnes-

GnocHEMISTRY 1 PHYSIOLOGY

Which intestinal enzyme breaks down the 0-glycosidic bond between glucose and fructose?

Maltase Lactase
Sucrase

3
Copynght 0 20092010 ()ental Dk..s

~IOCHEMISTRY I PHYSIOLOGY
Glucose, fructose, and galactose are classified as:

Car~

Monosaccharides Disaccbarides Oligosaccharides Polysaccharides

Cop)rigbt 0 2009201 0 Dt11tal l.)t(;ks

Su<.:rasl'

A ilisaccbnride is a carbohydrate whose molecules contain two s11gar units . .Examples include: Maltose ("beer .wgor '') - consists of two glucose molecules joined together by a reaction (condensation reaction) in which a molecule of water is removed. This reaction produces a bond between the two glucose molecules called a glycosidic bond. The intestinal enzyme maltase promotes the conversion of maltose into glucose. Lactose ("milk sugar'') - consists of glucose and galactose. The intestinal enzyme lacrase promotes the conversion of lactose into glucose and galactose. Sucrose ("table sugar)- consists of glucose and fructose. The intestinal enzyme sucrase (invertase) promotes the conversion of sucrose into gl ucos~ sod fructose. R~member: The final digestion of these substances (disaccharide.<) to absorbable monosaccharides is completed by enzymes of' the small intestine (mallase, sucrase, cmd lactase). These monosaccharides can then be absorbed by enterocytes. Monosaccharides can be linked by glycosidic bonds to create larger structures (disaccharides. oligosac<'harides. and polysaccharides). These bonds form when the hydroxyl group on the aoomeric carbon of a monosaccharide reacts with an - OJ-! or - NH group of another compound (ryptcal(v an a/cohn/, purine, pyrimidine, or in this case another sugm~. Maltose, lactose, and sucrose cousisr of monosaccharides joined by au 0-glycosldic bond.
,___ I. If o;otygen is involved, rltis bond is classified as 0-glycosidic; if nitrogen

Nor

is Involved. this bond is classified as N-glycosidic. 2. D-glucose is a monosaccbsride, the most important of the aldohexoses.

\ l onos:H."l"h aridl's

The simplest of the carbohydrates are tlte monosaccharides, which can be classified ac.cording to tbe n\Jmbcr of carbon atoms they contaiu. Those with three carbons are called trioses (for example, glyceraldehyde and dih,vdro:<y ocetalle); four. tetroses (for ex!lmple. erythrose): five, pentoses (far ~xanlple, ribose); aud six, hcxoses (fur example, glucose). Monosaccharides with. an aldehyde as their most oxidized ftauc1ional group nre called aldoses (for example. glyceraldehyde); those with a keto group as their most oxidized functional group are called ketoses (for example. dihydroxyaceto11e). Remember: The naming of con.figurations of simple sugars (mo/losacclrarides) and amino acids is based on the absolute configuration of glyceraldehyde. Tbe symbols Land D refer to the absolute con figuration of tbe four constituents around a specific chiral carbon (asynunetric carbon) in monosaccharides and amino acids. In a Fisher projection. the 'D form has the hydroxyl group on the right; tl1e L form bas the hydroxyl group on the left. Sngars of the D form, which are related to 0glyceraldebyde, nre the most common in nantre. Other monosaccharides include: mannose, ribose, and l(ylose.

(s10CHEMISTRY I PHYSIOLOGY

Which of the following polysaccharides requires the glucan transferase to breakdown?

en~yme

Starch Glycogen Cellulose Glycosaminoglycans

5
Cop)'tiJh'O 2009-2010 Dcn~~ol Dtt-ks

~IOCHEMISTRY I PHYSIOLOGY
Which of tbe following statements concerning glycosaminoglyeans Is true?

They contain branches of N-acetylneuraminic acid They seldom contain sulfate groups They are most ofien positively charged They contain repeating disaccharides They contain short oligosaccharide chains

I Cop)'lilhtC 2009-2010 Denulll)cd:J

Polysaccharides are carbohydra1es that are po1ymers of monosae-charides. Polysaccharides are made up of many sugar units joined by COJldensation re.actions (wMdr rt<Srtlts 111 g(cosldic bonds). Sinco polysaccharides have large molecules. rhey are insoluble. Their main functions in living organisms are to act as storage molecules (.rrarclr unci glyoogen) or as struc\ural materials (cellulose). Homopolysnccharidcs (starc/r, gl)'cogen. dextrans. and glucans) contain only a single monosnc.charide species. lleteropolysacch~rides (glyc<mllnhrog(vcans) contain a number of differem monosacch aride species. The two most important sto,..~e polysaccharides arc starch and j\l)'cogen. Starch is a large. insoluble carbohydrate that forms an lmponam energy store in plants. Starch is a polymer and consists 0( a large number of a-glucose molecules j~incd tu!:clhcr by conden~lion reactions. It consists of two main components thnt may be present in different proportions. Amylose (whidr is rmbrmrclred) forms long Straight chain while amylopectin has highly branched chains with alpha-1 ,4 linkages. Note: Both amylose and amylopectin arc rapidly hydrolyzed by the enzyme olpho amyl11se, which is secreted by the par~tid glnnds and the pnncrcns. Gtycog.u, like umylopccun, is u branched polyrnor of glucose, However. glycoj!.cn is more highly branched (witlr 11-/,1$ /fnkuge,,) 011d v<ry comp:rct. 11 is especially ahundnnt in tho liver. Nute: The glucose units of glycogen can enter tho glycoly~ic pathway afier removal by the :ction ofglycogen phosphorylase, Note: rhe cleavage of glycogen b<:yon<l a brsnching point rcqlflrcs the activity of glucantnlllsfcrun nnd amylo-&IJ>ha-1,6 glucosidase.
Cellulose is the most common organic compound on earth. Cellulose L< not digestible by 1m m.ans1tnd fs often rofern.>d tollS "dietary fib~r~ or "roughago," acting as a hydrophilic bulk ing agent for feces. The term glycan r..-fers to a polysaccharide or on oligosaccharide.

l he~ cmtl~dn rcpcalin~ diliiHCrh~uidcs

The most abundtLnt hetcropolysaccburiMs. in the body are the glycMaminoglycan~ (GAGs). GAGs are long, linear carbohydra te chains that contaiu repeating disaccharide units, which usuHily contain~ hexos;tmine~ and a uronic acid. GAGs often contain sulfate groups. The uronio acid and sui tate residues cause GAGs to be negatively chaflled. They are nnbr11ncbed and do not contaln N-acerylueuraminfc

Held. GAOs arc highly negatively charged molecules. with extended conlonnution that imparts high vlscoslly tO the solution. GAGs are located primari ly tlf! the surface or cells or in t~e extr acellular rnatriJ< (ECM), Along wilh the bigh viscosity of GAGs comes low tomprcssibillfy, which makes these molecules ideal f<>r a lnbr.icntiog fluid ln the joints. At the same time, GAGs rigidity provide$ structural in tegrity to cells <UJd provides passageways betwee!l cells, alhnving for cell migration.

L G lycosaminoglycans function as important structural components of connective tissu (wlri~;/1 includes adipose tis.~ue. < artilage, and' hone as well as cnllagenmrs, ela.<tic, and relicular fib~rN) . lotportaul: GAGs net as "molecular sponges" and hold water in the extracellular tnatriX. Z. ltyuluroni c l!cid i; unique among the GAGs iu tbar i1 does not contain any sulr.-.te and is oor found covalently attached to proteins ~s nre prmeuglycans. 3. Tite nlJiiority of GAGs in the body arc linked to core proteins, fonniug prolcoglycans (also t:ltlled nwcopo~y.<occhmi<Jes). 4, The bucterial tell wall contains a h~teropolysaccharide made up of ahemating N-acctylglucosaminc aud N.acel}'lmtn:1l1Tlic licid un!t:;.

&IOCHEMISTRY I PHYSIOLOGY

The ground substance of the extracellular matrix is made Ull of:

Type 11 collagen Type Ill collagen Proteoglycan molecules Fibrillin

7 CoP)'ri&bl 0 20092010 Otntal Oks

&IOCHEMISTRY I PHYSIOLOGY

The most abundant glycosaminoglycan in the body is:

Keratan sulfate Dennatan sulfate Chondroitin sulfate Heparin sulfate

CopynaJ>t" 20091010 _ , , .,....

PnHLogl~r:tn mulccuiLs- which ure uhmtt 95~~~ po(l','illlTiwritle autl5~o protein

Proteoglycans consist of a core protein witb glycosaminoglycans (GAG.<) attached in a brush-like fashion. The linkage of GAGs to the core protein involves a specific trisaccharide composed of two galactose residues and one xylose residue. The protein cores arc rich in serine and threonine residues, which allow mulriple GAG attachments. Major functions include: lubricants. extracellular matrix. and being a molecular "sieve.'' Glycoprote!ns are prOteins that have a carbohydrate covalently attached to them. The carbohydrate portion of most glycoproteins differs from that of proteoglycans in that it is shorter and branched. They serve as enzymes, honnones, antibodies, and structural proteins. Glycoprotetns are often components of cell membranes and are involved in cell-to-cell interactions. Glycolipids (or sphingolipids) are found in the cell membrane with the carbohydrate portion extending into tbe extracellular space. They are derived from the liptd cerantlde, and tb.is class of compounds includes cerebrosides, globosides, and ganglioside&.

Chondroitin o.,:u lfure

Chondroitin sulfate is a major constituent in various connective tissues. especially in the ground substance of blood vessels, bone. and cartilage.. In cat1ilage chondroitin sulfate, provides structure by holding water and nutrients. and allowing other molecules to move through cartilage - an important property, as there is no blood supply to cartilage. Chondrollin may work by acting as a building block for proteoglycan molecules, and may also have anti-inflammatory properties. Importa nt : In our joints, chondroitin sulfate contributes to strength. nexibi lity, lllld shock absorption. Remember: The extr acellular space in animal tissues is tilled with a gel-like material, tlte extracell ular matrix, also called grou nd s ubstance, which holds the cells of a tissue together and provides a porous pathway for the diffusion of 011trients and oxygen to individual cells. The gruund substance is composed of an interlocking meshwork of beteropolysaccharides (glycosaminog/ycans), most covalently linked to protein fonning proteoglycans, and fibrous proteins. Important: Hyaluronidase will promote depolymer izatioo of the extracellular matrix (ground substance). Hyaluronidase is an enzyme that splits hyaluronic acid (glycosaminoglycan) and so lowers its viscosity and increases the permeability of connective tissue and the absorption of nuids.
---... I. Heparin coma ins the largest proportion of sulfate (ve>'. even mnre thnn heNotes parin sulfate).

2. Hyaluronic acid conlllins the lea~ I proportion of sulfate.

~IOCHEMISTRY I PHYSIOLOGY
For each letter, choose the most appropriate answer to fill in the blank.

Dextrans are (A)_ _ of (B)_ _ produced extracellularly by bacteria and yeast. The enzyme used to produce dextrans is (C) _ _, and the substrate is (D) _ _ . A side product of dextran production is (E) _ _, which is formed into (F) _ _ and stored intracellularly as reserve nutr ients.

(A) Monosaccharides f polysaccharides f oligosaccbarides (B) Glucose f fruc tose f galactose (C) Dextran synthase f glucosyl transferase f fructosyl transferase (D) Maltose f sucrose f lactose (E) Glucose f fructose f galactose (F) Starch f glycogen f !evans
Copyright

e 20092010 Dent:~ I Dctb

(siOCHEMISTRY I PHYSIOLOGY

sso)

Which statement concerning rods and cones is incorrect?

Rods contain rhodopsin -a photopigrnent Cones are respOnsible for color vision Rods are used for dark adaptation Rods and cones are located in the retina Cones are more abundant than rods

10
Copyright C 2009-2010 Dental Ocd:s

(A) Pol~:mcdulfid('S (U) (;lucu'e (C) Ghlcos~ llnmsfcrase (tlextrau

(0)
~IICfUSl'

sul'rlt'iP)

{El Frurtuw (F) l.e\ans (jim:llms)

Dcxtrans are polysaccharides of glucose produced extracellulary by bacteria and yeast The enzyme used to produce dcxtrruts is glucosyl transferase (de.Ytran SIICrtse), and the substrate is sucrose. A side product of dextran production is fructose which is fomted into !evans (fructans) and stored inrracellularly as reserve nutrientS. A few bacteria, notably Streptococcus mutans, produce dextran from sucrose. Dextran is a "sticky" polymer of glucose molecules linked together in 11- (1,6) linkages with some a- (1-3) branches. ll is produced outside bacterial cells by tbe enzyme dextran s ucrase (glycosyl INmsforase). 'This enzyme splitS sucrose into glucose and fructose and links the glucose molecules into a dextran polymer. The dextran is deposited as a thick glycocalyx around the cell and seems to be essential for the cariogenicity of Streptococcus nwtans. Note: Levans ((ructans) also increase the adhesion of bacteria to surfaces of the teeth and promote the formation of dental plaque. It is formed from the fructnse moiety of sucrose by the enzyme levan sucrase. Levans are considered to be reserve nutrients for bacteri<L

Ctut('\

are mon. abundant than nuts

The retina Is the innermost layer (nervous tissue) of the eye. Tbe retina receives visual stimuli and sends the infom1ation to the brain. Photoreceptor cells called rods and cones compose the visual receptors (for the optic nerve) of the retina. Rods and cones contain photoplgments. There are fou r different pbotopigments, each consisting of a protein called an opsin to which a chromophore molecule called retinal is attached. Opsins differ !Tom pigmem to pigment and confer specific lightsensitive properties on each phOtopigmenl. Note: Retinal is produced from vitamin

A.
Rods contain a pb01opigmem called rhodopsin. Their response [ndicates dffferenr degrees of brightness, but the entire rod system is charactetized by a relative lack of color discrimination. Rods are numerous in the periphery of t~e retina. Cones are primarily responsible for color vision. There are dtree ditTerent types of cones (red, green. aud blue). Each one contains a different photopigment and is selecttvely sensitive to a particular wavelength of light. They are concentrated in the center of the retina, c.spccially in the fovea. I. During dark adaptation (night vision), rhodopsin is synthesized tn the 2. Cones arc the principal pbotoreceptors during daylig ht or in brightly lit areas. 3. Rods are more abundant, have higher sensitivity. and lower acuity compared to cones.
Nlltes rods.

(BIOCHEMISTRY I PHYSIOLOGY

sso)

Which of the following structures of the eye l!&n !Ill! change in shape?

Lens Retina

Cornea Iris

11 CopyriJ'ht 0 l.OW2010 Dcol3l DeW

~IOCHEMISTRY I PHYSIOLOGY
(
A sound wave will s trike the
fir st'~

sso)
)

Membrane of the oval window Membrane of the round window Tectorial membrane Tympanic membrane

12
Copyrigh! 0 20092010 Denul OeckJ

Corm. a Basic anatomy of tbe eye: Cornea - The crystal clear dome that covers the front of the eye. The maJOnty (70%) of tbe bending (TY!froctlng) of light rays 1S accomplished by the cornea The shape of the cornea does not (honge (wull tile exception of small cltange that ouur mer a lifetime). L ens - The crystalline lens fmishes the focu~ing of ligbl. The lens helps to "fine-tune" vision, and it is able to change shape tO allow focus on near objectS. When tbe lens becomes cloudy, it ts coiled a cataract. Pupil -This is the opening m the middle of the iris. Iris- This is the part of the eye thut gives it color (I.e.. blue. green. brown). The iris functions like a shutter in the camcrn analogy. allowing more o r lcs. light.nto the eye. l~etina -This is a thin layer of nerve tissue that senses light. Spcc~alizcd cells called rods and cones convert light energy into nerve signals that travel tbrougb the optic nerve to the brain. The retina is analogous to the tilm in a carne,ra. Fovea -This is tbe center of the retma tbat receives the focus of the objrtt of regard. Nerve ceUs are more densely packed on this area, so illl3ges that are focused on the fovea can be seen in greater detatl. Optic nerve - This is the nerve that runs from the eyeball to the bram. The t>ptic nerve carries information from the retina to the brain for interpretattoo. Note: The eyeball itself is divided mto two segments, each filled with Outd. The anterior segment has two chambers (anreriur and ptmerior). which arc both tilled witb aqueous humor (watery .fluid). and the posterior segment is filled with vitreous humor (thick. gelatinous material).

I' lllfJ~tnh: mcmhnuu:

Sound waves strike the tympanic membrane ond couse it to vibrate. This eaus"" the membnane of the oat window tu vibrate. whtch causes 1he tterilyrnph to the bony labyrinth of the cochlea and rndol)mph in the membranous labynnth of the o:ochka 10 move. This moement of the endolymph caus"" the basilar mcmbra11~ to v1br-te. wh1eh, m turn. stimulates hair cells on tbe organ or Corti to uansmn nerve unpulscs along the cramal nerve. Eventually. nerve mrulscs reach the auditol)" conex and aro mterpretcd as sound. Parts of the Ear: External car - consists of the cxtemal pan (pinna) and the car canal. Au dele (pinna) - direcls ~ound wove!\, External auditory cnnal (mcnltts) .. contain~ hair aod centmen (brown carn-a.t). serves as a resonator.
~IIddie

ear (rympauic covlt)~- M air-tilled cavity in the temporal bouc. Auditory tube - equalizes pressure. Ossltles (malleus. 111ct<.r, Slllftu.J - link together to transmit sounds to the oval window. Inner ear- formed by a membranous labyrtnth within a bony labyrinth. Vestibule {saccule t~nclurncle) - :.ssociattd W!lh sense of balance. Semicircular canal$ concerned with equilibrium. Cochlea (contam.r rwo memhraMs. ~sttb11lar one/ INuilar) ponu>n of toner ear responsible for heanng. fhe sptral org~~n (orgn of Corti) contams the r~eprorf (called hair cef/s) for bearing. The cochlea is the baste functional UDit of beanng because tbis ponlon transforms Ouid vibratiOn from sound waves tmechanlcal elltrg)~ into a nerve impulse {ele<'lri(al ene1gy).

~IOCHEMISTRY I PHYSIOLOGY

sso)

#'A patient comes to your office directly from an eye appointment. The ophthal=' mologist has used tropicamide to induce mydriasis of the eye. What significance does this have on his or her dental appointment?

The patient will not be able to distinguish colors when you present h im or her with the color choices for his or her dentures The pupils are dilated, so the patient will be sensitive to the dental light if you don't control it well The pupils are constricted, so the patient will have trouble seeing anything without high light The patient has tempora rily lost the ability to control his or her lenses, a nd so he or she will not be able to focus on anything
13
Copyngh! 0 20091010 Dc:ntal Deck$

~IOCHEMISTRY I PHYSIOLOGY

Bl~

Normal range for hemoglobin is different between the sexes and is for women. approximately for men and

5-8 grams per deciliter , 2-3 grams per deciliter

9-1I grams per deciliter, 7-9 grams per deciliter 13-I 8 grams per deciliter , 12-16 grams per deciliter 20-22 grams per deciliter, 18-21 grams per deciliter

14 Co(l)'liglll 0 2009-201 0 Oenttl Ded(*

Thl pupih. .tfl' dihlhtS. tlnn ' l \"unlrulll 'HII.

~u llu

p .lli-:nl niiiiH' " "U\IIIH" fu thE'

d~nf :ll

h:,:hl if \uu

Remember: I. Mlosi is 1he constriction of the pupil of1he eye. Mio~is can b< cnused by s nonnal response to un increase in light, certain dn1gs, nr pathological conditit\ns. 2. Mydriasis i~ 1hc prolonged abnormal dl111tlon of tbe pupil of the eye 1ndnccd by a drug or caused by a disease. In myopia (t~eorslghled,ess), tbe eye is too long for the refractive power of the lens. and far objec1s arc focused at a point in front of I he retina. The eye can focus on very ncar objects. Th1s is caused by a cornea that i~ >leeper. or an eye rha1 IS lonttr, than a normal eye. !'learsighted people 1ypically see \\ell up close but have d10iculty sc~ing far away. To treat myopia. concave ltnses are used. Farsightedness, or hyperopia. occurs when hght en1ering the eye focuses behind the retina. instead of directly on it. This is caused by a cornea mat is Oattcr, or nn eye that is shorter, thnu a nonnal eye. Fars1gbted people usually have rrouhlc seeing up close but may also have diniculry seeing far away as well . To ttem hyperopia, C(lll\' e)C lenses are used. Astigmatism occurs when 1he curvature of the lens ts not unifonn and is corrected with cylindric len ~ Presb)opla ~~ the inability of me eye lo focus sharply on nearby obJects. resulung from the loss of elast1ci1y oflhe lens with advancing age. Presbyopia is corrected with bifocal$.

Hemoglobin a quaternary pro1ein consos1ing of four 1<n1ary (fold~d) polypcp1ide chains - two alpha chams and two bet chains. Each chuin b:u l!ll 11550Ciatcd iron-C(ln10inmg heme group. Oxygen can bond to the uon of 1be heme group. or catbon dlo,jde can bond to amine groups of 1he amino acids m the polypeputk chains. HemoglObin o< essenlialto tbe ability of erythrocytes to transpnn oxygen oud carbon dioxide. and n single erythrocyte c01 11ain, up to 300 million hcmoglobm molecules. Important pOio11: Each hemoglobin molecule contains four iron 01oms. Eoch 810111 ~i01ds one diatomic oxyscn molecule for a onnx1mum capacity of eight oxygen UtOJ11$ per hemoglobin molecule. ~oTma l Olood Valuts of Hemoglobin ( tnQ 111/ I ci/J Women: 12 to 16 grams per deciliter Men: 13 10 Ill grams per ckciliter 'lewbom 14 10 20 grams per deciliter l mporhlnl: The Hgb value depends on the number of RllCr and 1he amount of 11gb In each RllC. A low Hgb value i~ found in anemia. 10 hyperthyroidism and in cirrhosis uf the liver. A high llgb vah1e is found in polycythenoin, in COI'D. and iu congestive hcun failure. l, He1 noglobin carries oxygen to tl5suc from the lungs and cu rbon dloxld~ Notes away frono tissue lo 1hc lungs. 2. Blood leaving lhc lungs is 98% saturated wi1h oxygett. However, tbc hemoglobin of normal 'eoous blood re1urning to the lnngs It only 75% saturated. J .Corbomlnobemoglobin IS hemoglobm 1hat IS carrying carbon dio.,de from the ussue.1 to rhe lungs. Whereas abou1 97"o of the oxygen ~~ tnosponed by bemoglob1n, only about 30% of rhe carbon dioxide is earTied by hetDoglobou; 1be rest IS trAJl.~ported as bicarbonate. or as carbon dioxide.

~IOCHEMISTRY I PHYSIOLOGY
For each letter, choose the most appropriate answer to till in the blank.

BI~

(A) is a major type of protein present in human blood plasma. It represents an important (B) reserve for the body and, more Importantly, plays a crucial role in maintaining the blood's (C) _ _ __ pressure, which tends to draw water (D) the capillaries.

(A) Beta-globulin I albumin I hemoglobin I fib rinogen (B) Oxygen I iron I amino acid I carbon diox.ide (C) Hydraulic I colloid osmotic I oncotic

(D) Into I out of

15 Copyright e 20092010 tkn~al Dks

~IOCHEMISTRY I PHYSIOLOGY
The principal hormone for calcium-level regulation is:

Bl~

Calcitonin Parathyroid hormone Thyroid hormone Vasopressin/antidiuretic hormone

16 Copyngbt 0 20092010 Denal Dc<k.s

j \)

\lhttmin

( R) \minn acid IC') ( ulluid u'rrimutit..

(UI Inth

Serurn -albumin. oOt.n referred to sim1)ly os albumin, is lhc most abund:ant pJiL.'imii: rrolcin u1 humuns and olhcr mammals. Albumin i~ ess(.'ntial far maintainius lhc u~molic pre-ssure nt:~ded for J)f()pcr distrih11ti00 Of body Otllds betWec:.n irttRVftSCUiar COmpartme.niS lllld

body tissues. Albutnio also acts as a plasma carrier by non-spe<:ifically blndiog severalltydruphobic lilter<Ud hormones itnd as -a transport J)I'O~ein for hemin -and fatty acid~. ~onnnl blood \10IUC! for ttlbumln is 3,55.0 g I H)O mi. Albumin is decreased in l'nalr'l\ttriti(tn, livor

f;ul'ure. and pregnancy. Colloid osmotic pressure in the plasma is also C'~lld onco(ic pressurl'. This- pressure. tend!f to drow WQter into the capillaries by osmosis. Note: The capillruy toomhr;ute I~ highly permeable 10 water as well a~ 10 the other subsumces dissolved 10 plasnta amJ tissue nuid.s. e:<cC'pC the plasma protems (mainly albumin). Tbis prts,sure ~~ il'l1J)OI'htl'lt because it prevents plasma loss from t11e capillal'it.S, This colloid o~moltc IJressu,e tnthe plusu1U 1s u,.po~td by the coll'oid osmouc J)ressure in the- interstitial nuid, Wh1 ch re-sult~ from the presence of nondiAu.<iible prot~i1\S in ~h~:. inl~;;rstitial fluid. Thts pl'e.'~sUHl tends tn tJrnw w~tt~r out of the capiHarie!O by osumsis. Important: If forces tendirtS to ! OOVI.! Ouid out or a capillary arc
grcalt:J than fore!,."~ ltrlding to OIOVC {luid in, nuid w111 lc;avc, t111d Vite versa. I . l'he other force~ that r'tgulatc. the movemeni of nuu1ocross capHlury membrane& Nolts are the tluid or hydraulic pressure fnsil;le the cnpilll'lry rarevu(l qfaneriul am/ vetwu~ Pf{!,\''Wi'es) and lhc nuid pressure IH interntitlul fluid. 2. The kidney is the organ tl1nt JS c hiol1y IO>l)<>nsiblo for the re~ulauon uf the oslllolic- prcssuro in the body nuids by reguluting.lh~: fi.!::lbsorption of water ill restlQnse (()

antidiuretic hormone (A DH or \~t~sopt't'.s~ln). 3. Albumin also transports thyro)(in ,'> ntl triiodothyronine as well a~ ruuy t~citls, bilirubin, bile aci&, steroid hormones, phannaceutic<!ls, und inurga.nlc ions. Wilh the eU!CIJtion of ttlbumin, -almost all pla.;ma J'lfC'IIein~ art ylycoprotcins.

rarl1th~ ruid

hormone

Tho hwnan body contains 1-1 .5 kg Ca"", most of which (about 98%) is lvcated in th<' mineral substance of the bone. The nonnal plasma conceotratiou of clcilm1 varies between 8.5 mg% sod 10.5 mg%. Calcium l~vels are regulate{! by parathyroid 1\omlOlte (PTfl), which increases bone resorption and rcahsorprion of calciurn in the kidney tubules, which in tum increases plasma calciUm levels. Vitrumn UJ rcgulutes the uptake of calciwn in the Gl tract. Low serum calcium levels will result in hyperirritability of nerves and muscles. Patients With hyperparathyroidism will have increased renal calcium c<erction and will also bu prodi~JJO..<ed hJ an increased llkcllhootl of b11ue fractur~. The bone resorption seen in elderly patient> with low dietary calcium is fntcn;;ificd by parathyroid honnone. Calcillm blood levels nrc increased in hypervitaminosis D. iu hyperparathyroidism, and In hone cancer and otbet bone diseases. Calcium blood levels are clccre~scd rn severe didrrhca, in hypoparath)'l'Oidism. and in avitruninusis D (ickets and osteomalacia).

Plasma phosphorus couceotratlon (tor111111 is qpproximatcly 4 mg%) is also regulatod by !JUra thyroid honnone. fncreased hormone causes the kidneys to increase the rate of phosphate excretion. which decreases plasma phosphate concontration.
Pla~ma glucose concemrution (normal Is approximolely 1110 mg%) is regulated by insulin (lower.t glacose levelv) and glucagon (increase.< glucose levels) . GluCQse nonually does not ppcar in the urine although glucose is freely filttr~d because it h reabsorbed in the proximal convoluted tubule of the kidney (lite rellilltresholdfor glucose has 1101 been e.rceeded). lmporta.n t: The oormnl glucose clearmtce is 0 mglruln.

~IOCHEMISTRY I PHYSIOLOGY
Which of the following blood equations is correct?

Bl~

Serum; plasma - fibrinogen Plasma = serum - fibrinogen Serum = hematocrit + plasma Hematocrit = fibrinogen - plasma

17

Copyright e

2009-lotoDetlut Dks

~IOCHEMISTRY I PHYSIOLOGY
The general term for reactions that prevent or minimize loss of blood from the vessels if they are injured or ruptured is:

Bl~

Erythropoiesis
Syneresis

Homeostasis Hemostasis

18 Cop)'ligb.t C 20092010 Dctltal Oed:s

Serum

-=

plnsma tihrinu;,!t'll

Human blood constitutes about 8% of the body's weight. BIO<>d consists of cells and cell lragments in an aqueous medium, tl>e blood plasma. The proportion of cellular elements, known us hematocrit, in t11e tOlal volume is approximately 45%. The blood is the most important transport medrum in tbe body. Blood maintains homeostasis and plays a decisive role in defending the body against pathogens. Serum is the clear, thin, and sticky fluid portion of the blood obtained after removal of the fibrin clot and blood cells. Serum differs from the plasma in Ibm serum lacks fibrin and other coagulacion products. Plasma is blood minus the formed elements. h is ihe fluid portion of the blood (plasma makes up 55% of the blood). Plasma also contains no cells. Plasma contains: Proteins (7%) -consist of albumins, globulins, and fibrinogen, Water (9 1%) Other solutes (2%) consist of metabolic end products, food materials. respiracory gases, hormones, and ions. ---,. I. Remember: The other 45% of the blood consists of formed elements Notes erythrocytes (red blood t:ells), leukocytes (White blood cells) , and thrombocytes (platelets). 2. The function of platelets in hemoswsis is that !hey agglutinate and plug small ruptured vessels.

Tbrough a three-part process. cbe circulatory system gtmrds against excessive blood loss. In this process, vascular injury activates a complex chain of events -vasoconstriction, platelet aggregation, and coagulation ~that leads to cloning. This process stops bleeding without stopping blood flow through the injured vessel. Three essential steps for blood clotting: 1. The production of tbrombin from prothrombin during the clotting process requires a prothrombin activator, whic.h is lbnned either by way of an extrinsic pathway or by way of an intrinsic pathway. A tissue faceor (tlss</e thromboplastin) not normally presem in the blood participates in the extrinsic pathway, buc only factors present in the blood panicipare in the intrinsic pathway. 2. Prothrombin activator acts enzymatic.11ly to catalyze the fonnation of thrombin from prothrombin, 3. Thrombin acts as an enzyme to convert fibrinogen into fibrin threads that enmesh red blood cells and platelets to form the clot itself. I. When b lood vessels are ntpcured and tissues are damaged, both tho extrin'Note sic and intrinsic pathways arc usually activated. 2 . In cirrhosis of the liver, prolhrombio and fibrinogen levels will be deficient and cause impaired clot fom1ation. 3.Homeostasis- tendency toward equilibrium between different but inter dependent elements of an organism. 4. Erythropoiesis- the production ofred blood cells. 5. Syne.resis - liquid separating from a gel doe to funher solidification or coagulacion.

~IOCHEMISTRY I PHYSIOLOGY
1

81~
,

r Iron, the most Important mineral In the formation of hemoglobin, Is resorbed~I

\.. mainly In the and Is only resorbed as

.J

Large intestine, Fe> Large intestine, Fe Upper small intestine, Fe' Upper small intestine, Fe'

18

Copyn;}lt Cl 2009-2010 Otmal Decb

~IOCHEMISTRY I PHYSIOLOGY
(
Universal donor Universal recipient Neither of the above 0 blood type is referred to as:

81~
)

l !ppt-r small inh."Siiuc

(duodenum)~ 1-'c~ (ferrum~.

hhalenl)

Iron is quantitatively the most important tmce element. The hwuan body contains 4-5 grams of iron, which is almost exclusively present in protein-bound fonn. Approximately 75% of the tot~l amount is found in heme proterns, mainly hemoglobin and myoglobin. In addition to hemoglobin aud myoglobin, 15% to 25% of iron is stored in the liver, spleen. and bone marrow, mainly in the form of intracellular iron-protein complexc~ called ferritin and hemosiderin (o comp!e-t of ferritin, denatured ferritin , and otlrer proteins). Iron is resorbed almost entirely in the upper part ott be small intestine, primarily in the duodenum. Here iron immediately combitles in the blood plasma with a beta globulin npotransfcrrln, to fonn transferrin, which is then transported in the plasma. lroo is bound loosely with tiausfcrrin and can be rolascd to MY of the tissue cells ~t any point in the body. Approximately 60% of excess iron is storeJ in the liver. The iron Stored in ferritin is call ed storage iron. Important: Iron can only he resorbed by the bowel in bivalent form (i.e. 11s Fe''), For rbis reason, reducing ageuts iu food sucb. a.~ ascorbate (viramin C) promo!~ Iron uptakt.

I. The dominant factor contTolling absorption or iron from the Gl tract is

' Note< the Sllturalion of mucosal cells with tron.

2. ffcmochromaiosis is an iron-storage disease that results in the deposition of iron-containing pigments in rhe peripheral tissues with characteristic brouzing of the skin, diabetes, and weakness. 3. Bilirubin is a product of heme degradation.

Type 0 people do not produce ABO antigens. Therefore. l)'pc 0 rcople's blood normally will not be rejected when it is given to others 1\-ith different ABO l)'pes. As a result. type 0 people are universal donors fur transfusions. AB-I)'pe people do not make any ABO antibodies. A-B type peolpe's blood does not discritlllnate agamst any other ABO l)'pe. rherefore, they re uuiversol receivers for transfusions. All humans and )nany other primates can be typed by the ABO blood group. T here arc four type.: A, B, AB, and 0 . There are two antigens and two antl~odles that are mostly responsible for the ABO types, The specifoo comb[nation of these four components determines ~n individua's type. T)le table below shows the possiblo pcntlutations of antigens und 1111tibodies with the corresponding ABO types {"ye...' 111dicates 1/re prese11ce Qj' tJ companent. and uo" indicmes ils abse,ce ;, the blood ofau imlivitlual).

A 1)0 Blood T ype

A B

Antigen A

Antigen B

Antibody Anti-A No

Antibody Anti-B

Yes
No No

No

Yes
No

Yes
No

Yes
Yes
No

0
AB

Yes
No

Yes

Yes

For instance. type A people have the A antigen an the surface of their red cells (us shown in tire urbleaboe) .As a result, anti-A antibodies will not be produced because they would cause the destruction of theit own blood. However, if B-type blood is injected into their systems, anti-J3 antibodies in the plasma will Tccognizc the blood us alien and burst or agglutinate the introduced red cells In order to cleans~ the blood of alien protein.

~IOCHEMISTRY I PHYSIOLOGY
The amount of oxygen bound to hemoglobin:

Increases if DPG concentration increases Is constant between Po2s of 40 mmHg and 100 nunHg Decreases if the Pco2 increases Is directly proportional to the partial pressure of 0 2 Increases if the temperature increases

21 Cop)'ligbl 0 2009'20 I 0 lkntal Ottb

~IOCHEMISTRY I PHYSIOLOGY

Bl~

IA ' ll of the following will promote the release of oxygen from oxyhemoglobi; ---the hemoglobin dissociation curve will shift to the right-- EXCEPT one. Which one is the EXCEPTION?

Increased carbon dioxide concentration (Pcoz) Increased tissue temperature Increase in the pH Increased diphosphoglycerate (DPG)

22 Copyri.gbt e 20092010 lkn~31 Dk$

Hemoglobin is lbe oxygtn-bearing protein of red blood cells and constinues about 33~. of rhe cell weight. Oxygen is picked up in the blood (from the lung>) and forms 01ybemoglobin (HbO:): blood leaving the lungs is saturated with oxygen and carries oxygen ro rhe tissues with decreased oxygen pressure; oxygen splits away from the hemoglobin and creates reduced hemoglobin (HHb). The combination of bemoglobm (lib) with oxygen (0:) is r~venible, and wberher Hb binds wilb or releases 0: depends m large pan on !he oxygen partial pre.~sure (Po,). When lbe Po1 [s relatively high, (as in tire pulmonary capil/(lr/es), Hb bas a higher affinity for 0, and is 9R% san~rored. At a lower Po,, (as in 1/te tissue capillaries), Hb has a lower affinity for 0 2 and is only parrially saturated. The partial pressure of 0 1 (ppO~is u factor in determing the amount of 0 1 bound to Hb; however there is no diretl proponionnliry ro lbe pp0 2. The ppC0 1, pH, rem perature, and OPG levels SUilCrsede the ppO, 's influence. The following ~tualions also promore the release of oxygen from oxyhemoglobin: ( *** Oxygen diSsociation Cllr\'e shifts to the right) lncrea,s e in diphospboglycerste (DPG) lnuease in tissue lemperature - exercise. physical activity - Decreased pH - increased artenal H ion concentration

This shifts the curve to tlle len. The influences of pH. Peo2 , and temperature on the oxygen bindmg by hcmoglobrn (Hb) operates to ensure adcquare deliveries of oxygen to activ tis.ues. When a muscle is actively contractrng, the following events occur: lactic acid is produced (lowering the ptl), C02 is produced by the tissues (thereby increasing Pro:), and hear is produced (thereby increosing tissue temperature). Therefore. the by-producrs of exercise are also the exact factors I hal Mlrnulate o, release from oxyhemoglobin. Active !Issues have the following characteristics: - Lnwer pH. Nore: Aciwc co11ditious wrll decrcnse rhe alliniry of Hb for 0 2 . The ltrgher rite H" ion concentration (lower p/1), rhc less 0 1 is bound to Hb. Increased arterial Pco,. Note: The panial pressure of carbon dioxide (Pco} affects the binding of 0: to Hb because carbon dioxide molecules brnd with Hb molecules and alter lhc l ib molecule, thereby reducing their affinity for 0,. Therefore, the higher the Pco2 the less 0 2 is bound ro Hb. Increased temperature. Note: The higher the temperature. the less 0 2 is bound ro Hb ar any gi,en Po2 - Increased DPG. .Note: Ilypox1a increases the form01inn of DPU which also shifts rbe oxyhemoglobin dissociation curve lo the nghl.

GnocHEMISTRY 1 PHYSIOLOGY

Bl~

Which of the following globin chains are not commonly found in humans?

Alpha
Beta

Gamma
Omega

23
COpyrigh! 0 20092010 Dcnul Decks

~IOCHEMISTRY I PHYSIOLOGY

Bl~

Which of the following is considered to be the normal hemoglobin?

Hemoglobin H Hemoglobin S Hemoglobin M Hemoglobin A Hemoglobin C

24
Copyri,aht 0 2009-2010 OC'n1al Dks

A Mole<ule of Hemoglobin Is Composed of the following: I. Globin (protei11) portion Consists of four polypeptide chains 1wo alpha chsins aod rwo beta chains. Tbe norm;U aduh globin portion of Hb consists of two alpha and two beta chams. and the normal fetal globin portion of Hb consists of two alpha and two gamma chains. 2. Four rlngsb:.tped berne molecules (nfJilprmein groups) Each heme is a nitrogencontaining organic pigment molecule- t.hnt has a single atom of iron in the reduced state (F(t' ~ or ferrous iron) in its ttmer, which can combine with one tnolecuJe of oxygen. These heme groups arc- auachcd to 1 hc globin polypeptide chains.
Each iron atom can bind reversibly with one molecule of oxygen; therefore, a hemoglobin molecule c~n potentially associate with four oxygen molecules. When it is combined with oxygen, tbc compound is called oxyhemoglobin. When the hemoglobin molecule is not combined with oxygen. the. c.ompound is cul led dcox.yhemoglobio (reduced

- - - I . Hemoglobin combines reversibly with carbon dlos ide at tJle prottin .Notes- portion of the he-moglobin molecule. .. 2. Carbol\ monoxide decreases the <\mount or oxygen that can ~ lnutSpOr1Cd by hemoglobin by competing with oxygen for hemoglobin binding sites. Carbon monoxide has a much hlghH afl'inity (240 x ssronger) for hemoglobin than does oxygen. 3. As pH decreases, so does the affinity of hemoglobin for oxygen. 4. l\tttbcmoglobio contains iron in the ferric state rrr:J) and cannot funclion as an oxygen carrier. 5. Hemoglobin is n major H' buffer ortbc blood. Deoxygenated hemoglobin is less acidic than oxygena< ed hemoglobin and thcrcrore ideally suited to bulf<T lbc H' ioru; (comlngfrom tiss11e COz).

lll'mngluhin .\

Hemog.l obio C is abnormal hemoglobin in wbkb lysine has replaced glutamic acid, causing reduced plasticity of the red blood cells. l:lemoglobirl H is an abnormal hemoglobin composed of four beta chains; it is usually associated with a defect in three of the four alpha chain genes resulting in alpha-thalassemia. Hemoglobin S is an abnormal hemoglobin in which valine has r eplaced glutamic acid in I be. beta chain. The presence of hemoglobin S causes the red blood cell to deform and assume a sickle shape when exposed to decreased amounts of oxygen

(suclt as might happen wlten someone exercises or in lite pcripltcral circulation). Sickled red blood cells can block small blood vessels, causing pain and impaired circulation, decr~ase the oxygen-carrying capacity of the red blood cell , and decrease the cell's life ~pan. HemoglobinS is the predominant form of hemoglobin in persons with sickle-cell anemia. Important : A major effect of sickle cell anemia is the decreased solubiUty of the deoxy form of hemoglobin.
Hemoglobin M is a group of abnonnal hemoglobins in which a single amino acid substitution favors the formation of methemoglobin and is thus associated with methemoglobinemia.

~IOCHEMISTRY I PHYSIOLOGY
Erythropoietin is produced by _ _ _ _ _ , and bas its primary action on the

Bl~

Kidney, liver Liver, kidney

Bone marrow, kidney

Kidney, bone marrow

25
CopyrigbtO 20092010 Den1ul Oects

~IOCHEMISTRY I PHYSIOLOGY

Gls)

There are three major cells in the stomach that help to digest the food you ingest. There are four major secretions. Match the secretion to the ceU that produces it.

"

Secretion

Parietal Chief

Pepsinogen Gastrin

HCL
Intrinsic factor

26
CoP)'ri.gbt 0 2009-2010 ~ntal Deck!!

1-.:idm' hone m;Jrrm\

Erythropoietin is a glycoprotein honnone produced in tbe kidneys that stimulates the production of red blood cells by bone morrow. The production of erythropoietin. and thus erythrocytes. is regulated by a negative-feedback mechanism !bat t> sensitive to !be amount of oxygen dehvered to the tissues (panicular(v rile kidne);). Anoxia (low oxygen) leads to greater production, while an increased oxygen supply leads to decreased production. The site of action of this hormone appears to be at the hemocytoblast (a pluriporem srem cell). Inadequate erythropoiesis leads to anemia, increased cardiac output, and hypoxia. Excessive erythropoiesis can lead to polycythemia, an increase in blood viscosity, and sluggish blood fl ow. Important: Anemic individuals have no1mal oxygen tension but reduced oxygen content in their systemic arterial blood. Characteristics of erythrocytes: I. Biconcave discs, 7.5 microns in diameter, lack nuclei and mitochondria. 2. Contain hemoglobin. 3. Have a lipid membrane contaaning lipoproteins and specific blood group subst ances (A. 8, 0). 4. The principal function is to transport os)gen and carbon dio~lde. 5. The proportion of erythrocytes m a sample of blood is called the hematocrit - 46.2% for males and 40.6% for females is !be normal range. 6. The amount of bile pigments excreted by the liver is a good indicauon of the amount of erythrocyte destruction per day. 7. Life span of erythrocytes lOS to 120 days.

........................ I I< I ancl Inlrilhil" Iactor ( hll'l cl'll\ ..................... .... ... Ptp,innc.tn (. tdh .................................. ( .a,trin

laril'lllll'ell ~

Gastric pits are depressions in the epithelial lining of the stomach. At the bonom of each pit is one or more tubular gustrl< glands. Chief cells produce !be en.tymcs of gastric juice. and parietal cells produce stomach acid. These glands produce as much as 2-3 liters of secretions per day. Tbc plf of gastric secretion is 1.0-3.5. Note: The mucus produced by mucus-secreting cells is very alkaline and protects the stomach wall from being exposed to the highly acidic gastric secretion.
Ctll lype

Part of Srumac.h SterNion prOOutlt

Stimulus tor SrcrNion

Parietal cells
(Oxylltlc)

Body (/imd<~)

IJCt

(<'"'"' ')
Chie( cells (/.)'mORenic)

fntr1n~tc

1actur-

Body lfimd.s)

l>epslnoaen (con-.,~rtt>d to peps;,

otlnwpHJ

Gas1rin Vagal sti111ult1tt011 (ACh) Hi :~tam inc Vagal

~timulahon

tACh)

G :Us
(meromJocnnr utlr-)

AniNm

(is,trin
Mucuo Ptp<11101:m

Vayal !ltirmJIJuon fua GRP)

Prot~-tn

M_.,.<dls

AniNm

Vapl !ltinllllauon (A Chi

~IOCHEMISTRY I PHYSIOLOGY

For each of the following, tell whether it will SLOW or SPEED up gastric emptying:

Gastric inhibitory peptide Activation of the sympathetic nervous system Activation of the parasympathetic nervous system
Secretin

Activation of the enteric nervous system Cholecystokinin Ingestion of food and its presence in the stomach
27
~ahl 0 20092010 ""'"' Dc<ks

(BIOCHEMISTRY I PHYSIOLOGY

GI S )

Th~ following list contains: Three (3) secretions from tbe enteric tndocrlne systtm that stimulate tbe pancreas Three (3) secretions from the pancreas acinar cells O ne ( I) secretion from the pancreas duct cells Categoriu tlum as to wltich ones are which:

Cholecystokinin Amylase Chymotrypsin

Trypsin

Secretin Gastrin
21
Copyn,aht 0 2009-2010 lkn111 Detk:s

G:tc.;lric inhihitnry peptide ... Sln\\ Adi\ :1tinn uf llll' c.;yrnpathl'lic O("nuus syc.;tcm ... Slo\\ :\tti\:lliuu nfthl' IHlras~ mpathe-tic mnnu. c.; '~ liiitl'm ... SJH.+ld ti J) ~rln.:Hu ... Shm .\eli\ :Uinn nf lht. tnhrk mn uu\ s~ stem ... Slo\\ C'hult.cy,tnldniu ... Slon l u:,:t.'stiun ur ruol1 :md its l)rt.''il'n(."(" in the sromach ... !\p(('d lljl

foodstuffs entering the duodenum, CSJH:clally rut_ $ und acidic

cbymc~ stimulate lhc release of honnones. including cholecystokinin, secretin, and gtric Inhibitory peptide (GIP), l.bnl inhibit the pyloric pump. Note: Sro111ach o11ptyin~ is fnhr~ced by the presence of food in the stomach aud ga5tTin.

The small intestine sends inhibitory signals w the stomach to slow sccrt:tion aut! motilily~ Two types of signals are used: nervous and (ndoc-rint. Oisten~;on of lhc.
into gastric inhibitory

small intestine. as wel l as chemical and osmotic irritation of the m\,ICOsa, is transdu~ed impulses in the emenc nervous system. This uervuus p3thwa.y is caJicd the enterognnric reflex. Secondly, enteric l\ormooes such as dwlc.cySlokinin
and ~!Oecretin are released from cells in the srunll iot~slinc: :Jnd ountributte lo

sllppression of gnstric activity. Remember: !n general. sympathcUc stimulation causes inhlbilion of gastrointestinal secretion -and motor activity, and coouaction of gastrointestinal Sflhincters and bloo(l vessels. Conversely. parasympathetic stinurlf ond acetylcholine typically stlonulate tbe$e digestive acliVities,

They are two majQr types of contraction< 111 the ()J trac\, pcrlsrnlsb ~nd mixing (segmenJulion) eontracrlons. Peristaltic contractions generate propulsive movements. Mixing contractions strve lo spread oul the foodstUffs- and increase the surfac-e area available for dige-sliC'In and absorpLion.

Slimul:lturs urI h..: pancreas: Chole"cystnl,inin. !\('i.'l"l'tin. (;a!'lrin Pancn~h adnar ccll sccn.tions: \ m~ last:, Ch~ nu11r~ p~o;i n~ rQ (l'ltin ramnas due& l'l'll Orrit.'Crl'tiOn"i: Rkarhnn:ltt. inn

Secretion from the exocrine pQncrcQs is regulnt<d by both neural and endocrine controls. Durin& interdfgestivc periods. Ycry little secretion rakes plact. but as food enters the stomach and. a little later, chyme flows into the smaU intestine, pancreatic secretion is strongly stimulated. Like the stomach, Ihe pancreas is innervated by the

vagus nerve., which anticipation of a meal.

applie~

n low-level stimulus to soerCJtion in response to

l'ancrearle ~~crctions (daily secrelioll 0,7-2.5: with a 11H beiWeetl 7.5 a11d R.8) from pancreatic acinar cells include enzymes involved in protein breakdown (ttJ'psln. chymotrypsill, olld curhuxypu~vpeptidose), carbohydrate breakdown (amylose). and fat breakdown (lipase, cholesteml esterase, pilosplto/lpase). Pancreatic enzymes arc secreted in an inactive fonn called a zymogen, and are then activated in the small intestine. Note: Pancreatic duct cells secrete a Jluid that is high in bicarbonate ion. Tbc secretions t1f the exocrine gastric glands, com)>Oscd of the mucous, parietal, and chief cells, make up the gastric j ulce (dt~ily .vecretion 2..J liters; with tt pH betwee/1 J.Q ~ltd 3.0), Gastric see.retions includ<' HCL, mucus, pepstnogco, and inlrin~ic facto r.
lnte~tinal secretions (doily s~cretiot~ ,,~,townwillt (t pi{ bellveen 6,5 nnli 1.8}, mainly mucus, are seorcted by goblet cells and cnterncytes.

Bile (p/1 around 7.8) is produced by the liver and sto red in the gallblodder. Bile aids it1 the emulsification, digestion, and absorplion of fatS. Cholecystokinin is a horruont' produced by the wall of the UppU part or the intestine. It siirnulates t~e contraction of the gall bldder, releasing bile.

~IOCHEMISTRY I PHYSIOLOGY
r
Your patient tomes in and s ays that his physician bas diagnosed him with pernicious anemia. As you know, this is caused by the malabsorption of vitamin 8 12

I. What protein is crucial in the absorption of vitamin 8 12? Gastrin Intrinsic factor Pepsin
2. What cell type is the cause of the faulty production of this glycoprotein? Chief cells Parietal cells Mucous neck cells G cells 3. What type of glands contain these cells? Pylonc glands Gastric glands Cardiac glands None of the above; they are not pan of the glands
28
Cop)Ti&htO 2009-2010 f)tn!al Dttb

~IOCHEMISTRY I PHYSIOLOGY
Neural, mechanical, and hormonal factors affect the intensity of segmentation within the small Intestine. For example, djstension of the intestine by chyme and parasympathetic neural activity both the contractile force, while sympath etic neural activity it.

Decrease, increases
Increase, decreases
Have no effect on, increases

None of the above

30
Cost>Tishl o 2009.20 1 o Dm~al .:>11

t. lnlrinsic f:1clor 2. P:trill;tl cdls J. ~Oih.' nf tlw ahO\ l~ :

thl~ :tn. not part of the ~lund~ ... ,. I hl''i{' cdh antl:Jrt ofthl' t:pilhdium .md 1Jrl' not parr of

tlu.~ ~.:land....

The secretory glands in the stomach can be deUneated into 3 regional divisions: Cardiac glands: mucous secreting found primarily in proximal stomach. Gastric or oxyntic glands: HCI, pepslnogen, and mucous. Pyloric glaods: mucous secretion into stomach and gastrin into the blood. Found in "Aotrum," region oear pyloric sphincter. Note: Enterocodocrinecells (G cellv) scrctc. gastrin. which is absorbed in the blood and carried to the gastric glands, where gastrin stimulates rbe parieta I cells to secrete HCL. Cell t)']les in gastric or oxyntic glands: Mucous neck cells: secrete mucous, and some pepsinogen, migrate to rep1ace surface epithelia. Parietal cells (oxyntic cells): secrete HCI and intrinsic factor Chief cells (peptic cells): pepsinogen Functions of secretions: Hydrochloric acid produces an acid environment that helps to kill bacteria and to activate pepsin. This solubilizes C-01\oective tissue. Secretion is increased by acetylcholine 1 gastrin, and histamine. Pepsin proteolytic enzyme secreted in an inactive form (pepsinogen) and converted by stomach acidity or by autocatalysis to pepsin. Active m pH <5.0. Mucous- -viscous and alka1ine. produce-S a barrier along the walls of the stomach to protect the stomach from the ~cid and from abrasion. lntrinsi~ fartor a glycoprotein that is essential for normal absorption of vitamin B 12 in the intestine. Without intrinsic -factor, pernicious anemia wi ll develop.

I nlrcus(.~ dccrrolst's

Coordinated contractions of smooth muscle, called segmentation, pantctpate m several ways to faci litate digestion and absorption in the small intestine: Foodstuffs are mixed with digestive enzymes from the pancreas and bile salts from the biliary system. Nutrient molecules in the lumen are constantly dispersed, allowing them to contact the epithelium, where enzymatic digestion is completed and absorption occurs. Chyme is moved down the digestive tube. making way for the next load and eliminating undigestible, perhaps toxic, substances. Following a meal, when the lumen of the small intestine contains chyme, two l)']les of motility predominate: segmentaiion contractions chop, mix. 11J1d roll the. chyme and peristalsis slowly propels the chyme toward the large intestine. - - I. Chyme is the semifluid contents of the stomach consisting of partially Not.. digested food and gastric secretions. 2. Gastric motility and emptying are influenced by distension of the stomach (via neural reflexes and gastrin) and by volume nod composition of chyme in the duodeown (via enterogaslrlc rcj7ex and intestinal hormones).

GuocHEMISTRY 1 PHYSIOLOGY

Grs)

( \..

Which of the following pairings is incorrect regarding the absorption in the small intestine?

Fructose - Facilitated diffusion Free fatty acids- Simple diffusion Dipeptides - Primary active transport Glucose Secondary active transport

31

CopyriShtC l0W2010 Den1ol Decks

~IOCHEMISTRY I PHYSIOLOGY
Place the following phases of gastric secretion in their proper order:

Intestinal phase Gastric phase Cephalic phase

32 O.lpyrialn O 1()09..2010 Onnal Ded:s

Oiplptid('li rrimar~ artiH tr:msporl

*** Dipeptides are absorbed by secondary active transport. The bulk of dietary lipid is neutral fat or triglyceride, composed of a glycerol backbone with each carbon linked to a fatty acid. Additionally, most foodstuffs contain phospholipids, sterols like cholesterol, and many minor lipids. including f.1tsoluble vitamins. In order for the triglyceride to be absorbed, two processes must occur: Large aggregates of dietary triglyceride, wbicb are virtually insoluble in an aqueous environment, must be broken down physically and held io suspension -a process called emulsification. Triglyceride molecules must be enzymatically digested to yield monoglycerides and free fatty acids, both of which can efficiently diffuse into the enterocyte.
The key players in these two transformations are bile salts and pancreatic lipast. both of which are mixed with chyme and act in the lumen of the small

intestine,
Dipeptides and amino acids are the end products of protein digestion. The final digestive stage occurs by brush border peptidases, and absorption immediately follows. Absorption across the brush order occurs by multiple secondary act ive transporters utilizing either the sodium or hydrogen gradients. Disaccbarides and small glucose polymers are hydrolyzed at the brush border by lactase, sucrase, maltase, and alpba-dextrinase. The resultant monosaccharides, glucose and galactose, are then absorbed by secondary active transporters driven by tbe sodium gradient. Fructose absorption is mediated by facilitated diffusion.

Crphalk phasr (;as I ric phasl' lnestinal phase

Phases of Gastric Secretion: Cephalic phase ("wake up call'): sensations of thoughts about food are relayed to the brainstem, where parasympadtetic signals to the gastric mucosa are initiated. This directly stimulates gastric juice secretion and stimulates the release of gastrin, which prolongs and enhances the effect. Gastric pha,se ("full steam ahead"): the presence of food, specifically the distension food causes, triggers local and parasympathetic nervous reflexes that increase the secretion of gastric j uice and gastrin (which further amplifies gastric jtlice secrelio11). Products of protein digestion can also trigger the gastrin mechanism. Intestinal phase ("step on the brakes ') : as food moves into the duodenum, the presence of fats, carbohydrates, and acid stimulates hormonal and nervous reflexes that inhibit stomach acth<ity.

~IOCHEMISTRY I PHYSIOLOGY
( As an action potential reaches a skeletal muscle cell, which of the following

1\.. the proper order of substances moving into and through the muscle cell?

i;'\
j

Acetylcholine, Calcium, Troponio, Tropomyosin, Myosin heads Calcium, Acetylcholine, Troponin, Tropomyosin, Myosin heads Acetylcholine, Calcium, Tropomyosin, Troponin, Myosin heads Calcium, Acctylcholioc, Tropomyosin, Troponin, Myosin heads

33 Copyn&flt C 20092010 ()cntnl Db

~IOCHEMISTRY I PHYSIOLOGY
' The immediate source of energy for muscle contraction is ATP binding to "' myosin. The ATP pool, however, is extremely small and has three sources of replenishment. Which of the following is not a source?

Creatine phosphate Lactic acid Glycogen Cellular respiration

34
Coprrigll~ . 10092010 Dentall)cd;s

\ret~ lcholirll'. Calcium~

I ro1mnin. I rnpnm~ osin.

\t~o~in

htads

When an action potentia l arrives at a muscle cell, the action potential causes Ca1 " to be released from the sarcoplasmic reticu lum. As intracellular Ca'' is increased, Ca'' hegins to bind 10 ITopouiu C on the thin filament.>. causing a conforma1ional change in troponin that permits the intcruction be1ween actin and myosin.
After calcium binds with troponin, tropomyosin moves from its blocking position,

penuitting actin and myosin to interact. High-energy myosin binds weal<Jy to actin subunits: however. when illorgauic phosphate is '"leased from myosin. the rnyosin bind tightly to the actin subunits. Energy stored in the high-~ncrgy myosin i> discharged, and the myosin h~ds swivel, pulling on the lhin filaments. This repeated pulling of the thin filamems past l.be tliick filam"nts toward the cenlers of the sarcomercs draws the Z lines closer togrther, a.nd the muscle fiber shortens (contracts). This proces. is culled th e Sliding Filament Theory. Note: This process is repeated as long as calcium ions are bound to rropooiu and AJP is available. Once calciUm ious are rctw-ned to the sarcoplasmic reticulum, 1ropomyosin moves back io10 its blocking position and prevent~ fttrthor interaction be.twccn higb.cncrgy myosin and actin subunits. Contraction ceases. a11d I he rnt~scle ubcrs relax. Important: In the contrartile cyele, the dissociation of the actomyosin results from AT!' replacing ADP on the myosin heads. Remember: Composition of myofilament$ T hick lilamcnt- composed mainly of be pr01eio myosin . 'l'bin ftlamonu composed mainly of the protein uct.in.
comple~

The hydrolysis of ATP (adenosine ll'iplro<phcl!e) provides the immediate source of energy fur muscle comraction. Although a musde J i oer contains only enough ATP to poWer a few twitches, ils ATP ''pool" is rcplcnishod as ncc<lod, The three sources of highenergy plt\lspbate to keep the ATP " pool" ti llrd are creatine phosphate, glycogen, and cellular rr>11irntion in the mitochondrin of rhe muscle fibers, Creatine phosphate -The phosphate group in crc~tinc tJhosphate is attached by a "high.~nergy" bond like that in ATP. Creatine phosphat dorives it.> hign.energy phosphate from ATP and can donate the phosphate back to AOP to form ATP. Creatine phosphate + ADP io+ creatine i' ATP. Tbe pool of creatine phosphate t11 the fiber is about I0 times larger than that of ATl' and rhus serves as a modest reservoir of AT!'. Glycogen -Skeletal muscle libers comain about 1% glycogen, The muscle fiber can degrade lltis g.lycogeJ by glycoggno!ysis, producing glucoselphosphatc. This enters the glycolytic pathway to yie ld IW<J molecules of ATP for each pail of lactic add molect~les produced . Not mucb, but enuugh !u keep the muscle function ing if it fails to receive sufficient oxygen to meet its ATP needs by respiration. However, this source [s limited. and evcnt\oally rhe muscle musl depend em cellular rCSt-pirntion. Ccllnlnr rcspirtion Cellular respiration not only is required to meet tho A 'rP neods of a mUAole engaged in prolonged activity (thus clwSilfg /1/0rc rupid t111tl dueper bteathing), hut is also required afterward' to enable the"body to resynthesize glycogeu from the lactic acid produced earlier (deep brmtiJing continue.< jiw a time after exerct~<e is slopped). Noto: The body must repay its oxygen Jcbl.

~IOCHEMISTRY I PHYSIOLOGY
During exercise, which of the following is thought to be an immediate \ '\.. source for high-energy phosphate groups with which to replenish ATP ? }
~

NAOH FADH 2
Phosphoenolpyruvate Creatine phosphate

35
Cop)-riSht C l0092CIIO l)mt-11()red:$

~IOCHEMISTRY I PHYSIOLOGY

Msl)
on~

' As yon complete the seating of a crown, you ask your patient to tap lightly the articulator paper. Which of the following statements is correct in describing the physiology of the patient's light tapping?

The "all or nothing'' phenomenon occurs; all fibers in the masseter and medial pterygoid are partially stimulated, causing a light contraction Fractionation occurs; each muscle fiber involved is stimulated only by a fraction of the alpha-motor neurons innervating the fiber, and so the fibers contract tightly Fractionation occurs; only a few small alpha-motor units are recruited, and the masseter and medial pterygoid muscles contract lightly The "all or nothing'" phenomenon occurs; the muscles that close the mouth are stimulated fully but are countered by stimulation oftbe muscles that open the mouth, causing as light closing of the mouth
36
C<lp)-rightO 200?-2010 ~utal 0-l:s

Cre~1tint

phosphate

Creatine phosphate is one of the basic mus cle energy stores, particularly in fastswitch glycolytic fibers. Normal metabolism cannot supply energy as quickly as a muscle cell can use it, so an extra storage source is needed. The phosphate group can be quickly transferred to ADP to regenerate the ATP necessary for muscle contraction. Tbe phospha te compounds found in living organisms can be divided arbitrarily into two groups based on their standard ftce energies of hydrolysis.

1. Higher phosphate group-transfer potential than AT P: Pbosphoenolpymvate Carbamoyl phosphate Acetyl phosphate Creatine phosphate 1,3-diphosphoglyceric acid 2. Lower phosphate group-transfer potential than AT P: Glucose- 1-phosphate Glucose-6-phosphate F ructose-1.6-dipllosphate Creatine

fr.nlionatiun occurs: onl~

ma"'sl'll'l
~md

ll rl'\\ sm~tll :tlph:Hnotm unit\ are recruited and thl' nwdial pter)coid muscks contr~lct lil!h11)

The motor unit is the a lpha-n1otor neuron and all of the muscle fibers t11at lt innervates: Each muscle- is composed of several muscle fibers Each muscle [jbcr is innervated by a slngle alpha-motor neuron Each alpha~motor neuron innervates many mus<:lc fibers All of the fibers innervated by a motor neuron contract when that motor neuron fires un action potemial

Remember ; The Si:ce Principle 4 ~ motor units are recruited in order of the size of the moror unit. If only a small amount of tension is required to perform d1e move men~ then only small motor unils wfll be activared. If greater force is required, more and larger mmor units will he recr uited. Important: \Vhcn a patient bires down rapidly on an unexpected hard surface while chewing, tbe cessation of motor unit recruitment in the Jaw closing muscles is caused by p eriod ontal mechanoreceptors. fra ctionation means that it is not necessary to activate all of the moror units in a muscle. The contraction of skeletal muscle is controlled by the nervous systern. Action potentials traveling down somatic alpha motor neurons cause dcpolnrization of the skeletal muscle fibers at which they terminate. The junction between the tcnninal of a motor neuron and a muscle s at a neuromuscular fiber is called a neuromu!\cular j unction. When an action potential arrivejunction, calcium ions enter the nerve tenninal, causing the release of acetylcholine from synaptic vesicles within the motor neuron. Acetylcholine then bincl..s to the nicotiojc cholinergic receptors in the muscle fiber plasma membrane. This causes depol arization~ which triggers an action potential (rhe action potcntial travels along the membrane and the t~tubules). TI1is action potential triggers the release of calcium ions frum the sarcoplasmic reticulurn. This leads lO crossbridgc fonuation between actin and-myosin. These interactions arc responsible for the development of tension and tl1e shortc:ning of tl1e fibeo;.

~IOCHEMISTRY I PHYSIOLOGY

\.

AU of the following statements concerning muscle fibers arc true EXCEPT one. Which one is the EXCEPTION!

Fast-twitch fibers are about twice as large in diameter Slow-twitch fibers have a greater resistance to fatigue The enzymes of oxidative phosphorylation are considerably more active in slowtwitch fibers Fast-twitch fibers contain more mitochondria and myoglobin Fast-twitch fibers can deliver extreme amounts of power for a few seconds to a minute

37 Copyright() 200!MOIODental Ob

~IOCHEMISTRY I PHYSIOLOGY
All of the following statements concerning muscle spindles are true EXCEPT one. Which one is the EXCEPTION?

They are found within the belly of muscles They consist of small, encapsulated intrafusal fibers and run in parallel with the main muscle fibers (exrrafusal fibers) The finer the movement required, the smaller the number of muscle spindles in a muscle They detect both static and dynamic changes in muscle length

38 C;lopynJht 0 2009-2010 Den;al De<:lts

Fasl-h\ilch lihlrs

con1~1in

mor{' mifochondria and

m~oglohin

*** This is false; see chart below.

(
h::~racfl' ri\ lll''

of Skl'lttal \lusde l'ihtrs

Characteristic Myosin-ATPase activity Speed I Intensity of conlnlction Resistance to fatigue Oxidative capacity Enzymes for anaerobic"glyeolysis Mitochondria Sa.rcoplasmic reticulum Capillaries Myoglobin eontent Glycogen content

Slow T\vitcb (Type I)

Low

Fast Twitch (Type ll) High Fast I High

low

Slow / Low
High

High Low Many Less extensive Many High

Low

Hi gil Few
More extensl ve
Few Low

Low

Hi gil

,....__ I. "Fast" muscles a.re for rapid. powerfut actions (jumping. shorl disJant:e Not~ running! while "slow" muscles arc fo r prolonged activity (body posture,

marathon). 2. Oxidative capacity is related to (I} the number of capillaries, (2) the myoglobin content, (3) the number of mitochondria.

Tht riawr tht mu\ l'III{'Ut H'C.Juired. the smaller the numbl'r of musclt spindll'S

in muscll'

This is false; the finer the movement required, the greater th~ number of muscle spindles in a muscle.

**

Muscle tone is "fine-tuned" by two .sensory organs:

I. Mu.sclc spi" ndle (measures muscle length) three components: I. Specialized muscle fibers: {intrafusalfibers)

2. Sensory terminals: group Ia and IJ afferents 3. Motor terminals: gamma motor (efferent) neurons ***Activates alpha motor neuron when stretched. 2. Golgi tendon organ (measures muscle tension): innervated by a s ingle-group Ib sensory (affereflt) fiber. Inhibits alpha motor neuron.

-:J !.The muscle spindle is a small, highly differentiated part of muscle Note$ tissue located within the belly of muscles and ruos parallel with the main muscle fibers. 2. The annulospiral endings (sensory terminals) are wrapped around ~pec ialized muscle fibers that belong to the muscle spindle (imrafisa/ fibers) and are quite separate from the fibers that make up the bulk of the muscle (extrafusa/ fibers). 3. Motor (efferent) neurons can be fu rther classified as alpha or gamma motor neurons. Alpha motor neurons innervate and stimulate skeletal muscle. Gamma motor neurons innervate tbe muscle spindle. 4. Activation of the gamm~ motor neuron maintains the spindle sensitivity.

GnocHEMISTRY 1 PHYSIOLOGY

Msr)

When a muscle is _ _ _ __, the is considered and t he result Is

reflex reacts. This reflex

Contracted I Golgi tendon I monosynaptic I contraction Stretched I Golgi tendon I disynaptic I relaxation Stretched I stretch I monosynaptic I contraction Contracted I stretch I disynaptic I relaxation Stretched I stretch I monosynaptic I relaxation

39 Copynaht 0 2009-2010 OC'n;al De<ks

(BIOCHEMISTRY I PHYSIOLOGY

Msl )

(
Three basic clements Four basic elements Five basic elements Six basic elements

All reflex arcs have:

...,
C<>pyrigh! 0 20092010 IXnul Dks

Sln:lchl't.l / sln.lch

/ nwnoo,~naplir I

rcl:n;tliuu

The stretch reflex, also known as the myotatic reflex, responds to passive stretching of the muscle. The muscle stretch is detected by muscle spindles \VhOsc afferents (Ia fibers) synapse. with lower motor neurons (a motor neurons) and iutcrncurous (Ja inhibitory imemeurous}. The renex is important for Ute automatic mtintennnce of posture and muscle tone. When the muscle is stretched, so is the muscle spindl e. Tbe n1usclespindle depolarize.~ in response to srretclting (senses tlte change in lengrlt) and sends action potentials to the spinal cord where it synapses With a motor neuron. This triggers the stretch rcllcx, causing the muscle to c<lnrract. The basic fuuct ion of the muscle spindle is to convey infurmation to the cemral nervous systl'fn concerning muscle length aud tension. lruportant: The sensory receptors serving the stretch reflex are classified as proprioceptors.
Rn~
Strercl1 reOa ,.,.,.j.,k)

Numbtr or Synap11es

Stimuhu

Afferent Fib.,..

ll~tW)lljt

Monosynap1ic

Mu$le ls. stretChed

Connacdon \')fthe mu~cle

Oolg; ...,don refl<ll Disywlpti< (o/!J.>pblif't:)

Atxor~wi1hdmwal rafle~ {tlj1ttr 1611ch

Muscle oonuuct!) lb

Rela1{:uiun of t.ho m~&scle

Potysynapli.c

Pllin

rv

fl, II(. and Jpslbu~l fle.\iOO, COI!Irllli!et'l)

c.Klt'USWH

ing u lint stove)

1. The Golgi tendon refle.l is the reverse of the stretch reflex. Golgi tendon orgaus also depolarize io response to muscle stretch but inbibit tbe motor neuron, causing the muscle to relu . 2. The flexor-withdrawal reflex fs a polysynaptic reflex th&t is used when n person touches a hot object or steps ou 11 oeedk.

The reflex arc is a simple neurul pathway connecting receptors to an effector, A receptor detects a st[tnulus or environmental change. An effector is an organ of response (i.e., skeletolmusc/e). It produces a response calkd a r enex. Rotlexcs ~re quick because they involve few neurons. Reflexes are ~ither somatic (resulrmg 111 t'Ontracrion of skeletal muscle) or autonomic (nr.civr:tion of smooth uml cmdiat muscle). All reflex arcs have si~ bnslc element.~: a receptor, o<ll-'0'Y (a.fleri!llt) neuron, integration center (CNS), interneuron. motor (effereur) neuron, and effector. Spinal TeOexes are somatic reflexes mediated by !lte spmaJ c<.>rd. Two importa11l s pinal rellexe<> influence the contraction of skeletal muscles. These are: I. Slret~h re llex - it is initiated at receptors called JUuscle spindles that are sensitive to muscle length and tension. This reilex stimulates the metched muscle to contract. An example is the patellar rrnex (knee jerk r~flex). in which U1e striking of the patellar tendon at the knee causes the quadriceps muscles to contract and swiug the lower leg forward, 2. Tendon rellex - it is initiated at rc.ccptors call ed ncurotendinons organs (Onlgi tendon urgans) <hat are sensitive to tension that occurs us a result of m\lscular COJ ttraction or muscle stretch . This reflex stim~lat<:s the contracted muscle to relax. Note: When tlte stretch rellex stimulates !ltc stretched muscle to conrract, antngonistic muscles that oppose tbe c<lllrraction are iuhibtted. Tbis occurrence is called reciprocal inhibiUon, and tbe neuronal mechanism that causes this reciprocal relationship is called reciprocal innervation.

~IOCHEMISTRY I PHYSIOLOGY

In a single muscle, there are both intrafusal and extrafusal fibers. All of the following statements are true in tbe description of intrafusallibers EXCEPT one. Which one is the EXCEPllON?

Contain nuclear bag fibers that detect fast, dynamic changes Innervated by gamma-motor neurons Contain nuclear linking fibers that transmit afferent signals Encapsulated in sheaths to form muscle spindles Contain nuclear chain fibers that detect static changes

41

CopyriJhtCl 20092010 Denllll Oed:s

GnocHEMISTRY 1 PHYSIOLOGY

I"Within

the spinal cord, the Hsbapcd mass of gray matter is divided into""~ horns, which consist mainly of neuron cell bodies. Cell bodies in the posterior (dorsaf) horn relay:

Voluntary motor impulses Reflex motor impulses Sensory impulses A II of the above

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Cont.1in nuclc.u linking fihrrs Ihat transrnil <tft"ercnt sij!nals 1\vo '!)'pes of Muscle Fibers: 1. ExtrafusaJ Fibers Fibers that make up tl1e bulk of the muscle lm1ervated by alpha-motor neuron.s (efferent ner/lons) Provide the force for muscle contraction

2. Intrafusal Fibers Are encapsulated in sheaths to form muscle spindles Innervated by gamma-motor neurons (efferent neuron.<) Two '!)'pes of Intrafusnl Fibers: I. Nuclear bag fibers Detect fast, dynamic changes in muscle length and tension . lnnervated by group I a affereuts- fastest iu the body. 2. r\uclcar chain fibers Detect s tatic changes in muscle length and tension. !noervated by the slower group IJ afferents. Remember: l. A sensory (afferent) neuron transmits afferent nerve impulses from the receptor (perip/reral ending of a sensmy neuron) to the spinal cord. 2. A motor (efferent) neuron transmits efferent nerve impulses from the integrating center (in 1l1e spinal cord) to an effector (muscle cell).

T his dorsal horn is also referred to as the dorsal root ganglia. Those cell bodies in the anterior (vemrol) born (root) transmit motor impulses.
The white matter surrounding these horns consists of myelinated nerve fibers, which
f01111 the ascending and descending tracts. A tract represents a group of axons within the central nervous system having. the same origin. termination, and function. and is often named for its origin and termination (i.e., spinothalami< ilact).

Axons of cells that run on the same side as their cell bodies of origin are referred to as ipsilateral. Axons of cells that run on the. opposite side of their cell bodies of origin are referred to as contralateral.
Note: Sensory pathways are ascending sys1ems (i.e. , spinothaltimlc and
DC~ML

systems); motor pathways are- descending systems (i.e .. pyramidal and extmpyramidal systems). Remember: The white matter refers to those parts of the brain and spinal cord that are responsible for communication between the various gray matter regions and between the grey matter and the rest of the body. ln essence, the gray matter is where the processing is done and the white matter is the channels of communica[ion. Hy analogy, the gray matter is like the CPU in a computer, and the- white matter is like the printed ci.rcuJt board that connects it to the other parts oft he computer. White Matter vs. Gray Malt~r -- Both the spinal cord and the brain consist of: Wltite Matter = bundles of a.'ons each coated with a sheath of myelin Gray .' \'latter = masses of the cell bodies and dendrites. each covered with synapses In the spinal cord, the white matter is at the surface, and the gray matter ioside.ln the brain of mammals, this panem is reversed.

~UOCHEMISTRY I PHYSIOLOGY

"

Which structure functions to control complex patterns of voluntary motor behavior?

Hypothalamus Hippocampus

Basal ganglia
Thalamus

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~IOCHEMISTRY I PHYSIOLOGY
All of the following are main str uctures of tbe hindbrain EXCEPT one. Which one is the EXCEPTION?

Medulla oblongata

Pons
Cerebral hemispheres Cerebellum

Copynjhl 0 20092010 Dnltal Decks

..

117,118

Coiled ions of ntne e.ells (nuclei) lie at the base of the cerebrum (subconlcal) m structures called the: Basal ga nAii - includes the caudate nucleus, putamen. globus pallidus. suhstantia tugrn. snd the ubthalamic nucleus. The basal ganglia's lltnction is to control complex patterns of volwttury motor behavior. T halamus -

a large ovoid mass of groy mutter Uuu rolays ull sensory stimuli

(etcepl olfo,rory) ns they ascend to the cerebral cortex. Otttput from the cmte~ also
can sYOOPSC in the thalamus. Oypoth alamus- control' lllllny homeostatic proc:esses. which are ollen BN)Ctnted with the autonomic nervous system. The hypothalamus is involved tn regulating body temperatUre. water balance. appetlle. gastrointestinal activity, sexual activity, ~lcep, and even emotions such as fear and rge. The hypothalamus also regulates the release of the bornu.>llC.< of Ute pituitary glund; und thus the hypothalamus greatly a!Teets the endocrine system. Important: Stimulation of che posterior bypotltalnmus by a reduction In tore temperature will produce shivering. Hippocampus- functions in tht consolidation of memories and en teaming.

The basal ganglia are a group ofanatomically closely related subcorucal nucle1. Dncmge
to these nuclei dCX's not cause "eakness. but can cause dramatic motor abnormalities. CUnical syndrome~ associated with damage tu these nuclei include l'arktnsonism. Hemiballismus (hemichorea), and lluntington's chorea.

The human forebrain /prosencephalon) is mudc up of: A pair of eerebral hemispbert's, called the telencephalon
A group of scructures located deep within the cerebrum that make up the diencephalon Main Structures of the Hindbrain (rhambMC'-fllrulm): Cerehellum - lies beneath the cerebrum JUSt above the brd.n stem. The cerebellUln's fu nctio11< are concerned with coordinating voluntary muscular activity. maintaining equilibrium, and conrd inntiotL Pons- connects the cerebdlum with the cerebrum and links tho mnlbrnin to the medulla oblongata: serves as the exit p.>int lor cranial nerves V. VI, and VII, Medulla oblongata -the medulla looks like u swollen tip to the spmnl cord. Nerve tmpulses ansmg here rh) thmically <timulate the intercostal muscles and diaphragm -- making breathing possible. Al110 regulates the beanbeat and regulates the dtamcter of arterioles, thus adJUSting blood flow. Note: Tbe neurons controlling breathing have mu (iJ) receptors, the receptors to which opiat~s. like heroin. bind. This nccountb fo r tlte suppressive effect of opiates on breathing. The bralo st~m l!es immediately interior to the cerebrum. just antcrtor to the cerebellum. T he brain s tem conststs oftbc midbrain, pons, and medulla oblongutn. The midbrain (mc,,ellcepha/on) connects dorsally with the cerebellum nud contains large voluntary motor oer. e tracts. The limbic system rs a primitive bracn area deep wtthin the tempor~llobc. Bcsrdes initiating baste dnves -- hunger, aggression, a nd emotional f""Hngs and sexual arousal -- the limbic system scree~ all sen~ory messsges trut ehng to the cerebral cortex.

0IOCHEMISTRY I PHYSIOLOGY

Patients occasionally come to your office and claim that they are having trouble maintaining their oral health. For each of the following problems, try and match the most appropriate lobe of the cerebrum that is not functioning properly.

Patients' complaints are: I. I always forget if I brushed my teeth already. I just cannot remember if I already did -- so I just assume I did. 2. I ... ummm ... just cannot make my wrist move the brush ... um ... but .. . and .. .why do l need ... to brush my teeth? 3. Every time I grasp my brUSh 1 it won ~, fit in my mouth. It also huns to have the water on my teeth. 4.1 brush every day, bull have !rouble getting IOOihpas1e on my brush. I have no trouble getting my brush to my mouth, bull just cannot manage 10 see the toothpaste and the brush. Lobes or the cerebrum arc: Temporal Frontal Parietal Occipital
45 Copyri,ght 0 2009-201 0 lknul Ottks

llO,Hl

~IOCHEMISTRY I PHYSIOLOGY
For the following questions, usc the same answer choices.

Circs)

Veins

Arteries
Capillaries Arterioles

Vcnu1es

180
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I. Tl'mpuriJIIohe - this p<Jtilnt will nl~o h:J\'1.' trouhll' hearing you rc~pond 2. Frunl:tl Lub~: - motor truuble. and truuhk ulth lanf,!ua~c expression J. l,aril.t:lllohl' - ~t. nsutions -' Ocripitallnhl - Pttknl has 'is inn truuhll'~ ~- tdl him or h~:r to put toothpu(\te dinrtly fH) his ur hl~r lrtth anduS\' Ihe hrm.h as nurmal

The cerebrum {cerebral cortex), of the brain, occ11pies the supetior po rtion of lhc cranial cavity. The cerebrum consists of right and left hemispheres. The right controls lhe !ell side of the body; the !ell hemisphere, UJe right. The corpus callosum is a maS-s of nerve fibe.rs connecting tbe hemispheres.. Each cerebral hemisphere is divided into four lobes, based on anatomical landm11rks and functional differences. The lobM arc named for the cranial bones that overlie thorn. Note: In addition to the !unctions of the primary areas in each lobe, the vast r oajority of the cerebral cortex is in\olved in assocHLtivt and higher order functioning such as ideation, language, and thought. Luhcs of the Cerebrum Frontal

Contains the pnmary motor (mo,emem) area and influences personality, judgment. abstmct tc3Soning. social behavior. and language expression.
Controls heanng, language comprehension, storage and n..'Call
of memories.

Temporal Parietal

lntcrprcts and integrates $ensation, including pain. tempe-rolure. and touch: interprca size, shape. distance, and tc.xmre; imponan1 for >waroncss of body shape.
Fuuctions m~inly lo interpret visuaJstimuli.

Occipital

I. . \rll.'ril~ 2. ,\rtHiolls J. \ ' tins 4. S)sh.rnic n ins - E.YCEPT/0.\' -- (JUihnun:~ry vd11s c:1rry O\)':!rnafld blond. and pulmnnar~ artc1ies cnrr~ dt.>o\~'l!<'l1:1h'd hlom.l) 5. \ ' l'ins have higher cmnpliance. and urterit~ han. a lnw ... r compliance

Systemic arteries - 1ransport pre-ss1tre nw\Y the hear1 to tissues of the body. Tese arrerios have strong muscular walls to withstand the high pressure aod low compliance. Note: The pulmonary and umbilical arteries are the only urtenes thut contaiu unoxygenatcd blood.
Systemic -veins- function as conduit~ for 1he lrausport of unoxygenutt'd blood from thf

tissues back to the heart. These veins have larger lumens and thinner walb; than dte arteries the veins accompany but a higher CQmpliance, and act as volume reservoirs. Some conta[n valves (i!specially the vei11s oj' tire limh<) that allow blood to flow tOWiir<l the bean but not away from it. Note: The pulmonary vein~ arc the only veins that contain oxygenated blood. Capillaries - this is where the exchange or fluid. nutrients, and metalxllic waste products occurs. between the blood and the interstitial spaces. The capillary walls are very lhin. They consist of a single )ayer of endothelial cells surrounded by a thin basal lamjna of the tunica tntimu. Note: The amount of blood 01at tlows through the caplllaries per minute is equal to the amount of blood that flows through the aorta per minute. Arterioles - regulate the flow o f blood into capillaries. Blood flO\V is regulated to meet tissut! metabolic: oeeds. Vcnules - are very small veins that collect blood from the capillaries; venules gntrluntly coalesce into progressively larger veins.

~IOCHEMISTRY I PHYSIOLOGY

C irc0

(
Veins Venules

Which structures are the site of highest resistance in the cardiovascular system?
Arteries Arterioles

When these structures ore acted on by nitric oxide or adenosine, they will: Constrict Dilate Stay the same This will affect total peripheral resistance in what way?
Increase Decrease Stay the same

47
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~IOCHEMISTRY I PHYSIOLOGY
For the following questions, usc the same answer choice.~.

Circs)

l. Which 2. Which 3. \Vhich 4. Which 5. Wbicb

circuit supplies the aheoli of the lungs? circuit supplies the connective tissue of the lungs? has a lower blood pressure? bas a greater volume of blood flow per minute? circuit involves the thick-walled left ventricle?

\..
Pulmonary circuit

Systemic circuit
Both Neither

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I. \rteriole"

2. llilafl'
.1. th."i: n;t\e

Arteriolts are lhe las1 small branches oflhe artenal sySlem and ael as control Vllvts lhrougb "'hch blood IS released imo 1he capillanes. Ar1eriolos vary in dJBmeler rang1ng from 30 11m 10 400 fADl. Any aneT) smaller ehan 0.5 mm in diame1er is considcrN to be an an<riol<. They have a small Jwnen and a rclauvely thick tunica modia thai is compo;ed lmost entirely of smooth muscle. with ,er y Ill tie elastic tissue. The inlima of an nncriole 1$ composed of endolhelial cells lying Oil a basement membrane with an underlying line internal clastic lami na in the larger tll'le rioles~ Arterioles play a major role m regulating 1he now of blood inlo the capillories. 131ood flow to tissue is mainly regulated by arteriolar diameter. Constriction of the nnedoles restricts the now of blood into the capillaries. while dilauou allows the blood to enter lhe cupillaris more freely. lmportonl: Arterioles are rhe primary resi;toncc vessels and dc1onnin< rbe distribution of" cardluc ourpu1. Arteriolar resrstance is regulated by the autonomic nervous system. Remember: Alpha 1-adrenerg1c roceptOrs arc round on the arterioles of the skin and splanchnic crrculahuns. Beta zadrenergic receptor> are found on artenoles of skele-tal muscle. Local blood llow is regula red b) trssut mC111bolr<m. Various humoral factors can alliO aff<et arteriolar diame1er, includ~ng eodothelins (asnconsrricror). nitric o"dc. and adenosine (va.vodilarnr.<). Sympathetic o<llvallon resuiiS in an O'erall vasoconstnchun or arterioles and an increase in IOIDlJ>Criphcral rcsrslancc (TPR). Key Polo I: An increase in nncrlolor re'i~Hlnc:~ w11l wcr~ast TPR_

I.
.1.

l'ulmnnar~

drcuil
drcuit

! . s~,ll' RJic circuit

Pulmuna~

.a . 't.ithl'r (they hu(' th, \fmu. ulm ut 5 I./min)

5. ~~'lc-mk circuit
')'~em can be d1v.ded uno No s eparstt cirtultJ~ c-..ch leaves and mums 10 the bean. The purnp for rbe pulmonary circuit, "hich <ir.:ulatc> blood 1hmugb lhe lungs, Is Lhe rigbt \folrlrle. The left nntrlcl< tS the pump for lhe ~)>lemlr circuit, wbicb provides rhe blood >Upply for the tiS$\lc cells of the body. I. Pulmonary circuit - Pulmonary crrculalion tr:msporiS oxygen-pour blood from the righr venlticle 10 the lungs where blood picks up a new blood supply. Then the rulmonRry circulation rclunrs tbc: oxygcn-ricb blood t<l the l ~ll atrium Note: The vessels oflhllt t1rcuil <upply only th ~ alveoli. 2. Syst.(!mlc circuit - The systcn11C clrculuuon provides the funcuunal blood supJlly to a,lll)ody tissue.. The: systemic c:irculotum corrlc!l mcygen and nutrients ~o lbe cell~ nud rucks up carbon dioxide -and W3.!1te products. Sy.t~tCin!C circulalion carries O);ygeuutc:d hloud flom lh~ len ventricle. 1 hrough the srtcncl', to the capillaries in the tissue~ of the body, Frum the li>su capillaries. the dcoll)'gcnatrd blood return.< 1hrough a 'Y>lcm of veins ro the ng)lt rium or lht heart l"olt: The vessels ofth1scin:urttranspoo blood lo all1i"'ucs of1hc body ucept the ahe<~ll Nott: The: votume- or blood n o~ Jk:r mmme (S UmiHJ h the: $0\JtlC in both ~n.::u1b.

The \'~is

R.tntembtr: I Mean arterial blood pressure carchac oulpul .- 10<al periphmll rcsisrancc 2. \ 'ascular complinre =- ralt of change C\flhe "aseuld.r "Volume I change 111 ~.uur~ l . Blood pressure in lhc pulmomuy circuit IS mucb lo~er than that or tht '))Mcmtc

circulation, bec-ause pulmonary artcrto1e:. ttrc usually dilated and have litllt rcslstanre 10 blood flow. The pulmonary vencl~ arc hlathly tompllant, aJiowing the pulmun.uy tu'tuit tn ~turc bluod volume \\.1lthoul chongu'l~ blood pressure,

GuocHEMISTRY 1PHYSIOLOGY

Circ

s )

If' Your patient tells you that he just had a heart bypass operation. He says that"" they used a vein from his leg and re-routed blood that previously flowed through his left anterior descending coronary artery (often referretl to as tile widow maker). Which of the following explanations is correct in answering II.. how a vein can adequately replace an artery? _.J
Although veins have higher compliance nonnally, when under high pressure, compliance decreases, and so the vein acts very similar to an artery when put in these conditions.

Although veins have lower compliance nonnally, when under the high pressure, compJi .. ance increases, and so the vein acts ver)' similar wan artery when put in these conditions.
Although veins have higher resistance nonna lly, when under the high pressure, resistance decreases, and so the vein acts very similar to an artery when put in these conditions. Although veins have lower resistance nonnally, when under high

pressure, resistance increases. and so the vein acts very similar to an

artery when put in these conditions.
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( '
II..

Circs)

Yottr patient presents with stage 1 hypertension. Ris blood pressure is 1 SO mmHg I 99 ounRg, confirming his diagnosis.

~)
A!

I . Is his pulse pressure nonnal, high, or low? 2. To bring his blood pressure down to normal, he could attempt to do what to the total peripheral rcsistanc.e?

Increase it DccreMe it
3. Normally, the mean prc>sure in the aorta is about 100 mmHg. Eventually, the blood will return via the vena cava at a pressure o f 4 mmHg. Where did the blood pressure decrease the most as blood traveled through the body?

Large veios Large arteries Arterioles VcnuJcs Capillaries

50 Cupyngb! 4) 2'0092010 Dental Decks

\lthuu:!h \ ein'\ haH' hiciH.' r " mnpll.uu. norm all~." lun under hi).!h pn.-.,un. c.:nm""' :1nd '\O lh(' H'in a~o:h \l'f~ 'imilar tu an al"l('r~ nlu.n put Itt lhl'\~' pll:mn. dt(rea"
l'UIItliliUU\.

Total peripheral rtsistan<e (TPR) regulates the flow of blood from the systemic ar1enal circulation into the eoous Ctrculauoo. Cardiae output regulates the now of blood from the veins back into the arterial side. The amount of blood located in the systemac veins 11 regulaced by their coruplia11ee. Sympathelic activation decreases vcnou compliance and returns more blood back to the heart, increasing cardiac output and blood prcsurc, thus causing more biOO<lto be pushed through the anerial circulation. The ability of a blood vessel wall to cxpnnd and contract passively with changes in pressure constitutes un uuportnnt function of large aneries and \eins. This ability of a vessel to dlsientl with increasing trnMil'lurul pressure (/11slde minus outside pn.~o,mre) is quantified ns vessel compllo~nce (C). wh1ch is the change in volume (DV) divided by the change in pressure (DPJ. Important points about compllan<e: {I ) Compliance decreases at Ingber pres>tlteS nnd volumes (i.e.. \'e.fsels become ..SIJfftr at higher pressures and WJlumes). (2) At lower pr<ssures, the compliance of a vein tS about 10 10 20 rim'" greater than that of an anery. Therefore, veins can accommodate lar&e changes in blood volume w1th onl) a small

cbangt in pressure. Howe,er. at higher prt':>!tures and \olumes. \lenous compliance

becomes similar to arterial compliance. This makes veins suitable for use as arteril

by-pass grafts. Relative volumes or blood at rest in dlff<renr parts or the adult cardioascular system : 66~. -in the syslcmic vems, venule~ 6% - in the hean 11% in the systemic anerte~. arterioles 5% in the capillaries ll% - in the pulmonary loop

I. ll 1:,:h Z. UtHl':hl' il
.1. \rll'rmlh- lhl' \ill of bi~tu.,f n'i'I:U1H

Although capillaries bave a smaller diameter than anerioles. there are vastly more capillaries arranged in parallel than there are artertol~. Thus, most of the pressure drop in the systemic circulauon occurs 1n the arterioles. Pressure decreases as blood mows through the systemic circulauon. This prc,sure gradient is required for blood Oow. Remember: blood Oow = pre~sure gradient I resistance The reslstanre to the now of blood ofrered by the entire system1c ctrculot ion is co iled the totoI peripheru l rcslstuncc (Tf'R). The target systolic blood pressure is 120 mmllg, and the recommended diastohc blood pressure is 80 mmHg. However, as blood enters arterioles. the pressure can drop to as low as 30 mmHg. The pulse pressure equals the systolic pressUie 1mnus the diastolic pressure (Pulse p uttSure SBP-DBP). The most 1mponant determinant of pulse pressure as stroke \'Oiume. The pressure is highest tn the aona and lowest in the venae cavae. ll'otes 2. Mean pres~ure is as follows: in the aorta - 100 mmllg: at the end uf the arterioles - 30 mmHg; and 111 the ' 'en a cava -- 4 mmHg ,

(BIOCHEMISTRY I PHYSIOLOGY

Circ

s )

Whith two of the following will increase tissue edema?

Increased colloid osmotic pressure of the plasma Increased colloid osmotic pressure of the interstitial fluid Increased capillary fluid pressure Increased interstitial fluid pressure

51 CoP)'naht 0 20092010 [Nntal ()e(k.s

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Circ s)

~our patient has just finished her 2-hour appointment and is eager to get out;)
the office. She stands up from the chair ,ery fast, and quickly becomes dlay and nearly faints. This Is termed orthostatic hypotension.
I. Which of the following receptors are most imponant in the shon-temt regulation of her

blood pressure and returning it to nonnal? Stretch receptors in the caro1id si nus Chemoreceptors in the aortic bodies
Chemoreceptors in the carotid bodies Stretch rece ptors in the pulmonary circulation

2. This drop in blood pressure will cause what to happen? Sympathetic impulses to increase Parasympathetic impulse> to increase Both to increase Neither to increase 3. The effect OD the heart wHI he: Increased bean rate. decreased stroke \Oiume Increased bean rate. increased stroke \'Oiume Decreased bean rate, decreased stroke volume Decreased bean rate, increased stroke volume
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I m:n.asl'd ca,)ill:u, nuid JlrCS\11fl' l ncreawd colloicJ osmotic pressure hf thl.' intl'rslilial lluid

Capillary pressure is the pressure of the blood within the capillaries. Capillary pressure tends to fo rce fluid out of the capillaries and into the tissue spaces by liltration through rhe capillary walls. Capillary pressure ls determined by venous pressure and arterial pressure. The colloid osmotic pressure. of the interstitial fluid tends to uraw water out of the capillarie.~ by osmosis. The interstitial fluid pressure is the pressure of lhe interstitial fluid, and it opposes the capillary pressure. This pressure tends to move fluid out of the tissue spaces sud into the capillaries. The colloid osmotic pressure of lbe plasma (also called the onco/ic pressure) opposes the colloid osmotic pressure of the interstitial tluid. This oncotic pressure tends to draw water ioto the capillaries by o;;mosis.
All ancre~se in capiUary permeability (e.g., due tn iufecliou) can also result in u~sue

edema. Edema formation is reduced by lympbatic drainage oftl1c interstitial space. I mportant: When the right ventricle weakens, fluid builds up in the. peri]lhcral tissues, leading to edema and liver engorgement.

I. Sfrt'tch receptor' in llu. co1rotid -;in us 2. S) mpathctic impul~r~t'~ to incrr~se ' lncrl'ast.d ltt~art r!ll(, incrcas('d >slrokl' \olume
baror<~eptor regulatory system is compo>cd of two groups of stretch rec~pmrs: ( I) un< group 1n the c::Hotitl sinuS:t!S near the bifurcations of the common carotid anerit:S i" lll~: nee~ and (2) a sccon/J group i n the arch of the aorta. These receptors dclc~::t clmn~cs in b1mul pre.o;sure and feed lhc information back to the cardiac control ce-nter ~d the. vasomo~or c..:-mc:r i11 the medulla. In response~ these control centers a lter the rauo between sympathetic: 11nd

The

parasympathetic output. If the pressure fs roo hlgb, a dominance of parasympathetic impulse>

will reduce the pressure by slowing the hearl rate. reducing slrokc vo)ume, and dilating blood "reservoir.. vessels. If the pressure is roo low. a dominance of sympathetic impulses will
increase the pressure by increasing 1J1c- bean rate and stroke volun1c Q.nd cnnstricting "*reservoir" vessels. Stretch receptors in the elirOiiiJ sinus arc stimulated by elevated blood pressure. resuhing in the acthatlon of the pamsympat.hetlc nervous system and fnhlbirion of the sympathetic nervous system to reduce blood pressure back toward its set poinL
Chtmor~ceptors i-n the carotid and aortic bodies~ as well us chemoreceptive neurons in the vasomotor center of tJ1e medulla itself, d..:tect lnercascs in carbon dioxide. decreases 10 blood oxygen, and decreases in t, li (which i.'i re(l//y an increase bt lly1irogen i'on concentration). This infonnation feed.~ back to tJ1e cardiac control ccnlcr and vasomotor control center fhe ffil.{dUlla, which, in lutn, alter the ratio JHUasympatbctic and sympathetic ()l.ltpUt. Whrn ox.ygen drops. carbon dioxide increases. and/or pH drops, a dominance of sympa(bctic impulses increases heart rate and stroke volume and constricts "rcs.:rvoir'" vessels. in response.

or

or

Stretch receptors in the- a1ria a nd pulm('lnary circulations arc stim ulated by an expansion of blood ' 'olumc. They DO NOT dirccily respond to changes in sy~temfc arterial blood pressure~

~IOCHEMISTRY I PHYSIOLOGY

Circs)

It's 4 o' clock on a Friday afternoon, and you are about to do a quick preparation and restoration. When you give the injection, the patient complains of severe discomfort. You realize you forgot to aspirate the needle flrst, and you have just Injected into an artery......

"

I. Your needle passed lhrough the anery layers in which order? Tunica adventitia, tunica media, tunica intima Tunica media, tunica intima. runica adventitia Tunica intima, tunica media. tunica adve.ntitia
Thnica adventitia, tunica intima, tunica media

2. Judging by their relative thicknesses, which is the toughest vessel to puncture?

Artery

Vein Capillary
3. Which layer is thicker; tunica me<lia or tunica adventitia?

4. Which layer is innervated by the autonomic nervous system? Tunica intima Tunica media Tunica adventitia 5. By puncturing this artery, you have hit lhe vessel wilh lhe grealcSl: Resistance

Pressure Cross-sectional arc-a

Blood volume
53 CopyrlgbtC '2009-2010 Dent:t1 Db

(BIOCHEMISTRY I PHYSIOLOGY

Disord I Dis)

I - -- - - - - - '
\.

somctlmes called vasogenic shock, results from the disruption of autonomic nervous system control over vasoconstriction. ~

Anaphylactic shock

Neurogenic
Cardiogenic shock

Hypovolemic shock

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T~lH'-

or Venel

'l'un1ca intima
(6nd()tllclium)

Tunle Mtdl~~;

(Smooth MuseJe; Elastic Connective Tissue-) Allows consaiction and dil-ation of \lt:Sstl~ thicker than m ..-cins; mus etc iMervatcd by au1onomic fibm:

Tunic Adventitia (fibrous C't.m,u!ctit'e Ti.'>.Wte)

Arteries

SmO<>th lin ins

ITovWes flexjble support tbal resistS collapse or injury; thicker Ulan in Ycins; thinner 1han tumca media

Veins

Smooth hning wlth se- AIJows cons~ri~ion and dilation of milunnr valves to ensure vessels; thinner t_ han in ::uterit:~.;
OntWa)' Oow

muscle inncrva1cd by autonomic

libcrs
Absem

Pro\'ides nexiblc support thai resisucollapsc or injury: thinnt'f than tunica media
Absent

Capillaries

M3k.es up w lir<: wall of

capillary; thinness per

mitS ease ofD"ans.J>OI"'

across vessel wall

Properties of Vessels
Arteries Arterioles Largest pre.ssure Largest resistance

Capillaries Veins

Largest cross-secliooal area Largest blood volume

.'\eurn!!,l'llir shock

Shock is the collapse of the cardiovascular system, characterized by circulatory deficiency and the depression of vital functions. There aro several types of shock: Hypovolemic shock - caused by the loss of blood and other body Auids. Neurogenic sboc.k - caused by the failure of the nervous system to control the diameter of blood vessels. Cardiogcnlc shock- caused by the heart failing to pump blood adequately tO all vital parts of the body. Septic shock - caused by the presence of severe infection. Anaphylactic shock - caused by a life-threatening reaction of the body to a substance to which a patient is extremely allergic. Shock is the inadequate perfusion of tissue. The symptoms of s hock include tiredness, sleepiness, and confusion. The skin becomes cold and sweaty and often bluish and pale. Other symptoms inc I ude tachypnea (rapid respiratory rate), hypotension (low blood pressure). and tachycardia (high pulse rate). The stages ofshock: I. Compensated: compensatory mechanisms (activation ofthe sympathetic nervous system, increased cardiac ouiput, oml increased total peripheral res;sumce) maintain perfusion to vital organs. 2. Progl'essive: decreased perfusion of the heari leads to cardiac depression and deereased cardiac output. 3.Irreve rsible: depletion of high-energy phosphate reserves. Death occurs even if treatment can restore blood flow.

(BIOCHEMISTRY I PHYSIOLOGY

Disord I Dis)

' Jay Sack is a pediatric patient of yours. AI a young age, be was diagnosed "it;;" [ray-Sachs disease. Be bas severe mental and motor deterioration, and your treat men! is minimal as be is expected to die by age 5. His neurologic symptoms are due to the accumulation of the CM2 ganglioside. This is caused by:

A deficiency of a lysosomal enzyme that degrades gangiiosides Increased synthesis of the ganglioside precursor, ceramide A genetic deficiency of phospholipase A2
An increased concentrat10n of the UDP-sugars required for ganglioside synthesis

ss
Copyn&bl 0 2009201() DrntaiiHch

(BIOCHEMISTRY I PHYSIOLOGY

Disord I Dis)

A patient walks into your office "itb yellow discoloration oftbe skin, sclera, and ti.ssues. You Immediately can infer that:

TI1e patient has jaundice caused by hyperbilirubinemia TI1e patient has jaundice caused by hypobi Iirubinemia The patient has diabetes insipidus caused by high levels of ADH The patient has diabetes insipidus caused by low levels of ADH

Cop)'~l C

2009-2010 Deml Deets

Lipid~

d-.,l>f the lipldos... m: I group ur tollemed m<taboli< di.onlcr> In winch hmnful

emouniS u(fauy INII<rial> ..ucd hpuls accumulate'" some: oflhe body's oells and tiSSU<i P<ople with
the$e disorders C'Uht'f do not produce- eoough nf o~ llf'1ht enzymes needed LO met.abo1lzc: hpH.l" or rhc

i-ndhidua.ls produce eneyme$ that do not work properly 0\ er time, lhi_o; ext'..:ssh C' il<rragc of lltts can cause pcnnancnt ccllulnr 11nd tissue damage. J :Nl.rticularly tn the brain. peripheral nervous S)~em. ltver,
spl~en,

and bone marrnw,

Cauclltr dlsran 111 the n1os1 common of tbe lipid sl<irugc disc.scs, It 1s caused by u ddic11.111C:)' of lhc: enzyme ~lll coctrebl'osido!ie. Fatty motcrii\1 t.:nn collect m the splt"en. Hvet, kfdncyr,. lung'\. hrnint -and bone marrow. SyrnJltom~ may inc tude: enlarged spleen and liver. liver malf\tn<.:uoo, skclclal dts-. orders. nd bone I~:Sions that m.ay caus-e ~'" K\cre nc:umlogic oompJica:lions .swellins of Jyrnph nodes. and (ocauloaliy) adjattn< joint>. di,.ended nbdomen, brownish tint to !he tk1n . .,.,.,1.., '-"<
~ftnltnn.. Pltk dllea.se IS JctuaUy 8 group Of tUI\QOmal f'('(lC::SSI\C- dJsordcB c:IU'-C.'<d by n :tunlU latlon of faa and tholesttmlu\ ce1h. of the lhc:r. ~plcc:n. bone martow. lun1t1. nd. an 1t0rne p:lttcntJ,

blood pl.llclctt. 1111<1 yellow'"""' in the C)'t>. nu, d.-<< p;ontrobrly lt-eq\J<nttn Bnuhcs orAsbke> nan (rontrof.._.,.,.,. E~l JeWish an<eW')

bl'3in. ~eurological c-ompltt'Srions mJt)' inch1 de 1U\JOC!a. eye par3lysi~t, brllm deg(11tt:mon, learning pn1\llcms. SpiiJoticit)'. fc:tdin!,! and swa11owing 1.hnicu lt 1~. li:tum.'d spcech 1 losr. of muscle tone, hyperstnslhYitY to touch. aod some cun1eal cloudma. 1l1e diseiJ!Ilt: rc.sulrs frotn tbt- deficiency \lrt h~ cnz:yrnc sphlngomyellruai\lt, which re.<iulls in the autlumularion nr spb l n go01 yeJJn ~ The ch4JtI1Sc iS mor~,: com1m>n in 1h(,sc of Ashkenazi Jewish anccstty TayS~hs dlsu~e ~~ &t nm: inherited dJSOI'dcr th~t causes progressive destructi!Jrl "'r nc~e ~dl5 in the bnin and ;p1nal cord (the ce,II,,JJ ntMo~, ~.ct.-m) The d!SC3St: is uu:;.cd by a dclit1erscy
of cbc enzyme ber . bhou.mlnidrue J\ ~hich rewhS' u1 th~ ucumulatlon or C:tfl gangUo!ldts. e~pt.:~11lly in ne-urons. The dl~i"t tXturs pnmarily in familu~ .. orAsh1cen&71 Jt\\ i~h aottstry ll '" charwetmled by CNS dcgcnt'n111.m "'nh ~\ere menuI and motor detcrionu"n. Death usual!) uecurs by ase 5. Knbbt dls.ellt ''an autosomal reci:$Sh-c dt50f'dC'r cau~ed bydeficicnty of the t"'n:tyme galaciO'\) 1ctramldasr. t~abry dl~tast, ttiS.O known u alpha--gahtcto,ldlut~A dendenc:y, causes a buildup ol (any mutcn"l in the au101101nic nervous system, eyes, kjdne:yl!<, unJ Cl:lrdiovascular system.

Tht p:Hilnl h.1 ... j:tUudin cau"icd h' 11, P"thillruhintmi:J JIIWldiee i> a ytllllWI>~ Jtocoloomoo ofrhe skutsnd ol 1he "h11e. of the eyeo ulb<d b~ abnonnally high ltvcl or !he ppmcnl bilirubin in the bloocbtream. Jaundice JS \el')' r,:(lmm<m Al'd is lbe IQ_dang mamrc~UUCH1 ofhn-r di.SCJSe. Jaunchce C.tn OC:C\lt AI
tmY age lind In (llh" ~X. and. IS t. :0:)'1t1JXUtn Of many dltri01"\1Cti~ liver d1seibe~ p.JI~ti.Jnt~. r.anc-rt411C
ca.n~c:t,

and acute biliary nb~otruction The normal pta,mo t.'at'l~trahon of bilirubin

~Unctlllrttllln

a\'C'.NJC:S

U.S

.-ng per I00 ml uf pl~sma . In jsun<hcc. the plastlll

Dyptrblllntblnttn la c:ould be cause-d b):

of b11irvbincan

n~c

co :t.i htg.h as

hKrtas~d f,lfirobJn produc-non Dtcrcasc\1 \tptnkc into the Hver cells .. lm,-,aJred cunJUJ:Pition lnterfc:rcncc wnh the ~creuoa ofOOiljll!:,-tlttJ bltrubin Example> of .w..:..., m Whith hyperbillrubineml b oll>er>rd:
fltmoi}II<Jounrll : ResultS '"ncffhed pcOOuct"'m <.'(bfhf\1.,10. Here mort b.tinlbH11$ cQ41jup1ed and c;w;cKIC'd 1h3n nunnally, but the COilJU,gauon m-twusm is Ch e:whclmcd, and Ill abnorm~lly lllll< OII"IOWII ofunconjUJlllted bilirubin i> round tO lhe hloodGilbe.rt's dlstase:

May be c:t~u l!c.d h)' ~m inability of the hepah.~YltS t(l L1k.o 1.1p bilirobm &om the h1ucxJ. As:\ teSUh1 unconju~ned bilirubin u t~:~unwhH~.
Ph)'$lol ogltt~l

jltundlce twd CrlglerNojjllt

~)1 n drn m c:

Are c:onchllon1 in whiC'h c-onjugalit.~n h lmpu1rcd. Untonjuga<ed bilirubin i> relllin<'<l by tho bvdy
Oubhwoho<on <yndromo: Is ass~>CiarcJ with ln>h1ii1y of the hepotot:yt<! to ~r<t< co1\jupted bihrubm ol\er il h>.< been

rom>ed.
COOJIIPiod bil1rubm n:l\lm> 1o the blood BiliaT) ob>truetlon: (For v:att~piJ bthat)' clruh aUS<s backup nd rc:11fhorp1ion of<oiii\IJ!Oied holirubon. Blood I<' tis ofcoojugoted bilirub10 ,..,,..,,,..,

BIOCHEMISTRY I PHYSIOLOGY

Disord I Dis

( Oo the medical history form, your patient answers yes to aU of the following) \.. symptoms. Your patient are most likely suffering from what condition?

Feel nervous, moody, weak, or tired

Have hand tremors, or have a fast or irregular heartbeat, or have trouble breathing even when you are resting Sweat a lot, and have warm, red skin that may be itchy Have frequent and sometimes loose bowel movements Have fine, soft hair that is falling out Lose weight even though you are eating normally or more than usual

57
Copyri_gbt C 20092010 ()('n.tal DtckJ

BIOCHEMISTRY I PHYSIOLOGY

Disord I Dis

Addison's disease occurs when the adrenal glands do not produce enough or the D ~ormone and, in some cases, the hormone . A.

Glucagon, estrogen ADH, oxytocin Cortisol, aldosterone Epinephrine, norepinephrine

53
Cop)'rigbl 0 20092010 Delta! Dc<:k$

II~ perlh~

ruith..,m

Excessive production of the thyroid honnone thyroxine produces the symptoms of bypcnhyroidtsm. The primary role of thyroxine is to stimulate cellular metabolism, growth, and differentiation of all tissues. lu excess, therefore, thyroxme leads to htgh basal metabolism, fatigue, weight loss. excitabflfty, elevated ICntfleramrc, and generalized osteoporosis. People wnh Gruvcs' diseQse (the most cummmrjonn of!ryperthyiYJIIIismJ oflcu hove ad ditional symptoms, including the following: Goiter, which is an enlarged, painless, soli thyrmd gland Thickened nail that lift off the nail beds Mytedema, whrch is lumpy. ttddr>h, thick >kin on !be from of the shin.' and some times on top of the feet Clubbmg (fltlgers "ith wid~ tips) Exophthalmos (bulging eyes)
I. Oral manifestations arc not too tcmnrkable, but if th~ disturbance begins Note< iu tbe eotly years of li fe, premaluru eruption or the treth and loss of the deciduous dentition are common finding,. 2. Plumm~r'> disease (also called Pcmy ~ tlr<etLVe) is tlte cau.<e of ubout 5% of cases of hyp<~nhyroidi<m. Tbts ~sulrs from the pre.~ence .,r m:my toxic thyroid nodules \>itbm the thyroid gland. Exophlhaltnos is r-..re 3. The symptoms of hypoth) roldism include weight gain, ~nld mtolerancc, decreased cardiac output, hypovenrilation. droopmg C)Ciids. lowered pitch of voice. mental and physical slowness. constip~uon. dry sk.in. coarse hair, and puffinc~, of the face, eyelids, and hand.

Addison's dbuse tolro ,;a(fed odrenul /n.<ufliden~. or ilypQt.'Orti.rolrim) is a life

threatentng conditron cuused by parttBI or "'mplctc fatlure o( adrenocortical fu nction (insuffici~nl giH<'<JCOrtiCOJc(s ond mmeralocorlll:ocdsj. More than 90". nf the cnne~ of the adrenal must be destroyed before obvioui sytnptl>m< <lur. In 70% of people wtth Addison's disease, the CIIU~e tR not prectsely known. but the ;tdrenal gland 11re 01ffected by an autoimmune rructlon in which tit< bally's tmmune system attacks aod destroys the adrenal cortex. In the other 30%. the adcenul glnnd nre destroyed by cancer. an 111feclion such as tuberculosis~ or unutb~r 1 dentifiable d)senrse. The disease ls chnractcrized by weight lOS>. musde wcakne~s. fatigue, low blood pr.,;sure. and sometimes darkening or thf skin in both c.,po,cd an.l nonexposcd pans of the body. Oral signs consiSt of dinu>e pigmentation of the gtngiva, tongue. hard palate. und buccal mucosa. Conisol is oomu.lly procluced by the adrcoal gland>, locatedjustab'"" the lodll<.")'>. It belongs to a class of bo~ called glucocortlrolds. which affect alniOst evel') organ and ll>SU< in lhe body. Conisol's most imponant joh i to help the body respond Ill stn:ss. Amon~ conts.>l's other vitultasks, conisol: Helps maintatn blood pressur<: and cardmvascular 1imction Helps slow the immune system's inllummatory rc:.<ponse Helps bolnnce the ell"ects of insulin In bn::tkmg down sugar for ener~y Helps regulate the metabolism of protein>. CQrbohydmtcs. and fats Helps maintain proper arou.al und sen.-. of well-being Aldosterone btlong> tO a classofhomtonescalk~l mlneralocorticoids. uloo ptttduced by the adrenal glancb. It helps maintain blood pres""< and water and salt balance '" the body by helping the l..ldney n:tain :.odiwn and excrete powstum. \\"h<n oltlootc:ront' proclucuon taUs too low, the ktdneys are not able to regulate salt and warer b31anee, uusing blood volume itDd blood prcs.,uro to drop.

~UOCHEMISTRY I PHYSIOLOGY

Disord I Dis)

All of the following statements about a person with type I diabetes mellitus are true EXCEPT one. Which one is the EXCEPTION?

There is linle or no insulin secretion Dietary treatment may not suffice There is hypoglycemia Ketoacidosis and dehydration may develop

51
Cop)'rigbl 0 20091010 Denl.ll Oecb

(BIOCHEMISTRY I PHYSIOLOGY

Disord I Dis)

Diabetes insipidus resembles diabetes mellitus because the symptoms of both dl~eases are:

..J

Decreased urination and hunger

Increased urination and thirst

Decreased urinary output and weight gain Increased urinary output and weight loss

.,. .,. This is. raise; there is hyperglycemia. Diabetes is a disease in which the body either fils ro produce any Insulin (type I . ol.<o ~ailed Insulin-dependent or juverrile-onset). or the insulin thnt the docs produco ;, unable to ade quately trigger the conversion of food into energy (I)'J)e 2, "lsu called llonillsulilldepe~~tle/JI or adult-onsel). Sylllptoms or diabetes: Excessive rhirst Frequent skin, bladder, or gum infections Frequent urinmioo lrrit3bility Weight loss l'iu!!ling or nwubntss in hands or feet Blurred vision Slow-to-heal wounds Increased hunger Extreme unexplained fatigue
( 1111Jlllf"~()n ul I \pt I 1111d I 'JH ! lhahcl~'' \lt'lilm
Ch.araer erl~tlt

T)pt 1 Ulahtft!

Typl' .2 Dlabt:tli$

r...:vel ofrru.1.111-n ~100

Typical ageofmto.:t-

Nooc: nr almosl nooe

M!ly be: mmnott or 01\.tCed norm11l

i\duhbood
80-90~1

CllildiOO<l
I D-10%

Pc:rtentayc of diabet.es
n~1odC'fce~

Oc$tructmo ofB otll\

1"0

R.OOuc< ~~tiVIly of Insulin '6 carget ~lls

,.,_;ftlod Wilh obesity

Uunlly
Slow
Rare

Speed of deve:k>pmcnt M
SYJt!P\l1JIU

Rapid
Cm1mun lflln~led

Oevelop.ncnt of ketoJS1S
'f'fe:tlll)COI

fmsul tn injhOn~ Jietar; manal!cc1nem

mecary conrrol ~d weiglu redoolot~: ocett slomolly ani h)'ll<l!l)yccmic droll'

lm:naM:d urination and thi"t

Diabetes insipidus i. not-the same as diabetes mellitus. Diabetes io~tpt<lu roserubles diabetes mellitus because the symptoms of both dise~ses arc increased urination and thirst However. in every other respect, including the causes ~ud treauncnt of the <llsor<lers, the iliseases at completely unrelated. Sometimes cliabetes insipidus is reft"rrtd to as ""'''ate.r' diabetes to dfstin,Yllish it from the more common cliabetes mellitus or '"sugar'~ diabetes. Diabetes insipidus (D/) is a disordl;!r in whjch thcr~ ls an abnormal increase in urine nutpu1, Ouid intake, and often thirst. Dl cause:; symptoms >UCh as urinary frequency, nocturia (frcquclll awakening at night to ttrinate). or enuresis (irtVt>lunwry z'nnation dun'ug sleep or 'hedwel ling"). Urine output is increased because it is not concentrated normally. Consequently, in stead ofbeiog a yellow color, the urine is pale. colorless. or watery in appearance and the measured concentration (osmnlality or $pecljicgravfty) is low. In diabetes insipidus (Dl), thero is a failure to either produce ADH (more co/IWIOII) or for the laduey tu respond to ADH (rare). Ln Dl, there is almost pure water loss. often witl1 maintenance of norOlal sodiunl balance. ln Dl, the insufficient levels of antidiuretic hormone (ADH) cause e.cessive thirst (polydipsia) and e~cessive production of very dihue urine (polyuria). The normal net inn ofADH is to increase the reabsorption of water from the renal tubule, producing a smaller volum" of concentrated urine. AOU is produced in the hypothalamus, and then stored aud released into the bloodstream by the J lOSterior pituitary gland in response to elevated plasma osmolarity. Important: Hypoactivity ol' the posterior pituitary glaud or destruction of the supraoptic nuclei of the hypothalamus will result in diabetes insipidus. This deOciency of ADA results in failure of tubul;u- reabsorption of warer in the kidney and the consequent passage of a large amount of diluto urine ond great thirst. Note: ln diabetes insipidus. the body fluid volumes romoin pretty clos<O to normal $0 long as rhe person dtfnks enough Water to make op for the increased clearance of water in the urine.

(BIOCHEMISTRY I PHYSIOLOGY

Disord I

Oi0
)

(
Have mental retardation Jlave srunted growth

Newborns wllh phenylketonuria:

Have seizures, tremors, or jerking movements in the arms and legs Don r have any symptoms

61

Cocl>,.iahtO 2009201 0 lkntal Oeel:s

(siOCHEMISTRY I PHYSIOLOGY

DNA/ RNA)

In your practi~e, you see quite a few HIV/AIDS patients. These patients ba"e the unique ability in that they c.an:

Produce(+) ssRNA from a(- ) ssRNA molecule Produce(- ) ssRNA from a(+) ssRNA molecule Produce DNA from an mfu'IA molecule Produce dsRNA from an s;,RNA molecule

62
Cocl>'rialt1 o 200920 1 o J>mtal Oecl:s

 u Newborns with phenylketonuria don't have any symptoms. Without treatment,

though, babies usually develop signs of PKV within a few mouths.

Enz) nu: Uclicu.nn
Ob-easr
Ui~~a'>('"'

Cause or En1.yme T'hst I s Oenclc-nc PhcnylaJanine hydroxylase

Results or De.fidenc:y Appeamnc:e of phenylalanine and its degradalion pmd1,1Cl$ (c..g.. pkcn:ylketOMs) in lbe urloe

Phwylk<:tonunn

Maplt.syrop wine Alpha-keto acid dchydtogenast

diseose
A1C.'Ipt()nuria

Branched amine~ acids (wlin~, i.tolt'IIC'im:~ ami le11cine) are CXCfl!tcd ~n til<" c.srin~
Oxidized l!rodlscts ofbOftlogentisic &cjd @ivc urine \II
da:rk color

llomogentistc ucid oxidase Delieimey of he intestinal and k.idnty tr.loSpOrt protein of cystine Tyrosinase

Cystinuria

K id.ney stcmes
Defect of melanin pro<JuctiOI Jih.al resul13 in p311ial or full nbs::.ooc or-pigm~'1ll0lrion

A1binism

- - I. Phenylalanine and tyrosine are both essential amino acids. Notes 2. Tyrosine is produced by hydroxylation of the C$sential amino acid phenylalanine. 3. In phenylketonuria, tyrosine cann ot be synthesized in adequate amounts and is required in the diet.

Product ()'JA from a mR'\.\ rnnlr-cul('

*** Using lhe enzyme "reverse transcriptase"

Reverse transcriptase is a DNA polymerase rhat uses RI\'A as its template. Thus, the enzyme is able to make genetic iofonnation now in the reverse (RNA -- DNA) of its normal direction (DNA -- RNA). Certain RNA viruses contain within the viral particle a unique RNA-directed DNA polymerase that is called re\'ersc transcriptasc. On infection, the single-stranded RNA viral genome and the enzyme enter the host, and the reverse transcriptase catalyzes the synthesis of a ONA strand comp lementary to th e viral R.~A. Reverse transcriptase enzymes are foUJld naturally in certain viruses called retroviruses. These are viruses in which the genetic information is carried on an RNA molecule. When one of these viruses infects a host cell, it uses this enzyme to make a complementary DNA (eDNA) copy of its genetic infonnation, which is then incorporated into the host ON A. - - . I. The human immunodeficiency virus (H!V), the causative agent of AIDS, .Sotes' is a retrovirus. 2. The drugAZT (a thymidine analog) is a competitive inhibitor oft he H.IV reverse transcriptase. The wild-type reverse transcriptase seems to have a bigb affinity for AZT and other base analogs. 3. Reverse transcriptase is one of the enzymes used in genetic engineering, in which tbe enzyme can be 11sed to obtain a copy of a particular gene from the relevant mRNA .

~IOCHEMISTRY I PHYSIOLOGY

DNA/RNA)

Some proteins are produced by r ibosomM that are attached to the cytosolic surface of the rough endoplasmic reticulum. Whkh of the following is not a possible destiny of these proteins?

Becoming a collagenase Becoming a sodium/potassium pump Becoming a proteolytic enzyme Becoming a ribosome

63 Copyright C 2009-2010 Dc1t~al Deets

GrocHEMISTRY 1 PHYSIOLOGY

DNA/ RNA)

Genetic recombination experiments depend hea,ily upon the action or which two enzymes?

Restriction endonucleascs Alkal ine phosphatase DNA ligases

Creatine kinase

64 Copyri.gbt 0 20092010 Denu.J Deck$

Recomin~

a ribosonu

Because ribosomes are found in the cytoplasm of cells and are made of rRNA. Ribosomes are the protein-synthesizing machines of the cell. They Lnmslate the information encoded in messenger RNA (inRNA) into a polypeptide. Ribosomes are small smtctures found nouting free in the cytoplasm (polyribosomes) that contain rRNA and protein. At a ribo$ome, amjno acids are linked together in the order specified by mRNA to form a polypeptide. or protein (/his process is called prorein ,vnrlu!Sis or rranslarion). Ribosomes have enzymatic activity, T~ey catalyze the forma<iou of peptide bonds, which link amino acids to one another. Many ribosomes in different stages of~tanslution can be attached to a single mRNAstrand, thus multiplying its effect . Some are anacbed to the cytosolic surface of the endoplasmic reticulum mmbrane (wlte1t they are allac/1ed, 1/ is railed nmgh endoplasmic reticulum. RER): others remain as free ribosomes tu Oto cytop13$m. Proteins fomted by ribosomes attached to Ute RER are destined for secretion from the cell, iucurpuratJon into the plasma membraue. or !ormation of lysosomes. Since Hll protein synthesis begins on free ribosomes, atraclunent of a ribosom" It> Ute RR requires the presence of a specific sequence at the am ino end of the growing protein chain to signal Ute attachment of the ribosome to the ER. I. The 70s ribosomes are tbe sitt.S or protein synthesis (nanslaiiau) in Not.. ba"tcrial cells and chloroplasts. 2. The 80s ribosomes are the sites of protein synthesis (tr!lns/atirm) in the cytoplasm of eukaryotic cells. 3. The other answer choices are incorrect because: -A collagenase invul vt-s secretion !Tom the cell. -A pump protein involves incorpomtion into the plasma membrane. -A proteolytic enzyme involves incorporati(m i~to Jysosomes.

l~l'St rirf ion t'tHIHU lll'IL'USt'S

l>i\ .\

lig<\\L'\

Tlte nuclease is used to cleave both the DNA to b~ Dloncd and o plasmid DNA. The specificity of the n11cleose is such that, when mued. the DNA to bu cloned rutd tho: plasmid DNA will anneal (base pair) and can then be joined tQgerher by a DNA ligosc. Important point: Restriction enzymes ore site-specific endonuclease~. Southern blotting is a technique that can be used to detect mutations in DNA and cau also identify DNA restricuon fTagmenb;. lt combines Ute use of restriction enzymes and DNA probes. Advances in tbis technology /ONJI cloning) are revolutionizing many aspects of medicine, agriculture. and other industric,~. Commercial products of r ecombintnt DNA tec hnology include hurnon insulin ({or diabe1es), anticoagulants (tissue plosminugenfacto~. or ythropoletin ({or 1111et/lia), and bum an growth hormone (for

dwarfism).
l. The first organism used for DNA cloning was E. coli. and it is $ Iill the 'lot most cQmmo~ nos\ cell. Bacterial c loning vectors include plasmid s, l>acteriophg"'l. and cosmids. 2. Som~ otber enzymes that ar~. used in recombinant D NA technology (ge11e clo11ing) arc: DNA polymerase l -- tills in the gaps in duplexes by stcp-wi$c addition of nucleotides to 3' -end. Reverse transcriptase --makes a DNA copy of an RNA molccul~. E;ronucl~ases -- remove nuclcotidcs from 3'-ends of a DNA strand.

(s10CHEMISTRY I PHYSIOLOGY

DNA / RNA)

All of the following statements arc true EXCEPT one. Which one is the EXCEPTION?

The replication of DNA involves some RNA intermediates The replication of DNA involves DNA liga.s e linking DNA molecules together The replication of DNA requires unzipping of the DNA molecule The replication of DNA involves the bui lding oft he new ssDNA strand from 3' to 5'

65
Copynght 0 20092010 l>tMIII ~ks

(smcHEMISTRY I PHYSIOLOGY

DNA / RNA)

Which or the following enzymes Is not involved in unwinding, unzipping, and rezlpping the DNA molecule during replication?

Topoisomernses Helicascs Gyrases Polymerases

I he. r('pliration ol 1>:":.\ itnuhes the l'rnm .r tn ~

buildin~

nf' th('

IH'\\ :oo;!-iO~-\

strand

***&'<A intermediates are involved to prime the DNA polymemse and later being rc. placed by DNA. Replication is the process of completely duplicaHng the DNA witbin a cell. The primary enzyme in this process is DNA polymerase, which reads a single strand of DNA from the 3"-end toward the 5'-end while forming the new, complementary, continuous strand from the 5'-end toward its 3'-end. As the DNA polymerase complex moves along the DNA molecule the original complementary strand (laggi11g strand) is also duplicated. The DNA polymerase that is moving along the Jagging strand from the 5' -end toward the 3' -end titus tilllnOt form a cominuous copy of the Jagging strand. Instead, the DNA polymerase forms approximately 1,000 to 5.000 base long multiple segments (Okazaki fragments), which arc joined together by DNA ligase to form a continuous stTand. DNA polymerase can only add nucleotides to a pre-existing piece of nucleic acid (primer). During replication. the primer is provided by R NA polymerase, which has no primer requirement. The short IObase segments created by RNA polymerase are removed, once the DNA has been added to it, by an exonuclease, and the gap in the sequence is filled in by a DNA polymerase. I mportan i point: RNA polymerase synthesizes polypeptide chains from oucleotidcs and does not require a primer chain. Note: Topoiso mcrascs are responsible for unwinding supercoiled DNA to allow DNA polymerase access to replicate the genetic code. The enzyme DNA gyrase reforms the supercoilcd structure once the replication fork has passed.

Pol~ me rases

*** Polymcrases are used in

replication itself.

The hydrolysis of DNA (deoxyribonltcleic acid) wi ll yield: Phosphor ic a cid Deoxyribose (sugar) Nitrogenous base (adenine, guanine, thymine, aud !J'tosine) Tite hydrolysis of RNA (ribonucleic Acid) wW yield: Phosphoric acid Ri.b ose (sugar) Nitrogenous bases (adenine. guaniue. uracil, and cy tosine)
I. Ribose and uracil arc the only differences between the products of R..'IIA 'Nores and ONA hydrolysis. 2, DNA is double-stranded ; RNA is siJ1glestranded. 3. R eplication forks are sites at which DNA synthesis (replicmion) is occur-

ring.
4. Helicascs unwind the helix. Topoisomerases arc responsible for unwinding supcrcoi led DNA to allow DNA polymerase access to replicate the genetic code. The enzyme ONA gyrase re-fonns the supercoiled structure once tbe replication fo rk has passed.

~IOCHEMISTRY I PHYSIOLOGY

DNA / RNA)

Which of the following Is contained in a nucleoside?

Nitrogen base Ribose/deoxyribose sugar Phosphate

Two of the above All of the above

&1 CopyriSbtC 2~ 2010 Dcn1ol Db

~IOCHEMISTRY I PHYSIOLOGY

DNA / RNA)

Which of the following are the same in RNA and DNA molecules?

The purines The pyrimidines Both the purines and pyrimidines Neither the purines and pyrimidines

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T" o of thl' abo\ r

**" Nitrogen base and sugar, A nucleotide also contains the phosphate.
A single base-sugar-phosphate unit is called a nucleotide. Without the phosphate group, tbe molecule is called a nucleosid. These individual nucleotides are linked together to form a polynucleotide chain (tire link or hond is between a plro.<plrate group of one nucleotide and tire sugar of the ne:rt). lf tbe polynucleotide chain contains the sugar ribose, the chain is called ribonucleic acid (RNA): if tl\c contains the sugar deoxyribose, the chain is called deoxyribonucleic acid (DNA). Nucleic acids store and transmit information to synthesize ilie polypept ides aud proteins present iu tlre body' s cells. Nucltic acids are complex molecules composed of stmctures known as nitrogenous bases (pru1nes and pyrimidines). five-carbon sugars (pentoses), and phosphate groups (w!ric!r contain plwsphoru.< and Q>}'gen). Important : The backbone of nuclek acids is made up of alternating, phosphate and pentose units , with a purine or pyrimidine base a"ached to each. The cat;ibolism of a nucleotide (single bose-sugar-pho. plrare writ) results in no energy produc.lion in the form of ATP (as opposed to tire cmabolism of a lipid, protein, ur carbo!rydrate, w!rlc!r does).
Rem~mber:

'I lu Jlurint.s ***The purines (A and G) are the same.

.DNA, the pyrimidine bases are thymine (T) and cytosine (C). In R;~A, the pyrimidine bases are uracil (U) and cytosine (C). *** The phrase "CUT down lhe pyramids" may help you remember that cytosine. uracil, and thymine are all pyrimidines. Remember: The backbone of the DNA molecule is constant throughout the entire molecule, and consists of the deoxyriboses linked by pbosphodicstcr bridges (I.e., !he 3'-0H group of tire sugar of one is linked to tire 5'-0H of rlre nexl sugar by a phosphate). The variable part of the DNA is the sequence oftbe bases, and tlte precise soquence of the purine and pyrimidine bases carry IJ1c genetic infonnarion to express the characteristics of the organism. The DNA chain bas polarity with one end of the chain ha,ing a 5'-0H group while the other end has a 3'-01 r group. - - 1. Purine bases that are consumed In tbe bum<Ul diet ao the form of DNA or Notes RNA are mostly excreted in the form of uric acid. Xanthine oxidase catalyzes this formation or uric acid from purine bases. 2. The use of tetrohydrofolic acid (TFA) by several of the enzymes in purine and pyrimidine synthesis has made 'J'FA metabolism a prime target for a number of anti metabolites, such as methotrexate, used rn cruwer chemotherapy. 3. Ultraviolet light produces pyrimidine dimcrs in DNA, which then interferes with replication and transcription. These lesions are removed via tbe action of rur exonuclease, an enzyme that excises it 12 bp (ba.ve pair) fragruent surrounding the dimer. Then DNA polymerase J !ills iu llr< gap, :rnd DNA ligase seals the searns.
[n

GnocHEMISTRY 1 PHYSIOLOGY

DNA / RNA)

Which of the following RNA mutations is least likely to have a significant effect on the product protein?

The elimination of the third amino acid in a codon The elimination of the first amino acid in a codon A substitution of the third amino acid in a codon A substitution of the first amino acid in a codon

69 Cop)Tight e 2009-201 0 Dcn~al Ottb

~IOCHEMISTRY I PHYSIOLOGY

DNA/RNA)

r A sequence of DNATeads "A-T-T-GC . many hydrogen bonds would ~Yl - -A." How
\.. you expect to see holding this sequence to its complementary strand?

12
1 4

16

1 8

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\ \Uh\tilulion of fhl' third aminu .1dd in a cm.J:on Due to the "'\Yobble" effect Oegeneracy or the gene lie code: There are 64 different 1riplet codons, and only 20 nOJino acids:. Unless some amioo acids are specified by more than one codon (sometimes nfrnw!d to a\ a triplet), some codons would be completely meaningless. Therefore, some redundancy is buill into the system; some nmino odds arc coded for by multiple codons. In some cases, lh~ redundant codons arc related to each other by sequence; for example. leucine as specified by the codons CUU, Ct.JA. CUC. and CUG. Note how tbe codon~ are tlw same e~ccpt for the third nucleoti de position (althe .l 'ut~d). This third posiuon is known "' tho " wobble" position of the codon. This is because in a nwnber Qfcases, rhe identity ot' the base at Ihe third position can wobble. und the same 31111110 acid will slill be specifLcd, This property allows .some prorection agaillSI mu til~ion -- if a mutation occurs at the 1hird position of a codon, the~ is Agood cb:l.uce tbat tbe. amino acid specified ln the encoded protein won '. t <-h-angc. l mpo rtnt: Only trypt<ophan, mcth1onlne, and sclrnocystcine arc coded by just one codon. Tbc other lR amino acids ~to coaed by t>vo or ruorr. Codons that srecify 1he sume an11nn acid are callc(l synonyms. Several of the codons !Serve special f\utctions: l. lnititttion codon (II UG) signals the beginning of roiYJleptide chaons and codes ror 111elhion1nu: thus illl proteins begin with methionita.'. 2. Termination coduns (UAA. UA(;, nnd UOAJ .. signal the cud of polypeptide
**-

chain ~yn.thesis. These oodons are ttlso rofcrred to as stop coduns or nunsrnst' codons. I. An anticodon is a specific sequen.ce- of three l'\llcleolidt;S in v transfer RNA. Not~ complementary to a codon for an am iuo acid In n messenger RNA. 2. Remember; The IWO RNAs ue paired antlparll<l the first base of the c.odon (olway.r reading iu the 5 ' -- J tliremimiJ pairiog with the third base of the anlicodon. fo r example, if 1he anticodon on a 1ransfer RNA is 5' ACG 3 then its corresponding codon on the messengor RNA would be 5' CGw 3' .

14 (2 in each 1-T puiriu~ ami 3 in

C'tli'h

(,.('pairing)

The two antlparallel polynucleu tlde chains of double-helical DNA are not identical in either base sequence or composition. Instead, they are complementa ry to each other. Wherever adeniue appears in one chain, tl1ymine is found in the other: similarly, wherever guanine is found in one chain. cytosine is found in the o lher. Important point: The acluality that separated DNA strands are able to r eassociate represents the conseqt1 euce of the fact that DNA strands are cumple.mentary. Note: Watson and Crick deduced this s pecificity of base pairing because of stearic and hydrogen-bonding factors. In the Wa tson-Crick structure, the twu chnins or strands of the helix are ntipurallcl, such that one strand runs 5' to 3' ("five prime lc> three prime') whi le the other l'\lllS 3' to 5'. The DNA d o uble helix is held together by iwo sets of forces: hydrogen bonding between complementary base pairs and base-sta cking l ntQractlons. The helix structure results in a m ajor and 11 mluor groove being formed along tl1c DNA molecule. Tb~ major groove is the binding region for many p ro teins th.at control tbe transcriptional activ[ty o f the DNA molecule. l.mportant: Three h y clru~cn bonds can form between G and C, but o nly t wo can form betweeo A and 1 . The weaker bonding between A ~nd T (or U /11 RNA) is Ltsed in transcription to aid in the release of the newly formed RNA from t he DNA rcmplate.

~IOCHEMISTRY I PHYSIOLOGY

DNA/RNA)

\..

A sequence of DNA is "T-A-G-T-A-T-CAT," What would the complementary RNA sequence be?

A-T-C-A-T-A-G-T-A A-U-C-A-U-A-G-U-A U-T-C- U-T-U-G-T-U

71 CopyriJb! 0 2009-2010 Oo:ntal Olx:kl

(BIOCHEMISTRY I PHYSIOLOGY

DNA / RNA)

( All of the following statements concerning the backbone of DNA arc tru;'\
\._ EXCEPT one. Which one is the EXCEPTION? }

h is constant throughout the molecule

It consists of deoxyriboses linked by " phosphodiester bridges" or "phosphodiestcr bonds"

It is hydrophobic
It is highly polar

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A-l '-C-A-l' -A-C.-l'-A

cousi~ts of two polynucleotide chains that run In opposite directions to one another. The two strands of DNA fonn a double hcUx that runs antiparallel such that one strand nms 5' to 3' t:flve pri1ae 10 three prime") while the other one runs 3' to 51 The purine and pyrimidine bases that are opposite one another (adenine with thymtne and guanine wit!t cytosine) in each polynucleotide chain are linked together by hydrogen bonds. The A-T buse pair has two hydrogen bonds while the G-C base pair bas three. This base pairing (A wilh Tand G with C) is known as complementary base pairing.

A complete DNA molecule

Remember: This complementary base pairing can also occur in RNA and between RNA and DNA; however, uradl subslllutes for thymine in RNA. Uracil base pairs with adenine. Important point: The A-T base pair promotes helix stabilization in DNA but docs not do so in RNA .

!.In all DNA, the number of tl!ymioc residues equals tlle numb~r of adenine
)iot.. residues. Also, the number of g uanine residues equals the number of

cytosine resid11es. 2. P urines are the larger of the two types of bases fount! in DNA. 3. In addition . the sum of purine residues equals the sum of pyrimidine residues (A + G ~ T C). 4. The melting temperature of tht double helix is a function of the base comrosition with a higher GC content having a higher melting temperature and an increasod stabili ty of the double helix.

It is h)drHphnhir
*-

This is false; it is bydropbilic. The backbone ol' ON A, which is constant throughout tbe molecule, consists of deoxyrlbuscs linked by Jlllosphodlester bonds. .Note: The backbone of RNA couststs ofrlboscs linked by tbe same phosphodicster bonds.

Spe~iOcally, the 5 ' -hydroxyl gr011p of one nucleotide unit is joined to the 3' -ltydroxyl group of tbe next nucleotide by a phospbodicstcr linkage. Thus, the covalent backbones of nucleic acids consist of alternating phospbate and pentosc residues, and a purine or 11yrimidine base is attached to each pentose. The 5'-0H group and the 3'0H moiety are Hnked in <1 condensation reaction. Features of the DNA Double Helix: 1\vo DNA strands form a holical spiral, winding around a helix axis in a right-handed spiral. The two polynucleotide cbains run in opposite directions. The sugar-phosphat< backbones of the two DNA strands wind around the helix axis like the railing of a S}liral staircase. The bases of the individuul nucleotides are on the inside of the helix:, stacked on top oft'llch <>Uler like the steps of a spiral staircase.

l. The backbones of both DNA nod .RNA are hydrophilic and highly polar.
Note 2. The hydroxyl grouJlS of the <ugar residues form hydrogen bonds with

water. 3. The ribose phosphate p011iou of purine and pyrimidine nucleotides comes from 5pho<phoribosyl-lpyropbosphate (PRPP) . PRI'P is synthesized from ATI' and ribnsc 5-phosphnte, whicb is primarily formed by the pentose phosphate pathway.

~IOCHEMISTRY I PHYSIOLOGY

DNA/RNA)

Which material comprises most of the RNA in the eell?

Messenger RNA Transfer RNA Ribosomal RNA

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~IOCHEMISTRY I PHYSIOLOGY
The activity level of which enzyme controls the rate of glycolysis?

Aldolase Phosphoglucose isomerase Phosphofructokinase Triose phosphate isomerase

17.J
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Ribosom;ll It'\ \ Transfer RNA is next. followed by messenger RNA. Types of RNA: I. Messenger R. " 'A (m.RNA) molecules carry infonnation (genetic <:ode) !rom DNA in the nucleus to ribosomes in lhe cyloplasm, where polypeptides and proteins are synthesized (lranslatiort} -- utRNA Is the 1emplu te for protein syn thesis a nd conlalns the rodon.

1. Transfer R NA (tRNA) molecules carry the amino acids to ribosomes, where the amino acids are linked together in the order specified by mRNA to limn l)articular polypep1ldes nnd pro1eins. Nole: Amino acyl-tRNA synthetase is a group of ligases (enzymes) that ensures thllt the correct amino ac\d is attached to the tRN A with the COITect anticodon 10 be used during protein synlhcsi~. Individual enzymes arc highly specific for one amino acid. No error check i.ug occurs during the tran$1ation process on the ribosome.

3. Ribosom al RNA (rRNA) molecules ate the major componenr of ribosomes, which are the physical and chemical stntctllres on which protein molecules are actuall y assembled. Remember: Transcrip tion is the process in which DNA serves as a template for the assembly of molecules of RNA (all three types). This process involves the enzyme MA polymerase.

Phosphol ructokina"il'

Phosphofructoltinast (PFK) is a glycolytic enzyme that catalyzes the irreversible transfer of a phosphate from ATP 10 fruclose-6-phosphate. TI1is is the moSI important control point of glycolysis. lmportanl point: The phosphofructokinase reacrion is 1he rare-limiting step in glycolysis. The rct1clion, wbieb is shown below. requ.ircs an input of energy from ATP. fructose6-phosphate + ATP pllOsPho-rruitOkinas.r fructose-l.6-bisphospbntc + ADP This allosteric enzyme IS Slimulaled by ADP and AlvlP and is inhibited by ATP and citrate. In other words, the enzyme is most active when d1c energy of a cel l IS low. l'ructose-2,6bisphosphale i,s an lmportaJli allosteric acliVaiOr ol"thls enzyme and an allosteric inhibitor of fructose-1,6-bispbosphalase, which physiologically reverses thfs rcac1ion at lhe. end of glu concogenc$IS (glucose iYntlresis). Aldola~e convens frucwse-1,6-hisphosphalc (6-carbou metaboJite) into two J..c~trbo n metabolites. dihydroxyacelonc phosphate and glyccraldehyde-3-phospllate. ThiS 1~ called the aldolytic reaction of glycolysis. Aldolase is plentiful in skeletal and hear! muscle ussues. Glycolysis occurs in the cytoplasm in the absence of 0~1'geo and involves the lbllowing~ I. Two molecules of ATP are used to pho:<phorylatc glucose and start glycolysis. 2. 'nte phosphorylaled molecule is !hen broken down in a series of reactions inlo two, !bree carbon molecules (lysis). 3.Two molecules of NAD capture " and are reduced to 2 molecules ofNADH H 4. Four molecules ofAT I' are produced by substralc phosphorylarion. 5. The end product pyruvate may then either undergo aerobic respiration in the mitochondria or anaerobic respiration (/e1,;entation). Net Gain on ATP I. l'hosphoglucosc Isomerase catalyzes < ho isomerization of glucuse-6-phospha<e 111 ~Ot~ fructosc-6-phosphate. 2. Triose pho5ph16te i!iomcrase iruerconvcns dihydroxyncetonc phosphale and glyoernldehyde-3-phosphftte.

~IOCHEMISTRY I PHYSIOLOGY
I. The flrst sign of myocardial infarction In a patient is a

high plasma level of which enzyme listed below?

li.. 2. ln liver disease, wbicb two of these enzymes will be elevated in the plasma?..J

Creatine kinase (CK) Lactate dehydrogenase (LDH) Glutamate-pyruvate transaminase (OPT) Glutamate-oxaloacetate transaminase (GOT)

75 Copyrigbt e 20()9..2010 t>tntal Deeld

~IOCHEMISTRY I PHYSIOLOGY
/
~

All of the following statements concerning transamination reactions arc \\.. true EXCEPT one. Which one is the EXCEPTION? .J
j

These reactions involve the transfer of an amino group from one amino acid to an a -keto acid The enzymes that catalyze these reactions are known as transaminascs or aminotransferases Glutamate and a -ketoglutarate arc often involved in these reactions, serving as one of the amino acid/a -keto acid pairs Pyridoxal phosphate (PLP), which is derived from vitamin B. serves as the cofactor for these reactions All am ino acids participate in these reactions at some point in their catabolism
76 Cosl>TiiNO 2009-2010 Dental Dttb

I. Cnatinc Kina\e (Ch) 2. (;lutamolfc-u,uluaCltah. lnn~lliiiiii:&Sl' ((,'{}TJ Lluhtm:tll.. p~ rll\ at{' tr.msmninuse (fii*T)

** The plasma levels of these ellzymes are commonly determined in the dingnosis of
myocardial iufu rction. They are panicularly useful when the ECG is dinicuh to
interpret.

*** Cre-atine klnase is the nrst heart enlyme. to appear in the blood after a hean attack, GOT is the ncxlto appear, followed by GPT and LDH.
Some enzymes show relatively high activity in only one or a few tissues. The presence or increase<! levels of these enzymes in plasma thus reflectS damage to the corresponding
tissue.

For example: In rhe liver: Glutamate pyruvate transaminase (GPT): also called alanine aminotransferase (ALT). This enzyme functions in the trnnsam1nation of alphakeioglularate and L alanine to glutamate and pyruvate. Glutamate-oxaloacetate tran< amlnase (GOT): also culled aspanate aminotransferase (AST). ***These two enzymes are elevated in nr:ar1y all liver diseases. ln the beart: Creatine kinase (CK): also called creatine phosphokinase (CPK/ Lactate dehydrogenase (LDH) : dffterenr isozyme characteristic of heart muscle Glutamate-oxaloacetate transaminase (G01J Glutamate-pyruvate transaminase (GP1J

.\11 nminu :tcich participate in these r('actions al some puinl in thl'ir CHI.tholism

... This is false; lysin~. serine, no threonine are not transaminated. The first step in lhe catabollsm of most amino acids involves the removal of the a amino group. Once removed, this nitrogen can be utcorporated into other compounds
or excreted.

Nitrogen is trans ferred from one amino acid to another by transamination reactions, which always involve two different pairs of amino actds and thctr correspondi ng o.-keto acids. Note: Glu tamale and a -kcloglutarate usua lly serve as one of the paors; transaminases (aminotransferases) catalyzed the oan~fcr of amino grQups; all transaruinases require the coenlyme pyridoxal phosphate. [n contrast to transamination reactions that transfer amino groups, oxidative deamination reactions result in the liberation or the amino group as free ammonia (NH.). Tbcse reactions occur primarily in the liver and kidney and provide a ketoacids (for energy) and ammonia (which Is o source of nitrogen in urea synthesis). Note: En:r.ymes involved in deamination reactions include glutamate deh ydrogenase (/'or glutamate), histidase (for histiditre), aud serine deh ydratase (for serine and threonine). All amino transferases (transominascs) share a common prosthetic group, pyridoxal phnsphate (PLP). PLP is tl1e coenzyme fonn of pyridoxine or vitamin a,. It functions as an imermediate carrier of amino groups at the active site of aminotransferases. PLP undergoes reversible transformatio11s between its aldehyde form, pyridotal phos phate (PLP). which can accept an amrno group. and its aminated form. pyridoxamin e phosphate (PMP), which cau donate its amino cid to an a -keto acid.

~IOCHEMISTRY I PHYSIOLOGY

\..

All of the following are true of oxidative dcamination reactions EXCEPT one. Which one is the EXCEPTION?

Provide a -ketoacids for energy Provide ammonia for urea synthesis Occur mainly in the liver and kidney
Provide a detoxification mechanism

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~IOCHEMISTRY I PHYSIOLOGY
Carbonic anhydroses arc -containing enzymes that catalyze the reversible reaction between carbon dioxide hydration and bicarbonate dehydration.

Manganese Selenium Zinc

Mercury

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Prm ide .1 dtttnilicu tiun

IJI('Ch:&UI\111

Deamluatlon is also ao ox.Jduthr e reuction thal occurs under aerobic conditions in all tissues b111 especially the liv~r lllld kldney. During o~idative deamination, an amino acid i conwrted into the corresponding keto add (for "'IC'ltJ~ by the removal of tho amine functional group as nmmonin and the :otniuco functtonul !:roup is replaccod by the kelOn~ gruup. The lm monia eventually goes imo the urea cycle. O~idathe deAmination occun1 primarily on glutamic acid bcocause glutamic add was t))e end prodttct of many transamination reactions. Glutamate dehydrogenase is :m enzyme of the o~idorcducrose class that catalyzes the o:<idative deamioation of glutam<Ue, Atnmoni is released. nod r.t ketoglmarate is fhrmed. Glutaruate dehydrogenase is tmusttnl in that it can usc either NAO 01 NAOI as " coenzyme. The reversible reaction has a major function m both tl1 e synthesis and degradalion of glutamic acid and, via trnosamiuases, o1b.;r amlno acids as well. important: Both asporate aruinotrnus fcrQSO (AS'f) and alanine aminotransferase !ALT) ar~ hausiUlJinase. (ambwlralt'.[e,'ases) T~ey 1te not involved in oxidative deamiuation ret;~ctions~ In coutrast to traosaml.uariou r('attions that transfl!r amino groups, o~ldatlve deauJ!natlon results in the liberoriotJ of til~ ~mino group as free ammonia. L Glutominase deaminatcs glutamine to glutamate and anunuuium ioo~ NotCJ' aspar-agina~e dcaminatcs asparagine to aspanate aud a:Jnwonium iou. 2. Glutamate i~ unique in thar it is the only auuuo acid lhut uodcrgocs rapid oxidative deamination . .3. Hilidine is de.1miunted by histidasc to form :munonium iot1 (NH) and
uroc-nnate.

4. Serine and threonine UJ'e deautinmed by serln~ dohydratase. Serine ~c; couv~rted to pyruvate, and threonine ro o.ketobutyrate: ammonium ion -is released.

Zinc Carbon dioxide (CO;) is a 1<cy metlibolite in all lfving organisms. Carbon dioxide exists in equilibrium with bicarbonrue (NCO;-). which is poorly soluble in lipid membranes compared to corbon diox[de; carbon dio~ide can freely diffuse in and out of the cell, while bicarbouote must be tronsponed. The conversion of bicarbonate to carbon dioxide f<ocilitates liS arnnsport into the cell, while the conversion of carbon dioxide to bicarbonate helps nap the carbon dioxide in dte coli. TI1e interconversion of carbon dioxide and bicarbonate proc<eds slowly at pbystologic>l pH. so organisms produce enzymes to speed up the process. Carbonic anhydroses arc zloc-conliuJng enzym.stbat catalylcl.he rcve.rsible reaction bcMecn carbon dlndde hydration a.od bicarbonate dehydration, Carbonic anhydrase eatalyzes !he follo,ving reaction: H20 1 102 <-> II' I llC03
Carbonic unhydrose is one of the fastest known l~n~es (nue molecule a/ curbouitonilydr(Ise ca11 p/'Q~ess one million molecules ofC01 eaclr .vecmrd) and is found in grout

concentration in erythrocytes. Carbonio anhydrase is an enzyme that cnnbles red blond cells to lr:msport carbon dioxide from the tissues to the lungs. I, Within the erythrocyte. uarbonic 3nhydrase facilitates the combmatiou of carbon Note df()Xide und water to form carbonic acid, 2. C!U'bQJtic ;mhydrase also functions in the kidney with the renhsurpllun of bicarbonate ion, 3. Although nol required for carbon dioxide and water to fnm1 carbonic acid~ c.arbouic -unhydrasr greatly increast.).S the reaction in hoth rt:speciS (fu,.muliun
uml disNot'iotion).

4. Mosl of the carbon dioxide (CO) is transported in the blooo as hicarhnnnlr Ion (HCO.rJ Jt is converted to crboni< acid (H1COJ) more rApidly in whole blood ~han in plasma, The reuon for t:his is thet whule blood contnm erythro cytcs with cnrbonic auhydrnso wbik p1a<ma doe$ not tonlain orythrocylcs.

GnocHEMISTRY 1 PHYSIOLOGY

\..

Which of the following components of the electron transport chain accepts only electrons?

FMN (flavin mononucleotide)

Coenzyme Q (ubiquinone) Cytochrome b Oxygen

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~IOCHEMISTRY I PHYSIOLOGY
Which of the following is not a classification of an enzyme?

Enz)

Oxidoreductase

Ligase
Transferase

Oxygenase
Hydrolase

Isomerase

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C~ tnchrnme

D(l'lpt h)dro~""

b --the c~totbroml:'s acnpt and ('l('ctron\,

nnl~

l..'lel'trons. J h<.> other

compon~nts

of the energy cnnserved during cawbolism reactions occurs near the end of the metabolic series of reactions in the elevtron transport chain. The electron lran ~port, or respi ratory chain, gets Its name from the fact electrons are rransp011ed to meet up with mcygeo from respiration at the end o f the chain. This chain is present in tho inner mitochondrial membrane and is the final commiHi pathway by which electrons derived from different fuels of the body flow to oxygcu. Electron transport and ATP synthesis by oxidative phosphoryla\ion proceed continuously in all cells of the body that cotltain mitochondria. Compunetts of the electron transport cbaint FMN: receives e lectrons from NADH 1111d transfer~ them through Fc-S centers to coenzyme Q. FMtJ is derived from ribonavin. Remember : NAD is derived from

Th~ majority

niacin.
Coenzym e Q: receives electrons from FMN and also through fe-S centers from FADH 2 Coeozyme Q is not derived from a vitamin (th~ body 'J'Iltile.<izes it}. Cytochrome~ (b. c, a. tz11d a:J: receive electrons from the reiluced fonn of coenzyme Q. Each cytochrome consists ofa heme group associated with a protein; cytochrome~ is also called cytochrome oxidase. llctnc is synthc.sizcd from glycine and succiuyl CoA in humans. H~me is not derived from a vitamin . On:en: ultimately receives tb.e electrons at the end of the chain .and is reduced to water. Remember: A coenzyme is a nonvrotein substance (orgalliC cofactor) that combines with an apoenzyme (the protein portion of a complex enzyme) to f01m a holoenzyme (<1 complete. cotalytieally active enzyme Jysrem).

-a,

Enzymes are catalysts. Most arc very large proteins. Enzymes bind temporarily to one or more of the r~actanL~ of the reactiop the enzymes c~talyze. In doing so. they lower the a mount of activa tion energy needed ancl thus speed up the renctioa. The funcuoning of the enzyme is determined by tho $bape of tho protcio. Enzymes are s ubs tr ate s pecific. For example, the enzyme peptidase (which break. peptide bond. in proteins) wiU not work on srareb (which is hroken down by hWIIIIIII'''Odllceti amylase in the mowh). The arrangement of molecules ott the enzyme produces an area known as the active s.i tc within which the specific substratc(sj wi ll "fit." Jl rccogtli~c~, con fines, aod orients the substrate in a particular direction. Cl.assilicotion of enzymes: Oxidoreductases: catalyze a redox reaction Tnutsfer;~Ses: transfer a functional group 1lydrolascs: cause hydrolysis reactions Lyases: break C-0. C-C. or C-N bonds Isomerases : rearranges functional groups Ligases: joins two molecules for example, DNA ligase joins pi~ces of DNA !.Substrate concentration, pH, temperature. and cn:>:yme concentration all have lllute< an etl'ect on the activity of an enzyme. 2. Tbe enzytlliltic model that "-'SUtn"'' that en7ym~s hove nexible cotlformations is called induc~d fit. 3. The inact ive precursor of au euzymc i cal led a proen:<ym~. 4. A catalytically inactive protein formed by removal of the cofactor fi'om an active enzyme is called an apoenzyme.

~IOCHEMISTRY I PHYSIOLOGY

Enz)
~

'vour patient has Alzheimer's disease and asks you about this new article read on blood clotting problems. Re mentions that they talked of an enzyme that has been found to be deficient in AD patients. The Jack of this enzyme would prevent him from dissolving clots at a normal rate. !Appropriately enough, he forgot the name of this enzyme. Help this patient \.. by telling him what enzyme he is thinking of. ~

Prothrombin Thrombin Fibrinogen Plasmin

81 Copyright e 20092010 Ocnul Deck.$

~IOCHEMISTRY I PHYSIOLOGY

\.

A zymogen is converted to the active enzyme form through which of the following ways:

Removal of a peptide fragment Addition of a peptide fragment Addition of an amino group Removal of an amino group

82 Cop)Tig!n O 2.009-2010 DtntaiiXd:s

Plasmin ~~ it is also r.tllld tihrinol~sin Plasmin is nomtally present in the blood in an inactive form called plasminogen. Substances known as plasminogen activators (for example. urokina.<e produced in the kidney) can convert plasminogen to plasmin, which will cleave the peptide bond in fibrin, leading to itS breakdown and dissolve clots.

Fibrinogen is a soluble protein normally present in the plasma that is essential to the blood clotting process. Fibrinogen is convened into an insoluble. thread-like polymer called llbrin by the enzyme thrombin. Thrombin is produced from the inactive plasma protein precursor prothrombin, which is formed i n the liver. In the presence of thromboplastin and calcium ions, prothrombin is converted to thrombin. Note: Research has sbowo that thrombin acts upon the arginyl-glycine linkages (<pecific peptide bonds) in fi brinogen to produce a fibrin monomer.

f~tmo' al

nf *' pt'llfidt lragmcnf

Zymogens are enzymatically inacthe precursors Of proteolytic enzymes. The digestive enzymes that hydrolyze proteins arc produced and secreted as zymogens in the Stomach and pancreas. They are convened to their active forms by removal of a peptide fragment in the lumen of the digestive tract. Proteolytic enzymes, are synthesized as inactive zymogen precursors to prevent unwanted destruction of cellular proteins. <1nd to regulate when and where enzyme activity occurs. Note: The release and activation of the pancreatic zymogens is mediated by the secretion of cholecystokinin and secretin. A good example of what occurs when some zymogens become active enzymes inside the cells is seen in acute pancreatitis, in which the premature activation of some of the pan creatic enzymes, such as trypsin, phospholipase A2 and elastase, produce the autodigesz~ mn~ens

Site or Synthesis Stomach

Zymogen Pepsinogen Chymotrypsinogen Trypsinogen

Active Enzyme Pepsin Chymotrypsin Trypsin

Pancreas
Pancreas Pancreas Pancreas

Procarboxypeptidase A Carboxypeptidase A Procarboxypeptidase B Proelastase Carboxypeptidase B EJastase

Pancreas

~UOCHEMISTRY I PHYSIOLOGY
Starch molecules are broken down by enzymes known as:

Oxygenases

lsomerases
Peroxidascs

Amylases

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~UOCHEMISTRY I PHYSIOLOGY
~

Your patient's medical history says that she has von Gierke's disease, She is \ \.. missing the eneyme which converts .

"

.J

Glucose-6-phosphatase, glucose-6-phosphate to glucose Glucose-6-phosphatasc, glucose-6-pbosphate to fructose-6-phosphate Pyruvate carboxylase, pyruvate to phosphoenolpyruvate Pyruvate carboxylase, pyruvate to 2-phosphoglycerate

l'Z4
84 Copyright C 2009-2010 l>e'ntn.l l>ecla

Amylase ls the pame given to glycoside hydrolase enzymes that hreak down starch iuto glucose molecules, Amylase is also known as ptyalin. Although the amylases are designated by different Greek letters, they all act un a-1,4-glycosidic bonds. Classification or amyla<eo: a-amylases: By acting at random loca~ions along the starch chain. rtamylas, breaks down long-chnin carbohydrates, ultimately yielding mnltotriose and maltose rrom amylose, or mnltosc, .J!Iucusl!. a.ntJ ''limit dextrin'' fron' amylopectin. Because uamylase can at:l :111ywher~ ou the subtrate, n-amyln$e tends to be faster acthtg than ll nmylnse. In animols,n~;unylase JS n major digestive enz)'nle. Note: In human phy~iolog_v, both the snlivary snd paucreutic amylase-s nre o.-amylases. ~-amylue: working from the non-r<duciug cud, ~-amylase catalyzes the hydr<)lysis of the second n-1 ,4 glycosidic boud, clcavu1g off cwu glucose unit' (malw.<e) at a rime. rmylaso: in addilton to cleaving the last a- 1,4-glycositlic linkagos at the n<>n-reducing end of amylose and amylopectin, yielding glucose, y-atnylase will cl.,ave tt t,6 glycosidic linkages.
- I. ''Limit dextTins" are various branched polysaccharide fragments that rernnin tol-

Notn

lowing the hydrolysis of starch.

2. Disaccharides and small glucose polymcn; are hydrolyzed at the inte.tinal bntsh

border by lacl~sc, sucrase. mallas~. and alpha-dexlrinase. 3. Remember; Only mooosacebarldes (e.g.. glucose, galactose.fnu:tosc) are Bb sorbed in the small intestine. Lactase deg,rades lactose to glucose and galactose. isumaltase cleaves a glucose linked t,6 to another glucose as is lound at the branch points in starch and g)ycQgen, and sucrase deg.rades sucrose to glucose and fructose.

Glucose-6-pbosphatase (G6P) is the liver enzyme that converts glucose-6-phosphate Into glucose, G6P i& vital for the release of glucose into the blood$tream !rom glycogen breakdown (glycngenolpi.). iwporllwt: Gluco$o6-phospbatase, like pyruvate carboxylase, occurs in the liver and kidneys but not in nntscle. Therefor<l, arty glucose released from glycogen stores of muscle will be oxidized in the glycolytic pathway. In the liver, the action of glucose-6phospbatase allow8 glycogenolysis to gonerate fi-ee glucose for maintaining blood glucose levels. Gluconeogenesis ls a biochemical proce,~s in which glucoso is made fiom molecules that are not carbohydrates (primarily from amino aciclv but not fotty aci<L<). This process occurs primarily in the liver, and the process provides glucose for exjlOM to otliCr tissues when other sources of glucose arc exhausted. Typically, gluconeogenesis involves the cOn\'ersion of lactic ucid or amino ucids into pymvatc or phosphoen<.>lpyruvrue, wMich is theu converted to glucos"Some key reactions of gluconeogenesis: Pyruvate-- oxaloacetate (cullllyud t>.v pyruvate carboxylase) Oxalouc11ilc - phosphoenolpyntvate (carol)'Ulf by pho.;pltoenalpytlllote ctlrbo.\)~

kinase)
Fructose-1,6-bisphospbate .. fntctose-6-phos phare (clltaly.ed by [ructose-J,Uisp/losphattls~)

Glueose-6-phosphnte .. glucose (ctlloly;ed by g/ucose-6-phosplwtll.,e) l . Glucose-6-pbosphatase doe not COT\tain a high-energy bond. Not.. 2. T o glycolysis, glucose ls converted to pymvutc - glycolysis is the first part of the respiratory pathway; in gluconcogcuesls, pyruvate is convrled ro glucose.

~IOCHEMISTRY I PHYSIOLOGY
(
Independent of pH Numerically equal to 1/2 Vmax Dependent on the enzyme concentration Numerically equal to the substrat~ concentration that gives half-maximal velocity The Mi~htells
~onstant,

Km, is:

1$
COflrrlst~ o

200920 to lkntal D-b

~IOCHEMISTRY I PHYSIOLOGY

All or the following statements eoneerning allosteri~ enzymes are true \. EXCEPT one. Which one is the EXCEPTION? ..J

"I

They frequently catalyze a committed step early in a metabolic pathway T hey often have two or more subunits, each with substrate binding sites that exhibit cooperativity Allosteric activators cause the entyme to bind substrate more readily Allosteric inhibitors cause the enzyme to bind substrate less readily They follow lhe Michaelis-Menton kinetics

Copytipt C 2009-201 0 Dtntallkds

"

~Umt> rir:lll~

Clfual ro Ihe suhslrah. concentration Ihat ~iH'\ h:tlf-m.a\im.ll \ducil)

:

This can be expressed as K,n [S], wben V0

1/2 '""

Km Is equivalent to that substrate concentration at which V0 (initial reaction

velocity} is one-half Vmax Note: Km bas unit> of molarity.

The Km values of enzymes range widely. For most enzymes, Km lies between !0'1 amllO- M. Tho Km value for an enzyme depends on the particular substrate and also o n onvironmental cond)tions such as the temperature and ionic mength. The Michaelis constant (Kn,l is frequently, incorrectly, sad to be equivalem to tbe dissociation constant of the enzyme-substrate complex. For mo~t reactions, The Mithitelis constant is a complex function of mauy different reaction constants, but tbis constant does give a means of comparison of rhe affinily (reciproeal ~f di.rsociMion) of an enzyme for different snbstrates or different enzymes for tbe same substrate. The lower tbo K., the higher tbe relative afllnity.

Not..

I. K,n values fo r enzyme substrate reacrions:

Increas e in the presence of a competilfw lnhlbi.to r. Are not affected In the presence of a noncompeti tive inhihiton however, V max is reduced.

lmpOrtunl: The nutximul rare (V.,.,J is attained wbeu the enzyme sites are sstumted with ;ubstrnte.

Th l'~

fulln\\ thl'

:'\1ich~tclis-l\lcnton

ldn etics

***Tbis is false; allosteric enzymes usually show a complex relation ship between the velocity and substrate concentration . Tbe regulation of metabolic processes is achieved through 2 mechanisms acting directly on en.zymes: aUoste.ric regulation and covulent modification. Allosteric regulal'ion: an allosteric enzyme is n regulatory enzyme and has both an active s ite for the substrate and an allosteric site for an effector (non-active site) of the enzyme. In the absence of the"enzyme's effector, the substr11ic is able lo bind to the euzyrue's active site and C!ld products are produced. Tftlte effector is present, it will bind to the enzyme's allostcdc s ite. Eftcctors cause confom1atiooal changes !hat are transmitted through rbe bulk of the protein to the catulytically active site(s). The hallmark of effeNors is tltat when they bind to enzymes, the effectors alter the catalytic properties of an cnzymes active site. Those thai increase catalytic activity arc known as poitive effectors, Effectors that reduce or inhibit cataly1ic acriv;ty are negative effectors. These modifiers may be either lbe subsirote itself or some other metabolite. For example, ATP inhibit$ phosphofructokinase (<In allo.,teric emy me) eveJl though ATP is also a substrate fot this enzyme. Covalent modification (tire rever>ible covalent modificariOir of (lit enzy me) : enzyme phosphorylation is the most common form of covalent m<.>dification. Phosphorylation occurs on either s~r-OH, Titr-01-l. or Tyr-OH groups. Adding o r rem<.>ving a phosphate group (a brrlky, lreavily neRntivel;~clrarged frmdionul gmup) has dramatic effects on pro tciu conformouon. Bn1yme exists in 2 stales. modified (plrosphmyloted) and unmodified (tmphosphmylatcd). where one is active, snd the orher is inactive. En~ymt phosphorylation is catalyzed by ATP-depondenL protein kinases. Phosphory lated ~ozymes ar<" dephospborylated by phosphoproltin phospbHtases.

~IOCHEMISTRY I PHYSIOLOGY
What is the substrate for glycogen synthesis?

Enz)

. UDP-glucose TOP-glucose ADP-glucose CTP-glucose GTP-glucose

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~IOCHEMISTRY I PHYSIOLOGY
Which of the following best describes an " oncompetitive inhibitor"?

Enz)

Essentially a noncompetitive inhibitor that can bind only when the substrate is attached EssentiaUy a competitive inhibitor that can bind only when the substrate is attached A noncompetitive inhibitor that can be overcome by increasing substrate concentration
An irreversible inhibitor (the two are synonyms)

Copyri.gtlt e 2009-2010 Dt1 ua1 ~>teu

The synthesis of1Jiycogen iiom glucose is carried out by the enzyme glycogen ynthase. It is the key regulatory enzyme for glycogen synthesis and utilizes UDP-glncose one substrate :llld the non-reduc;ing end of glycogen as another. Sole: Glycogen symhose Is r~$ponsible lo r making the 1,4 linkages in glycol!en. Ul> l'-glucose is the subsltatc for glycogen synthes1s. Glucose enters the cell and '" phosphorylated to glucosc-6-phosphate by hexokinase fin most 1/sme.r) or by glucokinase (in the liver). To initiate glycogen synthes1s, the glucllsc-6 -phllsphatc i reversibly converted into glucose-1-phosphate by phosphoglucomutase. This glucosc-1phosphate is then con,c rtcd to UDP-glucose by the action of UllP-gl ucosc p yrophosphorylase. I. Glycogen S)'lllhnsc occurs 10 both phosphorylated und dephOSl)horylated 'Note. fonns. The active ~nzymc, g lycogen syntbas, A io lhe dephosphorylated fonn. G lycogon synthase 6 is the phosphorylated form and i~ tle lonctive form of the enzyme. 2. Glycngon phosphorylase, wlllch breaks down glycogen, also ba.- two fonns; (a) and (b): however, in this cnse the phospborylntloo of this enzyme (which happens in liter cell.v) fom1s the nctive enzyme (a) and the dephosphorylation forms the inactive enzyme (b). lruportnnl: Both enzymes (glycogen .yntlla.ve and plmsphoiJifls) ore phosphorylated ul s pecll1c serine residues. 3. Unti l rec-ently, the source of the first ~lycogeu molecule that might act as a primer in glycogen synthesis was unlmnwn. Recently, it has been discllvered that 8 plotein known as gly cogenin is located at the core o f glycogeu molecules. Glycogenin has the unusual property of catalyzing its own glycosylotion, attAching C-1 of a UDI'-glucose to a tyrosine residue on the enzyme. The attached glucose is believed to serve as the primer required by glycogen synthase.

Esst'utiall~ ~~ uoncmupctithe inhibitor that can hind on I~ \\lll'll CIH.~ suhstratt is

att:tch<'<l Enzymes are subject to Ote following types of inhibition: Reversible: 1. Competitive inhibition: the competftive inhibitor resembles the substrate unu binds to the active she of the cneymo. The sobsltate is then p revented from binding to the same active site. The hallmnrk of competitive inhibition is th 1nhibi!lon can be overcome by tncrcasing the substrate concentration. 2. Noncompetitive inhibition: the inhibitor and substrate can bind simultaneously to an enzyme molec1lle. This meaiJS lhl their binding sites do not overlap. Because Lhe inhibitor and substrate do not compete for the same site, noncompetitive inhibition cannot be. overcome by increasing the Sllbs<rate concentration. A noncompetitive inhibitor is by defutition au allosteric Inhibitor. 3. Uncompetitive inllibition : like noncompetitive, the inhibitor and substrate. hind at different sites which do not overlap. However, au uncompetltlve Inhibitor wm bioi! only tc;> an eozyrne that has a substrate alread y attached (S c-omplex). Re member: The noncompetitive inhibitor binds to either a free en.Gymc or the ES complex . Irreversible inhibitors !tie those thai combine with or destroy a fl!nctional gtoup 011 the enzyme that is essential for its activity. A clas.~ic exampk is the irreversible inhibition of cyclooxygcnase (COX) by aspirin (aceiylsu/icylate), which acetylates the active site serine residue.

~IOCHEMISTRY I PHYSIOLOGY
(
A competitive Inhibitor of an enzyme:

Enz)
)

Increases Km without affecting V m ax

Decreases Km without affecting V max Increases Vmax without affecting Km Decreases both Vmax and K m

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~IOCHEMISTRY I PHYSIOLOGY

Enz)

Trypsin ogen is transformed into trypsin as a res ult of the cleavage or a single peptide bond by:

Endopeptidase Alanine aminotransferase Enteropeptidase Pancreatic lipase

90
CoP)'Ti&bt e 2009-2010 Dtn1llllktb

lnc r'a't.'\ f\.Jn \\ithuut

affectin~.:

m.\\

U>mpetillve inbihilion: Inhibitor and sobstrate compete for the same binding itc on the enzyme Is overcome by increasing substrate Vrna;,: remains the sanle

Km is increased
Noncompetitive inhibition: lnh ibitor and substrate bind at different sites on the enzyme Is not overcome. by increasing substrate Vmax is decreased Km is unchanged The rstc at wbich sn enzyme works Is influenced by several !actors: The concentration of substrate molecules (the more of litem availnhle, che quicker th" enzyme mo/ecrlle. collide and bind with t!rem). The concentration of sobstrate is designated [S] and is expressed in unit of molarity, The temperature: As the temperature rise:;, molecular motion ancj, hence, coll isions between enzyme. and substrate speed up. But as enzymes are proteins. tbere is au upper limit beyond whicb the enzyme becomes denatured and ineffective. The presence of inhibitors (competitive and nom:ompelilive) pH: The conformation of a prutein is innuenced by pH and as enzyme activity is crucially dependent on the protein's conformation, the enzyme's activity is likewise affected. I. The velocity of a reaction incteases with the substrate concentration if tbe Not.. enzyme concentration is constant. 2. At V"""', all ofthe active s ites arc saturated with substrate.

Endnpcpt ida st.

The presence of amino add~ (from protein r1igesrion) iu the small intestine (specifically the duodenum) stimulate.s the release of cholecystokinin fCCK). Thas hormone cause tbe release of the pancreatic zymogcns (e.g . /l')'psiiiOJ5e11, cilymorrypsi11ogen, proelastase, and procarbo:rypeptldase A and B) and the contraction of the gallbladder to del iver bile ro the duodenum . The pancreatic proteases (e.g.. trypsin, clr ymotryp.in, e/a~lase, am/ curbo,,_vpeptidnsc A and 8) are secreted in inactive rorms (zymoge11s) that are activate(! in the small intestine as follows: Trypsinogen is activated to trypsin by enteropeptidase Ttypsin converts trypsinogen, chymotrypsinogen, proelastase, and procarboxyj>eptidase A nod B to their active forms. Ltupurtant point: Trypsin can act as an activator for all zymogens of pancreatic proteases I. Pepsinogen (secreted i>y chiefcells ofche stumach) is activated to pepsin N"t"" by tile low piJ io tbe stomach or other activated pepsin molecules. 2. Trypsin cleaves peptide bonds in \Vhich the carhoxyl group is contributed by lysine aod arginine (basic amf11o acids)3. Cb)'motrypsin cleaves peptide bonds In whieh the carboxyl group is contributed by the aromatic amino acids or by leucine. 4. F.lastasc cleaves at tbe carboxyl end of amino acid residttes with small, unchauged side chains such as alanine, glycine, or setinc. 5. Catboxypcptidase A has little activity on aspartate, glutamate, arginine, lysine, or proline; carboxypeptidase B cleaves basic amino acids, lysine, and arginine. 6. Endopeptidase (jor example, trypsin) refcn; to any of a large group of euzymes tbat cutalyze the hydrolysis of peptide bonds in the interior of a polypeptide chain or protein molecule.

~IOCHEMISTRY I PHYSIOLOGY
Which enzyme is used as an indkator of osteoblastic activity?

Enz)

Creatine phosphate Hyaluronidase Alkaline phosphatase Acid phosphatase

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Decks

~IOCHEMISTRY I PHYSIOLOGY
Which of the following equations is correct?

Haloenzyme +cofactor = cohaloenzyme Apoenzyme + cofactor = haloenzyme Coenzyme + cofactor= enzyme Coenzyme + apoenzyme = coapoenzyme

92
CopyriJbl 0 2009-2010 Oc-.ntal Otcks

*** The other marker of bone formation that is used is osteocalcin. This is a bone
matrix protein that is the second most abundant protein in bone after type. I collagen. Alkaline phosphatase is believed either to increase the local concentration of ioorganic phosphate or to activate the collagen fibers in such a way that they cause the deposition of calcium salts. Alkaline phosphatase is involved in bone mineralization and hydrolysis of phosphoric esters and functions optimally at pH 8.6. Phosphatascs are any of a group of enzymes that liberate inorganic phosphate from phosphoric esters. Two examples are: l. Alkaline phosphatase: most of this enzyme in normal serum is derived from bone; however, this enzyme is present throughout the body. Note: High levels of this enzyme are seen in Paget's disease of bone and osteosarcomas, wh ile low levels are seen in cases of bypophosphata.sia. 2. Acid pho.spbatase is a phosphatase with optimum functioning at pH 5.4 and is present iu the prostate gland. Note: High levels of acid phosphatase are seen in carcinoma of the prostate gland.
- , I. Creatine phosphate (also called phosphocrea1ine) is an organic compNotes ound found in muscle tissue and capable of storing and providing energy for muscular contraction. 2. Pyrophosphatase also may play a role in the mineralization of bone .

.\pcll'nz~

nu. +cofactor :: haiOl'nzyme

Cofactors are organic molecules (coenzymes) or ions (usually melal ions) that are required for its activity. They may be attached either loosely or tightly (proslhetic group) to the enzyme. A cofactor binds with its associated protein (apoenzymes), which is functionally inactive, tO fonn the active enzyme (holoenzyme).
Snnw t'OJ'"\fllf'' ctml.linmg n~jlll rm~.: 11U1 r<~.wk \'lt'llll'Ut\ I" cnr:tclnr.

Cofacior
Fe1 or Fe3'

Enzymes Cytochrome oxidase Gat.alase Peroxjdase

FerTCdoxln

cu!Zn''
Mg~

Cytochrome oxidase Pyru\'ate.phosphokinase

Carbonic anh):drnsc
A l coboldehy~gcnasc

Hexokinase Glucosc--6-phosphatasePyruvate kinase

,Argmase

Mnz...

Ribonucleotide reductase

K'
Nil>-

Pyruv;:ttC

Urease
Dinitrogenase Olu1athione pero~tidasc

Mo

Se

~IOCHEMISTRY I PHYSIOLOGY

\...

Which of the following functions as a coenzyme vital to tissue respiration?

Pyridoxal phosphate
Biocytin

Thiamine pyrophosphate Tetrahydrofolate

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~IOCHEMISTRY I PHYSIOLOGY

Hrm)

,.
I
\..

Which or the following docs not increase as a result or the action of growth hormone?

Amino acid uptake Protein synthesis Glycogenolysis Gluconeogenesis

Copyri.ght C 2009201 0 Oen1311ki;Q

Thl.aminc pyrophosphate functions as a coenzyme vital ro tissue respimtion. Jt is rcquirod as a tofactor for the enzyme pyruvate- dehydrogl'na.set which (..."atalyzcs the oxidative decarboxylation of pyruvate. to fomt 11cetyJ-CoA, which then enters into the Krebs cycle for the gc.neration t>f energy. Thlaml11e pyruphosphutt! is also :t coenzyme for tra.nsketolase~ \\lhich functions in the pr.ntose phospbate patbway. an alcernate pathway for gluco~ oxidation.
Smnt" !.'fit' Ill~ lilt'~ w n 1t1~ II\ trun'ilnt c:..rnl'r' nl Col!ozyme
Oerht d l'rc:>m
'Pl'l'ifi~

.lltlltl\ HF funl.'fiOilotl
Yuncdons

~roup'

't'hia~e pyrophosphate (TPP) Thiamine Mlamln 8 11 Vital to tiS5Uc n'$pu-atioo Ploys o. rule m the r~oval of entboxyl (.COOtO ~truops f'rom organlc 2Cids. Ttlt3:iing 1M ~rbon Md ox,rten
atom. .; nt auboni!ibXtde (COi).

Flavln ad~lne dinuckooLlde.

(FAD!
N'icoUnamid~ ldenine d!nu-

RJboRavin (\'J'mmln BU
l'[ieotinic ucid (,h:dn)

Fu~tions in cerfatn ()Xidlniou I

tcduc.tion re;)C.tiotS

m lb, e body.,

olwdd INADJ
Cc:tefleymeA Pamothenlf: ll(;ld
f\'/lam/N 8;)

Utilizod alternately 'With NAOfl as an Oltiditing Or n:ducin.e,agem In VilrimJS me'labnlic proct!'s.es. Functions IU ao~C)'I grotlp cnmer IIJ')d i!) ntiecs!i&ry fot r~ny 11cid synlhest.s o.od midatipn. PYfU\'tUC ollldtuicro. and other a=tyrodon I"Clcd<ms.

Pyridoxal phospho!< IPLPJ

Pyridoxine (\>(t4mln BJ l$ essential for ln;&n)'' enzymatic rt';Jctioos. almost \\II ~f"'hiCb :ttt- DSSOC:iattd wlth amino t1c:id
.flk."tabofisttt

Teu:nb)'drt~tblatc

Folic acid

Panicfp.'Ue$ in tbc lrnMf""ol vnrious Qllbon frap!ents fmm aM: mo1ecu1e to another: they are. for instlntt.. invol\1-ed in the S)tllhesis or methionine and thymir.oC".
Cotact fCif' lht: pyn1 vate dt'hydrag.ennse.COIAPICx.

Llpoate

N(J' rtgu1tlld in diet

wbiQh brcnb- down pyruvate t<' fonn uct1yl-CO..-...

Cbcrt:eymo Bl:

Viuunin 0 1~

l.s an essential cofactor forsc\lcral Cll?.>'fllt$,

(; ltJCOUt.'U:!t.'n l'~is

Growth honnooe, also known as somatotropin, is a protein honnone of about 190 amino acids that is synthesized and secreted by cells called somatotrophs in the anterior pituitary. Growtlt hormone is a major panicipant in control of several complex physiologic processes, including growth and metabolism. Growth hormone (GH), in contrast to oilier honnones, does not function tl1ro ugh a target gland but instead exerts effects on all or almost all tissues of the body. GH is pro<luced by the acidophils in the pats distal is of tbe anterior pituitary gland. GH causes the liver (lmd to a much lesser extent other lisst1es) to form several small proteins called somatomcdins (also called insulin-like growtlr factors) that in tum have the potetll eOect of increasing ail aspects of bone growth. Basic metabolic effects of growth honnone: Increased rate of protein synthesis in all cells of the body. Decreased rate of carbohydrate utilization throughout ihc body. Increased mobilization of fats and the use of fat for energy. Growth hormone causes cells to shift from using carbohydrates 10 using fat for energy.

l. Secretion of GH is iuc.reased by s leep, stress. starvation, exercise, and Notes hypoglycemia. 2. Secretion of GH is decreased by somatostatin, somatomedins (negative feedback control), obesity, hyperglycemia, and pregnancy.

~IOCHEMISTRY I PHYSIOLOGY

Hrm)

"-

In the following list, find the two pairs of hormones that work on the same target organs.

Follicle-stimulating hormone Oxytocin Prolactin Luteinizing hormone Adrenocorticotropic hormone

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~IOCHEMISTRY I PHYSIOLOGY

Hrm)

Which of the following is not a recognized type of a second messenger?

Cyclic AMP Protein kinases Phosphoinositides Cyclic GMP Azidothymidine

96 CopyriSh e 2009-zoJo l)mul ()eeh

Follklt stimulalin:! hormone: hnth \\nrk on tin 0\:nirs I tcsti'S and llrulartin: hulh \\nrk on the m.1mmar~ ;.:lands (o.\ :rtndn ubw ll'or/1' on tlu "'"rhu \moot/J mu., clt)
th~tocin
llornhllh' uf lht> l"1hUflln (.hmd

.Hormone

Sou:rte.

Tt.et

A(.tiOn(l)
Slirnult'l~ $)'Mill$i$ :mil $t>::re110n or

Thyrold..sclmolnting

Anterior pituitary Thyroid gi!Uld Anltrio1 pituilal'Y (N.uy

\b)'n;Jicl

hacmoo<
FbllklM'timulotiog

hormones StimulaiCS growth or graafiM follicles :md

ll\mnoneTc;s.!G.
Ltllt1rli7..ins }!(ltmO!X:

c:s.trogen secrccion Promotes gptiTI'I mau.lfalic"'"t:risJ

Slimul~tes OVl.llation. formation o oorpus lutcurn, and synlbesis of estrogen and ptoge5:teront

Antenor phuil..l j Ov-.>1)'

(Do:4JY)

'""''
Grow1J1 bom'IO!toe
Prol3cl.in

Stimul;at.;S S)'lltbesi.s nod scr:retioo oftest~eronc

(res1J.J)
Sti muta~.CS protein .$)11\hnis Md

Anterior J>iluilary flOut! Anterior pituitary Mammnry glands Anttrior pituitary

A.dtenn.l COI'tCX

ONernll g.rowtlt

Ssimubtt~ milk plodut;ll<'l :.nd bl'h$1 de-.'<lopmwt

..,"""".

Adrenoooctiootropk.
Mt!anQCYte~

Stimulates ~ynihes~ a.nl,) ~tiOt t>f adtcn:U

curticaJ hormones
Stimulllt~$

:\nterior pituit:al')' Stfl\

nehl.rti1l syp~l,l:$f,~

s,tim\lla.tint ll()nnOne

0leyl()Citl

P0$!1.'1i('W' pi111i~ry M~mmllly iJI<mlb.

U~llt smooth

Mtk ctiectlon
U~.erir..c conlrn~ioo

mustk
1\lltldil.lret!O bOI"DlCCIW PO$terKlt pitW'-'Iry Kid.oe)' tUb\l.les
(l'II;)IJIH'tfttJ

Stinwlwes w~tcr reabsorption by renal c:olle~:ung

du<l<

ALitJoth~

midiue

Cyclic GMP (cGMP) and cyclic AMP (cAMP) are second messengers that carry signals from the cell surface to proteins within the cell. These ''second messenger" molecules intervene between the original message (tire neurotransmiller or hormone) and the ultimate effect on the cell. Frequent ly, they act to stimulate protein kinases, and they are rapidly broken down in cells {to terminate respome) by enzymes called phosphodiesterases. Currently, four second messenger systems are recognized in cells. Note: Not only do multiple hormones utilize the same second messenger system, but a single hormone can also utilize more than one system. Important: Hormones that util ize second messengers are usually water soluble peplide/protein hormones.
Sttund Mcsseogu
t<:xa mpl~s nf Hormones T hat

UJt Thl5 ~y.nf'm

CyclioAMP

Epinephrir.t- and norepinepbri~. glucagon. luteinizing bom1onc. folliclestimulilfu8 bomW>ne, tbyroid-MimuJating h<>nnon~. calcitonin.. p.untbyroid hormone, ll.ltlidilatetic hormO!Ji.e

Protein kinMe BCtiVil)'

Insulin, growth hormone. prolactin,. ox.ytocm, l"1)'throp01etin, sevt:raJ growth

f~etors

Calcium and/or pboi:pho1nosi1e$

Epitl('rhrine a.nd ooreplnephrin.: .1ngjo.ensin 11. antidiwetic hormone. f:Ot13dotropin-rele3,1ins hormQon.e, tlaytOidorek<ssing homl(,>f'!C
Atrial nalllrt1.ic honnont

CycticGMr

-.,. I. Azidothymidine is a treatment for HIV. }lot.. 2. cAMP is fonned from ATP in a reaction catalyzed by adenylate cyclase. 3. Adeoylate cyclase is an integral protein of the plasma membrane.

GnocHEMISTRY 1 PHYSIOLOGY

Hrm)

Which of the following Is the best-known stimuli for increasing the rate of thyroid-stimulating hormone (TSH) secretion by the anterior pituitary gland?

Exposure 10 beat Exposure to cold Exposure to st ress Exposure to relaxation

91 Copyngllt C 2009-2010 Den11l Deck1

~IOCHEMISTRY I PHYSIOLOGY
Releasing hormones are synth esized in the:

Hrm)

Posterior pituitary Hypothalamus Anterior pituitary

Ovary

Cop)1i&}ll Cl 201*2010 t>tnW Dcds

Thyroid-stimulating hormone (TSH), also called thyrotropin, is secreted by basophils of the pars distalis of the anterior pituitary gland. TSH controls the rate of secretion of thyroid hormones (1/tyroxine and lriiodolhyronine). Thyroxine, in tum, controls the rates of many metabolic processes and the metabolic rate. Various types of stress can inhibit TSH secretion, most likely by way of neural influences that inhibit the secretion of thyrotropin-releasing hormone (TRH) from the hypothalamus. Remember: TSH secretion is stimulated by TRH. There are several negative feedback loops that regulate the secretion of thyroid hormones, including the following: I . High levels of circulating thyroid hormone decrcass the secretion of both TRH and TSH. 2. Elevated levels ofTSH decreases the secretion ofTRH. -----:. I. Hypersecretion ofTSH results in Graves' disease. Notes 2. Hyposecretion of TSH results in cretinism (in young people) or myxedema (in adults).

II~ pothal:tmus

The secretions of the anterior pituitary are oontroJied by honnones called hypothalamic releasing and inbibitory f9ctors, which arc secreted within the hypothalamus itself and then conducted to the anterior pituitary through minute blood vessels called 1he hyi)Othalamit-hypophyseal port:tl system. The hormones of the posterior pituitary (ADH and oxytoc:br) are synthesized in certain hypothalamic nuclei (wpraopUc and parawntricu/ur) or the br.tin, which contain lbc cell bodies of oeurosec.r etory cells. T hese honnones are then transported along the axons of the neurosecretory cells to the pars nervosa (posterior pituitary). Neural inputs to the brain influence the hormones' release.
llurmouw\ ulll!t
UOt'I:IIOotlt
ll\pnlh e~lanua ~

So.rte
H)l'IOtNllur.w

Trt.rt
Menoi'oypo)ph.)"SlJ

AtCII)IP(j)
Stlmu~ ~rtb>:lnorpwlb ~

GfO"oth bom'lCincRlt~bo!.l.OOIIC:.

(tomr:m.mpk.9
Hypolba:IOIIVS

IGRifJ
Grvwlh honr!ol\t

Adcoobypopb)sis
{II()WhlJI~J Adeoollypoph~s

ltlh1b1b SlrC:I'diOO orpW!h bnrmone

&!tul,iting~

(Gill)

Conloo1ropm~11Wf!li, bol!l)o)nl,'_

U)pnlhalan:ns

lmrlkotroplu/
llypcllhahm:u~ Adet~oll)'popb)S!J

Stirn~ <.l't'IJQn ofa..irel'll'IC'Oni<olroplle ~fACTI/)

ICIUIJ
Thynltropis:a-

17/!H)

rtittJ.!nt blrmxmc
llypnlbal:mus
n:lc~Wn&b.-om:lC'lle

(t.rr,r(fli'CfJM
.Aden~)tiS a._,.,;..,

llotn'lonc n$H) a~ pr1>l.ctin

Sflmu~ Srttl!On or1hyf\l'id~limul.:ttins

Ckluadocrop.a.
(ONRJ/)
l'~Jn Rlt~i-~"IKII\C.

Sc;muk1C':t rtlem.ofFSIJ ~tnd Lll

U)'fl(llhalarcw

Adenollyp;Jih)'5is
(~l.:()lropiu}

Slirnul:ues 5ttlp)tj ofprolettm

fPRif)
Pmt:..:tm~

ll)f~lhalomus

tnlubtlot libn'nonc'
(1>111)

AdC'IIOIIypopll)ti.IJ (~lrJJ

lnh:.bio ~ion orpml-"l::itl

GnocHEMISTRY 1 PHYSIOLOGY

Hrm)

Wbieb of the follo,.ing are produced and rei used by the posterior pituitary?

ADH
FSH Oxytocin
Prolactin Two of the above None of the above

Copyrijbl 0 20092010 Oenul Dh

"

&IOCHEMISTRY I PHYSIOLOGY

Hrm)

,
I

\..

All of the following are factors that decrease insulin secretion EXCEPT one. Whleb one is the EXCEPTION?

Decrease in blood glucose level

Secretion of somatostatin
Secretion of glucagon Secretion of either epinephrine or norepinephrine

100
Cop)TIIht 0 2009-20 I0 Dental Decb

~une

nt tlu. ahoH

Oxytocin is secreted by the posterior portion of ihe pituitary (!leurohypop/zysis) in response to dilation of the cervix and to suckling. Oxytocin stimulates the smooth muscle of the uterus. Oxytocin also promotes the contraction of myoepithelial cells surrounding the sac-like alvC()Ii o f the mammary glands, resulting ln the ejection of milk during breast-feeding. Oxytocin re lease causes a positive feedback mechanism to begin. Uterine cont ractions push the fetus against the cervical opening, which ca.tscs more oxytocin to be secreted. Tbe rise in oxytocin causes greater uterine contractions, and the cycle continues until parturition is complete. Remember: Although both ADH and oxytocin are stored and released from the posterior portion of the pituitary (.pecificall;'. tire pars nervosa). neither hormone is produced there. These hormones arc manu facturcd by the hypothalamus, specifically the supraoptic lllld paraventricular nuclei. l. ADH decreases the production of urine. hy increasing the reabsorption Note< of water by the renal tubules (ADH increases the water permeability ofthe collecting ducts and distal tubules). Without ADH, there would be extreme loss of water into the urine. 2. FSn s timulates growth of ovari an follicles and estrogen secretion. FSll Also promotes sperm maturation (in the testes). 3. rrolactin stimulates milk production and breast development.

Sl'CTrlion nr l!IUCiiJ!On

*** Tite secretion of glucagon causes an increase in insulin secretion.

Insulin is secreted by the beta cells in the islets of Langerhans of the pancreas in response to a rise in the blood glucose level. lusuliu causes glycogenesis in the liver (conversion of glucnse to glycoge't) . Insulin lowers blood glucose levels by stimulating and facilitating the uptake of glucose and the utilization of glucose as an energy source by many cells. Insulin also promotes the symhesis of glycogen, ll'iglycerides, and protoins. Insulin release by the beta cells Is promoted by the following: A rise in blood glucose !~v el (hyperglycemia) - this is the major factor govemlug insuliu release. Elevated level of amino acids (especianv arginine, lysine, and leucine) In the blood plasma. Glucagon, Gl:l, and cortisol. Plll'8$ympathetic sti mulatlon. Note: Sympathetic stimulation or epinephrine inhibits insulin release, lruportant: Insulin Inhibits lipolysis (ir enhance$ triglyceride synthesis) and stimulates protein synthesis (Inhibits protein breakdown). In other words, insulin conserves proteins, carbohydrates, aud fats in the body. The removal of the anterior portion (adenohypophysis) of the p\tuitllry gland res11lts in increased scnsitfvily to insulin. Clinical manifestations of hypogly<eml inclllde: hunger, nervousness. and shakiness, perspiration. dizzinesS' 0( light-hcadcdncss, sleepiness, confusion, difficulty speaking, nnd feeling nn,'lio11s or wealL lruportaut: Seizures can occur as a result of severely low glucose level~.

(BIOCHEMISTRY I PHYSIOLOGY

Hrm)

(
\..

Glucagon has all of tbe following actions EX CEPT one. Which one is the EXCEPTION?

Increases plasma glucose Increases plasma free fatty acids and ketoacids Decreases plasma am ino acids Increases urea production

101 C<:lp)TightO 20092010 Oental D:ks

~IOCHEMISTRY I PHYSIOLOGY

Hrm)

\..

Which of the following is not secreted from the duodenal segment of the small intestine?

Cholecystokinin Gastric inhibitory peptide

Gastrin

Secretin

102 Copyright C 2009201 0 DctnaJ Deets

Ol''-'rl':tsc."i pltpr;ma ~u ninn acid.;

*"* Important: l flll~lin, not glucagon. decreases plasma amino acid. The most important funcUon of glucagon is its ability to cause glyco~enolysis (con, crsion of glytug~u It) glucose) in the liver, which, in turu, Increases plasma glucose. For thrs rea~oo, glucagon is found in emergency medic.al kits. It can be used on an emergency patient who has diabetes and is suffering lrom hypoglycemia. Note1 It does not ~timulate glycogen degradation 111 muscle. Glucagon is secreted by the alpha cells in the islets ufLaugerbans of the pancreas in respouse to a fall in th~ blood glucos level. Glucagon is frequently called the hypcrglyce111ic factor. Glucagon has many of the opposite effects of inst1lin. Nolet Insulin is secreted in response to a rise in the blood glucose level ~nd causes glycogeneJ;is in the liver (conVel'Sion ofghtcose to glycogen). Glucagon release &y alphu rell~ f~ promoted by the following~ A fall in blood glucose Jevel (hyp,>glycemln) - this is the major rrgulator of glucagon releqse. Sympathetic Stimulation Epinephrine, norepinephrine secretion Elevated level of amino acids (especially arginine) in the blood plasma Cholecystokinin secretion Factors tbat decrease glucagon secretion a rise ln blood glucose level, insulln. somatostatin, free fattY acids. and ketoacids.

Gashin

The following are secreted from tbe duodenal segment of the small intestine: Secretin: the small intestine is periodically assaulted by a nood of acid from the stomach, and il is impot1ant to put out that lire iu a hurry to avoid acid b~ms. Secretin functions as a type of firefighter: secretin is released in response to acid in the small intestine, and stimulates the pancre~s to release a flood of bicarbonme base, which neutral izes the acid. Secretin has the following functions; Inhibits stomach motility and gastric acid secretion. Stimulates the pancreatic duct cells to secrete a fluid that contains a lot of bicarbonate ions but is low in enZym~s. Stimulates the secretion of bUe from the gallbladder. Cholecystoklniu ph1ys a key role in faollilating digestion within the small intestine. Cholecystokinin is $CCreted from mucosal epithelial cells in the first segment of the small intestine (c/uodenum). and stimulates delivery into the small intestine ofdigestive enzymes (trypsin, chymollypsin, ond mrboxypeptidase) from the pancreas and bile from the gallbladder. Cholecystokinin is nlsopmduced by neurons in the enteric necvou.~ system, and is widely and abundflJitly distributed in the bruin. Gastric inhibitory peptide (G!P) is a member of !he secretin family ofhom10nes. GTP was di~covcred as a factor in extracts of intestin.c that inhibited gastric motility and secretion of acid, and initially called enterogastrone. Like secretin, GJP is secreted from mucosal epithelial cells in the first part of ihe small intestine, Gastrin is a major physiological regulator of gastric acid secretion. Gastrin also has an important ti'Ophic or growth-promoring ioflueuce on the ga<tric mucosa. Gastrin is syn t~esized in G cells, which !lrc.locatctl in gastric pits, primarily in th~amrum region of the stomach and binds receptors found predominantly on parietal and enlerochromaff'Ul like cells.

~IOCHEMISTRY I PHYSIOLOGY

Hrm)

The enterogastrlc renex, which is initiated when the duodenum Oils with - -- -- - ' inhibits the "pyloric pump," thereby inhibiting gastric motility and emptying.

Bicarbonate
Acid chyme Enkcphalins

Water

101
Copyn&}lt 0 200920 1 0 Dt"aJ lkcts

~IOCHEMISTRY I PHYSIOLOGY
Which of the following is not true involving aldosterone?

Hrm)

Causes Na retention Causes K excretion

Renin controls

i1

Acts at the distal tubule Is produced in the kidney

,,.
Cop)Tisbl 0 20092010 lkntall)re:\s

Acid Ch) llli..'

As acid chyme enters the duodenwn, the decre~sing pH inhibits gastrin secretion and causes the release of negative or "stop signals in the duodenum. These take the fomt of chemicals called enterogastrones, which inclt1de GIP (gtlstric inhibitmy peptide). GLP inhibits stomach secretion and motility and allows time for the digestive process to proceed in the duodenum before it receives more chyme. The entcrogastric reflex also reduces motility and forcefully closes the pyloric sphincter. Evontually, as the chyme is removed. the pH increases, and gastrin and the "go" signal resum~s. and the process of digestion occurs all over again. The process of"go" and ''stop" signals continues until stomach emptying is complete. Important point: Enterogastrones are released by the small intestine in response to the acidity of the duodenal chyme and the presence of amino acids and free fatty acids in the chyme.

***This is false; aldosterone is produced in the adrenal cortex. Aldosterone is the principal mineralocorticoid and is secreted by cells located in tbe zona glomerulosa of the adrenal cortex. Aldosterone promotes reabsorption of sodium into the blood rrom tbe glomenlar filtrate. Potassiwn is lost in th~ urine. Note: Increased blood aldosterone levels will result in high plasma vohune and low potassitun levels in the plasma. The major target of aldosterone is the distal tubule of the kidney, where aldosterone stimulates exchange of sodium and potassium. Three primary physiologic effects result: Increased resorption of sodium: sodium loss in urine is decreased under aldosterone stimulation. Increased resorption of water, with consequent expansion of extracellular fluid volume. TI1is is an osmotic effect directly related to increased resorption of sodium. Increased renal excretion of potassium. Tbe two most significant regulators of aldosterone secretion are: I. Concentrations of potassium ion in exbacellular fluid: Small increases in blood levels of potassiwn strongly stimulate aldosterone secretion. 2. Angiotensin Jl: Activation of the renin-angiotensin system as a result of decreased renal blood flow (cwally due 10 decrellsed vascular volume) results in release of angiotensin 0 , which stimulates aldosterone secretion. Important: Decreased sodium concentration causes the juxtaglomerular cells of the kidneys to secrete renin, which converts angiotensinogen to angiotensin L Angiotensin I is converted to angiotensin II, which, in rum, stimulates the adrenal cortex to release aldosterone. Note: Addison's disease is caused by the hyposecrefion of aldosterone and cortisol.

~lOCHEMISTRY I PHYSIOLOGY
(
Oral contraceptives work by:

Hrm)
)

Inhibiting follicle fonnation by elimioaliog the LH surge Inhibiting ovulation by eliminating the LH surge Inhibiting follicle fonnation by eliminating the FSH surge Inhibiting ovulation by eliminating the FSH surge

105 Cc>p)'riihl 0 2009-20 I 0

Dtn~al

O:l:s

~IOCHEMISTRY I PHYSIOLOGY
Which of the following is not found in the thyroid?

Hrm)

TSH

TRH

Tyrosine

106

Copyri,gbt 0 2009-2010 Denial Dccb

lnhihhiug o\ulaliun h~ eliminating thll.lt surg~

Oral contraceptives ("the pill") are pills consisting of one or more female sex honuooes taken by women to prevent pregnancy. Most oral contraceptives are combined pi lls that contain synthetic estrogen-like (ethynyl estradiol and mestranol) and progesterone-like (norethindrone. norgesrtel) substances. These synthetic hormones apparently prevent the rise in luteinizing hormone. This, in tum, prevents ovulation. The exact mechanism is thought to be as foUows: ln the presence of either estrogen or progesterone (or a synthetic s ubsritme), the hypothalamus fails to secrete the norm:U surge of LH-releasing factor (also called gonadotropin-releasing factor). This then inhibitS t he release of luteinizing hormone from basophils of the anterior pituitary gland. Subsequently, ovulation does not occur. 1. Ovulation occurs as a result of the estrogen-induced LH surge. Notes 2. Unlike other steroid hormones, all estrogens have an aromatic A ring.

TRII

Thyrotropin-releasing hormone (TRH) is a hormone released by the hypothalamus thai communicates with the pituitary gland and stimulates release of thyroid-stimulating hormone. Thyroglobulin contains ioclinc, which is attacned to tyrosine molecules. The follicle cells of the thyroid gland synthesize thyroglobulin and secrete it into the colloidcontaining regions of the follicle$. Here" the thyroglobulin ttndergocs iodination and coupling processes that produce the thyroid hormones, thyroxin e (T,J and triiodothyronine (Tj). The thyroglobulin molecules containing these hormones are then stored in the colloid-colltaining regions of the follicles. When the thyroid is actively secreting, these thyroglobulin molecules arc then taken back into the follicle cells and broken down into the two honnones, thyroxine (T,J and triiodothyronine (Tj. Note: Normally, T4 concentration in the blood is approximately 20-fold greater than the concentration ofT3. However, T3 is approximately five titnes more physiologically potent than T4 , and can be fonned by removing one iodine atom from T 4 . These hormones (mostly thyroxine) enter the bloodstream aod produce tbe following actions: Important for normal growth and development (especially the brai11) Afl'ect many metabolic process es and the metabolic rate lncreasc oxygen consumption and beat production Note: A dietary iodine deficiency will increase the secretion of thyroglobulin (as opposed to th)roxine, Jriiodothyronine, or TSH).

~IOCHEMISTRY I PHYSIOLOGY

Hrm)

\..

Which amino acid is taken up by chromaffin cells in the adrenal medulla and converted to hormones?

Alanine

Tyrosine
Proline
A rginine

107 Copyn&flt 1010092010 Dental Decks

~IOCHEMISTRY I PHYSIOLOGY

Hrm)
~

A All of the following are affected by epinephrine and/or norepinephrine \

\._ EXCEPT one. Which one is the EXCEPTION?

..J

Blood glucose Total peripheral resistance

Heart rate

Kidney function

108 Cop)TightO 200!MOIO Dcotal Dtt.b

I~ rosine

***Tyrosine is converted to epinephrine and norepineplnine. Secretion of these bonnones is stimnlated by acetylcholine release from preganglionic sympathetic fibers innervating tbe medulla. Common stimuli for secretion of adrenomedullary honnoncs include cxe.rcise, hypoglycemia, hemorrhage, and emotional distress. Following release into blood. these hormones bind adrenergic receptors on target cells, where the ltonnones induce essentially the same effects as direct sympathetic nervous stimulation.
Outside~ the nH,ous system, norepinephrine and its methylated derivative epinephrine act as regulators of carbohydr~te and lipid metabolism. Norepinephrine and epinephrine increase the degrodation of triacylglycerol and glycogen as well as increase the output of the bean (specifically. epineplrrl11e) and blood pressure. These effects are part of a coordinated response to prepare the individual for emergencies and are often called the "fight or night" reactions. Norepinephrine can be released in 2 ways : By the adrenal medulla into the bloodstream (as discussed above). Directly onto au urgan by a postganglionic sympathetic (adre11ergic) neuron that stores norepinephrine.

i mportant: Tbc effects arc more widespread wben norepinephrine is released into the bloodSU'eam by the adrenal medulla as opposed to directly onto an organ by a postganglionic sympathetic neuron.

l'idnc~

function

The adrenal medulla is a specialized ganglion of the sympathetic uervous systom. Preganglionic fiber:; synapse directly on cbromaflin cells in lhc adrenal mc~dulla. These cells secrete epinephrine (80%) and norepinephrine (20%) into !he ci rculation. Both of these honnoues are water-soluble, direct-acting adrenergic agonists and are bi<,synthcsizcd from the amino acid tyrosine. Water-soluble~ hormones cannot pass through the plasma membrane and must have a plasma membrane receptor. Epinephrine (adre11aliu) has the following effects: Stimulates glycogenolysis and gluconeogenesis, which tend to raise blood glucose levels. Also stimulates lipolysis in adipose tissue (break-

down oftriglycerides into glycerol and fat(v acids)

Increases the rate, force, and amplitude of Ibe heartbeat Constricts blood vessels in skin, mucous membranes, and kidneys Dilates bronch ioles in the lungs and r elaxes bronchiolar smooth muscle Activates muscle g lycogen phosphorylase Norepinephrine (11aradrenalin) bas tbe following effects: Increases tbe heart rate and tlte force of contraction of heart musc le Promotes lipolysis in ad.ipose tissue Constricts blood vessels in almost all areas of the body, thus increasing total periphera l resistance

~IOCHEMISTRY I PHYSIOLOGY
Parathyroid hormone causes which of the following to occur?

Hrm)

Removal of Ca via the kidney Removal of Ca from bone Removal of Ca via the Gl system None of the above

101

Cop)TighcC 2(109.2010 Dcnt.tl Ottkt

GnocHEMISTRY 1 PHYSIOLOGY

urm)

Which of the following hormones' secretion is stimulated by stomach distention?

Gastrin
Cholecystokinin (CCK) Secretin Gastric inhibitory peptide (GIP)
All of the above

110 Oilp)1i&b'O 2(109.2010 Dmtal 0-b

Rl'OIO\ al

of C:t from hone

Parathyroid hormone (PTH) is secreted by chief cells in the parathyroid gland in response to decreased plasma-calcium le\els. The plasma-calcium level is the major controller of parathyroid hormone secretion. PTR is a principal controller of calcium and phosphate metabolism and is involved in the remodeUng of bone. PTH increases the plasma-calcium concentration and decreases the plasma-phosphate concentration. PTH has three modes of action: I. Increases calcium removal from s torage in bone and increases absorption of calcium by intestines, increasing blood calcium levels. 2. Acts on the kid neys to decrease calciwn excretion and increase phosphate excretion in the urine. Also stimulates !-alpha-hydroxylase in the kidneys. 3. Increases the absorption of calcium in the OJ tract. I. Hyperparathyroidism (von Recklinghausen ~ disease) causes extensive INot.. bone decalcification and is marked by extremely high blood calcium levels and low blood phosphate levels. This leads to muscular weakness. 2. Hypoparathyroidism (tetany) causes decreased bone resorption, decreased renal Ca>- reabsorption, increased renal phosphate reabsorption, and decreased production of the active form of vitamio D (1,25dihydroxyclrolecalcifero/). Together, these effects decrease serum calcium and increase serum phosphate.

::::-:-:J

***A diet deficient in calcium will result in production of PTii and bone resorption.

Ga~trin

Gastrin is a major pbysiological regulator of gastric acid secretion. Gastrin also has an important trophic or growth-promoting intluence on the gastric mucosa. Ga.-<trin is synthesized in G cells, which arc located io gasnic pits, primarily in the antrum region of the stomach. and binds receptors found predominantly on parietal and enteroclu-omaffin-like
<.lllurmonc~

tlonnou~

Sour

Sl:lnull ror ~tlese

f"tes~:rwc af ocrta1 n food.~ruO$, Stam:.~::h

At.tlonCs)
Stitnub:tcs gastric acid $W~tion

Gastrin

G etlls~ wtleh are

located in-gastric pits.. pri.marily in tbc IUitrum c:specially pc-fMides, tt&ion of the ~!Om;&t;b <ertlun ltmioo
acids, ~n(l t;:d!1.'11Jm

moliUiy

m r.bc gostric lumea

Cholccyslokinin

Mucosal epithelial ccJis l'n-$L'1Wr'A! of fat ty in lhc 1luodcmnn ;ICid:l. nnd amino :acid$ in tile $11'11111
fn:leStinc

Prin<apa1stimulus tGr the delivery of p11ncreatic cozym."S and bilt il'!\0 lhc $mnll intcli.linc:

Secretin

cpi!l1i!lh ll <:~It\ Acldific:utJuo oflbc in lhc duodenum duodenum

Muros~~l

Ptincrpal stimulus l()f the p:tsM:~ IQ SCCt~W :1 bie.arlx>nllh~ncll OuiJ. which neutralizes lhc acid

Gastric inhibiiOI')' Mu...--osal epilhcli:d ~;dl:s Pn:s~.: ortat Md pqni<k in the duodenum ehw:oM""in ll'lc llmlln

Inhibits ga.<i.uie $~o--cretioo :u1(! mNility l!:nh;mc:cs llsc release ofinsulin il'l tespoos<: Cl,'l
inf~ioos M glu~

--

Intestine

1. Tho five C-tenninal amino acids of gastrin and cholecystokinin are identiNotes cal, which explains their overlapping biological effects. 2. Excessive secretion of gastrin. or hypergastrinemia, is a well-recognized cause of a severe disease known as Zollingcr-Ellison syndrome.

GnocnEMISTRY 1 PHYSIOLOGY

Hrm)

Which Gl hormone has been referred to as glucose-dependent insulinotropic peptide?

Gastrin Gastric inhibitory peptide (GIP) Cholecystokinin (CCK)

Secretin

111

Cop)'ligbi C 2009-2010 Dental Ottb

~IOCHEMISTRY I PHYSIOLOGY

Hrm)

~tumor of the adrenal gland is causing your patient to conserve sodium;:the renal tubules causing increased blood volume, pressure, and edema. Where Is the location of this adenoma?

Zona glomerulosa of the adrenal cortex Zona fasciculata of the adrenal cortex Zona reticularis of the adrenal cortex Adrenal medulla

112 Copyright 0 2(109.20 I0 l)cntlll Dcd&

**"Another activity of GIP is its ability to enhance the release of insulin an response to infusions of glucose. Gastric inhibitory pepllde (GIP), like secretin, is secreted from mucosal cells in the first part oftlte small intestine (duod~mm). GIP inhibits gastric acid secretion (HCL) and gastric motility and potentiates the r~lease of insulin from beta cells in response to elevated blood glucose concentration. Note: GIP was initially called enterogastrone (which now refers to tlte group ofetrterogastric inilibitory hormones liberated from the duodenal mucosa).
---. I. GIP tS synthesized by K cells. whtch are found in the mucosa of the duodeNotes num and the jejunum of the gastrointcstmaltract. Like all endocrine hormones, GIP is 1nnsponed by blood. 2. GlP is also thougbtto have significant effects on fatty acid metabolism through stimulation of lipoprotein lipase activity in adipocytes. 3. Gastric inhibitory polypeptide receptors are seven-transmembrane proteins found on beta cells in the pancreas. 4. ll h:li been found that type 2 diabetics is not responsive tC> GIP.

/.on;t r:.t":h:ul.ll.t

u(

tin adren:ll cnrh'\

U ormnnr. uf llh \1IHn.tl (,I& nth

Htnnoat
AldoSI.crone

Sortt

(u,fln J:{QmN"t;/(Jfa)
Adrennl concx

Adrtnll OCX1~

Kidney

T""'"

Actionhl
SI!MIII.a'c:t tid.ney tubules to ~lCJ"\c .001un,, '"htrh., tn hrm, tnggm the relta.~ or ADII ilnd the rtlluhtng

conservation of watc.rby chc kidney

Coni.sol

GcoUlll

(:onafa.sdl'Uinta)
Adrenal andfOIItM Adl'l'nal c>OI1Cll (:tJMU rt'linllori:l)
Admlol.,_.,. E91~
"Sort'plfK'I'I'hl'ine St:x Ofi'UIS

Jromolcll gloconrogcnesis, lirol!'~'" 1111d pfOIOOI)'Sts, immun<xruppresslon '" larae ~moonts.lt has an antllntlamnu.tary ciTete
Exct role unOffi.Aln. but may support u:<u31 furiC'Iion

OOerdrmn

Adnonal eann
(:tiM rtti!Cfllo.rl$)
AdmW~Ja

Scot~"""' effectors.
Sympa~k

ThousJ>Iro be phy<;otog;caOy =!IJDf"""'

Enhanots and pto1or:gs W dTt"tU oftht t)mplllhdlC dt\'l<ion of the aU'lOOOft'Uc nmOUi S)'Sltm
Fnt!anon, and prolongs the efTrcts of the ~)'mpathec l( d1v1~ion of ~ auonomic nervous ~yscc:m

Adrmal medulla

efl"ectof'l.

Important point: Cortisol (glucocorricoid) lnOucnceJ carbohydrate. lipid. and protein metabolism. Glucocorticoids promote gluconeogenesis by inducing ;ynthcsis of ohe en2ymc phosphoenolpyruvate carboxykinnse (PEPCK). --. I. The mineralocorticoid aldosterone and the glucocorticoids are collectively .'lotos called the corticosteroids. 2. Cortisol and aldosterone arc produced from progesterone.

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I"Cortisol is the primary glucocorticoid produced by the adrenal cortex gland.~

Cortisol's principal physiological actions include all of the following EXCEPT one. Which one is the EXCEPTION?

Increase hepatic gluconeogenesis Increase hepatic glycogenolysis Increase protein catabolism Stimulation of fat deposition and inhibition of lipolysis Inhibit ACTH secretion (negative feedback mechanism) Maintenance of blood pressure by sensitizing arterioles to the action of noradrenaline

Renal excretion

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~IOCHEMISTRY I PHYSIOLOGY
Which hormone is often called tbe " stress hormone"? Growth hormone (GH) Thyroid-stimulating hormone (TSH) Adrenocorticotropic hormone (A CTH) Follicle-stimulating hormone (FSH) This hormone stimulates tbe excretion of: Cortisol Adrenalin Aldosterone Two of the above
114

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Stirnulatinn nt fat dl'IJn"'ifiun and inluhitmn nf lipoh'i\ ... This is false; glucocorticoids (mainly. cortisol) promote mobili.rolion of fany acids from adtpose rissue and stimulate lipolysis.
llnnlliiP\' IIMI \fhtl \ltl.lhuh'm

Bormonb

Met boll< EffctiS

Jlromotcs: Glucose uptake into cells Amino acid uptake imo cells Gl~ogenesis, Lipogenesis lnh1b1u: Lipolysis. procein synthesis Ptomocts: Glycogenesis. g.Juconeoscncss.. protc'm synlbesis

Insulin

Glucapland tpincphrio<
Tbyroxjne

Promot.-.: Glycogenolys,.,J!)~mesis. lipolysis

Gro-.'th honnonc Pro moles: Amino add uptake uuo cells., prutcin synthcsis.glycogaJoly.)n. hpoi)'SJS

Coni sol

Promolcs: Gluconeogenesis, hpolysis, breakdown of protein

Testosterone

Promotes: Protein synthesis

Remember: Cushing's syndrome is a metabolic disorder resulting from rhe chronic and excessive production of cortisol. The mos1common cause of this syndrome is a pituitary tumor that causes an increased secretion of ACTH.

1. \dn.nw;u1 t ll'UI rupic honnOill' f I ( IllJ 2. ( urti,nl

ACTH secretion is controlled by the hypothalamus, to which the pituttary gland is attached. When the body is stressed, corticotropin-releasing hormone (CRJI) produced by the hypothalamus travels through a portal system to the anrenor lobe of the pituilary, where the hormone induces the production and secretion of ACTH by the basopbils of the pars distalis. ACTH in 1 um stimulates tbc adrcnul correx to synlbesize and secrete cortisol. ::::\ l. The secretion of aldosterone from the adrenal cortex is induced not by NoW. ACTH but by the elevaled plasma potassium and by angiotensin. Aldosterones p rlmaryeffe<:t is on the kidney tubules. where it slimulares sodium rcteouon and potassium excrelion. 2. Analysis of ACTH is used as an indicalor of pituitary function and is useful in the differential diagnosts of the foUowing: Addison s disease, congcnilal adrenal hyperplasia, and Cushing's syndrome. 3. ACTH deficiency is characterized by adrenal insufficiency symploms such as weight loss, lack of appetite (anorexia), weakness, nausea. vomiting, and low blood pressure.

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r
\..

Cortisol (hydrocortisone) has a direct inhibitory effect on wh ich two structures?

Adrenal conex

Hypothalamus
Anterior pituitary gland Posterior pituitary gland

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Which of the following hormones are/Is secreted by the placenta?

Testosterone Progesterone

Estrogen

Human chorionic gonadotropin (hCG)

A II of the above

Cop)-nibt c 2(1(19..2010 Dmtal Ort<:b

...

II~ pnlh~1k1mu'

Anterior piluitar~

~land

TI1e release of cnrtisol is controlled primarily by ACTH, which is secreted by basophils in the pars disrnlis of the anterior pituitary gland. The release of ACTH, in tum. is influenced by corticotropin-releasing honnone (CRJ/) from tlte hypothalamus. Cortisol exerts an inhibitory Influence on botb ACTII and CRll release by way of negative feedback. Feedback circuits arc at the root of most control mechanisms in physiology. and are particularly prominent in the endocrine system. Instances of positive feedback certainly occur, but negative feedback is much ruore common. Negative feedback is seen wheu the output of a pathway inhibits input to the pathway. The heating system in your borne is a simple negative feedback circuit. Wben the furnace produces enough heat to elevate the temperature above the set point or the thermostat. the thermostat is triggered and shuts off the furnace (heat i.l feeding back negatively on the source of heat). When the temperature drops back below the set point, negative feedback Is gone, and tbe furnace comes back on. Cortisol is the main glucocortlcold produced and secreted by the cells of the zona fasciculata in tbe adrenal cortex. Cortisol allows glucagon and epinephrine to work more effectively at their target tissues, but aotugonl~es the actions of insulin. Glucocorticoitls have and-inflammatory effects. suppress the immune system, and influence metabolism by causing the movement of fuels from peripheral tissues to tbe liver, where gluconeogenesis aud glycogen synthesis are stimulated. lmporiani: A patient taking cortisol for a long period of time may experience atrophy of the adrnal cortex due to inhibition of ACT!! production.

II um01n ,horionic ~onadolropin (IICtiJ "** Human chorionic go nadotropin (hCG) is produced by lbe placenta and stimulates the corpus luteum to produce estradiol and progesterone.
llormonl''> nr Otlwr i\l.tJnr t- otJncnnl' t .t:.md!~. ftl)rmont
T~~1crooc: Sourc~

'ra!llCI

Acllonls)
Spc:nnntogcqesi.$~ m:s:le SN:onda.ty lt.'

TC'sl.is

Spc-tnllli.c,gmic cells

Mw..;le.
B~t1$$uc:.

charncsttistics

01 hCt tissues
EsttU~O

Ovt1tn1n

follicl e:~

UICJU!:
~1QmtOIIt)' :glllnch

Urow'th and <f.e\!elopment of fem~~te reproductive org.an.i

Oil~ Pl~tmmc

tissues

follicular phn.sc- of mt"n:S11Uill cycle

Malnl:nnS (nlong with estrogen/ du: lining: of the uterus nec.essary fur MJc~.~n.l preJ;niint)'

CCirpus luteum

Utcrufi
0Jhcr tissues
Ovary

(Iuman ' cltorioni!i1 Cborioo (/nal

gOnl\dOt~tn
/iS)11C COfllfNJflf'lf(

111cruscs c:;lrogen tt11d rwuestemne $Yflthesis

by !he C>Orpu.$ lutl."um

(/oCG)

ofrhe- plnrenta)

esrrogen), aud follicles. The corpus lutcum is a yellowish

The ovaries of a female produce ova, the tntal sex hormones (progesterone and mas~ of cells that lbrms from an ovarian follicle after the release of o matme egg (ovultuiun). If the mature egg is not fertilized and pregnancy does not occur, tbe corpus luteum retrogresses to a mass of scar tissue (corpus albicans) which eventUally disappears. If the mature egg is fertili~ed and pregnancy does occur, the corpus lutown does not dege.nerate but persists for several months.

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Secretion of growth hormone is increased by all of the following EXCEPT one. Which one is the EXCEPTION?

Sleep Stress Obesity Starvation

Exercise
Hypoglycemia

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Somatostatin acts by both endocrine and paracrine pathways to affect its target cells. A majority of tbc circulating somatostatin appears to come from the - - - -- - - - a n d

Gallbladder, large intestine

Pancreas, gastrointestinal tract

Stomach, adrenal medulla Bladder, small intestine

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 Secretion of growth hormone is decreased by somatostatin, somaroiTiedfns, obesity.

h~perglycemla, und pregnancy. Growth honnonc Is a protein hormone of nbout 190 amino acids that is synthesized and secreted by cells called somatolrophs in the anterior pituitary. Growth hormone is a major participant iu control ofseveral compltx physiologic processes, including groW1h and metabolism. Physiologic Effects of Growth llormote -two distinct rypes of cffccL" Direct effec.ts .are the result of growth honnone binding its receptor on target cdls. Fat cells (adipocytes), for example, have growth honnone receptors, and growth honnonesimulates them to br<'llk down triglyceride and sttppresses their ability to tnke up and accumulate circulating lfpids. lndlrect effects are mediated primarily by insuliu-like growth rnctor-1 (IGF-1), a hormone hat is secreted by the Hver and other tissues in rC.<ponse to growd\ hormone. A mnjor ity of the growth promoting effects of growth hormcme is actually due to IGF-1 acting on its target cells. Production of gro\\111 honnone is modulated by many fa~tors. includihg stress, exercise, 1tU trition, sleep, and growth hormone itself. However, it' prin1ary controllers are two hyrothalrunic hormones and one hormone from the stomach: Growth hormone-relea,\ing hormone (GHRHJ is a hypmhalomie peptide th;;t stimulates both the synth.,is and sec_retion of growth hormone. Somo111sttin (SS) is a peptide produced hy several1issues in the body, tucluding the hypOthalamus. Somatostatin inhibits growth honnone releaae in response 10 GHRii and to other Stimulatory factors such as low blood glucose concentration. Chrelin is a peptide hormone secreted from the stomach. Ghrelin binds to receptors on somatotrophs and potently stimulates secretion of growth hormone. Growth hormone nnd ersecretlon produces pllullary dwarfism in children.

Ovcrsecretiou of growlh honnone causes glguntlsan in children or. ln adults. ac-romegaly.

SortUltostatin was first discovered in hypothalamic C$;t{ael." ~d 1dt-nrificd a.~; a homrc,ne lhatlnhlbite<J sel'rt hon of growth hormon~ Subsequently, s.omatO$tUin \\3~ fu110d 10 besette:ted by a broad rnnge of tissues, m eluding: the paocrcas, imestinal frtiC1 1and regions oft be cenml nci'V<l\IS sys.tem outside the hypolh:tlnmus. Somatostatin acts by bolh ~ndoalne and pamcrme p3thwayll t\1 p.tyccl irs largcl cttls. A maj,,ril)' orLhc cis~u tahng somato$1llttn appear.$ 1o come from the pan~o-reas 11nd ~suolnteslina' traet.lf Me bad to summ.-.ri7c the effec1s afsomMostarin fn one phrnsc. it would be: .._so mato~u&Hn fnhlbiu the mrttinn or U12ir'IY ull\tr hur mmn'S."'

Effect.'\ uf l><)mamstatin:
Inhibits th.e scc.relio11 of growth hormont from the ritu1tary gland Jobibil:S the stcretion or both insulin llOd glucagon .. loblblts the secretiPn of mnny of the other Gl hormoneS;, including g>lltnn, c:holec)'SlOklnin. !lecrt:tin, and vasoactive intes.tlnul peptide
l',lll(n:IIIC I ru!nCrtl! \ llurm+lll\..,
Uern.o~ Pt1i'p~

M~~A

C!u,Q!Wll

~~\11 ):1\Uii:n in rc-&WJtins blond~ ;n tht.IIQmUII

Faro:. IlDDY tl!lb \11

~~~G~

'""""'
So!~\Dh1

"'""'

IU!'\iWc: b)i!Gd ,:u~:~-. Ul fie: fflm::t ttllll)' ec:lb

DOmraJ rang!!.
lh:)l~l...:

tMclttaul UK IJ_uocec
SllrM~lwn

.,,....

.Sf("'' f4 tn

ft~Mt i.O l~' blood

-...
lohlbW;!Ct by

Olwait [lvc
IObC!ftdb U

Dl~~

Ac:tlon

.Ac:Uoa

"'-

&u.ero

Ulgbtolood

lf_y[',~)'t"CCI~ H,.r-1trc~~

Hl,thbl~

''"""'
t..wblbl:'!d

l)l!l~t

llm~ti)'Odnil
f);l!;e~ei

l)n:; JllodUI.'U&Jfl Rn.cl

Hteh lc:Yillt
11fU1l:ntmolocrfM

"mri1m flf tlfher fl!doxnn~ hormone'

l'f'Oolnatiun or im:ulln
&J~IA, gaatrill..and d blft'mdoamc

bunoone.. fOOCi m !be

.:.IOCI..tb An4
11\to!lilltl-

OaUrio

AUbl in dl5dlfi ~lflio Itt~lvn~cb

""""""'

. """"""'
ot(liber

~~~~c:

t,.,.,.. ll:.,.el"

~..":yllrillld'l

....,.,_
P~{f 6dJnL-d St<lhW.O:~IM~

1111>1~ :aad)rid'billi:IIJ

1\bsmOI!{If

~IU-ohlc ~110 ~..td

ll>od
il(l!l\1\.tlaud

V~i~

H~lpCQIIt''l ~ ~IOfl
&r~d llb~llllfl (flX'Il d_t.

.,. .;'61

c.....,. ~tln.t:(lt
ti)~4'1.WJ:I!f"''d &l)l) ~Milfb;~jDt

\lnel0r

'"'"'""'
li!Kie

t-o~O'!OS

"tY(:fe-.. 0~

l"'t-

iQtttl.inu

diArtMa 11116 Ulf U:nbl!l.ukt

(BIOCHEMISTRY I PHYSIOLOGY

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Prolad in is said to be under "predominant inhibitory control." Which of the following explains why?

In normal conditions, prolactin is constantly synthesized in the anterior pituitary. Only when prolactin is not needed does the inhibitory mechanism kick in . In normal conditions, prolactin inhibitory factor is produced by the hypothalamus. Only when prolactin is needed does the hypothalamus stop synthesis and secretion. In normal conditions, prolactin is synthesited by the hypothalamus. However, prolactin inhibitory bormooe prevents the secretion unless prolactin is needed. In normal conditions, prolactin inhibitory factor is produced by the anterior pituitary. Only when prolactin is needed does this stop and the ovaries are able to produce prolactin.
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)

(
Insulin Glucagon Cholesterol

The precursor for steroid hormones is:

Somatostatin

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In nurm:rl rnudititUI\,IJrul:utin i nhibitur~ factur i'\ pruduccd by lhr h~pollwl:uuuo;. Onlv ''tum prttl:u.1iu hi mt.tktJ tlnt.s fht> h~{lnthalamus s.lflp li0\n1hl ~;i, :.nd ~Cft"('tion

Prolactin is a siogJe.-chain protein h001101\C closely related to growth hormone. Proluctin is I!CCrctcd by so-<:alled Jactotroph< in the anterior pituitary, Prolactin is also :;ymhestzed and se creted by a broad range of other cells in the body, most prominently various immune cells, the brHin. and th., decidua of the pregnant uterus. Prolactin timulates milk production in Ibe breast. stimulates ~rea.<t developtlleQt, inhibiiS ovulation (hy decreasing symhesi:t muf releuse of gmwdotr'Qpill-t't!lea.s:ing hormone), and inhibits spem\atogenc;is (hy detreasing GnG/1). The hypothalali'IUS synthesizes a prolactin inhibitory factor (dopamine!. Under norm al condition<, large amounts Of dopamitle are COntinUillly tranSmitted to the anterior pituitary gland so that the normal rate of prolactin SeCI'etion i:; slight. Important: This is why ptolactin is srud ro be under ptedomhtQnt Inhibitory tontrol by the hypothalamus. Howevt~ during pregJtancy a lid loCt;tllon. the fonnation or dopamine itself is suppressed, thereby allowing t.!Je aotrior pituitary gland to crete lll1 elevMed amount of'prolactlu.
Pactors thar in crcns~ proJactin secreti.oo:

Estrogen (prt>giiUII<J'). bre.1st-feodin11.. sleep, stress, thyrol.r<)pin-releasing hormone (TRH), and dopamine a111ngouists Fac1ors that d~ crease prolatd:n sccrecioJ1 : Dopamine. bromocrlprine (dopamine agonist). som~tO$tatln. aud prolactin fby 1wg<1
tiv fecdbm:k). ,.,.. Dop:unioe servt> as the major prolactih-inhlbitlng fn~tor or "brake"
on prol3clin ~ecrction .

In contrast to whar Is seeJt with a lith< otlter pitllitary hormone'- the hypothalamus tonically supp,...se:; prolactin secretion from tlte pituitary. In other wot'ds, there i usually a hypothalamic ''brake" set nn the lactotroph, and prolactin is secreted only whrn the brake is released. If the pituitary stall< is cu~ prolactin secretion Increases, whiie.so.:rotion of all the other pituitary lomtones fafl dramatically due to toss of hypothlllamic. relc.>ing hormones.

f'hnlllitlrnl

Steroid honnuues are crucial substances for the proper funclinn of the. body, They mediate a wide variety of,.jtal pbysiological funcuons ranging from anti-ili0UJ11matory agents to reguloting events during pregnancy. Steroid hormones are.<ynthesized and secreted into the blood streom by endocrine glantls such a.s the adrenal cortex M<i the gottads (O\'ary a11d te.strs), Steroid honnonc nrc ali characterized by the steroid nucleu<, which i< composed of three six
member rings and one five--member ring. Choles!llrol is a sterol, which l~" natural product delived from th< steroid rtudcus. In addiMn

to being the building block for steroid ltonnones. chol~.sterol is also a component of the cell membrane, It Is thought thnr tltechol'*terol present in tltt cell mcmbrJnt i~ responsible !orallowing oteroid honnones to entor the cell, bind to tltc ilonnonc reotptnr, and ultimately to a specific. site on the chromatin, in ~urn sttlv~tit1g the ge1le in Qltc-!ition. nvc classes or steroid hormonC>ic I. Androgens: urigiuate iu tbc adrcnul cor\ex.and gonad.< and primarily affect maturotiot\ and function of secondary :;tx urgnns (male se.mal tlf:!rel"minotitm). 2, Estrogens: onginate in the udrenal cortex and gouuds and primtl!ily aftl:ct matura(ion and function of secondruy s~x urgaus ({emole sexual detef'miutJtion). 3. Progcstins: originate frotn both ovnrlcs and placcutu, und mediate ih" men<tJ'UJIJ cyele and maintain pregnancy. 4. Miber':llocorticoids: originate in ndrenol con ex .Hod ruaintai:u sulr and wa(er. 5. C luco<O rtitoids: originate in the adrenal cortex nnd llffect muinly metabolism in eliverse ways; de<.:Tc.mSt: inflammation tJnd increase rcsi,tunce to siress. The producrion >lltd secretion ofHtoroid hormuoes "recontrolled by trophln hoiTIIOIICS. Which themselves are ~llhcr proteins or pepudes. Steroid hoiTIIonts. Which ~ro non-polar molecule$, simply psss tbrougb the plaHma metn bnmes of th~ir tatget cell to the c)'losol where they hind I<> their r.spcctivc receptors. Tht $teroid honnoll~ penetrates the cell membrane und moves through the cytoplasm to the nucleus: it then oottple.s With the rccoptor protein, fonning a hormone r..:cptor oomple~.

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Parafollicular, or, C cells in the thyroid gland are the major source of:

Gastrin
Calcitonin Glucagon Parathyroid hormone

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( \..
Hypotbalamus

The amount ofT4 produced and released by the thyroid gland is cootroUcd by the?

Medulla oblongata Parathyroid gland Pituitary gland

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( aldtunm

Calcltooln is a hormooe known to-participate: 10 calcium and phosphoms me1abolism. In mammals, the 1 najor source of calcitonin is- fn;n"tl the para(oiHcuJjtr. ur, C cells lu lh4.! thyroid glund. C.aJc-honJn has the abUity ro dt~re.ase blood calcium lc:vcls at least in pa11 by efT~:cb nn twn hugct urgan~:

Bone: Calcironin suppresses n!!;O!l)tion of bone by inhibiting 1ht' actlv1t}' oful!iteot:lasr~, n cell 'YPt: that "digt:..sLS'' bootie m<.lttix.. roleasmg calon1m and phosphunll'i inlo hlood. Kidneys: Calcnrm and phosphoru~ arc pri!vtnh.."<l from being lost m urine by reabsorption ir\ tbC bdney tubuJes-. Calcitonin inhibits tubular rc.'lbsorptiou of these two iony;, t~Jdln.gto incrl!il$t:J rates of their los.s in urine: The most promincnl factor C:()nlr'Ollill~ ~;alcitonio setfction ts thccxltardluhu l'Onccntnnlcm oflhni1.td c:aklum. Elevated blO<Kl ~al c1um levels strongly srimulaic c.'\lcitoulu sccn:tinn.md s.ccrctiou is suppressed when calcium conccmrnrion fa.lts below normlll. Note: Calcitonin is not required hi adult humans. Although It 1 s- hnponant duriug bout! development, the major r'l!gu1ator of plasma Ci:tlcium levels in tht ~tduh i~ p11n11hyroid honnonc. Thus, while an mcrcase 10 the sccrcuon o( parathyroid honnone wil 1im:rcase plasma csJcium Jevel-$. as pa.raU1yr0id S1.!trct10n decreases, plasma calcium will also deere~tse.
tt .. nuun~"

,,r llw

lin rn1 rl oan1l l'ar.11 h\ n>lrl C.l.!fid~

Hormone
T'r!Mld.)lbyroin'iile

S(llh'tt

Turg.tl

1\tlltllll\)
I DCrca.<~~ rrue ttf Mt!!UUKll~n

(TJ!
l.etr?.lodotll~lni!

Thyroid gbod ffol/lculur cell$)

General
Gcncn~l

lllyml(l gl;lliJ
(folllcula.r ct>IIJ)
Thyrotd S)lnd
(p~Jrq(oll/nJIIJJ' c~II.~J

lncn:nses r.uc of fi)C\:Ibolism IIUUU.(Il C',mwn..d ,,, 'r,

/trsr)
h.,.,-ru;~~e 1.~klum S\Ot0C

"' lh)'rOXlno fT,J

Calcitonin
P\\ralbyniid heft

801\l' li~i'll:
I(J~n"Y'

in booc, l010ng hlood Ca

!~dt.s.

Pnn111.byroid glands

II-(T'T1/)

B9ne lis,ue l.nc~3$C$ c;Ucium fC!ItK.IVJI from -stomge in bone and ln!Oilltlal tract ,n..'TI.~.\Sits ab~rrl.i,on f, rcalc:ium \Jr in~,~:;;LbK*. inc:t\!a.1ng blOod C1 '' levels

J'ituitar~

ghmd

TI.1e thyroid gland is a small gland. connally weighing less than one ounce. located in the front of tbe neck. The thyroid gland is made 11p of two halves, called lobes, that lie alcmg tbe trachell and are joined together by a natTow band of thyroid tissue, known as tho
isthm u~.

The function of the thyroid gland is to take iodfne, found in many foods. and conven it into thyroid honnones: thyroxine (T.J and triiodothyronine (T,). Thyroid cells are the only coils in the body that can absorb iodiue. These cells combine iodine and tlte amJUo acid tyrosine to make T3 and T4 T ~and T4 are then released into the bloGdstream and nre D'!lnsported tbtooghoot the body where they control mewboUsm. Every cell in the body depends upon thyroid hormones for regulation of cell metabolism. The normal thyroid gland produces about 80% T, and about 20% T ,; however, T 3 pos.osses about 4 times the ltonnone "strength~ as T4 The thyroid gland is under the control of the pinitary gland, a small gland the size of a peanut at the base of the brain. When the level of thyroid hormones (T3 and T,) drops too lmv, the pit:uit'ry gland produc.es thyroid-stimulating honnon~ (TSH or ih)won-opin), whlch stimulntes tho thyroid gland to produce more hormones. The pil:l.titury glr.nd itself is regulated by the hypothalamus. The hypothalamus prGduces thyroid-rclea~ing honnone (TRfl). which tells the pihlitary gland to strmulate the thyroid gllllld (by mlewsing TS/1). I. Thyroid honnones increase glycogenolysis, gluconeogenesis, lipolysis. Notes protein synthesis, and degradation . 2. Thyroid hormo~cs stlmu\ate bone maturation as a result of ossification and fusion of the gtowth plates. 3. Thyroid hormones are lipopbUlc hormones tltat exert their cOects via trnnscriptlonal process<-.s.

(BIOCHEMISTRY I PHYSIOLOGY

Hrm)
~

,
~

On his 21st birthday, .John celebrates with his first few beers. He notices (along with other symptoms of i11ebriation) that he bas an increased need to urinate. This is physiologically caused by a decrease in production of:

Oxytocin Antidiuretic hormone (ADH) Parathyroid hormone (PTH) Aldosterone

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(BIOCHEMISTRY I PHYSIOLOGY

Hrm)
J

( Your patient has a disorder and is unable to metabolize cholesterol. Which o~ \.. the following hormones will he be unable to synthesize?

Insulin Thyroxine Growth bonnooe Retinoic acid Aldosterone

Two of the above

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.\utidiuntil' hurnwnt ( tni/J

Antidiuretic hormone, also k.uowu com.mooly as vasopressin, is a nine-amino acid peptide secreted from the posterior piruitary. Wilhl11 hypothalamic neurons (st,praopli"m'cleO.the hormone is packaged in secretory vesicles wilh a carritr protein called nourophysin, and both
are released upon hormone secretion. The single most lmp4rtanc ~ffed of antidiuretic hormone is to conserve body water by re-

ducing the loss of water in urine. Antidiuretic hormone binds to rcceptms on cells in tbe col-

lecting ducts of the kidney nnd pmmot<s reabsorption uf wat<r back into the circulalion. In the absence ofantidil!J'Ctic hormone, the collecting ducts"'" vortually impermeable to water, and it tlows out as urino. Antidiuretic hormone s1imu)ates water rel!bsorbtion by stimula1ing insertion ofwat er channels," or aquaporins, mto tl1 e rnetnbnme of kidney tubu)es, These channels ll'anspon solute-liee water through tubular cells and back into blnod. leading to a decrease in plasma
O$'molarity and cu1 increased osmohuily of urine. The mO$timportant variable rcJ;UIBtlng anlldiurellt hormonesorr<tion l pl:uma O$mO l~rily, or the concenrrotion of solutes in blood. Osmolarity is sunsed io the hypothalamu.< by neurons known as an osmoreceptors, und those neurons, in tum. simulate secretion from the neurons that product: antidiuretic honnone.

Secretion of antidiuretic hormone is simutared by decreas~ in blood pressure and volume, conditions sensed by stretch receptors io tbe bean nnd large arteri~. Another potent stimulus of antidiuretic homtone is nausea and vomltlng, both or which 1l!e controlled by rO"gions in the brain with links m the hypothalamus. I. Ethanol and caffuine dccrcose ADH release while nicotine increases it> release. Notes 2. Sweating causes 3.11 lot'rease in ADH. while drinking large amounts uf wuler causes a dec!rease in ADH. 2. Hyposecretion nfADH results in diabetes insipidus (po(vurio. po(dipsia, om/ po~ypilaglq). Diabetes in~ipidllS would also result from the bypoacth<ity of the postcriur pituitary gland.
\ lclosttunl'

With t ~e exception of rctiooic acid, tbe steroid hormones are all derived from cholesterol. Moreover, with the exception of l'itnmio D . they all contain the same cyclopentanophenanthrene ring and atomic numbering system as cholesterol. These hormones aro not w ter-soluble and bind to intracellular receptors. forming complexes that activate or Inactivate genes. A mint hormones are derived from tyTosjne_, an essential aruioo acid found in mosc proteins. Atnine hormones include th~ thyroid honnoues (TJ ami T,J and the cate cholamines (epi11ephrine, noreplnepilrine, a11d dopami11e). Polypeptide hormones are proteins with a defined. genetically coded sm&ctme. They include the anterior piruitary hormones (Ott, TS/l, FSN, LN, and pl'tl!actin), the po tertor pit~itury hormones (ADH and ox.vro<:ill), the pancreatic honnones (insttlin <lnd gi<lcagon), and PTH . These hormones have the following characteristic~: I. They are synthesized in precursor form (a pre.prohormalle), 2. They are usually transported tmbouod in rbe plasma_ 3. They are s tore<,! io ~ecretory vesicles, 4. They act by binding to a plasma membrane receptor and generating a second messenger. Note: A particular honnone docs nN necessarily affect all cells, only its turget cells. Target cells of a hormone possess receptorS to which molecules ol' a hormone can attach. Tbese receptors can be located cilhor on the plasma membrane or within the cell itself.

~IOCHEMISTRY I PHYSIOLOGY
Which of the following ceUs has a resting potential?

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Cardiac muscle cells Neurons Histiocytes Two of the above AU of the above

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All of the following statements are true EXCEPT one. Which one is the EXCEPTION?

Peripheral nerve fibers can sometimes regenerate if the soma (cell body) is not damaged and some of the neurilemma remains intact The neurilemma forms a regeneration tube through which the growing axon reestablishes its original connection If the nerve originally led to a skeletal muscle, the muscle atrophies in the absence of innervation but regrows when the connection is re-established Nerve fibers of the CNS (brain and spinal cord) possess the thickest neurilemma

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.\11 of th~ aho\C

All cells (not just excitable cells) have a resting potential: an electrical charge across Ute plasma membrane, with the interior ofthe cell negative with respect to the exrerioL The size of the resting potential varies but in excitable cells runs about() 70 01V. Note: Excitable cell~ include neurons and muscle cells. In neurons, the action potential is also called Ute nerve impulse. Depolarization of a membrane occurs when sodium channels open. allowing sodium to move to an area of lower concentration (and more negalive charge) insid" the c"ll -- reversing the polarity to an ins[d.,positive stare. Important point: During the upstroke of the action potential, the cell depolarizes, or becomes less negative. The depolarization is caused by inward current, wbich is, by definition, the movement of positive charge into the ceiL In nerve and in most types of muscle, this inward current is earned by sodium (N!I). Note: As sodium (Na) floods the cell during initial depolarization, the membrane potential can reach as high as {-) 55 mY (inside positive). Certain e~temal stimuli reduce the charge across the plasma membrane. Mechanical stimuli (e.g.. stretching. sound waves) activate mechanically gated sodium channels Certain neurotransmitters (e.g.. <1teiylcho/iue) open ligand-gated sodium channels ln each case, tbe facilitated diffusion of sodium into the ceU reduces the resting potential at that spot on the cell creating an excitatory postsynaptic potential or EPSP. lf the potential is reduced to the threshold voltage (abou/ -50 mV in mammalian neurons), an action potential is generated in tl1e cell. Important: lf the neuron docs not reach this critical threshold leveL then no action potential will occur (all or none). So long as suprathreshold stimuli can reach the threshold oftlte cell, they produce the same action poten~ial that threshold stimuli do.

"l"l'l"\t" fihtrs nf thl' C~S

(bruin twtl spimtl cord)

pos~css

th(' lhicl\.l'SI

neurilemma
***This is false; nerve fibers of the CNS (brain and spinal curd) arc not enclosed by a neurilemma. This is wby regeneration of severed axons is more difficult in tbe CNS (brain and spinal cord).

The neurilemma (a/sa called a sheath of Sc/lwa/1/t. Sc/tii'OII/1 s membrane. or

neurolemma) is the thin membrane spirally enwrapping the myelin layers of certain fibers. especially those of tbe peripheral nerves, or the axons of certain unmyelinated nerve fibers. --. L All axous of tbc PNS have a sheath of Schwann cells (aud tlws a neuriNo<.. lemma. made up of the outer lay er ofSclmmm cell.v) around them. 2. When a Schwann cell is wrapped successively aroun<Lan axon, it becomes a myelin sheath. Remember: Right-sided lesions of the spinal cord result in loss of motor activity on the sam e (ipsilateral) side and pain and temperature sensations on the opposite (con/ralalertd) side.

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( \..

When you administer local anesthetics to your patients, what effect does this have on the nerve membrane?

Increases potassium flux Increases the membrane excitability by increasing the membrane's permeability to sodium ions Decreases the membrane's permeability to sodium ions and reduces the membrane excitability Increases the calcium and chloride flux

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The fasciculi gracilis and cuneatus are the:

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Largest ascending tracts of the spinal cord Largest descending tracts of the spinal cord Smallest ascending tracts of the spinal cord Smallest descending tracts of the spinal cord

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llelreascs tht mrmhranl"s

lll('mhrant
l'\l"it.-hilit~

p{'rmrothilil~

lo sodium ions .mrl reduces thr

Local anesthetics bind to the inactivation gates of fast voltage-gated sodium channels, stabilizing them in a closed position, effectively prolonging the absolute refractory period. This decreases sodium membrane permeability, and therefore reduces membrane excitability. When the excitability bas been reduced below a critical level, a nerve impulse fails to pass through the anesthetized area. Potassium, calcium, and chloride conductances remain unchanged. Local anesthetics reversibly block nerve impulse conduction and produce reversible loss of sensation at their administration site. Small, myelinated nerve 11bers, which conduct pain and temperature sensations, are affected first, followed by touch, proprioception, and skeletal muscle tone.

l .argtst

ascemlin~

lrach uf lht o,;pinal cord

The white matter of the spinal cord contains tracts that travel up and down the cord. Many of these tracts travel to an(! from the brain to provide sensory input to the brain. ing tracts, those or bring motor stimuli from the brain to control effectors. Ascend. tbat travel toward the brain are sensory; descending tracts are motor. For most, the name w ill indicate if it is a motor or sensory tract. Most sensory tracts' names begin with spino, indicating origin in the spinal cord, and their names end witb the part of the brain where the tract leads. For example, the spinothalamic tract travels from the spinal cord to tbe thalamus. Tracts whose names begin with a part of the brain are motor. For examplt, the corticospinal tract begins with fibers leaving the cerebral cortex and travels down toward motor neurons in the cord .
\1aJIII \<,:4'("lHflfl~ I r<JCI\ or thl Sl)lll tl { urtl

Name lalcral
spit~olhttiMtic

unction

t.OClldon

Origin

TtrmbnHIOn

Pain, rcmpenturc, Slid crude Lateral \.Vhite

Poslerior gray column: ih:lltmus

opposite sick

touch: opposite side

Crude touch and pl'C'$$Ure

co1umns

Anlerior .wioolha.l.am.ic Fucicllli gracilis and eunearus

oolumns
Discriminaning toucb and

Aotesior white Posterior grny cotwun: thalamus opposife side

Miulla

pressun: sen.-:alioo.s

'P05teriQr Spmal g$.1lglia: s.ame white columns side

l,..ater:tJ white

J\ntenor-and posterior Unconsciou.s kinesthesia spinoctn:bellar

eolomns

1\nteriOT or p~terioT gray column

Cen:bcUum

Tbe origin refers to the location of cell bodies of neurons from which the axous of tract arise. The termin.ation refers to the strucrure in which the axons of tbe tract terminate.

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(
Spatial summallon occurs wben:

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)

Two inhibitory inputs arrive at a postsynaptic neuron within I minute of each other Two excitatory inputs arrive at a postsynaptic neuron s imultaneously Two inhibitory inputs arrive at a postsynaptic neuron 10 seconds apart Two excitatory inputs arrive at a postsynaptic neuron in rapid succession

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r

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SaltJttory conduction happens in myelinated neurons only. Wbicb T WO of the following arc effeet.s of saltatory conduction compared to conventional conduction?

Conduction is faster Conduction is slower Conduction is at the same rate Conduction consumes more energy Conduction consumes less energy Conduction consumes the same energy

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1\\u t.'\citatur) inputs :urht. at

~l

posh)nartic neuron simultaneous))'

Neurotransmitters may be excitatory, increasing the probability of causing an action potential in the postsynaptic neuron (an exciUIIOIJ' postsynapric potential or PSP), or in hibitory, decreasing the probabi lity of an action potential in the postsynaptic neuron (an inhibitory posts y naptic polential or JPSP). Note: Neurotransmitter molecules may have excitatory or inh ibitory effects depending upon their binding to different subtypes of receptors. There are two forms of summation by which EPSPs may combine to reach threshold and initiate an action potential: I. Spaiial summation occurs when two excitatory inputs arrive at a postsynaptic neuron s imultaneously. [I is the re-sult of a converging circuit and is dependent upon the simultaneous arrival of impulses from multiple presynaptic tlbers. 2. Tempora l summation occurs when two excitatory inputs amve at a postsynaptic neuron in rapid succession. In temporal summation, there is an increase in the frequency of nerve impulses in a single presynaptic fiber. Note: An action potential initiated at the midpoint along the lcngt11 of an axon w il) spread toward the cell body (soma) a11d nerve ending.

C nndurtion is l:.ster Conduction con~Uilll'S less

l:'nl:'r~~

In an unmyelinated neuron, the impulse travels along tl1c entire membrane surface and is known as continuous conduction. Note: This conduction is relatively slow ( 1.0 mlsec) compared to saliatory conduction (up to 100 ml.vec). In a myelinated neuron, the myelin sheath decreases membrane capacitance and increases membrane resistance, preventing movement of sodiwn and potassiwn through the membrane. If the myelin sheath were continuous. action potentials could not be produced. However, the myelin sheath is interrupted by nodes of Ran vier. The distance between these nodes is between 0.2 and 2 mm. Action potentials traveling down the axon jump" or "'leap" !Tom node to node. This is called saltatory conduction. SaltatOry conduction is of value for two reasons: I. Increases velocity of nerve transmission in myelinated fibe rs. 2. Conserves energy for the axon because only the node depolarizes. Thus, it takes less energy fo r the sodium/potassium ATPase to re-establish resting iott gradients. Importan t point: Saltatory conduction is not only faster but also consumes less energy, since the pumping of sodium and potassium ions need occur on ly at the nodes. Conduction velocity depends on: I. Diameter of the nerve fiber. Au increase in diameter reduces resistance to current flow down the axon. 2. P resen ce of myelin sbcalh.

(siOCHEMISTRY I PHYSIOLOGY

The most abundant inhibitory neurotransmitter In tbe central nervous system is:

Acetylcholine (ACh) Norepinephrine Glycine GABA Do pamine Glutamate

Serotonin
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(siOCHEMISTRY I PHYSIOLOGY

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r A patient of yours presents with symptoms similar to Parkinson's disease. H~

claims that the l>hysicians have not diagnosed him with Parkinson' s because it was due to trauma. Tbc trauma affected which part of his brain ?

Pons Parietal lobe Basal ganglia (basal nuclei) Thalamus

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Release of e xcitatory neucotransmillers from the presynaptic me11brane opens channels in the postSynaptic membrane and leads 10 an increase in the concentration of sodlum ions within the postsynap tic cell and a decrease in thai of potassiwn ionK This leads to a depolarization 6fthe poStsynaptic cell, which is propagated fun her along the cell membrane by an action po tential. Inhibitory neuro~ilnsnuners encourage the hyp erpola riza tion oftbe post5ynaptic cell, mak ing it less likely to generate an uclio~ potentiaL Whether a ncurotrnamuttcr acts in an extltatQry or itthlbirory mannel is dctcnnined by there action of lhe receptor to its binding. Thus, a given chemical can be ~.<cit tory at some tecep tors and inhibitory at others. Sotne examples of n curottnnslllitler action: AcctylchoUne voluntury movement of the skeletal mw;cles Ma tile < ympathmic p<tt/IIW~i'S) and movement of the visccrl-) (vin the part~.rympotlu!lh;: pathway.,.. . ). Norcpinephriue - wkefuln.,;s or urousal via the sympathetic path\vays. F.pinc,>hrioc sitnilnr to uorcpinephrine. Large n,ountll of it aro pr~duced and are released by the adrenal glands. A l<o coiled adrenaline. Dupamine .. voluntary movement and motivauou, "wanting," pltasurc, associated with ad~ diction and Jove.

Serotonin ~ memoryt emotion, wakefulness, sleep, and tentpcralurt regulatjou.. Glutamdte the rrtost abundant excitatory neurotrnnsro..hi~r w th~ ceotral nervous system. GABA the most abundanr inhibitory neurolruusmi1ter in Ibe: ccut.rat utrvous system.
GlyCine . spinal retlexes and motor behavior. Ubt~ mine ;nvolvcd in the sleep/wake cycle and intlammotory response. Also has a mod-

Ulating action on norepinephrine, serotonin1 and acetylcholine.

Monoamine oddase (MAO) is an enzyme that catalyzes the oxidati,o deamination of

monoamines such as norepinephrine. serotonin. and epinephrine. This deamination process

aids in metabolizing excess neurotransmitters that111ay build up at postsYnaptic temtinals.

In current usage, the phrase " bas al ganglia" tneans the caudate nucleus, putamen, and glob us paliidus. They a re. fi mc rionally impot1ant, at a mluimum, J(tr controlling voluntary movements and establishing postures. When the basal ganglia are altered, say in disorders like Parkinson's disease, Htmt ington dise<lse, or Wilson disease, the person has unwanted movements, such as involuntary Jerking movemenls of an a rm or leg or spasmodic movement of facial muscles. The ca udate nucleus and putamen along with the interposed anterior limb of the internal capsul are coflectively known as the corpu~ s!rialum (i.e .. > 'lriated body) because of their appearance. Similarly, the shape of th~ putame.n ;Uid globus pallidus resembles a lous, and they are collectivel y called the lcntlc ulnr nucleus. The basa l ganglia and ccrcb~llum are large collections of nuclei tbat modify movement on a minute-to-minute basis. The cerebral (muto,.) C\lrt<>X sends intom1ation to both, aod both stmcntres send in formation back 10 the cortex via the thalamu s. The basal ganglia are located deep to the ccrcbllll cortex. Note: The outpu r of the cerebellum is excitatory. whi le tbe basal ganglia ate inhibitory. Re member: The cercbeUum is situated below and posterior to the cettbrum and hove the pons and medulla. It is motphologicnlly divided ioto two lateral hemispheres and a middi<' portion. fts 1imction is to maintain tulllhriurn and mu~cle

coordination .
Not e! The major pnrrs of the cJrtrnpyramidal system ure th< "subcortical nuclei." Tlus includes lhe c~udate nucle us, putnmeu, and globus pallidus (which are nlso
/i:IIOtl'/1

as the basal ganglia).

~IOCHEMISTRY I PHYSIOLOGY
C holinergic receptors are subclassified into which two categories?

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Nicotinic and alpha Alpha and beta

Nicotinic and muscarinic

Muscarinic and beta

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The brain has two motor systems: ( 1) the voluntary or pyramidal motor system that moves your muscles under the direction of the mind and (2) the extra-pyramidal systems that control muscle tone, posture, and motor activity without conscious thought The voluntary or pyramidal motor system is located in the:

Cortex

Brain stem
Dural sinuses Cerebellum

,,.
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'i~.u linic

and mnwnrink

poS~ganglionic neurons or un etrector orgGns

Cholinergic receptors arc membrane receptor proteins located on outonomoc that are regulated by acetylrholine. Cholinergic rc:ceptoxs an: subelas.,fied IntO two c.tegories, nicotinic and trnoscannoc, oWltl for the extnnsic compounds !bat stimulate 0<1ly that category. The properties of the two categories ""' sWIIIl1llrizA:d as follows Nicotioir Receptors Stimulated by ACb and nicotine. not sumulated by mlL<;earine Pound a1 uff gonglionic synapses AJso found at neuromuscular juncUons Blocked by hexamethonium Muscurinic Receptors Stimuluted by ACh and muscarutc, not stunuloued by nicotine found uttsrgcl organs when ACh i~ released by postgan~lionic neurclns (a// ofpar!l .f)'mpalhelic and some sympatiretic) Stimulated sel:tivdy by muscaronc, betbanechol Blocked by atropme

lnt por tant: All preganglionic autonomic neurons (/xJI/o ynop.uhrk ~ml porrm mpathetic) and aft postgotngllonlr part>ympatbetic neurons are cholinert!oC, m=g they use acetylcboline as a neurotransmitter. The choiJnorglc tfTects of prtgaoghonic amonomic neurons !both .rmpJthrti< and parn..f)mpathetic) are excitatory. Tho <'ilollnergic tfTl'<tS of postganglionoe parasympathetic fibers can be cuber e.rltntor ) or Inhibitory (e.g.. para>ympatht~k jibt'r> lrlllrnwtiflg the heurf thor cauN slowi11g nf tloe loearr).

( Hl"l'-' \

The e~tnp)Tamidol motor systcnt, centered in the basal ganglia. rdk., on dopamtne to maimoin proper musck tone and motor staholhy. Thel'ynlmldal Ttatt: Thos group of fibers camcs m=ges for voluntar) motur mne ment (ji11e kiJ/ed moements of4ktlttctl muscle! to the lower motor neulQnS on the bnnn <t<m and $pinal cord. Appro:timattly 80'!-o of the cell bodots of the pyrarrudaltmet re locut<J un tht precentral ll)TUS or the frontollobe, "hich is also kno"n as t:hc motor >trip. matcly 20% of the pyramidal tract fibers al<o onginate in the pustcentral gyrus of the pari< tal lobe. in Brodmann's areas I, 2, and 3.

API"'"'.

Tiois tract is dire<t and monosynaptic. meaning that the a.tons of its neuron> do not $ynap<e with other cells until they reach their fiMI destination on the bram gtom ur spinal cord. Ote;e direct connections lxtween the cortex and ~he low~r motor neurons n11ow n'lessuges tu be transmitted very rapidly from the control nervous system to rhe periphery. The fibers of the pyramidal oract tlwl >)'llllll~ with cranial ntrves loatcd in the bmnt stem fonn the corticobulbar tract. Tbos o s the part of the pyramidal llilct that carries the motor messages that are most important for ~peech rutd swallowing. The fibers of the pyramidal tract that synapse with spinal n~rvos sendin~ infonnarion about voluntary movement to the skeletal muscles fonn the cortkosplnal tnct. AI the pyramids on tbe inferior part of the medulla. 85% to 90% of corticospinal fibers dl'Cussate. or cro>s to the otber side of the brain. The rcmaonina 10";. to 15' contmue to descend ipsilaterally. Th< fibers that decussate are cull! the lateral corticospinal tract or the crosstd p)romidtl 11'11cL Because they descend alonath< sides of lhc >-piJul oord. tbe uncrosnd or direct fibers that synapse with >pinal nerves on the opsilatcral side of the body are calk-d the direct pyramicW tract. They may also be referred to os the ventral pyramidal tract or the anterior corticospinal troct since they travel down the ventral aspect of the spinal cord.

(BIOCHEMISTRY I PHYSIOLOGY

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....._

All of the following statements are t rue EXCEPT one. Which one is the EXCEPTION'?

Preganglionic neurons have their cell bodies in the CNS and synapse in autonomic ganglia Sympathetic ganglia are located in the paravertebral chain Cholinergic neurons, whether in the sympathetic or parasympathetic nervous system, release norepinephrine as the neurotransmitter Tbe majority of sympathetic postganglionic neurons are noradrcnergic

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f~
.j

(which of the following is the cause of the hyperpolarization that occurs \. a few milliseconds after the action potential is over ?

Many sodium channels remain open for several milliseconds after repolarization of the membrane is complete All potassium channels remain closed for several mi lliseconds after repolarization of the membrane is complete Many potassium channels remain open for several milliseconds afler repolarization of the membrane is complete All sodium and potassium channels remain closed for several milliseconds after repolarization of the membrane is complete

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C hulineq,:ir 11l'Urons. \\hclhrr in lht ''"'llalhllic nr para,~mp~11hl fh:' thnuu' '~'tt:'m. rdlaw nun pinlphrint :.t' tht' nt:urutran,mitter

This is false; cholinetgie neurons , whether in the sympathetic or pru-asympatheuc nervous system. release acel)lcboUo< .u the neurotransminer. Important Points to Remember: . Autonomic nervous system: Synopses between neurons are made w the autonomic ganglia. . L Sympathetic ganglia: are located in the parovenebral cham or prevenebral ganglia. 2. Parasympntbctlc gangliu: are located in or near the eiTcctor organs. Two Types of Motor Neurons: . 1. Pregnglionic neurons: bnve tlteir cell bodies in the CNS and synupse In sulont>mic ganglia. . . Preganghonic neurons or the sympathetic nervous sys tem ongmatc '" spinal cord segment> T1- L 1. Prega11gliooic neurons or !he porasympathetic nervous 5)'stem onglnatc in the Ducli of cranial n~rvcs in spinal cord se![ment' S 1 - S,.
~ Thrso: preganglionic neurons of both the sympalbetir and paruympathelit systems are rbolinergic, which m~ans they release atet~ lchollne a~ the neurotransminer. 1.. Postganglionic neurons or both the symp~tberic and parasympatltcoc systems have their cell bodies 10 the autonomtc gangha 11nd synapse on eiTector

Parasympathetic postganglionic neurons are cholinergic; the maJoruy o sympathetic postganglionic neurons are noradronergic, whkh means they release norepinephrine as the neurotransmmcr.

**

organs.

\Jan~ pclla\iSillm dUOIIl'l\ rl'lliOlifl UiJt'll lor \l'\l'f:t( miiJis~cnnch, :lrttr npnJarinlliun or Cht Oll'nthr:llll' h t'OIIl(lll'h'

The mcreased potassiUm conductance allows ror addmooal potasstum effiux. leaving the mterior of tlte cell more negath e. This opening of pota>~tum channel;. although delayed, is due to the initial dcpolanzing >limulus. Remember: After the acuon potenttal is l)ver, for a fe-.v millisecoodl. the membrane potential becomes even more negative than the original resting membrane: pot~ntial. This is called hyperpolarit atJon. Gradually, the ion .:-oncentrntions go back to resting level~. and the cell membrane returns to (-) 70 m V.

Tho importance of !he hy perpolarization is that th< cell rcmins In a "hypoexcitablc state," the r~l.athe refractory period. 11tis means that, in order to Lngger u second uctiou potential. the depolarhclng stimulus must be of a greater magnitude I<> ocbteve threshold.
Important point to remember: During rhe absolu te refractory period, the membrane will not re.,pond to any stimulus. During the relarJve rerrcrory period, however, a very strong stamulus may elicit :t response in the membrane.
Notts

J Presynaptic neurons trao,nnt tnformation toward a synapse: pos tsynaptic neurons transmit information away from o >ynapl<C. 2. Nerve impulses trneJ In only one directton becall.!.e of the fact that syn~tpses llt e pnlarlnd. 3. Electrical synapsu lll'il rare tn the CNS (common in cardiac and .fmootlr muscle) Thty are connected by gop juncHoos, wbkh allow local electrical current resulting frorn ucuon potentials in the presyuaptk neuron to pass directly to the postsy!Ulpllc neuron.

(siOCHEMISTRY I PHYSIOLOGY

Nrv)
kno~
-4

I~
\...

patient of yours lists a selective beta-blocker in her medication list. You that this is for her hypertension. What is the mechanism of Ibis drug?

Blocks beta- I adrenergic receptors in the heart, causing a decrease in heart rate and force of contraction Blocks beta-2 cholinergic receptors in the heart, causing a decrease in heart rate and force of contraction Blocks beta-1 cholinergic receptors in the heart, causing a decrease in heart rate and force of contraction Blocks beta-2 adrenergic receptors in the heart, causing a decrease in heart rate and force of contraction

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(
\...

Wbjcb of the foUowing does not help to maintain the resting membrane potential of a resting neural cell?

Resting potassium conductance Sodium/potassium pump Electron transport chain All of the above

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IJiocks htt:t-1 adn'l1l'fJ!iC l"l'('('lllo,s in thl' ht>art. causinJ! ::1 decnasl' in hearl
n.1U :111d fort.'<" nl cuntractinn

Beta-blockers "block" the effects of adrenaline on the body's be-ta receptors. This slows the nerve impulses that travel through the heart. As a result, d1e heart does not have to work a; hard because it needs less blood and oxygen. Beta-blockers also block the impulses that can cause an arrhythmia. The body has two main beta receptors: beta land beta 2. Some beta-blocke rs are selective., which means that they block beta- I receptors more tban they block bcta-2 receptors. Beta 1 receptors are responsible for heart rate and the strength of yoor heartbeat. Nonselective beta-blockers block both bctal and bcta-l receptors. Beta-2 receptors are responsible for the function of your smooth muscles. Adrenergic r eceptors a re membrane receptor proteil\s located on autonomic etTector organs that are regulated by cate.c holami nes (epinephrine and noreplneplwiue). Two main types of adrenergic receptors: Alpha receptors: Alpha 1 : !ocate.d on smooth muscle; prodnce excitation (C'Ontractiou or c :oustriction) Alpha 2: located in presynaptic nerve terminals, platelet<, fat cells. and the walls of the G l tract: produce inh ibition (relaxation or dilation) Beta receptors: -seta 1: located in the heart; produce excitation (increased HR. incrensed contract~ ility. etc.) Beta 2: located on s mooth musdc; produce relaxation (dilation) Important: I . Norepinephrine stimulates mainly alpha receptors. 2. Epinephrine stimulates both alpha and belli receptors.

Elect ron f ranspurt chain

The eleciron transport chain is used in respiration and is located on the inner mflochondrial membrane, moving hydrogen ions into the intem1embrane space. Resting membrane pote ntial (RMP) results from an excess of positive ions on the outer surface of !be plasma membrane, More Na ions are on the outside of the membrane than K ions arc o n the inside of tbe membrane. The size of the resting memb rane potential varies but in excitable cells n10s between

{-) 40 and ( -) 85 mill ivolts. The resting membrane potential ar ises from twu activities:
1. There is n resting pot"assium conductance that allows positive charges to leave the cell down their electrochemical gradient. fn most excitable cells, this is the most important dete rminant of IUvfP. 2. The sodium/ potassium pump esta blishes the sodium and po tassium gradients across the membrane using ATP . This pump is electrogenic, i.e.. it exchanges two potassium ions (K) into the cell fo r every three sodium ions (Na) it pumps out of the cell, resulting in a net loss of positive c harges w ithin the cell. Nearly one-third of all resting energy expenditure is spent maintaining the proper Na/K' gradient. Note: Visceral smooth muscle and ca rdiac pacemaker cells lack a stable r esting membrane potential.

~IOCHEMISTRY I PHYSIOLOGY
Afferent nerve endings in joints and tendons are called:

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Exteroreceptors

Viscerorcceptors
Proprioreceptors

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When scaling and root planing, you are using a firm finger rest for minutes at a time.

Nrv)

( (

1. Which of the following are the receptors that are used in

\..

sensing this continuous pressure?

\.

2. Which of the following arc the receptors used when you are manipulating an instrument in your fingers?

Pacinian corpuscles

Meissner's corpuscles
Ruffini's end organs

Merkel disks Hair foll icle receptors

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P'ropricu: ..rHors

*** J>roprioceptors are a type of afferent nerve endings relaying information about
body position and movement, the ex:tent of stretch or forco of mu.>clo contraction. sensory receptors of the stretch retlex. Receptors are structures that are gcorally ocrivoted by c~anges (: timuliJ in either the internal or external envtronment of the body, As tt re;;ult of the ttctivity of these receptors, nerve impulses are initiate<i within sensory nerve cells. Receptors are classified broadly as interorcccptors (visceroreceplors) or exterorecepturs. Bxteroreceptors are the sensory nerve endings associated w[th the skln that provide information about the external environment. Visceror<ceptors are associated with the viscera or organs and provide information about the internal cnviron111~nt,
E~ampte:

More specific classification involves reference to the type of stimulus monitored by a receptor. For example, your body bas cbemoreceptors, baroreceptors, phowreceptors, and mechanoreceptors. TI1ese monitor shifts in chemistry. blood prcss11rc. light. and touch, respectively. All receptors are linked 10 seusoty ueurons. When a receptor responds t<> a stimulus, a signal is sent along the sensory neuron to the CNS {b1'0i11 or spitwl <'01<1). Within the CNS, the stimulus is identified, and if a response is required to maintain homeostasis, signals are sent to effectors along motor neurons, 1. Adapta1ion is the decreased sensitivity to a continued stimulus. Not.. 2. Free nerve endings respond to itch, movement. pa[n. and temperature. Examples include nociceptor$, Merkel discs. and root hair ple:<nses.

1. f':u:inian corpm.ch.s 2. Ruflini'' cml urt:ans Receptors can be clnssilied according to the 1)1>< of stimulus to which they are sensitive:
l\1erlutuorerepton arc sensitive to pressure or stre1ch. These receptors are htghly

prone to adaptation from continued stimuli. Examples Include the followrtog: " Paclninn corpuscles are the nerve endings founJ in the hypodermis or deep in the
den:rtis that sense deep ClH~neou:, pressun.', vibrulion. and proptioc~ptlon.

-Meissner's corpuscles are the uerve eodings that are found in the dermal papillae and are associated with two-point discrimination, - Ruff1ol's end organs are the uerve endings in the dermis of the skin thar sense continuous touch or press11re. Thermoreceptors are free nerve endings sensitive to changes in temperature. Cbemoreccptors arc stimulated by various chemicals (ill food. the air. or blood). Peripheral chemoreccptors (carotid and aortic bodies) and central chcmoreceptors (medullaly neuro11s) primarily fotnction to regulate respiratory activity. This is an important mechanism for maintaining arterial blood Po2, Pco2, and pH within appropriate physiological ranges. Photorcceplors are specialized receptors that arc sensitive to light energy. They are located only In the retinas of the eyes (spetijicuiiJ; /Ire rods llrrd cones). Note: Rods are seusitive down to a single photon of li~hi energy. Nociccptors are free nerve endings sensitive to painful stimuli. GeneraJJy! 'hese have a higher activation threshold than other receptors. Reme,mber: Bororeccptors are specially adapted groups of nerve fibers within the walls of the carotid sinus and llte aortic arcb. Baroreceptors are stretch receptors that respond to changes in blood pressure.

~IOCHEMISTRY I PHYSIOLOGY

Nrv)

"

Which of the following Is not a function of the autonomic nervous system'!

Innervation of all visceral organs Transmission of sensory and motor impulses Regulation and control of vital activities Conscious control of motor activities Two of the above are not functions

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134

~IOCHEMISTRY I PHYSIOLOGY
The neurotra nsmitter of the prega nglionic sympathetic neurons Is:

Norepinephrine Acetylcholine Dopamine

Serotonin

C nn,tiou\ cuntrul nr runtnr acfh irh~,

Important: The actions of the autonomic nervous system (ANS) are largely lnvolontaf) (in contrast 10 those uf til~ romatic .f)'stem). The ANS also differs from the somatic system in using two dftrent neurons from the CI\S to the effector. The ~entral nervous system (CNS) spinal cord + braiJl The peripheral nervous system (PNS) afferent neurons from sensory receptors to the CNS- efferent neurons from the CNS to the muscles. organs, and glands. The PNS is subdivided into the: Somatic nervous system: consiS1~ of 12 pairs of cranial nerves and 3 1 pairs of spinal nerves; consists of both sensory and motor neurons; innervates the skeletal muscle and includes sensation of touch, movement, tcmpcmture, and pain. Autonomic nervous systtm: bus two main subdivisions: I. Sympathetic nervous system 2. Patasympathetic nervous system The enteric nervous system is a thtrd divtsion of the autonomic nervous >ystcm that you do not hear much about. The enteric ncrvou.< system is a meshwork of nerve fibers that innervate the viscera (gastromtestinaltroct, pancll!as, and gall bladder).
~

Preganglionic neurons arise in the CNS and run to autonomic ganglia tn the body. Here they synapse with postganglionic neurons, which run to the effector organ (cardiac trriL5cle. smoorh muscle, isceral m-gam, or glands).

\err~

lrholinl'

It stimulates action potentials in the posrg;mgliontc neuroos.

The neurotransmitter released by most postganglionic sympathetic neuron, ~ norepinephrine, which bmds to alpha and beta adrenergk re<:epton 111 us,ue Exceptions: blood vessels in skeletal muscle and sweat glands. \\hrch use acetylcholine at muscarinic cholinergic re<eptors. Note: Each sympathetic preganglionic neuron branches extensi,dy and synapses with numerous postganglionic neurons. It is this higb ratio of postganglionic to preganglionic fibers that results in widespread effects throughout the body. Remember: I. The sympathetic nerves originate in the spinal curd berwcen the segments T 1 und ~2. Parasympathetic nervous system : the main nerves of the PNS arc the vagus nerves, They originate in the me(hrlla oblongata. Each preganglionic parasympu. thetic neuron synapses witb just a few postganglionic parasympath<tic neurons, which arc located near or in the effectors (organs, muscles, or glands) Important: Atetylcboline ts tbe neurotransmitter ofbotb the pre-- and the postganglionic neurons of the parasympatbeuc nervous system. ACh binds m nicotinic cbolloergic receptors on the poStganglionic neurons. But ACh released by the postganglionic neurons stimulates muscarinic cholinergic receptors in the u~sue.

~IOCHEMISTRY I PHYSIOLOGY

Nrv)

Nerves connect with muscles at the . There, the ends of nerve fibers . These connect to special sites on the muscle's membrane called plates contain receptors that enable the muscle to respond to

Gap junction, motor end plates, norepinephrine Mucocutaneous j unction, visceral end plates, epinephrine Neuromuscular junction, motor end plates, acetylcholine Neuromuscular junction, sensory end plates, norepinephrine

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Wbicb of the following changes happen in the synaptic cleft upon transmission of an action potential?

Calcium decreases, acetylcholine increases, sodium decreases Calcium increases, acetylcholine decreases, sodium decreases Calcium increases, acetylchol ine increases, sodium decreases Calcium decreases, acetylcholine decreases, sodium decreases Calcium increases, acetylcholi ne increases. sodium increases Calcium increases, acetylcholine decreases, sodium increases Calcium decreases, acetylcholine increases, sodium increases
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nl'nrnmuwulltr junrliun. nantur emJ pl.lh'' an I~ lcho linl.'

Acetylcholine 1! released by the nerve to transmit a nerve impulse across the neuromuscular junction AOcr a nerve stimulates a muscle at this junction. an clectricnl impulse flows through the musele. causing it co contract. Acetylcholine (ACII) is che n~urntransmicccr released from the presynaptic ltrminal, ond tbe postsynnpt ic membrane contains a nicotinic receptor. ACI\ is synthesized in lhct neurons from which it is released. Choline acetyltransfer,sc cncolyzcs tll< fonnation of acetylcholine from acetyi-CoA and choline in the presynaptic terminal The cennioals of motor axons contain thousnnds of synaptic (.torage) wsiclcs filled with ac;:tylcholine. The action potential conducted along the motor nerve causes depolartzauon and au in nux or caltinm. The lllflox of calcium >ltmulate< lhe release of ACh from storage vestcles tnto the oynppse. ACh binds co mcocinie reeeptors on che mocor end plate. Sthnulation or the ACh receptor results 1u the npeninj! of sodium channel< (aud <1)/lle puta,tsillm chanuels), and an influx of sodtum ond potassium into cite cell that rc:<ula. io depolariZhtJon. Depolarization is termed "e nd-plate potentiul" (F.PP). If the llPP is ~umcicntly htrgl), an action potential i pi'Oduccd, muscle contruccion <)<:cur~, Ut>d ACb is metabolized by ocetytcholine$teras~. lmportun t; Following its release from the p~ynaptic terminal, AC'h IS rapidly broken down into acet3te nnd choline by tbc enzyme eeL~ lcholloesterae (4Cil) on the motor end-place. ott: If neetylcholinesterase is inhibiled . there "ill be proloogauoo of the end-plate potential (I!.PP). which can lead to lecnnus of the affected mu!>Cie fibers. Note: Tbe neuromuscular junction (NAfJ) is the synapoe t>etween tbe presynaptic motor neuron and the postsynaptic muscle membrane .

.,. Calcium influxes into the presynaptic cell, acetylcholine is roteased from the postsynaptic cell.lltld sodtum influxes into the pos1synapuc cell.
An axon le.mtinol of o presynaptic neuron closely approaches a dendnte or cell body of a postsynnpuc neuron; however, the two cells are seplU'Skd by a small synaptic deft. Ncurotransmillers are stored wilhiu cbo uxon terminal of a p~ynapuc neuron in synaptic vesicles. When an action polenuttl dcpQiarJ,..cs chc presynaptic membrane, voltagegaletl cukhtm cbnnnels are opcnccl, Cflt1sing an increase 111 mcracellular calcium. Calcium causes the syuaplic vesicles to empty the neurotransmitter molecules into ~1c synoptic deft. These ncurotmn>mitters diffuse across Ute synaptk ctert IUid bind to specific receptors on tbc postsynaptic cell. Tilis process b called synaptic trQnimi~lon, snd the time requued IS called the S) naptic delay. The f111nl step is enzyouttic deactivntion or the neurfllrnnsmmcr throug}t conform3honal change or rem<>val from the synaptic cleft.

A synapse.- ~ an anhlomical junction becween two neurons where the depolarization of che presynaptic cell iniliates a rcspon~e In cbe postsynaptic cell. The most common c ype ofsynaps~ is a chemical synapse, which cnnsists of: Presynaptic mcmbrnne: 5ynuplic vesicles within chis terminal contain '' neurotransmitter Synaptic cidt: ;.paco between the presynaptic and postsynaptic cdls Postsynaptic membrane: membrone of postsynaptic Tteuroo that contatn!l specilic receptor.. for the oeurotrnnsmiUer

~IOCHEMISTRY I PHYSIOLOGY
Strictly speaking, the an-or-none principle refers to the:

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Strength of muscle contraction Resting po tential Action potential Excitatory postsynaptic potential

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Tracts descending to the spinal cord arc concerned with voluntary motor function, muscle tone., reflexes, equilibrium, visceraJ jnoervatioo, and modulation of ascending sensory signals. The largest and most important of these tracts is:

Rubrospinal tract Vestibulospinal tract Reticulospinal tract Corticospinal tract

,-

108
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Any stimulus strong enough to initiate a nerve impulse is referred to as a threshold s timulus . A single nerve cell, just like a single muscle fiber, transmits an action potential according to the aU-or-none principle. The principle states that if a stimulus is strong enough to generate a nerve action potential, the impulse is conducted along the entire neuron at maximum strength, unless conduction is altered by conditions such as toxic materials in cells or f:nigue.
'-.tq' <ollh( \kcham'm I h.rl
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1111 \.;-luw

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llesc:ripliuo

A stimulWi lnggers stimulus-gated Na c.hann<.'ls ro o~n and :~.llow in..-vard )fa-dift'u$ion. Tbts caustlS tht mcmbraoe lo depolanze.
As t)l( lhrcshold polential is reucbod, v.ohagegattdNa- dumnel~ open. As more 1\'a colers the cc.Ulbrougb voltagc-gatod Na. _ channel$, the membraM depolati.ZC$

2
3
4

eVr:o finMr.
The magnitude of the action potential pe3k~ (:u +30 tnV) when \Ohll.S,t~llreiJ N"u channels close. Rep<>lari:r.arion begins when vollag,c.g.'Ued K channels optr~, aUowlng. outward diffusion of K. Afltr a brief l)eliod ofhypcrpolariz:uiQil, 1he re$tin3 pocesuj,J is rescor-ed by 'be so<Jjuropotassiwn pump and the rerum ofion channels to 1beir reiting stare.

( ortil'ospin:lllr:.tct

Universally regarded as the single most important tract cooccmcd with skilled voluntary activity, the corticospinal tract originates from pyramid-shaped cells in the premotor, primary motor, and primary sensory motor.
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Ul,n;ndm~o:

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Name

Function

t.ourion

Ori{:ln Motor runs or cerebral corteK oppo$itc side ftom tmetlocution in cord

Termin.ttion

Laleral oortkospinai

Volunb'Uy mow;:mem, La1 enU white eqntrac(ic>n of individual or columnssmall groups of muscles. particularly those mo\ing: hands. fingcr~. rcct., and toc:s of oppotitc .side

Lateral or antior

srey columns

Ante:riQC'

et>rticosp.inal

Same u.s later.sl corticospinal Anterior white Motor cortex but on La1 eml 01 unterior ti'ICCPI mainly muscles of column~ same side tts location b~)' oolumns .same side in cord
LtttM i white

Lateral rcti,cul<'lspinal Mainly faeilatory influence

on motor oturom to skeletal columns muscles

fteti-cular fomll'llion, pons, and medulla

midl>~io,

L3.1eta.l or lttH eriO't

gray oolunms t.-:uml or anterior

Medial retic. ulospiool Mainly inhibitory infliiCilCe Anterior white Reticular formation, .on motor ocurons 10 skeletal colwnns medulla mainly muscles

gray oolomns
Lateral or-amnior
~columns

Rubrospinal

COOrdination of body move: latal Wt\i~ ment and posture COIIllnllS Modi:tte$ (he influences Qf Lateral wbite lhe ves'tibulat .end Ol'gAn and cohmms.

Red nucleus (of midbrain) Lateral \'CStibular nucleus (4th ventricle}

Vcstibukispioal

lateral or anterior
py col-umns

lhe cerebellum upon

c~tensor muscle

IOn<:

~IOCHEMISTRY I PHYSIOLOGY

Nrv)

\..

W hich motor system is affected In your patient who has limited facial expression due to Parkinson's disease?

Pyramidal system Extrapyramidal system

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Which of the following characteristics is shared by simple and fadlitated diffusion of glucose?

It is saturable

Requires metabolic energy Occurs down an electrochemical gradient Require n Na grudient

,..
CopynS}It C '2009-lOIO Dental DKL.

E\t rap~ ramidal

~)stem

Tbis system is involved in automatic motor movements, and in b'<OSS rather than fine movement. Facial expression is one important comnmnicmive bebavior that is mediated by the extrapyramidal tract, Note: This is the rell-'011 tltat some Parkinson patients have Unle facial expression. In contrast to the pyramidallt'Ct, the extrapyramidal tract IS au indirect multisynaptic tract. The extrapyramidal uuclel include the s~IJstamia nigra. basal ganglia (cmtdare, putamen, afld globus pal7idus). thalamus, red nucleus. and ,subtbalamJc nucleus. All ofthse

nuclei are synaptically connected to one another, the brainstem. the cerebellum and the pyramidal system. Note: The s ul>s!JJoti nigra is located in the midbrain. It is particularly affected in Parkinson's disease. Extrapyrnmidal tracts Include: The rubrospinal tract originate.~ in lhe red nucleus. The cerebellum sends messages to lbe spin~! nerves along this U'act. Information flows from tbe superior cerebellar peduncle to the red nncleus and finally to tho spinol nerve<. Tbio information is very itoponant for somatit motor, <>r skeletal muscle control, and the regulation of muscle tone for po;ture. The reticnlospinnltrllct origillates ill the reticular nucloi of the pons uod medullo to the spinal nerves. The trnct is involved in somatic motor control like the rubrospinal tract and plays an imponant role in the control of nntouonuc functiotc5. The tectospinal tract has points Of origin throughout the brain stew, but especi<tlly in the midbrain area, and ends ill<be spinlll uerves. Tbe trJct is involved In tbe conn-ol of ueck muscle'S. The vestlbulosplual tract originates in Ute vestibular nuclei located in the lower pons and medulla to the spinal Jicrvcs. This ITllct is involved in balance.

{)tturs dcm n an tlt<t rnchemkul

~radhml

Both rypes of tronspon occur down an dcttrocbemical gradient ( "dowllhi/1 "). nod do not requtro metabolic energy. ProccNscs by which liubsHtutes are trunderred across cell membranes: OIJtuslon: lb~ process by wbioh molecules spread from arens of high concentration. to nreus of low conccntrntion. Oxygen <nter.; the cell in ~tis manner. Oxygen moves from tM blood. where i1 18 ouncc:ntrnted, to lhe inside- of the cell, where it is not concenlrat.ed, Note: When the molecules nre ev<t\ throughout a >'Jlace - it is called equilihrium. Oswosl~: a type of dlffu.~lon. ~ut 1nvolvlng only the movement of water across the mem brsnc. The water moves'" tb~ side of the rnembnttle that contains the moSl moleouk.i of solute dissolved in it. *"'* Dltiuslon and osmosL~ are both typs of passh'e tr;ua.sport -\hat iS1 no ~ncrgy is required fur the mulcculcs to move into or out of tile cell. l'ncilltotcd diffusion: a prt>coss whereby~ substance pusses throtlgh membrnne with the. nid of an intermediary or facilitator. The faoilitator i.s an integral membrane prot fin thut spans the width of the membrane. The force th. at drives th~ moleQule from one sidl' of the membrnue to the other is diffusion. Active transport: th" pltmping of molecule.' or ious through a mcmbrne against tltetr cooceurration gradient. It requires a tronsmembrnne pmtein (IISIIol/y 11 comple:r of /hem) called a trsnsponer atld ene~gy. The source of this energy is A'l'l'. Important: Most mammalian cells ITaJtst10t1 glucose lhrougb " family of membrane proteins known as glucose transpol1ers (GI11t ut SLClA fimlil,t~. Glul-1 mediates glucose transport into red cells, and thmughout the blood braJn barrier. It is ubiquitou.ly expressed and transports glucose in most cells.Giut-2 provtdt.,; glucose to the liver ~nd pancreatic cells. Glut-3 is the main trans110t1et in ueurous, wber'"'s Glut-4 i< primarily expressed In muscle nod adipose ~ssuc and 'gulntt'd by lnsuliu. Glut-S trllll-'port$ fructo<e in Ute intestine and tc.o;tis.

&IOCHEMISTRY I PHYSIOLOGY

Misc.)

Which of the following patients has the least chance of edema formation?

A patient with inflammation A patient who is standing A patient with venous constriction
A patient with arterioJar constriction

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Misc.)

Match the scenario to tbe solution options.

Solution options

Scenarios

Isotonic
Hypotonic Hypertonic

A solution that when placed on the outside of the cell will cause osmosis out of the cell A solution that when placed on the outside of the cell wall will cause osmosis into the cell A solution that when placed on the outside of the cell will not cause osmosis

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arflriolt:~r

constriction

Constriction of anerioles causes decreased capillary hydrostatic pressure and, as a result. decreased net pressure (Starling forces) across the capillary wall. Note: Ancriolar dilation increases the likelihood of edema. Venous constriction and stoodiog cause increased capillary hydrostatic pressure and tend to cause edema. lnOammation causes local edema by dilating arterioles and increasing permeability. Conditions T bal Will Cause Extracellular Fluid dema : I ncreased capillary pressure due. fo r example, to blockage of a vein. Decreased plasma colloid osmotic pressure due to decreased plasma protein concentration. Increased interstitial Ouid colloid osmotic pressure caused by a lymphatic obstruction. Increased capillary permeability, whlch may occur in certain allergic responses. Edema occurs wbeu the volum~ of interstitial fluid exceeds the capacity of the lymphatics to return the fluid to the circulation or the accumulation of fluid io a tbll'd space, suoh as the peritoneum (ascites), pleural cavity (hydrolfrnra,r), or pericardia! sac (pericardia/ effusion). Jmportant: The physical cause of edema is positive pressure in the interstitial fluid spaces. Systemic, or generalized edema, may be due to hcan failure or renal disease. Massive systemic edema is called anasarca.

lsotnnic- A ~ulutinn that \\'hC'n placed on lh( oubidr of lhl' cl'll "ill nor cause O'S mosis ll ~polonic .. .\ \oluriouth:.u ''hrn pl~trl'd on lhr outside or the cell \\all "ill caU!'il' osmosis into flu.~ crll

II)IH'rtnnic ~ t\ wlution thai \\IH.'n pl:tc('d no Ihe oul!-iidc uflhl cell will CliUSl' Wrimnsis out uf the
""~'II

AJl

solution

bas the same saJt concentration as the oorm3l ccJis

of the body and the blood. This solution, when placed on lho ouiside of a coli, will not c.ause osmosis and the cell will not shrink or swell 'lot<: Either a 0.9% solution of sodiwn chloride or " 5% glucose solution Js both :3.pproximrue1y isotonic to plasma. A hypertonic solution is a solutlon with a hlgher salt concentration than in normal cells of the body and the blood. This solution. when placed on the outside of a cel,l will cause osmosis out of the cell and lead to shrinkage of the cell. Note: Sodium chloride solutions of greater than 0.9% concentration are all hypenonic, A hypotonic solution is a solmion with a tower sa lt concentration than in normal cells of rbe body and the blood. This solution, when placed on the outside of a cell, will cause osmosis Into the cell and lead to swelling and lysis of the cell. Note: Any solution of sodium chloride whh less than 0.9% concentration is hypotonic.
Isotonic solution ~ have the same solute conc.t:nt.rations as each other. If isotonic solutions

are separated by a panially permeable membrane, the water potential wiII be the same on either side. There will he no oet osmotic movemenl of wn1er between the two solution~-;. The amount of water that moves in one direction will be exactly balanced by the amount that moves back in the other.

(siOCHEMISTRY I PHYSIOLOGY

Mise)

The method of measuring heal loss or energy loss is called:

Enthalpy Hydropathy index Calorimetry Entropy

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Misc.)

Whi<h of the following Is not an oncogene?

HER-2/neu
ras
myc
Strc

CAAT

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Decb

Culurimt'lr~

Putting a person in u rank of water and noting the temperature change in the water can measure human body heat. The body heat causes this change. Olrect ralorimetry - the measurement of the amount of heat made by the body' s processes. This is a method of measuring energy released by rite cells. Important: Oxidatin! reaclloos (e.g.. evaporation. rruliation. coJtdl/clion. a11d convecrioll) produce heat. Human caloric use can also be measured in terms of the amount of oxygen inhaled

and the amount of carbon dioxide exhaled during a given time. This is called indirect
calorimetry. Remember: Enthalpy is the heat contem of a system Entropy is a physical value that describes the degree of order of a system * ..'the second law of lbe.r modynamlcs states that in any chemical or physical process, the entropy of the universe rends to increase. The second Jaw is based on human experience. The law doesn 'r come from complicated theory and equations. So, tl1ink of these experiences that you have had: A rock will fall if you lift ir up and then let go. llot frying pans cool down when takeu ofT U>e stove. Iron rusts (1Jxidi;rcs) in the air. Air in a high-pressure tire shoots om from even a small hole In the side to tl1e lower pressure atmosphere. Ice cubes melt in a warm room. What's happening in every one of those processes'] Energy or some ldnd is changing from being loQaliled ("MIICelllrated" somehow) to becoming more spread o ut. That's the f'undamenhll science behind the second law: Energy spontaneously disperses from bmng localized to becoming spread o ut if not hindered.

c \\T
*** CAAT is the blnding site for RNA transcription facto!';.
An oncogene is a defective gene tllat is involved in triggering ~<tncer cell growth . Oncogenes are altered fom1s of genes (prnto-onf'ngener) that nom1ally arc involved

in stimulating cell djvi:;ion. These nonnaJ gene!'i are mutated and funca iou iu au
inappropriate manner in cancer cells. Important: One or more oncogenes are mntant in all fnrms of cancer. Note: A pr<Ho-oncogcnc is a gene that has functtou~ ro promo!~ coli division. Wben these genes are mUtated. defective versions of these genes arc formed (<'ll< 'ogenes). which may produce products tbat promote cell division au au abnormal fashion. A key feature Moncogene activity is tht a single altere<! copy leads to unregulated growth. Tbis is in contrast with 111mor suppressot genes, wbich otust both be defective to leatl to abnormal celt division , The following selected oncogenes have been associutcd with numerous cancer types; H.ER-2/nen.: a growth factor receptor - it has been idcntijictl in up l\1 30% of human breast cancers. ras: a sig nal transduction molecule- it has been identified in cancers of many different origins, including pancreas (90%), colon (50%), lung (30%), thyroid (50%), bladder (6%), ovarian (15%), breast, skin. liver, kidney, and some leukemias. myc.: a transcription factor- mutations itt the myc gene have been found in many different cancers, including 13nrkitt's lymphoma, B-cellleukemia, and lung cancer. sre: a protein tyrosine kinase- it was the first oncogene ever discovered. It has been identified in human neoroblastorua, small-cell lung cancer, colon and broast carclno ruas, and rhl!bdomy():;arcoma.

(smcHEMISTRY I PHYSIOLOGY

Mis c.)

"

Whioh of the following makes up most of the organic component of bone?

Collagen secreted by ostcoblasts Glycosaminoglycans secreted by ostcoblasts Collagen secreted by ostcocytes Glycosaminoglycans se<:reted by ostcoeytes

153

c.,nam c 100920to o.n.., """

(sroCHEMISTRY I PHYSIOLOGY

Misc.)

All of the following bonds are considered to be weak bonds EXCEPT one. Which one is the EXCEPTION? Hydrogen bonds Ionic bonds Covalent bonds van der Waals forces

, I "'

Weak bonds are involved In all or the following EXCEPT one. Wb icb one Is the EXCEPTION?

" )

Secondary structure of proteins Cell membrane dsONA structure Amino acid linkage

1$4 COf))'I'IJI\1 0 20092010 Dental Dtels

The organic part of bone matrix is mainly composed of type I collagen. Osteoblast.s are mononucleate boue-fonrung cells that descend from osteoprogcnitor cells. Osteoblnsts .re located on the surface of osteoid scams and make a protein mixture kuown as osteoid, which mineralizes to become bone. Osteoid is primarily c<>mposed of type I collagen.
The intercellular matrix of bone contains both o r ganic co mponents (glycosamlnogi)'ClltJ.< i11 lh~ grormd substa11ae a11d collagen fibers) and inorganic salts. The inorgan ic salts consist primarily calcium phosphate. wlticlt is present in the fonn of highly i nsoluble crys~dls of hydroxyapatite. The collagen fibers provide bone with gr<>at tensile strength, while tbe inorganic salts allow hone to withstand compression. Note: Bone is no imponaut calciwn reservoir.

or

Some of tho common glycosaminoglycans present in the intercellular matrix of bone include hyaluronic acid and chondroitin sulfate. The intercellular matrix also contains a calcium-binding protein called osteocalcin as Well 11s a C<Jicium and collugen-binding protein called ostconectin. Age, race, anti gen.der affect bone mass, smtcrural integrity, and bone loss. For example, bl~cks commonly have. denser hones than whites, and men common ly have denser bones th<tn womcu. Point to remember; Bone density and structural integrity (abi/Uy 1 0 wii!Jsraud srress) decrease after age 30 in women and 45 in men. Thereafter, a rlatively steady quantitative loss of bone matrtx occurs.

{ m :lllnt houc.h -\mino acid llnka~l'

Covalent bonds are the stl'Ongcst possible type or chentical bond. Other cuentical bonds include ionic bonds, hydrogen bond., and the van der Waals force. There are numerous other types of rare and exotic bonds. but the first four are hy far the most common. Covalent bonds are created between atoms with similar clcctroncgativity. In general, electronegativity incr~ases as you move to the right oftbe periodic table and decreases as you move down th~ periotlic table. Electronegativity is not an atomic property. but emerges when atoms imeracl with other atoms. Covalent bonds arc fo rc"s that hold atoms together. T~e forces are formed when the atoms of a molecule share electrons. 1\vo example..~ covalent bonds are peptide and disulfide bonds. Note: Hydrogen, oxygen, nitrogen, and carbon arc capabl of forming oue, two, three, and four covalept bonds. respectively. Carbon is very versatile and can form covalent single. double, and triple bonds.

or

Weak bonds may be easfly bro ken but are very imponam because they help to detennine and stabilize the shapes of biologicallllolecules. For example weak bonds are imponant in stabilizing the secondary structure (a.-helix and fl .vheet.v) of protefns. Hydrogen bond~ keep complementary strands of DNA together and participate in enzymatic catalysis. These interactions aro individually w~ak but collectively strong. Note: Denaturing agents (nrgmric solvenl.v, urea, and detegeuls) act primar ily by disrupting the bydrophobit interactions tbal make ttp the stable core of globular
proteins.

~IOCHEMISTRY I PHYSIOLOGY
r

Misc.)

I
\..

The pitch of a sound is rclolcd mainly lo which or I he following cbaraclerlsllcs of a sound wave?

Amplitude of the sound wave Frequency of the sound wave Superimposed wave Secondary waves Length of the sound wave

us
Cop)'rigltt C 20092010 Dcnb1.l [)e,. - l:'

(BIOCHEMISTRY I PHYSIOLOGY

Misc.)

(
Sodium Potassium Magnesium Chromium

The major intracellular calion is:

CopynaJ>I 0 20092010 ""'"' Oo<LJ

...

Frcqucnc~

uffht> snund \\a\C

A sound can be characterized according to its pitch, loudness, and timbre (quality). As mentioned. t.h c pitch is related to the frequenc.y of the sound wave. In general, the higher the frequency of a sound wave, the higher the pitch of the sound wave. Note: Frequency is measured i n hertz (Hz) or cycles per second. The loudness of a sound is re lated to the intensity and the amplitude of the wave. Usually. the greater the amplitude of a particular sound wave, the greater the i ntensity of the wave attd the louder the sound. Note: Intensity is measured in decibels (dB). The timbre or quality o f a sound is related to the presence o f additional sound-wave frequencies s uperimposed on lite principal frequency.

Pot:ts-.ium Functionally. the body's water is effectively companmentalized into two major fluid compartments: L n tracellular Fluid (JCF) comprises 213 of the body's water. If the bodynas 60% water, the ICF is about 400/o of the weight. The ICF is primarily a solution of potassium and organic anions. proteins, etc. The cell membranes and cellular metabolism control the constituents ofthis JCF. The lCF is not homogeneous in the body. The JCF represents a conglomeration of fluids from all the different cells Extracellular Fluid (ECF) is tbe remaining l/3 of the body's water. TheECF is about 20% of the weight. The Cf is primarily a NaCI and NaHC03 solution. The Cf is furlher subdivided into three subcompartments: I. Interstitial fluid (!SF) surrounds the cells, but docs not circulate. It comprises about 314 of the ECF. 2. Plasma circulates as the extracellular component of blood. Plasma makes up about 1/4 of the ECF. 3. Transcellular fluid is a set of fluids that are outside of the normal compartments. These 1 -2 liters of fl uid make up the CSI'. digestive juices, mucus, etc. The 6040-20 Rule: 600/o of body weight is water 400/o of body weight is intracellular fluids 200/o of body weight is extracellular fluid 1 - - I.AII the body's fluid compartments are in osmotic equilibrium (e.<ceptfor transielll / Notes changes). 2. The ions and small solutes that constitute the ECF are in equilibrium witb similar
concentrations in each s1,1bcompanmem.

3. The ECF volume is proportional to the total Na content.

~IOCHEMISTRY I PHYSIOLOGY

Mise)

When the ambient temperature is above body temperature, which heat transfer mechanism(s) is (are) used by the body to transfer energy from the body to the environment?

Radiation Conduction

Convection
Evaporation of perspiration All of the above

151 Copyngtlt 0 20092010 Otntl Dk.s

~IOCHEMISTRY I PHYSIOLOGY
Which of the following solutions has an osmotic pressure different from the other two solutions?

Mise)

I M glucose

I M sodium chloride I M potassium nitrate They all have the same osmotic pressure

151

CopynaJnC 20091<110 ll<ma1 o..u

1:\apttralinn uf fh.r-.piratiun When the dmbicnt temperature is ubove body t~mperature. tben radiation, conduction, and convcchon !111 tran<fcr heat 11110 the body rather than out Stnce there must be a net outward heat transfer, the only mcchamsms left under those cond1hous are the evaporAIIOn of pcropiration from tbc nkju und tl1" evaporative coohnt.: from exhaled moisture. Tbe bumnn body has the remarkable capucity for regulaung its cor~ tcmpel'ftture somewhere between 98F and 100F when the ambiem temperature is between approximately 68F and 130F. The temperature of the body is regulated by neural feedback me<hanlsm thm operate primanly through the hypothalomus. The hypothalamus contams not only the control mechanjsrns but also the key temperature sensors. Under control of the.'c mechanisms. swealing begins almo>t preci>dy at a skin temperature of 37C and increases rapidly as che sk.in cemperature rises above lhis value. The beat production of the body under these conditi011s remains almo;t constant as the skin lcmpcmmre rises. If the skin temperacure drops he low J7C, n variety of respouses are mitinted to conserve the heat in lhe body and to increase heut production, These include: vasoconstriction to decrease the 11ow of heat tn the skm, ccsntion of sweating, sh1vcring Ul increase he~t production ill che muscles and the ~ecretmn of norepinephrtoe, cp1nepbrine, and thyrOKine to mcrcase beat productiOil. Shhering IS the most pote<lt mechanism for increasing heat production. Radiation is beat transfer by tbe emiSSIOn of dcctromagnettc waves that carry <n<rg) away from the emitting object. Conduction i\ heat lransf.r by means of molecular agicauon within ~ material without any mouon of the material a.' u whole. Connctlon is heat transfer by mn~s motion of n fluid such as air or wuter when tbe heated fluid is caused to move awuy from th~ sttlrce of heat. carrying energy witlt it.

1 \ I !.!111\nw

u The key lo th1~ question is Ute facti hat osmotic pressure of a solution depends on the number or solute particles precnt and no1 on their V:trluU> prop<rues. Soctium cbloude nod potassium cblonde "Ill tomze into two ions p~r molecule, "b"n!tiS glucose w1ll remain a single molecule in >nlution. Osmosh is the net diffusion of Wolter lhrough a semipem1enhlc membrane caused by n conccntrlltion difference .
Osmotic preSNure is the pressure lhat develops in a solution a. !I I'Csult net osmosis into that solution: <>stnotic pi'CS>urc is offccred by the number uf dissolved particles per unir volwne of Ouid. Not~: l nhacellular (fluid witlti11 cc//.1/ and extrac~liutar (lmerstitial fhlicf tllld plrunra) nuids have silllJiur total osmotic pressures. Osmolarity IS expressed Ill ofosmole. JI'!T ht<r or solution (o;mol:L). lali1y is defined a.< O<moles ~r kilogram soh ent (o:.mollkg).

or

uruts

1\ hlie osmu-

While similar, o;molarity and tonicity are 1101 che <alP!!. The key difl'creuce between tbe lwo thai osmola1ity is a 111easure of all solutes in solution, whcrens conicity is a measure or lmi>CI'IIIC&ble solutes. O;molnrity compares the amoUilt of solutes Itt two solution>, whereas tonicity compres the osmotic pressure grndlcnt. lf n solution in compartment A ;, hypenonic 111 a sohtliou In compartment B, wuter will Oow from co111panment B to compartment A in an effort 10 dilute the soluteli '"compartment;\, l'his allows the two companmeuts to have equol solute concentrotion.

~IOCHEMISTRY I PHYSIOLOGY
Which of the following stoterne nts concerning the two principal laws of thermodynamics is false?

Misc.)

They apply only to closed systems, that o s, entities within which there can be no loss of energy or of mass The first law says that the total quantity of energy in the universe remains constant

(this is the principle of the conservation of energy)

The second law stmes that the quality of this energy is degraded irreversibly {this

is the principle of the degradation of energy)

The second law, known as Camot's principle, is controlled by the concept of entropy The two laws describe the concept that Delta G is positive in an exergonic reaction 159
Copyright C 20-l O I0 Der mal De~:k:.f

(BIOCHEMISTRY I PHYSIOLOGY

Misc.)

Isotopes of an element:

Have different chemical properties but the same weights Have the same chemical properties but different weights Have different chemical properties and weights Have the same chemical properties and weights

I hl' tno rc;Jdinn

lan~

dcsrrihc the concept that l>elta c; is posith c in an

l'\t'r~onir

The principle energy Jaws that govern every organization are derived from the two famous laws of thermodynamics. Heat, being a fonn of energy, is subject to the principle of energy conservation; this princ iple is called the first Jaw or thermodynamics Tbe total energy, including heat, in a closed system is conserved. Heat, being a form of energy. can be transfomed into work and other fom1s of energy, and vice versa. However, this transformation of heat energy is subject to a very important restriction, called the second law of thermodynamics.

It can be given in three equivalent forms: I. Heat flows spontaneously from a hot body to a cool one 2. One cannot convert heat completely into useful work 3. Every isolated system becomes disord ered in time
*** Entropy is a measure of the degree of randomness or disorder of a system. Certain chemical reactions proceed spontaneously until equilibrium is reached. Reactions that proceed with the release of energy are exergonic. Because the products of such reactions have less free energy than the reactants, the free-energy change (aG) is negative. Chemical reactions in which the products have more free energy than the reactants are endergonic. For these reactions, the 4G is positive, and heat is consumed as a reactant.

HaH tht. samr chl'mical properties hut differcnl \\{'ights

Atoms of the same clement can have different numbers of neutrons; the different possible vers ions of each element arc called isotopes. For example, the most common isotope of hydrogen (protium) bas no neutrons at all; there's also a hydrogen isotope called deuterium, with one neutron, and another, tritium, with two neutrons. Isotopes are stable or radioactive forms of an element that differ in atomic weight but are otherwise chemically identical to the naturally abundant fonn of the element. Isotopes of a given element have the same number of protons but differ in the number of neutrons. Important point: Isotopes have the same atomic number but different mass numbers. Remember: The atomic number is the number of protons, and the mass number is the stun of prmons and neutrons. Note: The radioactive fonns of isotopes arc often used as tracers m medical rad.iograpby.

(sroCHEMISTRY I PHYSIOLOGY

Mise)

Growth and preparation of the chromosomes for replication occurs in which phase of the cell cycle?

175
181
Copyright C
2~2010

Dcn1111 Decb

(smcHEMISTRY I PHYSIOLOGY

Mise)

Which class of antibody constitutes about 75% of the antibodies of the normal person?

lgA
lgD

lgE
lgG lgM

112 Copyna;ht c 2009-2010 OcntaJ Db

The cell cycle is an ordered set of events, culminating in cell growth and division iuto two daughter cells. The stages are G 1- S - G 1 - M. The G 1 stage stands for "GAP 1" The S stage stands for " Synthesis" (lhe S!age ll'hen DNA replication OCC'III'S) The G 2 stage stands for "GAP 2" The M stage stands for "Mitosis" (lite slage when n uclear clrromosomes separate and cytoplasmic (cytokinesis) divisio11 occur). Mitosis is further divided into 4 phases: (telophase, inrephase, metaphase, and anaphase) T he cell cycle consists of the following: G 1 =growth and preparation of the chromosomes for replication

S =synthesis of ONA (and centrosomes) G, = preparation for mitosis

M =mitosis The period between M and S is called G1; that between Sand M is C1 . Note: Maoy times a cell will leave the cell cycle, temporari ly or pennaneotly. The cell exits the cycle at G 1 and enters a stage designated G0 (G zero). Many Go cells are busy carrying out their functions in tbe organism (e.g., secreiion, a/locking pothogen<). Important: Protein and RNA synthesis occur in all phases of the cell cycle except M (mitosis). A eukaryotic cell cannot divide into two, the two into four, etc. unless [\VO processes alternate: doubling of its genome (DNA) in S phase (~)'11/hesis phose) of the cell cycle. halving of that genome during mitosis (M phase).

Antibodies are protein molecules produced by plasma cells in the spleen and lymph nodes in response to stimulation by antigens. Antibodies leave the inunune system environment and travel through the circulation to the infection site. Here they interact with microorganisms or other biochemicals and exert a specific immune response. Antibody molecules are composed solely of protein; a typical antibody molecule consists of two "heavy~ chains of 400 amino acids and two "light" chains of 200 amino acids.

&urftlce bssu.:s; S)1ltbt-si:z00 by tJ>e p13.$1llll urim'lry &met&.

1,&0
~'es as tht roecpton.itc on the surface oflhe B lyml)hoc~es: function U unkno\'1 nor not fully undc!l-tood.

JgM

antibody units; lmponan~ in the pcirnary a111ibody response; fint an" antigen stunul:tliQn; does noi pass i.bt. plpeentil or (011" the feud

lgE

Is presc:nt in Oflly trace *moun1.~ in s'-rum~ reaginic uctivity re:sidC$ in lhe immunoglobulin: protects ~xlem.1l murosal surfaces, tia.tnly bound coils receptors on m~1 odls and bssophil$~ tesp>nsib-le fi.'lr I)'PC I
h>l)cr5eO.'iill\'it_y

GnocHEMISTRY 1 PHYSIOLOGY

{rhree patients Ingest three different substances. Match the substance to \... description of the patient's urine.
Jim ate a substance that is filtered into the renal tubules but is then reabsorbed fully
Art ate a substance that is filtered and excreted, so the en-

t~

Inulin

Glucose tire amount of substance was released in the first pass Matt ate a substance that was freely filtered and neither secreted or reabsorbed Para-aminobippurate (PAll)

Which patien t is being tested for his glomerular filtration r ate (GFR)? )

1$3

COflrriaMO 2(109.2010 Dcnt.al Dr<ls

(BIOCHEMISTRY I PHYSIOLOGY

(\.

The thick ascending limb of the loop of Henle is called the "diluting segment" because:

Sodium chloride (NaCI) is reabsorbed with n proportional amount of water Water is reabsorbed from the rubular lumen Water is secreted into the tubular lumen Sodium chloride (NaCI) is reabsorbed without water Sodium cblol'ide (NaCI) is reabsorbed and wnter is secreted

Ccp)'nghl 0 2(109..2010 Dctltal Dtds

...

12

 .lim a h. f.,!IUC'OS{!

Art ate PAH :\laH ate iuulin Inulin was caleu

h~

Matl. ami hl' is hrinJ.! leo.;, ted for his GFH.

Inulin is a starc.b i.bai is giveu by mouth. Insulin is freely tittered from the glomerular capillaries into Bowman's capsule. but insulin docs not undergo l\>bular secretion or renbsorption. The glomerular Oltrnlion rat (OFR) cnn be calculated by the clearance of inulin ttom plasma. The rate ot which a suhstQnce is cleared rrom plasma= plasma volume completely cleared 1 unit time= (lbe urin concentralion of the snbstaoce urine volume) I plas ma cuncentratlon of' the substrate.
I mportant: 1f the clearance of a substance that i~ frc~ly fihrnted i! less than that of inulin, then there is n net reabsorption of ihe substance, If tho clcaranc of a subslllllcc that i8 free ly filtered is greater than rhnt of hmlln. then thcr. is " nee secretion of the Sltb~rance. If the dMruncc of a freely filtered substance is equal to that of inulin, then ( I) it is neither secreted uor absorbed <)r (2) it i~ h~ th secreted and absorbed in equal umounl$. I. PA H is both filtered and secreted and is used 10 estimate rcual plasma Note.- now. Glucose ll/lU sodium <'hloridc are filtered "nd subsequently teobsorbcd, 2. Assessment of blood urcn ultrogtlu (BUN) and se.rum creatinine can also bo used 1 0 estimate tlto GFR. Some literature states that the most accurate measure of GFR is creatine clcarnnce. 3. Jftbe amoum of a substance excreted in the urine is le.ss than Ute a mount nJtered, then the substance is reabsorbed.

Sudium t." hlnl'itlc (\a('/) i!<i n.ahsurhcll \\hhoul \\:ttcr

The nephron is the bosio structural and functional uni> of the kidney. Tite ncpbron's chief functfon i~ to regulore the concentla~Otl ol'"'aiCrMd soluble substances like sodium sahs by filtering the blood, reabsorbing what is necded1 -a(ld ei(CTC:1in.g the tt:sl ~s urine. Two general classes ofncphrons arc corneal ncphrons and j uxt:lmcdulhlry nepbrous. Cur tical nephro!l$ have their renoI corpuscle in the supcrfic>al renal conex, while the renal corpuscks ofjt.xtomedullory ncpbrons arc located near the enal medullu. l'unctionally, cortical and juxtamt'dullary ncphro11s have distinct roles. Cortlcol nepbrons (85% ofall nephmns) mainly perforn1 excretory and regulatory function,. whOe joxtamedullat1' ne1>l'~rons (15% ofuephrmrs)
concentrate and dilute urine. Tile now of tho renal tubule is"" follows;

'fbe pro~ltnaltubule: fh1 id in the filtl'dtc cmenog the pmxim"l convulutcd tubule is rbsorbed into \he peritubuJoJ' capillaries, iltcluding approximately two thirds of the filtered sal\ and wAter und all filtered organic solutes (pr;marif.l' glt;Othe <md amino add.~). The loop of Arnie extends troru the proximal tube and consist.; of;} descending. fimh and a-.cendi~g limb. The loop or Htnlc begins in the cortex, rccetviug t11lruto fmtn the proximt convoluted tubulo, cxtcnd.5 into the medulla, and then returns to the cortex to empty into > he dish> I convoluted tuhulc, The luop ofHeule';; primary role is to concentrate the ~all In the'""
tcrstirium, the tis..~ue surrounding the: loop.

I, Its descending lfmb is penneuhle to 1ater but completely impermeable to .<111 1, Bl\d
thus l'nly inditectly contributes to the concentration of the imersthimn.

2. Unlike Ute dcsccudiug limb, tho acendlog limb oflhc loop of Henle is impermeoble to Water, a critical fe.oantre or 1he countercurrent ex.rhaoge tnffh: m ism employed by the loop. The ascending limb artivcly pum~ sodium out of the Iii Irate. gencrotiog ~'" hYJ!ar. tonic interstitium that drives countercurrent exchange. Much of the ion trun.,polt ta~ing place i~ ti1C distal convoluted tubule is r<gulnted by the
endocnnc S)'~~tem. Cn lhe JI'Csentc Of"J>HrUtbyro1d bOJ"DlODt', the distal C'.OJ'IVO(Uted lubulerc-absorbs more cutQi\lm tal'ld cxcr\!tcs more phosphate. When aldosterone i Jo; present.,. mort.~

sodium is re;,hsorlx:d, .md more po>Msium e~ctcted.

~IOCHEMISTRY I PHYSIOLOGY
The kidneys regulate acid- base balance by the:

Secretion of bicarbonate ions (HCO;) into the renal tubules and the reabsorption of hydrogen ions (If") Secretion of hydrogen ions {lr) into the renal tubules and the reabsorption of bicarbonate oons (HCO;) Secretion of both hydrogen (/1) and bicarbonate ions (HCO;) into the renal tubules Reabsorption of both hydrogen (/1) and bicarbonate ions (HCO J)

185
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Dffi:s

~IOCHEMISTRY I PHYSIOLOGY
Is the best overall Index of kidney function.

CPR

TFR

GFR

1H

CopynPt 0 20092010 Dttltal DLs

S~:rntion

uf h)dnJ;!l'n ions (H) into rlu.. nmal tuhul""' nnd fhl' nHbsorptinn

ul hkarhonatl' ion(i (I/C0 1 )

There are three prtmary systems tht regulate the bydrog"" ion concentration in tht body fluids: I . The chomkal acid base buffer system of01e body fluids, which immediately combine with acid or base to prevent cxctsslvc changes in hydrogen ion concentration+ 2. The respiratory center, which regulates !he removal of CO, (and therefore H1CO;) from !he extracelluar fluid. 3. The kidneys, which can excrete either acid or alkaline urine. thereby readjusting the ex:traccJiular fluid hydrogen ion concentration to\vard nom1al during :,~cidosis or alkalo sis. The kiOneys, although providing the most powerful of an the acid-base regularory systems, require many hours lo several days to readjust !he hydrogen ion

concentration.
!'he hydrogen ions are secreted into the tubules by tubular cells. The secretion mechanism derives hydrogen lons from carbonic acid. The enzyme carbonic anhydrase is present within tubular cells. and it catalyzes the formation of carbonic acid !rom carbon dioxide and water. The carbonic acid dissociates into hydrogen ions (H) and bicarbonate. ions (HCO,). The H ions are secreted mto tho tubules, an<llbe th" HCO, ious pass out of !he tubular cells aod ioto the blood. " Phosphate compounds (HPO,') and amJilonia (NHJ act as buffers 10 tie up hydrogen ions in the rubular fluid. Phospllate compounds are excreted in combination with a cation such as sodium (Nai), Ammonium ions are excrete.d in combination with anions such as cWoridc (CI'). I. Anunonia is fonncd m the tubular cells by thc deamination of certain ammo "'"'"' acids, particularly glutamic acid. 2. Pbosph:ttc and a.mmonium excretion measurements provide good information on how much acid is being eliminated by the ktdneys.

The glomerular filtration rate (GFR) is the rate at which the glomeruli filter blood, normally about 120 mllminulc. GFR depends on: Penneability of capillary walls Vascular pressure "Filtration pressure Clearance T he G FR Is incr ea;ed by: Vasodilation of afferent arterioles: inc.rcases the glomerular capillary hydrostatic pressure and increases renal blood !low (RBF). Vasoconstriction of efferent arterioles: also increases the glomerular capillary hydrostatic pressure. Decreased hydrostatic pressure in Bowman 's capsule: blockage of urine transport through the ureters 'VIII fncrease hydrostatic press\>re in Bowman's capsule and cause a decrease in GFR. Decreased plasma colloid osmotic pressure: associaled with a decrease in the concentration of plasma proteins. Remember: lf the tubules neither reabsorb nor secr ete the substance-- as bappeus wltll inuli1 1 or creatine - cleacance equals the GFR. lf the tubules reabsorb th e substance, clearance is less than the GFR. lfthe tubules secrete the substance, clearance excee.ds the GFR . If the tubules reabsorb and secrete the substance, clearance may be less than, equal to, or greater than the GFR. Note : Excessive constriction of the efferent arteriole will decrease RSF ancl G FR.

~IOCHEMISTRY I PHYSIOLOGY
The countercurrent mechanism is a system in the renal - - - - - that facilitates the of the urine. The system is responsible for the secretion of urine in response to plasma osmolarity.

Con ex I concentration I byperosmotic I elevated Medulla I dilution I hypoosmotic I depressed Concx I dilution I bypoosmotic I depressed Medulla I concentration I hyperosmotic I elevated

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Reabsorption of glomerular filtrate would be most affected if modifications were made to the permeability to which section of the nephron ?

Descending loop of Henle Distal convoluted tubule Proximal convoluted tubule Ascending loop of Henle

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ml~dulla

I concentration I h) pl~rosnwtic I t!ll'' :~ted

The countercurrent mccbani.s m is a system in the renal medulla that faci li tates concentration of the urine as it passes tbr~>Ugb the renal tubules. This mechanism is responsible for the secretion of byperosmotic urine in response to elevated plasma osmolarity aod requires the penetration of the loop of Henle into the renal medulla for the development of a medullary osmotic gradient. The mechanism depends on the special anatomical a.rrangement and transport propenies of the loop of Henle. I mportant: The kidney dialysis machine is an example of a countercurrent mechanical system. The countercurrent multiplier in the loop of Hen le is dependent upon the active reabsorption of sodiwn chloride by tlte thick ascending loop or Henle, the osmotic equilibrium between interstitial fluid and tubular flwd in the descending loop of Henle, and continued inflow of new sodium chloride from tbe proximal tubule into the loop of Henle. The sodium ch Iori de reabsorbed from the ascending loop of Henle keeps adding to tbe newly arrived sodium chloride, tbus " multiplying" its concentration in tbe medullary interstitium. Countercur rent exchange occurs in a region of the peritubular capi llary bed called

the "vasa recta.''

Important poin t: The vasa recta do not create the medullary hypcrosmolarity bu t do prevent it from being dissipated and can carry away the water thm has been reabsorbed.

*** Approximately 2/3 of the glomerular filtrate is reabsorbed in the proximal

convoluted t ubule. This includes almost 100% of the filtered glucose and amino acids. Glomerular filtration is the filtration process as blood flows through the kidney. Some of the plasma ( 16% to 20%) is filtered out oftbe glomerular capill aries and into the glomerular capsules of the renal tubules a.~ the glomerular filtrate. This filtrate contains most plasma components but is free of large proteins. The Excretion Rate; Tbe Fil tration Rate - Reabsorption +Secretion Reabsorption is the movement of solutes from tubular fluid into interstitial fluid. Reabsorption takes place not only in the proximal tubule but also in the loop of Henle, the distal convoluted tubule, and tbe collecting duel. Processes include: primary active transpon, secondary active transport, faci litated diffusion. simple diffusion. and solvent drag. Transport can be either transcellular or paraccll ular. Secretion is the movement of solutes from the interstitial fluid into the tubular fluid,

G_noCHEMISTRY I PHYSIOLOGY
#' Your afternoon patient complains that she has consumed "tons of liquids" ""
today. The patient asks if this will have an effect on her urine concentration. What would you say in response to this question?

Your plasma osmolanty ts lower than nonnal, and you will likely excrete a large amount of concentrated urine Your plasma osmolarity is lower than nonnal, and you will likely excrete a large amount of dilute urine Your plasma osmolarity is higher than normal, and you will likely excrete a large amount of concentrated urine Your plasma osmolarity is higher than normal, and you will likely excrete a large amount of dilute urine
What are the normal values for daily glomerular filtrate amount and excretion amount, respectively?
150-250L; I-2L 150-250L; 12L 45 75 L; I - 2 L 45 - 75 L; 12 L
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Ammonia is produced from the metabolism of a variety of compounds. 1. Wbiclt compound listed below is quantitatively the most important source of ammonia? 2. Which compound is not a source of ammonia? 3. Wbicb compound is converted to ammonia mainly in the kidney?

Glutamine Amino acids

Amines
Puri nes and pyrimidines Triglyccrides
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\our (>lasm~ osmolaril) is hi~hlr rlum normal. and ~ ou \\ illlil\tl~ excrete a 1.1rgt amount of dilute urine l>olil~ c;FR in normal indhidual~ is \ariahlc. ''ilh a nmgc of 150 to 250 IJ 2.a hr and I - 2 L nl urine (trndured per da~

When tubular secretion and reabsorption processes are completed, the fluid remaining within the tubules is transported to other components of the urinary system to be excr eted as urine. Urine consists of water and other materials that were filtered or secreted into the tubules but not reabsorbed. Although the daily GFR in normal individuals is variable, with a range of 150 to 250

U24 hr., the kidneys nom1ally excrete only I to 2 L of urine per day. Approximately
99% of the filtrate is returned to tbe vascular system, while I% is excreted as urine. Water and substances the body needs are returned to the blood, whereas waste products and excess fluid and solutes remain in the rubules and are excreted from the body as urine. Note: In response to elevated plasma osmolarity, a small volume of concentrated urine will be produced . If plasma osmolarity is lower than normal , a large volwne of dilute urine will be excreted.

1. Amino :1cids 2. Trigl~ reridl's

-' Glutamim'
Sources of Ammonia: 1. From amino acids: many tissues, but particular ly the liver, form ammonia from amino acids by the aminotransferase and glutamate dehydrogenase reactions. 2. From glutamine: the kidneys (specifically, the tubular cells) form arrunonia from glutamine by the action of renal glutaminase. Most of this ammonia is excreted into the urine as Nl-l~, which is ali important mechanism for maintaining the body' s acid-base balance. 3. From amincs: amines obtained from the diet and monoamines that serve as honnoncs or neurotransmitters give rise to ammonia by the action of amine oxidase. 4. From purines and pyrimidines: in the catabolism of purines and pyrimi dines, amino groups attached to the rings are released as ammonia . Note: The formation of urea (which is a main producr of prorein nitrogen metabolism) itt the liver is qualitatively the most important disposal route for ammonia. Urea travels in the blood from the liver to the kidneys, where urea passes into the glomerular tiltrate. Important: Excessive accumulation of uric acid crystals in the blood causes gout. Remember: Arginase directly catalyzes utea formation in a cell.

GmcHEMISTRY 1 PHYSIOLOGY

1. Which of the following processes is not involved in the formation of urine?

2. Which two of the following processes in the formation of urine involve the most similar amounts of lluld tr ansport?

3. Which two processes s upplement each other, working in the same "direction":
4. Which process is most affected by levels of ADH? 5. Which process occurs in Bowman 's capsule?

'
Filtration Reabsorption

Tubular excretion
Secretion
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Which cardiac muscle has a longer refr actory period?

Ventricular muscle ALrial muscle

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l. Secntinn -- urirh' h. "l'cri.t(d fiOCt' it I\ formed. ~tcrNiun is nut part or fornwlinn 2. Filt1a1inn and n ahc;mptiun -- ahnut '1')0 /0 of th( lillr:lh. is re~thsorbt:d 3. Filtr~Hion ;uu.l tubular e\cretinn - hnth 'end suh\tanrrs from hluot.lto tuhul~:s 4. ftcuhsurptiun 5. filtntlion

The tonnation of urine had three processes: foltrotlon, r eabsorption, and tubular
~~crtHon.

During filtration, or glomerular excretion;l blood pressure forces aJI the !\maJI

tnolecules in the blood imo the lumen of the nephron through the pores both in the walls oft he glomerular capillaries and in the wall of the 6owmaus capsule. The li lt rate has tbe
.sam~

concentration of dissolved substance.~ as the blood miuus the formed eh:menls :md

the plasma proteins that are too large to fit through the pores of the capillaries s ud the Bowman's capsule. As the filtrate passes through the tubules of1he netlh on, water and many ~issolved materials arc reabsorbed by the blood. In fact, during the filtrate's passage through the tubules, up to 99% or the. water is reabsorbed. In addition, the tubules also remove .substances rrom the blood. This process, called ntbular excretion, supplements the initial glomerular liltration. Nonnal urine is clear, nraw-cotored, and SliGhtly acidic, ~nd has the characteristic odor of urea. The formation of urine is imponam in the regulation of acid-base balance. maintenance of ECF vohtme and blood pressure, and In maintaining the normal osmolarity of ECF. Diuresis results from a decrease in the tubular reabsorption of water.
1ossible Cause.~ of Dilute Utlne l'ossible Causes o(C()ntcnlrated Urine

Absence ofADH Diabetes insipldu

Decuasc:d plasma volume Cellular dehydrotion Diabetes mellitus

Exce.sS-AOH

\"enlricular muscle- 0.2=' lu 0.-' Sl'Conrls

Atrial muscle bas a refractory period around 0.15 seconds. Therefore, the rhythmical rate of contraction of the atria can be mocb faster than that of the ventricles. This tong refractor y period (also called ahsolme refraciOIJ' period) of cardiac muscle i~ responsible for preventing the heatt from undergoing rc entry, which would not allow the heart to relax lltld refill with blood. [mj>Ortant: ( I ) By preventing pre.mature. recntry, cardiac muscle is prevented from ever undergoing tetanus. (2) TI>e strength of cardiac muscle contraction is increased when extracellu lar Ca" is

increased.
for comparison, the tfme required for excitation to spread throughout the heart is 0.22 seconds , Important: Skeletal muscle cells have a short refractory period that allows them to be s timulated to contract u second time before they have relaxed from an initial contraction.
1\\'0 types of refractory periods:

I, Absolute: is the period during whicb another action potential cannot be elicited. no matter how large the stimul us . Note: The length of the absolute refractory period of an action potential is determined by the duration of~odiwn inactivation gate closure. 2. Relative: begins at the end of the absolute refractory period and continues until tho membrane potential returns to the resting level. A second action potential can be elicited only if the Slintulus i~ larger than usual.

~IOCHEMISTRY I PHYSIOLOGY
Which of the following valves is located between the right atrium and right ventricle? Mitral valve Tricuspid valve Pulmonary semilunar valve Aortic semilunar valve Which valve is unique in having a different number of cusps than the others? Mitral valve Tricuspid valve Pulmonary semilunar valve

Aortic semilunar valve

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,
I

The T wave of an electrocardiogram wave segment represents the of the

Depolarization f atria Depolarization f ventricles Depolarization f atria Depolarization f ventricles

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t ric u,Jml ' ~IIH' \1ilr:tl \,lhl' thltli'J''J \UinJ

The bean tOn)i)IS

or four chambers: two iltna fuppu chambers) and l\lO vcntncles (l()ker

chumhers). There " \'alve through whocb blood poe> before leaving ""ch chamber of ohc
hearl Tht vah'h prevent the backward Oow of blood. These valves are actu31 llap~ that are loculed on coch end or lhe two ven1riCllcs (lower clwmbers of 1/ze hear/). They acl us one way inlets of bloud on one: side of a ventricle ond one~ way ou1le1s of blood on the t)lhcr side of a ventricle. 1'hc nrrfoventrlcular valves arc tuugh. fibrous llups of cndocurdiwn. Both are SttUr\!d IO pap1lllll')' nlUSCles or tht: VCr'llriCul3r Wall$ by chordae tendineae. The trlc:u~pld valve b located between the right 1!Hnum am.l nght ventricle. ~urruunding

the AVon lie<:. The lricuspod valve l5 composed or lhree CUJpS thai pn:\cnt. backOO\\ or blood from the n1.h1 \CDtriclc: into the right amum during ventricular contmcuon. The mitral (bicuspid) vahe I$ localtd 1><1\\en> the left atnum nd lhc lcfl cnlnclc. surroundmJ! dw AV onfice. The rnitra1 \'81\t 15 composed (\f two (Utp' that prevent a backtlow of blood from the left ventricle 10 the left a1nun1 during' entriculll! eontrac1ion.
Note: These vnJvcs nre open during vrntrlculnr dfnstole, but L hey are forced Ji.hut as the pressure in the vcouicles increases. thus prcvcnHng the now of blood back Into the- otrio while the vcnlriclc.s nrc COIHractir\g. The pulmonary semnunar " 'alve is located ot the cnnonce 10 th\! pulmonary lrunk II is composed of three cups that preven1 the bocktlo"' of bhKI [rom the pulmonory anery ln1o tbe righr \CDtnclc during \'entncular rela:uuon The aortit' .semilunar \'alve 1s located at the eou..ucc lo 1hc uccndong aona. II os composed or lhrM cusps lhat prevent a bae~llo" or blood from the aona toto the left ventricle dunnJ vcntncu1ar rclaxauon. Th~ val\'c~ arc opto during \'tntricular J)\lole.
Jmpor,..nt: At no lime during lhecordiac eye I~ time.
or~ a litho \OIVCJ ofthc heal1

open a11he some

npnlar11:ttiun f 'L'nlril'h.'

An electrocard1osram (ECG or EKG) is a tc>t that measures the electrical activoty of the hean. The signab thai make the bean, muscle fibers contract come from the sinoatrial nude, whlcb IS lbe natural pacemaker or the hearl. The prutclpal ECG intervals are bet-..een the P, QRS. and T waves.

Remember: I , Tbe P wa1'C is I he electrical recording from the body surface of nlrlnl depolarization and precedes atrial contraction. 2. The QRS com111ex represents vcntl'lcular depolarization. 3. The lirst hcnrt sound represents closure of the AV valves at I he on>ct of sys10le. 4. The stcond heart sound represents closure of the semilunar valve> at the onset of <tias1ole . .."There is no dislinctly VISJble wa'e representing atrial repolarlzation in tbe

ECG because alnal repolariutioo occurs durin& ventricular depolanzauon. and is thus obscured. I . An ECG thai shows extra P waves before each QRS complex indicates
Noles (JnrtJal heart block (or second-degree block), 2. A11 ECG thai shows the I' wnvc and the QRS complex being dissociated is indicative of complete bc:u't block: thnr is, there is no corrclnlion be1ween lbe P wave and the QRS-T complex on 1he ECO.

~IOCHEMISTRY I PHYSIOLOGY

\.

Cardiac function is the volu me of blood pumped each minute, and is expressed by which equat ion?

CO=SV -HR

co= sv + l!R
CO = SV x HR CO =SV I HR

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The Bainbridge reflex, also called the reflex, Is an Increase in heart rate due to an increase in t he blood volume_

Ventricular Atrial
Mitral

Semilunar

11t
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CO " S\ ' IIR

Where: CO is cardiac output expressed in L /min SV is s1roke volume per beat HR is the number of beats per minute Car diac outpu t (CO) is perhaps tlte single most important filctor that is used in relation to the circulation, for it is the CO that is responsible for transport of substances to and
from the tissues. The average resting c ardiac output is about 5.6 1i1ers per minute for men and 10% to

20% less for women. CO varies depending upon the level of body activity, age, body size.
condition of the heart, etc.

Heart Rate (HR) is directly proportional to cardiac output; an adult HR is nonnally 80100 beatS per minute (bpm). HeMt rate is an intrinsic facto r of the SA (pacemaker) node in the heart, and is modified by autonomic, humoral, and local factors. Stroke Volume (SV) is detemtined by three factors: preload, afterload. and contractility. The preload gives the volwne of blood tbat the ventricle has a'ailable to pump. as well as the end diastolic length of the muscle. The contractility is the force ~tat tho muscle can create at the given length, and the afterload is the arterial pressure against which the muscle will contract. SV =End Diasto lic Volume - End Systolic Volume ** The average SV is 70 to 80 m l Impor tant: The cardiac output of the left and right sidos of the heart is equal, Blood ejected from the left side of the heart to the systemic circulation must be oxygenated by passage through the pulmonary circulation. Total peripher al resista nce (TPRJ is the sum of the resistance of all peripheral

vasculature in the systemic circulat-ion.Thus we- have the equation. BP = COx TPR. This is one oftlte t\wdamental equations of cardiovascular physiology. You can sec from the equation that blood pressure can be maintained by altering cardiac output and/or total peripheral resistance.

\trial 11tc Bainbridge reflex is an increase in heart rnte caused by a rise in pressure of the blood in the right atrium due to increased flow and/or pres.,ure in the great veins at rigltt atrium s entrance. This reflex increases the heart rate and cardiac outpm, which then transfers blood volume from tbe pulmonary circulation to the systemic circulation. Note: Receptor cells in the right atrium are sensitive to pressure and stretch. This reflex helps prevent the accumulation of blood in the pulmonary circulation. wbicb could lead to pulmonary edema. The baroreceptor reflex is the dominant cardiovascular mechanism responsible for control of blood pressure. Stretch receptors located in the carotid sinus and aortic arch send afferent impulses via the glossopharyngeal and the vagus ner ves to the n ucleus solitarius located in the cardiovascular center of the medulla. The bruoreceptor reflex plays a domitUtnt role during acute blood loss rutd shock.

~IOCHEMISTRY I PHYSIOLOGY
Use the same answer options for the following questions.

( I. Your p atient has a defective mitral valve, allowing backflow. Which ofl
\.. the following cardiac phases will be least affected by t his defect? } 2. Normally, which phase would have the highest ventricular pressure? Jsovolumetric contraction Filling phase Isovolumetric relaxation Ejection phase

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The first heart sound corresponds to which two valves closing?

Hrt)

Pulmonary valve
Aortic valve

Mitral valve

Tricuspid va1ve

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I. lillin~ pha"'e- br-cau't.' tin mitral \:IIH '' upln throu~h Ihi' ph!.l\t. nurmulh 2. I JL't'liun ph:t'l' - i-.o\nhlm rldt rnnlmtlmn \\uuld h~n, an incr":l\inc. pn-..,un n:,.:ht UJl unlillhl' \'jC<'tinn "lwn lh~ pn.-...,un \\nuld bl the highl""t The $J1011taneous gener.nion of an ac11on poten~oal withtn the SA node imuau:s a sequence of e\ents known as the cardiac cyde. Elich cardtac eye I<: lasts approximately 0.8 seconds and pans the intcn"'l from the end of one hean <ODII'll<tion to the end of the subsequent bean contrJcllon. Thm: are two phases of the cardiac cycle. In the diastole pba~ the bean ventricles arc relaxed, and the hcan fills with blood. [n the sy~tole phue. the ventricles conltllct and pump blood tnto

Ole atleries.

Dunng the diastole phase, the atria and ventricles arc relaxed. Blood flows mto the rtght and lefl atria. The vnlves loented between the attut and ventricles are open, allowing blood to now through tO the Ycntricles. Here is a summnry of1he events 1htll ot"Cur during the dias1olc phase:
Alriuventricular valves arc O!X:Il

The stnoatdal node, which stan~ cordinc conduction. contracts. causing curial

contrCtCtlon

The atria empty blood into the ventricles Semilunar \'alve.'ii close. prevenung hnckOow into the atria During the systole phase, the ventncles cuno-oct pumping blood it1to the aneries. The roght vcn tricle send:. blood to the lungs vta the pulmonary anery. The lei\ ventricle pumpS blood to the aona. Here is a summary of the events dml occur dunng the systok phas<:: The 'entricles contn1<1
Atrioventricular vaJ\'es close and senulunar \'al\<~ open

Blood flows to either the pul11>01131')' anery or o('na

1. Blood flow 10 the coronary aneric~ would be gre-ate-st during' eotrlcular rei a~~ Nolts arlon in a re.!l.ting individual. 2. Ventricular volume is greatest follo-..ng atrial systole.

3. Vemricular pressure is grtlllf"st during \'cntricular ejection.

4. Incr~scd ventricular volume Increases end-diastolic fiber length. T11is 1s why nn increased filling of tho ventricle dunng diastole causes a more forceful henrtbcot.

\titr:ll \ahc (hit'll\f'itll'tlheJ . l ricu,pitl ,ahr (tlu: nfnm1.nlricular \uh.c~)

The first heart sound ("lub'') is associated \lith the closure of the atriove.ntriculor valves (mitral and tricuspid oles) at the beginning of venrricular contraction. Thts sound is largely due to vibrations of the taut A-V valves immediately nfier closure a.nd to the vibration of tbe walls of the hc:m and major vessels around tbe heart. 1. It is louder and loogH than the second heart sound. Nntn 2. VentriculllJ' systole starts wtth the first heat~ soun<l 3. Ventricular diastole ends wnh the first heart sound. The second sound ("Duh") is assoctatcd with the closure of the semilunar valves {plllmonaiJ and aortic Valves) ns the ventricles begin to relax following ~teir conlraction. This sound is due largely to vibrations of Lbe taut. closet.! sem il unor valves and to Lhe vibration of tbc wnlls of the pulmonary artery, the aorta. and. to some extent, lhe ventricles. I , Diastole begins with the second henn sound. 'loti!$ 2. The aortic valve doses before the pulmonary valve; this causes "SJlliLLing" of the second heart sound.

(BIOCHEMISTRY I PHYSIOLOGY

Hrt)

You have four patients with the following heart defects. For each patient, choose which portion of the cardiac conduction system that is most likely malfunctioning.

I'

1. Craig has a higher than normal heart rate (tachycardia). 2. Cary's ventricles contract nearly simultaneously with the atria. 3. Ashley's right ventricle does not contract on the lateral side. 4. Jimmy's entire left ventricle does not contract.

\..
Sinoatrial node Atrioventricular node Internodal pathways Atrioventricular bundle Purkinje fibers
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Hrt)

Use the following answer options to answer all of the following questions. QRS complex QT interval S-T segment

T wave
P-R interval
,1' I. The ventricles arc completely depolarized during which isoelectric

"'I

\..

portion of the ECG? 2. This portion of the .E CC represents atrial depolarization. 3. This portion of the ECC represents the segment between depolarization of the atria and depolarization of the ventricle.
~

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I. C'rai~- Sinoatrial node- the pact.rnal-ar of fhl' heart 2. (;ar~ - Atriunmtticular nmh --I he portion rc~ponsihl(' for dtlnying impul\l'S :-tS IJu.~ (JUS\ f1om the alria IO tfl( \'{'lltrici('S 3. AshlcJ- Purkin.i e fib(rs an not transmittin~ impulws lui he latl'r:tl side uf
lhl' right nntriclt. 4 .. Jimmy- ..\trio'"ntricular bundll' i~ dhidcd~ and the left bundlr is not transmillin~ imJJulscs {ltdmhnl~r. h( t'tmltl hm e u prahhm with all Purkinjt. .fibl!r.. on the leji :o.;ich t~{ lu\ /umt. but tlw mm+t/i/.((r pruhlem wouhl he at tltr ,our(''' of tftt split - the A I 'Jmmi/C')

cardiac system arises from fbe fact that caidii>C electrically coupled ro one anorher vla gap junctions. SA node (pacemake1) : located within the posterior wall of the right atrium near the opening of the superior vena cava. Specialized pacemaker cells depolarize at an intrinsic rate tbat drives the depolarization of tbe remainder of the bean. Internodal pathways: rapidly transmit the wave of depolarization to the left atrium and to the AV node. Atrioventricular node (AV node): located within the lower right interatrial ~eptum. An impulse is delayed in the AY node for about 0. 13 seconds to allow the atria to contract before ventricular contraction. Aside from the AV node, the atria and ventricles are electrically isolated. AV bundle (bundle of His) : originates in the AV node, dividing into two bundle branches that exteod down tbe two sides of the interventricular septum. Purkinje fibers : originate uom the right and left bundle branches, extending to the paplllary muscles and lateral walls of the ventricles. The wave of depolarization travels extremely fast through the bundle branches and purkinje fibers (total elapsed time of 0. 03 seconds).

I. S-1 St'1!111t.' nl

2. ,. \\:l\t' .'4. 1-1t intrnal

The Normal Flgctrocardjggntm CECG) Is

Composed of':
.P wave: represents atrial depoturlzaUon prior to the atria's contraction.

R wave

T wave: represents ventricular repolarizatP wave ion. QRS complex: represents ventricular depolarl:tatlon. _ _, .

ST

Twave

S-T segment: represents the period when the ve.nrricles are depolarized; is isoelectric.

Q wave S w:.w e

P-R lnten-al: represents {he length of time between depolarization of the ~tria and depolarization of the vemrlcles (approximately 0.16 seconds). Note: varies with heart rate; when HR increases, the P-R interval decreases. Q-T interval: represents the period between ventricular depolarization and the ventricle.< repolarizuiion (approximalf./y 0.3J secomls). Note: The ECG is also isoelectric between the T and f' waves (the ventricle is at resting membrane potential). This period of ventricular diastole. when the ventricle is filling with blood. greatly diminishes at high heart rates.

~IOCHEMISTRY I PHYSIOLOGY

Hrt)

Venous return (VR) Is the flow of blood back to the heart. Under steady-state conditions, venous return must equal when averaged over time because the cardiovascular system is essentially a closed loop.

SV

CO HR
BP

,..
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~IOCHEMISTRY I PHYSIOLOGY
r

Hrt)

Blood flow Is dlrec.t ly proportional to the pressure difference between "''I the two ends of the vessel but is inversely proportional to the fractional resistance to the blood flow through a vessel. This relationship can be expressed as:

Flow= pressure difference x resistance Flow pressure difference resistance

Flow

resistance pressure difference

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 Otherwise, blood would accumulate in either the systemic or pulmonary circulations. Although cardiac output and venous return are interdependent, each can be independently regulated. The circulutory system is made up of two circulations (pulmonm)' and S)'Siemic) situated in st~ ries between the right ventricle (RV) and leftvemricle (LV). Balance is achieved. in large pan. by the Fr ank-Starling mechanism. for example, if systerruc venous rerum is suddenly increased (e.g .. changing from upright to supine position). rigbt ventricular preload increases, leading to an increase in stroke volume and pulmonary blood flow. 1'he.left ventricle experiences an incre-ase in pulmonary venous rerum. which in turn increases left ventricular preload and stroke volume by the Frank-Swling meclmuism. ln tbis way. an increase in venous return can lead to a matched increase in cardiac outpUI.
I. Preload is the muscle length prior m contractility. and is dependent of veutricular filling (or end diastolic volume). Thi value is related to right atnal pressure. The

mos1 important determining factor tOr preload is venous reh1 rn. 2. Afterload is the tension (Or tire llrteria/ pressure) against which the ventricle must contract. Ifanerial pressure increases. after load also increases. Afterload for the left ventricle is determined by aonic pressure; afterload for d1c right ventricle is determined by pulmonary anery press w-e. 3. Increases in heart ra1e will also increase cardiac output, EXCE PT at very high hean rates where there will be less time for filling. 4. Sympathetic acti,atlon of the heart will increase heart rate, conduction velocity in the heart, and cootractillty of the cardiac mustle. 5. Venous return !Tom the legs (peripheral l e110us reltlrn) is achieved by the pumping of the calf muscles with the )lelp of efficient venous valves that prevent backflow of venous blood.

Flo\1 ~ ~

resisfnr1Cl'

This rclation~hip indicates that I) the greater the pressure gradient, the greater the now rate: nod 2) Ute Oow rate decreases with increased re,;lstance. Factors influencing resistance are expressed as: Res istance= vlss:ositv (ofbloo41 x length Cot vessciJ (radius)' Important: The larger the vessel, t.be less the resistance --- Not~: II is the fo urth power of the radius. Titis means that if the r nrlius is doubled the resistance w[ll decrease by a ractor of 16. Thus, the major physiological regulation of blood now is via the activatiou of vascular smooth muscle (V<>soconstriction). This fact explains why arterioles, with their ability to quickly conshict or dilate, are the JUOSI critical factor in conrroll ing blood flow to peripheral tissues. Regulators of vascu lar smooth muscle include the sympathetic nervous system, circulating honnones, and local factors. Pressure is the dnving force oftbe blood flow. When blood vessels are connected, the bloud flows from the higher pressure site to the lower pressor site, and the rate cf llow Is proponional to the pressure different<. The overall. pressure difference is between the ascendiug aorta and the entrance to the right atrium -- the circulatory pressure (abo111 100 mmllg).

(smc HEMI STRY I PHYSIOLOGY

Hrt)

Changes in vessel are most important quantitatively for regulating blood now within an organ, as well as for regulating arterial pressure.

Thickness Length

Diameter

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GIOc HEMISTRY 1 PHYSIOL OGY

Venous return is the blood returning to the heart via the inferior and superior vena cavae. There are four key actions that facilitate the return of blood. Fill in the blanks (using options in parentheses) so that each statement describes a situation that will increase venous return to the .4

The contraction of _ _ _ _ __ (skeletal / cardiac I s mooth) muscle

A (n) -

- - - - - (increase I decrease) in intrathoracic pressure

The presence of venous - - -- - -- (valves I peristalsis) A (n) - - - - - - (increase I decrease) in venous compliance

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Uiaml'llr

Resistance to blood Oow witllin a vascular network is determined by the size of individ ual vessels (length and diameter), the organization of the vnscular network (.<eries and parallel arrangemems), physical characteristics of tile blood (vi<cosity. laminarflow er sus turbulent flow) , and extravascular mechanical forces acting upon the vasculature. Changes in vessel diameter, p:uticularly in small arteries and arterioles, enablcorgatiS to adj ust their own blood flow to meet the metabolic requirements ofthe tissue. Therefore, if an organ needs to adjust its blood flow (tmd therefore. oxygen delive1y), cells surroundtug these blood vessels release vasoactive substances that can either constrict or dilate the resistance vessels. The ability of an organ to regulate its own blood flow is termed local regulation of blood llow and is mediated by vasoconstrictor nnd vasodilator substances released by the tissue S\lrrounding blood vessels (a.waclive metabolites) and by the vascular endothelium. There is ~lso a mechanism intrinsic to the vascular smooth muscle (myogenic meclumism) that is involved in local blood flow regulation.
In organs such as the heart and skeletal muscle, mechanical activity (comraclion andrelaxation) produces compressive forces tl1at can effectively decrease vessel diameters nnd increase resistance to flow during muscle contraction.

sl~<'h:t.tl

decrease \:.lhl's
dcl'r<-'a'!ot'

Venous return is influenced by several factors.

1\'luscle contraction. Rhythmical contraction of limb muscles as occurs during normal locomotory activity (walking, nmnin~ surimming) promotes venous rcturn.by themusck

pump me<>banism. Decreased venous compliance. Sympathetic activation of veins decreases venous compliance, increases central venous pressure, and promotes venous return indire<>tly by augmenting cardiac output thro11gb the Frank-Starling mechanism. which increases the total blood now through !he circulatory system. Respiratory acljvity, During respiratory inspiration, !he venous return increase$
because of a decrease in right arriaJ prl!.ssure. Vena cava compression. An increase- in the resistance of the vena cava.

Remember: Under normal circumstances, the rate of venous re!um is the major factor that detennines cardiac outpu! as s!ated in Starling's law or the heart (or the FrankStarling mechanism). - I. Contractions In skeletal muscles (espeCially in the legs) pushe on the blood Notes' in t11e veins. which is d;rected back toward the heart because of one-way valves
in tho veins. Thus, rhythmic c.ontractiuns of the leg muscles wi II counteract tbe

force of gravity, which tends to cause pooling of blood in the feet in standing
persons.

2. Vcios have a great degree of compliance that can be regulated by the sympathetic nervous system. An increase io :;ympaU1etic activation decreases
venous compliance and tncreases venous return. Lmportaut: An increase in intrathoracic pressure will decrease venous retum.

(smcHEMISTRY I PHYSIOLOGY

Hrt)

Which of the following parameters is decreased during exercise?

Heart rate {HR) Cardiac output (CO) Total peripheral resistance (TPR) Stroke volume (SV) Arterial pressure

185
Copyright C> 20092010 Ocnu.l tkcks

(smcHEMISTRY I PHYSIOLOGY

Hrt)

Which of the following contribute sympat hetic fibers to th e heart and increase cardiac function?

Right vagus nerve First four thoracic spinal nerves (accessory nerves)

Left vagus nerve Trigeminal nerve

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*** Tbis is caused by the acctunulatioo of \'asodilator metabolites (lactate, potassium imu. aud adenosiue). These metabo)jtes accumulate because of an increasing metabolic rate within the exercising muscle. This arterial vasodilation accounts for the overall decrease in TPR. Three major effects are essential for the circulatory system to supply the tTcmcndoos blood flow to the muscles during exercise: I . Mass dlschar~e of the sympathetic nervous system throughout th~ body \viih consequent stimulati ve effects oo the circnlation.
2. Increase in cardiac output.

3. Increase in arterial pressure. Uoriog exercise, the dilation of blood vessels in active skeletal muS<:les greatly increases blood flow to the muscles. At the same time. sympathetic vasoconstrictor activity causes a compensatory cons triction of ve.~sel s elsewhere in the body. There is also an increase in tbe activity of tbe syulpatltetic nerves to the heart and a decrease in the activity of the parasympathetic nerves. In addition, venous return is enhanced by the increased pumping effects of the contracting skeletal musc les and by the sympathetic vasoconstTictor effects. As u result, both heart rate and stroke volume increase. causing an increase in cardiac output. During exercise, the increase in cardiac output is somewhat greater than the tkcrcase in total peripheral resistance. Therefore, the mean arterial pressure rises. Important: An anxious dental patient may have a higher systolic blood pressure than previously noted; this is most likely due to decreased arte.r ial compliance.

Fir\t fnur 1horacic spinul ner\'C"S (acct.>"i'iOIJ'

uerte~)

Reart rate is comrolled primarily by the autonomic nervous system -- sympathetic (norepiuephrille} stimulation causes an increase in heart rate, and parasymp~thetic (aatylciloline) stimulation causes a decreas~ in heart rate. The main centers for autonomic cardiac control i1re located in the medulla oblongata of the brain stem. Sympathetic Cardiac Effects: I. An increase iu the rate of discharge of the sinoatrial node. (S-A node). 2. Au increase in the rate at which the depolarization spreads thronghout the heart, The heart then contracts more uniformly, whioh tncreases its pumping effectiveness. 3. An increase in ICF (intracellular fluid) calcinm, which iucreases the force of vcntric.ular contractions. Parasympathetic fibers innervate the bean by way of the vagus nerves. The right vagus nerve goes to the SA node while the left vagus nerve goes to the AV node. Parasympathetic activation decreases heart rate and decreases the s pread of depolarization from the atria to the veurricles.

Note

I. The SA node is called the pacemaker of the heart. The Tale of discharge of this node sets the rhythm for the entire heart. 2. The slowest rate of conduction is in the /\V node. Tbis results In a delay betweeo atriul depolarization and ventricular depolarization, which allows the atria to pump blood into the veutricks.

(BIOCHEMISTRY I PHYSIOLOGY

If a l>atient's SA and AV nodes fail, what is the most likely situation the patient will be in?

Dead; the patient's hean will fail immediately Both the atria and ventricles will continue to contract on the pace of the bundle of His (30-40 Impulses) The ventricles wi ll contract and passively fill, keeping the pateint alive for a short period The atria will take over and contract: the ventricles will allow the blood to flow through and out tO the periphery of the body

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(BIOCHEMISTRY I PHYSIOLOGY

The isoelectrlc point (pi)

Is the pH at which the number of positive and negative charges on a molecule equal each other
Is the pH at which the number of positive and negative charges in a solution equal each other

Can be determined using the Henderson-Hasselbalch equation

Is the pKa of a solution at which it is neither basic nor acidic Two of the above

,..
Cop)TiJbl 0 2009-2010 Dtntal Drcd;t

Rnth Ihe .t fria und \cntrirlls \\illlontinu( to contract on thr ,,ace of tht. hundlc of His (31/-.JI/ imp11lsn)

The bundle of His is located in the proximal intraventricular septnm . The bundle of His emerges from the AV node to begin tbe conduction of lite impul~e from theA\I node to TbeAV node together with the bundle of His make up the AV junctional tissue. TheAY junctional tissue is considered supraventricular (above Ihe ventricles). The AV junctional tissue bas an intrinsic rate of 40-60 beasts per minute. lftbe SA nodes are injured, AV junctional tissue can take over control of heart rate and rhythm. T11e bnndle of His branches into the three bundle branches: tbe right, Jell anterior-superior and left posterior-inferior bundle branches that run along the imervcnticular septun1. The three bundle branches comprise the trifasdcular system. Tlle bundles give rise to thin filaments known as Purkinje fibers. These fibers distribute the impulse to tbe ventricular muscle. Collectively, the bundle branches and Purkinje network comprise the"' 'entrlcular conduction system. It takes about 0.03.(>.04 seconds for the impulse to ~ravel from the bundle of His to the ventricular muscle. Remember: The ventricular conducting system is capable of intrinsic pacemaker activity at a rLe of30-40 impulses per minute. If the SA and AV nodes are Injured, the ventricular conducting system can take over control ofbeart rate and rhythm.

h llw pllut ''hit:h the numhc1 orpo~iiitiH and ne)!ollhe char~es on a moleculr t.>{lu~tl each other

Another way of stating it is - the isoelectric point (also ~ailed 1he isoe/eclric pFl) is the pH at which a solute has no net electric charge and thus docs not move io an electric field. lt is designated pi for that solute. Tltis Information has practical importance -- for a solution containing a mixture of amino acids. the different amino acids can be separated on the basis of the direction and relative rate of their migration when placed in an electric field at a kno1vn pH. The same applies to protein molecules and is frequently used to separate proteins. Example: The <ttnioo acid glycine has a net negative charge at any pH above glycines pl and will thus move toward the posithe electrode (the anode) when placed in an electric field. At any pli below glycine's pi, glycine has a net positive charge and will move toward the negative electrode (the cathode). The farther the pH of a glycine solution is from its isoclectric point (pi), the greater the net electric charge of the population of glycine molecules. Note: At physiologic pH, all amino acids have both a negatively charged carboxyl group (-COO) and a positively charged amino group (-NH3), T11ey are. therefore. dipolar ions (in this slllle, Ote compound is said to be a zwitterion).

~IOCHEMISTRY I PHYSIOLOGY
Which of the following represents the 11H of a solution that hns 10-'~ M concentration of O H- ion?

8
7

10

18t
Copyng'htC 2009-2010 Den!a.l Dc:cb

~IOCHEMISTRY I PHYSIOLOGY
Proteins are effective buffers be<ause they contain:

A large number of hydrogen bonds in a.-helices

A large number of amino acids Amino acid residues with different pK;, 's Peptide bonds that readily hydrolyze, consuming hydrogen and hydroxyl ions

solved by using the following equatio.n: Kw = [H- ] [OH- ] Kw is the ion product of water and always equals 10"14

[H-) is the hydrogen ion concentration (pH= -log (B+I) [OR- ] is the hydroxide ion concentration (pOH ~ -log (OB - I)
Therefore, by taking the negative log of both s ides, the equation can be rewritten as follows: 14 =pH+ pOH Solving the problem on the front of the card -

14 = pH + 4 pH = 10

Amino arid

n.sidm.'~

'' ilh diiTlr('nt

pK~ s

*** The side chains of the amino acid residues in proteins contain functional groups
with different pK,'s. Therefore, the side chains can donate and accept protons at various pH values and act as buffers over a broad pH spectrum. Note: An increase in pK means a stronger ability to bind hydrogen ions. The pH range of our blood is in the range of 7.35-7.45. Acids and bases are being constantly added to the blood through metabolic processes, and therefore, the body need.~ a way to moderate the effect of these additions. The body actually uses three methods to moderate the effect. The first is with the removal of bicarbonate (HC03.) ions in the urine. The second is the removal of the co, in the blood by the lungs. The tbird is a buffer composed of carbonic acid (weak acid) and hydrogen <atbonate (conjugare base). Carbonic add is the most important buffer in extracellular fluid including blood due to
carbonic acid's decomposition to water and carbon dioxide, the- latter being el iminated

very rapidly through the lungs. Note: The carbonic acid system is very important in the oral cavity for the neutralization of acids in foods and those produced by oral bacteria. Important: (I) There are also other buffers in blood, such as proteins and phosphate. but they are less important. (2) Blood pH is determined by a balance between bicarbonate and C0 2 (3) Hemoglobin is a major intracellular buffer. Remember: Buffer systems most commonly consist of a weak acid (the prota11 donot) and a ~saH," or conjugate base of that acid {the proton accept01). These systems minimize pH changes brought about by a change in the acid or base content of the solution. These buffer systems reduce the effect of an abrupt change in H ion concentration by releasing H ions when the pH rises and accepting H i011S when the pH drops.

~IOCHEMISTRY I PHYSIOLOGY
The famous relationship stated In the Henderson-Bassclbalch equation can be used to:

Predict the pH that acid buffers work best at Predict the Pl<a that acid buffers work best at Predict the dissociation constant of a weak acid only Predict the dissociation constant of a strong acid only Predict the dissociation constant of any acid

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~IOCHEMISTRY I PHYSIOLOGY

(
\..

Which of the following is not one of the three mechanisms the body uses to control the blood's acid-base balance?

Excess acid is excreted by the kidneys pH buffers are found in the blood Excretion of carbon dioxide Filtering blood by the spleen

182

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Pn.<lirt thl pi I th~1t :tcid hulft>rs \\Ork hl'sf at - the relationship cannot predict an~ dissncialinn ronstunts

Buffers must be chosen for the appropriate pH range that they are called 01110 control. The pH range of a buffered solution is given by the HendersonHasselbalch equation. This equation describes the relationship between the pH. pK (the negative log of the dissociation constant), and the concentrations of an acid and its conjugate base. The equation is simply a useful way of res tating the expression for the dissociation constant of an acid (Ka). The dissociation constant of an acid (K.J is:
(WJ [A) K, = _ [H _ A_ ]

Note: The larger the K,, the stronger the acid. because most of the HA has been converted into H- and A-. Conversely, the smaller the K the less acid has dissociated, and therefore the weaker the acid. The Hendersoo-Hassell>alcb Equation was derived from the equation for the dissociation constant: [A) pH = pJ<. - log - [HA]
- - - 1. The Hendersoo-Hasselbalch equation shows that pll~pK whon an acid is
INotes half neutralized.

2. The pH of a buffer system depends on the pK of the weak acid and the ratio of molar concentrations of salt and weak acid. 3. The optimum pH fo r an enzyme is the pH of the most rapid reaction rate.

FiltLrin~

hlnorl h~ tht.~ ~plr('n

The three mechanisms that the l>ody uses to control the l>lood's acid-base l>alance are the following: I. Excess acid is excreted by th e kidneys, as bydrogen ion, ammonium ion, or combined with phosphate. 2. The body uses pH l>uffers in the blood to guard aga inst sudden changes in acidity. The major blood buffers are bicarbonate, hemoglobin, and albumin. 3. In the excretion of carbon dioxide, the l>lood carries carl>on dioxide to the lungs where it is exhaled. Respiratory control centers io the braiJl regulate the amount of carbon dioxide that is exhaled by controlling the speed and depth of breathing. Note: From the Henderson-Hassel balch relationship, we can see bow plasma pH is determined by the plasma levels of carbon dioxide and l>icarl>onate. Tbe PK. of the bicarbonate-carbon dioxide buffer system is 6.1 pH = 6. 1 + log [bicarbonate] / (0.03 X partial pre.<sure ofcarbon diox ide) **The 0.03 multiplier is the solubility constant of C02 in blood. The multiplier converts the Pco, measurement to C01 concentration in mmol/L This is necessary to ensure that both the HC0 3 and C02 concentration bave the same units.

~IOCHEMISTRY I PHYSIOLOGY
Which patient is most likely to have metabolic alkalosis?

A patient who is vomiting A patient with sudden chronic renal failure A patient ingesting salicylate, leading to salicylate poisoning A patient with diarrhea

m
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~IOCHEMISTRY I PHYSIOLOGY
The primary disturbance In respiratory acidosis is:

Decreased anerinl Pc"2 Increased anerial Pc"2 Increased anerial bicarbonate Decreased ancrial bicarbonate

,..
Copynght C> ~2010 D<mal Dts

***AU of the other choices cause metabolic acidosis. All of the buffer patrs in body fluids play an 11nponant role in acid-base balance. However. only in the bicarbonate system can the body regulate quickly nnd precisely the levels of both chemical components iu tbe buffer pair. Carbonic acto levels can be regulated by the respiratory system and bicnrbonate ion by the kidneys. A 20: I ratio of base bicatbonate 10 carbonic acid (BB:CA) wil l, according to the lleudersouHasselbalch equntion, ma10taiu acid-base balance and nonnal blood pJl. Therefore. from a clinical standpoint, disturbances in acid-base balance depend on the rclacive quantities of carbonic acid and base bicarbonate in che extracellular Oucd. Two 1ypes of distUrbances, metabolic and respiratory. can alter the proper rauo of these components. Metabolic disturbances affect the bicarbonate element. and respiratory disturbances affec1 the carbonic acid element of the buffer pruL Metabolic acido<ls is excessive blood acidicy charactenzed by an inappropnatcly low level of bicarbonate In the blood caused by chronic renal failure. dianhea ond salicylate poisoning. Respiratory acidosis i~ excessive blood acidity caused by a buildup of curbon eli oxide tn the blood us a result of pour lung function or slow breathing (decrease in rcsplrtlft>l)' rare). Note: If you udmmtster a high nitrous-oxygen mixmrc (for example. YO: I 0) tn a patient. this will cause rcsptrntory depression and result in respiratory aeidos1s. )ldabolic alkalosis is a condiuon m which the blood;, alkaline because of an mappropriately lugb JC\!el of bicarbonate. Other causes Include hypen~ldosteromsm 1111d the u.se of thiazide diuretics. Respiratory alkalosis is a condition in which tlte blood LS alkaline becaw.e rJpid ort.lcep breathing results in u low blood carbon dioxide le,el. :-loce: Respiratory alkalosis is much less common chan rcspiralory acidosis.

Respiratory acidosis is a clinical disturbance tbat ~~ due to aJ,~Iar hypovemi13tlon. Producuon of carbon dioxide occurs mpidly, and railun: of entilation promptly mcreases the Pco1 Alveolar bypovenulat.ion leads tO an mcrtastd Pco1 (i.e .. h;p<>rropuia) The increase in l'co1 in tum decreases the liCO, /Pco, ilnd decreases pi I. llypercnpnio and respiratory accdom occur when impainnentln ventilation occurs and cbc removal ufCO, by tbe lungs is loss than the prodncrion of C01 in the tissues.
\\'ld-h:l\l'

Uhunll'l '
Prin1ary Disturbance
~(HC0,1
Co rnpt n~allt)n

Add-bas
Dl~turbilnct-

Cause

Mcoobolic ac:tdo>lli

Kc:toocidosis La~tue acidosis O.romc n:nal Gulure Salicylate iotoxicahon

Vomiting liYJ'!Cf'illdoSicronism Luup or thia;,ide dhtn:lictt

Dcctc:a.wcl I'C02

Metabolic alkllins

fnen:ased [IICO,]

IDCrca.-,cd 1'c02

Respiratory oddosh

Opiates
Sedatives Anesthetics

tn.........,d Pco2

lncn!a.M:d [IIC'O,)

COPD
RcspiralO<)' alk.U."'" l'o<ulllOIWI: puhiiCX1ar) <mbolus Dc<n:ucd Pco2 I ll&b alutuck Psyo:llogmit Salieyliue fnU)xic:allon

Dn-n:o><d (HCO,1

~IOCHEMISTRY I PHYSIOLOGY
Th e cell (plasma) membrane Is a fluid mosaic of:

Lipids and carbohydrates Proteins and carbohydrates Lipids and proteins Carbohydrates

IU Copyngbt C 20092:010 De111al DkJ

~IOCHEMISTRY I PHYSIOLOGY
( Proteins that make up the cell membran e serve as all of the following \_ EXCEPT one. Which one is the EXCEPTION?

.J

Transporters Enzymes

Neurotransmitters
Receptors :Mediators

IN
Copynabt 0 2009-1010 0.""' """

l .ipids and prott.'ins

The cell membrane (plasma membrane) is composed mainly of lipids and proteins. The lipids form a bilayer, with their hydrophilic head groups imcJ"acting with water on both the extracellular and intracellular surfaces, and lipids' hydrophobic fany acyl chains in the central ponion of the membrane. Peripheral proteins are embedded at the periphery; integral proteins span from one side of the membrane to the other side. _ l. Carbohydrates are attached to proteins and lipids on the exterior side of Notes' the cell membrane. 2. Integral prote,ins are associated with the hydrophobic phase of the bilayer. Important point: The membrane is said to be a " fluid-mosaic" since lipids and proteins can ditTuse laterally within the p lane o( the membrane, However, peripheral proteins seldom flip from the outer to the inner membrane or vice versa. The lipids that make up the bulk ofa cell's surface membrane fall intO three classes: phospholipids, steroids (primarily cholesterol), and glycolipids ((or e,<amp/e, gangliosides) . About half of the molecu les in an average membrane are phospholipids. Examples include: spb ingomyelio, phospbatidyl choli.ue (lecilhi11). und pbosphatidyl eU1anolamine (cephali11). Phospholipids are ompbipbilic with the hydrocarbon tail or the molecu le hydrophobic and its polar head hydrophilic, As the plasma membrane faces watery solutions on both sides, its phospholipids accommodate this by forming a phospholipid bilayer with the hydrophobic tails fating each otbel:.

~turot ransmittC'rs

The proteins function as: Transporters: they transpon substances across the membrane Enzymes: catalyze biochemical reactions Receptors: bind hormones or growth factors Mediators: aid in triggering a sequence of events Six Common Features of Biological M embranes: I. S heetlike structures, only a few molecules thick (60 to J(}Q) thick).

2. Consist mainly of lipids and proteins (carbohydrates are auached to eJ;mior).

3. The membrane lipids are small molecules with hydrophobic and hydrophilic groups tbat fOJm lipid bilayers in aqueous menia. The ltydrophobic cenrer of the bilayer form~ a barrier to the flow of polar molecules across tbe ruembrnne. 4. The proteins function as transporters, enzymes, receptors, etc.

5. They are noncovalent assemblies . The protein and lipid

together by many noncovalent interactions.

molect~es

are held

6. They are asymmetric. The msido and outside faces are usually differem. The plasma membrane has most of the carbohydrate (as glycnproteitts and glycolipids) on the outer face while the lipids pbospbatidylethanolarniue and phosphatidylserioe are more concentrated on the cytoplasmic face.

~IOCHEMISTRY I PHYSIOLOGY
What is the name of the structure shown below? Hint: It is the basic structure of cell membranes.

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(BIOCHEMISTRY I PHYSIOLOGY

M br)

Molecules that can easily penetrate a biologic membrane are usually:

Large and nonpolar

Small and polar

Large and polar

Small and nonpolar

198 Copynght C 2012010 ()('ma) Decks

l.ipld hll:o~r fn an aqueous environment (water), phoSpholipid molecules limn lipid bilayers (also called bimolecular sheets), in which the pohtr regions (phosphate group that i.< negallvely charged) are located at tbe surfaces of the bilayer, where the molecules interact with water (hydrophilic). 1'he nonpolar regions (fatty add portion) are hydrophobic, and oriem the!tJSelves tuward the interior of the bilayer so as to minimiz,e contact with the aqueous portion, In this lipid bilayer, globular proteins (peripheral and imegra{) are embedded at irregular intervals, held by hydrophobic interactions betw~en the membrJne lipids and hydrophobic domains in the proteins.
L Lipids, when suspended in water. s pontaneously form bilayer s tructures Notes that are stabilized by hydro~hobic interactions, 2. This lipid biluyer serves as a permeability barrier, yet it is ljuile fluid. The membrane mosaic is fluid because the Interactions among lipids, and between lipids and proteins, are noncovalcnt, leaving individual Lipid and protein molecules free to move laterally in the plane of the membrane. 3. Bilayers arise through lheoperation of two opposing fo rces: (1) attractive forces between hydrocarbon chains (van der Waals forces) caused by the hydrophobic effect fo rcing such chains together and (2) repulsive forces betwcc,n the polar bead groups.

Small and nrmpolar

The most important property of the lipid bilayer is that it is a high!~ impem1eable structurc.lmpenneable simply means lhar it dues not allow molecules to freely pass across it. Only water and gases (for example 0_, COJ can easily pass through the bilayer. This property means that large molecules and small polar molecules cannot cross tbo bilayer, and thus tl1e cell membrane, wilhout the assistance of other
structures.

Important: Molecules and ions tbat nre large and polar move across the membrll!lo via active transport systems that iuvo)ve binding molecules that are classified as proteins. Another important property of the lipid bilayer is its nuidity. The lipid bilayer contains lipid molecules, The bilayers' tl~tldity allows these srncntres mobility within the lipid bilayer. This 011idity is biologically important. intluencing membrtie transport. Fluidity is dependent on borh tbe specific stntcture of the fauy acid chains and lemperature (fluidity decretL<es with lower remperarure and increases with

increased temperarure)_
Remember: Polar: hydrophilic, or "water-loving;" describing mole,cules or group~ that are soluble in water (e.g. , ionsr glucose. nud urea) Nonpolar: hydrophobic; describing molecules o r groups that are poorly soluble in water (e.g-. oxygen. carbon dioxide. and alcohol) 8 ydropbobic molecules are lransponed across cell membranes by simple diffusion. Hydrophilic molecules require a carrier protein to cross the cell membrane. Note: Sodium is not very permeable Co the cell membrane.

~IOCHEMISTRY I PHYSIOLOGY

Tth i Mth)

Ameloblasts are involved in producing the enamel matrix by producing which two organic components?

Amelogenins Enamelins Apititins

Prism ins

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~IOCHEMISTRY I PHYSIOLOGY

Tth l Mth)

( \..

All of the following statements concerning enamel hypoplaasia are true EXCEPT one. Which one is the EXCEPTION?

It is a defect in the mineralization of the formed enamel matrix

The enamel of primary and permanent teeth appear pitted Radiographically, the enamel is either absent or very thin over tips of cusps and
interproximal areas
It can be caused by nutritional deficiencies

200 Copyrigbt e 20.2010 Dcmal Deets

\ llll' I Uf! l 'l1111'

En:~m, l i n'

Arneloblasts produce an enamel matrix (organic matrix) with protein components called amelngeniM and enamellns. This organic matrix makes up aoout I % to 2% of enamel, and w~tcr makes up about 4%. Enamel is a highly mineralized structure contaming approximately 95% lnort::n nic matter. Thtt hydroxyapatite crystals, which Jrc made up of calcium and phuspbutc, are the largest mineral constituents (90% to 95~) of this inorganic matter. Note: Enamel i.> semipermeable; it is thts property of enamel that allow> fluoride ions to be absorbed on the hydroxyapatite crystals. forming DuoropatJce via Ouonde ion displacement of a hydroxyl group. The tooth becomes more resistant to bacteria producing actds because fluorapatite bas a lower solubility product constant than bydroxyapaute (a11other way of saying tins Is hydroxyapatite lras a lriglrtr JOiubllity tlra11 fluorapatite). Remember: Enamel is harder than bone. The main reason for thi~ is that enamel hydroxyapatite crystals ar e lar ger and m ore Otmly packed. These tightly packed masses of hydroxyapatite crystals are keyhole-shaped rods call ed enamel prisms and fomt the structural foundation of enamel. Actually, these hydroxyapatite crystals in enamel arc four times larger than those in oone, dentin. and cementum
I. Amtlogenins are low molecular-weight proteins found in devcloptng tooth Sotes enamel. and they belong to a f:1mily of extmcellular matrix (EC\IJ protem>. 0.: vel oping enamel contains aoout 3001. protem. and 90% of this is composed of amclogcnins. Although not completely understood, the function ofantelogenins is believed to be in organizing enamel rods during tooth development. 2. Enamcllns comprise <1% ofprotcms found ill developing enamel.

It h a lll'IN.'I in tlh' minlralir:Jtion of llu. form~:d enamel matri\

This is false: 11 is a defect in the formation of the enamel matrix. The eoamelts hard 10 context but tbio and defictcnt in amount. The etiology may be hereditary or environmental. Examples of en' ironmental causes includr a \'it.1min deficiency (A and D), inadequate calcium intake, nuorosis, congcn.t31 syphtlis. high fever, injury, or tmumn to the mouth. Hypo plash\ results only if tbe assault occur':$ dunng the time the teeth ar~ developing. Either dentition may be involved . The teeth appear pitted. yellow to dark brown in color. and have open contacts. Radiographically, the enamel appears to be absent or very thin, especially over the cusp tips and interproximally.

- I. Enamel hy pocalcificalion is a defect in the miner aliution of the fonned

:\oU$' enamel matrix.

2. Tooth erosion in bulimic patients IS due to the solubility of lt~droxyapatite in acid.

(siOCHEMISTRY I PHYSIOLOGY

Tth I Mth)

Car ies actl\'ity is directly proport ional to all of the following EXCEPT one. Which one is the EXCEPTION?

T he consistency of fermentable carbohydrates ingested The quantity of fermentable carbohydrates ingested The frequency of ingesting fermentable carbohydrates The oral retention of fermentable carbohydrates ingested

201 Cop)'TiJht C: lOWZOIO Dlllal OkJ

(BIOCHEMISTRY I PHYSIOLOGY

Tth l Mth)

T he secretions of which rwo glands includes a substa nce that contains many glycop roteins and functions to lubricate food and the mouth?

Pa ro tid

Submandibular Sublingual

202 Copyn.Jl'ltO 2009-2010 Dmlal Dctk.s

The 'luantil~ nf frrnumlahlt carhoh~dratts iOJ,!l"Silfl Tbere is abundant evidence that tb~ initiation of caries "'quires u rdntively high proponion of mmuns streptococci within dental plaque. These bncterla adhere well to the tooth surface, pmduclo higher amounts of acid ii'Om ~ugars than other bacterin I types, clUJ survive better than uth~r bactcna m '"' acid environment, and produce extrnceltul3r polysacchal'ides from s ucrose. Because tl\ty arc more acid tOII!rant than other bacteria, acidic coodil ious within plaque f.wor tbe survival nud reproduction of muraus streptococci. Two other typ~s of bacteria are also r.ssociated with the progrtssiun uf caric" through dentin. These arc several species of lactobacillus, nod actinomyces viscosus. T bese bacteria are also htg Wy acidogcuic und survive well 111 a~'id condilions, Each time tltat plaque bacteria come into contact with food or drink containing simple S!lgars (monosucclwrides such as glucose and fructose, tmd dlsucc/wrftfes such 11s sucrose. lac-ro.<e atrd maltose). the plaque bacteria use the sugars for the bacteria 's metabolic needs, making organic acids (i.e., /artie add) a metnbolic by-product. II' these acids are nul buiTercd by sotiv, tbey dissolve the surlacc of the apatite crystals of aQjacent tooth slructure, This is called dcminerali1.ation rrlris occur wlren rir<' pH level oftlte mmlllt drnp.v he/ow 5.5). Caries depends o n the halance between demineralization 3Jid remintralization, i.e.,, on tJ1~ frequenc y of eu ting (and att tire

microbinl <'Ompositton of the phlql/e nne/ its clwmlcul nalltre tmd rhi<kne.~.,, on tht IIJCIII j1rwride concenlraliiJn, and 011 lite br(/feriug t'li[Jacity uf xnllvtt), A frequent patLero of eatin,g t.herefor~ lncreas~. -. . cnrio:s risk .
Exnacellular dettran$ are the structura l component o r pla~ue. They a!c formed from sucrose by bacterial enzymes (glycosyltron.,( ertrse~). wbich nte located on the cell surfuce of certain lactic acid bacteria (e.g.. S. /Ill/tans lllld /acrobaail/i), Dextrans are essential for the cariogenicity of these bacterin.

Suhmandlhui.Jr

Suhlint,!uul
Tbc basic "'ctotory units of snlivary ghmds are cluste" of cell~ cnll e<l acini. These cells secrete a fl uid (pH halween 6.1) all(/ 7.0) tbnrcontains wawr, clc'Ctrolyi<'S, tn ucu.<, and enzymes, nil of which 0Qw o ut of th acinus into collectittg ducts. Three mnjor pair:; of ssliva~y glands that differ iu lh~ type of secretion they product: Pnrotfd glands produce a serous, watery secretion. S ubmandibular glands prodttce a mixed serous anil mucous ~corotion. Subllugual glautls secrete a saliva th~t is predominantly mucous in characr.:r. Two Secretions: I. Mucous secretion: contains muci11s (glycoproteiiL1), which ~re proteins th~t have polysaccharides uu,.chetl tu them . l ttbricatcs the mouth and foot!. 2. Ser Qu$ S<cretion: contains the enzyme !>ali val)' a mylase (ply11lin). This ~nzyme splits starch into alpha-dexnin, mnltotri<tsc, aud ma ltose. A number of proteins (prolitte-rich proteins, .<tlll/zeriJ>, ere-.) play impot1tU11 roles in maintaining the enamel Sll!face and pre,v etlling calculus lbnnalion. The ccrction of saliva is under control of the autonomic nervous system, which controls both the volume and t)']le of saliva secreio<L Both purl!Sympathetic al\(1 sympathetic stimul<1tioos cliuse secretion, wilh parasympathetic having the greatest effect Note: Vagal stimulation increases saliva productiott. su vagotomy (or (tll'opine/ inhibits sali va pmduction and produces dry mouth. Atropine prevents the action of acetylcho line ou tbe sccrd111g cell~. Rcmembert Before swallowing cau bu initiated. ~tferent iltformation must be received from mucosnl mcehunoreccplors, indicating the coosistency or. ~o ft oolus of food.

~IOCHEMISTRY I PHYSIOLOGY

Tth IMth)

,
I

All of the following characterize saliva EXCEPT one. Which one is the EXCEPTION?

High potassium and bicarbonate ion concentrations Low sodium and chloride concentrations
It is hypertonic

Its production is inhibited by vagotomy

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~IOCHEMISTRY I PHYSIOLOGY

ProiAA)

( Of the 20 amino acids commonly found in proteins, bow many are not \_ essential in the adult diet because they can be synthesized in the body?

5
9
II

18

204 Copyrigbl 0 2009-lOtO Dental Ottks

It is

h~ pertnnh.

Tbjs is false; saliva is hypotonic due to the fact that the salivary ductal cells reabsorb sodium and chloride in exchange for potassium and bicarbonate. Funclions of S aliva : Lubrication: for the mastication anrl swall owing of food Protection: prevents dehydration of the oral mucosa Ora) hygiene: antimicrobial properties and washc.s away food particles Diges tion: starch digestion by a -amylase (not required) Composilion of Saliva (97% to 99.5% wate1)t Ionic components - The principle ions contaioed in sali va include sodiwn, potassium, chloride, and bicarbonate ions. Organic components - Tlte primary organic components of saliva are lingual lipas~. mucopolysaccharides and p rolinc-rlcb glycoproteins. Also present are small amounts of immunoglobulin A (wilich is the only imnumog/ohulin to oppear in saliva) Lysozyme, lactofcrrin. albumin, urea, and glucose. Note: Saliva supplies calcimn and phosphate, which ll!e importunt fo r remfneralization of the enameL Remember: Caries is modified by saliva. High llow-rate saliva is a very effective bu ffer. The balance between demiueraliution and romineralization can therefore be altered substantially by the rate of salivary flow. Flow is decreased by salivary gland pathology (as occurs in several connetlive tiss11e disease am/ which can follow radiolhernp)' and cancer chemotherapy), by many mood-altering drugs and some drugs used in other medical treaunent. in dehydration and during sleep. Flow increases naturally during vigorous chewing. A maximum s alivary flo w rate of less than 0.7 rnlJmin. Is associated with high caries risk.

are mammals are ge.neraJJy tl1ose with simple pathways. These amino acids are called the nonessential amino acids to denote the fact that they are not needed in the diet. The remainder. the essen rial omino ocids. must be obtained from food.
\minn \rids

e ssential (lndi>pe11sab/e)

.'lonessential (1Jispensable)
Alaoille

JListi<line
Leucine

isoleucine Lysine l'henylalanino Tryptophan

Arginino A>']Jartic acid Glutamic acid Glycine

Asparagine
Cyst~inc

Metbio11ine Threonine Valine

Glutamine Proline Tyrosine

Serine

Amino acids can also be classfied as ketogenic, glucogcnlc, or both according to the nature of their metabolic end products. Ketogenic: amino acids whose catabolism yields either acetoacetate or one of it$ precursors, acetyl-CoA or acetoacetyl-GoA. Examples include leucine and lysine. Gtucogenic: amino acids whose catabolism yields pyruvate or one of the intermediates of the citric acid cycle (a-ke10glutarate. oxa/oacelare, jiunarare, aut/ .w cciuy/ CoA). Exampks include llle remaining amino acid>. Glucogenic and ketogenic: amino acids whose catabolism yields both ketogenic and glucogenic end produc1s. Examples include tyrosine., isoleucine, phenylslunine, and tr yptopha n.

GmcHEMISTRY 1 PHYSIOLOGY

Pro / AA)

In eukaryotes, DNA does not exist free; it is complexed with an approximately equa l mass of basic proteins called histones. These histoncs contain a large portion of:

Cysteine and lysine Arginine and lysine Lysine and glutamine Glutamine and arginine

184,185
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Which one of the following s tatements about protein structure is cor rect?

Proteins consisting of one polypeptide can have quaternary structure The formation of a disulfide bond in a protein requires that the two participating cysteine residues be adjacent to each other in the primary sequence of the protein The stability of quaternary structure in proteins is mainly due to covalent bonds among the subunits The information required for the correct folding of a protein is contained 1n the specific sequence of amino acids along the polypeptide chain

2ot
Copyn~t 0

20092010 Dffllel 'Dks

Ar1-:inhh: nnd I~ 'in( The nucleus contains the chromosomes of the cell. Each chromosome consists of a single molecule of DNA complexed with an eqtml Ul3SS of proteins. Collectively, the. DNA of the nucleus with its associated protein< is called chromatin. Yfost of the protein c<>nsists of multiple copies of 5 kinds of histones (HI, H2A, H2B, 113, anti 114). These are basic proteins, bristling with positively char~cd arginine and lysine residues. Important: Both Arg and Lys have a nce amino group on therr R group, which attracts proroos (II"), giving them a positive cbarge (pe1,1'ect amino <lCi<l.~ UJ bind lightly to the negalively-cllarged phosp/wle gnmps aj' DNA). Note: 1'hese hi stones help neutro lir.c the large negat ive charge of the DNA pbosphUH> groups ond stabili1.c DNA iu a compact form.
Remember: Histones package and o rder the DNA into structural w1its culled nucleosomes. Nucleos01ncs are r~peatiug subunits of chromatin. consisting of a DNA chain coiled around a core of histone.~.

I. Chromatin also contains smoll amounts of a wide variety of nonhiston e Noro, prnteins. Most of these ar~ transcription factor< (e.g,. !Ire Sletoid receptor<) au~ their association with the DNA is more transient . 2. Activation of DNA fo r replication or trnoscript.ion requires breakup of the nucleosomo structur<", Phosphorylation of serine and threonine residues i n hlstones 1s pan of tho proecs$ fo r replication, while acetylatiou of lysiue residues iu t11e histone~ ts used f<>r transcriptional activation.

The information n.quired for lht' correct fohtin~ nf :1 (lrutciu is tuntaiuet.l in thl' 'Pl't'ilic wqm.nce of amino ac1tls ulon:: the pul~ peptide cha:in
.... The correct folding of a protein is guide\~ by specific interactions among the side chaios or the amino acid residues of a polypeptide chain.

Proteins are polymers built from ~mi11o acids joined by pepti de bonds. Tbe resuliLOg chain of amino acids (called a polypeptide) os then folde~ in different ways and 10 different extents. Generally, amino acid~ have a central o r alpha carbon to which is attached a bydrogeu atom (N), a carboxyl group (COO/!), an amino group (NH Y and a fourth group Ihat differs from one amino acid 10 another and is ofren indiC'ated by the letter R. Approximately 20 different amin<> acids (!hey possess tliffenml [{ groups) are commonly found in prot<ios of the body. Proteins are formed front amino acids by reactions that bon~ the atph~ amino g roup of one amino acid to the alpha carboxyl group of nnother. This bond is called a p0ptidc bout!. 1\vo amino acids joined to~ether hy a lJCptide bond fo rm a dipepUde. Ten or more anti no ocids linked in a chain by peptide bonds form a polypeptide chnin. A proleiu is a polypeptide chain of approximately 100 o r more amiuo actds linked by peptide bonds. Th~ order of amino acids iu a protein fro m the amino terminal to the carboxy terminal of the protein chain is referred t\l as the primary ~tn1cture of the protein. Higber-order structtores ar e dependent on the primary
&tructure,

Not..

I. T he two cysteine residues that react to form the disulfide bond may bo a great distance apart in the primary structure but are brought into close proximiry by the three-dimensional foldi ng of the polypeptide chaiu. l. Qunteruaty structure require> more tban oue polypeptide chain. 1"hcse cbnius associate through noncovalcnt inteructions.

~IOCHEMISTRY I PHYSIOLOGY

An old dental classmate of yours has been taking advantage of your free care for years. This time you see him, he tells you that all that drinking in dental school is catching up to him as his liver is failing. Which plasma proteins will be least affected?

Albumin Alpha globulin Beta globulin Gamma globu lin Fibrinogen

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Amino acids are joined together in proteins by peptide bonds. A peptide bond forms between the of one amino acid and the - - - - - - o f the adjacent amino acid.

Amino I amino Carboxyl / carboxyl Carboxyl / am ino

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Gamma 1,! 1ohulin'

*** Gamma globulins (immomoglobulins) are globulins made by immune cells,

spt'Cifically Blymphocytes and their dcrivauvc plasma cells in the lymphood ~)'Stem. All the pla.!>ma protcons are synthesized on liver e:cceptgamma globuli~. 60% of plasma proteins are made up of the protem albumin, which are major con tributors to tbc osmotic pressure of plasma. which assists in the transport of lipids and so eroid hoo mones. Globulins make "I' 35% of plasma prot ems nnd a~-e used in the transporto!'ions, hor mones, and loptds assisting in immune function. 4% is fibrinogen. and this is essentoal in lhc clotting of blood and caJt be con\ferted into insoluble libnn. ReguJatory proteJns. which make up lcs.. than I"' of plasma protem>. are proteins such as enryn><:s, proenzymes. and hormones. Plasma proteins act as buffers tbat help stabilize the pH of the internal environment. l mportunl point: Intracellular protein> absorb hydrogen tOns gcuct",l\eo by the body's metabolic processes.

Note: Other plasma proteins include the following:

I. Lipoproteins (cllylomicrons. VLDL. LDL. HVL) that are respon~iblc for the transpon m the blood of triglycerides. pbospbolopids, cholesterol, and cholesterol esters from the liver to tissues or organ' 2. Trusferrin (for iron rronsporr) 3. Prothrombin (a blood-clotring ptYJiein)

A pep tid< bond is a chemical bond fanned bet"..""''' m~lecule. \\hen the carbOX)l group of one mol<"<:ulc reuts \>ilh oho amino group of the other rN>Iccule, thereby relea.,ng a molecule of water. This IS a ('Ondtnsatlon tt.~:ttion and usually occurs be1ween amino acid~. n.e ~lung CO-Nil bond os called a peptide bond, and the resulton' Dll)lecule is an amid<. lroport:ant Chsaru~h~rlstics of 1he Ptpddr Bond: The bonds mvolving the a-carbon can rotate freely. Unlike it components (1/Je a-amino a11d u<<I'/JQ,t)'l group). the conlponcnts of the pep tide bond do not necepoor give oil' protun$; thercfnro it dn.,; not ionize at physo ologlc pi I. It is not clcaavcd by organic sol"ents or urea, but iK susceptible to stron!t ac1ds. They an: extremely stoble. It is generally 1.\ trans bond (occurs in 1rt111S COII}lgurotfon a.t oppo..,eJ I(' ti~ umfljp,ro~
linn). li tS unch1rged bur polar.

Prollo(. due to ronn.31iQn of a rentary ammc restricts the range of ro1auon or the a-carbon in the pertide bond. N:emember: Another type of co,ralent bond thai occurs 1n many proteins 1 s 1be disu1flde bond~ 11 is formed from the sullllydryl group (Sll) ol' coch of two cysteine resodues, to produce a cystine resodue. lo o~ wotlely thought that these strong, covalent bon~s help stublllze th strutrure of I)N>telnj and prevent lhem from becormng denatured in the I!XIrac~llular environment Examples include the hormone Insulin nnd the immunoglobulins.

1. A restdu'-' is a sing.le amino ttcid umt withm a pol_yp<:ptidc- cham. NOIH' 2. CystJne l~ an amino acid that is round 10 numy proreins. l H) dro>} proline is a constituent or collagen. and is l'llrely found on any other proteon llydro.,yproline pmvodes stabolity to the triple-helical Structure of collagen \'Ia hyclro1 bonding. 4, Glytln< ts the only non-chonol um1no ncod.

~IOCHEMISTRY I PHYSIOLOGY

( \..

All of the following statements are true EXCEPT one. Which one is the EXCEPTION~

Myoglobin has a higher affinity for 0 2 than hemoglobin Hemoglobin has a higher affinity for C0 2 than 0 2 Hemoglobin is capable of binding more oxygen than myoglobin can Myoglobin is dimeric while hemoglobin consists of four proteins Myoglobin is found only in muscle cells

209 Co.,yrigh1 Cl 20091010 t>ent;d l>eck.i

~IOCHEMISTRY I PHYSIOLOGY
All amino acids found in proteins are of the:

D-configuration

L-configuration

F-configuration
C-configuration

210 Cop)Tigh.tO 2~20 10 l)cn!a.l Oecb

:\1~u~lobin

h dimeric '"hile

hemn~lnbin

consists nf four proteins

Myoglobin nnd hemoglobin are heme proteins whose physiological importance is principally related t<) their ability to bind molecular oxygen. Myoglobin is a monomeric heme protein {it contains only one lreme wri1, twl jour/ike hemoglobin) fo und mainly in muscle tissue where my<>globin serves as au iutr3cellular torage site for oxygen. During periods of oxygen deprivation, oxymyoglobin releases its bound oxygen. whicb ts then used for metab<1lic purposes. Jt is also caHetl mus cle hemoglobin. Important point to remember: Hemoglobin contains four bemes and can poteminlly assocfatc with four o~ygen molecules. Myoglobin nas a mucb gre~ter affinity for oxygen than cloes hemoglobin. This makes myoglobin well suited for its biological function within musole cells. which is to store oxygen and make myoglobin's ava[iable to the mitnchondria. Myoglobin is. in fact. much b~ner at thi~ than hemoglobin because its very hil!,h ..rtinity ft~r oxygen at low P~ enables myoglobin to bind and store oxygen effectively. In summary. hemoglobin ami myoglobin are pecinlizcd proteins. aduptcd for dint~rent kinds of oxygeo-biudiug functions. Note: Carbon monoxide also binds coordinately t<> heme iron atoms in a manner similar to that of oxygen, bur tbe binding of carbon monoxtde to heme is much stronger than that of oxygen. Tbe preferential binding of carbon monoxide to heme iron is largely responslblc for the asphyxiation that results !rom carbon mooox.ide poisoniug.

L-eon fit,! nn' tinn

Stereoisomers (optical isomers. or eJnntiomersJ are compounds that have tbc same composition and Lhe same order of atomic connections. but different molecular arrangements. In a ll standard amino acids (except glycine). the a -corbon is asymmetric, bonded to fonr difl'erent substituent groups (a carbo.~y/ group. nn <Imino group. an R gr(lup. and a hydrogen atom). This carbon is called a chiral center. The four different substituent groups can occupy two different arrangements iu space. wbtcb are oon-super-imposable mirror images of each other. These two forms are called stereoisomer (optical isomers, or enanliomers). Note: All mo lecules with a chiral center are also optically active_ The cl~~Ssification and uamiug of stereoisomers are haserl on the absolute configuration of the four substituents oflhe asymmetric carbon atom. The reference compound to which all other optically actiVe compounds are compared is the smallc:;t sugar to have au asymmetric carbon -- glyceraldehyde. The naming of configurations of both simple sugars and amino acids is based on the absolute cuuligwstioo of glyceraJdehyde, as established by x-ray diffraction analysis.
Import;~nt: The stereoisomers of all chiral compouuds having a configuration related to L-glyceraldehyde arc dcsJgnared L ("levorotatory"). and the stereois()mcrs related to D-glyceraldebyde are des ignated D ("tfe.<trornrarmy "). Th~ right and left designations for glyceraldel1yde refer to the manner in which the two fonns r01ate plane-polarized light.

Note,: D-amino acids are found in some antibiotic and in bacterial cell walls.

(siOCHEMISTRY I PHYSIOLOGY

Pro / AA)

r
I
\..

Which of the following is not a similarity between cytocbromes and hemoglobins?

They both contain iron molecules They both contain porphyrin rings They both arc found in the cytoplasm They both are used by eukaryotes

211

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Pro /

AA)

What Is the general structure shown below? Hint: T hey are found In proteins.

H H 0 I I II H-N- C-C-OH I R

212 Copyngi'JI 0 20092010 Ore-Mal Dks

Thl'~

huth an found in the rytnph1sm

*** Cytochromcs arc found in mitochondria and cWoroplasts.

Cytochromes are, in general. membrane-bound hcmoprotcins that contain heme and carry out electron transport. They are fowtd ei!lter as tnonomeric proteins (e.g., qtochrome c) or as subunits of bigger enzymatic complexes tbat catalyze redox reactions. Cytochromcs are found in the mitochondrial inner membrane and endoplasmic reticulum of eukaryotes. in the chloropla.<ts of plants. in p~otosyntbetic 111icroorganisms. and in bacteria. The electric transport chain is the final common pathway by wbkb electrons derived from different fuel& of the body flow to oxygen, ~ole: Electron transport and ATP synthesis by oxidative phosphorylation proceed continuously in all cells of the body that contain mitochondria. Cytochromes receive electrons from the reduced fonn of coenzyme Q (llbiqui!IIJ!Ie). Each contains a heme group made of a porphyrin ring containing an atom of iron. This cytochrome iron atom is the electron carrier and i reduced when the cytochrome acceptS an electron ( Pe"' Fe"}. Cytochromes are distinguished by differences in their light-absorption spectra and ar< designated ll, ct, c, a3 , and n. These differences are a result of the hemo prosthetic group. Note: Cytothromes a3 and a are the. terminal members of rhe electron transpo11 chain. They exist as a complex, which is called Compte~ IV or cytochrome oxidase complex. Note: The prosthetic groups of cytochromes have four fivc,mcmbcre.O, nitrogencontaining rings in a cyclic stntcture called a porphyrin. The Com uitrogeu moms are coordinated with a central Fe ion that can be either Fe.., or Fe>. Remember. These porphyrins are also found in !lte heme proteins bentOglobin and cytochrome P450. Glycine and succinyi-CoA are the precursors to the biosynthesis of these rings.
group~

1f i~ IIH.'1!,l'IH!'f<-d slructun nftlu.- :ttninu adds found in proteins

H 0 I II - C_j,C-OH
Amino

iii'"-

Corl!"'J'UcAcid

Group

" ' "-.a r;wton Cirollp $de Cbaut

I. With the e,,ception of ahe uaturc of the R group, this structure is common Note,s to -all th~ aamino acids. The ccntral or acarbon is in 1he center. Attached to this is a hydrogen atom (H), a carboxyl group (COOH,I. an amino group (H3 N'J. and the R group. fn all umiuo acids except glycine, the a -carbon atom has four different substinten< groups (in glycine, rile R gro11p Is" /tydrogen
1110m)

2. Amino acidS can lose their nitrog..,n-cootaining amino grot1ps and be converted to fl-keto acids (nlp/r(rkelo (reid.') that can ultimately enter the Kiebs cycle -- for example, by way ot pyruvic acid or the Krebs cycle cnmpooent oxaloacetic acid, both of which are u-keto acids. An a-keto acid is similar to an amino acid, except that an a.-keto scid bus oxygen rather than an amino grout) bonded to its a -carbon. 3. When proteins are broken down and used lor eoorgy, most of this energy is derived from the oxid<l!ion of a-keto acids (i,e., py,.uvare. oxt~loacetate, and a ketoglutanrle). These substances can ihen enter the Krebs cycle.

&IOCHEMISTRY I PHYSIOLOGY

Glutamate can by synthesized by the addition of ammonia to a-ketoglutarate. All of the following amino acids can be derived from glutamate EXCEPT one. Which one is the EXCEPTIO/\'?

Asparagine Glutamine Proline

Arginine

213 C<lp)TigtuO 20092010 OentZJI 0\:$

&IOCHEMISTRY I PHYSIOLOGY

All of the following statements are true EXCEPT one. Which one is the EXCEPTION?

One-third of elastin's amino acids are glycine Elastin is one of the few places to find hydroxyproline Lysine is involved in elastin cross-links Elastin is one of the few places to find hydroxylysine

214 C<l9>'1iS:h1 C 2009l0 I0 Onn.:al Dttl:s

\"iparal!im

Synthesis or amino acids: a-ketoglutarate gives rise to glutamate, which, in turn is the precursor of glutamine, proline, and arginine. 3-pbosphoglyceratc gives rise to serine, which, in tum , is the precursor of glycine and cysteine. Oxaloacetate gives rise to aspartate, which, in tum. is the precursor of asparagine, methionine, threonine, and lysine. Note: Threonine is the precursor of isolcucme.
Pyruvate gives rise to alanine, valine, leudne, and i.soleucine.

Note: Isoleucine can be formed by either pyruvate or threonine. Pbosphoenolt>)'ruvate and erythrosc-4-phost>hate produce shikimate, which is converted to chorismate. C horismate tben gives rise to tryptophan , tyrosine, and phenylalanine. C'iote: Tyrosine is synthesized from ph en) Ia Ia nine in humans. Ribose-5-phosphate gives rise to histidine.

Fla~tin

., cUll' ul

thl fl'\\

place\ tu lind

h~ clrn\~ I~ 'im

Elastin is rich in small, nonpolar aliphatic residues such as gl)cine (/IJ of all residlles). proline, alanine, valine, leucine, and isolcucme. Elastin contam> a small amount of hydroxyproline (non-standard amino acid: deril'atie of pro/me) and no hydroxylysioe. In contrast to collagen, which forms fibers that are tough and have high tensile strength, elastin is n connective tissue protein with rubber-like propcrtic>. Elastic fibers can be stretched to several times their normal length - it is the elastin that gives these fibers the capacity of returning to their original lengths uf\er being stretched. These fibers are found in the skin, ligaments, and the walls of arteries, where the fibers elastic properties are important.

="'"'

l. Tbe polypeptide subunit of elastm fibrils is tropoelaslin. 2. Elastin fibers are formed as a three-dimensional net\\ork of cross-linked polypeptides. The cross-links involve lysine and oxidized lysine residues (a/lysine). which are covalently linked to produce a desmosine cross-link. 3. Tbe oxidation of lysine residues in both collagen and elastin is an extracellular process catalyzed by lysyl o~idase (a copper requiring enzyme).

~IOCHEMISTRY I PHYSIOLOGY

Pro/ AA)

Which two amino acids have sulfur-containing side chains (R groups)'~

Lysine
Cysteine
Arginine

Glutamate

Methionine

184,185
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~IOCHEMISTRY I PHYSIOLOGY
( A hemoglobin molecule can be distinguished from

Pro/AA)

~~~.-.-.-.-~.m~y~o~g~Jo~b~in .. m oml= ec=u=l=e=b=y=t=h=e=p=r=es=e= n= c~ eo f:aa.-. . . . . .~~~

A primary structure

A secondary structure
A tertiary structure
A quaternary structure

Both a tertiary and a quaternary structure None of the above

216 Copyri&}lt 4;) 20W20 I 0 Dental Oects

\ ldhionine
C~ sCl'inc

Each of tbe 20 amino acids found in proteins can be distinguished by the R-group substitution on the a-carbon atom. There are two broad classes of amino acids based upon whether the R group is hydrophobic or hydrophilic. Tbe hydrophobic (non-polar) amino adds tend to repel the aqueous environment and, therefore. reside predominantly in the interior of proteins. This class of amino acids does not ionize or participate in ihe formation of H-bonds. The ltydrophilic (polar) amino acids tend to interact with tbe .queous environment, are <lftcn involved in the formation of 11-bonds, and are predominantly found on the exterior surfaces proteins or in llte reactive centers ofe~ymes. The t:wo broad classes of amino acids are further distinguished by those with: I. ;lion-polar (lrydroplrobic), aliphatic R g r oups: includes alanine, valine. leucine, isoleucine. g lycine, and proline, 2. Aromatic (gf!nerally non-polar) R groups: Include.~ phenylalanine, tyrosine. and tryptophan. 3. Polar (hydrophilic), uncharged R groups: includes serine, throooinc, cysteine, methionine, asparagine, and glutamine. Note: The polarity of cysteine nod methionine is contribtlled by their sulf-ur atom. and tbat of asparagine ~nd glutamine by their amide groups. 4. Negatively charged (acidic) R groups: inc lude~ aspartic acitl and glutamic acid. S, Positively charged (basic) R groups: inclttdes lysine, arginine. and histidine,

.\

quutlrn:lr~

siructure

Remc.mber that myoglobin is mon()merir and hemoglobin hns four subunits; the quaternary structure is bow these four subunits ar<" armnged in space. Proteins difl'er from each other because each has a dlstinctiw number and sequence of amino acid residues. The amino acids are the alphabet of protein structure. No other property so clearly distinguishes one protein fr<Jm another. The primary s tructure consists of a sequence of amino acids hoked together by covalent peptide bonds.

The secondary structure refers to the spatial arrangement of a portion of a polypeptide chaiu determined by the aminu acids present (primruy structure), The most common types of secondary structures are the a-helix (coiled conformation of a peptide clwin).j3-pleated ~heels (an extended. zigzag arrangemem ofa polypeptide clrain), and llhairpin turns (reverse turns},
Ibe tertiary structure refers to tbe irregular fold ing of a polypeptide chain- ll1e overall three-dimensional conformation of tbe polypeptide (e.g.. globulm: fibrous. and pleated s/reet).

The quaternary s tructure refers to the spatial arrangement of subunits in a protein

that consists of more than one polypeptide chain. Two examples of proteins wtth quaternary structures arc the hemoglobin and nnt.ibody molecules found in the blood of a mammal. Note: The best method for dctennining the three-dimensional stntcttu'e of a protein is by x-ray diffraction.

~IOCHEMISTRY I PHYSIOLOGY
r
A patient of yours presents with scurvy In his medical history. The production of which of the following proteins would be most directly affected by this condition?

Elastin
M icrotubulcs

Collagen
Thrombin Fibrin

217 Copynjhc 0 20092010 Dc-ntll Dks

~IOCHEMISTRY I PHYSIOLOGY
r
Which

or the following serves as a principal source of

carbon for nonessential amino acids?

Fats
\Vater

Carbohydrates

Urea

211 Cop)'richl 0 20092010 tkfl~&l Ocd:t

(" ull.tt:C"Il

** Scurvy is caused by a deficiency of ,namin C. The hydroxylation of proline and

lysine residues 1n collagen requires vitamin C and oxygen. Collagen is JS'Yo ~lycine, 21% prolin e, and II % alanine. Hydro:<yprollne and hydroxylysinc arc also present. The basic suuctural unit collagen is tropocollagen. Tropocollagen is the longest known protein and is formed fTom procollngen. which is secreted by tlbroblasts. Tropocollagen is also present in reliculln, which is a co mponent of reticular fibe rs . Note: Mature collagen lacks aromatic and sulfur-containing amino acids.

or

Almost a tbtrd of all the protein found on the body is collagen. Each collagen molecule consists of three polypeptide chams that are wound rightly around each other to give a triple helix. This gives the molecule a structure that IS very resistant to stretching, a vital property, for example, for its functions in tendons and as a component of the matrix of bone and carti lage. Remember: Vitamin C inOuences the forma tion of collagen, which os the organic matrix found in dentin and cementum. Sec no te #I below.

1. ll ydroxyproUne and bydroxylys inc are nonstandard amino acids that Not<J are present in few other proteins. For this reason, their concentration tn a partJcular tissue 1s a good estimate of tbc coUagcn content as "ell . They a re not used directly in the reaction> of protein synthesis. These amino ac1ds arc fooned by the bydro,ylauon of probne and lysine. Thts bydro~ylation involves a-ketoglutarate, oxygen. and vitamin C (oscorbrc

acid). 2. Collagen and retirular libcrs make up the stroma of alllymplloid tissues
except the thymus.

nrhoh~d1

uh.'

Ten of the nonessential amino acicb contam carbon skeletons that can be derived from glucose. Note: Tyrosine, the lith nonessential ammo acid. rs ~yntbesizcd by b)droxylation of the essenual amino acid phenylalanine. Remember: The nonessential amino acid> are synthesized m mammals and generally arc those with simple pathways. Nonessen tial amino acids arc not needed in th~ diet. They inc lude glutamate, glutannnc. proline. arginine, serine. glycine. cystemc (carbon skeleton only), aspartnte, asparagine, alanine. and tyrosine. Important: Nonessential amino acids can be syntbesized from the corrc~ponding a-keto dclds. an a-amino acid (as tire Nil; donor). a sp ecific transaminase eozym~. a.n d the coenzyme pyridoul pbosphare (itamin B(j). These amino acids include alamnc, aspartate, and glutamate. The other nonessenltal amino acids an.syntbesl7ed by amidatioo (glutamin~ and asparagine). Note: Although cysreine's carbon skeleton can be fonned from carbohydrates, cysteine require;, the essential amino acid methionine to supply the suiOtydryl group.

(BIOCHEMISTRY I PHYSIOLOGY

A patient of yours suffers from phenylketonuria (PKU). Your dental assistant offers her a bottle of soda. The patient, a relatively Intelligent dental student, responds by saying: I caooot have this because it contains tyrosine. which I am unable to metaboli7e I caooot bave this because it contains phenylalanine, which I am unable to metabolize Thank you, I need to drink this to supplement my phenylalanine levels Thank you, I need to drink this to supplement my tyrosine levels

Which supplement would you expect this patient to be laking? Tyrosine Phenylalanine Both tyrosine and phenylalanine Neither. no supplement needed

218
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O~td:~

~IOCHEMISTRY I PHYSIOLOGY

(
\..

All of the following statements below concerning C proteins arc false EXCEPT one. Which one Is the EXCEPTION?

G proteins bound to GDP are inaelive Activation of a membrane receptor triggers an allosteric change in Ga, causing GTP to leave and be replaced by GDP Adeny late cyclase activates G proteins and causes dissociation into a and PIV subunits cAl\lfP activates G proteins, leading to an exchange of GTP for GOP

220

Copynghl 0 2009-2010 DtMal Dtds

I c~1nuo1 haH l hi' hl'r<~u't.' il run lain' phln~ lalanine. \\ hich I am un:.thl'- In
lahnliJ{'

lilt'

r~ ru"iint. ~ <iohC' cumwl lrndurt Uti' :uninn .-del

Tyrosine is fonned from phenylalanone, which is an essential amino acid lhat is needed for optimal growth on mf:uns and for nirrogeo equilibrium in adult>. Hydrophobic amino acids bave side chums !hat coutatn: Aliphatic groups: valine, leucine, and isoleucine Aromatic groups: phenylalanine. tyrosine, and ttyptopban Dopamine. the thyroid hormone~ (trtioduthyronine iwd thyro,vne), melanin, norepinephrine, and epinephrine art: all synthesized fro m the amino acid tyrosine. Remember: Melanin is the natural substance that gives color (pigment) to hair, skin, and the iris of the eye. 5-hydroxytryptamine {serotonm), melatonin, niacon and the nicotinamide moiety of NAD aud NADP are fanned from the essential amino acid tryptophan. L When the enzyme (phrnylalonille hydroxylase) that catalyzes the tran<~Notn' fonnarion of pbenylalantnc to 1yrosine is not acnve because of a hereditary defect, the serious disease known as phenylketonuria (PKU) resuhs. 2. ~egative nitrogen balance (nitrogen output exceeds intake) may be caused by a dietary lack of essenttal amino acids. 3, Albinism is a genettc drseasc that resulrs from errors in the synthests of melanin from tyrosine 111 melanocytcs. Albinos do not have problems with epinephrine synthesis, dcsplle melanin and epinephrine having DOPA as a common intennediatc, because a difTerenr enzyme is used in melanocytcs for DOPA synthesis.

( ; prnlt.iiJ"i hnund tn (;(lp an in~rtiH

The trlmerie GTP binding proteins (G proteit<<) play a pivotal role in lhc $ignnl transduction pathways for numer'OU> hormones and ncurotransmlllers. The three subunits of the protein are labeled ulphn, beta, and gamma. Both the alpha and gamma subunits are bound to lhc: ~Mmbrane vi aturched lipid molecules (rt!late,t to fimy aculs and cholesterol) The rtteptors are proteins wilh seven tran>mcmbr:me alpba-belices. One example as the wide.prcad epinephrine receptor. TI1e bmding of the hormone or neurotransminer to the receptor cause.~ GTP to rtJllace GOP on the alpha subunit. As a rc.<uh. the alpha subunit dissociates from the other two. Subsequently, !he alpha subunit and ~1c combined beta and grunma subunits move along lhc inner surface of the membrane to specilic ion channel~ or membrane enzymes. Jon channels opened lu this way arc oficn potassium channels; an exrunplo of a mcmbrune en2ymc with Ibis type of activation is adcuylate cyclaseImportant: The GTP-bound form the a subunit moves from the receptor to adeny lnrc cyclase, which is thus activated. I, Activation of the receptor causes an exchange of GOP for GTP. NoaH 2. The a subunit of G protem acuvates adenyiate cyclase. 3. cAMP activales protein krnase A.

or

(BIOCHEMISTRY I PHYSIOLOGY

Which of the following is a polyunsaturated fatty acid that Is not considered essential (11ceded in the diet)?

Linoleic acid Atachidonic acid Linolenic acid Stearic acid

221 Copyright 0 2009-20 I0 Dcnu:el Deck.J

GJmcHEMISTRY I PHYSIOLOGY

Bile sa lts arc detergent-like substances that are synthesized in the _---,-- from cholesterol, stored in the , and arc secreted into the They pass into the where they emulsify the dietary lipids.

Kidney / liver I blood I stomach Liver I kidney I blood I stomach Liver I gallbladder I bile I intestine Kidney I gallbladder I bile I intestine

.\rachit.lunic

The human body can produce all but two of the fatty acids it needs. These two, linoleic acid and linolenic acid, are widely distributed in plant oils. Essential fatty acids cannot be synthesized because humans lack the enzymes tO place double bonds at certain positions (ol/lega-3 a11d omega-6) and must therefore obtain them from tbe diet. All fatty acids are building blocks of phospholipids and glycolipids and are therefore needed for the synthesis of membranes. Cells derive energy from fatty acids through beta-oxidation. Fats can be classified by tbe number of double bonds between carbon moms in their fatty acid molecules: Saturated fat: contains no bonds between carbon atoms Monounsaturated fat : has one double bond between carbon atoms Note: Most mouounsantratcd fall)' acids are in the ClS (same-side) form. Polyunsa turated fat: has multiple double bonds between carbon atoms
l al1~

\l"ids

Saturated Fntty Acids Arachidonic acid Behenic acid Butyric acid Capric acid Caproic acid Caprylic acid Lauric acid Myristic acid Palmiuc acid Stearic acid

Monounsaturated Polyunsaturated Fatty Acids fatty Acids

Erucic acid

Arachidonic acld
Linoleic acid

Oleic acid
Palmitoleic acid

Ltnolenic acid

lhcr I J!allhladdf!r I bile l iufl.'stim.'

Like a detergent, bile salts contain hydrophobic and hydrophilic components. The hydrophobic portions of the molecule associate with the fat, and the hydrophilic parts associate with water, serving to solubilize (emuls if.v) the otherwise insoluble fat. The micelles, which are tiny microdroplets emulsified by bile salts, travel to the microvilli of the intestinal epithelial cells, which absorb the fatty acids, The bile salts are resorbed, recycled by the liver, and secreted into the gut during subsequent digestive cycles. Bile salts perform two important actions in the intestinal tract: l . Most impOrtant, bile salts help in the absorption of fauy acids, monoglycerides, cholesterol, and other lipids from the intestinal tract (form water-solflhle comple,res, called micelles, wilh flllty acids and glycerides). 2. Bile salts also have a detergent action on the fat particles in the food, which decreases the surface tension of the particles and allows agitation in the intestinal tract to break the fat globules into minute sizes. Bile acids are usually conjugated in amide linhge with the amino acid glycine or taurine, giving bile salts. The cholic acid conj ugates with glycine and taurine are called glycocholate. and taurocholate, respectively.

~UOCHEMISTRY I PHYSIOLOGY
The only membrane phospholipid not derived from glycerol is:

Lecithin

Sphingomyelin Cerebroside Cardiolipin

223
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~IOCHEMISTRY I PHYSIOLOGY

,
I
\..

Which one of the following sequences places the lipoproteins in the order or most dense to least dense?

IIDL I VLDL I chylomicrons I LDL LDL I cbylomicrons I HDL I VLDL

IIDL I LDL I VLDL I chylomicrons

VLOL I cbylomicroos I LDL I JJ OL

Chylomierons I HDL I LDL I VLDL

\..

Which or these lipoproteins Is the p rimary plasma ear rier or cholesterol?

224

Copyn&J'ItO 2009-2010 DemDI Db

Sphin~um~ elin

Most membrane phospholipids contain glycerol (ledtlrin. tereblvside, and cardiolipin). Sphingomyelin is ao exception and i~ based on sphingosine.
Pho~pholipids are lip[ds. Each molecule is made up of one glycerol molecule attached to two fatty acids and a phosphate group. Structura lly, phospholipids are similar to triglycerides excef1llhat a phosphnte group replaces one of the fatty acids. Phospholipid molecules bavc one end that is attracted to water whil~ the other is rcpellod hy it. This property is important in plasma membranes. The fauy acid end that is not tillractcd to water is said to be hydrophobic. At the other end of the molecule, the phosphate group that is attr dctcd to water is said to be hydropblllc.

Three major types of body phospholipids: l . The lecithins: are a group of phospholipids tbar upon hydrolysis yield two ratty acid molecules and a molecule each of glyc~rul, phosphoric acid. and choline. They are wat~( soluble emulsifiers and membrane ~onstitucnts . 2. The cephalins: are a group of phospholipids having hem()static properti.,.; and found especially in the nervous t.is~ut or !lle brain and spinal cord. The cephalins resemble lecithin. except lhey contain either 2-cthanolamine or !..-serine in the place of choline. 3. The sphingomyelins: are a b'TOUp of phospholipids that are found e~ccially in nerve tissue and yield sphingosine. choline. a Fany acid. and phosphoric cid upon hydrolysis. They are membrane constituent<. :-lote: The neurologic disturbances seen in Nicrnann-Pick di,ease are associated with the accumulation in CNS tissue of sphingomyelin.

1101. 1 LllL I VU>L I ch)lomicrons

1.()1.

Lipids (triglyc~rides and cht~lescerol) are not able to move in body fluids due to lfpids. hydrophobic nature so they are packaged in micellar stmctures called lipoproteins. The varinus lipoproteins are classified in terms of density, Not: Sin(:e lipids are much less dense than proteins. there is an inverse relationship b~tween the lipid cuntcnt and dens[ty (i.e. , high lipid conrentmeans low densily particle). Tbe major components of lipoproteins are cdacylglycerols (triglycerides), cbobterol and cholesterol esters. w~ich are the components being tronsponed, and phospholipids and proteins which make up the micellar membrane (the protein component alone i.< called 011 apolipoprotein). Types of lipoproteins: Cbylomlcrous: least dense lifloproteln: most lriglyceride and the least protein contenl Transport primarily dietary triacylglyccrol around the body. VLDLs ( YeiJ' /(Jw-de11sicy 1/poproteius): more dense thou cbylomicrous; high content of triglycerides. Tnwsport endogenous triacylglycerols to various tissues (primarily muscle a/Ill adipose tissue). LOLs (low-densf~p 1/popr()/eins): dt~tscr than VLDLs; less triglyceride and tnor" pro!ein content. Has highest content of choll,stcrol. They are the prim>1ry plasma carriers ol' cholesterol for delivery 10 all tissues. HOhs (high-density /ipoproteitts) : most dense lipoprotein; has the lowest lfiglycerlde ami highest protein conteut. Transfers chok$lerol as an acyl ester derivative frolll other li&Sucs bacl\ to the liver. Note: The;;e lipoproteins are tmnsponed iuto the cells by way of rcccptot-ltledlated endocytosis-.

~IOCHEMISTRY I PHYSIOLOGY

All of the following statements about plasma lipoproteins are false EXCEPT one. Which one is tbe EXCEPTION?

Chylomicrons arc synthes ized in the intestinal mucosal cells and transport triacylglycerol to the peripheral tissues. IIDL particles are produced from LDL panicles in the circulation by the action of lipoprotein lipase. HDL competes with LDL for binding to receptors on the surface of cells in extrahepatic tissues. LDL panicles have the least percentage concentration of cholesterol.

225 CopyrlaMO 20092010 lkntallkd:s

GnocHEMISTRY 1 PHYSIOLOGY

Ketone body synthesis from acetyi-CoA occurs in:

Hepatic mitochondria Skeletal muscle mitochondria Kidney mitochondria Cardiac muscle mitochondria

220
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Ch~ lnmicntns an~ s~ ntln.>si1ed

in Ihe iof('stioal mucosal nll~ and lran~purt

t ri:Jl'~ IJ:,l~ ttJnl to flu. pi.riph{'ral tissu~:s.

Chylomicrons are plasma lipoproteins con.,i,, ling nf a large droplet of triacylglycerols that ;uc slabili~o~ hy a coat of protein and phospholipid. Chylomicrons carry futty 11cids obtained In the diet til the tissues in clyomicrons they am consumed or stored as fuel. The remnants of chylomicrons. depleted of thdr triacylglyctrnl~ (lriglycerid~.;J but still coomining oholcswrol. move through the bloodslteam to the liver. Where they ore taken up, degrflded in lysosome", at~d their constituents reoyoled. Note: Cltylomicrons arc the lc:t! t dense of tlte blood Jipopm teins because chylomicrons bave the most triacylglycerols and the least protein oomeut. Remember: Lipoproteins are lipid-binding proteins. responsible for the transport In tile blood of tri!;lycerides, ph<"pholipids. cholesterol, and eholc-strol esters ljnm the liver to tissues or orgnns. Other lipoproteins lnc>lude the following: Very low-density lipoproteins (VLDL) : these oontain a hi~h conc oh'ntloo of triglycerldes and moderate concentrations of boUt phospholipi<l.s !llld cholesrerol, Low-dens ity lipoproteios (LDL) : are very rich in choles terol. fhcy drc the majo r cholest~rol oarricr in the blood und are derived from VLDL. High-density lipoproteins (HDL) : aro protoin rich with relatively lillie free cholesterol: most of the cholesterol is present as acyl ester dcrhrttives. I. HDL particles are produced de noHo in the liver. ~ot 2. l-!DL and LDL pao1icles each Ita''" their own ~pecitic binding sit<:> on cell mmbranc'$ - HDL on th~ liver, and lDl on the liver and extrahepatic tissues. 3. Lovastatia ("stulln '' dmg) lowers blood cholesterol levels by inhibiting HMG CoA reductase, a key regulatory enzyme in cholesterol biosynthesis.

l kpatic mitol.'hnndria

Liver mitochondria have the capacity to diven nny excess ncetyi-Cot\ derived from fatly ot<:id or pyruva1 e 01\idation into ketone boUie::~. The l.!ompounds clas~ificd ai ketone bodies are nee.. toceto te, 3 hydro~y buty rate (fl-bydroxybutyr te). ~nd rcton~. Ketone body production is r~gult.Ued primarily by availability of;tcctyi ..CoA. During. cond.hitln~aflow glucos-e avail ubiliey (a pi!rlf)d of~turvoiitm nrfu.vimg,. ar a emu:! qfJitlheitts melllmsJ, the ntubilit:uhonof fnuy aculs from adipose lis<uo is high. ntl hepMic b"ta-oxrdntion will ocrur at a ht~h rule. ond so will synthesis ofkctonc bodies from the rosultins acotyi-CoA . rhese ~erone boldle;; ore
then transported in the blood to pt:l'lphesal tlssuC!h where the kcWnc bodies cun be rcconM

vcrtcd to acetyi-C'oA nd oxidi<ed by the citric ac1 d cycle (/(rei cycle), They nrc Important source$ of cnr rgy for the peripheral tissues. Synthc:tis of ketone bodies hy the livc1' 1s a thrce-stcr' proccs!l : The tint stl.'p 1!' formatJon of acetoncecyi..CoA Ill -n reveri)'itl \:J I Ihc thloln!)e s1ep ltf'bctaoxidntion,

ln the scoond >tcp. 11 third molecule of acctyi"Col\ condc"cs with the HCctosce<yl-CoA, forming J hydroxy-J"mctl>ylglutaryl CoA (f/MG Coli) n a reaction oatalyud by HMCCoA >)'Tllhnsc. Note: This enzyme. llMG-InA yntlrnsc. is the rotelhulliog step in the synthosi of ke tone bodies And is present in significant qoantitics only in ihc liver. T o Ute tbild <tcp. 1 -fMG-<.:oA is clenved to yield acetucetatc (u ketone bod,1) in a reo uon cntalyze<lby HMGCoA lyase (f/MG-CnA cleavage O>Jt)'me). One 1\tolccule ol' aoetyiCoA io also produced. Note: A~etoacetat~ can be reduced to form 3-hydroxybutyratc or can be spomanenusly doCtlrhoxy luted w form -acetate. 1. Ke10ne bodi(.."5 urc utnlled n.clusively by cMrah~PH1ic- tissues: he-ar lind Nuto skclet&l muscle usc ketone budies purlicutarly e(fcctively. Unlike f~ny acids. ketnnl! bodies cao bt' o xldi~ed by the brain. 2. The li11c:r <:aunol r~COm'erl acetoacetate lo acctoaccryt~CnA~ unci thcretbrcetinuot Itself use ketone bodies a. fuels.

(BIOCHEMISTRY I PHYSIOLOGY

Lipids)

All of the following arc sources of acctyiCoA for fatty acid synthesis EXCEPT one. Which one Is the EXCEPTION?

"" II

Creatinine
Pyruvate Glucose

Citrate

227 CopyTigbtC 2012010 Dcn1 11l O f:Cks

(s10CHEMISTRY I PHYSIOLOGY

Which of the following Is ln,olved in both fatty acid catabolism and synthesis?

Camitine
Coenzyme A MalooyiCoA Alcohol dehydrogenase

221 Copyn.Jhl 0 20091010 Otatal Drck,

Cn.alinc Glucose is the major source of acetyi-CoA for fa rry acid synthesis.

Acetyi-CoA for fatly acid synthest5 comes mostly (rom the glycolytic breakdown of glucose when high amounts of glucose arc consumed - a high carbohydrate diet. Fatty acid synthesis occurs primarily in me cytoplasm of Lhc liver, ll11d lactating mammary gland and. to a lesser extent. in adipo>e tissue and kidney. lmpnrtant points to remember for fatty acid synthesis: Glucose is first degraded to pyruvate by aerobic glycolysis in the cytoplasm. l'ymvate is then transported imo the miwchoudria. where pyruvate dehydrogenase oxidatively decarbQxylat"s pyruvate. forming acctyi-CoA and other products. Acetyl-CoA can then serve as a sub~trate for citrate synthesis. Citrate, in turn, CllJl b< transported out of the mitochondria 10 the cytoplasm (where jarry acid symltesls occun), and there citrate splits to generate cytoplasmic acetyl-CoA for fatty acid synthesis. Su mmary or fatty acid synthesis: Acetyl-Col\~ Malo!lyi-CoA-+ Malonyl-ACl'-+ Acetyi-ACP-+ AcetOacetyl-ACP-+ Butyryi-ACP-+ Fatty acid form malonyi-CoA is cat.;ilyzed by acetyiCoA carboxylase (an allosteric <'n=yme lila/ is rile principal regulator oj rhe palhwa;). Remember: Malouyi-CoA is the three-carbon iotcnncdiate that participates tn <hL' biosynthesis of fatty acids but not in their breakdown.

*"* The cll!boxylation of acetyi-CoA to

Ctll'lll~ IIIC \

Carnitine - catabolism, Malouyi-CoA = syntl!OSlS, alcohol deltYdrogenase = neither Fatty Acid Catabolism (summnr)l): The fatty acid is traL~~ported to the liver by employlng ca rniline as a carrier substance. Once inside the mitochondria, the fatly acid is transferred ftorn the camitine. to a CoA and is oxidized (via beta oxidation) to acetyl-CoA. The acetyi-CoA molecules enter wto the citric acid cycle (Krebs eye/e) to fom1 carbo11 dioxide and reducing equivalents (NADH, FADHJ. The reducing equivalents are then reoxidizcd by electron transport system, and the energy released by that process is used by the oxidative phosphorylation system to fonn ATP. Important: Pany acids arc the predominant source of ATP for moderate levels (lasring longer !han I hout~ of activity. Biosyothesis of F'atty Arids (summary): This occurs in the cytosol. II invnlvt.s two carbon additions rrom ncetyi-CoA nod an acyl protein (ACP). A key mtenneiliate in the synthesis of !)my acids is malonyiCoA, which is fonned from acetyi-CoA, bicarbonate, and ATP. This irr<veroihle reaction is the commi rring step io fatty acid synthesis. Remember : During fatty acid b iosynthesis, the following arc expected to be active - the Krebs cycle, glycolysis, amino acid catabolism and the enzyme pyruvate dehydrogenase (cntalyzes rile o.ridalive decorbo>)'ialion ofpymvute. to form ocetyiCoA).

I. Coenzyme A (CoA) is a pantothenic acid-containing coenzyme that is ~otn involved in both fatty acid syuthe.s is and catabOlism. 2. Acetyi-CoA is n common intermediate of the metabolisn1 of not only fany acid but also amino acids <U1d carbo hydrates.

~IOCHEMISTRY I PHYSIOLOGY

Lipids)

A patient of yours has uncontrolled diabetes mellitus. T his causes ketosis, or high levels of ketone bodies in the body tissues and fluid. Which of the following is not a symptom of this condition?

Fruity breath

Lowered pH of the blood

Decreased potassium in the urine Ketone bodies in the urine

ut
Copyright C 20f.l 01 0 1)cntull)cd 'I"

~IOCHEMISTRY I PHYSIOLOGY

Lipids)

{ All of the following statements concerning fatty acid synthesis are true \. EXCEPT one. Which one Is the EXCEPTION?

.J

Fatty acid synthesis involves two carbon additions primarily from acetyi-CoA The important step in fatty acid synthesis is the first one in whtch acetyi-CoA. ATP, and bicarbonate form malonyi-CoA Fatty acid synthesis is not a simple reversal of 6-oxidation used for the catabolism of fatty acids Fatty acid synthesis takes place in the mitochondria while fatty acid btcakdown (catabolism) occurs in the cytosol (cytoplnmt)

230
Cop)TiJbl 0 2009 20 1 0 tkt'l~&l Ded;s

Kttosis is a condition characterized by ao abnonnall) elevated coocentralion of ketone bodjes in the body us sues and fluids. Ketosis occurs "hen fatty acids are mcompletely metabolized. a complication of untreated diabetes mellitus, starvation, fasting, and alcoholism. It is characterized by ketones in ihc urine (ketom.ria), ketone bodies in the blood (kcto,emla), potassium loss in the ur111c, and a fruity odor of ucetonc on the breath. Important: Ketosis can lead to ketoacidosis (two of the ketone bodies are acids that cause lo~>ering of blood pH.
I. A diabetic coma can be caused by the buildup of ketone bodies II is :'(ot.. commonly fatal, unless appropriate therapy ts instiiUted promptly. Glucose is effective in reversing ketosis an a non-diabetic patient. 2. Acetone is not utilized by the body as a fuel. 3. In o healthy diet, most acelyi-CoA is processed through the citric acid cycle. During fasting, the normal balance between carbohydrate Md fatty acid metabolism is disrupted. and activity of the citric acid cycle IS reduced. Then somcof the acetyl-CoA prod11 Ced from tlns will be converted to ketone bodies.

laiC~

alid

.,~niiH.'IIrih lak._~,

pia('(' in tlu.mitudwnc.Jria \\o hilt. r:1tt ~ o1rhl hn.akdu\\n

h ata/mli\111) uccur\ in thl c~ tn<iol fntot'lll\111}

*** This is false; fatty acid synthesis takes place 10 the cytosol while fatly acid
breakdO\\n (t:atobollsm) occurs in the mitochondria. A fat, or tri~:lyccride, contains three molecules of fany acid combmed w1lh one molecule of glycerol. A fatty acid is a long-chain compound with an even number of carbon atoms ond a terminal COOH group. Fatly acids can be sa turat ed (no double bonds). monounsaturated (has an~ louble bo11d betwee11 carbon atoms), or polyunsaturated (has multiple double bonds between carbon atoms). Remember: In humans, fatty acid syntbcsis occurs primarily in the liver. The "tail" of a fatly acid is a long hydrocarbon chain. making it hydrophobic. The "bead" of the molecule is a carbox)l. group which is hydrophilic. Fatly acids are the main component of soap, where tbeir tails are soluble in oily d1n and their heads are soluble in water tO emulsify and wash away the oily din. However, when tbe head end is atlached to glycerol to form a fnt. thntwhole molecule is hydrophobic. Lipids arc organic compounds that do not dissolve in water but do dissolve in alcohol and other organic solvents. The major lipids include trlncylglyccrols (the most common lipids), phospholipids, nud steroid s.

~IOCHEMISTRY I PHYSIOLOGY
The molecule picture below plays a major role:

As an energy source

As a membrane component As a signal mechanism Two of the above AII of the above

Fatty acid Fatty acid Fatty acid

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~IOCHEMISTRY I PHYSIOLOGY

Lipids)

(
\..

A patient of yours bas a dietary deficiency of choline. Which of tbe following would not be related to this condition?

"""'

Decreased speed of electrical impulses Disrupted water balance function in the kidney Decreased metabolism of triglycerides Decreased surfactant in the lung
Decreased muscle control

Decreased inte-~tinal absorption

232 Cop)righl 0 20092010 Dtntal Ded:il

,\san

erar~~

snurce - if is a

friJ!I~ cc1id('

A triglyceride is a naturally occurring ester of three fatty acids and glycerol that is the chief constituent of fats and oils. Triglycerides provide more than half energy requirements of some orgaus. parucuJarly d1c liver, heart, and sk.~letal muscle. Note: Triglyccrides are not membrane constituents as are phospholipids and steroids.

we

Trlglycerides play an important role in metabolism as energy sowces. Triglycerides coutain twice as much onergy (8000 kcal/kg) as carbohydrates. In the intestine, rriglycerides are split into glycerol and fatty acids (with the help of lipnses nud bile .-ecretions), which can then move juto blood vessels. The triglycerides are rebuilt in the blood from the.ir fragments and become constituents oflipoproteins. Various tissues can release the free fatty acids and take them up as a source of energy. Fat c.ells can synthesize and store triglycerides. When the body r<'qui res fa tty acids as an energy source, the honnone g)ue<Jgon signals the breakdown of the triglyceride~ by honnonesensitivc lipase to release tree fatty acids. In the human body, high levels of triglycerides in the bloodstream have btcn linked to alherosclerosi$, and, by CJ<Icnsion, to the risk of bean disease and stroke. However. the negative impact of raised levels of trfglycerides is lower than that of LDI~cholc.sterol. The risk can be partly accounted for a strong inverse relationship between triglyceride level and HDL-cbolesterol level . Pancreatitis can also be caused by high triglyceride levels.

lll'lTl':l\et.l intestinal :11Jsoqttiou

Although choline ls not by strict definition a vitamill. choline is an essential nutrient. Although humans can syntltesize choline in small amounts, it must be consumed in the diet to maintain health. Tite majority of the body's cboline is found in specialized fat moleJ::ules known as phospholipidS, the most common of which is called phosphatidylcholine or lecitbin. Functions of choline: Contribtlles to the proper strucnue and function of cell membranes. Choline is found as phosphatidylcboline (or lecithin) in the phospholipid bilayer of cell membranes. As pan of the sphingomyeliJ1 tbat makes up the myello sheath. choline insulates nerve fibers and aids in the rapid conduction of electrical impulses. Choline is a precursor of betaine. au osmolyte used by the kidney to control water balance. Choline func tions in tbe liver as a source of methyl groups required for lipoprotein formation and for the synthesis of methionine from homocysteine. Choline is necessary for the synthesis of acetylcholine, an important
ncnrotransmitter involved in memory storage and muscle control.

Cltoline is au active component of surfactant in the lung. Neonate surfactant deficiency lead.~ to respiratory distri!Ss syndrome in premature iofants. Note: A deficiency of c.h oline in d1e diet can cause abnormalities in the metabolism of fars and can lead to fatty liver disease and eventually hepalic cirrhosis.

~IOCHEMISTRY I PHYSIOLOGY
The binding of glucagon to its receptor:

Deactivates adenylate cyclase Activates protein kinase Activates adenylate cyclase Causes the breakdown of cyclic AMP to ATP Causes the production of ATP from cAMP Deactivates protein kinase

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The oxidation of one NADH by the electron transport chain (or respiratory cltai11) leads to the formation of:

I ATP

2ATP 3 ATP

4 ATP

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,\cl haft>!\ mJt'n~ late c~ clast. When l10rmones signal the need lor metabolic energy, triglycerides stored in adipose tis.<ue are brought out of storage and transported to those tissues (skeletal muscle, heart, and renal cortex) in which f.1tty acids can be oxidized for energy production.

The honnones glucagon and epinephrine activate adenylate cyclase in the adipocytc plasma membrane, roising the ino-acellular concentration of cAMP. A cAMP-dependent protein kinase, in tum. pbospborylates and thereby activates hormone-sensitive triacylglycerollipasc, which initializes the hydrolysis of the ester linkages of triglycerides forming free fatly acids and glycerol. The fatty acids that are released bind to serwn albwnin and navel to the tissues, where the fatly scids dissociate from albumin and dilfuse into the cells in which tbe fully acids will serve as fuel. Note: Insulin causes activation of a phosphorylase that depbospborylates the hormone sensitive lipase and thereby diminishes lipolysis. The glycerol released by lipase action is phosphorylated by glycerol kinase, and the ompresulting glycerol-3-phospbate is oxidized to dihydroxyacetone phosphate. This cound is then converted to glyccraldehyde-3-pbosphate by the enzyme triose phosphate isomerase. Glyceraldehyde-3-pbosphate is then o~idized via glycolysis.

3A'I P

Pairs of high-energy decO'ons and their accompanying protons (H.") are transferred to the components (cytochmmes) of the electron transport chain by NAD and FAD. Then the electrons and pmtons jump from cytochrome to cytochrome, losing energy along the way. The energy is used to pump protons (H. ) into the compartments between the [nner and ou1er mitochondrial membranes. The. diffusion of protons back into the itmer compartmettt drives the phosphorylation of ADP to form ATP. n te protons are joined together with oxygen and low energy electrons at the end of the cytochrome chain to fonn water molecules. This all takes place within each mitochondrion. Important: T he oxidation of fiADH 2 yields 2 ATP.
NOte$

J. Oxidative phosphorylation occurs in the mitochondrial inner membrane, glycolysis occurs in the cytoplasm. and the Krebs cycle (citric acid cycle) occurs in the mitochondrial matrix. Remember: Red blood cells do not contain an active mitochondrial electron transpon syslem. 2. The electron carriers (1/avoproteins. iron-.rulfiu wotelns, coe,zyme Q. a/ICI cyrochromes) make up the electron transport system (l)iso called rite re.vpiralniJ' chain). During oxidative phosphorylation, the proton gradient, created using energy from the electron transport system, is ltsed to produce AT P. The proton gradient is created by increasing the prolon concentration outside the inner membraul! or the mitochondria.

(BIOCHEMISTRY I PHYSIOLOGY

Which electron-carrier complex of the respiratory chain uses NAOH as the electron donor?

Complex I Complex I I Complex Ill Complex IV

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I ~11 of the following statements concerning the citric acid cycle (Krebs eye/;) J
I\. are true EXCEPT one. Wblcb one is the EXCEPTION?
_.j

It is also called the tricarboxylic acid (TCA) cycle The cycle starts with the 4-carbon compound oxnloacetatc, adds 2 carbons from acetyi-CoA. loses 2 carbons as C02, and regenerates the 4carbon compound
oxaloacetate

The pyruvate that enters this cycle is generated by the glycolysis of glucose or protein catabolism This cycle is controlled by regulation of severn I enzyme activities. The most important of these regulated enzymes are citrate sy111hasc. isocitrate dehydrogenase. ancl aketoglutarate dehydrogenase complex The enzymes involved in the citric acid cycle arc found in the cytosol
Aspanic ac:id and oxaloacctic acid are ioterconvenible
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178

The majority of the energy conserved do ring catabolism reactions occurs oear the end of tM metabolic series of reactions in lhe electron transpon chain. The electron transport ot respirutory chain gets its name from the fact that electrons are rransponed to meet up with oxygen from respiration at the end of the chain. There are four electron-carrier colftplexes, each representing a fraction of the entire respitatory chain. Each of the four separate complexes bas its uwu wtiquc composition, tll\d each is capable of catalyzing electron transfer through a poniou of the chain. Complexes t and IJ catalyze electron transfer to ubiquinone from two different electron donors: NADR (Complex I) and succinatciFADH, (Complex II). Comple~ Ill carries electrons from ubiquinone to cytochrome c. and Complex IV completes the sequc,ncc by transfeJTing electrons from cytochrome c to oxygen.
CumpUtll'llh uf tlu. F.kclrnn fr:m,pnrl
S~~tt m

Complex. l (NADH dehydrogenase oomple)

II (Sucoi nat~ddlydrogcnase complex)
ffi
{Ubfquinone-<.ytot~rome C oxidoredUCill$e comp)<i<)

Proctin Cornpottt."nt.i

NADH dehydrog~llSe
Succinah: dehydrogtnasc

lJI}iqoinone-cytoehfome c o.xidoreducUL~
Cytocltrome a and a1

N (Cytochrome oxldll$C complex)

I f~ i.' tl/\ nu.~ io\ ol' t>d 10 the \'IItie .tdd n ric ur'' rmuul In II~ c~ "'"'"' ... Thii Is rals~; llu:~ enzymes invoh1cd iolhis cyd.: nrc fmnd io tbe mitocbondria. Ail gJytolysb ltlket placu in the et:ll's e)'l(lplism., the pyru-..ic: add molecule.<> travel 1nto lhc- lntcrioroflhc.mito cfloodlion. Otcc: lhc pyruvic t1tid is iu~ide. tarbon diox.idc llS-cn:tymutJcu.lly rermwcd from each lhrt<'-tarbon p)'N \oic scfd molecule t<t fOml-aeetk add. TI\c em;yn\c then C\lmbirt\lht acttic ~ctd wich An cozym~, coc:ntymt A, 10 producl! accty' coc.n:zynle A. also l;nown as IICII'cyl-cuA. OllCc 3l""CI)'I CoA is fonnctt. !Itt Krebs Cytlc begins, The <.:ydc is splllll!to tight -111e~: I. The accb..: ach:l subu.nilofaerc1yi-CoA 1~ eombined ~\th o~nloactUIII' to form u rnulecule uf dtrMttl'~ The ~u;c.t)'l . cocct.tyme 1\ ac~ unly tLS t1 tr.utsportcr of acetic aeid from one-enzyme to another, Afk:r Step I, the ce>en;:yme i$ ~ lea~ h)' hydroi)'Sis ~ lh~l It m.1y cornbint with 100thcr &!Xtic actd rnolecuie to bct,oln the K.rcb$ cyclcagatn.. 2. n;c dtric acid roOit:~o-ulc uodcryQcs lsomtn:l.ation. A hydraxyl group und allydi'Ot~n molccul~ lilT rcnl\wcd ft'(ltn lhct"itnuesl.nl"we in the rorm of water. The two carbons. form a double bond unliltheW!Iter molecule l$ added back, Only now, the hydroltyl gt011p and llydro~ moi1."C::Ilc (l.rC rt.'\crsod wtth respct."llo tJ1e origmal strocmre oflhc ctlrnlc moh.-ule.. Thu..._ lsodtt~t t e IS IQnncd. J. Tn chiJstcp,lhc l~hnuc-molmll~ ts oxldl7.ed by a NAD moltctJ I~:. The NAD mo)~ulc 1S rcJu~c:J by lhc bydrogl!o aJom rutd Ulc hydroxyl L,'Toop. The NAD binds v,.ith a h)'drvgen 1\otn and earrics offlhc o(bcr hydrogen ~tOm. leaving a ~rbonylgro.up. Thl5 mucture is Vl"ry unstu.bk-, !iO a rnol\lle f'lrco1 is; rolt:lscd, ~ting 11lph11~
ktiot:,lu l~tnll '~

4. ln Ibis step, uur fn..-:nJ, coenzyme A. rctum.<; lo O:tldlz.: lh!: alphn--1\csaglulan!IC molecule. A molct-ulc ufNAD isf\."<<uccd again to form NADH Md te.we5 wilh Jnutbcr hydrogen '1'1\i$ instabili~ c-.au.<;c~ a ealbonyl gmtiJliO be rc.. leased a.\ calbon diolidc, aud rt lhi~etitef bond~~ (om'.ed m lts pl 11~o-e bc:i"cc:n tbc former alrhn-kciogJ~tua.lc and coenzyme A 10 crrole a mo!ccplct'fsuedo) l.oCue,>;O't)'J1t A r<Jn!jJiu . 5. A w:ucr n"k'lC(ulc sbeds il!S hydrog~.--n ntom~ I<> eoen:eymc A. 1 hen. a frcc-tloating pho!ipbalc groUjl di$f1\ncc..<o coetr.eymc A Md (onnli a bend with the $Uccinyl cnmt'le~ . Tho phCphaf Is t.l:tcn trunsrcrred to n roolcculc o(COP I (I pMdliCc. an ~ngy mO)C\..'Ute ofOTP. II !ca\'cs bchmd s mc1!l."C.ule ofsutclnalt., 6. In thi~ step, sno:inalc is. oxidih"'i hy Am<~lc.:ule of PAD (/lovi11 adtnim: din~rc.lt-'fllill~J. FAD rcml)vcs two tt-,dro~ gcn atoms llmn lJ1c ')'uccinau: and forces s OOuble bond 10 fonn bctwocrl tbe lwo carboo :uom.s.. lhusc crentmg fn~
mar~ it..

7. An enzyme odds ;~tcr lp the film3nue mo!ecnlu to fotm !Jtlllaie. Malnt.: is ercatod b)' udding ona hydrogen atom to a ca.fbun a(Oin a11d thcnaddfng-ahydroxyl !,.'TDUp ton Cftrbon ne-.;t to a tcnnin:d carbonyl t,rroup. 8. In this fitiSl i tl.l'p. lhe n11111ue rookculc is \l:tidizcd by ANAD molccult. l'he wbon Ull!lt earn~ dtc flydn,;tyl gtuuv ill nuw t.'<>nvcncd info a carhnnyl,\P\)Up ~ "-nd product t.~ o .uJo:tt:l'tJ~tf wtlkh entl th.e:n combine with 2t.:t'tyt-<oeru:yme A 1nd bcv,tn tile: Krc<bs L")'dc: all ove:r ag3in.

GJmcHEMISTRY I PHYSIOLOGY

'I.

Which of the following is the pace-setting enzyme of glycolysis? "' 2. Which of the following is the first step to use energy rather than produce it? 3. Which of the following is the enzyme that produces two distinct carbon\. based molecules? ..J

Hexokinase
Phosphoglucose isomerase Phosphofructokinase Aldolase

Triose phosphate isomerase

Glyceraldehydc-3-phosphate dehydrogenase Phosphoglycerate kinase Phosphoglyceromutase
0
r

Enolase
Pyruvate kinase
237

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GJmcHEMISTRY I PHYSIOLOGY

Which of the following is the metabolic pathway in which lactate produced by anaerobic glycolysis in the muscles moves to the liver and is converted to glucose, wbich then returns to the muscles and is converted to glycogen?

Hydrologic cycle Cori cycle Carbon cycle Glucose cycle

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I. Phu!iriphofructol.-inas(' 2. l ltxokinase -- traps gluco~l 3 .. \ldolase

lnr o

the cell
(,l~cnl~srs

I n t~ml"i nl
Enzym~

FunctfQn

Hcxokinn...e.
Phospboglucosc iSomer.lJtC

C<>nvtn.s ~lucose inlu gtucose--6-pho~batt

Conv~Tt$

RIUCQSC:6phosph:uc in!() fnrcrose--6-pb0-5phate

4

Phospboll1Jutokinase
AldolaseTri0$e pbosplut~c isomerase.

Converts (ructose-6 phosph.atc-in~o frQCtOSC l,6bi.sphosptl.ate Converts fnte(QS.O 1.6-bisphospht\le into dihydroxyAtt:tone phosphate and glyceraldehyde J.pbospbate Convcns dihydroxyacetone p!ro$phate into gl)":erslckhydc 3 phosphacc
4

Olyc=ldohydo 3pltospb>le debydrogones<

PltOsphoglycemte kinase

CotwtrLS glycernldebydc 3-phusphatc into

l,3 bispb<:6phoglycc:nue
4

Convert.~

1,3 bis-phO!>phoafyce:rnre into 3 pbospbog.lycet:ue

4 4 4

Phospboglyceroml.ltm Enolase

CoovertS l~bosphogl)'i:C:mlc mco 2 phospboglycer.ue

Convetts 2phosphoglycerale into pli~photnolpyruvatc

Pyruwue kinase

Convcns ph()$J)hoc:no1 pyruvatc into pyruvate

Nme reacttoos, eacb catalyzed by a spectfic enzyme, make up 1he process we call glycolysis. All organisms have glycolysis occurring in their cytoplasm. AI s1eps I at>d. 3 ATP is convened into ADP. inpuuing energy into the reaction as well as 31 ruching a phosphate to the glucose. AI steps 6 and, 9 ADP is converted into Ute bighcr mergy ATP. At step, 5 NAD+ is convened into NADH + H+. The end of the glycolysis process yields two pyruvic acid molecules, and a net gain ofl ATP and two NADH per glucose.

Lactate is released into the blood by cells that lack mitochondria. such as red blood cells, and by exercising skeletal muscle. IJJ the Cori cycle, bloodbomc glucose is converted by exercising muscle to lactate, wbich diffuses into the. blood. This lactate is taken up by the liver and converted to glucose, which is released back into the circulation. See diagram below. The cycle's importance is based on the prevention of lactic acidosis in the muscle under anaerobic conditions. The accumulation of lactic acid causes muscle pain and cramps; however, nom1ally before this happens the lactic acid is moved out of the muscles into d>e liver. The cycle is also important In producing ATP, an energy source, during muscle activity. The Cori cycle functions more efficiently wben muscle activity has ceased because the oxygen debt can be made up so that tbe citric acid cycle and electron transport chain also work.
The Cori Cycle

Gluoose -'~----f-+ Gtueose

2 l,yruvau:

6.\Tl'

'"" )

2 Pyruvate

2 L!!Ciate +-1-----\-- 2 lact~ue

Liver

Muscle
Cori Cycle

~IOCHEMlSTRY I PHYSIOLOGY

\...

Which of the following is not a possible immediate fate or pyruvate as it comes out of glycolysis?

Lactate
Acetyi-CoA Oxaloacetate Ethanol
Citrate

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~IOCHEMISTRY I PHYSIOLOGY
Which pathway is depicted to the right?

Entner-Doudoroff pathway Embden-Meyerhof pathway Pcntose phosphate pathway Urea pathway

IGlucose I

~2ATP
F2A01'

IFructose-!, 6-diphosphatc I
2NAO.

~4AOP

2NADRV4ATP

l2Pyruvate I
2 CopynjhtO 2009-2010 lknul Dks

Citratr --it bccomC's

O\alo;~cetalt>

lirst

Tbe possible fates of pyrvvate: Conversion to lactate: lactate dehydrogenase (LDH) converts pyruvate into lactate cytosol. This is the major fate for pyruvate in red blood cells, the lens and cornea of the eye, the medulla of the kidney, the testes, and leukocytes. Conversion to acctyiCoA: pyruvate dehydrogenase converts pyruvate to acetyl-CoA in tk mitochondria. Tltis acetyi-CoA can then enter the citric acid cycle or be used as the building block for fatty acid synthesis. Conversion to oxaloacctate: pyruvate carboxylase converts pyruvate to oxaloacctate. This reactiop replenishes the c itric acid cycle intermediates and provides substrate for gluconeogenesis. Note: Pyruvate carboxylase is found in tbe liver and kidney, but not in muscle. Pyruvate derived from glycolysis would not provide a substrate for gluconeogenesis - a futile, ATP-wasting cycle would result. Conversion to ethanol: pyntvnte is reduced to ethanol. This occurs in ye.ast and certain microorganisms, but not in humans.

Emhth.n \ 1i.~ <'rhof palh\\ a~

The Embden-Meyerhof pathway is a specitic glycolytic pathway by wbich glucose is converted to pynJVate. This is the most common pathway and is used by a large number of anaerobic and facultatively anaerobic bacteria. Important: Oral bacteria use this pathay. The pyruvate is reduced to lactic acid via fermentation. This lactic acid is cariogenic. Note: This glyc<.>lytic pathway results in the net production of 2 ATP molecules per molecule of glucose metabolized. The otner-Doudoroff pathway is also a glycolytic pathway used by many obligate aerobic bacteria. It results in the net production of only one ATP molecule per molecule of glucose metabolized by substrate level phosphorylation compared to the 2 formed in tbe Embden-Meyerhof pathway. The pathway ends with the formation of a pyruvate and a glyceraldebyde-1 -phosphate which is converted by enzymes outside the pathway to pyruvate.. Note: These bacteria lack either of the key enzymes 6-pbospbofructokinasc or aldolase of the Embden-Meyerhof pathway.
TI1e pentose phosphate pathway (also called !he pentose shw11. the /Jexose monophosphate pathway, or the phospltoglttconate patlnmJ~ is a pathway of hexose oxidalion whereby glucose-6-phosphate generates five-carbon sugars. This pathway plays a major role in lbe production of NADPH for reductive biosynthesis (e.g.. of

fauy acids).

(smcHEMISTRY I PHYSIOLOGY

I' I

\.

All of the following statements concerning the pentose phosphate pathway are true EXCEPT one. Which one is the EXCEPTION?

It produces carbon dioxide (COz} It can produce NADPH It requires ATP for phosphorylation
It can produce five-carbon sugars (11sed for DNA and RNA)

It is controlled by inhibition of glucose-6-phosphate dehydrogenase by NADPH

It occurs in the cytosol of the cell

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ATP Is produced by humans via all of the following EXCEPT which two?

Substrate-level phosphorylation Electron-transport/oxidative phosphorylation Photophosphorylation Pentose phosphate pathway

...
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Tht is false; ATP is not directly mvolved in th pentose phosphate pathway.

In the Irreversible oxidathe rcoctlons of the pathway, one carbon or glucose 6phospbate is relca,.ed as carbon d1o.ode, NAOPH is generated. ami ribulo~5-phO>llhate is produced. In the reversible nono~idtive reactions, pentose pho.phates produced from ribulo~c-S-phosphate are convened to the glycolytic intennedtates fructose-6-pbospbate and glyceraldehyde-3-phosphate. The major role nf tltis pathway is the produ<:tion of NAOPH fo r reductive biosynt11etie reaction~ (e g.. farry <ICicl syntl:e.m) and the prnductiun of e!senliaJ pcntoses, prtleulorly D-rlbose, ued in the biosynthesis of nucleic acids. This pathway is prominent 111 tiNsues nctivcly canying out the biosynthesis or fntty dcids and steroids from small precursors, partkularly rhe mammary glunds, ndlpose fis ue, the"adrenal cortex, .!nd the li ver. Largo nm<)UllL< ofNAOPH are r.:quircd rn the reductive synthesis of fauy acid.< from ncetyi-CoA .. specifically the reduction or doubl< bond.> and carbonyl groups. Other tissu<OS less acUve m synthC>121ng ratty acids, such as s keletal mu<tle, are vtnuall)' lacking in the pentose pbosphoh; pathway. Glucose-6-phosphate debydrogeno~ IS the commilted step of the pentose phosphate pathway. Thts enzyme i> regulated by a\o1lability oftl1e substrate NAOP' Additional enzymes include ribulo.e-5-pho,phnt epimerase, ribuloseSf'hll,pbate I>O merase, transkctolase, and tmnsaldolase, Note: It is also called the pentose shuut, the hexose monopbasphart' pathway. or the phosphogluconate pathwuy.

P'\'IIIO\f'

l,hnlnphusphof} Ia Iinn phn'IJhatl' f)>ilh\\a~

Remember: ~o ATP is directly con~umcd nr produc.!d in the pentose phosphMc pathway This pathway proidcs a maJor portion or tltc cell's NAOPH. "h1ch function' as a biochemical reductant Substrateled pbospbOr) latlon: h1gh-cnerg}" phosphate mtem1edmtt~ arc fonned and are transferred tu ADP to produce ATP Examples of thts are found 1n glycolysis and the citric ae1d cycle (Krehi C\de) Gl)'colysis ts the tirst pba>e, Jnd the Krebs cycle (cunc acid cycle) i~ the ~ecoud phase of the r<'Sptntory mctal>oli~m of glucose.
Rlectrontransport/oxidatlve
phe~spbnrylution: eJectfon~

move down tht.::

electron transport chain, and cbcmto<ltlo~i occurs. Beca11st the eloetrouhcnric~l grad ient generated by the trun~l'cr t>f electrons through the electron transport chnin io 0 1 is used in tlw prt)duolton oJ ATP, the overall process is kttown as eltclron cran.porl/o~idoth' pho~phnryltltlll. 11 is 01c tblnl ami linal phase 11f tht respiratory metubollsm or glucose und olhcr substrates. Keduccd coenlymes (NADII cmd FAD/I;) gt:ncr-Jttd earlier in glycolysis and the Kr<bs cycle ar< rcoxidized; tlte clectroru. these proccses release are ll~nspOrted through a series of membrane bound earners ({loVOJift''eJns. lrotf-sulfur proteins. L'Oenzyme Q. und cr wchrome$) to esiabhsh a proton gradient across a membrane. a terminal acceptor such as oxygen is reduced. and ATP JS synthesized by chenuosmost5. Note : O'!idatic pbosphorylatton i~ the major SOli ret or ATP ln :Leroblc organi<m~. l'botopbosphorylation: occurs as a result of photosynthesis (whrch also mi'OIvt.\ 1111 ~lecunn transpolt l~hul;l)

Noto: Oxygen uptake. which h dcpcndrnt on the presence or ADP, pho>llhatc, ond on eloetron ~onor, b tcnncd coupled rt~plrutlon.

(BIOCHEMISTRY I PHYSIOLOGY

(\..

In most bum an cells, one glucose mol~ule produces enough usable chemical energy to synthesize:

30-32 ATP molecules 32-34 ATP molecules 36-38 ATP molecules 44-48 ATP molecules

How many mol~ules or this ATP do not go thr ough NADH first?

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Coflyri&hl 0 1009201 0 Dmtal Ottl:$

(BIOCHEMISTRY I PHYSIOLOGY

Metab)

(
Lactic acid Pyruvic acid
Amino acids

The starting point of gluconeogenesis is :

Acetyi-Co A

2. .
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36-38 Art mulecule~ 4-2 from gl.uol~sis and 2 from the 1-:.rehs c~dt'

Some cells, such as hean and liver cells, shuttle electrons more efficiently and may be able to synlhesi...- up to 38 ATP molecules. A net profit of 4 ATP is produced by substrate-level phosphorylation dtuing glycolysis (2 ATP) and the Krebs cycle (1 ATP). and 32-34 ATP are produced by oxidative phosphoryltion during electron transport. Energy Extracted from Glucose

Important: A Na gradient across the. luminal membrane provides the i111mediate energy source for ibe transport or glucose into intestinal epithelial cells.

Gluconcogcncsls is the process of synthesizing glucose from noncarbohydrntc sources. The starting point of gluconeogenesis is pyruvic 11cid1 although oxaloacctic ac1d and dihy<lroxyace.tone phosphate also provide enfr)' points. Lactic acid1 some amino ncid.~ from protein. nnd g.lyccro' fro m fat can bt cunvt:rtt!ll into glucose. Gluconeogenesis is ::iimiJar bul not lhe exacl reve.rse of glycolysis. Glu~.:oneogencsisoccurs mainly in the lher \vlth il:jmall i'tmount a:lso occurring in the t(!Jte}( ofthe kid ncy; Very little gluconeogenesis occurs in the brain. skcl c~l muscles, heart m\.lsclcs, or other body tis sue. In fact, rhcse organs have a hjgh demand for glucose. Therefore. gluconcogc..ncsis is constan1ly occuning in the liver to maintain the glucose level in the blood to meet these demands. Remember: During starvation, however, the bruin can derive energy from kttone bodie!'i, which arc converted to Gluconeogenesis i~ a pathway cons-isting of II enzyme-catalyzed re.ittiuns-. Gluconoogclltsis begins in the mitochondria with d1e tClfm3tion oronloacelatt thro\lg.h cii.J1hlx)lll!tion o f PJ'ru\'Wlt at the expense ofone: moltculc o f r\TP. Thi$ reaction 1s-calllly...:ed by pyruntt c~rboxytase. which IS stimula.-d b)' hih levels of ~eetyi ~CoA fn/tttJ/rf) a c-Id oxidalion Is hi,~h In the liwtr) and inhibited by high levels of ADP. OxaloacNate must then be roducc.-d into malate u!ting NADH in ordL. - rto be tmn!ipt>ncd out of the mitOI:hondria.
lo the cy1opla:-.-m~ malate is oxidjztd to oxaloacclatc usin~ NAD-. where. the rcmainln.,g

steps of ,gJuconcogencsis occur.

Oxaloacetall!' is then dec11rboxylml!d and phusphoryl n~ed to produce ph0$phoenolpyruv;!te by phosphoenolpynnate c~rboJ~k:Jnase. Ooe molecule ofGTr is hydrolyzed h) GOP in lhc: oourSe of this n:action. T11c ncx1 .steps in 1h~: reaction an: the same as reversed glycolysis. However. frucws.e--

1.6blspltosph"lase <.-onvcns fructQSCI.6bisphosphatc to ti'uctose-6-phospllate.. The pur

pose ofthi.s rc--.tetion is to 1>\'crtome tfie large neg_:ujve 8G.

Glucosc--6-phosphatc is fonncd from fmctosc--6-phosph:uc by phOSf)hoglucoisomer3\e-. Glucose-6-pbosphate can then be used for glu<:ost ge.nerat1011 or in other mcttlbotic path way$. free _glucose ls not 3~c:ra1cd al .nomadcally because glucose. \tnlike glucose-6phosphatc. tends 10 freely ilitruse out ofche cell. "The final reaction or.t;lut. "QflL"QJ;.t'nCSI~ the fomJaliOO of gi\ICOSC, is carried OUl Ullbt lumen
of the endoplasmic rcliculum. Gh.lcosc:--6p11osphate 1s hydrolyud hy ~l u cose6 phosph:uaS(' tQ produce glucose. Gl11t:ose is thc.'1l ~h ub led into the CYIOSOI by glucose tr.tns-

poners located in d1e membrane of the endoplasmic reticulum.

(siOCHEMISTRY I PHYSIOLOGY

Metab)

'\..

Which of the follow~ing cells in the body metabolize glucose only through the anaerobic glycolytic pathway?

Muscle cells Red blood cells

Hepatocytes
Neuml cells

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A patient deficient in production of tyrosine would also be deficient in all of the following EXCEPT one. Which one is the EXCEPTION?

Catccholamines
Melanin
Thyroxine

Serotonin

246 Copyright 0 20092010 OenUII Ottks

Red hlnod \"l'll' ... Though they arc ne\er really in an oxygeo-depned emlTonment, they do llCII have rnl-

thercrun: cannot send pyru\'ate tO tho! cnnc ac1d cycle. The oxjdauon of glueose IS known as glycolysis. GlucoS<! 1S oxidized"' euher lactate or p~ru vate. Under aerobic condl1ions, the dominant product in most tissues is J>)'rtnutc. nnd tho pathway is known as erobic glycolysis. When oxy~en is depleted, us ror insloncc during prolonged vigorou.< exercise, the dominant glycolytic product in nw >y tissues is lnclute, and the process is known os anaerobic glycolysis. Glycolysis occurs 1n the CYtosol of all cell> in the body. Glycolysts stans wub molecule of giU<:ose and then porfonns 10 stepwiS<! chemical tnansformations. During this proces<;. the sugar molecule is pnmcd with two phosphates /t.smg up two ATP molen1ler), lhtn broken .nto two ptcc:o. aod finally reshaped and dehydnatcd. forming four ATP molecules in the process. Owrall. gl)rolysis builds two new ATI' moluule using the energy of this panial breakdown of ugar The ATP may then be used h> pov.,er molecular processes thmugho<ll the cell. In uddinon. one step in glycolysis also eKtro~t> four hydrogen atoms fr<>m the sugar molecule, which my be u.;ed for biosynthe<i~ or 10 create a~~itiunal chemical energy. Pyruvate is lhc end produut of glycolysis 111 cells w1l11 mitochondria and un adequate supply of oxygen. This series of 1 0 reactious 1S called aerobic gly coly~l~ because oxygen b required to reoKidize the NADH formed clur111g the oxidation of glycernldehydes3-pbosphate. Aerobic glyeolysis sets the Jla~e for the oxidati"' decarhoxylnunn of pyruvate to acetyl-Co/\, major fuel of the c1trt<: ac1d cycle. Alternatively. glucose can be COil\'ened to p}ruvatc. which is reduced by 'A01i h) form lactate. ThiS converston is called anaerobic gi~>I)Sis because there is no IICI fonn>uon of >'ADH. and therefore. this conversion con occur 111 the abs<:nce of oxysen Anoerobic glycolysis allows the production of ATP in u.sues that lack mitochondria (for l!.rample, ,..,d blood cells) or in cells deprived of Sllfficient oxy1:tn.

u~ehondria and

, Serutunin

Tyrosme ts not essential to the human diet. sine~ thts ammo acid can be synthesized in the body from ph~nylalanint. Tyrosine tS a precursor of the adrenal hormones epinephrine and norepinephrine as well a, of the thyroid hormones. tncludmg thyroxine. Tyrosine is also the precur;or to the ncurotnsnsminer dopamme . Melanin. the skin and hatr pigment, is also denvcd from !his amino acid.

Remember: Serotonin (also called 5-Joydrox)'I">'P"'mine) is synlhcstztd from the amino acid II')'JIIO phan. Serotorun ts released from platelets upon damagl! to the blood vessel walls. Serotonin aCIS as a potent \asoconstrictor and mcrcases vascular peripheral resistance. In gastric mu cous membranes, serotonin is secreted by the enteroeodocrine cells and causes the smooth muscle to contract. In the brain, ~ertunin aces as fl neurotransmitter. Note: Lysergic acid diethylamide intel'fel'es wtth the action ofserotonitt itt the bra1n.

QnoCHEMISTRY I PHYSIOLOGY

' A patient of yours fails to tell you about his or her allergy to latex. You""'' walk into the room and begin treatment. The allergic reaction presenting causes histamine release. All of tbe following are responses to this EXCEP1 one. Which one is the EXCEPTIO/II'?

Vasodilation (particularly the arterioles) Secretion of HCL

Bronchoconstriction

Increased blood pressure Increased vascular penneability (particularly i11 capillaries tmd vemdes)

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AJI of tbc following statements concerning heparin arc true EXCEPT one. Which one is the EXCEPTION/

Unlike other glycosaminoglycans that are extracellular compounds, heparin is an intracellular component of mast cells that line arteries, especially in the liver, lungs, and skin It serves as a powerful anticoagulant It is used in the treatment of certain types of lung, blood vessel, and heart disorders, and during or after certain types of surgery (open heart or bypass surgeries) Small quantities are produced by basophil cells of the blood
It is usually found in large quantities in tbe blood
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Jncre-ast'd blood prcssun

This is false; histamine causes decreased blood pressure. Histamint> is a chemical messenger tltat mediates a wide range of cellular responses. Histamine is a powerful yasodilator that is forn\cd by the decarboxylation of hL~tidioe (a11 amino acid). Histamine is found in all rissues, particularly in most cells and their related blood basopbils, with the highest concenlration in tbc lungs. Histamine is an importam protein involved in many allergic reactions. Allergies are caused by an immune response to a nonnally innocuous substance (i.e.. polle/1. dusr) that comes in conlact with lymphocytes specific for that substance. or antigen. ln many cases, the lymphocyte triggered to respond is a mast cell. For this response Lo occur. a free-noatiog lgE. (an int/1111/IOglobu/in associated with allergic response) molecule specific 10 the antigen must first be anachcd to cell surface receptors on mast cells. Antigen binding to the mast cell-attached lgE then triggers the mast ccllto respond or become activated. (:-lote: Degramliolion describes 1he acJion qf the most eel/when it is acrivatetl.) This response often includes the release of histamine. This increases llle local blood llow and increases the permeability of llle capillaries and venules. allowing large quantities of lluid and protein to leak into the tissues- the characteristic "wheal."
Histamine bas powerful pharmacologic actions, which are mediated by two specific recepror types: I. H1 receptors mediate the typical allergic and anaphylactic responses to histamine - hronchoconstrictioo, vasodilation, and increased capillary pcrmcabllity. 2. 02 receptors medio1c other responses Lo histamine, such :;IS the increased secretion of gastric acid and pepsin. lmportant: The actions of bradykinin (a vasodilating kinin) are similar to histamine. Bradykinin increases vascular pemteabi lity, dilates blood vessels. and causes the tissue swelling associated with i1tflammatiou.

It is

u~u:1ll~

rouut.l in lar~e '-IUanlities in the blnncl

** This is false; ils couceurration in tlte blood is normally sllgbt, so tha\ only under
lim iled physiological conditions does heparin have significant anticoagulant effectS. Heparin (a protein) is c<:>ntained in secretory vesicles or granules within mast cells and the basophil cells of the blood, which are functionally almost identical to the mast cells. Heparin occurs in greatest conccntratron in the tissues surrounding the capillaries of tbe hmgs and the li ver. - 1. The adminisiTation of heparin will result in an increase in bleeding time Notes due to the activation of antithrombin, a major protease inhibitor, which rapidly inhibits thrombin. Heparin is used fn treating patients who have suffered a coronary lhrombosis. 2. Heparin prevents the activation or factor JX (Christmas factor) and interferes with thrombin action. 3. Heparin can also enhance the removal of lipoproteins from the blood by binding apolipoprotein (pmtein.found 011 some liposomes) and by activating lipoprotein lipase.

~IOCHEMISTRY I PHYSIOLOGY
An apprehensive dental patient comes in and states that he already took ibuprofen for the pain be unticipates from the appointment today. As you know, this inhibits the synrhuis of prostaglandins. All of the following statements are true about prostaglandins EXCEPT one. Which one is the EXCEPTIO~?

They have a very short half-life They generally act locally on or ncar the tissue that produced them They arc synthesized only in the liver and the adrenal cortex The common precursor of prostaglandins is arachidonic acid (an 11nsawrared fauy acid) Their synthesos can be inhibited by a number of unselated compounds, including aspirin and cortisol
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~IOCHEMISTRY I PHYSIOLOGY
All of the following arc formed via the cyclooxygenase pathway EXCEPT one. Which one is the EXCEPTION?

Prostaglandins Prosracychn Leukotrienes Thromboxunes

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l'hc~ :JH s~nthr .. iled nnf~

in lhlIIHr and tin :1drenal rorlt.\

This i folse; prostaglandins are synlhesizctl by a broad vuriely of li.ssue.<, Prostaghwdillo <tre any of group of components derived from unsanmat<d 20-cnrbou fatly cids, prim~~n1y arachidonic acid, via tile cyelooxygenase pathway: protaglanclins 11re poteut mediator< of numero\IS dftlea em physiologic processes. Protnglandin belong to a subclss of llpi<L~ kn<>wn 1!0 tbe elcosanolds (along with thromht~xano.v und /e,kotricnus) bec-aMe of (hefr Sll'\lctural similarities to the C-20 polyunSllntrmed fntry :Jcids, the eicm:11noic acids. ln general. prostaglant.lins act in a manner ~imilar to thm of honnonos, by stimu luting rrger ~ells into action. Jlowever, prostaglandins differ from hormones in they act lccaUy, near the-ir sile of synthesis, and they arc metabolized vel'y rapidly. Also, tb" >ame prostaglandins act differently in difT~rent tissues. Prostaglandins are 20-cs~bou fatty acids tbal coma in u live-carbon ring. Prosmglandins ar< synthesized in the cell from arachidonic acid created by phospholipase A2 The inlcnnediatc is Uten passed into one of either the cyclooxygcnase or llpo:cygenu<e pathway to form oitlter prostaglandins and thromboxanes or lcnkotrienes. The cyclooxygenase paihwuy produces Utromboxane,, J>rostacyclins, and prostaglandin D, E. and P. The lipoxygeuase pathway is active in loukocytcs and in macrophagcs and produces lcukoirienes. Prostaglandins are released throu_gh the prostagland in tranSJ>Otter on the cell's plasma membrane. I. Pm.'itaglaodins s~em to modulate lbe actloo of honnones rather lhnn acr as NoteS' homwnes themselves. 2. A~p irin , inctomethncin, ibup rotC:.u~ and phenylbutazone, whicll -a e NSt\JO.s. inhibit the biosynthcsi~ of prnstagluudius by interfering. wlth tl1e e1,12yme cycloo>ygcnasc. the enzymo thnt initiates the fonnation of prosl:lglandins from orilchidonlC add. ).Prostaglandin~ ~nhancc mnnmmamry effecT s, whcn.. -s,s aspirin dJuainlshes them.

Lttulwf ricne-.,.

1'he prostaglandins and a number of rolatcd suhsuinces !prostacycfi/1. t!trombo.uwe:.,

tmd leukotrienes) ~re c.hemical messettge,., One of these messengers is present iu almost every body tissue. They act ptimarily as local mess~ngers that exen their effects in the lissue.s Utat synthesize prostaglandins. Note: Leukotrieoe.s are llOtent bronchocnnITictors and cause airway wall edema, Increasing mucus production. They also attract "osinophils into the tissues and amplify tlte inflammatory process. Arachidonic acid (an ull.<(llllr!lled }(lily 11cfd) is the major compound from which prostaglandins, protacyclin, lhromboxanes, a~d lcukotrienes ore derived. Arachidonic acid is a part orphuspholipicls in the plasma membranes of cells. VariOU$ compounds activate a plasma membrane enzyme called phospholipase A2. and this

enzyme splits aracllidonic aoid from the membrane phospholipids. Different metabolic pathways utilize different eliZymcs tltat convert arachidonic acid into the different messengors: To form prostaglandins, prostacyclin, or thrnrubonues, the cyclooxygenase pathway utilizes the enzyme cyclooxygenase. To fonn leukotrienes, the lipoxygenasc pathway uti lizes the enzyme Upo~gcnusc. Note: Many NSAIDs including aspirin, block the cycloo~ygeuasc patll\vuy. The het)l!tit of this blockade comes from the ability to slow the synthesi; of prostaglandin.>, thus reducittg their inflammatory ability. Remember: Prostacyelln is a prostaglandin produced io 1he walls of blood vessels that acts ~ s a vasodilator and inhibits pllllelel aggregation.

(BIOCHEMISTRY I PHYSIOLOGY

Liv)

{ T be liver bas a multitude of Important and complex funct ions. These ") \ :ncludc all of the following EXCEPT one. Which one is the EXCEPTION" ~

Manufacture (synthesize) proteins, including albumin Synthesize, store, and process (metabolize) fats Metabolize and store carbohydrates Fonn and secrete bile
Fonn urine

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(siOCBEMISTRY I PHYSIOLOGY

In a cotton-candy-utlng competition, you consume 14 moderately sized ""' and overpriced bags of threaded sugar. This causes your portal .-ein to drop tremendous loads or glucose to your hepatocytes soon after. \Vhlch of the following enzymes functions only when this happens?

Pyruvate kinase Glucokinase Phosphofructokinase

Hexokinase

2 52

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Form nrin"

** 11us IS a function of nephrons in !he kidney.

Hepatocytes (/1\'er cells) are metabolic superachievers in tile body. The.r functions include the following: Manufacture (syuthesi:e) proteins, including albumin (to help nwmlflin the olume of blood) and blood clotting factors. Synthesize, Sture, and process (metaholf:e) fats, including fatty acids (used for energ;~ and cholesterol . Metaboh1e and store carbobydrntes. which are used as the source for the sugar (glucouJ in blood that red blood cells and the brain use. Fonn and secrete bile that contains bile ac1d$ to aid in the Intestinal abs()lptoon of fats and the fa1-solublc vitamins A. D, E. 11nd K. Elimmatc, by metabolizing and/or secreting. !he potentially hannful biochemical products produced by the body. snch as bilirubin fmm the breakdown of old red blood cells and ammonia from the breakdown of prmelns. Detoxify, hy 111etnbolizing and/or secreting. drugs, alcohol, and cnvilonmentnl tox:ins. Note: The nonessential amino acids""" all be synthesized in the liver. To do this for most amino acids, an u -keto acid having the same chemical composition (~xcept 01 the keto oxygett) as that ofthe amino actd is first syn1hesized. Then the ammo radical is ttansferred through tranJaminatioo from an available amino acid to the ~eto acid to take the place of 1he keto ox:ygen.

Glucolonasc is the name ghcn to a specll li\'tr for m of the enzyme hexokinase. Like hexokinase, glucokinase catalyzes 1he ATP-dependeot phosphorylation of glucose to form glucose-6-phosphate (G6PJ and ADP This is 1he first step of glycolysis. The enzyme will act on a vanety of 6-carbon sugars. produc1ng moieties phosphorylated at position six. Glucokmase. however. has a higher K,. for ~ugar substrate co111parcd to hexokinase (/0 mM v.d mM). This difference Is ve ry important for the liver, which is a major source of glucose from gluconeo~tcnosl s. By phosphorylating glucose. glucokinase creutes glucose-6-phosphatc. Olucose-6pbospbate can then be used by the liver tluough the glycolytic pathway. Along with this process in the liver, glucokina;e also facilitates glycogen synthes1~. Through !Ius. the majority of the body's glucose is stored. Glucose-6-phosphale tS also one of 1he starting material~ of the TCA cycle, which IS responsible for the majority of ATP produc1ion in 1he body. 1. Glucokmase is not involved in the process of gluconeogenesis. Instead, Notes the enzyme glucose-6-pho~phatasc cnwlyzes the hydrolysis of glucose-6phosphate to glucose and pbosphalc. 2. Glucok inase is also the predomlnatll cn;<ymc for the phosphorylation of glucose m beta ce lls of the pancreas. 3. Other lissues use hexokinase to do the same thing as glucokinase. 4. Hcxoktnase, phosphofructokmase and pyruvate kinase an: the three regulatory enzymes of glycolysi>.

(BIOCHEMISTRY I PHYSIOLOGY

\...

The Hver releases glucose back into the circulating blood during exercise. Which two organs lake up this extra glucose?

Kidneys Muscle

Heart Brain
Lungs

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Liv )

Which of the following s tatements about the u rea cycle is correct?

The two nitrogen atoms that are incorporated into urea enter the cycle as ammonia and alanine Urea is produced directly by the hydrolysis of ornithine ATP is required for the reaction in which nrgininosuccinate is cleaved to form arginine Urinary urea is increased by a diet rich in protein The urea cycle occurs exclusively on the cytosol

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\tll'~dl

Brain

Remember: Glucose Is th< major fuel for the brain: glucose ox1d1zes approx1?'ntely 140 gldny to carbon d1oxide and "ater, producins ATP. TI1e bra1n contams no slgniOconr stores of glycogen, and is therefore completely dependent on the availability of blood glucose. The liver has the major responsibility for maintaining blood glucose levels. Glucose is required particularly by tissues such as the brain and red blood cells. Note: Red blood cells nxid1ze glucose to pyruvate and lactate. The liver releases glucose into the blood durin~: musculnr nctlvlty and '" the interval bctneen meals. The released glucose is derived from two sources: { l) The breakdown of stor ed glycogen . (2) The fom1ntion of new glucose by tbe process of gluconeogeneSIS.

1. In skeletal muscle, the glucose 1S phosphorylated, and tben degraded ~y Nntts glycolysis to pyruvate, which is converted tO acetyi-CoA and ox1d1zed Vla the citric acid cycle. 2. Glucose is the major end product of carbohydrate mgesuon . 3. The presence of glucose in the urine proves a ptr~on hus exceeded b1s or her renal threshold for glucose. 4. Fasting leads to d ecreased lher gl)'cog~n. . . 5, In addilion to the liver. skeletal muscle 1~ the other maJOT s ue of glycogen
storage.

*** The amino nitrogen of d1etary protein is excreted as urea.

Urea is the major end product of nitrogeo metabolism 1n humans nnd mammal;. Ammonia, the product of oxidative dcamfnation reaction~. is tOXIC in e'en small amounts and must be remo>ed from the body. The urea cycle or the ornithine cycle describe.~ the conversion reactions of nmmon1 a into urea. Since these reactions occur in the liver. the urea is then transported to tbe kidneys where il is excreted. The overall urea fonnation reaction os: 2 Ammon ~a+ carbon dioxide 3 ATP .. urea- water~ 3 A Dr

I. 11le two nirrogens enter the urea cycle as ammoma and aspanate. No1n 2. Ure.1 is produced by tbe hydrolysis of argtninc. 3. The cleavage of argininosuccinatc does not require ATP. 4. The un:a cycle occurs paniy in the mitochondria. 5. A complete block of any step in the urea cycle is fmal since there is uo known ahcmative pathway for the synthesis of urea. 6. Inherited disorders from dcfc..'"lhc enzymes may cause 3 paninl block in some of the reactions and resulis in hyperammonemia, which canlc.1d to mental rNtlf dation. 1. Extensive ammonia accumulation leads to extensrve liver dnmage and deatl1. 8. Liver Cll'l'hosis ca11sed by alcoholism creates an interference iu the enzymes that produce carbamyl pbosphtlte in the first step in the cycle. 9. Tile level of nonprotein nitrogen in tho blood is due primarily to the level of

urea. I 0. Death ti'om advanced hver <hsease is pnmarily due to the inbibiUon of urea
synthesis.

~IOCHEMISTRY I PHYSIOLOGY
The major regulatory enxyme of r holesterol synthesis is:

Thiolase
HMG-CoA reductase IIMG-CoA synthase HMG-CoA kinase

2U CopynJbl 0 2()09.2010 Dt1"11J Deets

(BIOCHEMISTRY I PHYSIOLOGY

Min i Vit)

Which essential n utrient bas the highest ROA for the 25-SO age group?

Riboflavin Vitamin E

Vitamin C
Folacin

2..
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U\1<;-Cu-\ redurtast.

Although cholesterol is synthesized in most tissues of the body, where cholesterol serves as a component of cell membranes, it is produced mainly in the liver. Cholesterol is synthesized from acetyi-CoA; key intennediates in cholesterol biosynthesis ~re HMG-CoA, mevalonic acid. isopentenyl pyrophosphate. and squalene. In the liver, bile s alts are formed from cholesterol; in certain endocrine tissues, cholesterol is converted to steroid honnones -- testosterone, cortisol, progesterone, and estradiol, which is the most potent naturall y occuniog human estrogen; vitamin 0 is also formed from cholesterol by a series of reactions requiring the skin, liver, and kidney.

I. C holesterol absorption depends upon the presence of bile sails in the Notes intcstinaJ lumen. 2. Cholesterol is mostly esterified with fatty acids when circulating in blood plasma. 3. Circulating cholesterol is taken up into liver cells where it inhibits synthC$iS of additional cholesterol from acetyl-GoA via allosteric inhibition of HMG-CoA reductase. This provides an intrinsic feedback control system to reduce exce~s cholesterol synthesis. 4, Thiolase and HMG-CoA synthase are both involved in the synthesis of cholesterol. The reactions these enzymes catalyze are reversible and do not commit the cell to the synthesis of cbolesrerol.

\ita min C
'

Summar~

of\ itamin C

Dietary Sources Major Body Functions

Citms fmits. tomatoes, green peppers. broccoli, spinach, strawberries, melon

beficieocy

Synthesis of connective tissues. Essential for the hydroxylation of lysine and proline in collagen synthesis Essential for integrity for capillaries and oral mucosa Needed for nonnal bone matrix fonnation Needed fortJOm1al phagocytic function and antibody synthesis io bost defense systeo1 Scurvy (degeneration ofskin, teeth, blood vessels, epithelial hemoTT!tages) Delayed wound healing Anemia

- I. Vitamin Cis also called ascorbic acid. Notl\$ 2. It is an antioxidan t. ' 3. Vitamin C deficiency primarily affects connective tissue (as opposed to hematopoietic, epithelial. m~tscular. or nervous tissue) 4. Vitamin C is essential for tht normal elaboration and maintenance of bone matrix, cartilage, and dentin.

~IOCHEMISTRY I PHYSIOLOGY

Min / Vi0

Which of the following is a p art of nclive cytochrome oxidase?

Zinc

Vitamin C Copper
Vitamin K

Magnesium

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Min / Vi0

~ I~ A patient of yours with a PhD in nutrition tries to trip you up by saying that he a

\..

supplements every morning with tocopherol. What is be talking about?

Riboflavin Vitamin E Vitamin C Folac in

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Copplr
Cytochrome oxidase is one of a superfamily of proteins that act as tbe terminal enzymes of respiratory chains. Copper is also imponant in the maturation of collagen and elastin as copper is a cofactor for the enzyme lysyl oxidase. The oxidized lysine residues formed in collagen and elastin by this enzyme fonn the cross-links tbat stabilize these molecules. Minerals are inorganic substances that are essential to li fe. They serve both structural and regulatory functions. Minerals may be classified as: Major mineral$ (more than 0.005% of body weight) -calcium, chloride, magnesium, phosphorus, potassium, sodium, and sulfu r. Trace mJnerals (less rhan 0.005% of body weight) -- chromium, cobalt, copper, fluoride, iodine, iron, manganese, molybdenw.n, selenium. and zinc. General Functions of Minerals: Maintenance of acid-base balance Coenzymes or catalysts for biologic reactions Components of essential body compounds Transmission of nerve impulses and regulation of muscle contractions Maintenance of water balance Growth of oral and other body tissues

\ .itamin F
Stlllllll<lr~

of\

i l~tmin

Dietary Sources Major Body Functions Deftcieocy

Vegetable oil and seeds, green leary vegetables, margarines, shonenings

Fw1ctions as an amioxidant. inhibiting the breakdown of unsaturated fany acids

Is almost entirely restricted to premature infants

I. Vitamin E is also called tocopherol.

'Notes 2. 1t prevents free radicals from oxidizing compounds such as polyunsat-

urated fatty acids. 3. It is the least toxic of the fat-soluble vitamins - vitamin D is the most toxJc of all vitamins. 4. Vitam in E supplementation bas been proposed to be of benefit in prevention of heart disease and cancer; however, controlled studies have been unable to show a link between vitamin E supplementation and the prevention of these diseases.

~IOCHEMISTRY I PHYSIOLOGY

Min

IVit)

If' Your practice is in an area where polished rice is a major component ""''
of the diet. Because of this, many of your patients present with thiamin deficiency syndrome. This is also called:

Pellagra

Beriberi
Scurvy Megaloblastic anemia

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~IOCHEMISTRY I PHYSIOLOGY
A patient of yours is deficient In niacin. This disease is termed:

Night blindness Pellagra Scurvy

Rickets

Beriberi

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llt.riht.ri
'umn~o~n

uf I hi:uum 0 1tmum B ,J

Dieo:ary Sources Major Body Functions Deficiency

Meat (especial/)' pork or organ meal$), grains. dry beans and peas, fish, poultry Involved in the metabolism of caibohydratcs and many amino acids Adult beriberi is characterized by dry skin. irritability, disorderly thinking, and progressive paralysis

Thiamin, also called vitamin B 1, is used in many different body functions and defic. iencies may have far-reaching effects on the body, yet very little of this vitamin is stored in the body, and depletion of this vitamin can happen within 14 days. Thiamin is also a miraculous nutrient. Somebody suffering from beriberi. scarcely able to lift his head from his pillow, will respond quickly to injected thiamin. and will be on his feet within a matter of hours. Thiamin may enhance circulation. and helps with blood fonnation and the metabolism of carbohydrates. It os also required for the health of the nervous system and is used in the biosynthesis of a number of cell constituents, includoog the neurotransmitter acetylcholine and gamma-aminobutyric acid (GABA). It is used in the manufacture of bydrocbloric acid, and therefore plays a pan in digestion.

Pl'lla!,!r:t

:"'tumm~tr~

uf 'hu:in

Diewy Sources Major Body Functions Deficiency

Lover. meat. fish. gnuns, legumes. poultry. peanut butter Component of NAD and NADP. which are involved in gl)col)SIS, the Krebs cycle, and other reactions Pellagra, which is characterized by diarrhea, dcnnatitis, and dementia - - the 3 D's

I. Niacin is also called nicotinic acid.

) Noles 2. It is a component of NAD and NAOP.

3. It can be formed from the amino acid tryptophan. 4. High supplemental doses are effective in treating hy11erlipidemla.

(BIOCHEMISTRY I PHYSIOLOGY

Min 1Vi0

rWhich of the following is a water-soluble vitamin and in contrast to othc~

~

water-soluble vitamins is not excreted quickly in the urine, but rather accumulates and Is stored in the liver, kidney, and other body tissues?

Vitamin A
Cobalamin (vitami11 BJJ)

Niacin
Vitamin E Riboflavin

261
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Dtmal Dcd.s

~IOCHEMISTRY I PHYSIOLOGY

Min I

Vit)

Which or the following is required for the balancing of hormonal changes in women as well as assisting the immune system and the growth of new cells?

Vitamin A
Vitamin 8 6

Vitamin K
Vitamio B12

212
Copyni}lt 0 2009-2010 Drntal t)e(k$

Cohahtmin (\il:.unin B12

) ---

alsu called

c~anocohalamin

As a result, a vitamin B., deficiency may not manifest itself until after 5 or 6 years of a diet sttpplying inadequate amounts. Vitamin B 12 func tions as a methyl donor and works with folic acid in the synthesis of DNA and red blood cells and is vitally important in maintaining the health of the myelin sheath that surrounds nerve cel ls. The classical vitamin B 12 deficiency disease is pernicious anemia, a serious disease characterized by large, immature red blood cell s.
Summar~

uf \ 'itamin U1!

Dietary Sources Major Body Functions

Muscle and organ meats, eggs. dairy products, fish Required for two reactions in the body: Involved in the formation of methionine 2. Involved in the coo version of methylmalonyl CoA to succinyl CoA
I. Pernicious auemta, neurologic disorders, glossitis

Deficiency

I. Deficiency is usually owing to the absence of intrinsic factor, which is 'Nut.,. pr(>duced in the stomach. Intrins ic factor is necessary for the absorption of vitam in B12 from the Gl tract. 2. It is the only vitamin that contains essential minera l elements and is the first substance containing cobalt that is fo und to be vital to life. 3. ll may be present in inadequate quantities in a strictly vegetarian diet.

\ i1;tmin

n..

Vitamin 6 is a collective term fo r pyridoxine, pyridoxal. and pyridoxamine. They are a ll derivatives of pyridine, differing only in the nature of the functional group anached to the ring. All three compounds can serve as precursors of the biologically active coenzyme, pyrido_xal phosphate. Pyridoxal phosphate func tions as a coenzyme for a large number of enzymes, particularly those that catalyze transamination reactions invoJving amino acids. Vitamin B6 is also used in the processing and metabolism of proteins, fats, and carbohydrates, while assisting with controlling mood as well as behavior. Vitamin might also be of benefit for children with learning di fliculties. as well as assisting in the prevention of dandruff, eczema, and psoriasis.

a.

assists in the balancing of sodium and potassium as well promotes red Vitamin blood cell production. Vitamin B6 is furthe r involved io the ottcleic acids RNA as wel l as DNA. Jt bas been linked to cancer immunity and fights the forma tion of the toxic chemical homocysteine. which is detrimental to the hean muscle. Deficiencies are rare but have been observed in women taking oral contraceptives and in alcoholics. Dietary sources of vitamin and egg yolks.

a.

a6 include meats (liver), vegetables. whole-grain cereals,

(siOCHEMISTRY I PHYSIOLOGY

M in I Vit)

I f"whtch of the following is a water-soluble vitamin that helps the body for~
\. red blood cells and aids in the formation of genetic material? _}

Vitamin A
Thiamin

Folacin
Pantothenic acid

283 Cop)Tigb1 c 20092010 Otntal Okt~

(smcHEMISTRY I PHYSIOLOGY

Min 1Vi0

Which of t be following fat-soluble vitamins is necessary for calcium's role In blood clotting?

Vitamin A Vitamin K

Vitamin E
Vitamin 0

Cop)Tiehi 0 ~0 1 0 IXntallko:b

...

Folarin lulatc~ folic acid Folacin plays a key role in one-carbon metabolism, and is essential for the biosynthesis of tbe purines and the pyrimidine, thymine.
Summ:tr~

of Folit \dd (fi1/ult' or joludn)

Dietary Sources Major Body Functions Deficiency

Liver, kidney, yeasl, musbrooms, green vegetables Involved in the synthesis of purines and thymine, which are required for DNA formation

--

Megaloblastic anemia Diarrhea Glossitis

I. Folic acid is stored in the liver and may be synthesized by the bacterial flora of the Gl tract. 2. Folic acid dcOciency is probably the most common vitamin denciency in the U.S., particularly among pregnant women and alcoholics. 3. Because of folie acid's importance in the synthesis of purines and thymin,e the metabilism of folic acid metabolism is the target of a number of antimetabolite drugs such as methotrexate.

Yilamin K- al'io called llh~lloquinont or antihcmorrhagie factor

The principal role of vitamin K is in the post-translational modification of various blood clotting factors (II, Vll. IX. and X), where vitamin K serves as a coenzyme in the carboxylation of certain glutamic acid residues present in these proteins.
Summar~

of \ 'itamin K

Dietary Sources Major Body Functions

Green and yellow vegetables, small amount in cereals, fmits, and meats Required for synthesis of prothrombin and certain other clotting factors in the liver

Deficiency

Retarded blood clotting Excessive bleeding

I. Vitamin K is synthesized by intestinal bacteria. /Notes 2. Warfarin is a synthetic analog of vitamin K. which acts as a competitive inhibitor of prothrombin fomlation. 3. Vitamin K decreases coagulation time and is present in low concentrations in milk.

~IOCHEMISTRY I PHYSIOLOGY

Min 1Vi0

Which of the following is a component of coenzyme A? Riboflavin

Niacin

Pantothenic acid Biotin

(
Fatty acid synthase DNA polymerase Phosphofructokinase Adenylate cyclase

T his Is also a component or:

2U Copyn.al'lt 0 20091010 lkntal l>ttk.s

(BIOCHEMISTRY I PHYSIOLOGY

Min I Vit)

(
The precursor of FAD

Biotin is:

Required for the carboxylation of acctyi-CoA to malonyl-CoA, an intermediate in fatty acid synthesis A cofactor required for the hydroxylation of proline and lysine A fat-soluble vitamin

266
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r,anlolhcnir acid- also calltd pantothenate or \'ita min IJ,

Futt~

acid

s~ nthasr

Pantothenic acid (PA}, a water-soluble B-complcx vitamin, is essential for growth, reproduction, and normal physiological functions. Pantothenic is a component of coenzyme A, which functions in the transfer of acyl groups. Coenzyme A contains a thiol group that carries acyl compounds as activated thiol esters. Examples of such stmctures are succinyi-CoA, fatty acyi-CoA and acetyi-CoA.
Summar~

of Pantothenic \cid

Dietary Sources Major Body Functions

Widely distributed in all foods, eggs, liver, and yeast

Component of coenzyme A, which functions in the entry of pyruvic acid into the Krebs cycle and in the degradation of fatry acids Also a compound of fatty acid synthase Fatigue Sleep disturbance Impaired coordination Diarrhea 01, renal problems

Deficiency

Rcquind for lh(' carlun~ Ia lion of acct~ 1-CoA to malon~ 1-C'o.\. an intermediafl in ratt~ acid s~nthrsis
Summ<lr) ol lliolin

Dietary Sources Major Body Functions

Liver, kidney, yeast, milk, egg yolk

Essential for the activity of many enzyme sys1ems that are involved in amino acid and protein synthesis

Required for the carboxylation of acetyl CoA to malonyl CoA, an intermediate in fatty acid synthesis Fatigue
Depression

Deficiency

Nausea Dermatitis Muscular pains Loss ofhair

--..,. I. Biotin (sometimes called vitamin H) is also syu!besized by inlcstinal INotes bacteria.
2. Avidin is a protein, found in uncooked egg whites, that binds to and inactivates biotin and that, when present in abundance, can result in a deficiency of biotin.

(smcHEMISTRY I PHYSIOLOGY

(
Required for blood clotting

Vitamin A (retinol) is:

Required for the hydroxylation of proline and lysine residues in the precursor of collagen A constituent of rhodopsin Required for synthesis of a cofactor required for reactions in the oxidation of pyruvate to carbon dioxide and water

287 Cop)'riihl 0 .10092010 lkl'l'-1 Dttl s

GnocHEMISTRY 1PHYSIOLOGY

All of the following vitamins have liUic to no risk of overdose EXCEPT one. Which one Is the EXCEPTION!

1\iacin
Biotin
Vitamin C

Vitamin K

268 Cop)npt O 2009--2010 I~IAI Db

~ummotn

nt \

i1.1111111 \

Dietary Sources Major Body Functions

Widely distributed lll green and yellow vegetables and fiuits

Constituent of rhodopsin (visual ptgmenl) Maintenance of c~ithelial tissucs Has a role in mucopolysaccharide synthesis, bone growth. nod retnodcling
Xeropbthalnua
(keratilli~atiou ofocular tUJrttJ

Deficiency

Night blindnc<S

I Vitamin A, along with vitamins C and D. is required for the nonnal producuon of sound denim and enamel; however, a delldency of ' 'ita min A will most likely affect the enamel more than the denun . Whereas. a dclldency in vitamin C will nffeCI the dentin more, due to the role of vitamin C in collagen synthesis.

\ita min I"

The others are water soluble and thus bnve little. if any. risk of ovcrdo>c The water-soluble vitamins. cxcludmg 'itamin C, popularly are termed the 8 complex vitamins. There are eight of them. namely; 8 1 (thtanrine). 8 1 (riboflavin)

acid). n. (pyridoxine) . niacin (nirotinic acid), llu (cobalamin) folacin (folic acid), and biotin (iramin H). The water-soluble vitamins, inactive ir their so-called free states, must be activated to their coenzyme form;. 8-comple> vitamins and vitamin C arc water-soluble vilnmins that arc not stored in the bod) and must be replaced each day, preferably through a high-quality liquid multivitamin
The water-soluble vitamins arc absorbed in our intestine, pass directly to the blood and are carried to the tissues in which the vitamins will be utili>.ed. Vitamin 8 1: requires a substanc" known as ~intrinsc factor" for absorption. Water-soluble vttamins usually are exc reted 1n the urine on a daily basts. Tbtamin< (13 1), riboOavin (8 1). pyridoxine (86). ascorbic acid (C). pantothemc acid (B,), anc biotin appear in urine as free vitamins. The tissue storage capacity of wat.,r-solubl, vitamins is limned, and as the tissues become saturated. the rate of cxerctior increases sharply. This keeps us from overdosing, but th is is also wby we need to lak< these vitamins daily, Unli ke the other water-soluble vitamins, however, vitamin 13 1: is cxcreu:d solely in the feces. Remember: Fat-soluble vitamins include vitamins A. D, E. and K. They are carried in fat and can be $tored in the body. II is possible to overdose on fat-soluble vitamins

a$ (pantothenic

~IOCHEMISTRY I PHYSIOLOGY

M in 1Vi0

~Vhich fat-soluble vitamin below is a steroid hormone and is known for it;' D i'important role in regulating body levels of calcium and phosphorus? -""'

Vitamin A Vitamin D Vitami n E Vitamin K

269
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~IOCHEMISTRY I PHYSIOLOGY

M in 1Vi0

In what order does vitamin 0 get converted from its inactive to its fully active form?

Skin, liver, kidney Skin, kidney, liver

Liver, kidney, skht Liver, skin, kidney

Kidney, Liver, skin
Kidney, skin. liver

270
Copynpt 0
l~lOIO Oema1 Pb

\ it;unin I>

Vitamin Dis a fat-solu ble vitamin . It is found in food, but also can be made in the body after exposure to ult<aviolet rays from the sun. Vitamin D exists in several forms, each with a diiTercnt activity. Some forms are relatively inactive in the body, and have limited ability to function as a vitamin. The liver and kidney help convert vitamin D to its active hormone form. Note: I, 25-dihydroxychole-calciferol is the active form of vitamin D. The major biologic function of vitamin D is to maintain normal blood levels of calcium and phosphorus. Vitamin D aids in the absorption of calcium, helping to form and maintain strong bones. Vitamin D promotes bone mineralization in concert with

a number of other vitamins, minerals, and hormones. Without vitamin D, bones can become thin, brittle. soft, or misshaped. Vitamin D prevents rickets in children and
osteomalacia in adu Its.
Summar~

of \.ih1min I>

Dietary Sources Major Body Functions Deficiency

Fish-liver oil, eggs, dairy products, fortified milk, margarine

Promotes grov.1h and mineralization of bones and teeth Calcium and phosphorus metabolism (bone formation) Rickets in children Osteomalacia in adults

Note: Vitamin D and parathyroid hormone both increase serum calcium .

7-dehydrocbolcstcrol, an intem1ediate in cholesterol synthesis, is converted to cholecalciferol (vitamin D:) in the dermis and epidermis of humans exposed to sunlight. Note: Preformed vitamin Dis a dietary requirement on ly in individuals with limited exposure to Slutlight. Vitamin 0 3 (cholecalciferol) is not biologically active, but is a precursor of the active molecule 1, 25-dihydroxycholecalciferol. The most prominent actions of this active molecule are to regulate the plasma levels of calcium and phosphorus. Note: Cholecalciferol (viramir Dy is convened to 25-hydroxycbo~calciferol in the liver. 25-hydroxycbolecalciferol is converted to 1.25-dihydroxycholecalcifcrol in the kidney.

~IOCHEMISTRY I PHYSIOLOGY
Which of the following is a water-soluble vitamin that acts as an essential coenzyme in many oxidation-reduction reactions in,olved with carbohydrate metabolism?

Folacin (folic acid) Riboflavin (vitamin 8;) Niacin Thiamine (vitamin 8 1)

271
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~IOCHEMISTRY I PHYSIOLOGY

MiniVit)

( All of the following statements concerning fluoride are true EXCEPT on;'\ ~\.. Which one is the EXCEPTION?

It is excreted by the kidney

It passes the placental barrier It hardens tooth enamel It is deposited in calcified tissues

272 Copyri.ght e 20()9..2010 l>eBIBI Decks

Rihutl:t\ 111 t I itmuin R:J

Vitamin

s 2 commonly called riboflovin, i~ one of eigbt w111cr-soluble 8

vitamins.

lo addtuuu to producing energy for the bod). riboflavin also works as an antioxidant by scavenging damaging particles '" the body known as free radicals.
These panicles occur naturally in lhe body but can damage cell membranes. mteract w:itb genetic n)a!cri<tl, and possibly contribute to the aging process as well as the development of a number of health conditiuns such as heart dtscasc 1111d cancer. Antioxidants such as ribonavin can neutrah le free ra..ticals and may reduce or even help prevent some of the damage they cause. The two biologically active forms are flavin mononucleotide (FMN) and flavin adenine dinucleotide (FAD) formed by the tr.msfer of an Al'v!P moiety from ATP to FMI\. FMN and FAD are boutttl ttgbtly . sometimes co~alently to Oavoenz ymes that catalyze the o~tidation or reduction of a substrate.
'unumtn of KthuO:I\111
(I llflllllll lf:J

Diclnry SCtu ~t$

Milk, leafy \'Cgctal>lc1. fresh nu~.ut. egg yolks or two fluvin nuclcolide coenzymu (fAIJ uml F/t.IN) th:ul funczu)n \l'1lh some 411zymes (fl.wiJprutclnJJ 1h:u c31lllya oxidatiOn ~duedot1 rc3Ctions
Constituent~

Majut Dod)' fuuthuns

D<f><ien<y

. .

Qocl<s at conocroflht mouth tattg>klr t/lti/lhtl

Dcrmatii1J

Glo$.51111 lh/l'f'~ UJ1'Nrf'lg SMOOJ.h tJ.1fli ptrrp/nhl

Note: Vitamin D ""d parathyroid hormone both Increase serum "alrium.

Fluoride dou not make the enamel hard<r. but reduces the solublllt) of enamel due to the loeorporntloo of fluoride into the apaute structure of the enamel Tbc concentration of fluoride in the body fluids is regulated by an equthbnum relanonsbp between bone and urinary excretion A d eOrieney or nuori~e can lead to an mcreased Incidence of dental caries. and to,lclt) leads to tooth enamel monllng and discoloration, mcreased bone density, ond calciflcntlon. Facts about Ouorlde: It is excreted by the kduey. It is depo~lted in calcified tissues (I.e., skeletal). It passes the placental barrier slowly. At I ppm. Ouoride is tasteless. colorleu, Bnd odorless. One ppm is the equtvalent of I mg/L. or I mch in 16 miles. It converts b)droxpparile to Ouoroapalire by the substitution of the OH ion w;th tbe nuonde lon. Fluoridation of community water bas heen credited with reducing tooth dec> by S0!.-60/o in the United State~ since World War II. More recent .,;11mates of this ell'ect show dec3y reduction at 18%-4()%. which renects that even m communities that are not Ol)tlmally lluondated, peorle a re receiving some benefits front othe r sources (e.g., bnrrled beverages, toothpaste). Fluonde works by stopping or even rcversln~ the tooth decay process. Fluonde keeps the tooth enamel strong and solid by pre\enting the loss of (unci enltcmcing tire 1'l'DIIaChmenf t>./) 11nponant mioerols frorn the tooth enamel.

Water fluoridation costs~ on av\!rage, 72 ctnu pe.r person per year in U.S. communities. Ch~ldrcn under age 6 years rnay de\ olor enamel lluorosts tf they tngest more fluonde tban needed. A common >ource of extra flunrtde is unuper.btd use of
toothpustt in very young children.

~IOCHEMISTRY I PHYSIOLOGY
Your dental assistant comes In one day all smiles. At lunch, she announces that she is pregnant. You recommend that she makes sure to keep her intake of this mineral high because II helps her immune system, as well as the growth and development of her and her unborn child. She orten comes in with loads of perfume on and you are hoping that this change in diet might also improve her sense of s mell, so s he tones it down a notch. Which mineral are we talking about?

Phosphorus Cobalt Copper Zinc

2'73
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~IOCHEMISTRY I PHYSIOLOGY
SUMMARY
l-.11 "oluhk \ lt .llltln'
t\1111111111111

Min I Vit)

Vlram_ ln
A

Major function

fl~lpt fonn sk1n and mucous membmnc-s t nd kctp them hca.lthy. lhus increasing rnu.tan

NtJbt blindness

10 i"(tlOib

- ....... -tooth.,........,._.
....... caoec.-

f.MC1UioJl (Of

nip \'i$ion

Bcu ~(N: 1S- OOXJdant JDd proCC'CU

Promotn hard<":nmg of bones and ccdh Inerea~ the absorptwn of caJc ium

. . . .

Deficiency Symplontt

AbnonmJ dtyn<$$ or the ~okm. eyes. or mu!Xlus

~nweomal:acia r.nroU~ b)'J>Crl<...-s

Ancw.xia

Bone changes

Osteomalacia in adults Rtckecs in chiJdtm Dtfonnity of bone nnd p:uholoaic frac-tures:

Neurologic syndron~s inciOOia attnexia (nbstnce of reflexes:) and gait diiilubonccs May c01nn"bu~e 10 bcmolylic.: unemla

. .

Protecu vhamins A and C and fatty aeids Prevents dllrn3ge to cell membr;~ncll Ando:udant \1a,or impottMet in b&ood doc formation

J lypotbrombinemia and hemonflaa:tt d1~

2U CopynaM 0 20092010 !Xntal Oecks

Zinc

Zinc is an essential mineral that is found in almost every cell. Zinc stimulates the activity of approximately I 00 enzymes. Zinc supports a healthy immune system, is needed for wound healing, helps maintain your sense of taste and smell, and is needed for DNA synthesis. Zinc also supports normal growth and development during pregnancy, childhood, and adolescence.
Kulri~nt/M in~ral

Functions Constituent of htmoRiobin and enzymes involved in e nergy metabolism Constituent of th)'roid hormones, rcg\llatcs energy metabolism Hone and tooth formation, blood c.touing nerve transmission, musc le contraction Bone and rooth forma lion, acidb3SC balance, release or energy (ADP. ATP) Constin1 cnt of active tissue compounds, tartilagc and tendon Acid-base balance. body water balance, nerve function, muscle relax:uion Acid-base balance, body watu balance. nerve function Activate,s enzymes invohcd in prottin synthesis Constituent ofvitaruin B 11 Constituent of enzymes associated wilb Iron metabolism and nerve function

Iron

Iodine

calcium Phosphorus Sulrur Potassium Sodium Magnesium

COOah
Olpper

~IOCHEMISTRY I PHYSIOLOGY
\\ ah-r-\uluhlc \
lbtnlll\ (\llfl/1114111 )

MiniVit)
Oeticieney Symptoms

Vit.a.min

u
M M A R
Thiamin

. . .

Major Function
Form3tion of eoU:tgen. helps hold them togethet and keep them he:llthy Wound healing
M3intaining blood vessels.. bon~. tth

Bleeding gums Filed wound healing

Absorpcion of iron, calcium., folacil'l PI'O<JI)Ction of brain homl<.>ne:s:. immune factors Antiwddunt Helps rtle:lSe tt~e"8)' ff'()m foods Promotes nonnal appccitc ImpOrtant in function of the nenrous system

. .
. . . . . . .

BNiSt' easily Dry, rough skjo

Scutvy
Sore jomts and bones lncrell$ed infeci<>ns Beriberi
P.den~ he(lrt

u
M M A R y

failure

Wcmid:c'ii cncq:>halopathy Peripheral neuropnthy Oroil(;ulogenital areas arc reddened, grtnsy, scaly. and pnuitic Seborrheic dennatili$ Angular stomatitis CheilO$iS Magenta conguc

" llibv01t\in

Helps release ct~ergy ftom foods

Promotes good vision and healthy !>kin

NlaC'In

Engy production from foods

Pcllap
t)irrbca

Aids di&CStion Promotes nom1al appetite Promotes he~hhy sl:in lind ner"es

Photosensitive dcrm:uitis Mucosal intl:arnmation Dementia Beefy red tongue

275
Coprright ~ 20092:010 Otnr.ll

O.lc:$

~IOCHEMISTRY I PHYSIOLOGY
(
During inspiration, there is a fall in:

Atmospheric pressure Intraalveolar pressure Intrapleural pressure lntraalveolar and intrapleural pressure

276 Copyri&ht 0 201-20 I0 Dental Decks

SUMMARY
\\ h r~oluhh \ itamins (SiiuWIIITl')

Viblmin

Major F'unc:,ion

Delic1cnq Symptoms

Fot11te

Aids in pr<Keil~ metabolism Promotes red blood cell fOrmation Prevents blnb deiC<:ts of the spine and bra1p lower'S homocys1cine levels and li\LIS <"Ore.nary heart di$Ca.Sc ris~ Aids in building of genetic material 1\rds in development of oonnaJ r~d bloOO
c.:lis
Maintc.n~11ce of nervous

Meg-ntoblastlu anemia Glossitis

Oiatrh(a

u,

l'antothenk ld

S)'Stcm

Megaloblastic anemia Olossius

Ano.rc~ia

Sensory nC\lropaihy
Ot:mentin

(nvolved in energy production Aids m rom1arion of hormones

61ulln

aumiog. fool syndrome fatig:ue

Abdominal rain and vomiting Insomnia
Sc3ly dermatitis .Alopcc1o Muscle pam

Helps I'(IC$C eoe:rgy from carboh_ydrntcli 1\lds in f:)t syn1hesis

n,

Aftb in protein mt.'tl\bolism. ain;orptioo Aids in red blood cell tOnnation Helps OOdy usc fa1

Depn:ssion 'i\oerola Seborrheic den:nlltiti~

Gtossitfs

Cheilosis Angular stomatfns J>cripbml neuropmhy

ln11':1nh t.ular und iu(r~tpll'ural pressure Air flows because of pressure di ffercnccs between the atmosphere and ;he gases inside the lwtgs. Air, like other gases. Oows from a region with higher pressure to a region with lower pressure.. Muscula r breathing movements and recoil of elastic ussues create the changes in pressure that result in ventilation. Pulmonary vcmHatlon involves three diffe rent pressures: At.mosphcrle pressure is the pressure of the air outside tbc body ln traalvcolar (intrapulmonary) pressure Is the pressure inside the alveoli of the lungs Intrapleural pressure is the pressure within the p leural cavity Note: In the resting position, the intrapleural pressure is a pproximately 4 mmHg less than the atmospheric pressure. Hence, tbe intra pleural pressure is appro;ocima1eJy 756 mmHg.*** It is subatmospheric, or ncgath1e. I nspiration (inhalation) is the process of taking air into the lungs. This is the active phase of venrjlation because it is the result of muscle contraclioo. During ins-piration, rhe diaphragm contracts, and the thoracic cavity increases iu voluml!". This decreases the intraalveolar pressttre so that air flows into the lungs. Important point: There is a fall in both intrapleural pr<:ssure and intraalveolar pressure. Expiration (-<halatinll) is the process of Jetting air out of the lungs dllt'ing tho breathing cycle, During expiration, the relaxation of the diaphragm and elastic recoil of tissue decreases 1 he 1horacic volume and increases tJ1e intraalveolar pressure. Expiration pushc:s air om of the lungs. Important point: lnirapleural pre.ssure becomes less negative and imrnalvco1ar pressure rises. I. Following a nnmta l expiration (frmcrional r~.sidrrcrl ccrpacir>' FRC), the alveoNotes lar pressure is 760 mmHg, which is dte atmospheric pressure. 2. At functional residual capacity. the expanding forces are equal and opposite to the collapsing pressures. This is the po int of rest. Either increasing or decreasing volume from FRC requi res muscle contractioo.

~IOCHEMISTRY I PHYSIOLOGY

Rsps)

Tbc factors that influence the rate of gas diffusion across the respiratory membrane include all of the following EXCEPT one. Which one is tbc EXCEPT!ON?

The thickness of the membrane The surface area of the membrane The temperature of the system Tbe diffusion coefficient of the gas in the substance of the membrane The panial pressure difference of the gas between the two sides of the membrane

217

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~IOCHEMISTRY I PHYSIOLOGY
(
Alveolar ventilation Is expressed as:

Respiratory rate x (Tidal volume Dead air space volume) Respiratory rate + (ndal volume ~ Dead air spau volume) Respiratory rate x (ndal volume - Dead air space volume) Respiratory rate - (Tidal volume - Dead air space volume)

271 Ccp)Tigbl C 20092010 Dental Ded.s

flu templ'rntun. or thl' s~ !.tem The respiratory membranes-of the. lungs are in the res piratory bronchioles, alveolar ducts-, and tdvcoli. Surrounding each alveolus is a network: of capillaries arranged so thnt alr within the a lveoli is separated by a thin respiratory membrane from the blood contained wi(hin thea lveolar capillaries.

Factors That lnnucoce the Rate of Gas Diffusion Across the Respiratory Membrane:
Thickness of the membune: the rate or dirrusion across the membrane is inversely proporrionaf10 the ditTusion distance. Surface area the res-piratory membrane: the nuc of diflusion L~ directly proporrionalto tbe surface area. F-mphysema decreas~.:~ the surface area. which im,,ede:t the exchangt:of gases. Tbe diffusion cocfflclenr of the gas in the substance of the membrane: the. dirrusion coefficicm is a mt:aSurt of how easily a gas will diffuse through a liquid or tissue, taking into acotmt the solubility of the gas in the liquid and Lhc size of tbe gas molecule (molecular weight). Note: The solubility of C02 is approximately 20 times grealer

or

<han <he solubili< y of 0~.

The partial pressu re difference of the gas between the h,'O side$ of the membrane: Tbc partial pressure. diffe rence of a gas across the respiratory membrane is the difference between the partial pressure of the gas io the alveoli and the partial pressure of the gas in

!he blood of<he alveolar capillaries. Wbcn !he partial pressure of a gas is greater on one side
of the respiratory membrane than on the other s ide, net diffusion occurs from the higher to lhc lower pressure. Normally~ the panial ptessure-or o;~ygcn (PoJ) is greater in the alveoli (han in the blood of the alveo lar capillaries, and the partial pressure of carbon dioxide (Pcoz} Is greater in the blood than in the alveolar air. The partial press-ure difference for oxygen and carbon dioxide can be increased by Jncreasi11g th~ alveolar ventilation rate. The greater volume or atmospheric a ir exchange.d with the residual volume raises -alveolar Po1, lowers alveolar Pcn1 , and promotes gas exchnngc.

UeSJli rnfo~ nltl' \

(Tic/ui1'0iume

Dtatf air ~pmr o/ume)

Tbe exchange of oxygen and carbon dioxide between !he lungs and the blood occurs within tbe alveoli located in respiralory bronchioles. alveolar ducts. and alveolar sacs. No gas c,,change takes place within the remaining respiratory passageways (nose, plwiJ'llX, trachea, ond conducting bronchioles) . These air-filled passageways are called anatomical dead air space. During qujei brealhing, the amount of air brought imo the lungs is the tidal volume {500 m/) , Approximately !50 ml of that volume remains in the dead air space. The volume of atmospheric air that actually reaches U1e alveoli (either per breath or in one minute) and that can panicipate in the exchange of gases between the alveoli and lhe blood is called the alveolar ventilation. I. Alveolar ventilation is a good criterion for the effectiveness ofbreathmg. Note> 2. Respiratory rat-e = Breaths/min. 3. Minute ventilation =Tidal volume 1< Breath/min.

~IOCHEMISTRY I PHYSIOLOGY

\..

Which two situations below will excite the respiratory neurons and increase res piration?

An increase in hydrogen ion concentration in the arterial blood A decrease in hydrogen ion concentration in the arterial blood An increase in the Pco2 of arterial blood A decrease in the Pco2 of arterial blood
An increase in the albumin levels
A decrease in the albumin levels

279 CopyrightCI 2000-2010 Dco~.tl Dl:t

~IOCHEMISTRY I PHYSIOLOGY

\,.

The volume of air remaining in the lungs after a maximal expir ation is called th e:

Vital capacity (VC) Tidal volume (TV) Residual volume (RV) Functional residual capacity (FRC)

280 COilrrighl 0 2009-20 10 lktltal Dcds

.\11 iucrl'a~e iu h~dro~tu inn l'onctntnJtion in lh4.~ arrcrial blood (dccr'0\et/ p/1) An increlsl in lhr I' o 1 flf ~rlerial hluud

These two are closely related in the following way. Any time the partia I pressure of carbon dioxide increases (PcoJ, this also increases tbe hydrogen iou concentration (decreases the pi!) bt>cau~e carbon dioxide combines wllh wnte.r to form carbonic acid. This carbonic acid then dissociate9 into hydrogen ions >llld bicarbouak These hydrogen ions decreuse the pH of the arterial blood, thus increasing respiration.
Peripheral chemorcccptors (corotid and aortlr bodie<) nntl ccntrJ cheruoreceptors (mi!tlul/(1t}' tWtii'Ots) primarily function to regulate respirat<Jry ~ctivily. This is an important mechanism for maintaining arterial blood Po2, Pco2, ~od pH withio appropriate physiological ranges. Chemoreceptor acti-vity, however. does affeot cardiovascular lirnction either directl y (br inlel'tlcling w/1/r mcdui/Diy tasomotor cen fl!rs) or indirectly (via a/tl!red pulmonm:v sl/vteh recef)/Qt acrivity). Centntl chemoreceptor> arc the major regulators of ventilation . The carotid bodies arc located on the ext<:mal carotirl arteries near t!Jeir bifurcation with the internal Cilfotids. Each carotid body is a few millimeters fn size and has the distinction of h~ving the highest blood tlow per tis~ue weight of any organ in the body. lmportnt: The hypoxia of high altitude stimulates ventilut.ion, The carotid body

senses hypoxia and signals tlw medulla to stilllulate ventilation (hypo,tit ventilatory

response). Decreased alveolar eatbnn dioxide allows for an equivalent increase in alv<olar oxygen. The cardiovascular system respond.~ to increased catecholarninos with a moderate increase in lwan rate, blood pressure. and cardiac output. Over days to wctks, there arc increase~ in hematocrit and capillary density. and changes in t!Je tissues nud Cdlls.

Determined by the force generated by the tnuscles of expiration and the inward clusuc recoil of the lungs as they oppose the outward elastic recofl oftlte ehe>t wall. The rcsulual volume of a healthy 70kg adult is 1.5 liters. Lung Yolnmes and Capacities: Total lung capaclly (TiC) is the volume of air in the lungs after maxio~l inspirMtory effort. Oetenniued by the strength of contraction of the in~pirMory mus~le< in opposition to the inward elastio recoil of the lung and chest wall. l'his I' ~bout~ liters in a healthy 70kg adult. Vitnl copacity (VC) is the volume of ir expelled from the luugs during a nuwm"l fnrced expiration starnng aft~ru maximal forced inspiration. VC 4.5 liters. VC oTV + I RV + ERV Tldnf volum e (TV) is the ~olumc of air entering or leaving the nose or mouth per bremh. D1rring normal. quiet breathing (eupnea). the tidal volume of tl 70-kg ~dult is about SOO ml per breath. Note: The normal tate of respiration is abollt 12 timos IJ<lr

minute.
Functional residual eapncity (FRC/ i$ til<' volt,unc of gas remaining in the lungs at ~\e end of a normal tidal expimion. This i U1e bulanc point between tho iuwat'<l elastic recoil of tl1e IIIJlgs and the outward elastic recoil of the chest wall. f'RC is about 3 liters in a healthy 70-kg adult. FRC = ERV + RV Inspirator)' resen'e (/RlQ is the Yolumc of gas inhaled into the lungs during a max [mal forced inspiratiOn Strting atlhe end of a normal tidal inspiration, IRV is about 2.5 liters. Expiratory reserve fERV! is the volume of gns expelled from the hrngs during a maximal forced cxp~rstioo tbat stllrtS ~t the end of normal tidal expiration. ERV is about 1.5 liters.

~IOCHEMISTRY I PHYSIOLOGY

(
"'"
Arterial Po2 Arterial Pco1 Arterial (H]

Which of the following factors has no direct effect on pulmonary ventilation?

Arterial [HCO~-]

281 Copyrijh1 0 2009-2010 Dc:n;al Dks

~IOCHEMISTRY I PHYSIOLOGY

Rsp0

(
\._

Which receptors below when stimulated initiate the Hering-Breuer renex?

Irritant receptors

J receptors
Lung stretch receptors Joint and muscle receptors

282

Copyright 0 20092010 Dental Dcclts

Ill<Od
HC03- docs not directly affect pulmonary \'.:t>ttlation. HCQ3 docs ha'c tnlluence, but that is through pH and {H]- there are no HCOr sen:.ors. Pulmonary ' 'rotllatlon is the total volume of gas per minute, u>sp~red or expired. s~nsory lnformallon is coordinated in the brain stem. The omput of lht brain stem controls tht resp~rutory muscles and the breathing cycle. Receptors ror C02. 02, and H': Central (metlul/ary) chemoreceptors - located in medulla; stimuh that Increase breath1ng rate include an increased PI."'2.

Peripheral chemorcccptors - located in the carotid and aortic bodies; stimuli that mcrease brcathmg rate include P"2 (if l#ff than 6() mmHg). Pc"2 and pH. Factor> That Stimulate These Receptors: Arterial Po1 (partial pressure of o>ygen /11 arterial Mood) - cry l O \\ Pol in arterial blood mcreases pulmonary ventilation . Arterial l'co1 (partial pressure of mrbon dlo.v/de in arterial blood) b the major stimu lu!i for che resp~ratory centers- elevated nrterial Pco 2 increases \ entilotion. Arterial pH - a low arterial pU (incrt!ased !Jydroge11 io11 cancelllration) increases ventilation. These "arious factors interact wirb one another to regulate brealhang.. Sormal Adull Arttrial \'a lues: Norntal Adult Veoous\'alun: pH-7.35-7.45 pH-7.317.41 Pc02 -35- 4S torr Pe~J2-- 41- Sltorr Po2 -- .79 lOtr P0 2- 30 40 IOIT C~- 23- 30 onmoi!L C'o~ .. _ 23 - 30 mmoi/L
1

These receptors arc located in the smooth muscle of the airways. When these receptors are stimulated by distcostoo of the lungs. the receptors mniatc the H ering-Breuer reflex, which preventS the overinOation of the lungs During inspiration, these strctcb receptors increase their activity, and stimuli arc sent over tl1c afferent vagus nerve to the respiratory control centers in the brain (medulla). When the stimuli rcacb lhe cntical level, Inspiration ceases. Note: T his rcncx docs not appear to be of great importance in the control of respiration during nom1al breathing. T his rcncx is mainly a protective mechanism that prevents the lungs from overfilling. Other Receptors for Control of Breathin g: J receptors - arc located in the alveolar walls; when stimulated these re<:eptors cause rapid, shallow breathing lrritant receptors - arc located between airway epithelial cells: arc stimulated by noxious substances (e.g.. dust, pollen) Joint nnd muscle receptors - arc activated during exercise to sti111ulatc breathing Remember: Carbon dioxide concentrntlon in the blood (Per>J) b the mOSt important sttmulus for the respiratory contml center (medulla). Ao Increased Pco~ increases respimtion by stimulating the central chemoreceptors. wbile a decrease io Pco1 tnbibats respiration.

(BIOCHEMISTRY I PHYSIOLOGY

Rsps)

A patient comes into your orncc breathing hard after running across the street to get to his appointment on tim e. Which or the following would best describe this patient?

Hypocapnea Dyspnea Hypercapnea Hyperapnea

283
Cop)Tiiht 0

20092010 IXYital l'>l:tl

~IOCHEMISTRY I PHYSIOLOGY
(
Surfactant:

Rsps)
)

Reduces the surface tension in pulmonary alveoli Increases the Pco, levels in blood Is a mucous secreted by goblet cells Reduces friction in the pleural cavity

2..
Cop)Tlcbl C 10092010 Dmtal Dtda

Ttml

Meaning
Transient cessauon or absence ur brtathing

Apnea
Byperc:apnca

Excess CO, in arterial blood Below nom1al C02 in ar<erial blood

Abnonnally deep and mpid breathing rermanent cessation ofbteathong (unless Ct>rre<:ted)
Increased pulmonary ventilation 1n C'CCCSS of metabolic rcqm~ments Undcroentilation m relation to metabohc: requirements

llypotl'""" Ryperapn ..
Respirator)' arrest
1:1~ pu>enllltlon

H}potntUIiun Dyspnea

Unpleasant sensation of difficulty of breathing

Note: H yperventilation results in the loss of carbon dioxide (COz) from Ihe blood (hypocapula), the reby caus ing a decrease in blood pressure and Sometime> fnimi ng. Bypovcntilntlon results in an increased level o f carbo n dio xide (COz) in the blood (hypercop11ia).

RltiUt'l'' tlw 'urfact h.n,ion in pulrnonnn aluuli

Small septal cells, di~persed among cells of the simple squamous epithelium lining a pulmonary alveolus. secrete a phospholipid surfactant thatlo\\ers the surface tension in tbe pulmonary alveoli. This reducuon m surface tenston prevents small alveoli from collapsing and increases compliance. Asthma is a chronic reacti ve airway disorder that causes episodic airway obs1n1ction. Such obstruction results from bronchospasm, increased mucous secretion, and mucosal edema. Asthma is a type of chronic obstructive pulmonary disease. a group of lung diseases charac!Critcd by increased airflow resistance. The immediate consequences of a patient having an asthmatic attack include: hypoxia. tachycard ia. hypercapnia. and acute respiratory acidosis. l mpor1ant: The cause of airway obstrocrion in asthma" bronchiolar coosmctoon Beta2-adrenergic sumulation {betol-adrenergic ngon/sts) produces rda.,auon of the bronchioles. Beta-2-agonists are the most cffectl\c bronchodilators ava1lablc and are rela tively free of unwanted effects. Short-acting beta-2-agonists are useful for symptom relief. Examples of short-acting bctalagonisu include: salbutamol and tcrbuta line. Long-acting bctn-2-agonisrs have been a significant advance in asthma management. They cause bmnchodilation fo r more than 12 hours and, when takett twice daily. improve symptom control. It is imponaot that long-acting beUl2-agooists should only be used in conjunction with inhaled steroids. Examples or long-acting bcra-2-a.gonists lnrlude: salmeterol and formoterol.

(BIOCHEMISTRY I PHYSIOLOGY

Rprs)
)

Ovulation occurs as a result of:

The progesterone-induced LH surge The estrogen-induced FSH surge The progesterone-induced FSII surge The estrogen-induced LH surge

17})
285 Co9> rish1 0 20092010 DanA I De<tks

~IOCHEMISTRY I PHYSIOLOGY
(
Ovulallon orrurs:

Rprs)
)

7 days before menses, regardless of cycle length 14 days before menses, regardless of cycle length 18 days before menses, regardless of cycle length 21 days before menses, regardless of cycle length

1J9
281 CopyriaMo 20092010 lknr.al Oec.u

't hl' l'\tro~en-indnet.d Lll \Urge Ovulation is the discharge of a mature ovum (oocyte) from the matme follicle (grllajian follicle) of the ovary. Ovulations occurs as a result of the cyclic ovarin cycle and pituitary endocrine functiotL The anterior pituitary secretes the gonadotropins PSH and LH , with LH predominating. Remember: Late in the proliferative phase, estrogen levels peak, FSII secretion declines, and LH secretion increases, surging at mid-cycle (around day 14). Important point: The LH surge leads to lin a I maturation of the follicle, rupture of the tollicle. and ovulation.

l. Without LH, even though large quantities of FSll are available, the
Note. follicle will not progress to the stage of ovulation.

2. The ruptured mature follicle forms the corpus lutcum, which secretes
progesterone and estrogen.

3. FSH and LH are both glycoproteins and act in both the ovaries (in
females) and the testes (in male.s).

1\vo sigu1ficant results of the female sexual cycle arc: I. Only a single mature ovum is normally released from the ovaries each month so that only a single fetus can begin to grow at n time. 2. The uterine endoruetritun is prepared for Implantation of the fenilized ovtun at the required time of the month.

The average menstrua"! cycle usually occurs over 28 days. although the normal cycle may range from 22 to 34 days.

T be Menstrual Cycle:
~fenstrual pbasc: the cycle starts wltl1 menstruation (cy cle day I) , which
usually lasts 5 days.

Prolifcrnti,c (follicular) pltase: lasts from cycle day 6 to day 14. LH and FSH act on the ovarian follicle (mawre ovarian cyst contol'ning the ovum). This leads to estrogen secretion, which in tum stimulates buildup of the endometrium. ~ote: Late in this phase, estrogen levels peak, FSH secretion declines, and LH secretion increases, surging at mid-cycle (arotmd day 14) . Then, estrogen production decreases, the follicle matures, and ovulation rn:curs. Ovulation day: day 15; it occurs as a result of the esl'rogen-induced LH su rge. Luteal (secreto1y) phase: lasts about 14 days. FSH and LH levels drop. The corpus luteum begins to develop, and it synthesizes estrogen and progesterone. If fenilization does not occur, the corpus lutcum d~generates (become no11viab/e). As a result, estrogeiJ and progesterone levels decrease until their levels are too low to keep the endometrium in a fully developed secretory state. -~ote: The endometrial lining is shed as menstrual nuid during menstruation. or

menses.
Decreasing estrogen and progesterone levels stimulate the hypothalamus to produce GnJUl, and the cycle begins again.

~IOCHEMISTRY I PHYSIOLOGY
All of the following statements are true EXCEPT one. Which one Is th e EXCEPTION?

Rpr s)

During early childhood, a boy docs not secrete gonadotropins, and thus hns litt le circulating testosterone Secretion of gonadotropins from the adrenal gland, which usually occurs between the ages I 0 and 15, marks the onset of puberty These pituitary gonadotropins stimulate testes functioning as well as testosterone
secretion

During puberty, the penis and testes enlarge, and the male reaches full adult sexual and reproductive capability Puberty also marks the development of male secondary sexual characteristics
287 CopyrJhl 0 20092010 lXntal Dks

~IOCHEMISTRY I PHYSIOLOGY
All of the following are a ction ~ of estrogen EXCEPT one. Which one is the EXCEPTION?

Rpr s)

Causes the development of female secondary sex characterist ics at puberty Causes the development of the breasts Maintains pregnancy Promotes secretory changes in the uterine endometrium during the latter half of the monthly female sexual cycle. thus preparing the uterus for implantation of the fenilized ovum

~ribt 0

288 !009-2010 Ottltal DL$

Srcrctiun ur ~onadntropins from thl' ndnn;tl ~land. \\ hich hrh\l'('O the agl'S 10 .lnd IS. marks lht' on,cl nf pnhl'l't~

usual!~

occurs

This is false: secretion of gonadotropins fiom rhe pituitary gland, which usually occurs betwe<:n the ages of I 0 and 15, marks the onset of puberty, At puberty, an alteration in brain function leads to an increased production of gonadotropin-releasing hormone (Gn-RH) by the hypothalamus, Gn-RH stimulates the secretion of FSH and LH (gonadotropins) by the anterior pituitary gland. These gonadotropins stimulate the growth and function of the testes. Specifically, F'SH promotes the maturation of sustentacular cells (Sertoli cells), which are involved in the development and maturation of sperm. LH s timulates the interstitial cells (Leydig cells) of the testes to produce testosterone. The onset of pubeny varies but most commonly occurs between 10 and 15 yea rs of age. The events of puberty (for example, enllllgemlmt of the penis, .<crotum, and testes; characteristic hatr growth; and voice changes) result from increased testosterone productiott by 01e testes, Note: The changes above are called secondary sex charaeteri~tics . Remember: A mole chi ld is considered to have reached his full adult sexual capabilities at the end of pubeny, This means that after puberty the male child is capable of reproduction. :Sole: Precocious puberty is a condition in which the changes associated wltb puberty begin at an unexpectedly early age and is due to an excess of androgenic (in hoy.) and estrogenic (in girls) subslances produced by tho adrenal conex. These substances resemble the male and female sex hormones,

half of the

in lhl' ulcrinc tndomctrinm durinf! thl' laUl'r rtmall' .Si.?'\Ual C~l'll', thus preparing the Utl\rus for impl:wtatiun of fertilized O\llnl
rnonthJ~

lrnmotes

'<'CTctor~ change~

u Important: This is the most important function of progesterone, not estrogen .

On average, females reach puberty I or 2 years earlier than males. In females, pubeny is marked by the first episode of menstmal bleeding, which is caUed menarche. At pubeny, an alteration in brain function leads to increased gonadotropin-releasing hormone.(Gn-RH) secretion by the hypothalamus. Go-R.H stimulates the secretion of FSH and LR by the anterior pituitary gland, which 11ltimately leads to an increased production of estrogens (androgen hormone) by the ovaries, The events of puberty in the female (such us enlmgemelll of the vagina, merus. and uterine tuhes; deposition offal In the breasrs and hips) are largely a result of increased production of estrogens by the ovaries. Estrogen is effective at very low conceotrations and generates a slowly developing long-term response in target tissues by binding to au iJmaccllular receptor,

1\licrohiology/Patholog~

Legend
Abbreviation Kid Dis Leuk LvDis Lng Disord Misc.
Neo

Major Topic Antibiotics Bacteria Blood disorders Bone disorders Cells/Organelles Diseases Disorders Fungi Heart disorders

Abbreviation Ab Bact Bid Disord Bn Disord Cells/Org Dis Disord Fung.i

Major Topic Kidney diseases Leukemia Liver diseases Lung disorders Miscellaneous Neoplasms Oral cavity Parasites
Compoundl En :cymes
Protein~

Oral Cav
p

Rrt Disord Substances

Sub

Hemodynamic dysfunction Immunology Infection Infection control Inflammation and Necrosis

HemodyDys Syndromes lmmun Inf IC loll & Nee Terms Vaccine

Syndr Terms Vac Vir

Virus

(MICROBIOLOGY I PATHOLOGY

Vir)

(\...
Oral-anal Skin

Mumps, M.easles, Influenza and Rhinovirus infeetion are ali transmitted via which route?

Blood borne Respiratory droplets

Cop)Tight 0 2009-2010 Dtntal Deks

(MICROBIOLOGY I PATHOLOGY

Vir)
)

(
Picornavirus family
Reovirus family

Rotavirus belongs to the:

Togavirus family Paramyxovirus family

2
Copyrlghc C> 20092010 Dcntol Dttl:s

\'lnu
H.c:pa.tdis A

t'amtly
PICOilllviNS

Ge1omt
:s:sR.~A

Tra.a.smtssloa

Db<UepabtuA

o..1..w
Blood bom
Blood borne

Rcpatiti5. h
HepaotbC

lleplldnavirus
F)lll\'.vtruJ

dlinNA

Hq.o:uiu$ n

ssRNA
.&S' {N.A

Hepa111U. C
J:lcp;mt~ 0: Om only

Hepatitis D
Hcpabtls E

1nlll=za

UlV

R_._l
Mtosle>
Ml.lmp$

,_

Dch"vtnlf

Blood borne
o~a.anat

lnr(IC, ccll.i

pre.,.iously infMed wuh l'lq)ll111ti D $$1\NA It"""A

.$$ R.'IA

C.IK.ivl.rus

flepolill. E
lnJbMI.a
Brondlioftns and pna.mon..a m in-

Onbonl)I)OVINS Si

.......

~dmpl<!s

R.,.,..._,. dmpl<!s R-ary dmpku RC$p1111101)' dn>pl<".s

Re..q11rt.IOI')' drop)C'I$

P~O'rirus
Pa~myxavirus

uR..'WA
"R.'IA
s.sRNA
dJ< DNA

'"""
t'!>

MC!Liles (~o)

M""'l>S
Robdl.a (~""f'.Ul "'t'fJ!ole:t)
Phluyl~gi1i!l.. Pneumonia. Car)junC'Iivi

lWbdla
.'\denoViruJo
Rhll'IDvl~

Tos,vtrus
Ad~-oovirus
l-lf.'On~;t\ltru6

Rc.!iptrul()ry drople\s
Rcspltooory d<opleu

S> RNA .. R.'IA dsDNA

ds DNA

Comii'IOO cold
Mtm(IIUE~D syndrome

R~troo.irus

Blood bof"ne, OcnitAJ AIDS

l!csp<IOiary dmpl<!s

C_ytomepio'VINf

llnpesvirus

,.--Ban
USV-1

llape:s,1Nf
lirrpe:i\iM
l-t~'1\1$

,...,.._,. &o!>l<u
OnJ (1~/ivoj
Oflti11ll (lcruall)' trYJnm.(tll'' dlseosr)

tnr~ lnQI'IOfti!Cito!.''

ell DNA
.ssONA

Girlgi\-ost0m8.1Jiil. Herru ltbWlt

HSVl

Gcmoalll"l'C<

RtO\ iru ... ramih

Reo viruses are non-enveloped and nave an iscohednl capsid compo,ed of an outer and inner protem shell containing segmented, double-stranded Rl~A . I mportant: Tbe virion contains an RNA-dependent Rl~A polymerase, which is required because human cells lack this enzyme and therefore camtot synthcstze mRNA from ao RNA templale. They replicate in the cytoplasm. Important members of reovirus fam ily that en usc human disease: R olaviruscs (al.<o called gastroenteritis virus type B): tbe most common cause of gastroenteritis In children (2 and under). Coltlvlrus (a /.so called Colorado tickfever virus): causes Colorado tick fever. Viral gastroenteritis is a self-limiting disease. often referred to as the 24-hour or intestinal Ou. An inOuenza virus does not cause it. [t is associated with RNA viruses and is often diagnosed by ELISA on fecal samples. The characteristic symp1oms of viral strocntemis include sudden gastrohllcstinal pain, vomiting. and diarrhea. Recovery usually occurs within 12-24 hours. l mport.ant : Dehydration is u major concern, especially in lnants where viral gastroenteritis is sometimes fotul.
RNA non-enveloped virus families: Picornavirus (Poliovirus, Cox.saclcie A & 8 viruses. Rhinovirus.

Her-A irus)

Reovirus
Calcivirus (Nfii'Oviruses: cause acute gturmemerlt/s in adults. Hep. 1rus)

(MICROBIOLOGY I PATHOLOGY

Vir)

Respiratory syncytial virus (RSV) is responsible for:

Herpangina Common cold Pneumonia and bronchiolitis in infants Encephalitis

3
Copyrigbt (> 20092010 Den1nJ Occl:s

(MICROBIOLOGY I PATHOLOGY

Vir)

(
\.

The cytopathic effect that is seen when a virus infects a specific cell culture:

Is the same for most viruses Is not useful in diagnostic virology Is characteristic of each virus and can be used for detection of that virus Does not affect the s pecific infected cell

Cop)Tight 0 2009-2010 Dt'nt.tl Dee.k$

l'twumuni:t and hrnnrhiuhti' 111 infanh

RSV is the only member of the paramyxovlrus family (whiclr also includes the measles, mumps, and parainjl11enza vlmses) that lacks the envelope glycoproteins hemagglutinin nod neuraminidase. Its surface s pikes are fusion proteins. ltemember: The envelope of paramyxoviruses is covered with spikes, which contain either hemagglutinin, neuraminidase, or a fusion protein that causes cell fusion and, in some cases. hemolysts. lts virion surface proteins cause infected cells to fuse, forming multinucleated giant cells (sync)lial), which give rise to the name of the virus. Ribavirln (Virazole) is used to treat severely ill hospitalized infants. There is no vaccine. J>arainOuenza viruses cause croup (acute laryngotracheobronchitis) and pneumonia in children and a disease resembling the common cold in adults. The surface spikes present on the viruses consist of hemagglutinin (H), neuraminidase (N), and fusion (F) proteins. These viruses are transmiHed by respiratory droplets and direct contact: there is neither antiviral therapy nor a vaccine available. Important: Interstitial pulmonary inOammation is most characteristic uf viral pneumonia. Paramyxoviruses: ss negative RNA Enveloped Conraln an RNA-deprnden t RNA polymtrase Resemble onhomyxoviruses except they are usually larger di fferent surface proteins as well as nonsegmcnted genomes.

10

slze, and have

The hallmark or viral Infection of the cell is the cytopathic effect (CPE). This change starts with alterations of cell morphology accompanied by marked derangement of cell function and culminates in the lysis and death of cells. Important: Not all viruses cause CPE ; some can replicate while causing little morphologic or functional change in the cell. Such changes include: Necrosis Hypertrophy Giant cell formation llypoplasia Metaplasia A Itered shape

Detachment from subsrrate Lysis Membrane fitsion Altered membrane permeability Inclusion bodies Apoptosis

These cytologic changes provide useful presumptive evidence for the diagnosis of tbc viruses that induce the cytopathic effects. Important: Viruses usc specific cell surfate receptors to bind to and subsequently gain entry into their host cells. The identification of the.s e receptors explains tbe cellular troprnn of viruses.

(MICROBIOLOGY I PATHOLOGY

Respiratory syncytial virus (RSJ1 is responsible for:

Herpangina Common cold Pneumonia and bronchiolitis in infants Encephalitis

3 Copyria,llt 0 2009-2010 Dental Deets

(MICROBIOLOGY I PATHOLOGY

Vir)

The cytopathic effect that is seen when a virus infects a specific cell culture:

Is the same for most viruses Is not useful in diagnostic virology Is characteristic of each virus and can be used for detection of that virus Does not affect the specific infected ce ll

Copyrigbt 0 '2009-2010 t>en~.al Ot<:\5

l'lll' umunia :and hronchiulili' in int:mh

RSV is the only member of the para myxoviru s family (which also includes the measles. mumps. and parainfluenza viruses) that 12c~ the e nvelope glycoproteins hemagglur;nin and neuraminidase. lls surface spikes are fusion proleins. Remember: The envelope ofparamyxoviruses is covered with spikes, wbicb conrain e1ther hemagglutinin, neuraminida~e. or a fusion protein that causes cell fusion and, in some cases, hemolysis.

lls virion surface proteins cause infected cells to fuse, form ing multinucleated gin111 cells (S)'IIC)'tial), which give rise to the name of the virus. Ribavirin (Virt~:ole) is used to treat severely ill hospitalized infants. There is no vaccine.
Parainfluenza vi ruSe$ cause croup (acrae laryllgotracheobronchitis) and pneumonia in children and a disease resembling the common cold in adults. The surface spikes present on the viruses consist of hcm:gglutin in ( 1:1), neuraminidase (N). and fusion (F) proteins. These vjruses are trunsmilted by respiratory droplets and direct contncl; there is neither antiviral therapy nor a vaccine available. Important: Interstitial pulmonary innamrnation is most characteristic of vira l pneumonia. Paramyxmlruses: ss negative RNA Enveloped Contain an RNA-dependent RNA 110lym erase Resemble onbomyxoviruses except they are usually larger in size, and have different surface proteins as well M nonscgmented genomes.

The hallmark of viral infection of the cell is the cytopathic effect (CPE). This change starts with alterations of cell morphology accompanied by marked derange ment of cell function and culminates in !he lysis and death of cells. Important: Not aU v;ruses cause C P ; some can replicate while causing li!tle morphologic or functional change in the cell. Such changes include: Necrosis Hypertrophy Giant cell formation Hypoplasia Metaplasia Altered shape

Detachment from substrate Lysis Mcmbrtme fusion Altered mcmbr anc permeability Inclusion bodies Apoptosis

These cytologic changes provide useful presumptive evjdeoce for the diag nosis of the viruses that induce the cytopathic effec!S. l mporlant: Viruses use specific ctll surface receprors to bind to and subsequently goi11 ~ntry into their host cells. The identification of these receptors explarns the cellular tropism of viruses.

(MICROBIOLOGY I PATHOLOGY

All of the following are included in the Herpes virus family of viruses EXCEPT one. Which one is the EXCEPTION ?

Varicella-Zoster virus (VZV)

Epstein-Barr virus (EBV)

Cytomegalovirus (CM V) Coxsackievirus (A & B)

s
C<lp)Tiihl 0 2009-2010 l)cotal Decks

(MICROBIOLOGY I PATHOLOGY

The infectious viral particle is called a:

Viroid
Virion Prion

Viproid

CopyrightO 2009-1010 OtruaJ Dttl't

u~ Both eoxsackievisus group A & B are m the picornavirus family (ss RNA, icosahedral capsid, "1th no envelope present) The Herpes VtrUs family contains five !mponam human pathogens: herpes simplex virus types I nnd 2, varicella-zoster virus (JIZV), cytomegalovirus (CMV), and Epstein-Barr virus (EBV). All herpt:sviruses arc morphologically identical.

Herpes viruses: ds DNA Enveloped Nuclc:~r membrane Icosahedral nucleocapsid Important: Hcrpc viruses replicate in tbc nucleu5 oflhe host cell and are the only viruses to obt:llll thetr virion envelopes by budding from the host nucle3r membrane, not tbe host plasma membrane. lt is a cbaracterlsflc of all herpes viruses thGI. following pnmary infection, the vims establishes a lat<nt Infection in sensory nerve ganglia, especially the trigcmtnnl ganglion which can Inter be reactivated. Reactivahon is frequently. but not nlways, associated with further disease. Three of the herpes viruses, herpes simplex I and 2 and the varicelta-zo,tcr virus, cause a vesicular rash. Certain herpes viruses have ontogenic porcntlll (causing cancer) 111 humans. The Epstein-Barr virus is associated wuh Burkut's lympboma and nasopharyngeal

carcinoma. DNA envelop~d viruses: herpes virus, poxvirus, hepadnavirus

\ irinn

In tontrastto bacterio, fungi, and parasites, vtruses are not cells: i.e . they are not capable of reproducing independently, do not have a nucleus, and do nor have organelles sw:h as ribowmes. mltochondna. and l:rsosomes. Viruses arc smaller than cells and cannot be seen in the light microscope. Note: Almo>t all viruses are haploid (conlai11 a si11gle copy of rlleir genome: tile exception is tile t'CtrtJ~iru.v foml/y, w!Jn.ve member. (li'C diploz'd). The viral particles, or virions, contain citlter single- or double-stranded DN A or H:>IA (11ever both) that is encased in a protein cont called a capsid. The combination of the nucleic acid and the protein capsid is called the nucleocapsid. They are either naked or enveloped, depending on whether tbe capsid is surrounded by a lipoprotein envelope. The capsid is composed of polypeptide units called capsomere. Some viruses (ortftomyxovlruses and paramyxovlnses) bave envelopes that are eo\ered with spikes. which contain either hemagglutinin, neuraminidase, or 11 fusion protein that causes cell fusion and, in some cases, hemolysis. Viroids con~ist solely of a single molecule circular RNA without a protein coat or envelope. They cause several plant diseases but nre nm impticawd lu ony human disease. Prions are infectious protein panicles (atypical virus-like agents) that are composed solely or p rotein. Tbey cause certain "slow" diseases such as Creutzfoldt-Jakob disease, a severe degenerative brain disease caused by the ingestion or beef from a cow infected with mad cow disease. Note: Prions do n ot elicit inflammatory or antibody rc~.spon~es.

or

(MICROBIOLOGY I PATHOLOGY

Herpes simplex virus type 1 (HSV-1) is most often transmitted through:

Blood Tick bite

Saliva
Respiratory droplets

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Vir)

All of the following statements concerning herpes simplex type I are true EXCEPT one. Which one is the EXCEPTION?

Many children have asymptomatic primary infections May be diagnosed by a Tzanck smear for rapid identification when skin lesions are involved May involve a primary infection (e.g., gingivostomatitis) or a recurrent infection (e.g., cold sores)

Can be treated prophylactically by a vaccine

a
Copyri,abtO 2009-2010 Dnnal Db

A. Herpes simples lrus type I . Primary herpetic :JnglvostomotitiJ Cau..ed by milia! exposure to HSV-1 Most often trnnsmiued through saliva Usually occurs in a child under len years of age Nearly all priulllry iofectioru; are of the subclinical ty pe - they may only I11H'e Jlulike symptoms - (md one or two mild sores ln the momh whicl\ go unnoticed by the parents.

13. Acute heqtellc gingivootomatis

In other children. the primary infection may be mnnifesu:d by acute sympwms. Acute symptoms mclude fevu; irritability; cen ical lymph-adenopathy; fiery "'d gingival tissocs; and small, yellowish vesiclcs which rupture and result m pamfuJ ulcers on tbe free and attached mucosa The most serious potential problem in a child with this infection is dehydration due tn the child not wanting to c..t or drink because of the pam.

C. Adu lt recurrence Following primary inll:ction, the virus remuins lfttcnt iu sensory nerve gnnglio. Reactivation occurs at the site of initial infection or in adjacent area> oncrvatcd by the infected nerve. The most common site of reewrence in adult is along the vermliUon border or tbe lips (hlon tiS h~rpes labia/is or cold sores). Herpetic conjunctivitis (in/tction ofthe eye is also common.
Remember: Of all of the herpes viruses, lt~rpt.\ simplex vi r us"" I and l cause manifestations of recurrent infection in otbenvise healthy people.

( un ""' tn.alltl prupln lacticall\ h~ a' :udm

This is false; it cannot be treated prophylactically by a vaccine. The inactive BSV-virus resides in senJOry nerve ganglia (most common~\', the trigeminal ga11glion), but wiU often reappear later as the familiar ~cold sore~ (herpe.s labia/is), mo>t often along the vennillion border of the lips. This disease is referred to as " recurrent herpes labialls." Emotional stress, trauma, and excesstve exposure to sunlight have been implicated as fuctors for t11e appear.mce of the recurrent herpetic lesions on the lip. Note: Zovirax is tbe brand nam e for acytlovlr, u synthetic nucleoside nnalogttc active against herpcsvimses. It acts as a compctlt[vc inhihito r of viral DNA polymerase. Remember: Typically, HSV-1 infects ABOVE lhe Other nucleoside analogues: waist: eye and mouth lesions. HS V-2 infects Penciclovir (Denavir) BELOW the wuist: genital lesions. Valacyclovir (Volu-ex) Note: Oral-gemtal sex can lead to HSV-1 below the waist and HSV-2 above the wabt.
Remember: The primary infection can range from 5Ubcllnical (asympltJmolfc) to severe systemic Infections. HSV-1 can also cause tbe foUowing recurrent infections: keratoconjttnctivi lis and encephalitis. A tzanck s mear ts a diagnostic test that reveals intranuclear inclusions in herpes virus infections. Genital berpt$ (ca11sed by HSV-2) may have serious consequences in pregnant women because the virus can be transmuted to the infimt during vaginal delivery. The virus can cause damage to the infant\ central nervous system and/or eyes.

(MICROBIOLOGY I PATHOLOGY

\..

A bacteriophage with tbe ability to form a stable, non disruptive relationship within a bacterium is called a:

Virulent phage P lasmid Temperate phage Phage T4

9
Col')'ri,gtuC 2~20 10 Dental Decb

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Typically, bacteriophages consist of:

An RNA core and a protein coat A nucleic acid core (DNA or RNA) and a protein coat A DNA core and a protein coat A protein coat only

10
CopyriJitC 0 2009-2010 DentaJ O~!eb

ll'Ul(H.r;.tll' ph~lt.!~

II is a bacteriophage which is capable of replication by an alternate method in which the phage genome is incorporated into the bacterial chromosome. h persists through many cell divisions of the bacterium without destroying lhe host, in contrnst to a virulent phage that lyses and kills its host. Remember the characteristics of a bacter iophage: a vints that call replicate only within specific host bacterial cells. A lysogenic b acterium is one !hat contains a temperate bacteriophage. (Example: Corynebacterium diphtheriae. see below.) L)sogenic conersloo: the alleration of a bacterium to a virulent strain by lhe transfer of a DNA temperate bacteriophage. The classic example of this conversion is in lhe alteration of Corynebacteriwn diphthcriae to a virulent strain. Tbe presence of this temperate phage renders the bacterium pathogenic (witholll tile phage It would not be lwrmfu/). Note: The integrated viral DNA is called a prop huge.

--. t. Enterobacteria pbage T4 is a phage that infects E. coli bacteria. ' Nott> 2. Plasmid! are exnacbromosomal, double-stranded, circular DNA molecules lhat are capable of replicating independently of the bacterial cbromOl!Ome.

\ nudt.i..: :u.:id nrt t/)\ torR\ IJ and a prull'illl'n<U

A barleriophage IS a very delicate bacterial virus which may attack and destrOy bacterial cei!J under ecnain conditions. h contains a nucletc acid core (DNA or RNA) and a protein ooat. Some bave a tail-like structure through whleh lhey inject their nucleic acid into the bacterial host cell. It is also called a phage. A host cell is u cell within whjcb a virus replicates. Once inside the host cell, the viral genome achieves control of the cell's metabolic activities. The virus then uses the metabolic capacity of the host cell to reproduce new viruses. Often the replication of these new viruses cau$CS death of the host cell. Bacteriophage infection follows one of two courses: lysis or lysogeny. If the infecting virus multtpbes Wlthin the host cell and destroys it. lhe virus is said to bel) tl<, or ' irulent. On lhc other hand, if the virus does not replicate but rather integnncs into the bacterial chromosome. the virus is said to be temperate. or lysogewc. The phage in the lysogenic cycle can spontaneously become lytic. The presence of tl1e integrated vinLS, which is called a prophage, generally renders the cell resistant to infection by similar phages. Lysogeny does not result in the destruction of the host ceiL Remember: l l"ansd uction is the trnnsfer of DNA from a donor cell to a recipient cell with the DNA packaged within a bacteriophage.

(MICROBIOLOGY I PATHOLOGY

Which group of viruses possesses an RNA genome that does not function as a positive or negative sense molecule but acts as a template for the production of viral DNA?

Coronaviruses
Orthomyxoviruscs Retroviruses Paramyxoviruses

11 CopyriaJlt 0 20(19.2010 Otntall>ecb

(MICROBIOLOGY I PATHOLOGY

(
\.

Herpes simplex virus I and 2 and varicella-zoster virus all establish latency:

Within B lymphocytes Within salivary glands Within T lymphocytes

In the dorsal root ganglia

Rl'lrO\ irusl''

*** This group includes the Human immunodeficiency virus (HIV).

This is achieved by an RNA-dependent DNA polymerase (1-everse transcriptase) that is packaged with the RNA genome. The resultin.g viral DNA integrates into the host cell genome to provide the template for viral RNA synthesis by host-derived mechanisms. Note: In order for RNA oncogenic viruses to be intregrated into the host genome, they must possess an Ri'IA-dependent DNA polymerase (reverse transcriptase). Important points to remember: For RNA viruses: - Transcription occurs in the cytoplasm except for retroviruses and influenza viruses. - Transcription involves an RNA-dependent RNA polymerase except for retro viruses, which as explained above possess the enzyme reverse transcriptase (tm RNA-dependent DNA polymerase). For DNA viruses: - Transcription occurs in the nucleus except for poxvinses. - Transcription involves a host-cell DNA-dep endent RNA polymerase.

In lhr dorsal runt :,!<ln:,!lia

Viru~

Usual Site orLatency Trigeminal ganglion

Disuse

HSV-1

Primary: Gingivostomatitis Secondary: Cold sore Keratitis Eoocphalitis

HSV-2

Sac:ral ganglion

GenitAl herpes

EpstcinBarr

Trigentinal or thoracic ganglion Primary: lnfectious mononueleosis Secondary: Burkin's ly!llllhoma B cell lymphoma Hairy leukoplakia. Nasopharyngeal ca.teinoma
Associated with

Cytomegalovirus

Unknown

Congenital infccrion (ifa nu>lher becom~s infected with CMYduring pregnancy) Infection in immunocompromjsed individuals Kaposi's sarcoma

t-Juman herpes virus 8

Unknown

(MICROBIOLOGY I PATHOLOGY

Vir)

All of the following are DNA non-enveloped viruses EXCEPT one. Which one is the EXCEPTION?

Adenoviruses
Poxviruses Papovaviruses Parvoviruses

13 Copyright C 2009-2010 Dtntai Oed:s

(MICROBIOLOGY I PATHOLOGY

The main target for human adenoviruses is the:

Brain
Genito-urinal tract Respiratory tract Digestive tract

Copyrig.ht C> 20092010 Dental Oecb

RNA enveloped viruses: Ortbomyxoviruscs: influenza A, B, and C Paramyxovlruscs: measles, mumps, respiratory syncytial, and parainfluenza viruses Togavirus: rubella vims Retroviruses: HlV (human immunodeficiency vims), and JlTLV The Plcornovirus family includes the following RNA liOotnveloped viruses:

Enteroviruses : poliovirus (causes po/io)1 coxsackievirus A (causes herpangina and

lwnd1oot-andmouth disease), and coxsacklevirus B (causes pleurodynia, myotarditis,
and pel'icartlitis) Rhlnovlruses: cause of the common cold Reovirus: rotavirus - causes viral gastroenteritis in young children Hepatitis A: causes infectious hepatitis

DNA enveloped viruse..:

Herpes v iruses (Herpes simplex I & 2. VaricellaZoster, Epstein-Barr. Cytomegal

oviros, and Hwnan lterpes virus 8)

Poxvinas: smallpox vinas (variola virus) Hepatitis B virus

ON A non-enveloped viruses:
Adcnoviruscs: causes respiratoty illnesses (especially in children). conjunctivitis. and pharyngitis. Papovavirus: papillomavirus causes papillomas (ival'/s) oo tbc skin and mucous membranes. Human papillomaviruses 16 and 18 are strongly correlated with the
appearance of cervical cancer.

Parvovirus: B 19 virus causes Erythema infectiosum, also known as fifth disease.

l{cspiratur~

Ir:td

Adenovin..1ses arc naked (non~envelaped) medium-sized viruses composed of an ico$ahedral nucleocapsid and a double-stranded linear DNA genome. They have spike.< (glycoproleinaceous projections that;, thfs cose are hemagglutinin protei11s) pro,.ruding ffom their surfaces that are involved in the absorption or attachment of the vi rus tu the host cclJ. Tbeso viruses frequently cause subc.linfeal infections. lntec;:lion is usually transmitted in droplets of l'espiratory or ocular secretions. Oisease.'i include respiratory illnesses (especially in children). conjunctivitis, and pharyngitis.
Virus Structure

Virion: infectious. complete virus panicle:; RNA or DNA and proteins. Note: Enveloped vinascs have carbohydrates and lipids Capsid: composed of~peating protein subunits (protomers) - protect viral genome from extracellular nuclenseg - impart structural symmetry to virion (icos(IJredral or lteUca/) - essential fOr the infectivity of virion -in naked (non~enveloped) virus. the capsid serves as the attachment protein thal bintll\ to I he bost cell re<:<!ptor -antigenic and provoke host immune response -most viruses have one capsid, an exception is Reoviridac that has rwo capsid layers Nucleocapsid: composed of capsid and nucleic acid Envelope: viral membrane, lipid bi1ayer carrying viral glycoproteins !\latrix protein: welds the capsid or nucleocapsid to the envelope
,---.,_ 1. The- ability of pathogenic microorganisms, including \'iruscs~ to attach to 'Notes and invade particular cells and tissues establishes specific tissue affinities for pathogenic microorganjsms, 2. Most viral antigens dia~'llUStic value are proteins:.

or

(MICROBIOLOGY I PATHOLOGY

Which of the following is widely regarded as the smallest RNA virus?

Rubella virus Poliovirus Coxsackievirus B

Rabies virus

15 Copyri&lltC 20092010 Dental Db

(MICROBIOLOGY I PATHOLOGY

Which of the following is the largest and most complex DNA virus?

Poxvirus family
Herpes virus family Papovavirus family

Parvovirus family

16
Copyri&fltC 2009-2010 ~tal Deets

Puliln i1 us

Poliovirus, the causative agent of poliomyelitis, is a human enterovirus and member of the Picornavirus family. lt is a very small single-stranded positive RNA virus with an icosahedral capsid. No envelope is present. The virus preferentially replicates in the motor neurons of the anterior horn of the spinal cord; thus, the death of these cells leads to muscle paralysis. It is transmitted by consumption of water with fecal contaminants. It is uncommon in the Western world due to successful vaccination programs. The initial symptoms of poliomyelitis include headache, vomiting, constipation, and sore tbtoat. Paralysis may follow and is asymmetric and flaccid. Two vaccines are currently used for active immunization against poliomyelitis:
'Note 1. Salk vaccine containing formalin-treated inactivated viruses that is given intravenously. 2. Sabin vaccine containing live, attenuated viruses wbicb is administered orally.*** Both contain 3-types of polio virus (trivalenQ.

The poxvirus family includes tbtee viruses of medical importAnce: smallpox virus (variola virus), vaccinia virus, and molluscum contagious vims (MCV). Poxviruses are the largest and most complex viruses known. Pox viruses are very large (400-m X 230-nm), brick-shaped particles containing an enveloped linear double-stranded DNA genome. and a capsid. These viruses multiply in the cytoplasm of host cells (as opposed to the nucleus) and are usually associated with skin rashes. The most important human poxvims is smallpox (variola). Smallpox is an acute, b igbly infectious, often fatal disease that is characterized by high fever, prostration, and a vesicular, pustular rash. This disease bas been eradicated by global use of the vaccine, which contains live, attenuated vacdnia virus.

---. I. The virion of poxviruses contains a 'DNA-dependent RNA polymerase.

Not.. This enzyme is required because the virus replicates in the cytoplasm and does not have access to the cellular RNA polymerase, which is located in the nucle-

us. 2. Smallpox virus has a single, stable serotype, which is the key to the success of the vaccine. If the antigenicity varied as it does in the influenza virus, eradication would not have succeeded. 3. HetJ>CS viruses, adenovimses, and papovaviruses are spherical or ovoid viruses and multiply in the nucleus of host cells.

(MICROBIOLOGY I PATHOLOGY

Vi~
""'

All of the following statements concerning coxsackieviruses are true EXCEPT one. Which one is the EXCEPTION?

They belong to the Picornavirus family They are divided into two groups (A and B) on the basis of the lesions observed

in mice
Group A viruses cause herpangina and hand-foot-and-mouth disease, whereas group B cause pleurodynia, myocarditis, and pericarditis Group B viruses have a predilection fo r skin and mucous membranes, whereas group A cause disease in various organs such as the heart, pleura, pancreas, and liver Their replication is similar to that of the poliovirus
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Vir)
~

The classic presentation of _ _ in children and young adults consists of the ) \.. triad of fever, pharyngitis, and lymphadenopathy. .J

Measles Mumps Hepatitis B Infectious mononucleosis

18
Copyright 020Q9.201(1 Dentall>c(b

Grnup 8 'iru'\eS haH.' a pndih.~tion lur skin and mnt'oux ml'mhraul!s. "hl'ren ~ruup-\ cuust dist':l'!it' in \al'ious oq,:~ms surh :1s ihe heart. pleuru. pancreas. and
lhtr

*** This is false; g1oup A viruses have ~ predilection for skin and mucous membranes, w hereas group B cause disc<tse in various organs such as tlle hean, pleura.
pancreasl and liver..
The pl<orna,iruscs are very small. non-envelope<~ and arc composed of a single stranded po~itive RNA genome with an icosahedral capsid. This family includes the cnteroviruses (poliov/ms, coxsacldeviruses. echoviruses. am/tile /ll!patitis A virus) and the rhinoviruses. Note: The picomaYiruses are incapable of causing cell trnosformntiou, due tu the RNA genome. Coxsackievlruses: Group A; cause herpangina and ltand-foot-and-mouth disea..e. Note: The location of oral lesions distinguishes these two diseases from one 8110ilier; the oral lesions of hepangina appear on tho tl1roat, palate. or tougte; the ornllesions uf hand-foot-and-mouth disease appear on the buccal mucosa and gingiva. Group 8: call!;e pleurodynia, myocarditis, and pericarditis.
I

I. Diseases associated with ecboviruses include: aseptic meninglti~. Nott cncephulilis, paralysis, rash, fever. acute upper respiratory tract infections,
enteritis, pleurodynia, myocarditis and neonatal infections. 2. Rhinoviruses are the main cause of the common cold. Tbere are more than I 00 serologic types. which is the main reason that a ',laccine bas not been found.

lnfccliull"i

munuiiUl'lttlsi~

The Epstein-BaiT v irus (8V) is a member of the herpes virus group. It causes infectious mononucleosis ood has been sooiuted with the subsequent development of two forms of cancer: Burkitt's lymphoma and nasopharyngeal carcinoma. EBV is also associated with hail")' leukoplakia, a whitish, oonmaligoant lesion on the tongue seen especially in AIDS patient$. The vin1 s specifically lnfect.s 8 lymphocytes and can remain latent in them after symptoms have resolved. Laboratory findings inch,dc lymphocytosis, me presence uf atypical lymphocytes and lgM hetcrophlle annbodies identified by the lteterophilc tc..~t (also called the moJJQ/Jitcleosis spot test). This antilxldy eventuolly appears in the serum of more than 80% of the patients witb infectious mononucleo;is; honce, it ls highly diagnostic of the diseas~.

r-

I. Rohellu viruse.s cause German measlos (11bella), which present with a Not. ; characteristic rash (flat, pi11~ spots onth~ j/1ce and then .vpreads Ia other body parts). 2. ParsmY3oviruses can cause measles (rubeola) and mumps. Rubeola is ch.nrcter ized by tile fonnntion of Koplilt'9 spots in the oral cavity. These spots are small, bluish-white lesions su1 TOW1ded by a red ring. They cannot be wiped off and occur opposite the molars, Mumps oausc cnlargcmenl of the parotid gland<. Serious complications include dearness in childreu and orcllltis (inflammation ~(the testis) in males past pubcn;y. 3. The MMR vaccine is a mixnre of tluee live aucnuatod viroses, administered via injection for itnmuniii.ation against meash:s, mumps and rubella. It is generaJiy administered to cbildnm at(IUM the age of one year, with a booster 5), dose before starting school ([,e. age 41

(MICROBIOLOGY I PATHOLOGY

Human immunodeficiency virus (HIV) and its subtypes are:

Paramyxoviruses
Togaviruses Retroviruses

Reoviruses

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(MICROBIOLOGY I PATHOLOGY

,
I

All of the following statements are t rue EXCEPT one. Which one is the EXCEPTION ?

DNA viruses, with one exception (poxviruses), replicate in the nucleus and use the host cell DNA-dependent RNA polymerase to synthesize their mRNA The genome of all DNA viruses consists of double-stranded DNA, except for the parvoviruses, which have a single-stranded DNA genome Most RNA viruses undergo their entire replicative cycle in the cytoplasm (except retroviruses and influenza viruses, which replicate in the nucleus of the host cell) Negative polarity is defined as an RNA with the same base sequence as the

mRNA

20
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l{l'lru\ iruws

Retrovlrust.-s-arc RNA viruses that have their genome surrounded by an inn~,~:r protein cnvelopu and an 0\ltcr envelope !hat contains liptd and gJycoprotein spikes, which serve to auao.b the vi,rus 10 the host cells. 1"hc word 14tetro' refers to the possession of the en-zyme re\l'ef'$e. transcriptase. (an RNA-directed DNA polymera.re), which transcribes RNA lo DNA during the process of virdl nucleic acid synlhe.<is.

The nucleocapsid of HI V consists of two single strands of RNA along with Ihe enZymes reverse traoscriptase, prote1uc, and integrasc, -all encaSt.'() in an outer lipid envelope derived from a host cell via budding. This envelope bas 72 surfac projeclions con1aining an anrigcn, gpl20, that aids
in the binding of lhe virus to lhe target cells with C0 4 r:et>tors. A second glycoprotein, gp4l, binds gp 120 to the lipid envelope. The go'llomc of HIV, similar to rctroviruse.< in general, contains three major genes: enl' gene codes for its two envelope glyc.oproteins pol gene codes lbr its three enzymes gag gene . . codes for core proteins The transmission of mv occurs primarily by sexual contact and by transfer of iuf:tcd blood.

The virus infects and kills helper (CD4) 1CceUs, resulting in the depression of both humor I n<l cell-mediated immunity. It travels throughout the body. particularly ln macruphuges:~ which are the first cells infected by NlV, !t induces a distinclive CPE (cytopathic ~lfrcl) called ginnt-cell (. yyncytla~) fonuaHon. ln uc.1dition to the CD4 rt-c~ptor, a core receptor known as a rhemoklne is required for HTV to infect cells. Important: The rapid emergence o f new strains of IflY,. primarily tJ1c. resull of frequent errors Introduced by viral rev(!.rse transC'rjptase. I. Acute lilY I primary iur~ction can present as a monooucleosis.. Jike syndrome with rever, fatigue. sore throat, and skin rash. 2. HIV differs from the RNA tumor viruses in that it lyse< the host cells. RNA tumor viruses uansfonn tl1e cells thal 01ey invade but do not possoss cytolytic activity.

\itgath r polaril) is dl'fintd :ts nn 1-{j'\: \ \\ilh Ihe s:.nnl' haw Sl.:'(lllcnce as tht mRN

***This is false; positive polarity is defined as an RNA with the same base sequence

as the mRNA.
RNA with negative polarity bas a base sequence thal is complimentary to the mRNA. For example, if the mRNA sequence is 0-U-C-A, an RNA witb negative polarity would be C-A-0-U and an RNA \vith positive polarity wollld be G-U-C-A. Note: Tbis term, positive or negative, polarity only refers to R.NA \'!ruse.~. not D\'IA viruses. Examples of negative polarity RNA viruses include orthomyxovintses and
paramyxoviruscs.

Important points to remember: Tite first step in viral gene expression is mRNA syn lhesis. The positive polarity RNA viruses can use their RNA genome directly as mRNA. The negative polarity RNA viruses must transcribe their own mRNA by using the negative strand as a template. Because the cell does not have an RNA polymernse capable o( using RNA as a template, lhe virus carries its own RNA depepdent RNA polymetase.
Note: RNA vintses have a geuome wbicb may be single-stranded or doublestranded. segmeoted, or ooosegmeoted.

(MICROBIOLOGY I PATHOLOGY

Chickenpox is caused by the:

Smallpox virus (variola virus), a member of the poxvirus family Varicella-Zoster virus, a member of the herpes virus family Respiratory syncytial virus, a member of tbe paramyxovirus family Rotavirus, a member of the reovirus family

21 Copyri:Jht 0 l009-20 I 0 Ottltal D:ks

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Vir)
~

All of the following statements concerning viruses are true EXCEPT one. \.. Which one is the EXCEPTION? AI
A

A viral nucleic acid (genome) is composed of either DNA or RNA (but not both) that is encased in a protein coat called a capsid They are either naked or enveloped, depending on whether the capsid is surrounded by a lipid bilayer known as an envelope They replicate only in living cells and therefore are obligate intracellular parasites
They are not sensitive to antibiotics

They depend on host cells for energy production They can be observed with a light microscope They pass through filters that retain bacteria
22
CopyrlghtC 2009...2010 Dc:nt:lll)ed:s

The variceJia ..zoster virus is a member of the ht.lrpes virus group. 1r causes the diseases chickenpox (vari<el/cl} and shi'ngles (herpe.r :osle1). The virus Is very contagi0\1$ and may be spre'<id by dltect contact or droplets. 90% of all cases of cbickenpux occur in child/en "llder 9 yen~s of age. Localle.<ions (ve.vide.v) occur in the skin after dissemination of the virll$ through the body. These lesions hccome encrusted and fall off in about one week. lntportant: The administration nf a<pioin is eontrolndlcnted in thi~ and in Qtlter childhood viral infections. Aspirin given to infected childreu increases lhe incidence of Reye's syodromeewhich ca11 cnuse enceplmlitL'\ and liver impainncnt. Shingles (herpes :oster) is cbe result ofreactivation of a latent varicellP-zoster vln~< 1hntll1~Y have remained within the body from o cl!ildbood case of chickenpox, The v[rus reaches the sensory ganglia oftbe spimtl or c111nial nerves (most ji'l!qlle/111)' tile rrlgemlllllltterw), producing an inflammatory response. 11 is characterized by painful vesicles thar occur on the skin or mucosal surfaces along ihe cllstrlbution of a sensory nerve. Jt is usually localized to a single dermatome~ and 1.$ n1ore rJommon in i1ldividuals who ate lmmunocgmpromi!iicd, Note: Adenosine arabinoside Mtlaroblue) suppresse~ the synthesis of V<tricetla-zosler and ltorpes simplex viruses, and it tends 10 diminish new lesion fom1arion and the durntion of fever and to prcveutlbe spread of !be virus lhrough the viscera.

Remember: Poxvlruses are ON A viruses that are the large<t and most complo:x animal viruses. fhis group includes the variola viruses that call$e smallpox. Smallpox is an acute, highly infectious, often fatal disease tlult is characterized by high feve~;, prosll'3tion, and a ve.<icular, pustular 111sh. Fonuuately, man is the only reservoir for the virus and vaccinarion with vacolnia, a related poxvirus, has been effective in e111dicating smallpox.

u This i< false; viruses

cannot be obsetved With a light microsc-llpe. !'he replitation of a virus 1vithin a host cell depends ou tho ability oflhe virnl genome to ente.r the hos! cell, to remain funeliqnal, and m direct the host cell to produce virnl 111BCJ'Qmolecules. Within the host cell, the virnl ge11ome al'llioves control of the cell's metabolic m;Hvi ties. Te vin1 s then uses the metabolic capacity of the host cell for production of new virus" es. Often the replication of a vi111S causes changes in che host cell, usually causing the dead> of that cell. Nolet for viruses, the burst size is the avemge uumbcr of progeny viruses released per infected cell.

Remember: The. capsid bas lhree functions: I, 1t protects the nucleic acid from digestion by en>.ymes. 2. lt contains special sites on its surface that allow the virion to anach to a host tell. 3, h provides proteins that enable the virion to penelr1!1e the host cell membrane and. in some ca.~s. to inject the infeclious nucleic acid into the cell's cytoplasm, Many type:;ofvims have a glycoproteio envelope surrounding the n~clel)capsid. The el\velope is oomposcd of two lipid layers intersper.;ed wilh protein mQ!ec~les (lipoprotein bi/ay. et) and may contain material from 1he melllbrauc of a host cell 11,'; weii11S that of vir~! origin. The VirUs obtains the lipid molecules llom the cell wcmbrnne during the vjrol budding wn proteins, ptocess. However. the virus replaces theproteins in tl1e cell membrane with iL< t> crea~ng a hybrid stlt\Cture of cell-derived li1>ids nnd vin1s-derived proteins. Many viruses also develop spikes !111lde of !tlycopmtcin on their envelopes 1hot help them to atc ach to spe,;ific cell surfaces,
Note: The most generally accepted laboratory method for the din~;nosis of most common viml infections is whether or nor specific Mtisera neutralize the vi1'US (cull cullure teclf . . trif!ues).

(MICROBIOLOGY I PATHOLOGY

Vir)

Innuenza viruses have all of the following features EXCEPT one. Which one is the EXCEPTION?

They are DNA enveloped viruses They contain an RNA-dependent RNA polymerase They have an outer lipoprotein coat They replicate in the nucleus They are known to show changes in antigenicity of their hemagglutinin and neuraminidase proteins

23
CopyrigbtC 2009-2010 Onltal Declcs

(MICROBIOLOGY I PATHOLOGY

- - - - - arc the most common viral infecthe agents in humans, and a causative agent of the common cold.

Paramyxoviruses
Coronaviruses

Rhinoviruses
Orthomyxoviruses

24 Copyribt0 2009-2010

l:>cn~l

Oeck:s

 Tbis is false; influenza Vintses re RNA enveloped vinues. Influenza viruses -are the only memb<ln< of the ortbomyxovlrus family. The inOuonza virus is composed of a unique segmented, neg"tive, single-strll1lded, RNA genom. a helical nucleocapsid; and an outer lipoprotein envelope. The envelope is covered with rwo different types of spikes (which are glycoprotemaceous projection,, or peplumers), that contain either hemagglutinin (which "'""'es the ~tggluti/1alioll of li.BCs) or neuramlnldase (which aids i11 llte allocltment ro rhe hosr C!e/1 via specific receptors). Influenza viruses are classified as rypeA, B, or C, depending on a nucleocapsid antigen. The ability of the influenza virus to cause epidemics Is dependent on antij(enic changos in tbe hemagglutinin and neumminidase. Tbere are two rypes of change!:: antlgeuJc shifts, wbich are major changes based on reassortment of genome pieces, and antigenic drifts, wbicn are minor changes based on mutations. Important: Reye's syndrome includes vomiting, lethart,'Y and may result in coma. It is rare, but approximately 40% of cases are faial. The origin of R.eye's syndrome is ~nclear but $Oems to follow certain viral infections such as influenza ot chickenpOX (varicella zosrer I herpe. zos/er), especially if they are in tne young and especially if they have been tre-dted with aspirin. Asptrlu is contraludlcated for childhood or adokscent fevers because it is a risk filctor in the development Reye's syndrome. Acetaminophen and [buprofen are apparently not associated with R.cye's ~yndromc.

lthinn' iru:~rot\

The common cold is most frequently caused by rhlnoviruscs (rileff! are over 110 tlij]'erenl stereorypesr this r's why tlevelopmeut ofn wu.:,:ine i,'i su difflculJ), Rhinoviruscs are memben. of the picornftvirus lamily, which have single-strouded posidve sense RNA genome, with an icosahedral capsid. No envelope is present. Note: 111e common cold is also caused by coronuviruses in adults.
Notes
I. Mumps is caused by an ttt'M puramyxovlrus and is transmit1cd via respiratory droplels. The most noriceab\esymptotll of mumps is the painful swciHng of the p3!0tid gland$, eitller unilatenll or bilateral. Note: Two complications arc of sign if icance: orchitis with paioftll swellillg of the t~ticlcs in postpubertal males, which can result in sterility, and denlhcss ln cllildren. 2. influenw is caused by influenZA viruses A. B. and C (ontrom)cwvimse.s). Compll<:J~tioos include Reye's syndrome in children. Amantadine and rlhtantadinc llCI to prevent vinll Ic'Pii<alioo and are only eft'ective against influenza A. 3. MeaSI('S (Rubeola) is caused by rubeola virus (RNA pnramyxoVinrs). It characterized by skin !'8b with KoJIIik's .<pots. and is transmlued via respiratory droplets. 4. Cernmn measles (Rubella) is caused by the rubella vi"ts (RNA vin<s). Transmined via respiratory dropletg. Flu like symptoms and lymp)ladenopaOIY. followed by rash on the emire body. 5. Pharyngitis is an inflammation of the pharynx. The m~in sym~tom is a sore lhroat. It is caused by a variety of vinscs (odenovint.Se.< and coxsockieir'4Ses). 6. Arthopod-bome viruses (ArbQviruses) are viruses which can be uansmitted to via an insect (arlltropod) vector. tn general, arboviru<es belong ro 3 families: Togavim<c. (i.e., t1tbella vints). bouyvirusos (i,~ -. Rift l'aliey je1 er). and fiavivirus<:s (i.e.. yellow fever vfru.;).

(MICROBIOLOGY I PATHOLOGY

( which growth curve describes the lytic repr oduction cycle that releases :'\... large number of phage simultaneously? .A

One-step growth curve Two-step growth curve Three-step growth curve Four-step growth curve

25
Co9rri&h.1 C 20092010 Dcnta.l Deck$

(MICROBIOLOGY I PATHOLOGY

The general structure of resembles the structure of orthomyxoviruses EXCEPT that they are usually larger in size, have different surface proteins, and have non segmented genomes.

Herpes viruses Togaviruses

Picomaviruscs
Paramyxoviruses

26 Copyri.gbte 2009-2010 DnuaJ J>etkS

A typical one--step growth analysis can be divided into several phases: 1. Adsorptlort of virus (initial pltase) 2. Ectip5-c phase: This lasts for 10..12 hours, and it corresponds to the period durins which the input virus becomes uncoated. As a result, no infectious virus can defected during this til'ue 3. Synthetic. phase: Tilisstart.~ around 12 hours post-infection and corresponds to the time during wh.ich new vi.rus panicles are assembled. 4. Latent period: During this period, no cxtmedlular virus can be detected. Afler a certain time pt."riod. cxtrncellu1ar virus is detected. Ultimately, production wiU reach a maximum plar~u level.
Steps lp the Rcnlkathe Cycle of Virnsn
I. Attathmc.nt: T hrough a receptor.

Specific: CD4 on T-eclls for HJV ICAM on upper cespiratory epithelial cells Rhinoviruses (commo11 cold) Jnununoglobulin-like receptors- polio \tirus 2. Entry - receptor-mediated endocytosis, e.g. influenta- and adenovirus - membtane fusion, e.g. berpcsvimscs and paramyxoviruscs 3. Uncoating triggered by pH changes in endosomes. e.g. Influenza A virus 4. Re.plication and viral protein produtrion: Transcription and translation ***All DNA viruses (except poxl'iru.ses) replicate in the nucleus usin.g_ ho5t cell RNA polymerase. *** AH RNA viruses (except retroviruses and orthQmyxovirus&) replicate in the ~ytoplasm usif\g their own RNA polymerase. 5. Assembly: The new viral nucleic acid and capsid proteins are packaged. 6. Release: Either by budding through the h~t plasma membrane or by hose plasma ml,."lllbranc rupture.

f':tr:un~ \0\ iruw"' Both paramyxoviruses and onhomyxoviruses are enveloped, negative, singlestranded RNA viru.ses. Orthornyxov i ru~es:

*** Aie known to show changes in the anti.g_enicity of their surface proteins.
J'aramyxovlruses: Measles. mumps. reSpiratory syncytial, and parainfluenza viruses ,.,.,.The cytQpatbic cffecl for paramyxoviruses is syncytia formation (Jirey induce cells to fcrm
mllltinucleated gitwl cells).

lnflw:nza viros

- __ . """"''
R.'I(A Yi!'11.w.tc
Jlltlij~

"""' I

..

Oiwast

I ..bchln l

h J Vccl.e

D:<A vltuus:

"'"" I

Olst>~!t

-r

A.n1tv1nJ 1'l T v.mn,

"""""'u
........w
l!Jb;a'Jinn

... orp($.~

..__...,
Q)flj~tli,

l)'pcl

l'lnln\lmn Ctwp a

.....,.,.,.

cbild~n

.,..

~~~''"""II$
tr~,~icalb

No

.,..,

A~IO"tin'ZoriMJ f'cllnt~(/H.vld} V~~rPIINIG)

Jl~~

lofondllohllf. II\ lnl'llnl

~((,j

fl"'lllln.Br..

I.!C'l.'lious mononudcods

.fttolleUI-

Ruldi!((J-

l'lo<>o

"""'"'
M-wr!J'\
lthiii()Yo r:o<
co~ital

Mw.l~libotulaJ

,.,,.
,.,~

""""" """"""'""'. ... "'""

Common told

...
Yoo
No No

Yoo

Vu.Otlh1~

Sllinlllt'

"""""""'
AU
('(l.~ll"f-

l'hid(tl po:o;

....
"'"

J',w,.<icl"'YU iF'<IIf(Wj \'tbq'fr.w.t P'~

AC)'<Iot"lf (Zao*"Di

"' ""
No

AC)'I:Ioo.-~r IZolhnJ f.MOd~lt tfi>.,..I'P.J

""
Yn

Valu:)<ei.:Mr()'.r/rr:f.l

Cfltljunt&MIIs

r hll)nJI'--

A:.lkfr.an111-. 111111!- rooe~nil~

s;rr~yn

m)':l:"''li("' anti pic:.u0rl3

....

""
No

(MICROBIOLOGY I PATHOLOGY

Vir)

Which one of the following types of viruses are second to respiratory syncytial virus (RSV) as a common cause of lower respiratory tract disease In young children?

Coxsackieviruses Adenoviruses

Parain fluenza viruses

Orthomyxoviruscs

27

Cop)'ligln 0 20092010 l)cntal Oeckls

(MICROBIOLOGY I PATHOLOGY

Vir)
l
J

I' Which of the following is a positive-sense, single-stranded RNA virus with

\.. spike-like, hemagglutinin-containing surface projections?

Herpes simplex virus type- I (HSV-1) Human papillomavirus (HPV) Epstein-Barr virus Rubella virus

28

Cos:lrrl&ltt 0 20()9.2010 Dental Decks

Parainnmn1n

'iru~l~

Viruses thai cause respiratory disuse iu children: Respiratory syncy1ial virus (RSV) Parainflut:nza virusc,s Rhinoviruscs Adenc;wiruses Common causes of viral gastroenteritis: Rot-a virus (inosr cottJmon caus~ u, childre~t) Noravirus Adenovlruses- aQd astrovin1ses (more commott In odulls) Causes of the common cold: Rhinoviruses lflfl\fc:nz;a C virns Coronviruscs Coxsackicviruscs Adenoviruses

Common viral causes of ph3J1'Dglt1s: Coxsacklevirus A Adenovituses Orlhomyxoviruscs (illjlue~tza l'iruses) EpsteinBarr virus Viruses that cross the pJact'nta: Rubella
Acrpes I:! IV

Cytomegal()virus

Most commnn pcdilltric viral dis(...-ases with a rnsb: Measles (me"'les virus) Erythema infectiosum Rubella (rtibella > ~rnr) (Pan'Qvl111s 8 19) Roseola (HHV 6)

Most common causes of

al\:C!ptie men.fngltis:

Coxsackieviruses

E~hoviruses
Mumps virus

Rcovin1scs are tbe onJ_y RNA viruses that ate double-stranded Rotavin.I.Ses -are the most common cause of infectious diarrhe-a in infants and young children Most common human disease caused by an arhoviru)li Js Dengue fever Mo~l common cause of epidemic e.ocepbalitis is Japanese cncephatits virus CMV is the mosl common viral cause of mental retardation in the U.S.

J(uhl'lla 'irns

Rubella virus is the sole membe-r of the genus Rubivirus in tlte family Togavlrldae. Only one serotype has been identified. It c-ontains three major structural polypeptides. The disease is rraosmltted via direct o r droplet contact with respira10ry secretions. Rubella virus multiplies in cells of tbe respiratory system; this ls followed by viremic spre<1d to target organs. 11 causes Cerman measles and is a teratogen (causes malformation af afl embryo or n jews). The typical picture or rubella includes a maculopapulnr rash that appears first on the face and neck and quickly spreads to the 1nmk and upper extremities and then to the legs. lt often fades on the face while progressing downwards. The lesions tend to be discrete at firs t, but rapidly coalesce to produce a flushed appearance. The onset of rash is often accompanied by Jow-gtade fever. Although the rash usually lasts 3 to 5 days (lle11ce the term "3-duy measles"). the associated fever rarely persists fo r more than 24 hours. The earliest and perhaps the most prominent and characteristic symptom of rubella infection is lymphadenopathy of the postauricnlar, occipital, tUid posterior cervical lymph nodes; this is usually most severe during the ras~ bullllay occur even in the absence of rash. Rubella infection acquired during pregnancy can result in stillbirth. spontaneous abortion. or several anomalies associated with the congenital rubella syndrome. T he classic rriad of congenital rubella syndrome incl udes cataracts, heart defects, and deafness. .--....... !.The virus ~rticlcs are generally spherical with spiky hemagglntinin-eontaining !Notes surface projections. 2.Tbe rubella vaccioe ill current use is prepared from attenuated rubella virus.

(MICROBIOLOGY I PATHOLOGY

Bact)

A All of the following statements concerning Staphylococcus aureus are true ~

\,..

EXCEPT one. Which one is the EXCEPTION?

It is a grampositive coccus that typically grows in grape-like clusters and is one of the most common bacterial pathogens It is the most common cause of suppurative infections involving the skin, j oints , and bones and is the leading cause of infective endocarditis

It is coagulase negative whereas other Staphylococci are coagulase positive

It possesses a surface protein (protein A), that binds the Fe receptor of lgG, thereby blocking complement activation by the classical pathway

29 CopyrighH O 2~20 1 0 Dental Ok:s

(MICROBIOLOGY I PATHOLOGY

Bact)

Streptolysin 0 and S produced by Streptococcus pyogenes:

Causes lysis of red and white blood cells Dissolves fibrin in blood cells Causes Scarlet fever Breaks down hyaluronic acid

30
Copyright 0 2009-2010 Ot!ltallkd::s

***This is false; it is coagulase positive whereas other S!aphylococci are coagulase negative. Staphylococcus au reus cannot in vade through intact skin or mucous membranes, and infection usually begins with traumatic inoculation of the organism. Once anside the body, it secretes n number of enzymes and toxins that hann most tissues. Note: The cell wal l ofS. nureus contains ribitol phosphate telchoic acid. S. aurcus infection usually produces s uppura tion and abscess fo rm ation. It most commonly causes skin infections. It it responsible for the foUowing: scalded skin syndrome, toxic shock syndrome; osteomyelitis; infections of burns or surgical wounds; respiratory tract infections; septicemia; bacterial endocarditis; and staphylococcal food poisoning. Coagulase-negallve staphylococci (ll!s.r vlrulemtlran S. aureus): S. epidermis: the most frequent cause of infections associated with medical devices. S. saprophyticus: the frequent culprit of acute urinary tract infections in young womeu. R emember: Staphylococci are faculta llve anaerobes that grow by aerobic respirntion or by fennentation that yields principally lactic acid. The bacteria are catalase-positive and oxidase-negative. S. aureus can grow atn temperature range of 15 to 45 degrees and at NaCI concenll'tltions as high as I 5%. Note: Nearly all strains ofS. aurcus produce the enzyme coagulase. :-lote: Major virulence factors include: protein A. bcla-lactamase, enterotoxin, byaluronihyaluronidase and staphylokinase.

( anw\ 1\ ..;i\ nl n d anti "hile hloud l'l'll'

Ort:JIIbct

Major Vinloct"

A<tloo(l)/ o-J<(t)
~IOpllll~t.
C'let~~D'\A

.... San .,..,_

.........
PMci!IA

F-.it)

OS.Nc8(L4> . JIIJ flytQpic ffn~td klo~.. SIJq'IIOtyf.b1 0 k S

Slftptokinauoe

",.,,
"

C'au..n 1brlet r~"" ~,11

Hyalurotlidast.

Exoco.dn B rsP 8) St~~Jit'rlntkttfl'

SUflhyiUIC\M..,. ........

~Qo!Q,'Iin A

(SP6AJ..

Strtpi CICOCtil1 tori~: si!Oorl.; t)'tl dNIIII(I

L)"tt orred & ""Mt blouJ ct:Jb OlswiY~ fibrin. in b\clood dou BmU down t.y.luMIIit aeld

R11pid))' dt<Stt0:ys u:;wr

ln.fubifl """J)Ic:mcu 6.~adon by blndln, i" cbr Fe pl)rtiUfl of IJ(i
Oi"-'41\er bl~ dot.s erc..n*""~--ld lfloldn~ pol'ia1Jin

. ,. . . . . . . _h<-.. ""'-"-w.
8&'

T"""'

TSST ~dod"~ IOJ:Mtl

C1uoo:n~Wm

OohlliAUm ltf'roles-ln:

-
Edobario

se (pclltkJ rk'*'WJ

c--r..d .........
c..ct ~ sl.Ni"" t)-.1.-.-.r ~ '"Wd~ dMidt'" ')'lldrHtt
M~ and tsen-c. s-r~l)'5i~o 8MttlbiU ~Tml'i !OI('gnt)' o[ cdi ii)Cit'lbrn~~ J d.J\\11 rib'w.lllli~IX

l11.1lloiiiiMTI

it. lhc ~ po1m1 tNlm. \nown 10

PO'!!l u otoJ1n: a- tO>.in (u lrdthimuti

"*"

Cloc.lrwhum prrlb"JI'"'

r.o, an,t;n"-11t

Clu~t!el.cm tdalli

s..,.to.llA:.Iiellll)UJ Ia
l!t'ttmO'fiGV")

t~cm ...tth IDOCDr nt\truM Ttluf~J

C"wtjlllcbiiiCIIIWft'

OipWinit 10),.10

o.,.u.......,.~......,._...

dipdeu
S...plll~ E<ooodm ~ ~

,._

__
r.. ~

..,..._

BMtttll l d)'teot.ft} ~Httm$}

(MICROBIOLOGY I PATHOLOGY

Bact)

Which of the following is the predominant type of bacteria on the skin?

Lactobacilli Lactic acid bacteria

Neisseria
Staphylococ.ci

31 Cop)'righ10 20092010 Dental Deeb

(MICROBIOLOGY I PATHOLOGY

Bact)

On blood agar plates a - hemolytic streptococci:

Cause complete lysis of red blood cells Cause incomplete lysis of red blood cells Cause no hemolysis of red blood cells

32
Copyri&}ltO 20092010 ()(nlnl Oecb

St!1ph~

lucorri

Pndomin:mf h.l(lcria Ul \,lritJU'\ ~n~IUtn l \"!l lfo(".thnn-; Ill .Hiull'\

Anatomical t..ocaHoo

Predominant bJJc.teri.u

Skin

St.apbylococci and corynebacteria

Sparse: g.ram-positi\c cocci and gr'.un negative rods

Conjunivn
Oru_ l c:avity:

r lb
Murous-membnmes

Strcptoc:oc:ci, lactobscilli

StreptOCocci ;:aod lo)Ctic ncid bacteria

Upper resplnuory trut

Nares (nasal membrane!~)

Ph"'}'a~ (lhroul)
Low~ respiralory trud

Staphylococci and ooryneb;l(.teria

Streptococci. neis..<ia, Omm--negative rods and cocci None

Gllstrolotestinal tr-ael

Stoolach

lttlicobacter pylori {Jtp ro 5~

Lactics, entcric.s. entcroco<X.i, bifidole~eria

smau

in~eMlne

Coloo
Urogenital tnct
Antennr ureth.m

Bacteroides. lac tits-, CDtaics, enterococci, clostridia SP"rse; Stapbyloc.oe<:i. cocynebacteria. coteries
Laclic acid baderia dunng ch.ild~~rin,s yc:tt$; 01herwisc mfxcd

Vagin3

Some streptococcal species produce to><ins, called bemolysins, that cause lysis of erythrocytes. Note: Streptoccal species arc cocci-shaped, gram-positive and are facultative anaerobes. Alpha-hemolytic streptococci produce a zone of incomplete hemolysis and green
discoloration adjacent to the colony. Beta-hemolytic: streptotocd produce a clear zone

of hemolysis around the colony. Gammn-Strrptococcl produce oo hemolysis. Beta-hemolytic forms are classified into Lancefield groups (A film U) according to lhe C carbohydrate composition of the cell wall. Group A strains arc pathogenic for humans. They are further subdivided by Arabic numerals into spcctfic antigenic types based on tbe cell wall M protein. This M protein seems to be closely associated with the virulence of the bacteria. The prototype isS. pyogenrs (ctmses rheumatic fever. scarletfeve~: and sore throat). Remember: Toxins produced by Group A beta-hemolytic streptococci include pyrogenic (e~ythrogenic) toxin, DNAse, hemolysins (sireptolysins 0 & S), hyaluronidase. streptokinase, and exotoxin A. -......, Important: Notrs I. Streptococcal Exotoxin A (SpeA) is a superaotigen (as is Exotoxin B) produced by Streptococcus pyogenes and is associated with severe infections characterized by rash, hypotension, multiorgan faHure and a high mortality rate. 2. Oral Streptococci are usually alpha-hemolytic (i.e., S. viridans, S. 11111tans, S. sanguis und S. salivarius). These bacteria are the most common organisms causing subacute endocarditis.

0ncROBIOLOGY I PATHOLOGY

Bact)

,.
I

"'

Identify the phases of a standard bacterial growth curve, labeled A through 0 below.

'--A
0 90

1ime (minutes)
)3

CoJ!rriaht 0

20()9.2010 Dtnlal Dedit

(MICROBIOLOGY I PATHOLOGY

Bact)

Endotoxins are part of tbc outer membrane of the cell wall of:

Grampositive bacteria only Gram negative bacteria only

Both gnunpositive and gramnegative bacteria

Neither gmmpositive nor gramnegative bacteria; they are a component of viruses

,.
('.opyn,Jbl 0
~20 I0

DcYital lk<:U

\ ~ Lag pha>e B =- l .u~ (/o,!~ttrithmic or L'Xpmrentia/j pha:-.:e C = Statiunar~ phasl' ll = Occlinl' rtl,uth) phaSl'

The bacterial growth curve reflects the dynamics in a population of bacteria over a period of time. When bacteria arc placed in a fresh, nutrient-rich medium, they exhibit four characteristic phases of population growth: Lag phase: cells are metabolically active but are not dividing. This is a period when the cells are resynthesizing enzymes, coenzymes, etc., necessary for growth and division. Log phase (exp<Jnential growtlr plrase): bacteria are growing and dividing at an exponential, or logarithmic, rate. This is ihe period of fastest growth: ihe generation time is maximal and constant Note: Most cidal antibiotics work best during this phase. This is the best phase to stain bacteria culture to sntdy them. Stationary phase: at this point, the medium is becoming depleted in some nutrients, and toxic quanti.ties of waste materials may be accumulating. The number of new cells produced is otTset by the number of cells that are dying; thus, the total number of viable cells remains constant. D eath phase: conditions are becoming less and less conducive to cell !,>rowth. Cells are dying more rapidly than new ones are bemg formed. resulting in a logarithmic decrease in the number of cells.

c;r~ltll-lll'!.!:\lhe

hat.'lt'ria

onl~

The biological activity of endotoxin is associated with ~1e lipopolysaccharide (LPS). Toxicity is associated witb ihe lipid component (Lipid A) and imruunogenicity is associated with rhe polysaccharide components. The cell wall antigens (0 antigens) of gram-negative bacteria are components ofLPS. LPS elicits a variety of inflammatory responses. It activates complement by the alternative (properdin) pathway.
( 'hatactlristics uf B:u:lt.ial Endotoxins und Exotoxins

P rop erty
Organism!>

E ndotoxin
Gramneg$1ive
Lipopolysaccharide
Part of outer membrane

Exotoxin
Ort\Jli-posittve and gram-negative

Cberu..lc.:atl nnture
RfJAUou"bip to c:eU
D~naturec,f

P-rotein
Bxl"r:lcclhdat.. diffusible

IJy boiting

No
Yes

U!tually

Antigenic:
Form toxoid

Yes
~c..,

No
R-elatively low Low deg.rce

Poreoey
Specificity
En:r.ymatl~

Relatively higb

High degree
Often

nctlvlty

No
Yes

Pyt"Ggeolcl<y
'R.e-h~nS"--d b'y oruanbms

Occasiotl>llly

No

Ye:o

(MICROBIOLOGY I PATHOLOGY

Bact)

~ Which of the following is essential to the function of the outer membrane of \.. gram-negative bacteria? .J

Protein
P antigen receptors Coagulase

LPS

35
CopyrightC 2()09.1010 De:ntal Declq

(MICROBIOLOGY I PATHOLOGY

Bact)

Which of the following is a type of gram-positive s pherical bacteria that occur in microscopic clusters resembling grapes?

Streptococci

Neisseria
Salmonella Staphylococci

36 CopyriiJll 0 20-2010 Dental Dks

I. PS The fum;tion of the outer membrane uf gnun-ncgativc bacteria i.~ to act as a pt otectivl' permeability bf.ln-1er. the outer membrtsne is imperme:~~hle 1o large mvlecutcs and hydrophobic comJtOUitds fhun che euvlrunmcnt. 1.PS is cssentiul to tJlc function 9f the outer membrane.

rmport ant:
I. EJidclo,.ins Rre: not i ('Uctet1 by bacterial GC'll.s. Tile bacterial cell mu$t die ttnd the outer membrane be broken down rur the endotoxin to be reJea.~ miQ the bloodsttcarn. 11Jc host's rcspc.m~c!i tu cudo-mxim; include chills, fever, weakness, gent..-nllitc<laoh..:s, ~and, m severe casts, shock t~nd death. 2. Eodotaxin.~ -are hlgt1Jy potht l lipopolysnccb;trldH releas-ed from the e<:ll waUs of gr.u.n-ltegative bacteria. Min\lle tLmounts in 1hc oral mucosa cause inOtamm:~ lion ~nd resorptJ~n Qfadjd\!C:Ill bon~:, EndotOxJn h~s 11 chcntota~tle eftC<'t un ncutruphilic granulocytes and iudU~6 phDgl'~C)IlP$iS by these cell>,

Notes

I. Jn addidon to endotoxin. plat]~(l b!\cltria; also prodoce enzyl\14!~ (/J)'tJiuronltltMe, colfn... dtlnt/roltfn f'ti/Qit,.se, elastase, and JH'Oift.ttJ'!.\') that may initiate: perlodoni&J disease. 1;-l'e~ endOtoxin is present in dental plaque 11nd in inflamed gingiva, fte.merobert The most H l<cly source ofb-Jcteria found in di~~ag.cd periodontal tissue is subgingival pll'uJue;. 2. Col1ngenase is the prole11sc which, degrades coUa~en. ont. ll f rtu: OOdy'$' pnmr-1 ry conm.oc~ live tilisucs. In pmie.nL~t with periodontal di se:l.~, lbc eo1Jag4-'n which fom1s the struCltJtaf basis of tht periodontium is br4;>ke'~ down by L"'IIagenasc. l~us protease has t>t!eu deuum srrntcd co be tt (lllfl of the uQmponr.'lit syst<.m tn the folluwiug b:tcteriiS: l'orphyromonas spe~es,-. Clt~Sttidhtm species, Bacteroides sJJt:<.'ies, itntl AA. 3, Althot1gh most bacicrial ~xutoxins ure prOioi"naccous tn natUie. end(U()<fn i$ A lipopolyMu:churide cmnplcx composed of a Upld A (porJion UIQ'( rcspQnJibl<:.for ro.Y/t! <Uti~.. ity) core polys~tcchArJd e. and an '"0 " a_rHigtnie s:ide c:h~in . 4, Endoroxin can activa1e the complt:ment sy&"lcm vfa the altcmarivc pathway. C3 tan be activated by endotoxin m the llbSCTHlc of preceding ac.nvatiou of Cl. 4, und 2. As " rosult1 the vartoli.S complement components (C3, 5-9) are con~umcd and Iben their 3Ciivlry dl<;:app~:oan> or 1s reduced from serum.
J;CIIUSe,

Sl;l(lh\ lut:occ:i

St:iphylococcus a\J.rcu.s c:.1uses a variety uf SUJ)l)UtnHve (jm,,.-furmillg} inf'cctions and lnxinoscs in hum. ans. lt couses su~'eyfiajal s~in lesion!. sUoh as boils. :,;cye,~ and furunculosis; more serious mfi.~tiuns such a.s l>nelmtOnia. mu:.titi~ phlebitis. m<..'TtingHis, and urinncy t11lC1 infecllo!l.s; ~.lld de-pSeQ\td inff.'tltion.s, such as ostcomyclili's and endocarditis. S. uurcus is n major cnuse nf huspit~l ~!PtJUircd (1Jo.socomiol) infectioo of surgtcal WO\IJlds and infections assouii.m'\1 . whh UterotetxinS: inio food, indwelling medica) devices, S. OIUI'fUS' caU$($ Cootl poi~111i11g by relt.-nsing C and toxic shock syn droru~ by release of ~upe.rnntiS~f' int< tJH: blood sln.:am, lmport:uu: Pr-otein A is a surface protein ofS. aurcus which binds- IgO molccuk-s by the-ir Fe region: it may be L 'Cspon .sible for its viruJence, The genus Neisseria contains two impO rtf:\tll human pathogens~ N. gonorrhoeae and N. meningitldi$. N. gotlorrhucM~ cnu.ses gouorrheu. and N. meningitidis caw::e.' meiJiti~QcC'Iocal meningHis-, '1. gonorrhiJ(;l:it. inf~tions have. a high prc,alcncc and low motialily, whereas N. numingitidis in ft..~ tions huvc J luw prcvoleooc: and blgh mortality. SalmontUa is a gram-negative facultative-rod-shape(l bocu:-rium in Ihe same protcobac-lcrlal fam1y Enterol>acterinceae. trivh&lly known as ''ent\lric-" bacteria. 1n ilY tts Escherichia coli. the fam1 bumaa<, Salmonella is lhe caijse of (WO diseas..s Cllllecl Slmonelhul5: cmcnc fever (/)yllroid), resuhiilg frumlmt:te.rial iuvu..'ilun of Ihe bloodstream. and acute gastrocnrc.titls. (eSUIIing (Col'n a IOodbomc infcc.tion J1nmxlcation. 1. Str eptui.'.OG C:f are aerobic: to faculmtively 3fl3elobic gnl.m--piJsitiv~ cocc1 that grow in l'Jnt~ pairs or chams in culture. 'll1cy aro. the mtMI nutneruus group of mic.ruotganisms tbut occur ln the ornl cavity, \\'here they CllJl grow und 'al.ls\:. denhd ~:.aries (mctifi(V S . mut:ms). Ol.l1er more serious tnCeclions ~m~<.J by Slrcptoc:oo:cus include pneumonia rS. pnetwJo,lioe), rheumatic. fev.;..r (S, pyogeucs), and heart valw Infections (S. ''iri
dan).
~. Stllpllyloklnast (jJmdue<!d b,v S. DIII'611S), Streptoklnaso (pt'OIIuted by ilemolytlt: sttv:ptt>MCGi)~ and Urokinase are enzymes tha~ d~o ve pl!lsmino~e Q. -producing plas-min, whfch causes theliquefaction of fibl'ln. They 11tc us(.'d clinically in the r<.'1DOVal of

bluucl cluts.

(MICROBIOLOGY I PATHOLOGY

Bact)

Neuraminidase is produced by intestinal pathogens such as:

Vibrio cbolerae and Shigella dysenteriae Streptococci and Staphylococci Clostridium histolyticum and Clostridium perfringens Bacillus anthracis and Bordetella pertussis

37
Cop)'l'igbt 0 2009-2010 Dcol&l Docks

(MICROBIOLOGY I PATHOLOGY

\..

Mycobacterium species, along with members of a related genus Nocardia, are classified as:

Coagulase-positive bacteria Collagenase-positive bacteria Acid-fast bacteria Phospholipase-positive bacteria

38 Copyright O 10091010 Dtntll1 Oed;s

\ 'ihrln chnler:Jl' and Shigetla d~Sl'lliC'I"ht

b.tr.1n1luhtr B:1chmll P1ufliu' Th :1l \rc ( umicltn :d 111\a~in'

ln"a.sin
Hyalumnjd~

Bncterl.a lnvolvtd
Streptococci, staphyl<lCooci Md c-IOS&tidia
CIO$U'idium spocic:s

Atlhfiy
~ hyn.lurot'iie-oc.d ofconnccbvc &issue

Cotlogc:nn.-;

Dissol~ c:oUagm frumework urmwb

'Oegrsde$ neur:t'litlie acid ofinlt!-Stinal mll~

N"eurumm1da!lt' Vibrio c.holerae a.nd Shigc:ILn dysenteriat

Coo~ l!tit'

Slaph)lli'l('(>ecus aUI't\1 $

Otvt:rfS fibnn..,gro to fibrin wb.lc:b cu:ltiCS clottmg

C'ncwms pl~nli!IOt(1:11 ClJ pl~ntll wllict'l dl~l$ ilbrin

Km""' L<llkooJdln
Stlq)I01)'llin

Stapbyloooccs and strctl'tooooci

Sia.pbyiOOI>Ceus eureu:s
Su~ococeus p)'og.enC$.

Disrupts. oculropbJ1 mt:mbrancs and eal.I.SC$ d~ha1p oflySOt;(Jrnal g:anuJcs

R~l! pfulgocyt.et 1111:1 durupl$ pba~ l e. m'tm bl'llne and C8llA d~har&c oflyr.oson1 at Jlf3.'11Uics

flemtMsln,
ll-dthinu.sc&

St.tepiOQoQc-i, $taployl~cl , omd \:lostridia Closlridium pcrfriogeos

Phpsphohpascs or lcciifunase&' lha1 dcsuoy n:d blood

ctlls (1mJ ulllt..-r ct.IL{) by ly~ts

De$110,Y iccilbin fu &;dl tntJnhr.u~~

Destroy phospholipids. in cell membnmo

Pho>pholir..., Ck\.strldiuro perfringens

An!tlnL.l( Bf
~'11\1$.)~ AC

B3Cilha$ anthracis

One cOnlpcMil1'1t (liF}

I~ 1111 adetly l:tu~ cyelflsewhkh

CIUse$ me~ l ey~l:s, C'tffnlr.u:cllular cydic-AMP

OnnkteiJa pn1l!Mis

()n(! toxm oomporu:olls nn ndcny1atecyd2setbal a<;ts-k'lcnlly !'fi'Oil~n:lfl.& ;"rn 10CN3$e in mln~ellul;tr

cyclic-AMP

Mycobacterium tuberculosis is not c.lassined as tither gram~positivc or grnm ..ncgativc bocause it does nol have the chemical characterisrics ofeither, although ihe bacteria do cootain peptidoglycan (nmrein) in their cell wnll. Important: Mycobacterium tuberculosis is a fairly large non-lllotile rod-shaped. acid-fast, niacin~producing bacterium. tt p10duces neither exotox.ins or cndmoxins. Many nonpatl1o~ genic rnycobacteria are part of the nonnal flora of hulllans, found most often in dry and oily locales. Mycobacteriwn tuberculosis Is an obljgate erobe. For this reason. in the classic case of tuberculosis, the M.TB complexes are always found in the well aerated upper lobes of the lungs. The bacte-rinm is a facultative intracellular parasite, usually of macrophages, and has a slow generation time of 15-20 h.onrs, a physiological characteristic that may cotribute to lts virulence.

No

l. Acld-rast staining is one of d1e me.thods used to diagnose activo tuberculosis. II is a ll1ethod of staining used in bacteriology in which a smear on a slide is flooded with carbol-fuchsin stain, decolorized wiU1 acid alcohol. and coltntcrstained with methylene blue. Acid-fast organisms resist decolorization and appear red against a blue background when viewed under a microscope. l11is property of being acid-fast is attributable to the presence of lipids and waxes (mycolic adds) in the cell wall of certain bacteria. 2. The classic skin test (Pf>D skirr test) is another method of testing for tuberculosis. It may indicate an infection, but not whether the infee! ton is active. A purilii.XI pro... tcin derivative (I'PD) extract fromnycobactcrium ruberculosis is injected subcutaneously, and the area ncar the injection is observed fo, evidence of a delayed hypersensliMty rcadlon. A positive test indicates a hypersensitivity to tubcrculoprotcins. 3. Common acid-fast bacteria of lllcdical importanc~ include the Mycobacterium tuberculosis, Mycobacteriwn leprae, and Mycobacterium avium ..intraccllulnre can1 plccs.

(MICROBIOLOGY I PATHOLOGY

Bact)

In addition to peptidoglycan, the acid-fast cell waU of Mycobacterium contains a large amount of glycolipids, especially that make up approximately 60% of the acid-fast cell wall.

Beta-lactamases Lipopolysaccharides Teichoic acids Mycolic acids

39
(;oslrright c 2009-2010 Dc01a1 D.ks

(MICROBIOLOGY I PATHOLOGY

Bact)

Most bacteria contain some sort of a polysaccharide layer outside of tbe cell wall polymer. In a general sense, this layer is called a: _.

Cytoplasmic membrane
Capsule
Pellicle Plasma membrane

40
Copyri8ht a 2()()9.1oto Oe:nt:ll Deck$

These mycolic acids are localized in the mner leaflet of the mycobacterial cell wall cother covalently bound or loosely assocoated with arnbino-galactan polymers. ~unctions orthe Actd-l'ast Len .. au l.Ornponrnts: I. The peptidoglycan preventS osmo11c lysis, ~-The mycolic acids and other glycolipid~ also impede the entry of chemicals causin 1 ho organisms to grow slowly and be more resistant lo chemical agents and lysosoma f:omponcntS of phagocytes lban most bacteria. p. The surface proteins in the acid-fa~t cell wall, depeodittg on the sLtain and species f:any out a variety of activities, including: Functioning as enzymes S~rving as adhesins. Adbesins enable the bacterium to adhere intimately to host cells and other surfaces in order to colonize and resist flushing. ~- TI1e periphtsm contains enzymes for nutrient breakdown as well as periplusmic bind ng proteins to facilitate the transfer of nutrients across the cytoplasmic membrane
I. Isoniazid inhibits mycolic acod biosynthesis and os an efficoent aoumycobacNotcs- 1erial agent, 2. A tubercle or Gbon focus is o small, rounded nodule produced by oofecuon wilb M. ruberculosis. It is the primary lung lesion of pulmonary TB.

The capsule is a gelatinous coot which surrounds the cell wall of certain bacteria nod is especially imponant in protecdng these cells against phagocytosis by eukary01o c cells. The presence of a capsule can be a major factor m detennioing lbc pathogenicity of a bacterium; that is, the ability of a bactcnum to callS<! disease in !he orgaw:.m that il infects. Oilier important functions onclude medlate adherence of ceUs to surfaces (i. 1!., caries on rhe woth rufaces) and tbr identification purposes. When the poly~c cbaride capsules are treated With antiserum, they swcl~ allowing lbem to he identified These antiphagocytic polysaccharide capsules surrounding tbe cells of strains of streptococcus poeumoulae, for example. pennit the.~e bacteria to invade tbe normal defense mechanisms of the host allowing them to reproduce and cause the symptoms of pneumonia. The virulence of other bacteria, including Haemophiius influen?..ae, Klebsiella pncumoniae, and Cryptococ~us IICOformnns is also enhanced hy capsu le production. Noo,.
I. The cell mcmbrone (cytopla.<mlc membro11e) is a sel~cliveiy penncable membrane tbat is involved in energy tr~nsfonnations (i.e., oxidative ploo.tphorylation). It is bordered externally by the cell wall in most bactenu. 2. The cell "all surrounds the plastnn membrane and serves to protect Uoe ceil from changes 10 osmotic pn:ssure. Then it also anchors flagella, maintains cell shape, and COOIIOl the tmnspon or molecules into and OUt of the cell. 3. The plasma membrane is o dynamic, selectively permeable membrane enclosing lbe cytoplasm. It ts located between the cell wall and the cytoplasm. and it regulates the movement of substances, including water. into and out of the cell.

(MICROBIOLOGY I PATHOLOGY

Bact)

Teichoic acids arc unique to the:

Gram-positive bacterial cell wall Gram-negative bacterial cell wall Gram-positive and Gram-negative bacterial cell walls Mycoplasma family of bacteria

41 CoPYfighte 20092010 Oe:ntall)cck:$

(MICROBIOLOGY I PATHOLOGY

Bact)

Lactic acid bacteria are:

Gram-negative usually motile, non-spore-fom>ing rods and cocci Gram-negative usually non-motile, spore-forming rods and filaments Gram-positive usually non-motile, non-spore-forming rods and cocci Gram-positive usually motile, spore-forming rods and filaments

42
Copyright C 20092010 Dental Deets

G rarn~pusit h t. bacterial crJI \\all

Gram-positive cell wall: Thick (15-80 tumomelers) Thick murein layer that makes up approximately 90% of 1he cell wall Teichoic acids, polysaccharides mat serve as attachment siles lor baclriophages Gnm-n<"gative cell woll: Thin (10 nanometrs) More complc. (multilayered) than gmm-pnsitive cell wall Thin murein layer that accoun~s for ooly nhont I0% of the cell wall Lipoproteins are an integn.l part of the cell wall Lipopolysaccharide layers (LPS or eudottJ.tiu) Phospholipids Proteins The proteins, lipopolysaccharide layers, and phospholipids make up the c.ell envelope. of the gram-negative bacterial ceU. This outer membrane protects the cell from antibiotics (e.g.. penicilliu) and enzymes (e.g. lysozyme).
'ote:s

I . Bacterial murein is a unique type or peptidoglycan. Peptidoglycan is a polymer ofsugars (a glycan) cross-linked by short chains of amino acid.< (peptide). All bacterial peptidoglycans contain N-acetylmuramic acid, which is the definitive component of murein. 2. The cell walls of-archaen may be composed of protein, polysaccharides, or peptidoglycan-like molecules, but never do they con1ain murein. This feature distin guisbes the bacteri.a ftom the archaea.

c;ram~pol\ilh l' u"uall~ uon ~ rnulilc~ non-spon~forming

rods and cocci

Most species of this non-sporefonning bacterium ferment glucose into lactose, hence lhe namo Lactobacillus. The most common application of Lactobacillus is industrial, specifically for dairy production. This genus also coma ins several bacteria that make up part of the natural flora of lhe human vagina. Because ofrbeir ability to derive lactic acid ftomglucose, these bacteria create an acidic environment which inhibits growth of many bacterial species which can lead ro urogenital infections. Although Lactobacillus species are normally present in low numbers in Ute oral cavity, they are fi'equently found in association with dental caries (especially Llctobacil/us casei), most probably as secondary microbial Invaders. Lactobacillus acidopltilus is aclcled to commercial milk products to assist !acrose intolerant individuals in digesting laclose sugars. The enzymes produced by these bacteria convert millc sugars to products tltal do 110t cause Gl problems. Lactic acid bacteria include Lactobacillus aod Streptococcus. These bacteria liSe the lactic acid fermenltltion pathway in which pyruvalc is reduced to lactic acid. These two bacteria are also rclcrred to as aciduric, meaning !hat Utey can tolerate an acid environment, aod aciclogenic, meaning acid forming. I. Lactobacillu~ is generally harmless to humans, rarely inciting harmful Notes infectioliS or diseases. Treatment of this vancomycin-resi>tant microbe usually consists of high doses of penicillin in combination wiU J ge.ntamicin. 2. Streptococcus muta.ns is th" main culprit in dental caries (especially

.wrootl surface caries).

3. Actinomyces ha been found to ben Cilusativ~ agent of root surface cnries,

(MICROBIOLOGY I PATHOLOGY

1 Which two organisms are most commonly associated with the etiology of ) Ill.. localized aggressive periodontitis (formerly called jrtvenile periodontitis)? .J8

Actinobacillus actioomycetemcomitans (Aa) Wolinella recta Capnocytophaga ocbraceus Porphyromonas gingivalis Actinomyces israeli

43
CopyrigbtC 2.009-2010 l'>c1ltal Dctks

(MICROBIOLOGY I PATHOLOGY

Bact)

Microorganisms which grow at an optlmum pH well below neutrality (7.0) are called:

Acidophile.~

Alkalipbiles Neutrophiles

CopyrightC 20091010 ()ental

..

i)k:$

Actinuhacillns

arlinnm~cctcmcomitans

( lu)

C:1pnnc~ toph:lga

ochr:u:eus

Important: The new classification system for periodontitis is more descriptive and not as temporal as was the previous system. The terms ndult, juvenile, eatly ouset, and prepubertal have been replaced with various forms of chronic and aggressive disease. The term refractory periodontitis has been removed as a distinct disease enricy, as the cur!'l:nt thinking is that any type of periodontitis mny be refractory, Aggre$slve periodontitis (formerly called .fllvenile periodontiti.) occurs in 1wo forms: I. Genor:Ultod form (formerly known as rapidly ptogressive periodonriris): PrevOtella intennedia and Eikenella corrodcns predominate. It occurs between the age. of 12-25 aod is characterized by r npid, severe periodontal destruction round mokt teeth.. It is characterized by episodic. rapid. and severe attachment loss. 2. Localized rorm: Gram-negatiVe anaerobes Actinobacillus Actluomycetemcoruitans (Aa) and Capuocyto-pbaga species (ocllraceus) predominate. Prevotell.a interrmedia and Eikenella corrodens may also be presem to a lesser extent. It occurs in an otherwise healthy adolescent (12-19). 11 is characterized by rapid :llld severe attachment loss confmed to tbe incisors and first molars. The one outstanding negative feature is the relative absence of local factors (plaque) to explaio the severe periodontal destmctioo which is present. Possible etiologic factors include a genetic predisposition or a dysfunction of neutrophils (a chemoractic dJ!(I!.ct). :-lote: Aa nnd Capnocytophaga species (specifically C. Od11a<'t!1L<) arc lllso associated with periodontitis in juvenile diabetes.

The range of pH over which an organism grows is defined by three cardinal points: the minimum pH, below which the organism cannot grow, the maximum pH, above which ll1e organism cHonot grow, and the optimum pH, at which the organism grows best. Those which grow best at neutral pH (7.0) are called ocutropbilcs. Most bacteria are considered to be ueuuophiles. Examples iuclude: Pseudomonas aemginosa, Clostrldillm sporogen"s, and Proteus

species.
Those which g row at an optimal pll weU below neutrality (7.0) are called acidophilcs. Examples include: ThiobaciiJ.us thiooxidaos. Sulfollobus acidocaldarius, and Bacillus acidocalda.rius. Note: Obligme acidophiles, such as ~ome Thiobacillus species. actually require a low pH for gwwth since their membranes dissolve and the cells lyse at neutrality. Those that grow best under alkaJ ine conditions are caUed alkaliphiles. Examples include: Nitrobacter species and Streptococcus pncumoniae. Remember: Aciduric means that the bacteria is capable of or can tolerate livrng under acid conditions. Acidogcnic means that the bacteri a can produce relalively high coucentrntious of acid (Streplococt:u.s and Locrobaci/lus produce lactic acid as the primory fermenrarion protlucr). St rep to cocci are Ihe primary acidogeuic microorganisms in the oral cavity. Lnctic acid is the main eause or eoamcl decalcification.

(MICROBIOLOGY I PATHOLOGY

Bact)

E. coli is in the bacterial family Enterobacteriac.e ae, which is made up of:

Gram-positive, spore-forming, rod-shaped bacteria Gram-negative, non-spore-forming, rod-shaped bacteria that are often motile by means of nagella Gram-positive, non-spore-forming, cocci-shaped bacteria that are often motile by means of nagella Gram-negative, spore-forming, cocci-shaped bacteria

45 CopyrigluO 2009-2010 lkt11aJ Ottb

(MICROBIOLOGY I PATHOLOGY

Bact)

Streptococcus pyogenes (Group A streptococcns) is a:

Gram-negative, nonmotile, non-spore-forming coccus that occurs in chains or in pairs of cells Gram-negative, motile, spore-forming coccus that occurs in chains or in pairs of cells Gram-positive, motile, spore-forming coccus that occurs in chains or in pairs of cells Gram-positive, nonmotile, non-spore-forming coccus that occurs in chains or in pairs of cells

46

Cop)Tighl 0 2009-2010 DcotaiiJceks

(,1 rtiiHU.'J;:.lli\ C. 111111-SJIUrt-tnrmin~. rmJ-sh:IJll.'d hactt.ri.l 111.11 :.tn: ofhn mntill' in Oll':IOs uf

na-

\!l'fla
E. coli aod its relatives are known to microbiologists. as "tnteric bacteria,.. because they li\'e in the intestin:tl tract of humans and other animal!>. The best ~--nown otbcr enteric bacteria are Salmonel1a, which includes the agent of typhoid fever. and Shigella, which is the bacterial cause of dysentery. lmport.aot: Escherichia coli (E. Coli) is not usually considered a pathogen. However, it is responsible: primarily' for thrc:e types ofiofcctions in bumans: urinary tract infections, neonatal mcningitist l.lnd intestinal diseases.
Slk<:tl ~d

Gruu p" uf ll3l'hn:t

Grou.p
ftn.letie-b,onl.mn~tive (OCL~

E-:c11mple$ of Btttrlaln Gruup

E.coli, P$wdon10fl3S at:ruai..crsa. Proleus, Slllmoodla, Shigella. Vibrio cbote~. l"lcli@:l.Ct.tr pyiun, OnclcrOidrr:!s sp. VeiUoneUa PkOOomonas, Wolinello.. Bordncll.!, 9ru.:-rlla. Nt'i$$el'ill
Canmyl<'lb:lltter. HeUcobaclcr. Spirillum
At1!nobaeill~,

aou.J11tive anaetabes
Grom-ocgauv~ llll!erobic

qxcl

Grnm-DC'gatl\OC aerobic rod~ & evcc;

OrnmotpUvc a.cmbtc bcftcal /vJDmid Gmmnegnhvc I'Odf\ tncult.ativc an.kmbes
Gtafu.I)Cgatfv~ ~tu.~:robic )tmigld, curvod 1111d bc;lical

EikeneJia, E,wli. Hac:mophilus. Kleb,i-ella, PrCrkldl., $.ahnoncll:a, Shigel1u.. Vibrio

Bnc1croides. fusobacterium, Porpb)~--;:;nk:s, PrevQC~hl, Wollnelln

St;~hyk>coews, S.rep:ococcu:s..

Ornm-positivc cotti

Eotcrocoo:l.d.. Pcptostrqttl'Coecus

Grnmpsiti"C. sporebrning rods and cocc1

Resulllr, non_.J)I)lcf!Jrming grnm-posuiw rods
r~1111, nono$1)0n.!rt~m~fug 8rom-pQ..ili~ rod$

Bacillu.'S,- Clo~tti<hum tac-tobaeillus, lisleti.a Actioomyccs., Corynebacterium., Eubll~alum,

M)~Ubllcter-iu.. Nocardia

Acid-fast

Spirotbct<>
CJ:tl.tltltydias arxl Ricltett$ia;

Treponema, ~ha, L<pt()lsplr.t

Rickettsia. Chlamydia.. C-<* idla

Myoopta_c;nas (celllwil/.l~.t)
Ac:tinom)'OC;ttll

M)'(Opla.s:ma. Spiroplllsma. Urtap1asma

N01.:ar1lia, Sutp(Otn)'CC::S. Rbodoooocus

(;nun-positi\1.'. nonmolih.'. nnn-sporr-formin:.:, coccu\ tlwt occurs in dwino,; or in

pair" ul C('ll\

The metabolism of S. pyogenes is fennentativc; the organism is a catalase-negative oerotoleranl anaerobe (faculratiVe o11aerobe). Group A strept<>Cocci typica lly have a capsule composed of hyaluronic acid and exhibit beta (clear) hemolysis on blood agar. Streptococcus pyogenes is one of the most frequent pathogens of humans. When tlte bacteria are introduced or transmitted tO vulnerable tissues, a variety of types of s uppurative infections can occur.
Slnptn('unu.,
Sflni ~,

Sp<ct"

.....

S~ut

Utmolyde Cb.u
(SiicMJ

Vin~lhl f

racten

l)bfo.titll

Mprotcin DNA:s< D'"~M11(1S,J l')fOSCittic /tfl')~'lflt') ac,:un

Sttt~O&S SIJ~IJruhc
ff}'~utOOI~ &wtoJtlt~B

J'tlll)'llgtlu fSm-p illm~.~lj Scat\(( (~Ytr (rn:sN

bnp.."'tii')
CeU1,1.llt~ To:citdlock~ NccmtQ:ina ~iti$M)~'l.ilk

\-OIOKifl A Suptnllt~t"

Slrf1!\qO:Imt..
lllln::tnODIIIC

O(a~

_ _ <...,.,,.
Pneoo!ob-ffu
IJApr~'ie

PO!il""l'rt'Pt(I(O(Clll nquda~t: ~e rltt'umlric ft"'ltt AM domcnalt!C~tj!ltrltill

Pl:xv!r.(!fliJ; M_ e n.i.1
Ot~ti.t noclin Enok"'~t~Ullllli-

StlqJIOCO!);,'\c;.
~

....

Strephxocc<l14
-.pl~~

-)
~-

<J (DII!IrdJ

Nooe
Pol)uoc!Ulrideontp.Uit

CeriC$
l\<'01\tta)

fo:('Onai<L) .ru.n:.iogltul\m111N -scp6'i

f!lloe:\llliOCII

"""'

St:qlll>:..i.l'W: ~Ox"'!
fnlrnkto:'t"l

N.-.e
N~

E.nd<lrdiri~

Urinary m~:c icf.don$

c
(

MICROBIOLOGY I PATHOLOGY

Bact)

Phagocytosis is mediated by:

B lymphocytes and plasma cells B lymphocytes and T lymphocytes Macropbages and polymorphonuclear leukocytes Kupfer cells and T lymphocytes

47 Copyri,gbtCI 2009-2010 Dmtal ~b

(MICROBIOLOGY I PATHOLOGY

Bact)

Which of the following is the process in which DNA is transferred from a bacterial donor cell to a recipient cell by cell-to-cell contact?

""
~

Traoslation
Transduction

Transcription
Conjugation

48 Cop)'fight 0 2009-2010 Jkn~l ()(o(:ks

\I:Icrnplm:.!l'' and 11nh nwrphnnud,.tr hu"m'\ ll..,

Phnt_s or Phpgocyto~ls
I. C11emolaxo> md adherence of m1crobe to

pbagocyac
2. Ingestion of microbe by

phogocyae
3. Format1on of 11 phagosome 4. fusion or the phagosome with I ly~ IO form I

pllagolysO>Ome 5. Dg.,.uon or angesatd microbe by enzymes

6. FormatiOn of residual
body conta~nang

indige:stnblt material 7. DiS<:httrgc ofwa..~te

matcrinls

Pbagoc)1e

Phagoc:ytes: Fued: do noa circulaae, fiXed macrophages and cells of ahe reticuloendothelial system Free: circulate in lhc bloodstream. include the leukoc)1es and tbe free macrophage

----

:~

cmju~-:~tliun

Conjugation is a form of sexual reproduction an which DNA is lrllnSfem:d from one live bacterium to another through direct contact. Tbas ph)Sical conlact is established through the presence of pili. The ability to transfer DNA by conjugauon is dependent on the presence of a C)10plasmic entity termed the fertility factor, or F Cells carrying Fare termed F+; ceUs without F arc F". F is a small, circular DNA element that acts like a minichromosome. [t is an example of a class of elements termed Jllasmids, which are self-replicating extrachromosomal DNA molecules
,..._ I. in conjugation. the &natest amounl of genetic information is transferred from Nolts one cell to another (compared to rromd11c11on and transformation). 2. CoOjuganon occurs more frO<Ju<nll) than 111lDSformation; it takes place within members of different genera (e.g. Eschtrkllia-Sirigella. Salnronella-St"atia). 3. Can resuh in passage of genes for antibiotic resistance !Tom one bacterium to another; baca erium potential for pathogenicity can increase. 4. F factors are plasmids transferred from a donor cell (an f"" cell) to a recipient cell (a11 F~ cell) during conjugation. S. An II rr (lriglrjieqllency ofrecambi!wtlon) is a cell witb an f plasmid inco~p<>rat ed into the chromosome. 6. Durang conjugation. portions of the Hfr chromosome are transferred from the

Hfr bactenum to the r baclcrium. 7. Tnnsfer or DNA within bacterial cell occurs vaa transposon!, whch are portions or DNA that move from one site on the chromosome to anothe-r (or to a plasmid).

(MICROBIOLOGY I PATHOLOGY

Bact)

Transcription occurs in the:

Cytoplasm of prokaryotes, while it occurs in the nucleus of eukaryotes Cytoplasm of eukaryotes, while it occurs in the nucleus of prokaryotes Nucleus of both prokaryotes and eukaryotes Cytoplasm of both prokaryotes and eukaryotes

49
Cop)'figlu 0 2009-2010 Denial Decks

(MICROBIOLOGY I PATHOLOGY

Bac~
~

The attachment of microbes and other foreign cells to phagocytes by antibody \ \.. molecules such as lgC and complement proteins such as C3b is called:

Conjugation Transformation Opsonization Adhesion

so
Copyri&fltO 2009-2010 Oemal Deets

Tmnscription is the transfer oft be genetic information from the archival copy of DNA to the short lived messenger RNA. The cuzyrne RNA polynu!r<Uie binds to a panicular region of the DNA and starts to make n mand of uo.RNA with a base sequence comptemen~ry to tile DNA template that is "downstream" of the RNA polymerase binding site. When this transcription is finished. the ponion of ihe DNA tl\ao coded fora protein (i.e.. a gtme) is now represented by a mu songor RNA molecule that can be used as a template for translation. The steps in transcription are: I . DNA uuzlps (h> DNA gyrase) and RNA poty111erase enzyme binds to one strand of DNA. 1. RNA polymerase m>~kes an elongating chain of RNA nucleotides: e>~ch new RNA nucleotide complimeniary to tbc DNA ouclootid" i~ hydrogn bon1led to i~ 3. The completed mRNA mole<:ule is rek'used from RNA polymerose- DNA complex_ and can begin nunslmion. In eukaryottc cells this mean_l tli'SI moving from tlte nucleus into the cytoplasm. Tn prokaryotic ceUs (bacteria), ribosome.' can bind and begin translation before polymemse ltll8 completed lbc new mRNA stran<i I. l'rnusltlou is lhe process wberuin infonnation in the fonn of nitrogenous bases Not< along un mRNA is trnuslated into lbo amino acid sequence of a protein.. 2. Transduction is the trnusfer of DNA via a phage panicle. Does not roqulre cellto-cell contact. 3. Reverse ttnllscriJtliOJI is tb" fonnation of DNA from an RNA template. Retrovin a scs- (e.g., fllY. lumm tinues), which are euvelooed and contain~ linear, ~ingle~strnnrled, positive-sense RNA genomt:, utilize this process. They use their RNA genome as a template for an RNA-dire<:ted DNA polymernse. These viruses have a virion..associated reverse trnnscrtptase-, which makes DNA copies !Tom RNA. This DNA is then integrated into the host geoomo. Important: Titis RNAdirected synthesis of DNA is the revewl of uunual infoomutional flow within lhe

celt.
(J(lsnnilatinn
Op~oni7.ation, or enhanced attachmen t, refers to cl1~ antibody molecule-; lgG (or lgM) Md tbe complemont proteins C3b 3nd C4b attaching antigens to phagocytes. This results in much more efficient phagocytosis.

The process st;lr!S with lgG (ur Igm) being made against a ourlace anttgen of the organism or cell to be phagocyto~ed. The Fab portion oflgO reacts with tlpitopes oftlt~ antigen. The Fe portion of IgO cru1 theo bind to neutropbils and macrophages thus Sticlcing tbe antigen to the phagocyte. Binding of IgO to the Fe receptor also activates the phagocyte. Attachment then promotes destruction of the aotigen. Microorganisms are placed In phagosome. where they are ultimately digested by lysosoones. If the antigen is a cell too large to be ingested -- ~ucb as virus-infected host cells. transplant cells, and cancer ceUs -- the phagocyte empties the contents of its lysosomes directly onto tlte cell fot extracellular killing.
Opsoni~Btion i especially iropo~ot against microorgauisms with antipbagocytic structures such as cops ules sine<> opsonizing antib<XIfes made against the capsule arc able to lick L'llp;ules to phagocyt~.s. In vaccines ugainst pneumococcal pneumonia and llnemophilus inOuenzae type, it is the c.apsular polysaccharide th~t is given as the antigen in mder to stimulate the lxldy to make opsotlizing ant!bodie. against the encapsulated hflctetiwn. Important: J:he two major opsonins arc lgG and C3b.

(MICROBIOLOGY I PATHOLOGY

Bact)

Match the virulence factor of Streptococcus pyogenes on the right with it's correct activity or description on the left.

Streptodornase

. . .

Pyrogenic (erythrogenic) toxin Streptolysin 0 Streptolysin S Streptokinase

Hyaluronidase Exotoxin A (SPE A) Exotoxin B (SPE 8)

Causes scarlet fever rash

Depolymerizes DNA in exudates or necrotic tissue DNA digestS ribrin and prevents clotting of blood

Oxygenstablc leukocidin A protease that rapidly destroys tissue Oxygen~labile leukocidin Convens inactive plasminogen to plasmin which Spreading factor. Attacks the ground substance of
connective tissue Srrongly associated with Streptococcal toxic shock syndrome (STSS)

51 CosriS)11 C 2009-2010 Dental ()eck.l;

(MICROBIOLOGY I PATHOLOGY

The two principal bacteria associated with acute necrotizing ulcerative gingivitis (ANUG) are:

Actinobacillus actinomycetemcomitans (Aa) and Spirochetes EikeneUa corrodens and Prevotella intcrrnedia Prevotella intem1edia and Spirochetes Capnocytophaga ochraceus and Actinomyces israeli

52 CopyriJhl C 2009-2010 Dnnal Db

Pyrogenic (eryrhrogenio/ toxin Causes scarlet fever rash Streptolysin S Oxygen-stable leukOCidin Exotoxin B (SP B) A protease that rapidly de..troys tissue. Streptodornase Depolyroer\zes DNA mexuStreptolysin 0 Strep10kinase Hyaluronidase

dates or necrotic tissue DNA Oxygen-lsbile leukocldill Co,:wens inactive plasminogen

to plasmin which digests fibrin 11nd provenl clotting of blood Spreading factor. Attacks the
ground sub.~tance of connettivc

EJ<otoxin A (SPE A)

tissue S1r0ngly assooiatt:d with Strep tococcal toxic sbtl<:k syndrome.

(STSS)

Not..

I . Streptococcus pyogenes owes itS major success as a pathogen to its abiiity to colonize and rapidly multiply and spread in its host while evading phagocytosis and confusing the immune system. 2. TheceU surface of Streptococcus pyogeues accounts for many o f the bacterium's determinants of virulence, especially those concerned with colonization and evasion of phagocytosis and the host immune responses. The surface of Streptococcus pyogenes is incredibly complex and chemically diverse. Antigenic components include capsular polysaccharide (C-sttbsrance), cell waU peptidoglycan and lipoteichoic acid (LTA), and a variety of surface proteins, including M protein_ funbrial proteins, fibronectinbinding proteins, (e.g. f'rorein F) and cell-bound streptokinase.

l'rt'\ otelh1 infermedia <tnd Spirorhtrts

ANUG is an acute recurring gingival infection of comple;~e etiology. characterized by necrosis of papillae, spontaneous bleeding and pain. Tbe two principal bacteria associated with ANUG are Prevotctla lntcrmedia and Spirochetes (Treponema demicola Is rhe intermediate-sized spirochete associ(l(ed Willi ANUG). Fusobacterium species as well as Selenomonas species can also be seen. Important: According to the American Association of Periodontics (AAP), A}JUG is now correctly referenced simply as "Necrotizing Ulcerative Gingivitis" wil110ut the "acUic" qualifier. The National Boards may or may not reflect this change. NUG (formerly called "Jii1tcem :s- infection'' or "trench moutlt'1 is a COi\dition which presents rather pathognomonic signs and symptoms. lnrerpro~imal gingival necrsois ("punched-out " papillae) Fetid oris Marginal gingiva! pseudomembrane formation Gingiva bleeds easily Pain Metallic taste 'o auachment loss low-grade fever, lymphadenopathy
INot

J. Predominant subgingival bacteria associated with gingival health: Streptococcus mitis and sanguis Actinomyces viscosus and naeslundii Rothia dentocarlosus Staphylococcus epidertnidis Small spirochetes 2. lgG is tl1e immunoglobulin that is found in the highest concentration in sentm samples from patientS with periodontal disease.

(MICROBIOLOGY I PATHOLOGY

Bact)

\,.

All of the following are eukaryotes EXCEPT one. Which one is the EXCEPTION?

Fungi
Plants Protozoa

Bacteria

53 Copyriglu 0 2009-201 0 Dental Decks

(MICROBIOLOGY I PATHOLOGY

Aerobic respiration is at extracting chemical energy than is fermentation.

Much less efficient Much more efficient A little more efficient A little less efficient

S4 Copyright C> 20092010 Denlnl Oecb

All living things can be cla'5ified as either prokaryotes or cukaryotes depending on cellular nnd physiological characteristics.

t~eu

( 111111mri\11n ul
N!1Ch:IM~1

l'rol\,l~ nlk

nnd l-. 111\!lr\ olic nil~

Prokaot')'ClW

ukaryotrs
Nu.dt-u.$ Jltc'$<'11<t

Nuclclr !'1\~lib-oc.'lll
"Nil prol(,fo in chto11ll>'ttt'~,, OlpPCIJI:$

Nuclear nxmbranoe l'rC:Setll

Pro~i-11 111 ~lltomosome.~

DNA i.:u ,-io_gl~ clo~ loop (k1M"nosomt- DN:A in tnulttple cflramc~

Otpuclll"$ {41-g . Ciolgi. ERJ

S~l1CJ riba5o~mS N~ '"li.Otillll fC!p~'f'd\~.;11011

Larp nOosomcs

Mi\O$is In rt-1mAucwm

B._l.IIO!pl~\ Uf(tt'Oko.r)tli U:t'

Pad~rin

lindwdlng RI~~IUia..

thl.am~d~ 11nf) ~1)coplum1

. . . .

E~mpiC'S or ('nkal')otcs~

t"rounoa Fu.o:l
l'l<~niJ.

Anim.nlt

Humam

Important points to remcmhcr: Eu~'lryotic cell~ contain organelles, such "s mitochondria and lysosomes, and larger (80S) ribosomes, wbereas prokaryo(e contain no organelles and smaller (70S) ribosomes. Most prokaryotes (except Mycupftssmas) have a rigid external ceU wall that cont-ains peplidoglycan. Euk:uyotes do not contain peptidoglyca!L Euk:uyotes ro~licate by mitosis, While prokaryotes replicate by binary fission. The eukaryoLic cell membrane contains sterols, wheresas no prokaryote. e~cept Mycoplasmas.
bas sterols in Jt.5 .membrane.,

Remember: Vuuse.s are not cells (tltey are ncellulor particles); they are obligate intracellular parasites. They contain either RJ A or DNA, do not con~<~in organelles, and have a protein capsid and lipoprotein envelope.

:\luch mnre l"Uicil-ut

Respiration refers to the melhod of obtaining metabolic energy that involves an OJidutive phosphorylation. It involves lhc fonnalion ofATP during electron transfer. It cao be acrobi.c (wflh molecular oxygen as the terminal hydltJgcn acccptot1 or anaerobic (w;,/1 n;rratc o,. Jlt/fote as the terminal hJ<lrogt!lf acceptor). Respiratiou is omcb more efficient than fennemation, thus respiring organisms, including us, bave corne to don)ina_te the earth. l'ermenting organisms are reslric<ed to niches where oxygen is lucking and suitable carbon Aerobic respiration involves a cell mernbmne respiratory (electron transport) chain. The electron transport chain is present in the inner mi.tochondriol membrane and is the final common pathway by which electrons derived from different fuels of the body flow to oxygen. 11 has four stages: l. Glycolysis 3. The citric acid cycle 2. Fortnarion of acetyl coenzyme A 4. Electron transport chain and cbemiosmosis Femtentstlon is defined as au euergy yielding process whereby organk molecules serve1!S both electron donors sud electron accepters. Tbe molecule being metabolized does not have oil its potential energy extracted from it. In other word., it is not completely oxidized. Key points of fem1entarion: NAD t is almost always reduced to NA DH Oxygen is not involved Fermentation results in a excess of NADII Enc11,'Y yie.lds ure low Pyruvate is often an important intennedlate Energy is derived from SubstraleLcvcll'hosphoryla(ion Fcnncntation can involve any molecule thar can undergo oxidation. Typlcnl substrates include sugars (.vuch as glucose) and amino acids. 'JYpicol products depend upon the substrate but can include organic acid.< (lactic acid, acetir n<id), alcohols (ctlumol, metlronol, bul<lllol), ketones (acetone) and gases (HJ ond C02).

(MICROBIOLOGY I PATHOLOGY

(
Ito._

Generally speaking, bacteria associated with periodontal health are characterized as:

Gramnegative, motile, aerobes

Gram-negative, nonmotile, anaerobes Gram-positive, nonmotile, facultative anaerobes

Gram-positive, motile, aerobes

55 O::lpyrii ht 0 20092010 OcGtl,l] Oed:s

c
(

MICROBIOLOGY I PATHOLOGY

Bact)

Obligate anaerobes are:

Superoxide dismutase (+),Catalase(+), and Peroxidase (+) Supcroxide dismutase (+), Catalase(+), and Peroxidase(-) Superoxide dismutase (-), Catalase(+), and Peroxidase(+) Superoxide dismutase (-), Catalase(-), and Peroxidase(-)

56 Copyriglu e 2009-2010 Dental Dceh

In the bealtby mcxuh, more than 350 spie> of mtcroorganisms ""'"' been found. Periodontal mfeclions are linked to fewer than S% of these species.
Periodontal health ls characterized by the presence of the foUowing baetena: Gram positive bacterin such as Streptococcus san~uis, Strcpux:oc::cus mitis, Ac:Li.nomyces viscosus, Actinomyces naeslundli and a few gram-negative species such as Vcilloncll parvttla and Capnocytophagn ochracea. In periodontal disease, the bacterial balance shifts over to graru-uegatlve, motile. strictly anaerobic bacteria. lnllammatory di..:a..e and injury cannot develop wuhout these bacterin. Among the boecena most implicated tn pcriodoniAI dtseasc IIJld bene los ore the following: Actinobacillus acclnomyutemcomltanJ (Ao). associated with aggressh< periodontal disease (/om"''>' cnlld enrly on.w periodontitis) and locall1.cd aggres>i>e pcriodonntis (Jamterly cal/etl I<KnlizedJwenile periodontltts). Po rphyrotnonas ~tin~ valls: assudated with chronic and aggrcssl\'c ptriodon!itis. Tnnerella l'ol'llythen<us (formerly Dacteroides fnrsJ11htiS): sl(ongly linked 10 periodontal u iscasc:. 'l'repon~mn dentlcola, sokransldi: associated with deep periodontal pockets, chronic peiiodontlhs and AL'\IUG Prt'ottlla lotermedla: associated with deep periodontal pocke<S, chrumc penodonutis
:mdANUG

Note: EikcneUs corrodens, Campylobacter recrus. fusobactcrium nuclea!Um. Pcptostreptocoocus. Prevotells mgrcseens, Enteric rods I Pseudomonas species and Eubectcrium species have also been implicated as periodontal pathogens.

Two toxtc molecules arise ,., a byproduct of acrob1c: mctaboli),lfl. hydrogen pero.:ddc :tnd &tt wpaoid rodieals Cells pos><ss an chlbont< ck:(cnse system to destroy lbesc toxac molcculcs, inc:lodmg mzy~nes suc.b a. catalaw ar.d superol"idt dlsmuiiJt. Supero:<jdt dl.smutaw c:ualyn:s the

decompOSnion of m. .. supero<ick: radu:als 1010 "'Iter tOld hydro~tn peroxld<. whteb IS subo<qu<ntly degraded by 04tllluc Cttala~ cotaly>.ts the d<c()mpostlton o(hydrogen pero<tdeco woter a..t W<yg<:n.

Peroxidase catalyzc:s the nxic:btion nf various subla3necs b) peroxides. Obligate ttn)h~ require 02 for growth; they use 02 (h " fioal electron acceptor In "c.rOblt m~plrn tion. Obligate anaerobe' (uC<.a,,{orwlly tullt!d atmphobtJ) do not need or use 02 ~ a nlllrief\t. In fact, 02 LS a tollic s.uMtance~ wh1ch tither k111s or inhibits lbcir growth. Obligate: anaerobic procaryolc$ may liw by fermentation. anacrobic rcspi:ratiol't, bactt.-rio.l photosynthesis. or lhe novcJ process of mrthanag.enesis. Fatulbllti\'t! aourobts (or fut.: ulcati\le a~rokt) are orpnnms tb3t can switcb btl\\~ tet<\btC md ouacrob"' typeS or mecnbulism. U..ta:r lllliiCrOb< CG<lduons (no 011 the) ll>"w b> rcm>mtot.., "' ....:robic =pranon. but '" the p=cc of 02 they swiu:b to a<mbic n:spnrion. Atrotoltrtni w_nurabe's are bacteria "'ith an ~xtlushcly anat"rotuc (/emunlaliW/ cype ofmct..bob'm but they are it\S<n>itive 10 the presence of 02. They hv by (ermentation lone whether or not 02 b
preSent in

their cnvironmenL

(MICROBIOLOGY I PATHOLOGY

Bact)

Endospores are formed by wblch two genera of bacteria?

Escherichia coli and Neisseria Bacillus and Clostridium Eikenella and Bacteroides Staphylococci and Pseudomonas

57 Cop)Tigbt 0 2009-2010 Demal Ocd;t

(MICROBIOLOGY I PATHOLOGY

Bact)

- - - - - produce an enterotoxin that can be detected using the ELISA assay.

Bacteroides Escherichia coli Neisseria Eikenella

IJ:.tcillu' and Cluslridium

Spores (or endospores) are the most resistant biological form known to exist. Only gram-positive cells fonn spores, specifically members of the genera Bacillus and Clostridium. Spores are fonned by bacreria that survive during periods of deprivation, such as the loss of a food or water supply. When a spore-forming bacterium (SFB) senses that tough times arc coming, a series of complex events are triggered that lead to the formation of a spore. Basically a spore is a s!T\lcture that contains the absolute minimum of genetic information and associated materials required to produce the vegetative form once rimes become good again. Example: Bacterial endospore is a heat-resistant spore fonned wilhin the cell. The endospore is a complex, multilayered structure containing peptidoglycan within irs complex spore coat and calcium dipicolinate within its core. Tbis bacterial endospore is very difficult to destroy (more so than HIV. HBV. and TB vintses) . To dcs~oy the bacteria it must autoclaved at the proper temperature (12/QC[or 20 minutes). l. Spores contain diplcollnic acid and outer components imparting high resistance. 2. By means of a process called asexual reproduction, spores are able to grow into new organisms without uniting with another reproductive cell. 3. Active spores have tbin cell walls; dormant spores l1~ve thick, strong cell walls. 4. Anthrax is caused by Bacillus anthracis. Botulism, gas gangrene, and tetanus are caused by Clostridium botulinum, C. perfringcns, and C. tetani, respectively.

E"chcrichia coli

The enzyme-linked immunosorbant assay, which is commonly abbreviated to ELISA, is a technique that promotes the bindi.ug of the target antigen or antibody to a substrate, followed by the binding of an enzyme-linked molecule to the bound antigen or antibody. Tbe presence of the antigen or antibody is revenled by color developmenr in a reaction that is catalyzed by the enzyme which is bound to the antigen or antibody. The ELISA procedure has many applications. The procedure can provide qualitative (''yes or no ~ and quantitative ( "/row much 'J information on a myriad of prokaryotic and cukaryotic antibodies. Serum can be screened against a battery of antigens [n order to rapidly assess tbe moge of antibodies that might be present. For example, ELISA bas proven very useful in the scrutiny of serum for the presence of antibodies to the Human immun.odeticiency virus.

Notes

1, S. aureu$ and Vibrio cholerae also produce enrerot(>Xins that can be detected using the ELISA assay. 2. Bacterial toxins are the most potent poisons knovm . and their potency is paralleled by their efficiency as antigens.

(MICROBIOLOGY I PATHOLOGY

Bac~

DNA in tbe bacterial cell Is generally confined to tbe:

Ribosomes
Inclusions

Capsule Nucleoid

59
Copyrlsh' 0 20092010 Denl~tll)cd:s

(MICROBIOLOGY I PATHOLOGY

1\..

'Genetlc Information is exchanged bcheen barteria in three ways: Conjugalio~~ transduction, and transformation. Which process is depicted below? ,J

Bacterial chromosome

so
Copynbt 0 2009-20 I 0 Dm~l Dcc:b

\uc!L>oid
(
l~o~r:.l(t( rhh(o; ttr I ~ Jlll:.tl

lillch:rl< ll <"II Sfrm'IUH'\

Stroc:turt>
~~lcOid

Fu.oetlon
DNA 1$ ~tlty -.-oofiDtd Kl tltig; Ct.<n!ml rtgi011
Srte ~~ ~'lb~ lpmuin SJ'Illht:sU)
Stw:!...v..~ or ~t~I!IYC'.) ufnt~tria!a

Ril.ndusUJet (3/IJroy UU"tllll-:1)

QpsuleCellwull

t..m ofpolyPCCiwide$ ((>U4.tiooally prouiru)i ~e:ltmcu1 to surfaces: protecc;oo 3.$ainst phegocytosis

P~cn.ls osmotic lyais qf cell p~top~

GI'IUD--IJ<'Sinve biitu:na
OfSIG-Ilc:J!'O"C baa~n

and eoniS$1iJtd.lty

411d llhzpe 10 ~JIJ

P~ptidogl)'t81'l preven.ts csmorie: l>sis and confcn ril(id11y nnd sb1pc: outer mc:mbnrlc is perm\!Ulnht)' bnrrk'r; 11$SCi3U'd LPS (~tcdo:oxl'") ani! preTN h;~\t \'lii'1Q\I$ timctimu.

.P1AmU membnmo
Chromosome
Plumt:d

Permcabitiw l.mrier; trnn~cntor tohltd; tnt:t'SY geUd1.liou.

lm-at~tK~ ofr'lml)(:n)IIS etll)'n'll: S)'StCtiiS

(i-endJC ftUlc:nllf of tdl

F..lCtradu'Otl'I0$011'1a.l @CDCik material

1 ;1-.el\4

MotOity (miJumillg mc>oenr.-nl) pilus

Mcdialc's DNA trnntfer du:nn.a Wf~Jiij)llrion AtnJ.t,flmcnt to.surf111; pf'l)lettiOIIIIRiitl$\ N!IIPJCY\t'6U

. . s..
Plii

Qlmmtm .PI'- l)t fnnb;ri~

The cell envelope 1s a descnptwe tenn for the several layers of matcnal that envelope or enclose lhe protoplasm of lhe celL The cell protoplasm (cytoplasm) is surrounded by !he plasma membrane, a cell wall and a capsule. The cell wall itself is a layered structure in gram-negative bacteria. All cells have a plasma membrane, which is the essential and definitive characteristic of a "celL" Almost all proearyotes have a cell wall to prevent d11111age to !he underlying protoplast Outside the cell wall. foremost as a surface structure, may be a polysaccharide C BJJSule or glycoc~lyx.

lr:tn,funn:tlinn

Transfonnation is the most primitive of mechanisms for gene transfer among bacteria. It occurs naturally among some bacteria. There is no requirement for cell-to-cell contact. Tmnsfonned cells are cells that have inrorporated DNA by trausfomtatioo. An example of this process is when rough pneumococci grown in the presence of DNA from dead smooth pneumococci develop capsules. Note: The DNA that is picked up by the recipient cell must be double-stranded. As it enters !he cell, an intracellular DNAase (endonuclease) degrades one of the strands. This hydrolysis provides the energy to pull the res1 of DNA into the cell. Uptake is dependent upon the presence of a protein kno\\'ll as competence factor. Once inside the cell, the now singlestranded DNA can insert into homologous regions of the recipient's chromosome.

"""

AM~,.,_

Tranducllon --..,. I. AII of the processes are significant in that tley bring about an increase in the 'Not.. amount of genetic variation within a population. 2. Regardless of the mode of exchange, the DNA becomes integrated in the host cell chromosome by recombination. 3. Serduclion L genetic transfer mediated by F- prime cells. 4. Transduction is the transfer of genetic material from one bacterial cell to another by viral infection.

(MICROBIOLOGY I PATHOLOGY

Bact)

- - - - produces two extracellular protein toxins, Exoenzyme S and Exotoxin A.

Neisseria gonorrhoeae Helicobacter pylori Pseudomonas aeruginosa Staphylococcus aureus

61 Copyri,ihl 0 2009-2010 Ocntal

~k$

(MICROBIOLOGY I PATHOLOGY

Terms)

- -- - i s a symbiotic relationship in which both members of the association benefit.

Parasitism

Mutualism
Commensalism Margination

62
Copyri,JbtO 20092010 Danai Decks

Pseudomonas aeruginosa is a gram-otgative, aerobk rod belonging to the bacterial family t'seudomonodaceae. M<>st strt~ins are obligate anaerobes. J>seudomonus aeruginosa is an opportunistic pathogen, meaning that it exploits some break in the host defenses to initiate an infection. lt causes urinary tract infections. respiratory sys tem infections, dermatitis, son tissue infeetions, bacteremia. bone and joint infections, gastrointestinal infections and a variety of systemic infections, particularly in patients with se.vere bums, cancer and in AIDS patients who are immunosuppressed. Pseudomonas aerugfnosa infeetlon is a $Ctious problem in pilticnts hospitalized with cancer. cystic fibrosis, and bums. I. P. aeruginosa stroios produce fluorescent pigment contained illmetachro!llllt /~ ic gmnules. Wonods infected witb P. ueruginosa, therefore, display a blulsh-gre;,n color. '2. 1'. aeruginosa 1S notorious for irs resistsutce to autlbiotic!i and 1!i, therefore, a pnnicularly d<mgerous and dreaded pathogen, 3. Only a few antibiotics are effec1ive agtnSI P;seudomonas, including Ouoro quinolones, gentamicin and imipenern, and even these:! antibiotics arc: not eflective againsrall strains. The futility of treating Pseudomonas iuf<ctions with antibiotics is most drnmatically illustrated in cystic fibrosis patiems, virrunlly all of whom eventually bec.ome infected with a snnin that is so resistnnt thm it Cnnol be rreated. 4. P. aeruginosa produces two extracellular protein tox.ins, xuent.yme S nnd Exotuxln A. II has been suggested 1hnt exonzynte S mny net to impair the function of phogocytic cells in the bloodstl'cam and intemal organs to prepare for invaSion by P . ncruginosa. E~otoxin A has exactly the same mechanism of action as the diphtheria toxin; it causes the ADP ribosylntion of eukaryoric elongation factor 2.

:\ l utuali1ill1

Mutualism. along witll commmcnsalism and parusitism desctihe three different kinds of symbiotic t elatioushlps. The term sytnblosis describes a close physical association between the individuals of IWO (en more) diff,,r~rit species. It Tcsults in a stable condition io wbich t:be two organ isms live together in close physical proximity. Symbiotic relationships are categori?.ed as follows: Mutuftlism: An interaction that is beneficial 10 both species. Mutualistic relationShips can be obligate (necesSOf')' 10 the survival of 111 least one of the o>ganiwn< illYOII'ed) , or faaultative (beneficial b1111101 essentiallo tile .n tnival uftlre organisltL' involved). Commensall~m: Literally meuns "lit table together;'' this type of internotion benefits one specfcs while leaving the other one unaffected. Often, the bosr species pmvides a home nod/or traospot'tmion for the othdr spccres. A common example would be tl1e removal of oxygen from a habitat, as a result of the metabolic l!Ctivitie~ or a populatiOn of' lacultative aoaerobic populations. Thls creates au cnvironwcnt favorable fur ilie growUt of obligately anaerobic populations,
Parasitism: This is a symbiotic relatiunshlp between two organisms in which one species (paraslre) benefits in tenus of growth and reproduction to the ham1 or the other species (host). It must be emphasized that the parasite and host interact sud lbal excessive harm is done to a host. wbich m:~kes it less competitive. and also endangers the sur. ivai of the parasite specie.~. l'amsites can he differentiated into ectopstasiles and endoparnsites, depending, respectively, au whether iliey \fve ()n or in the host. Lice, flea. ticks, etc. are ~am pies of ectoparasites. Tape-worms, schistos. omiasis fbil/lanias) and the malaria parasite are examples of cndoparasin:s.

(MICROBIOLOGY I PATHOLOGY

A is a genetic mutation in which nuclcotides are either inserted or deleted from a DNA sequence. Translation of mRNA derived from this mutated gene results in a protein with the incorrect amino acid sequence.

Nonsense mutation
Transverse mutation

Missense mutation
Frameshif\ mutation

63 Cop)'fiJht 0 2012010 Dental Dks

(MICROBIOLOGY I PATHOLOGY

Terms)

is the shrinkage in cell size by loss of cellular substance.

Atrophy
Hypertrophy

Hyperplasia
Metaplasia

Copyri.gbtC 2009-2010 Dental DttU

I r:lllll".;hlrt mutation

In the Jlving cell, DNA undergoes frequent chemical change, especially when it is being replicnted (in S phase ol!lle eukaryotic cell cycle). Most of these changes are quickly repired. Those that nre not result in a mtllation. Thus, mutation is n fa ilure of DNA repair. Mutation.5 may be caused by various mutagens, including UV light, rndinrioo,
chemicals, and certain viruses.

Point ruututlons: Silent ruutatloo: results io no dete~table chattge at tho level of the protein synthesized. Example of n silent mutation; the "A" and "T" at position 43 have b<:en clmugocl to "C' ncl "G" in a mutation event. Their sultant sequence \viii still encode rnRNA tlun is translated into the amino acid threonine, because of redundancy in the genetic code (bolh ''ACC'' and 1tc:A'' ~ncode rlm.>oni!le) . 1\'Usseuse mutation: the chang" io DNA base sequence resnlts in a change in the rnRNA 1hat translates into u difference in Ute amino acid added to the growing polypep1ide chuin (e.g., valine replaces glutamate cal/.9/tig sickle cell anemia).
Nonsen sl! m uta tion: tbe cbanyc ln DNA base s eq\lence results hl
(1.

cha,nge in the

mRNA (results fn 11 siOJJ cor/on) l.hat trllllSiates into prema~ure chain 1em1ination. Protein function is 11Silally profoundly affected. Tramrversl! mutation: -a point mutation 'involving base substitu~on il\ whicb t.he orientation of purine and J>yrhuldlue Is re,ersed (a putinc is vplaretl by a pyrimidit/0 ur a pyrimldi11 by 11 purl11e). Transition mntutinn : a poio1 mutation involving substitulion of one bn..c;e pair for another by replacement of one purine by unother purine 1111d of ODL' pyrimidine by another pyrimidine but without that~gc in the purinc-pyrim.idin~ orient3tion.. Framesbift mutotion: n mutnrion rhat insens or deletes a numlx.-r of nuokotides not divisible by three ond thus disrupts the reading fioame. Most codous fttr lh~ mutation will code for diffl!rent amino acids. Most of the time the n:sull ing protein is not tuuctioual.

\troph)

C of Cell Injury:

HypoJia (();e_yg,.,J dt;/iclcm'Y) and isthemfll (bloodjlnw Jejicfen~') Chemical agtnl$; indudlog poisons (tu.xln1), polluuant~-. inli<"Cticidc$. cart>On monoxide, drugs and

3lcohol Physical agents: iocludiog mecbanical trauma, hUmS, fro!tiblle, S\uJ~~;n fi!h1111gcs in pressbrc (borotnm~ ma), electric shock and mdiarion lofectiout agents: bacteria. fiutgi. J>.\niSites. ridam.iiiue. viru!ICS!:Ind prion~ lmmunoloekal r~artlons.: inclodlng anaphylai\is ~nd lo$.5 of immuur tolemnce d\at re<sult~ itt autoimmune disease Genetic dert.' th: hL-mogJobinOp31hles (hemogloiJ/,. S fh Mcldu tt:ll diseast-), stunlgl.! disea..,lics (1'~ Scchs). inborn t1l0111 of metabolism (mu11le 'tJ'nlp urinl! diseoRc) Nulrltiorud dcf>cts.; mcloding vitamin deficiencies, ube~ity leading to type II OM, fat leading to nthcro

sclemsi!
i\glng
(; ellular ftdt pflve ChA O.gt..~ U) ldjuryt ' Atrophy (decrww! In tell .tlte.p l~ tbe :illriWcage in ~u ID.c by 1oM of c..:Hul~~:r tubstancc. Ca\aScs of

iUCophy include

<k.'Crto..~d

worklond. prcsJ;.urc. diminished blood sur.pl)' <u ouuiliott. los$ of end<'!mne

J;timulation,1lnd aging ~
lil pctlnlph~' (it~~ntofeirt cell <~lze).' is ttl increase iu c.eu site. by b~in ofcellular subosumce. Hypertrophy ilt ~ausOO oitber by i.nCJUsed ftmctiooaJ demand Clf by sp~fic. cndoctin..: stimulatiOtl!i. Wiih increu$ing demand. hypertrophy can reach 11 limit beyond wbicb degc.uerntivc cJmn_g.cs- and qrga_n ft~il\1" wn cx;cur. Hyperphui-O (1/t('frtJSC' in cell m1mMr); ccm~rit1ncs Rn increase in the lUitlbet of imli~cnoU.s cdlc.: in an orgao or li!>"sue. Po.tlwloi\cal hyperplasia is ryptcally -he re::~uU ur e:cecss.{\'(- cnducrinc i:lfimuhnion, Im portan t~ HyperpiMiu is ofte-n d prediSpOsing condition IQ Ot.'('lplllsla. MHilplasla (r:hnngf ill cell type): is a .. r.e.\1trslblt"' cbilOJ!.~ io ,.,.h.ich one n,duh cell type IS rt.-plac<.-d by ono1ber adult cell type. h is a cellular adap;atian in which iod(g~oous ce-lb are replaced by cti!JO- th.al m bdtt.r suited to tolcrt~tc 1 .spec::! fie abuonn-u.l environment. ~ott!: The- most commoo type of epithelial roet3plt1Sia irtVolve... n.oplllt~m e.nt of tolurnnar cdb by stratifltd squw.1uuu$ epithelium. I. Aplasia is -n f3ilure of cell pro..tuc1~on~ During tctal d~wclopmc-nt, aplasia ~ull$ in ~l:t~IJC$is frlut
Not8 ubs~ltce of01r organ).

1. Uypoplnhl is u decrG~LSo-ln cell production less excreme: lban ~J'Jaqa.

(MICROBIOLOGY I PATHOLOGY

An allogeneic graft is:

Self tissue transferred from one body s ite to another in the same individual (often for burns) Tissue transferred between genetically identical individuals Tissue transferred between genetically different members of the sarne species Tissue transferred between different species

65 Cop)Tigh' 0 2009-201 0 Denial Dtt.ks

(MICROBIOLOGY I PATHOLOGY

_ __ _ refers to the cellular degradation by enzymes derived from sources extrinsic to the cell.

Necrosis
Heterolysis Autolysis Apoptosis

Cop)'rigln 0 2009-2010 Dental Dttl:s

Types of grafts: Autologous graft- self tissue transferred from ono body <ite to another in tbe same individual (often./(>r bunrs) Syn geneic g raft - tissue tnnsferred between genetically identical lnt!i viduals Allogeneic g ruJt - tissue transferred between gcnctic~lly di~Terent members of we sam~ species Xenogeneic graft tissue transferred betwe.e n diffcrtnt ~pecies Clinical Manifestations of Graft Rejecllon: Hy p erncutc rejection: minutes to hours tissue never betomes vascularized. becau.;e there is preexisting host serum Ab (lgG) specific for Agio <be graft. Acute rejection (cell-mediated allograjll'ejeclion): day$ to weeks later. this occurs when thorc are memory CD4 and CDS T cells from previous ~xpo~ures to

graft.
C hronic rejection: ruomhs or years after ~cute rejecHon llas subslde.d . Ooth humoral and cell modi:tted. An<ibody-1nedlated ncc.ro~is of graft vasculature. I. The most CcJired consequence of graft therapy i.na patient wjtb an immnn-

Notes odeficicucy is a graft vllrsus host reaction (GVHD). II occurs wh~n lransplanted immunogenic cells from the donor anack the host Occurs mosl com
mooly after bone marrow transplants and can be fat~l.

2. When u b'TBil is rejected the first time and iS tried again from the s~me donor, it will be rejected more ropidly than tbe fitst. This second set rejection oCC\U'S
because tbe individual bas been pmvtou.ly sensitized to the graft. 3, CD4 and C OS T cells elicit most of the dostruction in gmft rejection. 4. The most common types of bypemcUie rejection arc ABO blood mis matches.

The morphologic appearance of dead c"lls vary depending on which of the two processes enzym~tic digestion or pro1ein denaturation - is dominant Some degree of eu~ymatic uigos tion is nearly always present. and is manifc.ted by vnrious nnclenr and cytoplsmic chang"". Ifenzymatic digestion dominates, then dead cells arc Ukcly to be removed completely. Th[< process is accomplished by acrivarion of enzym<'S normally present ll'iUoin affected cells, T~e process of self dige>rion is known as autolysis. If enzymatic digestion is accomplishM "from omside," 1he prucess is tennctl betcrolysi. Here the enzymes are derived from tht lysosomes of cells such neutrophil or macrophnges. Irreversible damage to the nucleus shows itself in one of lllrcc patteons: I. Kru-yoly.,ls: <here is a gradual tllding away of the basophilic (bl11e stuining fmm the Jrematoxilih dye) nuclear material, presumobly s a result of the activi\)1 o f DNAses. 2 . Pyknosis: the nucleus shr'onks and becomes intensely basophilic; the DNA is packed

into a solid shrunken mass. J. l<aryorrhc>1s: the pyknotic nucleus undergoes fragmetuntion and completely disappears in I to 2 days. (. Apoptosis (also known as programmed cell death} ~lays a role opposing that of Notes mitosis in regulating the size of cell populations. 2. Ne<rosi< is death of one or more cells. or a portion of tissue or org;m . L the re-sult of irreversible exogenous uojury that resuiiS in an insufficient hluod supply ([I the tissue, whether from injury, radiation, or chemicals.

3. lo Apoptosis, in contrast with nec.rosis, there is no:

breakdown in the mechanisms Slipplying cellular energy failure in the maintenance of nonnal cell volume rupture of pla.<ma membrones llcnlc inDmma1ory reaction elicited by death

(MICROBIOLOGY I PATHOLOGY

In contrast to antibodies, interferons:

Axe virus specific but not host specific Are not virus specific but host specific Axe virus specific and host specific Axe not virus specific or host specific

67
Copyri.ghtC 2009-2010 Otntal Dks

(MICROBIOLOGY I PATHOLOGY

Which or the following cytokines stimulates hematopoiesis?

Colony stimulating factors (CSF) Tumor necrosis factors (TNF) lnterleukins (IL} Interferons (INF)

88
Co9ytigl1t C 20092010 ()ental [)(d;;s

o\n nnl 'irus spl'cilir hue hose \(Urific

Interferons are speeies~specitic protein.s, whicb induce antiViral and antiproliferarive responses in animal cells. They arc a major defense agaiJ>st viral lnfeclions and aboonnal growths (neoplasms). Interferons are produced in response to penetration of animal cells by viral (or synthetic) nucleic acid and then leave tb., infected cell to confer resistance on other cells of the organism. ln contrast to antibodies, inLcrferons art not virus specific but host specific. Thus. viral infections of hllman cells re inhibited only by human interferon. Intcrferons are members of a larger class of proteins called cytokines (prmeins tluu G'OriJ' signals be/ween cells). Most interferons are c1assificd as alpha, bc:ta, or gamma interferons_, depending ou their molecular sLructure.

Ther apeutic uses of interferons: Noles I. Jut.crfe.rons::tlpha and -beta have bee11 used to treat various viral infections. One currently approved use for various types of interferon-alpha is in the treatment of certain cases of acute and chronic- heparitis C and ctlronic hepatitis B. 2. lnterferon ..gamma has been used to treat a variety of diseases in which macrophage activation might play an important role in recovery (e.g., /epromttlous lepros)~ leishman;asis, Joxoplasmosis). 3. Since interferons have antiprollferath't: effects, they have also been used to trcttl certain tumors such as melanoma aod Kaposi's sarcoma. 4. Interferons play an important role in the first line of defense ngainst viral infections. They -are pan o f the non-specific immune system (as are lysozyme. complement, elc.) and are induced at an early srage in viral inlection before the specific"immune sysrem has had time to respond. 5. Interferons themselves are not anriviml anribodies. They Interfere with virus replication.

Culnu~ \timufalinc. f:ldnr (CS/) Cytokines are a family of smaJI proteins thai mediate an organism's response tu injury or infecrion. Cy1okincs arc crucial ro an organism's self..dt!ft:nse. Cytok.inc.o; operate by tr3nsmitting signaL~ between cells in an organism. Minute quantJtics of cytoldnes are secreted, each by a single celtlype,. a.nd rcguliue functions in or.ber cells by biJ1ding wilh specilic. rl!:ct:plors. Their mtcractions wid1 the reccp1ors produce secondary signals that inhibit or enhance the aerion ofcenain genes within the ce11. Unlike. endo(:riilt hur-moncs, which can act throughout the body~ mu~1 cytokin~~ uel luc:ally, ncar the cells that produced them-

I +<llr

\1~1'"

( ah1!Jnl' ul { \lui, Ill!"\>

Prcklud b)'

Ust r F~!11(tkl"

1ntdfU1)1U: -AJ....

T1le huffy .:om lay.:r from o~oo-tll~e bloeod cdls

flbrobl~

-~ -o.....
I - l:~ll:!rkulrin - J
Onmulccyfc I

Ac:tln1ed T ctll'

. . .

Trw~1 0~3 'arlcsy of'm~1l.at~d

itnmu:Jc diMI~nl Oitr.:GIIj be-eng: o:nltwlbd m(l;c !rl.'l!Ul\dl) Ofmult1pk j,OI~"'

lm!Millllttlltll!.tllOI~l!~ awh:cUk.

p.mitullu:fy l:n lllktJi:M! ~~

COknry SdmalalinJl Fd~tN:

Tbtlpcrcd b

Sri~lwi!l.llytll ~iupolohll
bolt~ mtrro<W ~l!ltlla

tic:~#nl,,~.,.lt1inw --rl'"'~

fll""'-

~f~"hawc CSP

\1m10locy;:c CSF MUJO!Iw.gr CSf TamClr ~H:I'OW- ~-o.:tOiril

- 'I'Nl'b .
t nttrl,.uJdJIIlr
~

-
n..-4

Lympboc:yn:1. ruacn.'Phaxc.s;.li~)b~~~
c:~ll~tQJ

R.!l!'IM!ttk" ~!Yr,...lll..,:lllltlti".ll~-

cclb.

~:;~t
J>;i/Qol\ ur ~t -&1: d~11du~b is ail!le(d l llrYmli liJ mhll!ll at~~ IIWVil} "' <Ot:f!ic r-''*' Al ..\ro tJtU bunut~,umon.,.

~~~,..,_~lllbrinOI>Nindloe,..OO

Ath,~N mv.rophas~..

Al:tlw:led T c:dbc

A Yllricty of C'ell i)l!Cs3ueb u

ln'IUoc.JU" 1

IL$

tnacm;IQ#i. T cc\4. aDd B cell~

C..lSC!I 'I' -Uild S cdb 10 j!1t!W. lfuiSttl a ~llt In abc llf9!)uc~ nflsl! antihodb.S1\mul.i'~B~ti~ d.od ~'Phil5. 1l
~IJ.tdts!QI pn!dlli.'\! lSI\ .nhliUiJ~,.-

II . Ill

lo JlfOiifq;i,ll! lllb.il)b- TJt~t-1 T MlpH)I"

(MICROBIOLOGY I PATHOLOGY

The arachidonic add pathway constitutes one of the main mechanisms for the production of pain and inflammation. The pathway produces different classes of end product. Match the end product on the left with the correct description on the right.

Prostaglandins Thr omboxancs Leukotricncs Prostacyc1in

Important mediators ofbronchial asthma Vasodilator and reduces platelet aggregation

Powerful vasoconstrictors and increase platelet aggrdg:ation Mediators of the cellular phases of inflammation and are potent vasodilators

69
Cop~ght O 2009-201 0 Dc:tual

Decks

(MICROBIOLOGY I PATHOLOGY

~I of the following statements concerning serotonin are true EXCEPT on: \

\. Which one is t he EXCEPTION?

It is widely considered to be a neurotransmitter It is present in the brain

lt is synthesized by enterocbromaffin (EC) cells in the gastrointestinal tract

It is believed to play a role in temperature regulation, in sensory perception, and in tbe onset of sleep
It is synthesized from the amino acid arginine

70
Copyrigh1 0 2(109..2010 l)cntal Oeck:s

Pmslsglnndins
Thrornboxanes

Mediators oflhc cellular phases of inllammation and are potent \18Sodilators

L01kotric:ncs
Pn.Jstacyclin

Important modlators of bronchial asthm.'l

Vasodilator and reduces platelet aggregation

The prostaglandins and a number of related substances !prosracyclia. tlrromboxaaes, and le11kotrienes) are chemical messengers. One or another of them is present in almost every body tissue. They act primarily as local messeugers !bat exert their effects in the tissues that synthesize them. Aracbidonk acid is a 20-carbun unsah,rrated fatty acid. ll is the major cumpouod from which prostaglandins. prostacyclin. thromboxanes. and lcukotrfcnes arc derived. Aracb.idollic acid is a part of phospholipids in the plasma membranes of cells. When a cell is stimulated by a ne11rotransmitter or hormone, a plasmamembrane enzyme called phospholipase A is activated, and this enzyme splits arachidonic acid from the phospholipids. Different metabolic pathways urilize different enzymes that con veri arachidonic acid into the different messengers: To form prostaglandins, prostacyclln, or tbrombo:mues, the cyclooxygennse pathway utilizes tbe enzyme cydooxygennse. To form leukotriencs, the lipoxygenase pathway utilizes the enzyme lipoxygenase,

It i">

"'~ nlh{'~i/l'd

from th(' ;uninu arirl arf!ininc

*** This is false;

it is synthesized from the amino acid tryptophan.

Serotonin is synthesized by serotonerglc neurons in the central nervous system (CNS) and by cntcrochromaffin cells (EC) in the gast:rointeslinalrract. It is synthesized from the amino acid tryptophan in a 2-step mebtbolic pathway: a hydroxylation reaction (rate limiring srep) and a decarboxylation reaction. The average adult human possesses only 5 to I0 mg of serotonin, 90 % of which is in the intestine aud the rest in bloQd platelets and we brain. Serotonin is widely considered to be a oeurotraosrultter. It is believed to play a role in temperature regulation, in sensory perception, and in the onset of sleep.

I. The chemical name for serotonin is 5-hydoxytryptamine which is Not<'S often abbreviated to 5-l IT. 2. Enterocbromaffln cells (EC) are a type of emeroendocrinc cell. Enteroeudocrine ceUs produce histamine and gastrin as well as serotonin. 3. In the pineal gland, whicb lies deep auhe center of the human brain. serotoniu is produced as a precursor to melatonin. 4. Serotonin is a powerful vasoconstrictor. 5. The function of serotonin in blood platelets is not clear ; it seems to have oo important role in U1e clotting mechallism. 6. Serotonin is secreted in tremendous quantities by carcinoid tumors (wmors composed of chromaffin tissrre). 7. Serotonin acts as an inhibitor of pain path\vnys in the spinal cord. 8. Lysergic acid diethylamide iuterfcres with the action of serotonin in the brain.

(MICROBIOLOGY I PATHOLOGY

Histamine is released largely by , causing vasodilation and bronchoconstriction.

Macrophages and enteroendocrine cells Eosinophi Is and lymphocytes Neutrophils and basophils Mast cells and basophils

71 CopyrightC 2009-2010 Dc.ntal Deets

(MICROBIOLOGY I PATHOLOGY

All of the following statements concerning plasmin are true EXCEPT one. Which one is the EXCEPTION?

It is also called fibrinolysin

It is a proteolytic enzyme derived from plasminogen It is essential in blood clot dissolution (fibrinoly.tis) It is a component of the body's nonspecific immune system
It is the most important fibrinolytic protease

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Cop)' Ti&:'ht 0 2009-2010 DcmaJ Decl:s

i\Jast cdls ami h.1suphils

Histamine is synthesized by the decarboxylation of the amino acid histidine. This reaction is catalyzed by the enzyme L-histidine decarboxylase. Once syothcsized, histidine is stored in the coarse cytoplasmic granules of mast cells and/or basophils. In the early stages of acute inflammation, histamine mediates the contraction of endothelial cells, increasing vascular penneability. Histamine Is liberated by degranulation triggered by the following stimuli: I. The binding of specific antigen to basoph il and mast cell membrane-bound lgE. 2. The binding or anaphylatoxins (C3a and C5a) to Specific coli-surface receptors on basophils and mast cells. 1. Histamine is responsible for the principal symptoms nf anaphylaxis. Not.. 2. Histamine causes vascular dilation and increases the penneabtlity of blood vessels durmg inflammation. 3. Mast cells are found in connective tissue and in extracellular spaces near blood vessels. particularly in the lungs. 4. Histamine is cberuicalty similar to serotonin. epinephrine, and norepinephrine. 5. Serotonin is synthesized from the amino acid tryptophan. Its actions are similar to histamine. 6. Bradykinin is a vasoactive kinin tbat mediates vascular permeability, arteriolar dilation, and pain (pain from inflamed tissues is associated with tile release of bradykinin). It is a potent vasodilator and is produced by the action of kallikrein (generated by activated Uagemau factor, factor Xl!a) on an alpha 2 globulin (kininogen). It may be involved in blood pressure regulation.

II is :t t.:lllllpunent uf llll'
~This is

hnd~ ~s nonspt.~ci fic

inmmnt. S)Sfcm

false; plasmin is not a component of the body's non-speci fie immune system

(as are lysozyme. complement, interferon. namral killer cells. etc.).

P lasmin, also known as fibrinolysin, is a proteolytic enzyme that is able to bytlrolyze fibrin molecules (jlbronolysis) and degrade other coagulation-related protelns, thus promoting dissolution of blood clots. It is normally found in plasma in the form of the zymogen plasminogen (projlbri11olystn). I. .Fibrinogen is a plasma protein that is essential for the coagulation of Not.. blootl and is conve.rted to fibrin by thrombin and ionized calcium. 2. Fibrin serves as a template for fibroblasts to repair tissue and walls of the infected area. It is the product of the action of thrombin Otl fibrinogen in the clotting process. 3. fn the presence of thromboplasti n and calcium ions, protbtombiu is converted to thrombin, which in turn converts fibrinogen to ftbrin. Fibrin tbteads then entrap blood cells, platelets, and plasma to form a blood clot. 4. Plasminogen is the inactive precursor to plasmm that is present in tissues, body fluids, circulating blood, and within clots. 5. A zymogen, also known as a proenzyme, is an inactive enzyme preclltsor thaf needs to 1mdergo some sort of biochemical modification to become ao active enzyme.

(MICROBIOLOGY I PATHOLOGY

(
Kidneys Lungs Adrenal medulla Pituitary gland

Renin is primarily released by the:

73 CopyrilfuCI20092010 Dcrnal Decks

(MICROBIOLOGY I PATHOLOGY

serve a vital function in the transfer of energy within cells.

N ucleotides lnterleukins Cytochromes Interferons

74
CopyriglnC 2009-201 0 Dental Dt-i:ks

1-\idnt~'

The reoin-angiolensinaldosterone system (RAAS) plays an important role in rogtdatiog blood volume and systemic vasc"lar resistance, which together inlluence cardiac output and artcrlal p ressure. As the name implies. there are three important components to tb.is system: 1) Renlo 2) Angiotensin and 3) Aldosterone. Renin, which is primarily released by the kidneys. stimulates the formation of angiotensin in blood and tissues, which in turn stimulates the release of aldosterone from the adrenal cortex. Renin is a proteolytic enzyme that is released into the circulation primarily by the kidneys. Its release is stimulated by: I ) Sympathetic nerve activation (acting via betaf{[drenoceptors) 2) Renal artery hypotension (C(IUsed by S)Stemic hypalemion or renal artery stetrOsis) 3) Decreased sodiwn delivery to the distal tubules of the kidney When renin is released into the blood, it acts \lpoo a circulating substrate, anglotenslnogen, that undergoes proteolytic cleavage to fonn angiotensin 1 (AJ). Vascular endothelium, particularly in the lungs, has an enzyme, angiotensin converting enzyme (ACE). that cleaves off two amino acids to form angiotensin II (All).

Att~t,1otttu:l.it

II (.4JJ) Ms

:oOc<..-~.nd ~'efy ltllp..ll'tl\1 t\lnc:tions 8$ depi.:t~ in the IIChernau~ lo tbc: lei\.

C) IOl'hrunus

Cytocltromes are hcmoproteins linked to a nonprotein. iron-bearing component (a heme group), which can w1dergo the reversible oxidation-reduction reactions that yield energy for the cell. Mitochondria contain three classes of cytochromcs: a, b. and c, which have heroes of different structures.
l'iot~

I. C}~ochromes contain a heme. group made of a porphyrin riug conmining an atom of iron. They are found in the mitochondrial inner membrane of eukaryote.,. 2. The iron atom of the heme grot1p acts as an electron carrier. 3. Unlike the heme groups of hemoglobin, the cytochrome iron atom is reversibly convened from its ferric (Fe-") to its ferrous (Fe") fom1 as a nom1al part of its function as a reversible carrier of electrons. 4.The mitochondrial ele<:tron transport proteins are cluste.red into compl"'es known as Complex 1, ll, II. aud IV (see chart belou~.
Prntdn f<:rt,dtmmt') ( ompll'\l's offhll.llcfrun Trmtstamt dtain

Complo
I

Eneymaiic funct ion I Name

func:tlonaJ Components
FMN; FeS clusten:

NADH I CoQ oxidoreductaS<

n
m
IV

Succinate I CoQ oxjdoreducmse (su(."Cirwte dehydrcgeuasc)

C}rlochrome c l):<idase

FAl): Ft>S clus1ers

CoQ-cytoch.-omc c oxidoreductase Cytochromes b_. cytochmme&cl, F'e-S cl'usters Cytocbromes -a and a3

lmportanl: C)1ochrome oxidase: is the terminal enzyme in the chain of events tbai

constitutes: cellular oxygen consumption.

(MICROBIOLOGY I PATHOLOGY

Which lntcrleukin fa,ors T H- 1 t y pe r esponses and counteracts the actio n of I L- 10 ?

IL-l

JL-6
IL-12

75
Copyri&M C 20092010 l)cneal Dec.kJ

( MICROBIOLOGY I PATHOLOGY

Match the cytok ine on the right colu mn wllh Irs function on the lcfl column.

fL. I

Stimulates bone marrow stem cells (hematopoiesis) Can induce apoptosis Stimulates IL-2 secretion, induces fever (pyrogenic) Stimulates proliferation of cytotoxic T-cells Stimulates chemotax is and adhesion ofneutrophils

IL-2
IL-3

IL-8
TNF-alpba

71
Copyri&bi.C 200..2010 Dcnt:all)c(:b

11.-12

lnterleukins (also called lymphokines) are a sub-group of small soluble proteins called cytoklncs which function as chemical messengers between cells. The role of interleukins is to mediate and control the immunologic and inflamatory response. There are at least 18 known interleukins most of which have only been discovered in the last few years.
I hl'
~~~~~~

ut lh~~ lnkrlt'u"-nh
AttlOll

1nterleukln CtUular s.oun:,e

IL-l
J[.,."l 1[.,.3 11..-4

Macrophage.-;

Similar to that ofTNF, t.e .. to induc.:c 3Dd prun'locc (he nllammatory reac.tioa m rnponse to GRm-negnrivt b:lc1cria :md 01fl~r "infectious mtl;roorgnn~. SlimuJa1es- the protitcrntion and .ctivatiou ofT cells and .B cells.

Helper T-lis
Tcetls
Nc:Jper T-cells
H~lp.."r'T-ctU s

Stimu)ate$-lbcpowtb llnd diffm:ntlation afhematcwoi~1ic cells.. wlikh mature in;o let,~koe)'tc$.. .(ttOinuloeytes. c:rytbroc.yles, cte.
Promote$ B~ell a<::ri\1:\li<MI ;)nd diff<rcoti.oation. It'$ ttlso o fa~:tm: 1n the prol;l.uctlon oflg,Eulibodies..
Sdmtilaltll B-cetls.aBLI eosiollphils. It ~~s S.-ecl!s d~~ prod.uc:o lgA ;~~~tlbodie$11) prOIIfenuc.

IJ..-.5
lL-6

'T-cell!:!

M.ncrophages

Works in COnibin:uT~'" ~ilh imerfc:rotHtlpba to indiKt h-<cU differenti.ltionProduces fever, slimvJales helper T..ctO.J. Cau$c:s lymphoid .mtll c:elt( to dlfferetHa111C: -lrlt() progenitor T-~od fJ.. cdis. 11..-S t.s "sticky" for "1'-cefl.$ and ~irophil.s ~nd b~:lps: bring 11~em to tbe $itc of intlii.mrnlltioo

IL-7
\lA
JL,fO

Stromal cells

M.ncrophnges Eodod'lelia1<:ell~

TMd8 CCJI$ Momx:ytcs

macmp113gc!l
MODOC)'ICS

lnhi 'bilJS Lbc: produ~nion of macroph.1g,c-deri\'od TNF and rL-12. lfi\IS ~upptb;)
ins inOanun:uocy ~ons 01$ well as \be 'Tll-1 pMbl't-ay ofT br-lpcr ocll dif-

ferentiadon.

lt.,.U

Favors THI rcapoDSes. wi1h nl;ltropbage und NK ~:cll rLttiV&tiun;: induces lntcrfetoo-pmm~ Jlf'Odi.ICiioo.

l l.-1 IL-2 IL-J

I L-X

Stimulatl'S IL-2 st'crcliun, induces flver (pyroglnic) Stimul;ths proliferation of c,\toto\ic Stimul:t{s hone
rn;~rru"

r~c('Jis

stem cells

Stimulnh.s chemotaxis and :HIIH.'sion Can inducr :l(JOIJiosi'i

ur ncutrophils

T;\'F-alpha

Cytokines are small, soluble, secreted proteins that mediate the development (hematopoiesis) and behavior of inrmune effector cells. They are synthesized de novo in response to a specific stimulus and operate by binding to specific membrane receptors on their target cells. Binding of receptors leads to activation of signal transduction pathways leading tO the regulation of one or various biological activities. General properties nf cytoklnes: Shon half-life Active at very low concentrations; allows for the establishment of a concentration gradient. Able to operate in an autocrine (on itself), paracrine (on nearby cells) or endocrine (on disllmt cells) f.1shion. Pleitropic: one cytokine can act on many different cell types. Redundancy: similar functions can be stimulated by more than one cytokine. Operate synergistically (acting together) or antagonistically (opposing each other).

(MICROBIOLOGY I PATHOLOGY

Cells I Org)

A bacterial cell waU component susceptible to lysozyme is:

Lipopolysaccharide Teichoic acid Lipoprotein Peptidoglycan

77 CopyrightO 2009-2010 l'.>eltal Dlc$

(MICROBIOLOGY I PATHOLOGY

Cells I Org)

Which cell structure synthesizes carbohydrates?

Lysosomes Golgi apparatus Ribosomes Nucleolus

78 Cop)'liiJu 0 2009-2010 Dco;al Decks

l't.ptidogl\t. ' an

The enzyme lysozyme is a hydrolytic enzyme found in human tears. saliva. and >crum. It has bacterial activity because one component of the bacterial cell wall is susceptible to this enzyme. That component is peptidoglr can (also .b!ow11 as JOIIII'I!i/0). There are two parts to the peptidoglycan molecule: 1. Peptide portion: is composed of short, attached. cross-linked peptide chains containing unusual amino acids. 2. Glycan portion: forms the backbone of the molecule, it is composed of alternately repeating unitS of the amino sugars N-acetylglucosamine and N-acetyhnuramic acid. Lysozyme clca,es the glycosidic bond between N-acetylglucosarnioe and ~acetylmuramic acid. Important points: I. Lysozyme is a component of the i1U1ate immune system because: Its action on peptidoglycans is immediate and not pathogen specific. It functions as a non-specific innate opsonin by binding to the bac1erial cell surface and enhancing pha~:ocytosis. 2. Lysozyme is also used to produce protoplasts of cenain bacteria. 3. Protoplast$ are cells that have had their cell walls and capsules removed by enzymatic (lyso::yme) or antibiotic (penicillin) treatment. 4. All other bacterial cell wall components are not susceptible to lysozyme. 5. l'enlclllln inhibit.~ the terminal step in peptidoglycnn synthesis.

1~ 1

'"'1>1~'-d boundnry ofthc cell, maintain in& 11.$ mtegnty: PfOtcin rnolocu.les

in ptiiSma mcrobrant perfonn ''ariou> (\u~ions.

_,.._.,.,,,.., honnones. nd ttins.

<moolh

mellmcmcarboh)dltllt:S used lO f01n1 Jlyt:o~

(MICROBIOLOGY I PATHOLOGY

Cells I Org)

( \.

Catalase and other enzymes that break down hydrogen peroxide are located in membrane-bound organelles called:

Lysosomes Inclusion bodies Microbodies Centrioles

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(MICROBIOLOGY I PATHOLOGY

Cells I Org)

All of the following stements concerning T cells are true EXCEPT one. Which one is the EXCEPTION?

They express CD3 antigen on their surface (they are CD3+) They express either CD4+ or CD8+ antigen, but not both They are able to phagocytize foreign antigen They recognize foreib'll antigen only if it is bound to MHC proteins They are able to secrete a variety of interleukins

80

CoP)'rigtnO 2009-2010 Oent.al OU

:\I icrohodics

Microbodies are roughly sp~erical in ihape, bound by a single membrane, and are usually 0.5 to I micrometer in diameter. There are severaJ types, by far the moJ<;t common of which fs the
peroxiso me.

Two important families of microbodies are: I. Pcroxisomcs: participate in the metabolism ol' fatty acidS and other metabolites. Peroxisomes have enzymes that rid the cell of toxic peroxides. These include oxidative enzymes, such as (';atala.se., 0-amino acid oxidase. and uric acid oxidase. 2. Glyoxysomcs: are common in the fat-storing tissue.' of the germinating seeds of plants. 'fhey contain enzymes that initiate the conversion of fats to sugar, a proce.<S that provide. seedlings with the carbohydrates Utey need umil they can produce them 6n its own via photosynthesis. I. Ca1alases are enzymes that catalyze the decomposition of hydrogen peroxide Notes into water and oxygen. Aerobic bacteria which possess this catalase arc able to resist the effects of H20 2 2. Superoxlde di~ mutast catalyzes the destruction of 0 1 free radicals. It protects oxygen metabolizing cells against ham11\tl effects ol' superoxide free radicals. 3. Anaerobic bacteria lack either superoxide di>mutase or catalase or both. The anaerobic bacteria that possess ca talase art: able to resist the effects of H,O,. 4. Microbodies are similar in function to lysosomos b11t are smaller. and they isolate metabolic reactions that involve hydrogen peroxide (Hp;). 5. Lysosomes are fom1ed when the Golgi complex packages up an especially large
vesicle of digestive enzyme proteins.

6. A phagosome is a ve.'iicle that fonns around a particle (bac/elia/ or other) within the phagocyte that engulfed it. It then separate.< from the cell membmnc and fuses with and receives the contents of cytoplasmic granules (ly.vosomes). This coupling forms a phagolysosomc in which digestion ofthe engulfed particle occurs.

\IIIJllm~ll\

I' alb

f'llhttiootCbarac:lt.rlut.o

c*

llclp;r I~ZIIt'1~1 t't1Mor ltou1 ~...o:)'et

Pro1001c or ~~au ~c kK'l!oo I)J'ttlbcr noll$ (I!!Olllbfy, 8 {\t~~~ td arrd n<N:Nph~gQ). EApran toole.:uk a.l!oed co. Ro::Q11-~ the nnli:r;cnio:: ~u~ 111 ((llljultl:li.,. w!tlt the i~.t-r.ll~d" ~me Cr.n II"' pmteilu.
Sisnl CD8 ~1!14o di fferec~I&Me ict<teylo!oti~: I' ;clbl: :~t)pltl ttwn~pbl.,gd l:h 1)';u:

rwu !N!!~tr ~" ''"l'*s or~*'"" cdl- l.no<M 111:

T.,.l M l\
Tll'"lml,
~101W.k Tcdl\

rv t~J h>~ti,-il)'maiUflf

Sign:! R celk IQ!lilbernill~ iMt,r!;cll!M celh, whidt r-uclut:o mt4lbod1'>7

t'D&'Iyr.nJiy~tt

tTrcclb,tw 1\l'lacl: a.,a ~ tuln ~lun,l ror<iW' :dolt~, ~~~~e~ IIIOOII!euktal!l:d CI)S. Rl!l.vp1ixe lbrllllligmil: peflridc;inClllllj unaiM y;jcl\ thcw-atkd ..MIICCia. I"
ptOieim:,
St!~m!tor fr.llibilt~ imlllllll.: (urc~ion arolll~ 1~111j)ll~e:\" Elc~fifl'll~le

~TilCIJJ-

ulk<ICDS
~tc111,'or;) T a!llt

lo,s IA--ed t":lls flml ~o,gnjr.t' pi'I:Villll.\11 utanntli~l 'l'..d~~tf!l otttl\j!eta

9d:Jli

n l~l!~ll'-t'b ,'di<J
P'lii.~CCII M~Oocll

1k ooiod" ~ttlC C'I& U"pro~

-"''I;t'lltll M\lj;M 1'\'ttPitn

A lll~ ~llWn:. o,frcrtnUIIk' m40 pU!IIill tclltUNimmiOf)' R c.eiU. P.\ptM

.'\CITV'ct)l tttWiiti\Ullldlc:... Only muoommc l~ l11nd 11> nrr dtf'M~CI nn Unfit

t...:Hlc.11V<IItllllltilt 111t1 c~ m ~ iv r~q~l."$un! tn lmtll!l!fl
~lt

'<ttu"ll ~1~/,YK,l

Pf'O,cdn~. lt.ve ~~~me~.

Kilt vf~fllftod coltt-lliO !MII\tl1 U.!IJ, fA,~ 11 ('t}k-.~u..i;ltod TC'R Dod 1111rl'a-c ''t Qf TiD Artt not ~tOe oAY "liJQI(fl, do OOt '":t<l t().:cos:aw:: .vruc

~otes

t. T cell~ lack lgG receptors. but bavt CD3-a.~suciaU!d T cell receptor.; (1'CH), which recogni1.c n lmiqu.c: antigen only in conjunction with Major Histocomp:uibility Cumple.<t (MNC) proteins. 2. Without MHC ptoteim, t1tere \VOuld be: no pn:ser~t:u:ion of mtcmal or 1!'':\'t~:mal amigens to 1hc T cell!i. 1'1le importanet of ~1HC proteins i.s tllal they ttllow T cells to di$tin_gois:h sc.oJr from oon

..set f.
J . lmrn'UT\0$1GI>\lJin$ { JgG alld lg{\1) rrceptOr$1lrl! found in B l'rlls.

.t. T -cell~ -.re no1 ittvolved In phagooytosis or antibody-dl::pe:nden1 ceUoka.r cytOto~icity.

(MICROBIOLOGY I PATHOLOGY

Cells I Org)

Surface membrane immunoglobulin is a marker for:

Mature T lymphocytes Neutropbils Monocytes Mature B lymphocytes

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MICROBIOLOGY I PATHOLOGY

Misc.)

- -- - - describes healing that occurs in surgical wounds that have been closed with a sterile suture.

Healing by first intention Healing by second intention Healing by third intention

12
Copylight c 20092010 ~all)ecb;

.B \:t'lls are characterized by thei1 ' Siurfflce immunogloblllins. These immunoglobulin omrkers
arc made by U1e cells lhem.sc;:lves, t~nd ate inserted into lhe surface membrane where-they act as s-pecific -antigen rec~l)tors.
T~ere at~ ho broad >ub-lypcs of lymphocyte. Titese ~re known as 8 cells nod T cells. All of them arc derived from the bone marrQW bu\ T cells undergo a process. of maturation in the thymus gland. Mature lymphocylcs all ha.e ~ similar appearnnce. They are small cells with a deeply basophilic nucleus ~nd sc!lnly oyloplasm. B and 1' cell circulate in the blood and througlt body tiS<ucs. D cells complete matumtiou in the bone ma1row ancl mign11 c lO lymphoid organs, 1'bey b:we a shon life span, ranging from days to wee)(s. These lymphocyte> ~re com milled lo diffcrcnliato into anlibody.. producing plasma c:clls involved i n autlbocly~m~diMed immunity. Whe11 8!1 imma~ turo a ceiJ ~~ exposed lO a ~~>1'cilic hntigen (they ft'ttCJJ...'11i5:c rmtigr m by 11wmhNme-hmmd immwrnglolmlin), 01c cell is activated. It tbCtl trnvels to the sploo~ or !lie lynlp~ nodes, ditl'ell:ntint~s. nd rapidly produces plasma cells and memory cells. 1 cell~ complete mat-unuion in the lh ymu~ and b(..\C'Omc thymocytcs. Tiley have a lung life Sl)i111, ranging from monlhs tu yC<~r!i. T11cy arc important in ce-ll~mediated hnmunuy. Tytle IV h~r sen.(\ilivUy reacliN\$ (con,(IC/ dermatitis). und in lhe moduhll1 on ofantibody-m~liatcd im1uuuity. Major classes include Helper T cells (subc/nssses: 7ype-l and 1} pe-1;, ('ytoto~ioT ocli> (CDS+ ly,,;p/IOCyle$), Memory T cells 3IId Suppressor 1 cells.

1. T cell lack lgG rc-cc'Piors, but bave CD3-a.<.<ociawd r coil "'""plors (TCR), Note5 which recognize a oniquc antigen only II\ conjunchou with Major Hlstocompnfibility Complox (MHC) proteins,

2. CDS+ lymphoc.ytes release perrnrhts and iullucc upnpto;ls (progrommed cell

death). 3. IL-2 tmieutiates 1he growth of Natur.U killer (NK) cells and lgG rullibodfes enbancclhcir cell elfec!fveness via antibody-de~endent oollulortoxily (ADCC).

lllulin~ h~ rir~1 inhntiun Healing is the desued outcome ufinn11mmntion. A liiUCccssfu1 inflammatory response resolves injury or infection hy rJpitl climin:nion of bacteri:t or foreign bodies, by repairing damnged t iSSbl! \vith t.>onnecdvc tissue1 Md by saving the ti,cosue's, 11bil"ity t() flm~tion. He~Hns diffen from simple repair in that heal.. iug i r~volves rcgencrotion of parenchymal ci.ssuc while repair by conn~tlve tissue doe!t noi. Th-e best healing OC<'lU'.S when the inflammatory I'CS'J)OliSt.' hus bt:len quick end crt'ectivc, rc.'iulling in minimal rissuc damage. The- process of healing begins very soon ilfle.t jrlOatnrr!lltiOTI start.,:;. lL1s net Uncommon for inflamm:t~ tion ro occur at the same Lime us healing. wilh nt;:.\Jlfophils and macrophagcs tngagcd ln their s-truggles (ight """' tO Rbroblasl> thai are ~rying down collagen. rrc-ulfn~ hy firat Intention (primnry' odiJl!SiOil or primary unlo!i): de.~cti be.' healing thul Qecurs- in SUrgical wounds that have been closed with su.mle~uturc, Thty :m.~ clean wounds-and are (01: at lell.sc.lratl lumer be) -a.sepuc, so the ii)Ou.mohlti<m doe$ nul iflvqlve l.nfec.rion,

Healing by sec:ond intention (svctJitda,.y udlle:tltm. :recnmlnt)' ullion): describe-s the procc..~s of healing a wound withottt cl1e benefit ur wrgical closure. In lhis cnse1 lhe wound is aUowed to "granulnte in;'" thaf is, the wmrnd clo,litcS by conlroccion Bnd filling wilb connective tissue,
lf('-allng by third lnrention: 1hL! slow fiiHng of a wound cavity or ulcer by granulations. wi1 h subsequenl ti;aui)'.ati()f'l (flu.> P''Ot..'CSS ofscdr fo,matioll). l.The- mttjlr diffen,."'nce5 between first and s~ooution uUC1Hion are t1mt wounds 11eallng by

Notts

s~ond intCJlnon 1trt- more open and arc more prone tu infection, and that mnch mol'e gran ulation tisso~ 1s necessary to close tile wound. funhem10re, while! the timing of 1he appear ancc oflhl" vati<,us cell type~ is the s~tme in bmh CBS(."S, he-ating by scc<md intention \"\1iUtake
l un~er simply bcCJtusc there is a larger wound to tlll. 2. 1'be ten slit strength of a healing woUfuJ depeods upon the fotmation of cullagen fibers. 3. Ch.atoc.'ortit'Oid$ ha v~ ~tn sho\\ll to have. the li:.I'C8te$t e-ffect uu grnuuhnfon tis'!iue. 4. \Vhe1hcr n wound heals by primary intcnllon or !iCcondary intcnlion is detennint:d by the natu.re of the-wound, rath~r lhan by the ht.tsling proccs!S it!iclr.

(MICROBIOLOGY I PATHOLOGY

Mise)

#' All of the following statements concer ning teratology or teratogens ar e true~
EXCEPT one. Which one is the EXCEPTION?

Teratology is the srudy of developmental anomalies Teratogens are anomalies

chemica~

physical, and biologic agents that cause developmental

Susceptibility to teratogens is variable Susceptibility to teratOgens is specific for each developmental stage The mechanism of teratogenesis is specific for each teratogen Teratogenesis is not dose dependent Teratogens produce death, growth retardation, malfommion, or functional impairment
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(MICROBIOLOGY I PATHOLOGY

Misc.)

( \..

The symptoms of sepsis include all of the following EXCEPT on e. Whicb one is the EX CEPTION?

Fever
Weakness

Painful urination

Nausea
Vomiting Diarrhea Chills
84 Cop)Ti&tu 0 2009-2010 Dcn1aJ 0\-cb

Teratoj.!t'iH..si~t is nut dust' dependent

*** Tills is false; teratog~nesis Is dose dependent.

Teratogenic drugs act in different ways; they can inhibit, interfere, or block, merobolic steps critical for normal morphogenesis. Many drugs or viruses affect specific tissues or organs. Teratogenic agents: l'hysicaJ agents: radiation. hypoxia, excessive carbon dioxide. aud mechanical trauma Maternal infection: IJ'ORC H complex) = T oxoplasmosis, Other agents, Rubella, Cytomegaloviru.s. and Herpes simplex Honrtoncs: sex and corticosteroids Vitamin deficiencies: riboflavin, niacin, folic acfd, and vitamin E Chemotherapy drugs: used for treating malignancies Antibiotics: mitomycin, dactinomyciu, and puromycin (11sed as chemotherapy

age111S)
Teratogenesis may be induced when ut least two conditions are met. Firstly, the teratogen must get into contact with the developing fetus. Secondly, the time these are in contact must be during tbe phase where tho organ systems are in process of belng formed. This critical phase is the first 3 months following conception, also known as the first trimester. The dose and the time of exposure to a particular agent often detenrtines the severity of the damage and the type of defect that occurs. The dose response is obvious: the greater tbe dose, the greater the ~Occt The time or CX])osurc is auother important concept, as certain stages of embryonic aud fetal development are more vulnerable than other.;.

urination Sepsis is a sovere illness cuuscd by overwhelming infection of the bloodstream by toxin-producing bacteria. Sepsis is caused by bacterial infection lhat can originate anywhere in the body. Common sites inch.tde the following: The kidneys (upper urinfl")' tract infeaion) The liver or the gall bladder The bowel (IISit<JIIy seen with peritonitis) The skin (cellulitis) The lungs (bacterial prreumonia) Meningiti~ may also be accompanied by sepsis. ln children, sepsis may accompany infection of the bone (osteomyelitis) . ln hospitali7,ed p~tients, common sites of infection include intravenous lines. surgical wounds, surgical drains, and ~itcs of skin breakdown known as decubitus ulcers o r bedsores . In some cases, sepsis leads to a life-threatening ooutlitiou called septk $hork. Th,e main culprits of s~psis seem to be Staphylococcus auteus, Escherichia coli, and Klebsiella. In addition. the LPS (endolo.<ill) released from the walls of dead gram-negative bacteria when they arc lysed can cause septic sltock as well as complement-activated anaphylactic shook.

,, ~1inful

- -... t. Bacterentia refers to the presence of viable bacteria iu the circulating Not"" blood. This can occur even in healthy individuals. For example, following some dental procedures, such as an oral prophylaxis and extractions, bleeding of the f,'liOlS results in a transient sy~temic bacteemia. Ctit1ioal s igns and symptoms are usually not present. 2. Virem ia is defined as a viral infection of the bloodstream. Tt is a major feature of disseminated Infections. The infecting virus is very susceptible to circulating antibodies.

(MICROBIOLOGY I PATHOLOGY

Mise)

Which of the following organs undergoes regeneration?

Hean
Brain

Lungs

Liver

85
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(MICROBIOLOGY I PATHOLOGY

Mise)

Which system is composed of monocytes and macropbages?

Lymphatic system Complement system Reticuloendothelial system Reticular activating system

86
CopynghtC 1009201(ll)cnul Db

Lhlr
This regeneration occurs as au adaptive mechanism for restoring a tissue or organ. For example, after removal of 70% of the Jjver, numerous mitoses of bepatocytes occur, reachin.g a peak at 33 hours. By the 12th day, the mass of liver excised is totally restored. This is why the liver is the most uncommon sile for infarcts. Celis of the liver, !>one marrow, blood (erythrocytes ai1d white blood ce/1.,), skin, as well as the salivary glands have tbls abilil)' to retain a latent capacity for mitotic division.
-..... I . Striated muscle (skeletal, vo!tmtmy. and cardiac muscle), smooth muscle,
JIIofes' and neurons of the CNS do not regenerate. Important point: Highly special-

ized tissue ha.~ a los.~er capability for regeneration. For example, surface cpithe lium has a marked capacity for regeneratio11, while neurons of the CNS have no power of regeneration. 2. The heart, brain, and lungs are very vulnerable to hypoxia and anoxia. These tissues die and are unable to regenerate. Tbe heart, however, does under go hypertrophy in response to injury. 3. Crtilage"and intestinal mucosa also are able to regenerate.

Kdil'ulotnt.lnthl'lial

-,~ \h.m

The reticuloendothelial system is a diffuse system composed of monocytes and macrophages located in rericular connective tissue (e.g.. spleen). These cells are responsible for engulfmg (phagocytosis) and removing cellular debris. old cells, pathogens, and foreign substances fiom the bloodstream. [t is a functional, r.lther than an anatomical system of the body involved primarily in defense against infection and in di>l'osal of the products of the breakdown of cells. Note: This system constitutes all phagocytic cells or the body except granulocytes including the cells present in the bone marrow, spleen, and liver. Examples include: Microglia: macropbages of the CNS. Kupffer ceUs: phagocytic cells that line the blood vessels of tbe liver. Alveolar macropbages (dust cells): macrophages fixed in the alveolar lining of the lungs (also called reticulum cells oflhe lungs). Histiocytes: fixed macrophag.es in connective tissue. Inherited disorders of the reticuloendothelial system (c/(Jssifioul as Lipid Storage Diseases): Gaucher's disease: most common, caused by a deficiency ofJ3-glucocerebrosidase.

Niemann ..Pick disease: caused by a deficiency ofsphiogomyelinase (tlie within a few .vears). Tay-Sacbs disease: caused by a deficiency of ltcxosamlnidase A (rapillly.fatal). Fabry's disease: caused by a deficiency in a-galactosidase.

,....._ I. The aoove disorders are most common in Ashkenazi .Jewish ancestry.
~otes

2. They are caused by incomplete lysosomal breakdown of sphingolipids and mucopolysaccbarides within phagocytes, leading to their accumulation. 3. 111ey are all autosomal recessive e.xcepl Fabry's disease which is X-linked

recessive.

(MICROBIOLOGY I PATHOLOGY

Which of the following is caused by fungi in the genera Microsporum, Trichophyton and Epidermophyton'/

Blastomycosis Dennatophycosis Histoplasmosis Coccidioidomycosis

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All of the following statements concerning fungi are true EXCEPT one. \.. Which one is the EXCEPTION?

There are two types: yeasts and molds They can be dimorphic; that is, they have two morphologic fonns They have a distinct nuclear membrane as part of the cellular structure They are prokaryotic and lack a cell wall They have both asexual and sexual reproduction capabilities Most fungi are obligate aerobes; some are facultative anaerobes; but none are obligate anaerobes
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The!ic: organisms) called de.rmatophytes, are tl1.; f)tllhogtnic members of the keratinophilic (kerntfn digestiJrg) soil fungi. MicrOSi)Orum nnd Trichophyton are human -and B11irnal pathogeos, Epidormophyton i~ a lmman pathog< n. Infection occurs by contact with arthrospores (nsexunl sporet formed rt~ tht hyphae of the pora.sitlr: ~~(~ge) or conidia (sc:wol or ase.'fua( spores .fr~rmt(l ;, tire 'free li''ing" tmvfronmenlal swge). Lnfcction usua.lly beglns In tt gtO\Ving hi\ir or tho stratum corneum of 'he skin. Dcrrnatophytes do not generally iuvade re.l'tlng hairn. since the essential nutrients t1ley need for growth are absent Qr l imited~ Hyphae .spread in the hair.;; and kerminized skin, eventually developing infectious arthrosporcs. ln hwnans, dcnnatophytose.' are ref~trd 10 as "tine.-." infections. and are named with rererence to tho area of the body nvolved. Infections can spread 10 orhcr areas: linea corporis in children, for example, is on en Ihe tesult of a tinea capitis infcoction that has spread tu the fi1ce. 'l'inea infections: Tinea capitis, must ()flcn seen In childre~ is u dennatophyle iofectiOr \ or the hK ir and scalp. Tinea corpotls. or ringwornt. oc<"urs on the trunk, e;ot:trcmities aud C.'\ce. 1'inea bnrbne is an inf""Ciion ofa hc hairs and skin in the beard at1d 11\USLache ar\Za, ancl is usually seen in men. T inea fach!!i is .st:cn on lhc .nonbL>arded pm:o; of l1\e face. Tinea cruris is- an infection of lhc groin. Co111monly ca11ed jock He b. Tioea pedi$ (At/Jlete .<foot) is an infection of the foot. Tioea numuutn is il dcmnttophyte infection of one or, occasiortally, both lla.nds. Tfnta ungu lum i s~ dem' d\Cophyte inft'Ction of the nail.
The t'll0$1 ellclive ant-i-mycotic (antlfimgal) agem IS griseofulvin. Althuugh griscofi1 lvln 1~ pre:;cribed tu lrcat infcelions of the skin) il canno~ be appHed :1$ ~ tr~.am and must be taken in pill form.

This is false; they are oukaryotlc and nave n ~omplcx t~ll wa ll. In addition. they are all gram-positive and grow in Sabournud's medium and contain both DNA and RNA. Two typos of fuogl: I, Yeasts: grow as single cells that reproduce by asc:n1ally budding. 2. Molds: long filaments (!Jyp!Jae) which form mm-like structure that is rcf<:rrcd 10 as myceli um. Dimorphism is a characterislic of some f< mgi, mconing that they form different structures at different temperamres. They exist as molds in the saprophytic, free-living state at ambient temperatures and as yeasts in host tissues ot body tenwer>Jture. These fungi include the major pathogens: Blastomyces, Histoplasma, Coccidloidos. and Candida. Most fungi reproduce a.~exually by fomting cmt ldla (asexual >/JOI'!!>) from the side. or ends of specialized s1ructures called conidiophores. Oifferem conidia help iu lhc identification of fungi. Examples or asexual spores (conidia) include: anhrospores, chlamydospores, blastospores, and sporangiospore.

Some fungi reproduce sexulllly by mating and fomllng seAual spores. Exampl<s
of sexual spores Include: zygospores, ascospores, and basidiospote.s.
Notes

....

I. All fungi except for those belonging 10 the class zygumycetes, aro st:ptatcd. 2. The cell walls of most fungi contain chitin and ~-J :3-llnkod glucau. :>. Sterols (egosterol) art in the cell membrane. Most anl.ifungal agents tllJllct this component of fungal cell membranes. 4. fungal infections generally initiate a type IV delayed hypersensitivity reaction, 5, The lbrniation of granulomas in response to a fungal infection is common
(as seen in t.YJC<:idioidomycosis. hi.ftopfa.wno.vis,
blastomycosis~

tdc.).

(MICROBIOLOGY I PATHOLOGY

All of the following statements concerning fungal spores are true EXCEPT one. Which one is the EXCEPTION ?

Morphologic characteristics (e.g., the shape, color. and arrangement) of conidia are a useful aid for the identification of fungi A conidium is an asexually formed fungal spore Fungal spores are as resistant to heat as bacterial spores Fungal s pores cause allergies in some people

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Coccidioidomycosis first infects a person's:

Brain
Kidneys Hean Lungs

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*** This is false; unlike bacterial spores, most fungal spores are completely killed ,;hen heated al for 30 minutes.

aoc

Some fungi are spor e-producing. This fonn allows them to survive extreme environmental conditions. Tt may also play a role in the lmnsmission of fungal Infections. Examples of asexual sporL-s (conidit1) : ArU~rospores: fonned by frag11'entation of the ends of hyphae; are the mode of transmission of Coccidioides immilis CWamydospores: are thick-walled and quite resistant to environmental changes; characteristic of Candida albicans Blastosporcs: fonned by budding, as in yeasts; multiple buds are called pseudoby pbae (characleri!;lic ofC. albican.s also) Sporangiosporcs: formed within a sac on a stalk by molds such as Rhizopus and Mucor Examples of sexual spores: Zygospores: single large spores with thick walls Ascospores: formed in sacs wbich are caUed an ascus Basidiospon-s: formed externally on the tip of a pedestal called basidlurn

Coccidioidomycosis is an infectlous disease caused by inbaling spores of a fungus called Coccidioides immitis. The disease starts out s a respiratory illness and may progress to a persistent infection. Disseminated coccidioidomycosis is the most sever~ form of the disease and is often f.tal. Note: Coccidioidomycosis is ulso referred to as

''vnlley fever', or san Joaquiu fever.'

Antifungal medications used to treat disease include: Amphotericin B, fluconazole. kctoconazolo and itraconazole. Blastomycosis (also called Gi/c/lnst's disease or North American blastomyco.n:v) is a disease caused by a fungus, lllastomyces dcrmatitidis, wlllch is found in parts of the somhcentral, south-eastern and mid-western United States. The infection is spread by inhalation of airborne conidia (spores) after disturbance of contaminated soil. Blastomycosis is not known to be transmitted from person to il"rson. For persons witb mild or moderately severe disease. itraconazole may be used for treatmcnL Histoplasmosis is a disease caused by the fungus Wstoplasma capsolatum. H. capsulamm is found throughout the world and is endemic in Obio and Mississippi river valleys. Infection is usunlly asymptomatic, but it can cause a granulomatous, tuberculosis ..fike iufecHon (primary form ofdi.ease). It is a frequent cause of pulmonary nodules. The infection may spread throughout the body, and this disseminated form, though uncommon, is quite serious. Antifungal medications used to treat disease include: Amphotericin B, fluconazole and itraconazole.
Notes maeropltages.

I. In infected tissues, yeast cells of lhstoplasma capsuimwn are found within

2. Histoplasmosis resembles 'fll, both clinically and palhologicaUy. 3. Histoplasma capsulatum produces chtamydospores. 4. Histoplasmosis and blastomycosis are rarely acquired from another individual.

(MICROBIOLOGY I PATHOLOGY

Fung~

Poorly controlled diabetics are likely to acquire:

Aspergillosis Candidiasis Mucormycosis Cryptococcosis

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\.

Aflatoxins arc naturally occurring mycotoxins that are produced by many species of:

Candida Coccidioides Aspergi llus Histoplasma

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J\ 1ucurm~(.'OS is

Mucormycosis is a rare but ofien faut.l disease caused by cenain fungi (i.e.~ AluC'Or sp .. Rhizopus sp., and Absfdln ~p.). l~ tli sometimes- called 1.ygomycosis or phyt..-omy<..-osis, They arc not

dimorphic, and are morphologically characterized by che lack. of septa in tllcir hyphae.
Muconnycosis is an opportunistic infeclion that typically develops in l)atiems whh weakened immune systems. diabetes, kidney failure. organ transplants. or chemotherapy for cance-r. It ruay aJ so develop in patients recei\ing an iron chclating drug culled dcsferrioxamioc (De.iferal) us treatment for acute iron poisoning.

Syndromes asSQCiated with !UUc;:ormycosis include:

Rhinocorcbml inl"ec1iun ('infection of sinuses and br11in)

-May stan ns a sin.u~ infection

May progress to involve inOarnmation uf c.ronia1nerves

-May cause blood elms chat block vessels to che brain (thrombosis) Other opportunistic flmgi which normally fail to induce disease in mosl normol perso"s bul
may do so in ptoplu with severely suppressed immuntl systems:
Cryptococ.cus: Cryptococcus neoformaos causes Cryptococcosh. C. 1u:orcmnuns is an oval, budding yeast and is not dimorphic. Cryptococcosis is m6r~ common th~n Other fw1gal i11fectio!ls. This infectioo is severe only 1n people with underlying immune system disordcr.i, such as AIDS. Cryptococcosis may spread~ especially to (he meninges.. whCf(' the resulting

disease is cryptocoocal meningitis.

Aspergillus: Aspergillus specie..,., ~r>ecially Aspergillus fumig;.ttus, causes an aspcrgillorna ("fimgus ball'~ in chc lungs and Aspel'gillosis. Apergillu.< ;pe.:ies exist only a.< mold.< and arc ooc dimorphic. They cause pulmonary inrcetions in people whu have AIDS Ol' have undergone organ transplantation. Candida: Candida utbicans, the mosl impot1anl .species ol' Candida, 1.'ii\1Ses lhrush, vaginitis, and other diseases. C. albicans is ao oval yeast with a single bud. Overgrowth of C. ulbican< en those with impaired hose defenses produces the candidiasis.

A!lacoxins are probably the best known and mnst cntensively researched mycotmtins in the world. l'hey are hepato-carcinogenic toxins produced by AspcrglUus nnvus. Tbuy cuu.""
liver damage and tumors in animals and are suspected of c:ausiug lu~putk rarduoWJI in hllllllUlli. This toxin binds to DNA and prevents transcription of genetic infOJruatton.

AspergiUosis is most commonly cau<ed by one of che followin.g pecies: A. fumigHtu.<, A. niger, or A. flavus. Aspergillosis begins when su.sceptible people inhale mold spores into their lungs. Caus<o;s three forms of lung inli!ctions; I. Allergic bronchopulmonary aspergillosis: characterized by ibe fonruction of bronchial mucous plugs 1n the lungs. 2. Aspergllloma: fonnation of"fungus balls~ in lung cavities withouc iuvasiou. 3. Invasive aspergillosis: occurs when the infection <preads beyond ~>e luogs to oilier
organs. Eveo when discovered -md trea1ed earl)", invasive aspergillosis is often fatal.
1 -

I. Nosocomial Infections are infections which are a result of treatment in a hospiNotes tal or a healthe<Jre secvice nnic, b11t secondary tQ the patient's original condition. Infections are considered nosocomial if ihoy first appear 48 hours or more sf\er hospital admission or wichiu 30 days af\c:r discharge. Common causes of nosocomial infections:

B. Coli Staphylococcus aureaus and S. epidcnnidis Streptococcus faecalis

Pseudomonas nenJg_inosa

Klcbiella pneumooiae Enterobnccer sp. Condida sp.

(MICROBIOLOGY I PATHOLOGY

Malar ia in humans is caused by one of four protozoan species of the genus:

Trichomonas Plasmodium Cryptosporidium Toxoplasma

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is the etiologic agent of amebic dysentery.

Giardia Iamblia Trichomonas vaginalis Balantidium coli Entamoeba histolytica

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l'la"intudium

Malari.a is an infectious disease caused by a parasite, Plasmodium, which infects red blood oolls. Of the four species of malaria, the most serious type is l'lasmodlum ralclpsrum malaria. It can he life-threatening. The other three species of malaria (P. ivax. /~ ma/(ltfae. and P. ova/e) are generally less serious and are not life-threatening.

FtwliU ~ (ll.lfot....,., 1/;-m/QeA,._ Nll~.rt:l,.

.rAe. tJfWI t;}!lfU_J, mla.-g~<d ~ bype!phN ct

!Nirtnr.S:I. CW$C~ ly,l~ oret')'fhril<ytts.

fet:~~J

~1110\tYl and l!'t'W:~i!CJ. T011!1 WBC ~~

TW.Qpfzlmom 1 By m.acsrin.ll its C)lt (WCJ&~ J. ....ihkh 1s rlJu.od In <.'ll.l ft.octl> llr ~.mo

1 ~,;:;::;:;r;::: ~ rltlCC:ntal borricr. l-tosz

1
o( mccpbo.lltls II\ AJDSpal.ltnlf.

in.f~ mOOI,llnl..odot.Oo

J'nt:llmCH.')'itl~ Pll"'-11211.mia '

lnhn)&tioo

En1:1111o~h:t hio,;tul~

tka

Amebiasis is an intestinal ill ness caused by a microscopic parasite called Entamoeba histol~1lta. Entamoeba histolytica exists in two forms during its life cycle: the active parasite. (trophozoite) and a dormant parasite (cyst). The main artribute of Entamoeba histolytica that is responsible for its worldwide distribution may be due to tlte extreme stability of its cyst in the enviroruncnt. Contaminated water is the ntosl common mode of the spread of this infection. Acute intcstin!J] amebiasis presents a dy.scntery (i.e.. blood)\ ttwcus-containing diarrhea). Note: E. histolytica can also produce liver (hepatic) abscesses. lt is treated with metronidazole, Giardiasis is a diarrheal illnc'Ss c-aused by a flagellated protOzoan Giardia Iambiia. Italso exists in twn fomts (rrophoz-oire and cyst), Giardia infection bas become recognized as one of the most common causes of waterborne disease ((omd in borlt drinking attd recreariottal warer) in humans ln the United States. It is more common in male homosexuals and in people who have traveled to developing countries. It is treated witll metronidazole. Tricbomoniasis is a sexually tr.ansmincd disease of the vagina (in wome1t) or uretbta (in men) caused by a Oagcllatcd proto7.oan l'richomonas vaglualis. T. vaginal is only exists as a tropho7.oite. Trichomoniasis is one of the most common infections worldwide. Symptoms are more conunou m women. It is also treated with metronidazole.
1

I, l.'ntllmocba and Trichomonas snecies are fo und tn the oral cavity. They appear Notes to be nonpatho~enic when located bere. 2. Balontidium coU is a ciliated protozoan that can infect the colon causing diarrhea with aC<lompaoying abdominal colic. nausea, and vomiting with bloody stools. 3. Balantidium coli is known for being the largest protozoau parasite ofhutnatJS.

(MICROBIOLOGY I PATHOLOGY

(
""'

Which disease below is acquired by ingesting undercooked meat containing tissue cysts or food contaminated by cat feces?

Cryptosporidiosis Trichomoniasis Toxoplasmosis

Giardiasis

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levels arc features of many nematode infections.

Eosinophilia and elevated serum immunoglobulin A (lgA) Eosinophilia and elevated serum immunoglobulin E (IgE) Basophilia and elevated serum immunoglobulin A (IgA) Basophilia and elevated serum immunoglobulin E (JgE)

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'1()\0plasmsb

Toxoplasmosis is an infection caused by the protozoan Toxoplasma gondii. Sexual reproduction by this parasite occurs only in <be ceUs lining the intestine of ca<s. Eggs (oocyte.s) are shed in a eat's stool. People become infected by eating raw meat containing the dormant form (cy.ts) of the parasite. ll may resemble a mild cold ot infectious mononucleosis in adults. It is treated with sulfadiazine. Crypiosporidiosis is caused by the intestinal proto7.oan Cryptosporidium parvum.

The main symptom of cryptosporidiosis is watery dlarrhfa that is sometimes

accompanied by abnonnal cramps, nausea, and vomiting. It is most severe in immunocompromised patients (tltose with AIDS). In ll1ese patients the infection may be fa~al. Tb. e treatment is primarily supportive.
I. Pneumocystis earinll is a protozoan tl1at call."es pneumocystfs pneumonia ~~01<$ ln immunocompromised individuals (AIDS patients). This lung disease is often fatal.

2. Pncumocystis caritlli ;., treted with trimelhoprim, sulfamelhoxazole, and pentamidine. 3. Candidiasis. hairy leukoplakia, and cryptospncidiwn enterocolitis are also opponunistic infections associated with immunocompromised individuals (AIDS patientS). 4. Protozoa are a diverse group of eukaryotic, typically unicellular; nonphotosyntbetic microorganisms generally Jacking a rigid cell wan. They largely infect blood cells, intestinal and urogenital tissue, and meninges. 5. Malaria is treated with chloroquine. mefloquine, and primaquine.

t:osinophili:l

!I !tel

df:'\ :He-el "'trum

i mmunu~lohuliu

F (/gi:'J

Roundwomls, or nematodes, are parasites lha1can in feCI humans. usually by residing in tlw intestines. According to lht Nalionallnstitulc of Allergy and Infectious Diseases, many roundwonn parasitic djsea.s~s result from a lack of appropriate personal hygtene and sanita1 ion measures. Mosl roundwonns or their eggs are found in the soil and can be picked ur O r \ the haods and trans~
ferred to the mouth or can enter through the s.km.

\jtrnatudt tround\\urm)

lnf('Cf iOil'i

Disease
Mearitb~

Roundworm
Ascaris; Iunibricoidcs

Characteristics
M'QstcommQn JQU(ldwoml tntccti{ln
worldwfdt-

'I riahuna~~ (whip'llt'nrniJ

1'richuri!i trichiurn
AncyiO!>Iomtl d~:tlc

Ancyh\Stqmasi.s-fluJokwurtll)

t1uldrcn...., p:llliculorty

"'"'"Piibl~

-SnungyJoidiasis: ffhr~ufw<mn) StrontQ~Ioides stercorali Common in Atficau cutmuic:.

llilh:robJuis (ptnt''Ot'lt)

Enten,brus vmn icu1aris Most COtllD10n \I(Omt in Uuned States

Tric;htnella $fliralis Tat.-nia M~liunl Taenia sagin.fiUi. logestiOn of mW (panftJJ!ilrl' pork) \hl\t lS undc~uoked.

rnc.hinosis
Ttleniasis (m~rm)
Tncni~si.s

J ngesUou uf meat (pnrlic;;tarl) pork) that '-' UllJorooolo:<l to.ec.stion or meat (parricularlv bc.oe() lhtall!; w1dercookl

(UIJ*n'r)rm)

An infesratlon is <be presence of parasites on <he body (e.g.. ticks, mires. and lice) or in the organs {e.g., nemnlorie..t or wonns). Infec-tions caused by certain nematodes cause marked eosinophilia (abnormally large 11umbers of eosinoplrils in the IJ!m>d). Eosinotlhits do not ingest the parsites: rather_. tbey attach to the "Surface of the parasites via lgE and sect~te cylotoxic t:"zymes contained within their eosinophilic granules.

(MICROBIOLOGY I PATHOLOGY

Kid Dis)

The most frequently occurring hereditary renal disorder is:

Nephrosclerosis Adult polycystic kidney disease (A PKD) Medullary cystic disease Medullary sponge kidney

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(MICROBIOLOGY I PATHOLOGY

Kid Di~

All the major organ systems are at risk from the severe blood pressure elevations present in malignant hypertension, but the seem to be most at risk.

Ears, lungs, and heart Liver, kidneys, and pancreas Kidneys, eyes, and brain Eyes, heart, and stomach

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Polycystic kidney disease is au inherited disorder characterized by multiple. bilatera~ grapelike clusters oftluid-filled cysts that grossly enlarge the kidneys, compre-<Sing and eventually replacing functioning renal tissue. The disease appears in two distinct forms: I. Infantile Polycystic Kidney Diseuse (lPW): Autosom~l ressive Clocd, small, bomogcnous cysts that are nol in co1\inuity with the collecting sy$tm C'f shows mtdtiple cysts at birth Resubs in death shortly after birth 2. Adull Polycystic Kidney Oiscasc (Al'KD): Autosomal dominant; 90"/o due to mutation of AJ>KDl geneou chromosome 16 Replacement of rena) pnrenchym~ bilatemUy with large, variably sized cysts Hyper tension, hematuria, and palpable renal ma~ses Bleeding into a cyst can cause flank pain: Kidney su)ues are more common than in fPKlJ Associated wiUl secondary polycythemia, polycystic liver disease, berry aneurysms, and mitral valve prolapse Slowly progressive, eventuaOy rcsulllng in end-stage renal disease (ESRD) Medullary cystic disease: a disorder in which kidney failure develops along with cysts deep within the kidneys (i11 medulla). Jt is uncollllllon and affects older chiltlrcn. Medullary sponge kidney: a congenital disorder in which the urine-containing tubules of the kidneys are dilated, causing the kidney tissue 10 appear spongy.

Kidm) s,

l') es.

:mtl brain

Malignant hypertension is a rare but very serious fonn of i\ij;h blood press\lre that. if left tuttreated, usually leads to death in 3 to 6 monlhs. The kidneys are especially sensitive to increases in blood pressure and pennane111 kidney damage is a commoo complication of untreated malignant hypertension. Like high blood pressure in gencr.ll, the exact cause of malignant hypenension is not C<Jmpletely uod.erstood. Nephrosclerosis l.s a kidney disorder in whiclt the smallest arteries in the kidneys, called the arrtrioles, are damaged. There ore 3 types of uephrosclero~is: l. Arterial! atTophy and ~caning of the kidney d\le to arteriosclerotic lhi ckeuing~ of the walls of large branches of the ren~l artezy. 2. Arteriolar: renal changes associated with hypertension in which the at1erioles thicken and the areas they supply undergo ischemic alrOJlhY ru1d interstitial fibrosi~. 3. Ma.liguaut: rapicl deterioration of renal timet ion caused by inflammation of renal arterioles, 11tis type accompanies malignant hypertension. Pycloocpltritis is an ascending urinary trad infection (us ual/.v E, Culi) that has rc;acbed the pelvis of the kidney. There are two form~ of pyclonepbriris: 1. Acuto, which is an active infection of the renal pel vis. The pelvis may become inflamed and filled \vith pus. 2. In chronic cases, extensive scar tissue is fonned )n the kidney. and renal failure becomes a p<1$Sibility. Remember: Chronic hypertension leads to reactive chang<'s in the smaller arteries and arterioles throughout the body. These changes arc collectively referred to as arlcrioscterosis. The vSJ;cular changes are particularly evident i.n the kidney, where they result in a loss ofreual parenchyma, ref~rrcd to as benign nephrosclerosis.

(MICROBIOLOGY I PATHOLOGY

Kid

Di~

The most commonly occurring form of nephrolithiasis is:

Struvite stones
Calcium stones Uric acid stones Cystine stones

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(
A viral infection

Hydronephrosis results from:

Chronic urinary tract obstruction A direct complication of diabetes mellitus A bacterial infection

100 Copyri.gbtC 200!)..2010 De-tltal Dttkl

 Calcium stones account for &0-90A. of kidney stones. They are composed of calcium oxalate. calcinm phosphate, or bow. Nephrolithiasis is another uamo for kidney stones. Kidney Stones are also called renal calculi. Stones in other parts of the urinary system are called uriuury cal.cull. Botil are rock-like 1>ieces li.Jat are about the size of a grain of sand. They form most often in the ~idn~ys IUld get stuck in the ureter. This blocks the tlow of urine and c~uses o enal colic (c/raractelized h) severe pain in tlw buck, !Qwer ahdomrn. and groin 011 tile side of tlr<> blockage). Compllt:ations m~y incl<~de obstruction of the ureter, acute or cbrooic pyelonepluitis, tllld hydroncphro~s. The formation of a -stone within tbe minary tract represents " potntial complication of many ditrcreut tli>eas<JS, In gen~r~l. ren31 stones are cornpo.-ed of c>~lcium ails, uric acid, cystine or struvlte depending upon the major etiologic entity. Each type of 5tone has iu; own group of causes so that managetnenr of each entity is specific. However, all four types of renal stones share a common pathogenesis that i~ based c.sentially 11pon excessive supersaturation of the urine with a poorly soluble material. Renal ~ton~s grow upon the surtaces of the papillae, becotn detached and accompany the urine. as it travels the collecting system. Since many or these stones are too large to negotiare the narrow conduits of the collecting system, they obstruct the tluw or urine and often cause sevete pain. Reual calculi are more common in men than in women and rareJy occur in children. The exact cause is unknown. Predisposing factors inchode; dellydration. infection, changes m urine pH, obstruction of urine flow, immobilizuuon causing bone reabsorption. metabolic factors, such llS hYI>erp rathyroidism (/e<td.v to hypt!l'r:/1/cemia), renal acidosis, elevated uric acid, and defective oxalate metabolism.

Chrnnic ut'inar.\ lr:u.t ohstrurtinu

Hydronephrosis develops when !he pelvis 1md calyce.< (11rine cQIIt!CiiJrg stnlctwes) oftbe kid neys become distended because urine is unable to drnln from tlte kidney down the ureters into the hiadder. f-Jydronepbrosis is UCJt a specific disease, but a <lgn of an underlying problem. Causes include: Blocknge of th~ urirtary system (present at biltlr co/lgelliral) A kidney or urerernJ stone (lephrolilhiasls) A blood clot Scarring of the ureter. usually from injury, radiation therapy or previous surgery
A tumor in or around tite ureter Prostate gland enlargement (benigu proSUItic hypt7J!Iasi<l), This condition is not malignant or inflammatory but is usually rrogressiv" and may lead to obstmrion of the orethm Pregnancy

- l. Other disorders that are-nssociated whl1 UrtlU&r:y outflow obstruction: Nutu Urolithiasis: urinary calcultc<, formed in any part of the urinary t.roct, Calcium stones ~ccot\nt for $0 to 90"/o of urinary stones. They are composed of calcium oxalate or calcium phol'hate or both. They are associmed with gout, hypercalcemia, renal Infection, and hyperparathyroidism. l'yelonephrttls: a bact<'rial infection (usually f... Colt) of the kidney and !be duct< that t;~rry urine away from the kidney (urcrer.v).l'yelonepltnt is most ol1cn occun; as a result of 11rinary tract infection. particularly in the presene< of O<.'casional or peristent backflow of urine from the bladder into the ureters or kidney pelvis ('vesicrmreteric l'f!jlux). Abscesses often develop. In chronic c.a!les, extens-ive scar tissue is fonned in the kidney, aJtd renal failure becomes a possibility. 2. Kidney infecrioi1S are usually causod by microorganisms ascending from the lower urinary trJct.

(MICROBIOLOGY I PATHOLOGY

( Nephrotic syndrome (NS) is a condition characterized by all of the following] \. EXCEPT one. Which one is the EXCEPTION? .J

Proteinuria Hyperalbuminemia Hyperlipidemia

Edema

101
CCop)'rigltl 0 2009--2010 !>ental Dk$

(MICROBIOLOGY I PATHOLOGY

Kid Dis)

In children, a common cause of glomerulonephritis is from a:

Staphyloccal infection Herpes infection

Fusobacterium infection
Streptococcal infection

102 Copyrig.htC 20092010 Dc:nu l l):k$

II~ PL'r~tllmminemia

Nephrotic syndrome (NS) is a condition characterized 1\y morked proteinuria, hypoalbuminemia, hyperlipidemia, and edema. These symptom.> resuJ~ ttom increased permeability of lht glomerular capillaries. Although NS is not a diseas~ Itself, it r<sults from a specific glomerular defect and indicates renal damage. Diseases that can cuusc nephrotic syndrome include umyloidosis, ~ancer. diabetes. l:flY. glomerulopaUties, leukemia, lymphomas. multiple myeloma and SLE. ;llote: Abollt 75% oftbe cases ofNS tc.<ult from primary (i<lippnthlc) glomcrulonephrltfs. The dominant cllnlral feature of NS i~ mild to ~evere. dependent edema of the ankles or sacrum, or periorbital edema, cspcciotly in children. l:ldema may lea~ to ascites, pleurnl effusion, and ~wollen o;<tero~l genitalia. Early symptoms include los~ of appetite, a general sick feeling. putTy eyelids, obdominal pain, wasting of muscles, tissue sweiUng from excess salt and water rcueuuou, and frothy urin (high proteiiJ comem). Major cotupliclldon ure malnutrion , Infection, coagulation disorders. thromboembolic vascular occlusion, and accelerated atllerosclerasi~. NS can occur at a ny age. In children it is most common between ages 18 months and 4 years, wtd more boys lhan girls arc at'f~ted , In older people, the sexes are mote equally affected. J. WBC's are more characteristic of pyelonephritiS than nephrotic syndrome. NO tot>' 2. With a nephritic syndrome RBC casts (clumps) will be present in the urine. 3. Infarction might le;~d to the presence of a few ROC's in the urine. 4. Hyperllpidemia associated with nephrotic syndrome is sccnndory to increased hepatic far synthesis and decreased fat cataboli~tT\.

StrepltJCncral inr<l'tinn

Kidney disordrs in wltich inflammation am<'t:. mainly the g,Jomemli are called glomcrtllopathles. When the kidney is injured, it cauuot gol rid of wa,o;les ""'! ~<tra fluid in the body. Jfthe illness conlinpos, the kidneys may stop working completely, rc;ul!in!l in kidney failure.. Although cause. ~ vary, glomemlopatbies are similar because glomoruli respond to seveml types of injury in a simil11r way. There are f'nur m~jor types of glomerulopalhic~:
1. Acute nephritic $yodrome (also called acwe glomerulonephritis or poststreptotocct~l glollllilon"pluiti.'i) is an inflammation of the g lomeruli that results

in the sudden appearance of blood iu the urine, with clumps of red blood cells
(ca.<is) and variable nmounts of protein in the urine. It is most common in boys aged

3 to 7 but can occut at any age. It starts suddenly and usually re"olvos quickly. 2, Rapidly progri'S~i.ve. nephritic syndrome (also called rapidly prof{l'es.ive glomeruloMphriri.t or (RPGN)) may be idiopathic or associated with a proli1erattve glomerular disease, such as acute ON. It is an uncommon disorder in which most of Ute gtomemli ;tre p~rtly destroyed, resulting in kidney failure. It starts suddenly and worsens rapidly. 3. Nephrotic syndr()me is a collection of symptoms roused hy many diseases that affect the kidneys. It leads to the loss of large amonnts of protein in lhc urine, lllung with hypoalbuminemia, generalized edema. hyperlipidemia. and hypercholesterolemia, 4. Chronic nephritic syndrome (also called chronic glomerulonephritis) is a slowly progressive disease characterized by inflammation of the glomeruli, wbicll results in sclerosis, scarring, ond eventual renal failure. Conditions that C!II1 lead to chronic GN include: SLB, Ooodpuslure 's sync.lrome 11Jtd Acute GN.

(MICROBIOLOGY I PATHOLOGY

LvDis)

Tbe most common cause of portal hypertension is:

Hepatitis D Polycythemia vera Cirrhosis Cholelithiasis

103
CopynghtO 200!).2010 Dmtal Dk:$

(MICROBIOLOGY I PATHOLOGY

LvDis)

Clinically, the first evidence of _ _ is an increase in abdominal girth accompanied by weight gain.

Ascites Jaundice Hepatitis A Hepatocellular carcinoma

104

Cop)'rigbt O 2009-2010 Dental Dttb

hypertension is abnonnally high blood pressure in the portal vein, the large vein thnt brings blood from the intestine to the liver. 1'his condition is often classified by the site of portal venous obstruction: Prehepatic: caus.:d by portal and splenic vein obstruction. most allen by thrombosis. Intrahepatic: cauS<:d by intrahepatic vascular obstruction, most often by cfrrllosis or metastatic tu.mort and mare rarely by schistosomiasis (parosiJic infection). l,osUtcpatlc: caused by VC!nous congestion in tl1e distal hepatic venous cir,ulation, most often as a result of constrictive pericarditis. rricospid in:,Ufficicncy, congestive hcan-failure. or hepatic vein occlus-ion (Budd Chiari syndrome).
l\vo factors can increase blood p-ressure in the portal vessels: I. The volume of blood ilowing through the ve-ssel.
2. Increased resistance to the blood flow through the liver: this is by far the most common cause of portal hypertension which is caused by cirrhosis of the liver (common In alcoholics).

Port~l

The classic complic.atiuns of ponAI hypertension are esophagea1 varites, splenomegaly, and ascites. Splenomegaly is cunsidcrc:d by some as rhe- single rnos1 impor1am sign of pmtal hypertension. In many patienl~ tl!c first sign of portal hypertension is bleeding liom esophageal varices (which are tlllated tortuous veins in the submucosa of tile fewer esophagus) witn assocfated coughing up of blood (ir<moprysi.<). lmportant: One of the most common causes ofdealh in patients wjth cirrhosis associated with portal hypertension is upper OJ hemorrhage from bleeding esophgcal varices. This causes massive- vomitiog of Mood (hemmeme5is), n.:quiring cn'li.!rgcncy treatment to control hemorrhage and prevent hypovolemic shock. ,....__., 1. Barrett's esopba~us is a columnar n>ctaplasia of the esophageal epithcUum that
"Nuld occurs with chronic reflux.

2. Iron deficiency anemia can be as.'K>ciatcd with esophageal webs. This is called Plummor-Vinson syndrome and it is quite rare.

Ascites is a detectable collection of free Ouid lu the peritoueul cavi ty, This fluid is almost pure plasma, containing tremendous quantities of protein. Two factors are imponrutt in the formatiol of ascites: I) an h1creased total body sodium and water 2) increased sinusoidal portal pressure Important : Liver disease is the most common cause of ascite~. Disorders that may be associated with ascites include: Cirrhosis Hepatitis Portal vein thrombosis (clots i11the veins nfthe /i<et) Constrictive pcr)carditi;;

Congestive heart tai lure Liver cancer Nephrotic syndrome Pancreatitis

I. Cirrhosis of the liver is an end-stage renal dise"se in which the nomml ' Not.. hepatic architecture is destroyed and replaced by bands of fibrous scar tissue. It is the most common chronic liver disease; 75% of cases are caused by alcoholism. Sib'llS and symptoms include ascites, splepomegaly, sudden onset of upper OJ bleeding with massive bcmatemesis (vomiring nf blood), and jaundice. 2. Splenomegaly indicutes portal hypertension, which in tum causes esophageal varices. These esophageal varices are the most common source of massive hematemcsis in alcoholics. 3. Spider angiomas are common in alcoholics.

(MICROBIOLOGY I PATHOLOGY

LvDis)

,Jaundice is not an illness, but a medical condition in which /~~--~~~~ ' to : o~m :: uc : h ~;;;;;;~i:s~ci~r~cu~J:ati:n ~ g ~i: n~ t: he ~: bl: o: od :.-~a-~-A~

'

Protein

Creatinine
Uric acid

Bilirubin

105 Cop)Tighl 0 2009 2010 Dtrtta.l Deel:s

(MICROBIOLOGY I PATHOLOGY

Lv Dis)

About 80% of people with hepatocellular carcinomas bave:

Diabetes mellitus Cirrhosis

Jaundice
Hepatitis A

106 Copyrigbt 0 2009-2010 Dental Deeb

Jliliruhi n JaWJdice is a condition produced wbeo execs., amouniS of blllrubin circulallng in lhe blood stream dissolve in the subcutaneous fat (the layer offor jusr /xmearh rlre skin), causing n yellowish appearance of lhc ;km and the whites of rbe eyes. \Vilh the exception of physiologic jaundice in the newbom (trormalnewb()rn jqundicc /11 rile firsr week of life), all oUter cases of jaundice indicate overload or damage to the liver, or inability to move bilirubin from the liver through the biliary tract to the gut. These defects in bile excretion produce elevated levels of conjugatd or unconj ugntcd bilirubin and other components of bile in the blood. It is very common ond is the leoding manlfi'Stntlon or liver disease. It can occur at any age aod in either .ex. Common <a uses of jnundlce: Inc~ destruction of red blood cells with rapid release ofbilirobiu tnto the blood
(UIICOIIJII80I~dj,

Obstruction oft.he bile ducts or damage to liver cells which results in the inability of bilirubin to he excreted into the Gf tract (<'Orr}ugared).
1

J. 13illnbin Is the waste product that rc~ults from th~ breakdown ofhemogloNotl"l brn molecules !rom wom out red blood cells, Ordinarily. it is oxcrttcd from the body as the chief component ofbtle. 2. ConJugated bilirubin is formed by the conjugation of bilirubin with glueuron ic acid. 3. Free bilirubin (unconjugaretl). unlike that bound Jo albumrn or conjugated wtlh glucuronic acid. is toxic. 4. High levels of bilimbin in !be bloodstream can cau.~e permanent dnma.ge to cenain urcns of the brain in newborn infnnl~; this is known tu; kernicterus. Titis can result in a characteristic form of crippling called athttold c<!rcbraf palsy.

Hepatocellular corctnoma is cancer that an;e; from hepatocytes, the major cell type of the liver. About 800 .4 of people with hepatocellular carcinomns have ci rrhosis. Chronic infection wrtb the hepa titis 1l virus a nd hepatitis C vi rus also incr~ases the risk of developing hepatocellular carcmoma. AOatoxins, which are produced by mold thut is a contaminant of nuts (mo.~I Cflllllllfln(l' pearrurs). grains, and beans. have also been rmplicated as il major risk foetor for causing hepatocellular carcinoma. Rcm cmblr : Previously, Viral hepatitis that wus nor cuuscd by the type Aortypc B virus wns called ''non-A, non-B bepatitJs. Rcocently th.ree more viruses that cause sontc of these non-A, non-B infections have been idcnti6ed. These viruses include: Hepatitis C: i5 a serum hepatitis that is caused by a \'irus amigerucally di!Tercut from Hepaliti> viruses A aod B. Most case> of po5ttransfusion hepatittdes are of this l)'pe. IllS usually mucb milder tban A or 0 but is olherwise eli meally indi.>tinguishtthle from them. There is a higher incidence of chroni< disease (chronic heparllf.t), cin'hOSJS nnd hepatocellular cardnotna. Importa nt: Hepatitis C is now the most common r=on lbr liver transplantation in the United Sulcs. HcpRti lls 0 : requires coinfecUon with Hepatitis n. Drug addicts urc at relatively high risk. Bep:lllti.s E: is transmitted cnteric:~lly. much like llepmitis A. It ts a common S)lOradic cause of viral Hepatitis in India. It has close to a 200/o mortality tn pregnant women.

0ICROBIOLOGY I PATHOLOGY

Lv Dis)

(Ita..

Which of the following does not develop into chronic hepatitis or cirrhosis - both potentially fatal conditions?

Hepatitis A Hepatitis B Hepatitis C

107 CoP)'l"iabtO 2.009-1010 Danai ~b

(MICROBIOLOGY I PATHOLOGY

Lv Dis)

All of the following statements concerning cirrhosis are true EXCEPT one. \.. Which one is the EXCEPTION/

Cirrhosis is a chronic disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells

It is twice as common in women as in men

It is especially prevalent among malnourished persons over the age of 50 with chronic alcoholism

Mortality is high; many patients die within 5 years of onset

10$
CopyrigbtO 20092010 l)cnttl Oeck$

Jlcpatitis .\ Hepariris A (HAV) is a highly contagious infectious disease involving the liver. It is usually transmitted by the fecal-oral route. However. it may also be transmitted parenterally, as can Hepatitis B and D. Hepatitis A usually results from ingl-stion of contaminated fond, milk, or water. Many outbreaks of this type are traced to ingestion of seafood from polluted water. It most often occurs in young adulls. The initial symptoms (lever. malaise, abdominal pain, auorexia, jauudice) of Hepatitis A appear after nn incubation veriod of 3-6 weeks. Complete resolution occurs in an ove..Whclming majority of cases. Important: There is nn ossocialiou of! lAY with either cirrhosis or bepatoceUular carcinoma, as tltere Is for Hepatitis Band C. Hepatitis B is tra.nsmittcd by parenteral and sexual contact. Risk factors iuclude multiple sexual panners, intravenous drug abuse, and receipt of blood products. The signs and ;yn1ptoms are simil~r to hepatitis A {/i!ver. aiNinmirml pain, nausea, etcJ but there is a longer incuba!ion period (6-8 weeks). The syntptoms are slowr in dcve!Qping but are of a longer duration. Most patients recover fully; howover, some develop chronic lfver disease.
I. An increased serum level of transaminase~ often indicates hepotocellulllr damnge. 2. The pre.~encc Surface antigen (A or B) in a patient's serum indicates that

or

tbe patient is poteotially infectious for Hepatitis (carrier state), 3. Hepatitis viruses are very heat-resistant (more so than the 1tlDS vim. ). 4. Proper autoclaving will kill these viruses.

It is lnic<'

:J'

cununun in \HUJICII ali in

m~u

This false.; it is twice as common in men os in women. Cirrhosis [s characterized anatomically by widespread nodules in the liver combined with fibrosis. The fibrosis and nodule formation causes distortion of the normal liver architet:ture which interferes with blood flow through the liver. Importan t: Cirrhosis i :lSSOciated with an increased incidence of hepatoceU nlar carcinoma. Among people ages 45-65, cirrhosis is the third most common canse of death, after beru1 disease and cancer. Cirrhosis often bas many compliCIItiun.s, including nccutnulation of fluid in the abdomen (ascites), bleeding disorders (coagulaparhy), increased pres.~ure in the blood vcssd~ (rmrtal ltypertension), and confusion or a change in ll1c levdl of consciousness (hepatil' encepiJalopat/ly). Causes of clrrhosl.s: Alcohol abuse: most common cause Chronic congestive bean failure Chronic viral hepadtis 13. C and D Pru-asltic infections (e.g., sc/ristosomiasfs) Inherited mctab<llic diseases Nonalcoholic steatuhepatitis (liver ir!fla(e. g., hemodnvmalosis, W'uson diease) moriontll/11 cull be ea11sed by./atty liver) 01ronic bile duct diseases Long term exposure to toxins or drugs (e. g. prlml1ly biliary cirrhosis) Signs of hepatic failure: Men with cirrhosis of the liver often develop IO'Jiecomasti from increased production of estrogens. Flapping tremor (AsterWs): this tremor commonly results from liver foil11re. Hypoalbuminemia: low albumin level. Spider telangiectasias or spider angiomas: small lesions on the skin containing a centrally dilated, enlarged. blood vessel from which several smaller vessels radiote.

(MICROBIOLOGY I PATHOLOGY

Log Disord)

\.

Which type of emphysema is associated with aging and alpha1-ant.itrypsin deficiency?

Paraseptal (distal acinar) Centriacinar (centrilobular) Panacinar (pan/obular)

109 Copyright C) 2009-201 0 DttnaJ Dttl:s

(MICROBIOLOGY I PATHOLOGY

Lng Disord)

( \.
Bronchiectasis

Hyperplasia of bronchial submucosal glands is the characteristic pathologic change in:

Chronic bronchitis Emphysema Bronchial asthma

110
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20092010 Dental Occb

P~m:u~imtr

(punlohulur)

Emphysema is a fonn of chronic nbslruc<ivc pulmonary disease (COPD) <hal involves damage to the air sacs (~l~oeoli), The air -"'CS an: unable to completely det1ate (ilypelinj/ation) and nre thcr<> fore unable to lill with fresh air to ensure adequa1e oxygen supply to the body. A pcn;on with emphysema will hove labord breathing and an increased susceptibility to infection.l11is person
has two basic problems: the lungs are ''fixf"d~ in inspitalion and the respiratory surfaces- or the lungs have deteriorated so much that they ure no longer adequate to accomplish nonnal g as exchange. Important: Obstruction. results rrom tissue ehanges rather than moc.os production, which uccurs in asthma and chronic bronchltis. The distinguishing cllaracteristic of emphysema is air flow limitalio.n caused hy lack or tlastk r~coiJ in the lungs. Emphysema als-o catt.'\eS au incrt.mse in lung

compllan<e. ComplJaoce is the volume change per unit ofpre"ure change across an elastic structute.

Three types of Emphysema! 1. Pan acinar (palllohul<ll'): destroys alveoli and alveolar ducts: lower lobes of lungs mosliy
affected; associated with aging nml olpho1-ontltrypsin deficiency. 2. Parascptal (di.twl ut:inar): connnonly tiiU!itS spontaneous pneumothomx In yow'S adulL~. 3. Ccntriaclnar (ccntn'lobufar): assoti1Utd wlth chrome bronchitis .and smoking; destroys

respiratury bronchioles; upper lobes of lungs mostly affected.

-, I. Cigaretle smoking is by far tlte most common cause ot' emphysema.
L'ntes' 2. A naturally occu.rring subshmcc in lbe lungs called alphar antilrypsia may protect

a,gainst emphysema

Peopl~; with alpha 1 ..

antitrypsin defic.1eucy ""are at an increased risk

for this disease. 3. Symp1oms of emphysema include shorU>ess of breath. cough and a limited exercise
tolerance. 4. Emphysema and chronic bronchitis frequently co-exist together to comprise chronic obstructive pulmonary disease (COPD).

Chronic

hrnnchili~

COPD is defined as a disease state characterized by the presence of airOow obstructlon due to chronic bronchitis or emphysema. ln most cases, chronic bronchitis and c!111physema occur together. Chronic brtlnchiHs is defined clinically as the presence of a chronic productive cough for 3 months during each of2 consecutive years. Note: COPD can and does often times overlap with asthma and bronchiectasis.
( llrunk ot ... lrurlhl' l'uhnon:u \
l)j<;,:.J\,('

Olsordtr
8ronchill1 u.siluna

P111hologlt

rindlo~

Bronchial !lmoo411 rnu.scte bypc:ruopby: hypetplasia ofbront:hial subsm.W:05.1J

gl:lnd$1t11d ~obJet ceUs: ai.rways are pJ\AUcd by Vi!>Cld IIIUCU!; COilLnining.

. .
.

K.cy reatul'es
l?.xpfratory wb~CT.ing
~trill$[<: (trigg"-rfd b>1 alf~rge111)

fhtri'nSit (lriggJI'I!JI by c(J/tl. e:rt-'r"ais& )

C\us..:hrnann spir.sls, oosinol)llil.~ Md

OwcotLt-ydtl'l crystals

Chronic:. bronclrllis

H)'pcrplsJ;ia ofbtcln(:hiiSI ~ubmucosa.l gll!nd$, leading 1 _ 0 i1~eJ Rdd index

(tht rutin ofth-Cf thfckn~ of1116 gland luycr lo Ihat ()j the broncltia/-..1101/)

Ulue blotuen; 0\roni:: -lnitation I infrctioo.o;

EmphY'<f!l4

Abnorm:1l djJotion
1~ c:Jas:ticity

ur llir 5plle(S. with

reduced

~ruetion of~'.:olar walls:

. .

Pink J~Ur,tfs, b:ttn'l chest

Bronch1ec1ui:s

Abnorm:!.lly dilated br(mtli 6Ucd Wlth

mucus end ne\llraphlls: inO-nrnmahoo

end necrosis ofbronehiaJ tva.Us and al\'tQiar fibrosis

Cupiows. punilent spuuun. hemOply <is

Resu11 otcla-on\c mfrctions

Important: 1) Cigarette smoking is the grctcst cusc of COPD 2) Secondary pulmonary hypertension is most often caused by COI'D.

(MICROBIOLOGY I PATHOLOGY

Lng Disord)

Extrinsic asthma is due to:

Type I hypersensitivity reaction of the airways Type II hypersensitivity reaction of the airways Type Ill hypersensitivity reaction of the airways Type IV hypersensitivity reaction of the airways

111
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(MICROBIOLOGY I PATHOLOGY

Lng Disord)

Left-sided congestive heart failure results in:

Bronchiectasis Chronic bronchitis Atelectasis Puhnonary edema

112

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T~ fH.' I li~ prr ..tusitl\ it) nactinn uf fhl nin\ a~ ~

Asth~nu 1.s a chron1c rcathve a1rwuy disorder that causes ~'Pisodic airwav obstruction. Such obstruction results from bro"ehospasms-~ Increased l;l1UCus secretion 1:1~ mucosa:1 edema Ahhuugb thb;: common condition can sLrike l\t any age, half of aJI ca.~ first occur in cbi1dre 1~ under age ten~ in I his age group asthma affects twice as many boys thun girls. 1\vo types or 115lbmn: I. l::xtrinsic ffn11111me) u.tbmo: is mC<Iiated by type f hypersonsitivity response involving lgE bound to ma cell;, Disease begins in ohildllood. usually in patients with family histucy of

allergy.

2. lotrin.sfe: {lwuimmuue) asthma: includes asthma assodtttcd wilh v;uients such as cxoer dse cold air, lobHceo smoke, re~pirJtory infections. etc. It usually begins in aduh Hfe 1tnd is- 110;

associated wilh a histocy ur allergy.

fntport$1\t:. There is marktd episodic dyspnea and whec>:Jng expiration caused by narrow" tng of the auways.
Cb.roni~ hJ"Odthitis is a very coounon, debilitating resplrotory disease. chamcleJ 1~et1 by increa~ed p~o~uctlo~ of muc?u.c; by th~ glands of the- 1rachea ~nd bronc hr. This: c:ond.itiCln has a strong a$SOflation_wJth srnokmg. ~or pulmon?lt' (e.nlarge.melll q{tlle tight wntricle nftlte heart). airway narrow aug. and ohstrucl(on ulong With squamous metaplasia of fhc bronchial ln.-t arc common

re-sults of chronic bronchitis.

R~mct?ber: The c:hancterl$tiC IJ~t,IJolo~orrie: cll!lnge in chronic. bronchitis is hyperplnsb of brt>nthtal ~ul~mucosal glilold> and bronchml sm~lh muscle hypertrophy, which caJ> he <tUMrifted by lbe Heod ondex, a cmo u of glandular layoc !h1ckue.. to bronchial w~ll lhicl'lless.

Jmp?11a.nt: 1-'alie;tt$ With chronic bronchitis rnay be predi.SIJOSt!d to lwlg CDncc;r (brom:/wgenic
C(iramoma).

em~olt~m all

Note: ~ chronjc lung abst.css-, TB, lobar pnt:unto11{a, bronchogeulc carcinomas, and pulmonary p~cscut with (l productive cough (a coug!J nmwi11ing .pumm). Ttus sputum oonttuns mucu..~. cellular de.b1is, bacteria. and 111 t1y contain blood or pus.

rulnwn:u ~ l'dcma

Pulmonary edema is the accumulation of fluid in the extravascular spucc'l; of !he luuy. II is wmaUy caused by beurt failure (left-sided) that r~sults in incre>lsed pressure in the pulmonary veiru;. The fi1iling hc.art lri1Jl$rnit' Hs increased pressure to the luug veins. As pressore in the lung veins rises, Ouid is pushed into the air spaces (alveoli). Thi~ fluid then become,, a barrier to normal oxygen exchange. resulling in shortness of breath. Physiologically. pulmonary edema is caused by: Increased hydrosllltio pressure, as a re.'l!lt of ten venuicular failute or mirral stenosis lncreased alveolar capillary pcrmCIIbillry, as in inflammatory alveolar reactions. resulting from inhalation of btitant gases, pneumonia, shock. sepis, pancreatitis, uremia, or dmg overdose The e"rly symptoms of pulmqnary edema include dyspnea, onhopuea, and coughing. Clini~al features include tachycardia. U!chyJmell. dep~ndenl cruckJes, and lle<lk win distension. The treatment is designed to reduce extravascular Ouid, to. improve gas exchange and \teart function (i.e.. o~ygen. diure.tics. vasopres;ors, positive iuolropic agents (lnd aurfarrhythmic.w). Jlrnnchiectasls is an irrever sible, abnormal dilatation of the bronchi or broochiCll<S caused by destruction of their snpporti.ng stmctures by a chronic necrotizing in foetion. It is conunon in childreJI with ystlc fibrosis. Most conunou symptom is a chronic, productive cou~h with a fouHmelllog, purulent sputum. Recurrent pulmonury illfeetiou may l ~ad to lung nbsccss. Note: Bronchiectasis most o1len invloves th" loWtr lobes of both lungs. Atelectasis is a shrunken and aitless stale of Ote lung. or portion of it. Thi~ is due to faihlfe of expnnsion or resorption of nir from the alveoli. Common in premature infonts due to a lack of surfactant. Known as atelectasis neonatorum.

(MICROBIOLOGY I PATHOLOGY

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Malabsorption offat soluble vitamins is likely in most patients with:

Von Hippei-Lindau disease Cystic fibrosis Marfan's syndrome Familial hypercholesterolemia

113

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Which of the following is caused by the inhalation of carbon dust?

Asbestosis Silicosis Coal workers' pneumowniosis Anthracosis

114

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Cystic fibrosis is a generalized dysfunction or the cxocrlu e ghmds that aJlocts multiple organ systems. It is .an inherited disease that affects sodiunt ch!UUJels in the body and causes respiratory and digestive problem>'. It is the mo<t onmmon fatol geuellc dist,.se in while children. Cystk 1\brosis affeCls the mucus and sweat glands of dte body and is caused by a defective gene. 'fhick muc'lls is fonncd in the breathing pussnges of t~e luugs and this Qredisposes the perSon to lung infections. CF affects males and females nd now carries ~ life expectancy of 28 yearS. Complications of L'}'~tic fibrosis illdude chronic pulmonary disease. pnnctc>~tio insullicicncy, and meconium ileus 111 /(m11 of itr/118/fna/ ob.<t1'tlctiOII in tewboms). l mport.1Rt: Patients with cystic iibrosis often have intpmred exoorino p!U)cre<t$ f\mclion. resulting in a ddiciency of rot-soluble vitamins. L The caose is mutations in 1~~ cystle fibrosl~ trao.s membrune oonduchmcc N o r~ regtJlar (CFTR) gene, 1vbich has lx:cu ltx:alizetl to the mld<eotion of the lOti!\ ;Jml of chromosome 7. This gene codes tor a membrane protem that facilitates the movement of chloride and oilier ions cmss membranes. 2. The sweat test is an important diagnostic procedure. Secretion by sweat glan<i!l of chloride and sodium is normal, but t~eir re11bsorption by sweat duct< is impaired. Von liippel-Liodau disease is characterized by beruaog<owas dlhe retina and Ure cerebellum. Also associated 'vith cysts of the liver, kidney, >1drenal glun<i!l, and pancreas. Marran's ~ytadrOme is an uncommon heredilary connec1ive tissue disord!!r that results in abnonnlities of the eyes. bones. heart, and blood vessels. Ptttieots ure tall n<.l tl>in with abnonnally long legs and nns and spider..Jike fingers. FamiUal Hypercholesterolemia is a genetic defect chamcterized by noomaUes ofreceptors for low density lipoprotein (LDL reo<ptots). Can result in atherosclerosis and its complicat-

ions.

\nthr:u:usis

Pneumoconioses ure envirorm1entai diseases cs~>ed by prOlonged inhalation of inorgonie dust particles. These diseases lend to fibrosis or th ltlllgS. 1ho m.uin symptoms nre chronic dry cough and shortness of breath. Specific types of pncumoconio~c:. inclttde~ 1. Anthracosis; is caused by the inhalation of carbon dut. Chamcterized hy cnrboncarryi ng mucrophs~:cs, it results in irregulat black patcht$ vi>i~le on gross 1npection. 2. Coal worlters' pneumoconiosis: is caUSlltl by the inhalation of coal dust, wWcb contains both carbon and silica. '1\vo forms: Simple: is marked by eo~l macules around tbe broochloles. lu most C!lBes, it produces no disallilily. Progressive ntQSSive fibrosis: is marked by fibrotic nodules filled with necroric black Ouid. It can re>'lll in bronchiectasis, pu.l.lllouary byportere<ion or doath from respiratory failure or rigbl-si<.le<.l heart fai Iuse. 3. Silicosis (stone mason j disease): is caused by the inhalation offt ee silica dust. It is characterized by silicotic nodules that eolarge aod eveurually obSll'\lCl the airways nod blood vessels. Lt is the mos t w mmun and most serious pneumoconiosis and is ru;sQciated with increased susceptibility to TB (r~{erred to as silicotuberculosis). 4, Asbestosis is caused by the. the inhalation of asbestos J1bers. Jt leads to dJITu~e in terStitial fibrosis, roalnJy tD U\e tower lobes. Jl is characteri7.ed by f'llmtginO\IS bodies (yellow-bmwl/, rod-shnped bodies thul stain wilh Pms.vian blue). Asbestosis results in marked predisposition to bronchogenic carcinom a outtl t<> mall~nuot mesothelioma of tit~ pleura ur perit< )neum. 5. Beryliosis: is caused by the inhalation of herylium particles. l t is a systemic granulomatous disorder cbsraclerizcd by nQncaseating granulomas and ptlmary pulmonary involvement, [t mimics sarcoidosis.

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or the three morphologic types of pneumonia, which is

most often caused by Streptococcus pneumooja?

Lobar pneumonia
Bronchopneumonia

Interstitial pneumonia

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Which of the following are most often responsible for lung abscesses?

Proteus

Klebsiella Staphylococci Pseudomonas

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l .ubnr pm. unHUJia

Pn~wnonin

is an inflammatory process of Infectious origin affecting the pulmonary parenchyma. lL is characterized by chills and fe,er, productive cough, blood-tinged or rusty sputum, hypoxia with a shortness of breath, and sometimes cyanosis. There are 3 uwrpbotoglc types of pneumonia: Bacterialpneumooins: I. Lobar pncuwuuln: is must often caused by Streptococcus pneumoniae. lt is characterized by a predom~taotly lutrs-11lvootar exudate, with inflammation and C<lnsoli(!ntion of a lobe or entire lung. h iltTects middlc:-aged persons. 2. Bronchopneumonia: is Cllused by a wide variety of 011;anisms (i.e., Stuphyloroccus aureu.\' HaemopM/us injltte.IJt.ue, Kleb.viellu, Streplucoccus pyugene.f), ll is chsracltrized by a patchy distribution involving one or more lobes, with an inflaUllllalory iuJJitrate extending from the bronchioles into the adjncent alveoli. tlafibcts infants and the elclerly. 3. Interstitial pncnmonto: is caused by vanous infeclious agents, most commonly Mycoplasma pncumoniae or vintses (I.e., RSV. tule!lulintses). ll is cbamcterizetl by dif. fuse, patchy inflammation localized to interstitial areas of alveolar walls. llaCfe.:ts youug
1

children. I. Bacterial pneumonia. tend "' he the most serious. ln adui!S, bacteria ere the Not"' most corumoo cause, and of these Streptococcus pneumoniae (p/reMrococcus) is tht mo>L common. lt i~ ~1e most common fatal infection acquired in the hospital.
2. l11e virulence of the pneumoco.:cus is associated witb Its capsular polysaccharide, 3~ Respiratory viruses (i.e..iJI}luolt=a '';ruses. adeno~+;nt.:,es, rhinovirus. and RSV) are the most common l:liUses of poewnoniu in young children, peaking between the ages of2 aud 3. 4. CUulcal findings in pneumoula: crackles on aW!cult~tion, bypo~ia 1!11d infiltrate on chest x-ray.

ShJ il h ~ lncm:c-i

is characterized l>y destruction of lung tissue fonning" mvlty, The cavity is filled with pus (necrotic debris I liquid) or pus. and gas (air). The content of tho abscess is extremely foul smelling. A variety of microorganisms may cause a luug abscess, but more than 60% ofcases are associated with anaerobic organisms found nom1ally in the oral cavity. These bacteria predominate in 1he upper respirntory tract and ate heavily concentrated in areas of oral~ngival disease. There are many mechanisms for the dcvelopn1ent of u lung abscess but d\e most frequent is aspiration of infective (contaminnted with micrrmrgaui:mt.v} mate rial. often in the Sl!tling of altererl consciousness. Other causes include: bronchial obstmctiou (often by cancet) bronchiectasi:~, or perhaps be a complication of bacterial pntrumonia, hn110rtllnt: Alcoholism is the single most common condition predisposing to hmg abscess . .Persons suffering from drug overdosage, wong with epiloptics, ~nd p~tionts with neurologit:: dysfunction impairing the gag reflex are also at risk.

A lung abscess is a localized area of liquefactive necrosis or th~ lung. The

ab~ess

1. Almost all patients with a lung abscess present with a cough and fever.
Note ., 2. One of the most characteristic clinical manifestations is the production of

large amounts of a roul-smellin~, pundent spuhun. 3. Dyspnea, chest pain, and cyanosis may be presenl Chest x ray reveals fluid fillod CU\ity. 4. Frequent causes include staphylococci, pseudomonas, klebsiella, and prottU.5, often i.11 combination with anaerobic organisms.

(MICROBIOLOGY I PATHOLOGY

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Which of tbe following clinical variants of malignant melanoma bas the poorest prognosis?

Lentigo maligna melanoma Superficial spreading melanoma Nodular melanoma Acral-lentiginous melanoma

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The classic history of a patient with a pheochromocytoma includes spells characterized b y - - - - - - - - - -- - in association with severe hypertension-

Polyuria, polydipsia, and weight loss Ketoacidosis, headaches, and polyuria Headaches, palpitations, and diaphoresis Palpitations, polydipsia, and hypotension

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Mnliguant melanoma involves the cclls (melanocyles} that produce pigment (melanin), which is responsible for skin and hail' color. Melanoma can spread very rnpidly and is tht mo~t deadly Corm of skin cancer. his the leading cause of death from skin disease .. Melanoma may appear Olt 1\0lill~l ;kin, or il may begin at a mole (nevr<<) or other arca that has changed in appearance. Sonte moles present at binh may develop into molanomas. The dcvclopmcnl of melanoma is related to sun exposure, particularly to sunburns during childhood, and is mo>t common among pooplc with fair skin, blue or &>reen eyes.. and red or blonde hair. Growth phases: Radil (initial pha.<c) There is growtl>in nll (llr.."<ltionl but is predominantly lateral Wilhin the cpidom>i; and papWary zone of the derrn1s lymphocyte respon.sc is promiucnt Melanomas in the radial gr<>wth phase do nut metastasize V~Crticn l (lmer p}uise) Growth extends into the rttlct.t1ar dermia or bGyond Prognosis vari.,; wilh th< depth uf tioe lesion lymphatics or hcmatogenou!; metost.nsis m~y occur CUnlc:tl v~~rinls of malignant melanoma: Super!icilll spronding molanomu is tl1t most eomruon type of metat>om~. lti$ usually iiTOgularly boruercd with laried pigmentation, Most fr<XJ"""tt hx:ations are lbe trunk and extremities. Radial growth phase predomhtute. Nodular melanoma begins with the vertic<~l growth phase. Poorest prognosis. Lentigo malign a melanoma occurs on sun-exposed skin. The radial growtit phase predominates. MO$t ofleJt develops from pre-existing lentigo maligns (Hutc.hinson freckle). Acntl-IenHgiuous melanoma is the. least common form of melanoma. It mO!it often appt<l!s on the hands and feel of dark-skinned persons.

Hcadat'hr\.

palpiCatiou~.

:1ud diuplwresis

J>heochromocyloma is a rare catccbolamine-$eereting 11mor derived from chromaffin ceUs of the adrcn~l medulla. Catooholamines lypically s~creted, either intermittently or
comlnuou~ly, include norepinephrine and cpioephrioe an(l rarely dopamine. Because of excessive catecholamine ~ecrct$on, pheochromocytomas may precipitale life-threatening hypertension or cardiac arrhythmias. If lhe diagnosis of a pheochromocytoma is OVerlooked, the consequences CO\tld be disaSirOUS, even fota\; UOWeVer. if a pheochrO mocytoma is fouud, it is potentially cumble, 1l1ese twnors are uncommon, ofien benign, and may occur in mon or women at aoy age, bm are most collUllou between agc.5 30 nnd 60. Tfthe tumor is derived from extra-adrenal chromaft1o cells, it is called a paraganglioma (metastasis is more cummu11 in thi$ tumor). Pheochromocytoma may be a part of or IL~sociated with MEN (multiple endocrine neoplasia), neurofibromatosis (von RecklinghmiSell :, disease), or von HippleLindau dise8$e (11ttltiple hemangiomas). Increased urinary excretion of catecholamim::; and their metabollres (lltNancphrine, normetanephrine. a11d wMiliYIIIIa/ldelic acid) is characteristic. '' can also cause hyper glyC1Jmia. - I. A neuroblostoms is a higWy malignant catecholamine-producing tumor of Notro early childhood lbattL,ually originates in 1hc adronal medulla. It is the most common mallgo11nt tumor of childhood and infancy. Complications include invasion of abdominal organs by direct spread and metastasis to l.iver, lung or bone. ihe first symptoms in many children include a large abdomeu, a sellSa tion of fullness, and abdominal pain. This is followed by an 11bdominal mass. This lllmorcauses hypertension. Oe<;asionally this twnor convens into a more diffcre.ntinted tbnn termed ganglioneuroma.

(MICROBIOLOGY I PATHOLOGY

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( Most bronchogenic carcinomas form a mass in or near the hilus. Which ..... \!:_lstologic type has a tendency to form a moss in the periphery of the lung!.-

Epidermoid (squamous cell) carcinoma Adeoocarcinoma Small cell (oat cell) carcinoma Large cell (anaplastic) carcinoma

11t
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Malignant lymphomas (Non-Hodgkin ~ lymphomas) :

Are two to three times more common in females

Are two to three times more common in males

Occur only in children None of tbe above

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Bronchogenic ( &rtf noma is a malignant neoplasm of Ihe lung -arising from the epithelium of lbc bronchus or bronchiole. BronChogenic carcinoma:; begiu ilS a small focu.o;- of ~cypical epithelia) cells wnhin 1he bronchial rntcosa. As the lesion progresses, the ntypin becomes malignant and tho nooplasm grows in size. Tile neoplasm may grow into the. b o,cbiallumen, along the mucosa or into the broncbial wall and adjacent lung parenchyma. Eventually lhc neoplasm spreads to regional lymth node and di.cant orgaM suQh as tho livo,. brnin and bone. Most bronchogenic c=inomas fo1m a mnss in or near the hilus. Some neoplasms. especially the adenocarcinomas~ fonn a mass in the periphery the luug,

or

Major histologic t)pes of bronchogenic ear"inoma: " Epidermoid (squatmms cell) carcinoma: mo:~t arise in or near the hilus; appears as a hilar milSS and often undcrgocsventrnl cavitntio11. huporlant: This n~oplasnt is most common in men a11d ls closd y relatM to smoking. Adenocarcinoma: rend robe smaller than other bronchogcmc carcinomas and located in dte periphery of \he lung. A distinctive typeofadeMOOroinoma is bronrhiolontveolar carcinoma. lmportant: ihis neoplasm js the. mos1 commo1 l tYPe in women and non~smokcni. SmaU cell (oar cell) '"' rclnumo: most arise i11 or ncar the hilus; it is the most aggressh~ form and !IIghty malignant. Most commonly ntTeeis men (ISO%), and 90% of them are cigllfc'ltc smokers. Important: '11tis nooplasm is strongly related to smoking. II is a very aggressive neoplasm, generally having m~mstasizcd at the rime of diagnosis. Note: The oat ceU tbat is obsc"rvcd in these crucinomas is a shorL bluntly spindle-shaped, anaplastic cell containing a relotlvely lllr~c, byperehromatic IJUcleus with litllc or no oytoplas01. Lar~e t ell (auaplimic) carcinoma: composed of large, undiffcrcntiaied malignant cells; variable location (periplemt ur centml). Note: Wl~1 all of the above. tho major findings are cough, we1ght loss, chest pain and dyspnea,

..\n l\\n rn thn.t

finw~o

nwrl' cnnunnn in nUtll'"'

Tltcse malignant neoplasms arise from lymphoid cells or other cells native to lymphoid tissue. They originate most freq uently witbm lymph noae.< or other lymphoid nreas. Titese lltmors do not spread in a contlguou~ manner. The cause of malignant lymphomas is nnknowu, alt~ougb some researchers sus,gest a viral source. They occur ill aU age-groups. Malig)lant lymphomas present as circumscribed soUd 1\tmors composed of ceU s tbat appear primitive or re.~emble lymphocytes, plasma cells, or bisciocytes. Usu~lly tllo tlr$t lndio:tllon of mailgnant lymphoma is swelling of the lymph glands, enlarged ton>ils and adenoids, and painless, rubbery nodes ill ~te cervical supraclaviculnr artas. As tho lymp11omn progresses, the p~tienl develops symptoms spedfie to tlte area involved and systemic compl.W.ts <!! fatigue, malaise, we)ght III$S, fever, un(lnight sweats, lmportnut: Durldtt lym]Jhoma is au aggressive B-ccll lymphQtnn. The African fonn frequently involves the maxilla or mandible; tbe American form usually involves abdominal organs. There is a close linkage ro Epsteiu-Darr Virus in fection (espe<'ially ilr tire African varie(y). ...,_ I. Mtt.lignnm lymphoma is pathopllysiologically similar to Hodgkin's disl!>1sc,
Ncu.,. bm Reed-Sternberg cells are not present, &nd the specific mechanism of

lyn1ph node desmtction is differem. 2. Histologk characteristics of malignant lymphoma include a "starry-sk~" appearance uf non-ncopll!..~tic macrophages. 3. There appcar8 to be a relationship between tlift'use lymphocytic Jymphomp and chronic lymphocytic leukemia (CLL). 4. Biopsy diffe.rentiutes malignant lymphoma from Hodgkin 's disease.

(MICROBIOLOGY I PATHOLOGY

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Which of the following is the most common of the cutaneous T-celllympbomas?

Sezary syndrome Burkitt lymphoma (African form) Burkitt lymphoma (American form) Mycosis fungoides

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\.

Invasion of the dermis by sheets and islands of neoplastic epidermal cells, often with "keratin pearls," is charactcrisitic of:

Squamous cell carcinoma Basal cell carcinoma Malignant melanoma

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\ 1~cosi\

rungoi<ks

Cutaneous T-cell lymphoma is a disease caused when T-Lympbocytes become malignant and affect the skin. Cutaneous T-een lymphoma usually is a slow-growing cancer that often develops over many years. M ycosis fungoides is the most common of the cutaneous T-coll lymphomas. Sezary syndrome, a more rare fonn, occurs in about 5% of all cases of mycosis fungoides. Mycosis fungoides affects men twice as often as women. and is more common in black poople than in whites. It can begin at any age, but the most common age is 50 years old. The cause of tbe disease is unknown. Sezary syndrome is characterized by the combination of skin lesions and c[rculating nooplastic cells with cerebriform nuclei. Remember: Burkitt's lymphoma ~< au aggressive B-cell lymphoma. It is classified a.~ a Nonllodgkin's t.ype of lymphoma. Non-Hodgkin's lymphomas are a gt'Ollp of relmed malignancies t~at originate most frequently within lympb nodes and usually sprt-ad throughout lh<> body. They are characterized by tlte absence. of Recd.Stcrnbcrg cells. Non-Hodgkin's lyn1phomas arc more common than Hodgkin's disease. Two forms ofBurkiu lymphoma: African fo~m Is closely associated with the EBY (95% of cases) . Atl'ects chi ldren of tl1e middle African regions. Usually begins as a large mass in the j nw. American form is less closely associated with EBV: Usually begins as an abdom-

inal mass; tumors of the jaw are rare.

Squ:lnwus cell carcinuma

Squamous cell cancer involves cancerous changes to the cells (keratinoeytcs) of the middle ponion of the epidemml skin layer. Jt is usually painless initially, but may become painful with tho dcvolopment 1>f ulcers that do not heal. TI1is cancer may begin in uonnal skin; in the skin of a bum, injury or scar; or at a site of chronic inflammarion (which may oocur with mrmy skin disorders). It most often originates from sun-damaged skiu areas, such as acUulc kerato~ls. It tL'uaUy begins afier age 50. Squamous cell callcer is a malignant tumor. Jt fs more. aggressive than basal cell cancet, but still may be relatively slow-growing. lt occws most frequently in suu-exposed llreas sucb as the face and buck of tbe hll!lds; in contrast to basal cell carcinoma, squamous cell carcinoma tends to involve the lower part of the face. lt is more likely than basal cell cancer to spread (merastasize) to other locations, including inlcmal organs.
1. SCC is also associated with chemical carcinogens, such as arsenic. and radiNotes' ation or x-ray exposure. 2. It is most of\en locally invasive ; ltowever, SCC can infiltrate underlying ti~ sue or metastMize in lymphatic channels. Treatment consists of complete excision or radiation lhet'8py. 3. sec resembles cer vical cancer in histologic appearance and biologic behavior. 4. Maligoat1l epithelial ceUs have an increa>ed number of laminin receptors. Laminin (a glycoproreill) is a major component of basement membranes and has numerous biological activities including promotion orcell adhesion, migration. growth, and difte.rentiatioo. 5, Squamous ceU carcinoma accounl5 for 90% of all diagnosed malignant cancers of the oral cavity.

(MICROBIOLOGY I PATHOLOGY

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(
\.

All of the following statements concerning basal cell carcinoma are true EXCEPT one. Which one is the EXCEPTIOJ V!

It almost never metastasizes It can be locally aggressive, ulcerate, and bleed It is a fast-growing, relatively benign skin tumor It is the most conunon malignant tumor of the skin It is almost always cured by surgical resection

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Which of the following interacts with water or with living tissue and forms highly reactive ions called free radicals, which then react with other molecules, including DNA resulting in car cinogenic and mutagenic effects?

An alkylating agent
Ultraviolet light

A virus
Ionizing radiation

CopyrightO 2009-2010 Dental Db

 Tills is false; basal cell carcinoma Is a slow-growing, destructive skin tumor. Basal cell carcinoma i$ by far the most common malignant tttmor of the skin (it accollnts for abour 75% <I/ all skin cancers) and actually is lhe most common form of cancer in the United States. It is <loriv~d from basal cells of the epiderrni$. It tends to involve sun-exposed areas, most frequently the head and neck. In contrast to squamous cell carcinoma. it tends to involve the upper part of the fnte. Tbe tumor is invasive. ulce.ratlve, often Indurated, and locally destructive but docs not melastasizc. Classically, il is described as a smooth. pearly-shaped lump often with small veins (te/(JJ)gectasia) snaking around the surface. Depending on where and how long it bas been there, BCC can look very different. Left untreated, BCC can eat away at the s~in, making it look as If a rat had chewed at it. Tllis type ofBCC is called a "rodent ulcer". Tite prognosis for BCC is good. The neoplasm can usually be cured by surgkaJ rc'SecBasal cells arc normal skin cells. They may develop cancerous changes, causing a lump or bump that is painless. A uew skin growth that ulcerates, bleeds e~sily, or does not hen I welt may indicate development of basal cell skin cancer. Imporlant: Histologically, basal cell carcinoma is characterized by clusters of darkly staining basaloid cells with a typical 11lisade arrangement of the uuclef of the cells at the periphery of lhe tumor ceU clusters.
I. The incidence of skin cancer hall incre.,.ed greatl y in recent years, due in prut
/ /Solos

to greater exposure to UV radiation from the sun.

2. Malignant melanoma is considered to be lhe most severe tumor oflhe skilL

l cu1i:1ing adialinn

A mutation is a stable, heritable change in the nucleotide sequence of genetic nucleic acid (DNA), resulting in an alteration in the products coded for by the gene. Mutations result from three types of molecular change: I. Base substitutions: one base is inserted in place of another; results in either a missense mutation or a nonsense mutation. 2. Frame shift mutation: occurs when one or more base pairs are added or delete<L 3. 'l'ronsposous (Insertion sequences} or deletions are integrated into the DNA. Mutations are caused by: Chemicals: nitrous oxide and alkylat:ing agents alter lhe ex,iting bll-'e; bl!.llzpyrene. (formd In tobacco smoke) binds to existing DNA bases and causes framc.shifi mutations. Ionizing radiation (gamma and < -rays): produce free radicab that can attack DNA bases. tJltraviolct lightt has lower energy than x-mys, causes rbe cross-linking of ~le adjacent pyrimidine bases w form tlimers (thymirre dimers result in inability of the DNA to replicate properly), Viruses: bacterial viru~ Mu (mutator bacteriuph11ge) causes either frnrneshi ft mutations or deletions. ImpOrtant: Cells witlJ high prolifertion are more sensitive to radiation Higb radiosensitive cells: Low ra<lioseusitive cells: Nerve cells Lymphocytes Mature boue coils Bone marrow blood-lbrming cells Muscle cells Reproductive ceUs Bpithelial cells of GI tract

(MICROBIOLOGY I PATHOLOGY

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)

(
Leiomyosarcoma Lymphoma
Adenocarcino ma

The most common type of colon cancer is:

Neuroendocrine tumors

125
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~

j A patient has prostate cancer. In addition to an increase in pros tate-specific ) \... antigen (PSA), which serum marker might also be ele,ated? ~

Human chorionic gonadotropin Acid phosphatase Carcinoembryonic antigen- I 25 Bence Jones protein

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Adt.noctn-inom;l

Over 95% of colon and rectal cancers are adenocarcinomas, which arise from preexisting adeoomatous polyps that develop in the nonnal colonic mucosa.
Colore<tal cancer: Second most common cancer causing death \o men Third most common cancer causing dea[b in women *** Lung cancer ranks first fo( both meo and womeo Peak age incidence is in the sixth to seventh decades There is no single cause for colon cancer. However. almost all L'Olon cancers begin as benign polyps which, over a period of many years, develop into cancers. Important: Colorectal cancer is associated with increased serum concentration of ca.rcinoembryooic antigen (CEA).
P redisposing factor$:

Adenomatous polyps Inherited multiple polyposis syndromes Long standing ulcerative colitis Genetic facors: up to a four..fold increase in incidence is noted among re.latives of patients with colon cancer A low-tiber diet that is high in animal fut
4

- - , . I. Rectal bleeding with either diarrhea. abdominal pain, and weight loss are com~

Notes' mon symptoms.

2. TI1e sigmoid colon is the most common site. 3. Tumors of the left side of the colon (descendu~g colon) usually cause constipation J obstruction and generally are diagnosed at an earlier stage than wmo.rs of the right side of the colon (ascending colon) which USU<llly do nor obstruct early.

\rid phosphatasl'

** A biopsy confinns the diagnosis of prostate cancer. PSA levels will be elevated in all, and serum acid phosphatase levels will be elevated in two-thirds of men with metastatic prostatic cancer.
Prostate cancer is a common cause of death &om cancer in men of all ages and is rbe most common cause of death from cancer in men over 75 years old. Prostate cancer is rsrely found in men younger than 40. Remember: Lt10g cancer is the number one killer from cancer in both men and women. Most prostatic tumors are adenocarcinomas that arise in peripheral glands, invade throughout tbe prostate, and may metastasize to bone and other tissues (lung>~ for etample). Common laboratory findings include elevated levels of acid phosphatase and prostate-specified antigen (PSA). Note: With the advent of PSA testing, most prostate cancers are now found before tbey cause symptoms. Nodular hyperplasia of tl1e prostate is a benit;n enlargement of the prostate due to hyperplastic nodules of stroma and glands distoning the prostate. This hyperplasia compresses the urerhrd and causes urinary tract obstruction. Complications iuclude pyelonephritis, hydronephrosis, and painful or difficult urinatio1t (dysuria). ft is not considered to be premalignant.

(MICROBIOLOGY I PATHOLOGY

Neo)
)

A leiomyoma is a:

Mal ignant tumor of mesenchymal tissue Benign tumor of epithelial tissue Mal ignant tumor of glandular epithelium Benign tumor of mesenchymal tissue

127 Cop)'liShl C 201)9..2010 Denial Oec-b

(MICROBIOLOGY I PATHOLOGY

Neo)

( \..

All of the following are well-known characteristics or associations of breast cancer EXCEPT one. Which one is the EXCEPTION?

Positive family history {.<pecifical/y in first-degree relatives)

Late menarche

A diet high in animal fats Delayed fll'St pregnancy Obesity

128
Cop)Tight 0 2009-201 0 Dental Oecl;s

Bcnil.!,n

lumur

of ntl"'i('llrh\ mnl

tb~lll'

A leiomyoma (also called a fibroid) is a bculgo tumor of the smooth muscle of lhe uteru~ aud thus ~~ an example of a benign tumor of mesenchymal origin. It may occur rutywhere in the body, but is moot frequently seen in the uterus. It i~ the most common tumor of women (20% of womeJJ o1er 30 yeiJJ'S, i/urillg the rt!prodmlie years). Other areas where they seem to occur less frequently than the uterus ltolude the stomach, esophagus, and small intestine. Tbe prognosis is good. Note: Profuse. painful menses und infertility are major ~omplications. A le.lomyosurcomu 1s the malignant cottnterp<rrt. llte cause of fibroid 1\tmos of tbe utenas is unknown. llowever, il is suggested that fibroids may e}llarge with estroget' therapy (.well as oral comracepti\es) or 'Vith pregnancy. Their growth ~cems to depend on regular estrogen ~timulation, showing up only rarely before the age of20 and sbrinking after menopause. ~ long as a woman wlth fibroids is rnenstmating. the fibroids will probably oontinue to grow, although growth is usually q11itc stow. Fibroids can be roicrosco1>ic, but they can also grow to fill t!Je uterine cavity, and may weigh several powuk Uterine t1hrnids ure the most common pelvic tumor and they may be presetlt ln 15 to 20% of roproductivo-agc women. and 30 to 4(>"A> in women over 30.
~ J. All neoplasms of muscles are rare, bui wheo encountered they are usually Nnt<,.,. mulignnnt. 2. A r habdr)myosarcoma is a malignant neopln>m derived from the ~keletal (striated) muscle. It affects the throat; bladder, prostate, or vagiua iu infants :!nd it affects I urge muscle groups of the arm and leg in the elderly. The prognosis
i~ poor. 3. 'fh<> benign variety, rhabdomyoma, can arise in any skeletal muscle of tlte body. This benign rumor produces n mnss (s11e/ling) in the affected muscle.

Latt nwnurclw
Brea~t

cancer is the most common cancer

atf~c:ting. women

and is the number IWo knler

(after lung canc01) of womeu age.,; 35 tu 5~. This rumor is almos always an adenocarcinoma. It is mre befor~ 25 and is increasingly murt' common with age \llttll menopause, 1\! which time the incidence slows down, Tho strongc'St nssociation with an increased risk. for breast cancer is o family history, specifically breast camer in tirst"<legree relat[ves (mothct; sister. tlaugirte~). Breo.\1 cancer occurs more commonly in the left brtast than the right brenst and more commonly in the outer upper quadrant. Widcst>rcad metut<lSis can occur by way of tho lymphatic !l)lstem and the bloodtroam, through th< right side or~'" heart :md longs. nod eventually to the other breat, the ~hest wall, liver. booc, :!nd bmio. PredisJ>oSing factors: Positive fumily history Ohesity History ofbre;,st cancer in one breast First pregnnncy after 30. ytars of agt Early met~orohe and late menopause Oiet bigh in animal fat Prolif~rative fibrocystic disease with ~typical epithelial hype!Jllasia A painless mpss in th~ breast is usually the initial sign or symptom; howevor, rctraouon of d1~ skJn or nipple and peau d'orange (a .vwolie11 pilred .vkrlr 3111/llce) along with enla!ll<mcnt of~te axillary lymph nodes may at so be present. Important: l,ymph uou~ involvement is tho
most vuluab)e prognostic pre(lidor,

fibrocystlc disease of rhe brensr is the most common cause of a clinically palpable breast mass in womQn 28 to 44 years old. Sig}IS aud symptoms inoludo lumpine$s througllour both breast:;.. Pain is c.ommon. "'recinlly prior to the tncnstruauon petiod. lt is not malignant, but may lead to an increm;ed chance of developing carcinoma. Note: A cborlocarcjnoma is a rapidly metaStasizing JtlaligJtant ntmor of placental1issue that typiclly causes profuse vaginal and Inn-a-abdominal bleeding. Hypere.trogcnimt is a major risk foetor for the development of eodomctri~l carcinoma.

(MICROBIOLOGY I PATHOLOGY

Neo)

Usually, the main symptom of bronchogenic carcinoma is:

A persistent cough
Diarrhea
A low grade fever

A skin rash

129 Cop)rightO 20()()..2010 Dtntal Df.eks

(MICROBIOLOGY I PATHOLOGY

Neo)

Often the first signs of lung cancer are related to metastatic spread, particularly to the:

Liver

Heart

Brain
Thyroid

130

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Bronchogenic carcinoma is the leading cause or death from cancer in both men and women. It is increasing in incidence. especiaU y in women, in parallel with cigarette smoking. Lung cancer usually develops in the wall or epithelium of the brouchinl tree. Bronchogenic carcinoma is subclassified into squamous cell carcinoma. adenocarcinoma (illcllldillg bronchioloalveolar carcinoma), small cell carcinoma. and large cell carcinoma. Other clinical manifestations may include bemoptysis, hoarsel)ess, wheezing, dyspnea, cltest pain, and weight loss. TI1is type ofcarcinoma is directly proportional in incidence to the number of cigarenes smoked daily and to the number or years of smoking. Various histologic changes, including squamous metaplasia of the respiratory epitbellum, often with atypical changes ranging from dysplasia to carcinoma in situ, precede bronchogenic carcinoma in cigarette smokers. Other lliseases due to smoking: Chronic obstructive pulmonary disease (COPD) , which iucluJes ewphysema aud cbrouic bronchitis Carcinoma of the larynx and oral cavity lncr.:ased incidence of carcinoma of the esophagus, pancreas, ktdney, and bladder Peptic ulcer disease Low birth-weight infants 1. Benzpyrene is the carcinogen in cigarette smoke Not., 2. 50% of cases are inoperable at the time of diagnosis 3. The 5-year sum val rate is less than I 0% 4. While lung cancer can spread to any organ io the body. certain organs, particularly the adrenal glands, liver, brain. and bone, are the most common sites for lung metastasis.

Lung cancer is the most common cause of dPalh from cuncor in both tnen and women. Hal.f of the cancers are inoperable by the time the patient is first seen in the hospital. Often the first signs of lung cancer are related to metastatic spread, particularly to the brain. Other common sites of lung canc<~r metastasis include the adrenal glands, liver, and bone. The route or metastasis Is through the lymphatic channels. Lung t:ancers can arise in any pa.rt of the lung, and 90%-95% of cancers of the lung arc thought to arise from the epithelial, or lining cells of the larger and smaller airways (bronchi and bronc/tioles); for this reasc.>o, lung cancers are called bronchogenic carcinomas. Cancers can also arise from tbc pleura (tile thin layer oftissue that surrounds tile lung.). c<~lled mesotheliomas, or rarely from supporting tissues within the lungs, for example, blood vessels. Pipe and cigar smoking cau also cause lung cancer, although the risk is not as high as with cigarette smoking. Whil~ someone who smokes one pack of cigarettes per day has a 25 time. ~ higher risk of developing lung cancer than a non-smoker, pipe and cigar smokers have a risk of lung cancer that is about five times that of a ttonsmoker,

Types ofbroochogcuic carcinomas: Squamous cell (Epidermoid ) carcinoma: 30% Adenocarcinoma: 40% -- is now lbe most cowmuu type Small cJI (oat cell): 20% Large cell (anaplastic): 10% - least common
Note: Lung cancer affects males more rhan females (4 ro 1).

(MICROBIOLOGY I PATHOLOGY

Neo)

Reed-Sternberg (R-S) cells are essential to tile diagnosis of:

Acute lymphoblastic leukemia Squamous cell carcinoma Multiple myeloma Hodgkin lymphoma

131 Copyri,gbtC 2009-201 0 Dental l'>eckll

(MICROBIOLOGY I PATHOLOGY

Neo)

A study Is performed to analyze characteristics of malignant neoplasms in biopsy specimens. The biopsies were performed on patients who, upon digital rectal examination, showed palpable mass lesions. Of the following microscopic findings, which is most likely to indicate that tbe neoplasm is malignant?

Pleomorphism
Atypia

Metastasis Increased nuclear I cytoplasmic ratio Necrosis

132 Cop)Titbt 0 20092010 Dental i'>,k$

l lod:,!kin

I~ mphun1:1

Hodgkin lymphoma (Hodgk/11 disease) is a malignant nwplasro with features (e.g.. fever. inflammatory Ci!/1 illjiltrates) resembling ao inflammatory disorder. Tbe first sign of this caocer is often an enlarged lymph node which appears without a kuown cause. The disease e<tn sprt-ad to adjacent lymph nodes and later may spread oucside the lymph nudes to the lungs. liver, bones, or bone marrow. The e<tusc is not known. Hodgkin lymphoma characteristically affects young adult~ (predominanlly young men); an exception is nodular sclerosis. which frequently affects young women. Important: This neoplasm is characteri<ed in all forms by the presence of Reed-Sternberg cells, which arc the acrual neoplasric cells. Symptoms include anorexia, weight loss, generalized pruritus. low-grade fever, night sweats. anemia. and leukocytosis. Prognosis is most favorable with early diagnosis and limited involvement. Lymphocyte predominance is also linked with a favorable prognosis. Note: Rood-Sternberg cells are bioucleated, or multinucleated, giant cells wilb eosinophllic Inclusion-like nucleoli. Classification of Hodgkin lymphoma: Lymphocytic-predominance: prognosis is relatively good; no a.-.ociarion with EBV infection Lymphocyric-rich: association with EllV infection; more common in men Mixed cellularity: association with EBY tnfection; fouud most often in older persons Lymphocytic depletion: least common; association wirh EBV infection and is also more common in persons with HIV; poorest prognosis Nodular sclerosis: most common; more frequently in young wmucn; presence oflatu oar ceUs (a Rced-Srem~rg cell variant); prognosis is relatively good ---.. I. Many researchers believe that Hodgkin's disease starts as au intll1Jl1D11ltory or /Notes infectious process and then becomes a neoplasm; others believe it to be an i:mmunc disorder. However, rhe etiology of the disc.asc remains an enigma. 2. Non-Hodgkin lymphoma is a malignant lymphoma characterized by the absence or Reed-Sternberg cells.

\lttasla\:is

Cl>aracteristics of benign and malignant neoplasms: Benign: Malignant: Well-di fferentiated L<lss well-differentiated (anapl11.51ic) Slow growth Rapid Growth Encapsulated I wcll-circurnscribcd Invasion Localized Metastasis Movable Immovable I mportant: Metastasis is the most important characteristic that distinguishes malignant from benign. The degree of localization is the basis of staging, which is critical to determine if a cure is likely. 11 i~ the most reliable Indicator or prognosis of maltgnant tumor:'. A vartely of staging tests are used to determine tl1e tumor's location. size, growth w to nearby structures, and whether or not it has metastasized. Note: A generalized classification system for the staging of luog cancer is the TMN system. In this ~-y~t<.m, TMN represents lhe following;

T: Tumor size (l=sm<dlestthrougl! 4 lorgesl) M: Metastasis (O=obsent, Js presem) N: Nodal involvement (!through 3 depending on severil}')

(MICROBIOLOGY I PATHOLOGY

Neo)

(
\..

The presence of Bence Jones proteins in a person's urine is associated with:

Chronic myelogenous leukemia Multiple myeloma Polycythemia Infectious mononucleosis

133 CopyrightO 2009-2010 Den1al DtW

(MICROBIOLOGY I PATHOLOGY

Neo)

Which of the follolling is a neoplasm derived from all three germ cell layers?

Carcinoma Sarcoma
Teratoma
APUDoma

134
C<IJ!rrigM 0 20092010 l>enta.l Occ.ks

\lulllplc m~clom.t Multiple myeloma is a malif,,'Dant plasma cell tumor usually affecting older persons d1at typically !nvloves bone and is associated with prominent serum and urinary protein abnonnalities. Multiple myeloma is characterized by tbe excessive growth and malfunction of plasma cells in the bone marrow. The growth of these extnt plasma ceUs interferes witb the production of red blood ceUs, white blood cells, and platelets. This causes anemia, susceptibility to infection. un increased tendency toward bleeding. As tbe cancer cells grow and expand in tlte bone marrow, tbey produce osteolytic lesions throughout tbe skeleton (flat bones, vertebrae. skull. pelvis. ribs). The bone lesions appear lucent on radiographic examiuation, with characteristic sharp borders. and are referred to as "punched-out" lesions. RcnaJ failure (kidney failure) is a frequent complication caused by excess calcium in tlte blood !hat results from bone destmction. Multiple myeloma accounts for about I% of all cancers -- mostly in meu over tlte age of
40.

The earUest Indication of multiple myeloma is severe. constant back and rib pain that increases with exercise and may be wor;;e at night. The pain arises from pressure created by malignant plasma cells on the nerves in tbe periosteum of tl1e bone. Important: The urine often contains significant quantities of free immunoglobulin light chalns, either kappa or lambda, which are referred to as llence Jone.~ protein. The absence of Bence Joues protein does not rule out multiple myeloma; however, its presence almost invariably confirms the disease. Other clinical features include: anemia, pathologic booe fractures, increased susceptibility to infection (mos1 common cause ofdeath). hypercalcemia, renal failure, and amyloidosis.

fl. r~liUIIli.l

A teratoma is a tumor composed of mulriple tissues (inuy contain elements of all three embryonic germ cell/ayers), including tissues not normally found in the organ in which they arise. It occurs most frequently in the O\'ary, where it is usually benign and fonns dermoid cysts. lr also occurs in the tc~U$, where it ls usually malignan~ and uncommonly in other sites. A carcinoma is a malignant tumor of epithelial origin. It occurs in the iollowing variations: Squamous cell carcinoma: originates from stratified squamous epithelium; is marked by tbe production of keratin. Transitional cell carcinoma: arises frorn transitional cell epithelium of the urinary
tract.

Adenocarcinoma: a carcinoma of glandular epithelium.

1. A sarcoma is a malignant tumor of mesenchymal origin. Examples include: osteosarcoma (bone) , leiomyosarcoma (.nnooth muscle). and liposarcoma (adipose tissue). 2. An APUDoma is a tumor characterized by amine precursor uptake and decarboxylation (JJ PUD) and the resultaut production of hom1one-like substances.

(MICROBIOLOGY I PATHOLOGY

Neo)
J

~' Which of the foUowing is a characteristic of malignant neoplasms in which )

\.. there is no differentiation to suggest a particular ceU type?

Dysplasia Anaplasia Metaplasia Desmoplasia

135 Copyrig:hrC 20092010 Dent:ti Oeck&

(MICROBIOLOGY I PATHOLOGY

Neo)

( A ll of the following are benign tumors of mesencbymal origin EXCEPT one.l \.. Which one is the EXCEPTION? }

Leiomyoma Rhabdomyoma Osteosarcoma

Lipoma
Fibroma Chondroma

136

Cop)'figlu o 2009-2010 Dental Decks

Differentiation IS a measureofa tumor's resemblance to normal1issue. An:lplnsia is the absence of dilfertnuatioo. Histologic features of malignancy: Anaplasia Hyperchromatism rleomorphism Abnormal mitosis The host response to a malignancy is best reflected by lymphocytic infiltration at tbe edge of the tumor. The most characteristic feature of a malignancy ''as opposed to an inflammatory lesion' is that malignancy will J;I'OW after removal of the causative agent. The most important characteristic of malignant neoplasms. which distinguishes them from berugn neoplasms, is their ability to invade and to metastaslu. Dysplasia is a type of nonmsligoant cellular gro,. th, but may precede !!lllhgnant changes in the ussue. It is associated with chronic irritation of a tissue by a chemical agent, such as dgarene smoke, or by chrome inflammatory imtation. such as chronic cervitis. The tissue appears someWhat stna ctureless and tfisorganized aJJ(l mlly consist of atyp leal cells without invasion. Epithelium exhibits acanthosis (an abnormal lhlckening ofllaeprickle cell layer). Metaplashtas the substitution of one tissue nonnally found at a site of another. It is common in the lower cS()phagos with gastroesophagcnl reflux disease (GERD). The epithelium undergoes metaplasia in response to the ongoing tnllammntion from refla~ of gastric contents The most common type of cpathelial metaplasia involves replacement of columnar cell~ by stratified squamous epithelium. Neoplasms, and malignant neoplasms in partacular, can form a fib rous stroota that gives the tumor a chamcteristic !inn or bard feel on palpation. This histologic fearure is called desmoplasia. This connective tissue can fix tlte tumor to surrounding structures.

(hh:m..tll"IHIIOI

... An osteosarcoma is a malignant rumor of mesenchymal origin. specificslly the bone. It is the most common primary maUgnan t tumor of bone.

These bemgn twnors of mesenchymal origin are most often named by the tissue of origin: Leiomyoma: derived !Tom smooth muscle. Includes the most common neoplasm of women, the uterine leiomyoma or fibroid tumor Rhabdomyoma: derived from skeleUJI muscle Lipoma: derived fmm adipose tissue. ll is tlle most common son tissue nunor Fibroma: derived from fibrous eooncctive ussue Chondroma: derived from cartilage Papilloma: derived from surface epithelium. such as S<jiU1lllOUS epithelium of tbe skin or tongue Adenoma: derived from glandular epi!hehum 1\t)'loma: derived from connective tissue

I. A chorlstoma is a small benign

ma~s

of normal tissue miSIIIacrd within

Not..- another organ, such as liver ti$SUC within the wall of the intestine.

2. A bumurtoma is a benign tumor-like overgrowth of cell types that arc regu larly found within the affected organ, such as a hemangioma. an arregulnr ae<umulntion of blood vessels.

(MICROBIOLOGY I PATHOLOGY

Neo)

Which of the following is a primitive "small blue cell malignant" tumor that most commonly affects young patients?

Ewing's sarcoma
Neuroblastoma CbondroblastOma Osteoblastoma

137 Cop)Ti&htO 2009-2010 Den1aJ Dttb

(MICROBIOLOGY I PATHOLOGY

Neo)

All of the following are benign neoplasms EXCEPT one. Which one is the EXCEPTION?

Adenoma Fibroma
Carcinoma

Hemangioma
Lipoma

138 CopyrightO 20092010 Dental Deets

 Tbo tumor Itself is composed of small round blue cell~ and is classified as a peripheral neuroMcctodermal tumor (PNT). 11tis means the: tumor may have st1med in fetal ur embryonic, tissue lha has developed intu ncrv~ tissue. Ewing's sarcoma is a cancer that occurs primarily in Ihe bone orson tissue. Ewing1ssarcoma can occur io any bone, but is most on en found in the extremities and can involve mu:wle and the soft tissues around the tumor site. Ewing's sarcoma cells can also metastasize 10 othe-r orcas of the body inclUding the bone marrow) lungs, kidneys~ heart, adrenaf gland.o;. and other soft tissuc.s. Ewings sarcoma is the second most common m11lignnnt bone tumor m children and ~tdo1cs ecots (osteogenic sun:omll.l' are tlut m(}St common). II most on en occurs in children between theages of ten and 20. The number of males affected is slightly higher thau the number of females. The majority of Ewing's sarcomas resull from a chromosome rearrangement between chromosomes 1111 and #2.2. Important: Paricnls almost always pre-Ser\1 whJl severe bone pain. The most imponant aspect of the presentation is to remember L hat it may be insidious and nuu-s. pedflc. --,. I. Cbildren may aJ so break a bone a1 the silc of the tumor after a seemingly minor trau /Not.. ma (palhologicfraclure) , 2.. Ewing's sarcoma follows an u tremcly malignant course with early metastases. 3. Histologically. it is ofi{..'Tl difficult tO distinguish tJ1is twnor from a neuroblastoma or a reticulwn cell sarcoma. 4. Morphologic.ally, it ha.< a n:scmblanc<' to maliQttant lytnpltoma. 5. Primary malignant bo11e tumors (also called Stlrcomas o..f1he boll e) are ran:. con stituting less tban 1% of aU malignant ntmors. Most bone luthors !lre secondary, caused by seeding from a primary site. Bo"e tum of$ may originate J n osseous or nonusseous lb; .sue. Osseous bone lumprs ari.s< rron1 bony stmc:ture itselfand oonosscous tumors arise from hematopoietic, vnsct~Jar. ot neural tissues. 6. l\1e-ta.static bone tumors are canc.."''"S that have lipread to bone from lhcir original site elsewhere in Ihe body. Cancers most likely to spread to bone include those of the breast, lung, prostatc1 kidney, .and thyroid.

{_ :trdnnrua

A carcinoma is an lnvasil'e malignant tumor derived from epithelial tissue that tends to metastasize 10 other areas of the body. A benign 1\tmor is characteristically localized, bas a fibrous capsule, a limited potential tor growth, a regolar shape, and cells that are well differentiated. A benign neoplasm does not invade SWTounding tissue or metaslasizc 10 distanl sites. It causes hann only by pressure. overproduction of a hormone, or hemorrhage following ulcet"'Jtions of an overlying mucosal surface. They usually do not recur after surgical excision. Important: Benign tumors grow by expansion. Mallgnant tumors spread by local invasion and metastasis. Metastasis is the spread of a mmor to a secondary sfte distant and separate from its primary site; metastasis is an absolute indicator of mallgmmcy. Metastasis occurs via lhe bloodstream, or lymph system. With lympltatic metastasis, tbe tumor first spreads to local and regional lymph nodes. From here lhc cancer disseminates via the blood. With hematogenous (blooc/slraam) metastasis, secondary tumor nodules develop in the liver, lung, brain, boue marrow, and gomelimes in the spleen t\llri soft tissue.

(MICROBIOLOGY I PATHOLOGY

Neo)

Osseous oone tumors arise from the bony structure itself and include aU of the following EXCEPT one. Which one is the EXCEPTION?

Osteogenic sarcoma Parosteal osteogenic sarcoma

Ewing's sarcoma

Chondrosarcoma Malignant giant cell tumor

139

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(MICROBIOLOGY I PATHOLOGY

Neo)

( \.

Which bone tumor of nonosseous origin is characterized by constipation and visual disturbances?

Ewing's sarcoma Fibrosarcoma

Chordoma None of the above

140 Cop)'ligbtO 2~20 10 J>tntal Df.eks

Most bone tumors arc secondary, caused by seeding from a primary site. Primary tumors are more common in males, usually children and adolescents, although some types do occur in persons betweeo ages 35 and 60. They may originate in osseous or nonosseous tissue. Osseous nmors arise from the bony structure itself; they include chondrosarcoma, malignant giant ce.ll tumor, osteogenic sarcoma (most common). and parosteal osteoge-nic sarcoma.
Nonosseous tumors arlse from hematopoietic. vascular, and neural tissues; they include

chordoma, Ewing's sarcoma, and fibrosarcoma. In children, the most common type of bone tumors are Osteogenic and Ewing's sarcomas.

Arises from OOaeforming osteoblast and bope-tlig-."$iiog uste.xlut OccursmostcQmmonly in femurbul :tl&o in tibia nod hun~: OCCII!tionally. ffi fibula, Ileum. Vertebra, OT mandible Usu~~oUy oc-:urs in males 10 to lO
Develops an surfstt ofbooc inst~d .;,tinlmor. progresses slowly Oocurs. most common!)' in diStal femur: occurs in tibi~. bumcrus, and ulnll
UiiuaiJy develops in 30 !O 40

CboOOrosan::oma

Oe\"Cf.ops from cartilage Oocsn'1 CJiuSe pain, grows slowly, and is locslly rum::nl tu1<l il1\'ll$i\c Ol~urs roostcommanly in pc:lvis, prox_itn<)l femur. ribs. and slwuldcr girdkU!iually 30 to 50
Ari~ from bolign giant ceil tu:moc Mo.:;l oommooly n Joor bnnes. e.specia.IJy in hlcc

Ma.lignantgillnt .11 tWfl<l'f

UsuaUy occurs in fc:mak!$

18 \4\ SO

Note: Bone is the thjrd most common site of met.static disease. Cancers most likely to metastasize to booe include breast, lung, prostate, thyroid and kidney.

( hurduma

Nonosseoos tumors arise fiom hematopoietic, vascular, and neural tissues.

Qrjgil\:lles in bone marrow and invades shafts of long. and Oru bones Usually affecL~ legs. most ronnonly femur, inoominate bones, ribs-, tibia. hu-merus. vertebra, and fibula; ma}' SJ)t'e'J'Id to lungs Causes inm::a.singty severe and persistec~u pain in malt$ 10 10 20
Rclativ~ly ran:; origina.tes in _fibrous tissue otbonc: iovade.s long or flat boncs (femur. tibia. and mandiblt); a,l.so inw>hes periooeum nnd O\'erlying muscle Usually de,clops in male." ngcs 30 to 40

Derived frocn embry<mic rtntMIU$ ()f 001oc.bord: pro!.oresses slowly Ckx:UIS al end of vertebrnl column and in spheno-occipilal.sacroeocG)ge-.aJ. end \'ertebral areas; c:aus.;$ conSii~rioll and vi$Ulll problems in mak::; 50 to 60

,____, l. Ewing's sarcoma is very radiosensitive and responds to chcmotberapy. INoteJJ 2. Bone tumors of osseous origin include osteogenic sarcoma (most common), parosteal osteogenic sarcoma, chondrosarcoma, and malignant giant cell tumor. 3. The most common indication of primary malignant bone tumors is bone pain, which is of great intensity at night, is associated with movement and is dull and liSuaUy localized.

(MICROBIOLOGY I PATHOLOGY

Neo)

Which of the follo\\1ng is characterized by rapid growth, about an inch in mass within weeks, followed by spontaneous resolution over 2 to 6 months in most cases? Dermatofibromas Seborrheic keratosis Acrochordon Keratoacanthoma Actinic keratosis

141 CoprrigbtC 2000..2010 rkntal Deck$

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

The Schilling test may be used to detect:

Folate deficiency Aplastic anemia

Pernicious anemja
Myelophthisic anemia

142 CopyrigbtC 20t-2010 Dental DU

"rr:IIO<Jcanlhnma

Kcraloocanthoma (KA) is n collllnon skin lllmor. In lhe pastil was regarded as benign, bul some of these rumor~ hnve been seen to lransfonn ln1o squan.nus cell rclnoma. Kem1oacanrhorna is now rel!"rde(l and treated by many as a moll~nanl growth. 1l originates in lhe pll<ls~baccous gland~ and pathologically resembles ~uamnus ceU carcinoma (SCC). It ,. chamctcri2ed by very rapid enlargement, foUowed by a stable period. and then a slo,v, nnrural regressiOn.

Both sunlfgltt and chemical carcinogens bnve been unplica1ed as maJOr factors in the grow1h of 1he nunor. Traumo, human papilloma virus, genetic fac1ors. and immuoocompromised statll!l also have been impocated ns etiologic factors. KAs occur mncb more frequently in men than in women, usually in th~ir 70s.
I, OcrmatoObromus are benign neoplasms that appear as small, red-to-brown Note< bumps (nodules) that result from an occumulation of libroblaSlS. 2. Acrochordon or a skin tag is an extremely conunon le:.ion, mos1 often folllld on lhe neck, in lhe annpt~ or in the gtOtn. 3. Actinic keratosi$ ts ~ premalignant cpidermall~ion caused by excessive chronic exposure to ~unlight. These are CQII10100. especially on lighrskinned elderly people. 4. Seborrh~lc k~ratosl$ (Sebonlreic worts) is an extremely common hnign neoplasm uf older people. Tbc wans are flesh-colured. brown, or bbtck growlh> lhnr can appear tmywhere on the sktn. 5. A<lUllhosis nigrlr1lns is a cutaneous di.o;onl.:r marked b) bypcrk~ratosis and pigmentation of the .Wila, neck, nexures. and anogenital rewon. More than half of lhe ralients wilh acanthosis nigricans have cancer (GI cancinomas, parricular/y of tile .rtomaclr).

l\S a

Ancnno is a condition in which lhe blood cannot acloquacrly o~ygei\Atc the trSSUC'l. h shows up decrea..cd RBC count, decreased hema1ocri1 or dec=>ed hemoglnbrn conccnlnition. Anemt may be caused by '"" major mC<'hanbm.: I. Decreased red cell produclion resulting rrmn: TlcnHttopoietic cell d~tmn~e from infcclton, drup, rsdia1iou, und other ~~;imllnr agents. Ocfi<iency of foctoro n~<es$ory for heme syothesls (Iron) ur DNA rmhe.,s (viwmin 811 or fo/ute). 2. lncrased rrd cell lo;s duc 10: t~rcrnaJ blood Ion Rtd cell destruction {htmr>lyric onMila)

l'erntclous anemia 1s 1hc moM common fonn .:.r vilnmin B12 deficiency met;aloblastit ane rnl. !tis considered 10 be an autoimmune disorder. his CIIUsed by a luck or lrrtrlnslc !actor, a substance needed to absorb viu~min U11 from 1hc gu$II 'Ointcstinal tr"dct Vitnmln B 12. in rum, is ncc.,sary for !he fonmuion of red blood cells. Bccuuse vi1amin B12 is nccdtd by nerve cells and blood cells to function properly, pernicious anemia causes a wide variel)' of >Yt11pl0n'" rncludrng fatigue, shnrtnes. of breath. peripbo:nl OCUNif'Oih~. difficull)' Wlllkrn& orul l!llltiog.

I The erythrocyt.. 1ha1 11re produced .rc macro<) rir and oppur hyPtrchromic. No1t< 2. Slomatltb and alrophie gloS>ltit ru-e cornnton. along wnh atrophy of lhe gos1n< mucosa. 3. An abnurmal Schilling lest. Is n test used to detennlne whether lho body absorbs vitamin B l2 normally. 4.Aplastic antmlB is thc result uf 1111 inndequotc production of erythn>eyrcs due to the inhibition or desuwllon o(Jhe rcd bone nwrow. 11 """be caused by rudtation, '"rious toxins. and cCfllm medications. lmpOr1ont: In drug-induced aplas1~e anornias. 111.! erytllrocyt<:s (RBC's} appc:>r to be nomH)chromic (lturmal rou, . of Ht~tll));l<>btn) and normocytic (nornral'" <ire).

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

Deep vein thrombosis (abbreviated as DVT) is ussually localized in the deep veins of the:

Forearm

Upper arm

Thigh
Calf

143 Copyngbt O 20092010 Oe:n,l Db

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

Wbat three organs are usually damaged from prolonged hypertension?

Intestine

Kidneys Hean
Stomach
Brain

..

CopynaMO 20092010

"''"''Decks

( :tlf Phlebilis is inflammation of dte veins. II is most common in the legs, and almost always takes place in vari<-ose veins. Comntoo causes of vein inflammation include loealtrritarion fjor example, becariSe of an IV line). mfection in or near a vein, and blood clots. TbrombophlebitlJ u; vcm inflammation "'late<! to a blood clot As the venous system is divided in deep veins and superli.cial veins one can have a clot m eacb of the systems. Only very rattly does clotliilg occut in both of the systems at the same time. Superficial vein tbrombosl (abbreviated o.s SVT) is also called superficial thrombophlebitis I phlebitis. The skin around the vein is red and painful. Swelling can be present as well. The maio cause for tbe condlltOn aro varicose veins. Blood ~agnates in these venous pools and will clot easily especially during mactivity. t>ccp vein thrombosis (abbre viated a.r DVT) is usually localized in the deep veins of the calf but it can extend into the deep veins of the thigh and eveu beyond. The more extensive the clot the moro dangerous is the condition. Among the climcal signs art calf palo and swetting of the llllklt and possibly calf. It tS potentially a dangerous condiuon as a piece of the clot can fiy" through the venous circulation and lodge in tbc lung. occluding the pulmonary circulation. This is called pulmonary emboli or PB. It can be fatal if 11 is massive 1. Congestion (hyperemia} ts localized increase in the volume of blood in Notes capillaries and small vessels. There are rwut~ pts of COI1g<Stion (h)permua) Active congcsrioo (ocri hyperemia) result, from !oeahzcd aneriolar dtlation (e.g. i"jlammarion, blushing).

Passhe congestion (pussiW! bvpt!rem.ia) resulls from obstrucrive venous rc1urn or increased back pressure from congestive bean failure. Two forms: I. Acute: occurs in shock or rig)tt sided bean failure. 2. Cbronlc : of the lung (moSI often ratiSed hy left-sided h~rt failure)
: of the U\er (most of/en cou;~d by right-Si(fed lreart failrm!)

fl~:ur : (,n~ ... dit. of " ::.1nh:.u ..-omplac:,llinn ... 14r .1111: 15" o dtt.' ul 'lrul,t. ur nturulu;:k cumplit.::tiWih l\lthh~..;: 25!'" dit. ul nnal f:ulun

If hypeneusion is not diagnosed and treated with antlhyptrtl'llsive rlnr~~><. the individual can ''wear out" (cardiac failure), ~blow out" (e<rebi'()\<IJC'I'Iar accidem). or " MJn out" (renal far luff!).

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

The most common cause of secondary hypertension is:

Pheochromocytoma Kidney disease HypOthyroidism Hyperparathyroidism

145

CopyriabtCI 20Q9.lOIO Dental Dccb

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

\.

Which morphological classification of anemias is frequently caused by a deficiency of folic acid or vitamin Bl2?

Normocytic Macrocytic Microcytic

146 Cop)Tiglu 0 2009-2010 Dental Ottb

There are two broad categories of hypertension -primary (or e<sential) and secondary hypertension. Appro;<imately 90-95% of patients diagnosed with hypertension have primary hypertension. Unlike secondary hypertension, there is no known cause of primary hypertension. Therefore, the diagnosis of primary hypertension Is rnnde after excluding known causes tbat comprise what is called secondary hypertension. If left untreated, primary hypertension can evennmUy lead to retinal changes, left ventricular hypertrophy, and cardiac failure. Genetic factors include a family history of hypertension, and it is more common and usually more severe in Amean Americans. Environmental factors include stress, obesity, cigarette smoking, and physical inactivity. I. Usually, b.igh blood pressure bas no symptoms at all. That is why it is often )Not"" called the "silent killer." 2. Although HP usually bas no symptoms, sometimes the following may be evident: tiredness, confusion, visuaJ changes, nausea. vomiting, anxiety, perspiration, pale skin. or an angina-like pain (cmsili11g chest pain). 3. The three broad classes of drugs used to treat primary hypertension are diuretics (ro red11ce blood volume). vasodilators (ro decrease .ysremic: vascular resistance), and cardioinhibitory dno gs (to decrease cortliac output). Secondary hypertension is elevated blood pressure that results from an underlying, tdentifiable, oflep CO!Tectable cause. Only about 5 to l 0 percent of hypertension CalC$ are thought to result fTom secondary causes. These causes include: Renal artery stenosis Sleep apnea Chronic renal disease Hyper- or hypothyroidism Primary hyperaldosteronism Pheochromocytoma Stress Preeclampsia Aortic coarctation

\1:u.roc~tic

Anemia is a condition in which the blood cannot adequately oxygenate the tissues. It shows up as a decreased R.BC count, decreased hematocrit or decreased hemoglobin concentration. The body geL< lcs.< oxygen and therefore has less energy than it ncctls to function properly. Symptoms include fatigue. weakness. Inability to excroise, and ligbtbcadedness.
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Microcyti<: Iron deficiency n~alassemias

Morphological Classaficanons of Ancmaas

Normocytic:
Aplastic anemia

Macrocytic:
Liver disease

Anemia of chronic disease

Acute and chronic blood 1oss

VItamin B t2 and Folate

deficiency

Anemia of chrooic disease

(MICROBIOLOGY I PATHOLOGY

Bld Disord)

1' Dicumarol is an anticoagulant that functions ""\ ~'-~~~~~-----= as~a :;;;~;;~a:n~t: ag ~o: n~is~t~~~~~~----~~~
Vitamin A
Vitamin D

Vitamin E

Vitamin K

147 Copyript C 2.()09.20 I0 Dctl1.8l [)e(k.s

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

In many cases, severe hemolytic disease results when the:

Fetus has Rh-negative blood and the mother has Rh-negative blood Fetus has Rh-positivc blood and the mother has Rh-positive blood Fetus has Rh-positive blood and the mother bas Rh-negative blood

148

Copyri,ht 0 2009-1010 Dental Dttb

\Humin I'

Dicumarol is an antlcoagulanl 01at inhibits the formation ofproO~rom.bin ip the llvdr. lt i~ u~ed to delay the clotting of blood especial ly in preventing and treating thromboem boUc disease. Note: Dicum:u-ol has largely been replaced by wurfarin. Circumstances that w ill cause delayed hlood clotting: A patient taking beprio, which is an anticoagulant. II acts as an antithrombin and antiprothrombin by preventing platelet agglutination and consequent blood clot formation. A patient with leukemia Qflen has thrombocytopenia, which is o reduced number of platelets. Pallems with cirrhosis of the liver have hypoprothrombinemia (abnormal(y small "''wu11ts ofprothrombin in the cirrulatillg blood). Notet Prothrombin is formed and stored in Ote parenchymal cells of the liver. ln cirr!Josis there is profuse damage to these ceUs. von \Villcbrand's disease: deficiency of vWF (von Willebrand:, Factor); results in impairod platelet adhesion. Loog-tenn trealllleut with aspirin: it is a cyc!ooxygenase inhibitor: results in impaired production of thromboxanes, which ate important platelet aggregants. Bcrnard-Soulier disease: a hereditary platelet adhesion disorder.

1. Warfarin (Coumadin) is also an Qnticoagulant that interfer~s with vitamin K. ft [nbibits the fonnation of prothrombin in the Uver. Tbe effect of delayed blood clotting is useful to prevent and lroa[ thromboembolic dlsease. 2. Remomber: In t.he pt;eSence of thromboplastin and CJIIcium ions, prothrom bin ls converted to thrombin. which io nun converts fibrinugento libri.n. Fibrin Olresds wen eot.n!p blood cells, platelets, und plasma to foml a blood clot.

The fetus' blood is Rb-positivc because the father pas,cd along an Rh-positive trait, which is a dominant trait. The mother responds to tfle incompatible blood by producing antibod ies against i~ These antibodies cross the placcnm into the fetus' circularian, where they atl~cb to and destroy tile fetus' ted blood cells, leading to anemia. This is called erythrob lastosis fetalis. Note: II can also result !Toni blood type incompatibilities. For oxample, the mother may have type 0 blood lllld the fetus bavc type A or 8 bluod. Remember: Patients wit.h hemolytic anemias (i.e., erythmbl11s10sisf~tnli.v, sickle rei/ !memia a11d the thalassemia.<) often have problems ihal result from au increase in bllirubln levels. This bilintbin is the b.reakdowu product of hemoglobin whicb is rolcascd JTom dying erythrocytes. Examples include: Elevated levels of orobilioogeo, which is a compound fonncd ln tl]c lntcstittc by the reduction of biUnthio. Elevated level& of uocon.j ugated bilintbio, which is water-insoluble bilirubin. Nunnally, tl1is unco11jugated bilintbin would combine with serum albumin Ia become water-soluble (COiliflgat!:d bllirubi11) in the liver. This would then be secreted with other components of bile into the small intestine. Toxic accumulation ofunconjugated bilirubin in the brain and spinal cord is called kernicterus.
I. PThalassemlu major Is also known as Mediterranean anemia 01 Cooley Nores. anemia. II is characterized by marked anemia and splenomegaly, as well as generalized hemosiderosis. 2. PTbalassemia minor- clinical manifestations include: increase in bcmoglobin Al. 3. a ..Thal;assemias are the most common forms of thalassemia i 1 Southeast J\s-i~

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

A Tbe classic pentad of thrombotic thrombocytopenic pupura includes all of the I\. following EXCEPT one. Which one is tbc EXCEPTIOJY! .I

Microangiopathic hemolytic anemia Thrombocytopenia Liver dysfunction Neurologic abnormalities

Fever
Renal dysfunction

149 Copyright c 2~2010 l;>ental Oh

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

There are several types of arteriosclerosis. By far, the most common is:

Monckeberg's arteriosclerosis Atherosclerosis Arteriolosclerosis {hypetplastic) Arteriolosclerosis (hyaline)

150 Cop)'right 0 2009-2010 Dtnt.tiiJrt,eks

Thrombotic thrombocytopenic purpura (1TP) is a lit'..threareoing multisystem disorder lht is coo.,idered a true medical emergency. The disorder is caused hy a defickocy of lbe enzyme von Willebrand tacror MI'F) mcralloprotea.s c (alst> calld ;tDA.MTS 13). The enzyme promotes degradation of very-high-molecular-weight mulrimers of vWF, and the enzyme clefici~ncy reults in multimer accumUhitioo in the plasma and consequent platelet microaggregate fom1arion. Treannent is by plaSma exchange. and the disotdercan be rami if iligno;;t.,md the111py are delayed. ldiopthic thrombncytopcnlc purpura (ITP) is a bleeding condition In which the blood doesn't clot'" it should. 1'his is due loa low number of platelets. TJt~rc are 2 types of ITP. One type affi:cts children, and the <)I her type oOecls adults.ln children. the 11.<ual ~ge for getring ITP is between 2 and fcmr years. Most adults with ITP aro yt>w1g women.. blt\ it can OCC\tr in nnyoue. 1TP dots not run in fa.rnllies. lTP is different in children than in adults. Most cbildn:u with ITP l10v" a very low platelet count that C<luscs sudden bleeding. The usual symptoms are bnusL'J> and the tiny purpura >l'Ol< (peteclline) on the skin. Nosebleeds uo<l bleeding gums are al<o common, In most adutrs, lTP lasts much longer than ir does in childt'ilu. Altho tune or diagno,is, Jm>sl adults have noticed increased bleeding and easy bmising f<Jr ~evcral weeks, or even months. In women. increased menstrUal blood Oow is a major sign. ~ _ 1. Purpura spots !lie p\lfPiish discolorations in the~kin protluced by small blecd'Not<" ing vessels near the surfce of!he skin. Purpuro may abo ocuur in the mlloous membranes (su~IJ os the lining oflh<' mouth) and in Ute internal O!gans. Purpura by itsol( is only a sign ofother uuderiying cnuses of bleeding. 2.Tltromboqtopcuin is a condition 1n wbicb there is a reduced number of platelets. This causes bleeding stoles in which blood loss oeuurs through capillaries and other small vessels. It is tbe most common c-Juse of bleeding disorders.

Arteriosclerosis ("hanlening of the l/rtetie.v") ia geneml term tbr several diSI'ase' in wruch the wall of an artery bcCOrlkti thicker and less elastic. The most important and most common of these diseases is atheroscl~rosis, in which fatty material (culled othmYJsclerolic ploqut!S) accumulates t>nder the inner lining of the arterial wall. Evenrually, this futl)' tisue can erode t.be wall of the artery, diminish its elasticity (strerchi11e.s) and interfcre with blood Oow. Plaques can also rupture. causing debris to m1gratc do\VllSTream within an artety. Typical signs ao.d symptoms of moderate atheroscl~rosis include changes in skin ctilor and temperature. headache, dizzincs., 11nd memory defects, Consequences of atherosclerosis: \rlln""d~ru,;.. lscheJnic heart dlsc~se (torouury <lri<'IJ' Key r1!G1ure; 1'!1>" disease) anti [leatt attack fiiiYO<:(m/ial ilifirrol) At.bc::msdcrosis UTg_c and tnodlu.m $I?.C nn.:-rie11 - JJID r<>presents an imb~lance. between Fatl)' srrc3ks. myocardial oxygen demand, and lJVailable AlhtotO!n:!S blood supply. It has a peak incjde)JCe ln met\ MO..:kobo!ol:- Mcdla cakific steJJI)SiS over 60 uud women over 70.. l;ieart tnUS<;le "j()OSt:ltt;cl t'lunp$" damage and scarrlng from h""n a!lacks greatly ' Small und ncdium sizt ~neries A)'lliplomatic incre>)ses the risk. of heart failure,

. . . . .
. . .

lmponanl risk ractors include: smoking, chronic hyi>Crtcuslon, heredity. ,ytcDru.clcmsi<; nephroselcrosis. diabetes, and hyperUpideuuu Dillbetcs mtJJitus (/t,.U/,..1 Thkkcncd ~1 "tem\w:lnl! (.pedjiaa/1)\ /ow-do11Si1y lipoprotein,<) . I. Atherosclcro.'>ls Js desc.nbed as degcnerathe chaugos in the '"'~lis of the arteries. 2. Atherosclerosis is more common In men ofall age groups. ll1< uorta and coronary arteries are mosr affected by urteriosckrosis. 3.lh ycry aMa.nced c.liSc:;, atherosclerolic phtqu<S cllll become <11lclfied and ulc.rated
(lt._VfJc!J'pltatJc)

Artcriosclcrosa:s

. .

Fibrino1d ll!e\.orosis Mnlig;rwu hypencnsil,)u "oniol'l sldrf hypernl;a,..J"a

Slloke or anc::urysm fonnation

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

In compariog the normal beta chain of hemoglobin with that of someone with sickle cell anemia, the sixth position in the normal beta chain bas _ _ _ _ _ _ __, whUe the sickle beta chain b a s - - - - - - -

Alanine, Lysine Arginine, Histidine Glutamic acid, Valine Leucine, Cysteine

lSI CopyrigbtO 2009-2010 Demal Deets

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

\..

AJJ of the following statements are true EXCEPT one. Which one is the EXCEPTION?

Carbon monoxide is a very dangerous, colorless, odorless gas, generally associated with fumes from a car or from a home heating system. Carbon monoxide attaches to the hemoglobin of the red blood cells and blocks their capacity to carry oxygen. Severe carbon monoxide poisoning can cause a coma or irreversible brain damage because of oxygen deprivation. The initial symptoms of CO poisoning are similar to the flu (but without the fever). They include: headache, fatigue, shortness of breath, nausea, dizziness. The affinity between CO and hemoglobin is 200 times weaker than tbe affinity between hemoglobin and oxygen.
152

Copyrigtu@ 2009-2010 Dc:ntal Detlo:

(;tulantil .u.:hl. \ ;1lint'

Sickle cell 311CU11a l< the mot common lter<<ll,.r) anemia of pcr.iOI1S of Afncan hne<~ge. II is caused by an abnonnaii)'IM' of hemoglobin (oxyg'n roo., lg molecule/ called hmoglobin S.lt is inhcnted u an autosomal recessive ~ra~t; I hut i~. it occurs in SOm'ne who has mhtnted hemoglobin S from both parents. The globin ponion of Ul< onolecule is abnormal due to lhe wnloo acid 1'lllna being subsliMed for glutarnk cld in the soxth posiuou ufthc hemoglobin molceule. Whcu the ~hn~>mJa) h~tnoglobiu nol e~ulcs arc c~J>OScd to lnw conccmnninns of o>cygen (loyfH>rlc I'OIIdlliom), they fom> fibrQ us proclpituros with the erythrocytes, distorting them into the sickle shape (crescent shope) chamctarisuc of tile dJoease. As a re.~uh, they function abnormally and cause small hlood clots. These clots give rise to recummt painful episodes called "$ltkle cell P"-io criSes." 1. Nonbea.llng leg ukon and recurrtnt bouts or bdominl chest pain an: charaeNola reristic of sickle ~ anemia.

2. Pantnt> wid Sickle cell anemia can booome functionally aspltnlc. As a n.:suh. they arc prone to Infection! cauied by encapsulated organisms (wcludtng Srrep/(}Wc;a,s pm!W/Ionia and HeonfJphil11s lif/roenza). S:ilinonella bone infec1\0ns/osteomyelitis CliJ1 occur. 3. Rpcn1od cpL"KiilS of splunlc iJJfurtuon followed by librolic hcnling lcud 1 0a fihroric. shmnken spleen (autOSillcnectomy) in nd~lt palicllfS with sickle cell anemia. 4. Si~klc cell anlmia may bceomc life-threaten'"& when darnagc'd n:d blood cells brcllk down (hemolytic crbb). when the spleen enlarges and ~raps 1he blood teUs (lllltoJC $4!CIUf111'11ttOO criru), Of ..h<'O 8 C<'flftio type of infection cU5CS the bone OIJilTQW IU slop producing ted blood tell- (apiA.<llc crul$). R<PtOotc....lc'ri>e> c.m cause da.mgc to the ltidneys, lungs. boucs,<')'CS, .md ccnlrnl Dl!tVOW> system. S. Olockcd blood vessels and doma~cd 0'1\0ilS ca11 ""use acute painful rpisodes. These pamful cnses. which oocur in .!.Imost allpetients 01 some point iu thc~r Uv<'S, can lnst hour.; to days, affecting the bone.,. of the back, the l~ng bones. and the chest.

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false; the affinity bet'"""" CO .tnd hemoglobin is 200 tunes >tron~er than Jhe affinity l:letween IJemoglobtn omd oxygc:n.

One of the 1mperfecnons of the human body '' lh:lt, gTVon a choice betweert carbon mon().<
ide and ox.ygen. the pn>~cin homoglobin in our blood will .Uways Jruch on to carbon ntonoxlde and ignore the lifc'-giving o>cygen. Because uf th1s usturol chemical affinity, our bl'>dies, in effect, replace oxygen with carbon monoxide in our bluodst.ream. causmg greuter or lesser le~ds uf cell sufl'ocntion depending on th mttnNlty nnd dutatlon of exposure:. Whc'O there are even mln11te amounts of c11rbon monoxide in the"" that is bn:athl they ptefcrentially a<:cUI')' the oxygen-binding sttcs of the hemoglobin molecule.. lllis htm<J~I~r bin-carbon moooxtdc bond is so strong that ~ry Dttle earboo monoxide i> rcmocd from the blood. Paucnt> wtth acute carbon monoxide po1somng exluoit chPrry-red dlscotonalon of the skJn, mucos, and tissues. Ultimately. ckath will oc:cur dill! to hyposla. lmportnt: The 'YillPtOms of low-IC~oel carbon monoxide po"onlf1!! ""'so <!l!Slly mt~l:!ken for thost of the oommon cold, flu or exhaus1i<1n 1b111 proper dagnosi< can be delayed, Other envinmmenlal chcmltnlagenL<1l1ld their mun l fest~tiuo if ingostcd: C.rhon tetl'athlorlde: hupatoccllular damage Mercu,ic chloride: severe reoultubular nL'<:tOf't~ nnd 01 ukeration Cyanld.: poisoning: prevents cell11lM oxidation, re.<ulfS in odor of bitter almonds Mrtbyl alcohol: blindness Btsmulb: naUtta, vomiting and abOOtlltDlll p.in u.ually occur within hours and prececk f-"lrun:, uf ncphrotoicity om! oeurutoxicU) uad: basophilic stippling of RDC's. anemia. ubdominal patn. illld -.nst and foot drop

(MICROBIOLOGY I PATHOLOGY

Bid Disord)

A presumpth e diagnosis of classic hemophilia (hemophilia A) is made, and ~ coagulation blood tests are performed. Which of the following is tbe most likely set of tlndings of coagulation screening tests?

Normal platelet count and thrombin time; prolonged bleeding time, prothrombin time (PT) and partial thromboplastin time (PTT) Normal bleeding time, platelet count, thrombin time, and PIT; prolonged PT Normal bleeding time, platelet count, thrombin time, and PT; prolonged PTT Normal bleeding time, platelet count, and thrombin time; prolonged PT and PTT

153
Cop)Tig'h.t O 2009-2010 Dernal Dttb

(MICROBIOLOGY I PATHOLOGY

Bn Disord)

,
\..

Which of the following occurs most commonly in elderly women and Is associated with tbe postmenopausal state and estrogen deficiency?

~)
~

Osteogenesis imperfecta Osteoporosis Myasthenia gravis Osteoarthritis

154
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1~

Il

Hemophilia A and 8 arc tnherited as on-Hoked ~esshe trait by whtch males arc afTceted and females are carriers. The nujorily of people afflicted with hemophilia have type A and it presents under the ag< of 25. The stgns, S)'111ptoms and clinical manife<tation. include excessive bleeding from minor cuts, epitnis, bemaoomas,1Uld hemarthroses. Classificutlons of ll emolthllla: Uenwphllltt A: considered the clas~icnl type. en used by a deficiency of coaguiHtllln fnctor VIII (ami-lremtlp/JI/Ic factor) . Uemophllla B (also called Christmas dlseore): due to a deficiency in fnclor LX /pill< mothrombapla. trin cumpotrent). l:lcmophllla C (o/su <wiled Rooentilot ~ S}'nd>VJme): not sex-linktd, lcs> .evere bleeding. Due to 1 ddicicncy of factol' XJ (plasma thmmbt>plastm cmtecedem/. lmportanl! A true hemophiliac is cllarncterized by having the follOWln~ I'Toton.ged paroolthromboplastin time (PTT) NorcnM I prothrombin ume (P1)
Nnruutl thrumhin time Norrnnl hleedlng tjmc

NormAl plntelel couot r-1. In classic hemophilia. the other lab tesl> remain norrual, because the bleeding !'I ott. lime i~ u meaure of platelet plug fonnation. the prothrombin time a measure ~fthe extnn:nc pathwoy of eoagul~tion. and the thrombin time an"-<llay of the conver.;ion of fibrliiOgen to fibrin. 2. von WUiebrand's disease is inb<nttd lb <U1 autosomal dominot bleL'ding d!.s order, it occur> wttb equal frequenc) tn b<lth sces. lr results from s deficicocy m the voo Willebrand factor; which is a large glycoprolcin tlrar has binding Ucs tor factor Yl!land also facilitates the adhesion of piAtelels lo collagen (im[JIJrlrmt ;, the jim11nlia11 uf a platelet plug).

Osteoporosis is cbaractcri:z:cd by a dccrcnse on bone mass due to loss of bone

matrill. Tbts condition Is the most common bone di.sord<r in older p~rsons Characteristics tnclude fractures, kyphosiS, and shortened stature. Predisposing factors include phystcal activity, hypercortfcism, hyperthyroidism. and calcium deficiency. Serum caltium and ph osphate levels ure typically norma l. The leading cause of osteoporosis is a drop in estrogen which is associated wi th the postmenopausal stnte in women. Nolc: Pby~ic~l Inactivity further a~celcratc; bon<' loss and decreases muscle mass and agi lity thnt contributos to f.11ls and fractures. I. Osteogenesis imperfeda (()r briule lx111e disettse) is ~n autosomal dominant NotH disorder characterized by multiple fmcrur~ with minimal lrowna. It IS catL<ed by mutations in either of !be genes that code for type I collagen. The blue sclerat, hcanng loss. and deotalabnonnaluie; are charecteristic. The teeth are poor because of malfonnation of dentin (detrtmogenesis imp<'ifecta). 2. l\1yltsthellla grnvis is an nutoimmune disorder Cllused by autoantibodies to postsynaptic Qcetylcboline recepton. oft he neuromuscular junction. The disease commonly presents as ptosis. diplopia, and difficulty chewin11. speakms, or swnlluwing. For unexplained reusons, myusthenia gravis i <t>~oci~tted with thytn.ic l1yperplasia or thymoma. 3. Osteoarthrith (degeueratile jotnt tllrete) is the most common form of artluiti~. It i$ chronie inflnmiTUltOty jotnt disease. lt is characterizcll by eburDition (polished. i>vry-/i/ce oppearonte of bo11e, tlue to eroswn of twer/_1;11g carrllage). cystic changes in ubc:hondral bone. and new bone fonnation. OsW~pb)tes (bo11y spurs/ can form ot the distal interphalangeal joints ( Ucbcrden nodes) or at the proxin~1l interpll31AngealjoUIL~ (Boutbard nodl!'l)

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Osteopetrosis is characterized by:

Greatly decreased density of the skeleton Slightly decreased density of the skeleton Greatly increased density of the skeleton Slightly increased density of the skeleton

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Osteochondritis of the tibial tuberosity is called:

Legg-Calve-Pertbes disease Osgood-Schlatter disease Scheuermann disease Kohler disease

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copetrosis (marble bone disease, Albers-Schonberg disease) is a ntre disorder racterized primarily by increased bone density as old bone is not resorbed and replaced 1 new bone. Tbe cause is failure of osteoclastic activity. It occurs in two major clinical ns: I) an autosomal recessive malignant infantile foiiD, which is the most severe form of disorder and death, usually occurs in lhe fl!St decade of life, and 2) a less severe >somal domioat variant.
. main features of this disease are:

Multiple fractures in spite of increased bone density Anemia as a result of decreased marrow space Blindness, dearness, and cranial nerve involvement duo to narrowing and impingement f neural foramina cr non-neoplastic dise.ases of bone: Achondroplasia is one of the most common causes of dwarfism. It is an autosomal domnant disorder characterized by short limbs with normal-sized head and trunk. Scurvy is caused by a vitamin C deficiency. [t is characterized by bone lesions leading o imprured osteoid matrix formation which is caused by the failure of the proline and ysiue hydroxylation required for collagen synthesis. von Reckllnghausen disease of bone (osteitis fibrosa cystica) is caused by primary or ecoodary hyperparathyroidism. Widespread osteolytic lesions are characte,ristic. Osteomalacia is caused by a vitamin D deficiency in adults. Defective calcification of tSteoid matrix is characteristic. Rickets is caused by a vitamin D deficiency in chiltlren. Fibrous dysplasia is characterized by normal bone being replaced by fibrous tissue. :here are three classifications depending on extensiveness of skeletal involvement (1) .tonostotic: one bone, (2) Polyostotic: more than one bone, and (3) Polyostotic with asso:iated endocrine disturbances (Albright s syndrome). Pathologic fractures are oflen the resenting complaint.

:,!,OtUISrhlattC'I' discasl~

ng the years of rapid bone growth, blood ~upply to the growing ends of bones Jhyses) may become insufficient resulting in necrotic bone, usually near joints. The avascular necrosis is used to describe osteochondrosis. Osteochondrosis e degeneration followed by reossificatiou of one or more ossification centers in lreu. Since bone is normally undergoing a continuous rebuilding process, the otic areas are most often self-repaired over a period of weeks or months. They are acterized by degeneration and ~septic necrosis followed by regeneration and sitication. rowing children, ostcochondro~is may involve a variety of characteristic sites

ding: Head of the femur - Legg-Calve-Perthcs disease ribial tuberosity- Osgood-Scblatter disease rarsal navicular bone - Kobler disease Intervertebral jointS- Scheuermann disease Metatarsal head (usually 2nd, less commonly in the 1s1 and 3rd) - Freiberg fraction

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A mosaic pattern of bone caused by an increase in both osteoblastic and osteoclastic activity is characteristic of:

Osteomalacia
Scurvy

Rickets
Paget's disease of the bone

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Osteomalacia mea ns:

'brittle bones"

..hard bones"
"soft bones"

" fragile bones"

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Pager's disease (osteitis deformans) is a metabolic bone disease that involves bone deslnlction and regroWlb that results {n deformity. The cause of Paget's disease is not entirely known, but it is thought robe caused in part from a childhood virus. A virus parlicle. known as a paramyxovirus nucleo<:apsid, has been idcntifiNI 'vithin the bone cells of individuals with Paget's disease, This virus panicle is not tbund in normal bone. While this relationship bas been identified. a clear connection between the vim' and the cause of Pager's disease is not knowo. Pagel's disease most commonly involves tbespine, pclvl!i 1 L"tlivarium of the skull, femur~ and tibia,The disease may localize to one (moltostollc) or two ([HJ/yo.wolic) areas withi.n the ske.letOil. otbecome wide,pread.Thc skull may enlarge head size :md cuuse hc.,.,.ing loss, if the cronial nerves are damaged by the bone growth. Abnormal bone architecture caused by incre~ses in both osteoblastic and osteoclastic activity is characteristic. -.. I. lntraorally the teeth spread, ' Not., 2.These patients are predisposed to developing <tsiL'O~rcomas. 3. laboratory findings include: uncmia, roo rkN!Iy increased serum alkali no pho.sphutnsc levels (an index ofosteobloslic activity and bene for!llalion), as well as no> elevated 24hour urine level for hydroxyproline (tm amino acid excrete</ by the kidneys and an inde.t of osteoclaJtic ilypel'flctMty). 4 . Mixed osteoblastic and osteolytic phase of bone lonnatiun leads to a characteristic mosaic pattc.rn. 5. Serum acid phosphatase levels are elevoted in patients with prostate cancer. 6. Von Recklin~buuscn's disease of bono (o.,teiris fibrosa cy.<tica) i< characterized by decrca.'ied serum phosphorus and an increase in stnnn ct~Jcium and alkaline phosphatase. 7. Condensing Osteitis (sclerosing ostems) is bnsiclllly an unusual roaction or inflammatory res1mnse of tlte dental pulp of the tooth to a low grado infection.

Osteomalacin means ''soft bones." Osteoid is the bone protein main:<, composed primlll'ily of type I collagen. Wltell there is in.suffkienl vitamin 0 or osteoblast dysfunction, tllo ooteoid doe-' not mineralite pro)lerly. and it accumulates. When lhe newly formed bone of ~te !:rowth plate does not mi11emli2e. the growth plate becomes thick, widu and irregular. This rtlliul.!.1 in the c]iliical diagllosis of rickets, and is seen only in chlldreu because adults no longer have growth plates, When the remodeled bone does not mineralize, osteomalacia occurs, and this happen.< in all ages. Most of the hereditary causes of osteomalacia appear during childhood and cu"'~ rickets, Osreomalatia: Vilamin D deficiency in adults Appears to be nlore common in women It is characte. rized by diff-use radiolucencies, whi<.:h crut m1m1c O!\tcoporosis * Bone biopsy is often the only way m diff~::remia1c: between osteoporosis aod ostt."' malacia. Symptoms may include diffuse bone pain (especi<1l6 /utile hips), musck weakness. and bone ftactute> with minimal trauma, Rickets: Vitamin D deficiency in children Clinical manifestations inalurle; -Skull: craniotabes may occur, in whtch the bones or lite skull soften, and flu11ening of the posterior skull can b<: seen. -Teeth: teeth may erupt later than nomml because of undermlnernli:zation, Enamel can be of poor quality, remtlting in c.1ries. -Thorax: rachitic rosary . thic. l\enlng of the costochOndral jlancrions huri11oo groove .. t.he groove .is a semicoronal impre. ~on O\'er the abdomen at the level of the insertion of the diaphragm.

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The reparative phase of the healing of fractures consists of which two histologic stages of fracture healing?

Fracture
Formation of granulation tissue around fractured bone ends Replacement of granulation tissue by callus Replacement of callus by lamellar bone Remodeling of bone to normal contour

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Cardiac tamponade has three classic features known as Beck' s triad. Which of the follo\\1ng is not one of these features?

Decreased blood pressure Muffied heart sounds A bulging (distention) of the veins in the neck Cyanosis

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Rc.plliC('III('nl ur grauulatiun tissue h~ t::tiiU'O l~l'{)latc.nHn l nr C'ollht\ b~ lmnciJar botH'

5 histologic stages of fracture healing: L Fracture 2. Fonnation of granulation tissue around fractured bone ends 3. Replacement of granulation tissue by caUus 4. Replacement of callus by lamellar bone 5. Remooeliog of bone to normal contour
3 phases of the bealing of fractures

I. Fractur~ . . } Reactive phase 2. Fonnllllon of granulatiOn !Issue around fractured bone ends 3. Replacement of granulation tissue hy callus }Reparative phase 4. Replacement of callus by lamellar bone 5. Remodeliog of bone to nonnal contour } Remodeling phase
Fractures fail to heal (non-union) for the following reasons: Ischemia: the navicular bone of the wrist, the femoral neck, aud the lower third of the tibia are all poorly vascularized and are therefore subject to coagulation necrosis after a fracture. Excessive mobility: pseudoarthrosis or pseudojoint may occur. Interposition of soft tissue between the fractured ends. Infection: most likely with compound frachne~. Important: A fat embolism is most often a sequela of fractured bones due to the mechanical disruption of bone marrow fat an<l by alterations in plasma lipids.

Cardiac tamponade is life-threatening, slow or rapid compression of the heart due to the pericardia! accumulation of fluid, pus, blood. clots, or gas, as a result of effusion, trauma, or rupture of tbe heart. Signs and symptoms include Beck's triad, diaphoresis and cool, clammy skin, an)(iety, restlessness, syncope as well as a weak, rapid pulse, tachypnea and orthopnea. Important: Cardiac tamponade is the most serious corupllcatioo of pericarditis. Perkarditis is the name given to a variety of diseases. all of which have the major characteristic'S of inflanumtion of the pericardium and an increase in volume of the pericardia] tluid Pericarditis may be acute or chronic: Acute pericarditis is accoll1panied by symptoll\s of sharp, stabbing chest pain, shortness of breath, fever, perspiration, chil ls, and the symptoms of !he underlying illn< ss. The chest pain may radiar" to the neck, back, left shoulder and upper nnn. The pain may intensify during respiration, CQughing, swallowing, or when one is lying supine or turning. Jf acute pericarditis persists for 6 to twelve months following the acute episooe, it is considered chronic. Constrlcti pericarditis is a serious fonn of pericarditis in which the pericardium becomes so thickened a11d scarred that it loses some of its elasticity. It compresses the heart, interferes with the ability of the hean to fi ll up with blood, and reduces the amount of blooo pumped out to the booy. Constrictive pericarditis may cause heart failure and lead to kidney disease. Syptorus include: chest paio, difficulty in breathing. swelling of the feet and ankles, fatigue, and weakness. Important: Aortic dissection, also called disse.:ting aneurysm characteristically results in aortic rupture, most often into 1he pericardiol sac, causing fataJ cardiac tamponade.

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The most common cause of right-sided heart failure is:

Left-sided heart failure Hypertension Ischemic heart disease

Aortic and mitral valvular disease

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Chest pain that is precipitated by exertion but relieved by rest or vasodilators is called:

Stable angina Unstable angina Prinzmetal angina

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Hcort failure is almost always a chronic, loog-tcnn condition, altl10ugh it can sometimes dcvelupsuddenly. 1'his condition may affecllbe rlgbt side, the left ~ide, or both sides of the heart. Usually the left ventricle fnils first, soon followed by tl1e rightsided failure. l'he common signs of CBF include: llxertloual dyspnea Paroxysmal nocturnal dyspnea (palicm wakes up gt1Splng[or ail)
Tbe above twu signs arc the earliest and most common sigrls

Peripl!ersl edema (swollen ankles) "Cyonosis Orthopnea (sillin.~ or s/all(/ing In order 10 breat71e comfortably) High venous pressure Le1-slded heart fuilure: Causes Clinical manifestations lsohemk heart disease, especially Ml - Dyspnea and orthopnea Hyperten,ton - Pleural eflusion with hydrothorx Aortic und mitral valvular disease - Reduction in renal perfusion MyocHrdinl diseuse, such a.~ carditlnyopatlties Cerebral anoxia aud myoeMditis Right-sided heort railnre: Causes Cflulclll manifestations Lert-sided heart failure, most common cause - Renal hypoxia, leading to fluid retenrion and peripberol edema Pulmonary hypertension Enlarged and congested liver sud Tticll!pld or pulmonary vatvulor disease spleen Cnrdlomynputbies and diffuse myocardlti.l Distention of1he neck vein' hnpurtont: Patients with CHF should be in upright position during dentul treatment 10 decrease collection of fiuid in lungs. When fully reclined in tho den lui chai.r, these patient;; may experience difl'icnlty in brea1hing.

Angina Peetori< Is recurring acute chest pain or disconlfort resulting rrom decreased bl06d supply 10 1he heart muscle (myocortlinl iscllemio). Angina occur.< when ~ heart's need for o~ygen increases beyond the level of oxygen av;llable from ll1e blood flowing into the beart. Angina is tho cl:usl~ symptom for toronwy artery disoasc (CAD). The sympwms ofangina include mild or severe pain, pre.5sure, or ~iscontibrt in the ohest. The pain i~ gcnc.rally d~scribcd as a feeling or a squee~ing, strnngliog, bt:avin<.-ss) or suffocation scnsu1lon n the f;hest. Type~ of angina: Stable angina is~ r~pea<ing pattern of che.t pain whiuh has not changed in charn.otcr, frequency, inte115lty or duration for :;evoral weei.;s. The level of activity or stress that provokes angina is predictable and the pattern changes slowly. Stable angina I$ U>e most common fonn and it appeal'S graduaUy. lmport>lot: lt is prcx:ipitalcd by e~<rtion but relieved by rcsl or vasodilators. ~'Uch as nitroglycerin. Unslohlc angina is chesc pain that is variable. either increa.'iiing io fn..~uen.cy or intcns:fty and with irregular riming or duration. Important: lt is prolougcd or r<!CUlTOnt psln at rest. It i o\\en Indicative of inunincnt myocardial intarction. Jrio~.metnJ's or variant angina is caused by a vasospaSm, which is a spasm rhat narrows tbe eoi'Qowy artery and l.,;sens dte blood flow to the heart. lmpor!llnt: Jt is intennitronl chest pain auesL Coronary rtery disc (CAD) is a coudltion in whicb fatty deposlls (plltqlles) a.ccumutare in the cells lining the wall of a coronary artery and obstruct 1he blood tlow, As an obsuuction of a coronary artery wor;ens, ischemia (inadequa1~ oxygen .tll/lflly dne t" decrr!ll.ved blo<HI flow) lo the heart muscle can develop, causing hea_rt damage. The major complications of coronary disease are angina and ht:arlattack. ._, l, The primary effect of OOronury artery disease (CAD) is the loss of oxygen nd nurri/~ore. ents to myocod[ol tissues be<:a~se of diminished coronary blood flow. 2. Atberosrlerosls is the usual cause of CAD. lr alfects tl" intimal arterial wall of nminly '"'\:" clustlc vessels. The aorta is usually d1e most severely involved. 3. The riglu coronary artery supplies blood from the aortu 10 the right slde of the bllllrt.

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Which of the following is the first cardiac marker to increase after a myocardial infarction?

Creatine kinase

Troponin
Myoglobin

Lactate dehydrogenase

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,
I
Serratia
Pseudomonas

Approximately 50% of cases of subacute (bacterial) endocarditis are cause by:

Staphylococcus aureus Streptococcus viridans

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Myoglobin is one of several cardiac markers used to make the diagnosis. Curdiac mlll'kers ore substances in blood whose levels rise in the hours following a heart auack. lncrcascd luvels help diagnose o heaii auack; persistent normal levels rule it out. Cardiac mnrl\ors elevated after a myoCllrdial inrarction: 'l'roponin Rise.;; 3-6 hours Peaks: 20 hours Duration: 14 days Sobuolts: I) Tropouin T 2) TrQponin I(> J.Q saggsts Acute Ml) Creatine PhoSJthokJnose (CPK) Rises: 4-6 hours Peaks: 12-24 bours Durotion: 4-5 days Subunits (Fractional' 10 CK-MJJ on(y ifCPK ilct'Cased.J - CK-MB Fraction (durmiou.for 2-J dfJ)'S) - CK-MB ( > 5% of total CPK .uggesl.< Myrx:l1rllial lnjur)') Myoglobin A dv: First cardiac marker to incrcru;e Disad.: Poor St>ecificity (only helps ifngame) Rises: 1-2 hours Peaks: 4-6 hours Duration: 1-2 days Glutamic oi aloacetic trunsaminusc (AST. SOOt) Peaks: 24-36 hours Duration: 5 <lays Lactic Dehydrogenase (LDH) Peak.~: 24-48 houflO Oorarion: 1 4 days Myocardial infarctions (MIN} are most commonly caused by corQoary atherQsclerosis which catl$eS intemrption in th~ SUpply of blood to the hean.'fhe Si&JIS anti symptolll.S include a crushing pain in the1!rea of the chest over the bean. sweating. and Gl upset. The prognosis of patieuts is f:1irly good if they reach the hospital. Most deaths occur outside the hospital due to urrhytflmis co.>ing ventricular fibriUatioo. Angina pectoris nain is similar 10 Ml pain except it is relieved by rest or nitrates. MT's are couwwo in males and po<ttnenopausal women.

lnfeeUous endoc- rditis is an inflammation of the heart valves. Endocarditis is distinguished from infections ofllean muscle (myoam/itit) or the lining of the hean (pericarditis). Many bacteria can cause endocarditis in patienll< with un.dcrlyiog valve problems, but an organism commonly fouud iu we mouth, Streptutoccus virldu.ns, is responsible for approx imately half of all bacterial endocarditis. Other common organisms include Sraphylococco.<
aureus and enterococcus. l..ess common orgru1isms include pseudomonas, serrstia, and can-

dida. Staphylof.:occus au reus can infect norrnnl henr1 valves. snd is tbe- most common ct~use of inf~ctious endocarditis in intmvenous clrug users. Characteristics Include large, soft, friable. easity detached vegetations consisting of fibrin an 1ntermeshed inflammatory cells and bacteria. Complioations may include ulceration, otlcn with pcnorntion, of the valve cusps or rupture of one of the chordae tcndineae. Classification of infecrious endocarditis: Acu te endocarditis: is caused by pathugeos such as Staphylococcus auretL< (appro.rf. mately 511% of cases). 11tis type of endocarditis is often secondary to infection occurring elsewhere in the body. Subacute (l!ocleria/j endocarditis: is CllUsed by less virulent organisms such as Streptococcus viridans (appm.rimalely 50% of cases). This type of endocarlli\is rends ro occur in patients with congenital he-an disease or precx.lstiog valvu.Jar beart dise~~e. often of rheumatic origin. Note: Pever is a hallmark of acule und subacute endocarditis .

.., 1. The mitrol valve is most frcqutntly involved. 'ot.. 2. The mitrl valve long with the aortic valve is involved in about 40% of cases. 3. The tricuspid valve is involved in more than j()% of cases of endocarditis of IV
dn1g users.

4. Munnurs resnlt from changes in blood flow across valves when vegetations collect on the valves.

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The most commonly encountered neck space infection is:

Angioedema

Vincent's angina
Ludwig's angina Hereditary angioedema

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Botulinum toxin Tetanus toxin Diptheria toxin Antrax toxin

Which of the following is a potent neurotoxin that inhibits acetylcholine release?

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Although not sctn otl~n, Ludwig's angina. when it does rn:clll'. usually ts au u~tonsion of inft<'tiou from the mandibular molar teeth into the floor of the mouth, since their root;; 1to below the attachment of the mylohyoid muscle. The iufec1inu has tb~ following charac1et1srics: Firs~ it is o brawny induration that doesn't pit on pressure. ,'llo nucwuncc is pr=ut Secondly. three fucial $paces are involvt-d bilaterally: submandibular, submtntul, and sublingual spaces. Thirdly. tM patient has a typical opcnmoutbud appe.raocc. Not.: ll b:u a rapid onset Oysphgi, dyspnea. and fever are present. Ludwig's angina may involve swelling to the extent that it blocks the airway. This is an emergency sltuution! The g<,>al <.>f eOJerge11cy tre~tmem is to maintain an open airway. This may involve intijbmiuu (breathing tube plru;e<J t/II'Oltgh the 1110111/r ur nose ancl into the lung:;) or tracbeostomy (1/irect opening to the lungs through smglml plotemellf ofa tube at the base of the neck). Tbc goal of treaunent of the dil'order is eradic~tion of the infection. i\utibio!ics,usu~lly pcnJcillih or penicillin-like drugs, arc given 10 rrea1 the infection. Usually dJ<se :11e given inttave.tously (in a vein) until I he symptoms diminish, then the aniibioics are continued as oral tnedlc:p.tions until uuhllrC:) are n~gutivc. Most caRes of Ludwig1s Angina appear l(l be a mlx.ed infection. tloiVever. Sttcptococ~l are almost always present. I. Actinomycosis (also t'flllefllumpyjon~, IS a chronic intC:ction withActinomyce.." /Note.< usllally A. ismelii. It is choracterized by slow-growing, deep, lumpy absl'les that extrude a thin, pumlent exuclute througb ruulliplc sinuses. It dovelnp>chiefly In the jaw and neck, less frequent!~ in the lungs aucl limontruy tr.lcl The dioea;e occur$ following ti:;sue damage that is contumirmt~d with the. cudugenoLL~ organl..l\m.It can be treated with long-term Pen. thempy. numcmbcr: Actinomyces naeslundll is a gnun-posilive, branching, filamentous bacteria that is normal inbabilant of Ute gingiVal crevice and tonsillar Cl)'l'ts. 2. Actinomycotic lesions have the chamctenrnc "sulfur wonulcs" in them which are aCtually COlOnies Of in[ecting organiRmS.

Rululinum

tu\111

Botulinom toxin (lJTX) Is produced by Clostridium bntuUnum, a gram-positive anaerobic bacterium. The clinical syndrome of botulism can occur fol1owing inl]:elltion of contaminated foo~ from coloni2:ation of the infant gasuointc~\inul tract, or iTom n wnund infection. Botttlism toxins arc the most pCitent toxins known t(l humans. ibcse neurotoxins act by binding pr~synaptical!y hl highaffinity recognition sires on the cholinergic nerve tcrmiMis and dooreaslng thell!lcas~ or ac~l)lcholine, c.tusing a neuromuscular blv;:king eiTect. Tbe inability 10 transmit impul~ thr<1ugl1 motor nturons can cause r-.pirotory failure, l'esultiog in deatb. I, C. Botulinum spores arc highly resistam to heat, bu~ tlte toxins rc out. Not.. 2. Th~ toxin is produced within the canned food and ingested preformed. 3. !'toper canning and heating of food prevents botulism. 4. N~trsea. vomiting an~ abdominal cramps usually precede the neurulugtcal symptoms; Dry mouth, diplopia, loss of pupillary reilexe.<. followed by descending par.~ lysis nnd respiratory failure. Tetanus, also known as lockjaw. is an acute exotoxin-mediated infeclion caused by the anaerobic., sp<.>re-forming, gram-positive bacillus Clostridium retaoi. Lt occun; tluougb 11 puncture wound tltat Is contaminated b.y soil or d<JSt. - -. I. Tetnnus 1oxiu is a neurotoxin that inh1bil' glycine rel~e. l'IJto~ 2. The toxin eme~~ tbe CNS aloug pcriphernl nerve;;. 3. Stiffucss nf tlte jaw, diflkul<y sw!liiOwing, fever, headache. 4. Risus sardonicus: ti.xcd "smile" nnd elevated eyebrows. 5. Severe ll"'>ms of the neck, back, and alxlomiual muscles. Olphtbcria toxin: inhibits protein synthesis, Anthrax toxin: fs made up of three protein~. One is a prot~clive antigen and two re enzymes t&ut arc csli..J edm factor and lethal facror, respec~iv~ly.

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Inr)

Eosinophilia is often associated with:

Acute infections
Viral infections

Tuberculosis
Parasitic infections

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Reye's syndrome is associated with - - - - - - administration to children with acute viral infections.

NSAID
Aspirin

Barbiturate
Antibiotic

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L-eukocytos.is, defined as a white blood cell count greater than 11,000 per mml (nonnal range is 5.000 10 10,000 per mml), is frequently found in the course of rouune laboratory testing. An elevated white blood cell count typically reflects the normal response of bone marrow to an infectious or inflammatory process.
I
l'lll, n~' IH\h

Nemmphils

Eo<i""!'hi4
L~

. .

s......

Acute. mfc:c:tlons. (IHrcttrilll)

Allt'f'J)', wbma Parulllc lt'lfec:onns

T\lbcm.tloJis
VJn.J mtiQtOnJ

\1o-

. .

Tubcrculosi
Matma

Ricl!t:ltilfl

l. Not oil bacterial infections shoiV this characteristic leukocytosis: fo1 example, !'lutes typhoid lever and brucellosis actually result in a depression of ncutrophils. 2. Many vlrnl Infections resull tn u lowered number of leukocytes (llmkope~tiu) , panicularly neuttophils. A genernl tndication of whether a diS<aSe is of bacterial ur viral origin ean be ob!:!ined by perfomung a leukocyte count (particularly ~tell trop/11/J). 3. On oorosion, the cin:utaring levels of leukocytes may reach >elY h1gh levels. up to 100.000 per cu mm of blood. Such an t\ent is referred to as a leukemoid reaction 11nd is sometimes difficult to dfferenuate from leukemia. 4. TI1e margination of leukocytes refers to the lining up of the white blood cells along the wall of a vessel.

Reye's syndrome is a potentially deadly dise= that typically occurs in children aged 4 to 12 years old. h is associated \vith the use of a;,ptrtn to treat cbickenpoA (\Qricella) or influenza. II lS characterized by encephalopathy. coma. and microvascular fatty li\ er. The basic rule: Don't gi"e aspirin to a child, unless specifically recommended by the child's doctor. When a child is taking llirin, steps must be taken to minumze the risk of acquiring a virnl illness (s11ch QS iifluen::.a and varicella mccinations),
---. I. lnllucnza (flu) is a v;ral infection that causes a fever, runny nose, cough, 'Notes headache, malaise, and muscle llche. lt is the fever and constitutional symptoms that distinguish intluenza from the common cold. Tntluenza viruses (A, 8. and C) are the only members of the orthomyxovirus famil). lntluenza A is by far tbe most common and causes the most severe disease. 2. Remembfr: The influenza vuuses have 2 envelope glycoprotein spikes, hemagglutinin and neuraminidase, which exhibit the majority of nntigenic changes. This is imponant in increasing the ability of the virus to auach to human cells during the establishment of an infection. 3. AmAntadine (Symmetrel) inhibits the replication oftbe influenu>A vinos by interfering witb viral attachment and uncoating. It is effective in the prophylaxis and treatment of the influenza A virus. Other antiviral medications include Rimantidine, Zanarcivir and Oseltamivr. The main mode of prevention is the vaccine, which consists of killed intluena A and B viruses.

(MICROBIOLOGY I PATHOLOGY

Cavitation and selective localization to the pulmonary apices are characterisitics of:

Primary tuberculosis Secondary tuberculosis Tertiary tuberculosis

Pneumonia

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(MICROBIOLOGY I PATHOLOGY

1nr)

Point tenderness at McBurney's point which, lies half-way between a line drawn from the umbilicus to the anterior iliac spine and is characteristic of:

Cholelithiasis (Gallstones) Ulcerative colitis Hepatocellular carcinoma Acute appendicitis

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An acute or cluonic '"fcction taust<l by Mycoboctcnum !llberculosis, tuben:UIO>ls (TBJ o< chllractenzed by pulmon:uy infiltrates, formation or granuloma wilh caseation, fibrosis, and cavitation. The lungs are primarily invoiV1'd. bu1 the infection can spread to other <lfllllns. Symptoms include minor cough. mild fever. fmiguc, weight loss, coughinS up blood, night swcaiS and eventually o co~gh producing phlegm. Note: Fever and ttight swCJ~ts. lhc typical hallmud<s ofTB, may not be present in elderly putioniS. who inslead may exhibit a change in activity or weight. Types ofThberculoh:

1. Primary tuberculosis:

Initial infecttoo, chlltll<lcrized by the pnntary, or Gbon complex (/mnwry /~liOn In the lullg ctJ/cifiHI h/lar lymph node) )1t>St oft<n asymptomatic, it U5Ually dOC" not rrogress to climcally cvidcnl dtkas<: 2. Secondary ruborculosls: Usually resuiiS from activation of a prior Ghon complex, which spreads to o new pul monary or exmmulmonary site. Locnh1.ed le'""'' fnvor upper lobtos of ~tc lung, lnvolvoment of hUar lymph nod,.. is

common.
1\Jberdc rormAtlon: caseous gn\nulornas frequently ruprure nn<J the. conltnts urc aocJ rc.sult in Ulfitary ltsion.s. hnporunt: Cavitation is a chnra~teriulc of secondary, but not pnnltLry, lubertulosas. I. Sccoodory TB may be complicated by lympbauc hc:matogenous spread. re<ulling in 1'NoiH mllil') ro or dl$$eOJIOated TB. This ITSUIIS in lhe ,.,eding of sevcnl oraans with nmluple, tmall, miUct. sc:edlike lcslof\S. 2. Oranuloma10us inflammation 15 cb:or.oc:temllc ofbotb primary and seccondory Tll . 3. The if1nuloma ofTB is referred to a. a l\lberclo. 4. TB " treated wi1h a combination of isoniazid - rifampin + pyrazmomtde - ethambutol. Serious side effeciS include ototoxicity, nephN>I"xtcity. and muscle weakness
c:~pcllcd

.t\cut~Appndidlb:

lhghffi inc:id<:ncc,. 1().19 year olds. II" unlllual under lhe of I yeor Appcnde<1omi.,. "-"' l!le most common em<lllr SUI\'tcal proccdu""' performed Ph}Sicot nndlrt~>! Th< chold wtll oncn walk into tloe oftlce bo:nt o'"' limping, and boldong Ius or her rll(hl sldr Tile child will look ill and lay quiedy There is oncn dtn"usc abdon1in3l 1enderness Point tendemcs.:t nt McBurney's point WhiC h lle.l{ half~way bewo~een a lil'll.! dniWn rrom the umbilicus to U1e amerior Iliac spiJ'I e\ Rtbuund ttudrrness ..~pressing the abdomen nt McBurney's point cause~ lcndtn.ess in a patient with arp<ndicitis. When the abdomen pressed, bcld moruenwoly. and then nlpidly
related. the: patient IUIJY expe-rience a U\QilH!fllary lncrt:a:iC- in pain. Th1s "rebound ttnder ness" SU&&~b inflammation ~ pread tu 11tc peritoneum

1. lflhe ppcl1di.tc ruptures. tbe pain may dtsaPI"'r for a sboll penod and the pauentrnay Notes feel suddenly bener. However, one~ pentonnis SCI5 in, llle rain teiUffi> and the pall<111 becomes pmgressiely rnoro ill. At thts tin1e doe abdomc:n may become ngid and extremely iender. For uncompU~-stted appendl"llis, Slrgcry (ap~mlectomy) ~~ per forn1cd 11~ SQO!l OS possible at\cr Ihe diagnOSIS IS much:. 2. floc uppcndix '""'no known physiologle&I I\Jnction but most likely is a vcstiglul <lnoccurc rcpre~cmins a degenerated portion of the cecum

3. Crnhn's dbtalt is a chronic inllannnatl001 uf the intestinal wall. floe cause ts not knov,;n and il ha::. no cure. It is charact~-ntal by ru:mnecrotiztng !;flnuiOf'nttlul~ infla.rn-motion wilh ulc=, s1nc1ures, and lhtulas 4. The <ordnold rumor ts the mos1 common neopla,m of lhc appc:ndi. In 1hos locauon it 111tely me1~105i~es. 5. Ul<tl'llthe cotltls i> a ebrorut disea.<c in which tht lllf\le 10tes11n< become> tnOsoned .nd ul~ted, leading to episodes of bloody dourrhl .. , abdominal crrunps. and f,;ver.

(MICROBIOLOGY I PATHOLOGY

In women, gonorrhea is a common cause of :

Pelvic inflammatory disease {PID) Epididymitis Condyloma acuminatum Toxic shock syndrome

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EncROBIOLOGY I PATHOLOGY

In~

The characteristic lesion of secondary syphilis is known as:

Chancre Gumma Condyloma lata Condyloma acuminatum

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Gonorrhea is a sexually transmitted disease (S1V). Gonorrhea is caut\Cd by Neisseria gonorrhoeae, a bacterium that can grow and multiply easily in the warm, moist areas of the reproductive tract. includ.ing the cervix, uterus. and fallopian tubes in women, and in the urethra in women and men. The bacterium can also grow in the mouth. throat, eyes. and anus. It is second only to chlamydial infections in the number of cases reported 10 the Centers for D i. ~ease Control and Prevention (CDC). The early symptoms of gonorrhea often are mild. Symptoms u<ually appear witltin 2 to I0 days after sexual contact with an infocted partJter. Gonorrh<:a is usua.lly treated with a single injection of ceftriaxone plus doxycycline.
When women have symptoms, tlu~ fir st qnes may Blec'dintr ussociatcd with va!9nai inWrcoursc
;nc)od~;

Painful or burning sensations when urinating Vaginal discharge that is yellow or bloody t:n women, gonorrhea is :1 common cau.<.;e of peh'ic inflammatory disease, which is a g~neral terrn for infe1iort of the uterus. fallopian tubes and oth~r rcproducrive organs. It is a common and seriot<s oornplicotion of some sexually tTllnsmitted disea.,cS, espe<:ial ly chlamydia rutd gonorrhea. M~n have symptoms more often than women. including; .. Acme purulent- urethritis and a burning sensations during urination tha1 may be severe *** In men, gonorrhea can cause epididymitis, a painful couditiou ofcbe ducts a1tached to rlte testicles thai may lend to infertility if left uoireared.
1

"l I. Not.~ 2.

Gonorrhc"ll often occur> together with chlamydla and $)'phili$. Chlamydiul ccnicitis is the most commou sex11nlly transmitted disease. It is caused by C. trachomatis. It is mosr llftcn asympiomalic. 3. Young women who contract chlamydinl cervicitis may also ac<juire salpingitis (ilif/nmmntirm of I he fallopian tubes).

\nnd~ lnnuJ

luta

Syphilis is a contagious, systemic venereal or congenital disease caused by the ~iro cliete Ttepon ewa pnllidum. Tt begins in the mucous membranes aud quickly spreads tl) ne~rby lymph nodes and the bloodstream. Transmission occurs primarily through sexual contact d\1ring the secondary stage of infectiotl. Transmission from a mother to her felu.~ i~ possible (spirocheJes ean cross the placenta and result in fetal mnl/ormolion). There are three stages of syphilis: Primary: finn. pni11less ulcer known os a chartcre which appears 3-6 weeks late~ at the site oflocal contact. The lips are the most conunon site tor chancres to appear In primory oral syphilis. Secon dary: highly infectious stage; it occurs 6 weeks after non-lreatmem of primary syphilis. A mculopapula.r ra~h and condyloma lata (gray, jlartened, W<lrllike lesirms) uppellr on the skin and mucosal surfaces. Tertiury: occurs in 30% of infected persons many years after non-ueatmeat of secondary ~yphilis. The gumma (focal nodular mass) typifies this stage, Most commonly occur'!; on the palate and Wugue. Neurologic symptoms are also evident at Ibis stage. Note: The prognosis is good if created early; te.r1iary syphilis callscs irr~vcrnible hean failure, dementia aod di,ability. Parenteral Penfcillin G is the drug of choice for trc:atiog all stages of syphilis. Condyloma acuminotum is a benitrn squamous cell papi lloma caused by human Jlapll lomo virus (HPJI). It is a sexually tr.msmltted disease and is most common in Lhe anogenitlll region. rt often bas multiple lesioos. Condyloma c trl!ateil by surgical exci sion.

EncROBIOLOGY I PATHOLOGY

In~
)

(
Bacterial infection Viral infection Fungal infection

Encephalitis is most often caused by a:

Parasitic infection

173 CoJ!rriSh.10 20092010 l>ental Oecks

(MICROBIOLOGY I PATHOLOGY

An infection is epidemic if:

It has a worldwide distribution It is constantly present at minimal levels within a population It occurs more frequently than normal within a population It is highly communicable

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\inti inf('cfiun Encephalitis is a severe inflammation of the brain, usually caused by a mosquito-borne or, in some areas, a tick ..borne vjrus. However, transmission by means other than arthropod bites may occur through ingestion of infected goat's milk and accidental injection or inhalation of the virus. In encephalitis, intense lymphocytic infiltrarion of brain tissues and th~. lptomeningcs causes cerebral edema, degeneration of the brain's ganglion cells, and diffuse nerve cell destruction. Encephalitis generally results from infection with arboviruscs specific ro rural areas. However, in urban areas, it is most frequently caused by enteroviruscs (coxsackievin,s. poliovirus. and echoviros). Other causes inc.lude herpes virus, mumps virus, Hrv, and aden-

oviruses. All viral forms of encephalitis have similar clinical features. Usually, the acute illness begins with sudden onset of fever, headache, and vomiting and progre1iSes to include signs and symptoms of meningeal irritation (stiff neck tmd back) and neurol\al damage (drowsiness.
coma, paralysis.
seizures~

auu:ia, tremors. nausea. vomiting and organic p.~ychoses).

In meningitis, the brain and spinal cord meninges become inflamed. It is caused by a number of mic-roorganisms, the most common in adults being the Neisseria meningitidis and

Streptococcus pneumoniae. Hemophilus influenue is the most common cause of menin~

gitis in children under the age of two. The organisms are thought to enter the body lbrough the nose and throat. Signs and symptoms include high fever, severe headache, and stiffness of the neck. Note: Waterbouse-Fridericbsen syndrome is an overwhelming, rapidly progressing infection caused by Neisseria meningitidis. It produces severe diarrhea. vomiting, seizures, internal blee.ding (bilateral adrenal hemorrhage), low blood pressure, shock, and often death.

It occurs murh mon fntrucnll.\ lhan nurmal \\ilhin

pnJinhtlinn

- _ 1. An infection is pandemic if it occurs worldwide. Notes 2. An infection is endemic if it occurs at m infmallevcls Within a pupulation. 3. If a disease is highly communicable, the teem ''contagious" is applied.

Infectious states: Acute: short-term active infection with symptoms Chronic: long-term active infection witb symptoms Many infections are unapparent or subclini cal and can only be detected by demonstrating a rise in antibody titer or isolating the o rganism. Some infections result in a latent state, after which reactivation of the ,.,.01vth of the organism and recurrence of symptoms may occur. Other infections lead to a chronic carrier state, in which tbe organisms continue to grow with or without producing symptoms in the host.

(MICROBIOLOGY I PATHOLOGY

Acute lymphoblastic leukemia (ALL) is a rare (11100,000 p er y ear) disease \.. characterized by a malignant proliferation of lymphoblasts. It is mostly a: _}

Childhood disease, with a peak incidence at age 4 Disease of middle-age, with a peak incidence at age 45 Disease of the elderly, with a peak incidence at age 65 Disease of young adults, with a peak incidence at age 30

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(MICROBIOLOGY I PATHOLOGY

When speaking of leukemia, the terms acute and chronic apply to:

How quickly the initial symptoms developed The duration of the course of the untreated illness Whether or not bleeding was present at the time of diagnosis None of the above

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( hilclhuutl dh: ;.t w. \Hih .t p t-.11\ lhd dt nu ul

Leuk.emi~ lln:

~.:~

mJligqant ncop~rns olt.,Uw:r lymphotd or hm!atopOCcttc-cc11 ong1n They ore tnc: IHdlnlt

Nute Of tantft dHth ln C 1 bUdn-n llndrr

t5 ) U

" of MCC. and lbc it:vcnth most comlN'In foml urcan.:tr

ck:ath twcratt Uuken:uas- &re primary dMXdc~ o( OO..c f'lMJ'OW, Tbe etiolO)' of lculr:anla II unknown. Lc\lkcmiC cells USliAlly <pill IntO Ill< blwd, ......., lhcy may be seen ill !&! ownbo:<l. lnfihm- or kulc<rmc C<tls tn rite lymph l'"'' spleen IUid 011>c:1 OIJ!IIlS os comi!!Oil. Acutr IC1tl<cmias usually ajlfl<&r wtllt ~mpoM>s n:sulting fi"om suppressiort of normal tnllttOW function. These sympl0015 include: Memiti, "ith ll(lc;QmJ)I:1'1Y'"I rangue; ft\W~ usua11.)' reflrctlnl In u\foctinnt ondlnr bleediog, usually caused by tlutmhoo)1optntl, Chtuni<' leukemias, on the olher hand, can appear

node.

wutt non..spedfic S}'Inptun4o", indudrn~ abdomen ~;auscd by splenomegaly.

tiui~;:ue.

"ctgtu loss. anemia.. or an 11hnunna1 !I.Cibntlo11 tn th.:

Arute Je.ukeru.iM ate U..4iually (illtl wiiJm'l Wct'ki tf lcit untreated, while f)!ltienbo Willi untrelited chronic leukemia usually su.Ni\<e mu~b l"ugt."f'. A.e:utr t hronlt lrulu~nlia cun be distiugutJihed hi liU1I0!~;1CIIIJy by !lie fucllhAt 9C!U(I' Jeuk.,mill) arc U t\ilr11Ctcritcd b)' 1be l>l'eRtmc-e orlmn1aturc, b lta~t tdl:c, Whiltl t h i'UU ..

v,.

It leukentiM are usuolly ass""hatcd w1lll mu"' m~ttu re 1 uu1 wcJl--tlif'f'ercnthucd C!t~ l h. &,me c h tOnl~ 1euke1l'lltl.,,. ma,Y. howevtr,tn~nsfom'l into an IW\IICpl\llSe, "lliO called '' blAst crisilf." Bestdes the acut.e ur chronic designation, hmk.cmins c::..n be subdhided inw tbo1:,c whlch o.r..: l,yrnphoblaJ tit (ortxtncuingfrom o u~cur~ tJ/ tJ B u 7; lyHJ.{JhVt.)IP) o.od tbl)se oJhkh are rn}d11t10Uf (QI'f~ft'UU.. i"':Jrtlfu a precJ~T:scr ofgramlltx:)'tt.J. monQ()rt&!l erylllflH.'VIb. or mtg.Jbuync.yres). Thu.t.., Jeukcm1;u C:M be clmtticd intO tliur gcn<tal types: IICUtt l)'lllphohlastt< leukttrua ~4LL), <hronoc l:nnPh"'d leu).omil !CLLI, """"' m)'<loblasti< IC1rkcmto (AMI., and <hronoc m""loid lfllk.,.; rC"'li I. ALL is thefonn Ufacult lelll..e'"t.t lhlf p lhe mort nspoasf, r \0 ~and I.J~ com"Noret moo rn ~hddma. Associated wrth oposurc to radi.at\on Mid d\tmjcals 2. Atut..,>)Oiold ttukomla (A \fiJ o<tll< mos< malogDIJit typt. lt nul<ts 119lbow 000.. of leukemtas dla~ in uJUib. h mon: rornmool) affecJS> mn. than women. fntHk"'''Cc: iDeasH wieh a..t,re. Cbrollic ~ mpbot) Ut.li!ukM1ht fO.I.-) ts Ihe lease maHgnwd type. ltts tllrtly dill_un~ rn mdivlduals youn~cr lltar! 40 ~corl old. It hos a vc:ry slow progression. Cbro~ myt lognOu> I'""' "'' (CMLitS "'"'o<:tated wioh lhe Phnlltlelrtua (Phi <hr<tmo.somr, If is 111ore common 111 middl~j;.od o.nd elderly mdividl.lnls.

.K\1"'

IIH' flu ration

ollh~ l'OUf~t

nf thl UIIIH:tll'fl iiJnt'''

l!acb ot the two major types of leukemia, m~elog<nous and lymphocytic. include both ucut< and chronic forms. Acut essentially refers to a disorder or 1'1lpld on~~ In the acute rnyeloblasllc letdmlas. the nbnonnal cens (>rlyelohlasls) gru~ rspldl~ and do not matun. Moo oftbc:!e tmrMture cc:lls tend to die rapidly. In the a<ul lymphoblastic l ukemias. growth of the lymphobla.ts are nut as rapid as that of the ll\)leloblasttc "'lb. R:.ther. the cells n-od to accumulate. Common 10 both types of leukemiu IS their tnability 10 cany out the functions of health) white blood cells. Uotru.trd, d ealb occur< wlfhln wttks or a ft., mooU11. O!htr important feature of acute leukemias: Not..- A p~ominance of blost cells, whteh ore immature pre<:Utsots of ottller l)mphocyre. Oymphoblasts), or gmnulocyte (m,relnblnsL<). They do not nonnally appear in periphcrnl blood. When they do, they can be recognized hy theor large si:te, ond primitive nuclei (ic tile uuclei contni11 lmclen/1). Abru,pt onset (Jew mont!t.) with sudden high fcve~ weakness, malaise, cvere anemia. and generalized lymphatlcnolllhy; bone lllld joint puio common in chil
Jn:n. Principal organ involved: bone m&rruw (along wir~ til< .rpleen a/111/ivt!r). Bone pain and tenderness are cxperieuc.:d "''a result of tl<JW1Sioo.

=w

Petechiae and Kdlyrnosb in sk.n 1111d mucous membranes, hcmorThoge from ,lltious sites: b&ctorial rnfechons common. laboratol)' findings. lcukocytosu 30,000.100.000 per cuJiml. \\1lb itumaturr form< (nt)elob/Q.t> orrd IJmphoblrmsl prcdommaung. In 15% of lhe c~ uf aoute lymphocytiC lt:ukemu1, tb.e l)mpboeyte. ate neither B nor T..:ells and arc called M nyll rc!I,,P
Remember: Acute leukcmtns occur must often in children. They c><hibit ,;coond peak incidence after 60 years of age. Leukemia con modify the inllammawry reactl~n.

(MICROBIOLOGY I PATHOLOGY

Leuk)

\..

In 1960, tbe overall 5-year survival rate for all leukemias was about 14%. It is now about:

19%

34%
50% 85%

1n Coprrishl 0 2009.2010 Deolal ()reeks

(MICROBIOLOGY I PATHOLOGY

_ _ _ _ is characterized by tbe presence of a unique chromosomal abnormality.

Acute lymphoblastic leukemia (ALL) Chronic myelogenous leukemia (CML) Acute myeloid leukemia (AML) Chronic lymphocytic leukemia (CLL)

178 CopyriJbl CIWQ9.1010 Dm1.81 Detks

SUrvival rates of leukemia have risen dnimaritally m the lliSl 40 year> with ompro>Cln<mts on diai!D<>Sis and tKatmem. The hogbeSl sUM val rates occur in children With the S<>-talled "common 1\U. \YreCbrooio leukoml-1 have u slo<r onset and JlrO~renlon than acute JeukettliM. rhey also bave a longer, less devastating clinical course o hon ucutclcukcmiss but are less responsive to therape\1110 intervention. Chronic leukemius uro charoctcrlzed by proliferation oflyonphoid or bemalopoietio cellsthrtt are more mature thautho.e of the acute leukemias. Other lmportnt features or cbronle leukemlu,<: lu.idiou onlel -.ith W<'llkntSS and wei4Jht los: dis.....: tnay be detected during exominatioo for some other condition, e.g.. ""<-mia. unC11plained hel!lorrbages, or I'<CUtl'l'nt intractable infectiOn. Organ invol>ement slmUar to acute type; mJWive splenomegaly "' chanlctemnc of chronic myelo11enou; leukemia; lymph node enl'\f'8cmem as the main pathologic finding in the lymphocytic ryp~. Pt<blat and teehymoses. recurrent hemorrhages, h;acterial infections; CLL maybe ~:umpli.:uted by outoimmune hemolytic lln<mta. Lborutory nndin~$: leukocyaosis obovc 100,0(10 per cu. mm. with ou1111ue fonns (g>'OIIultx.)'l<>s alit! lymp/locyre.s) predomiMtinl!; Philndelphi (Ph) chnmoome, nnd low level of Leukocyte alkaline phospllJltase a~ ~ommon in chronic myetnid lcukentl (CM.L) Medi311 urvtval time far ~tiems with chronic myelogenous h:ukemon rCML) " four yean wotb death due to hemorrhage or utfecliun; ch11>oic lymphocytic ll'ltlccmoa (LI.L) nons a vllrible course; older pariems ma) surv1> e yeArs ev<m without treannent. Not: The Pb Chromosome describes a specific translocation bel\\een chromosomes 9 and ;!2. The resulUJ1l! abnormal gene (BCR-.ABL) todc. lor an enzyme (a tyta.vine kiua.,.) dun is byputbeslzed to drive the growth of CM!.. cells.

About 95% of pauents with CML bave the l'hllodelphtn (Ph) cbromO!om"- an obnormality in which thelongnmo orchromosome 12 is tram located, usully 10 chromooome 9 Rll<liauon and careinogcme ehemocal~ n10y indue~ this chro-ma I abnonnalit). As a rtsuh or thll t11lnslodnion, the BCR geuc ID chroma.<Omc 22 is fu.ed Wtth the ABL {t<'lle in chrcmowme 9. TI1e resulting BCR-AIJI. gone cocks lbr a bcr..abl tyrO!!lne kmo$c (T'A.? enzyme that Is conslitUII>Ciy oelive. This TK enzyme inaeracrs wath other pmtemo to speed up cell divisoon while mhibiting DNA repair, 11 l'C.<ulliiiS: geow1ic instabilhy mAY leoJ to a blast crlsiJ. Climcully, CMI. ~" dt&CIIsc with slow progression. The f.1llo\vins pbose< cn11 b~ ob~tl"<d I. Chronic pbc: thi~ phase Is usually usymplon>ntic. F'migue ond abdominal fullne~' (a.< a result ofsvrtre splonom<"galy) ar< the most common cornploims l. Acteterated ph~c: fifty percent of CML c>CS prcgrcs into thi phuse. lneren.<ong anemilo, new lhromboc:yu'l""ni and ad<bu0tl41 c:y10genic abnormalities uxltcat p~ession or the wscase towatds a blast criso>. 3. Blut crbls: tlle other fifly peteent abrupt!) mo>c onto a blast cnsas. Clmlcally, thos las plwe CML 15 of mpid progression with lo\\ SUI'\'1\'8.1 nne.. Patients in the chronic and ace.:lenned pbol!Cs art treated wiOo TJ{ inhi~itQ" (i.r.. Glee'uC) that spocifieally inhibit the ocrivity of a subc of tyrooua.c kinasos. Patients in ... bias I crii are lrentl'd w. ith a hi&h Jose or Clll'lllOthcrapy followed by bone morrow

or

rransplontotinn. Note: The Ph chron10$00IC is also prccnt 111 n small percentage of ncutc lymphoblnstic leukemia (ALl,) and 111 ocMe myelogenOll> kukcmia (AML). No dcflninvc cause.< have been identified for leukcm1a. Possible mk faewr.o include: Gtnetlc prtdlpo>lllon: Down syndrome ha.< a higher i~cidente of acute lcuh-mias Environmental txpcnun to: chcndcaiJ (~Mcm~. rome ami-co~tc'7 Jrugf} : radiation - uaually myclOJ!.C:OOUS 1ype lcukemw V1rues: BTL\'-t- adllll T-cellleukornia :lcukl'lnl<' pBiic:nls have bjgh 1111hbody titer to the Ep.ucln-Barr Viru' (EBI')

(MICROBIOLOGY I PATHOLOGY

Immun)

All of the following statements concerning immunoglobulins are true EXCEPT one. Which one is the EXCEPTION?

They are secreted by activated plasma cells They are also known as antibodies Thay have enzymatic activity They activate compliment They are glycoprotcins

179 Copyright 4) 2CH-2010 IXn~l Dk$

(MICROBIOLOGY I PATHOLOGY

Immun)

An injection of a drug into a patient who is allergic to this drug may lead to death due to:

Low levels of histamine Hyperglobulinemia Severe anaphylaxis (anaphylactic shock) Localized anaphylaxis

180

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Thl~

hone

l'lll~ m~tlk

acth il~

Immunoglobulins (antibodies) are glycoproteins found in blood serum synthesiZed by plasma cells in the spleen nnd lymph nodes in response to the detection ofa foreign antigen. They mediate anaphylaxis. atopic allergiC-<>, semm sickness, and Anhus reactions. Immunoglobulins generally assume one of two roles: they may act as 1) plasma membrane bound antigen receptors on the surface of a 8-cell, or 2) as antibodies free in cellular fluids functioning to intercept and eliminate antigenic detenninants. In eitber rok, am1b<>tly function is intimately related to its stn~cturc. Immunoglobulins are composed uf four polypeptide chains: two "light" chains (lambda or l-appa), and rwo "heavy" chains (alpflu, delta, gamma, epsilo11 or mu). Tbe type of heavy chain derennines rhe immunoglobulin ismype (lgA, lgD, lgG, JgE. fgM, respective/;~. Light chains are composed of 220 amino acid residues whlle heavy chains aro composed of 44().. 550 amino acids.
:\1,\jflr (
l.l'!>t'\

ur lmmuuut,:luhuhn\
O~rlpllon

lmmuuo&,lCibulin
tgG
lgA

Is the mostbuodaut; prescn1 tn btood iltld e:wt~vasc:ulor fluids: only immunoglobulin whicll r:rt~SMS L bc pl.act.ota; main defense against Y.arious patllogenic Orsftnisms
S~ond mo$i abund11oh occurs in body secretions llod rnweets. surf.'\Ce lis._<lttS; synthc:si7.A."d by plasusu tells in mucous membraoes of the Gl, respinnory, 11nd urinal)l ll~ts; in b<xty ~ crebons i\ ex..ilSts ll$1l dimc:r. ]n pla~ma it exists A.~ a mon()n\.Cf

~1>
J~M

M1lk:e.s up lc:ss tbnn I~o of immunoglobulins; _preseru an membrn.ne of many cit(;Uhuins; 6 cells; func:llon -i$ unknown or not fuUy undco.1ood
IJlrt;.e$1 lnu.nu.ll(lg,lobullo: firSt >Ln1lbt.!dy produ~ed in response to infection: powcrfial ac(ivator or the. complemenl system; JKreJ.ed as 3 peocamtl

tgE

Is present in only tmct am<Hil'll111 Sm:Jm: n:agt'ok aclh'ily rc:Qdcs in this immunoglobulin; prolecl$ ex.ternal muoosal Sl..rfatts; tigbl.ly bouod tu its ren:ptono oo mas1 cells and ba.~hils; resportSible lbt l)'J)c I h~tivity rtactions (allergic aJtd anop}ty/act!c)

Sl.'\ l'rt.

~Ill!.! ph~ l:nis funaphyhu tic ..,froL It)

Tills represents a serious condition that occurs suddenly in an. allergic individual exposed to an antigen. It may occur within seconds or minutes after exposure. The first
symptoms are int~nse llnlUety, weakness, sweating, sbonness of breath, and generalized urticaria. Constriction of the bronchioli and drop in blood pressure are the usual causes of death. :-.lote: The above symptoms are caused by the drug (allergen) reacting with lgE and activating mast cells to release cytokioes (diverse and p<J/ent clremica/ mes.vengers). Hypersensitivity reactions may be trivial, resulting in a rash, or they may be serious, causing potentially lethal anaphylactic sbock. Immediate treatment for anaphylactic shock: Conscious patient - Injection of epinephrine 1M or subcutanoously Unconscious patient - Injection of epinephrine intravonously u Epinephrine opens the airways and raises the blood pressure by constricting blood vessels. Majotajo ajrnay (remember ABC's of CPR) Remember: Antihistamines such as diphenhydramine and corticosteroids such as prednisone may be given to further reduce symptoms (after lifesaviug measures and
epinephrine are administered).

(MICROBIOLOGY I PATHOLOGY

Immun)

(
Humoral immunity Cellular immunity

B-cells arc responsible for:

Both humoral and cellular immunity Neither humoral nor cellular immunity

181 Copyri,SbtC 2()09.2010 Ocntnll)cck.s

(MICROBIOLOGY I PATHOLOGY

Immun)

The most potent of the anaphylatoxins is:

C3a
C4a

C5a

182
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Humoral

iumwnit~

Hum11ral imm1mity (also called anlibody-mediatt!<l lmnulllity) is immonityproduced by the activ:uion of the B lymphocyte population. B-ceJis, like T-cells, have surface receptors which enable them to recognize tbe appropriate antigon, but do not themselves intor act to neutralize or destroy the antigen. On recognition of an antigen. B-cells take op reside. nce in secondary lymphoid tissue (.vuch as lymph nodes and spleen) and with additional stimuli from T-helper cells, !hey differentiate into elther an >~Ctivated plasma cell or a memory Bcell. The shon lived plasm~ cells produce amibodics and rdcru;t them into the circulation at the lymph nodes. The memory B-cells ~ontinue to produce small amounts of the antibody long after the infection has been overcome. There are 5 classes of antibodies, Each is called an immunoglobul in and lueo allocated a coda letter (tga fgM, lgA, /g. and fgD). Important: The key to humoral immunity is dle ability of antibodies to react specifically with antigens. This type of immunity provides proter lion against encapsulated bacteria. Cellular Immunity is immunity mediated by T-lympbocytes either through release of lymphokines or through exertion ofilin.<ct cytotox.icity, transmissible by trunsler of lymphocyte.< but not serum; it comprises delayed hypersensitivity reacrious, systemic response to viral and tnkr<>bial infecrions, contact dennaliti.s, granulomatous reactions, allogratl rejection, and gratl-versu.5-host reactions. lt is a specific acquired immunity involving T-cells. h acts to resist most intlilcellular pathogens (bacteria and viruses). The main fuoclioo of the immune system is to prewnr or limit infections by mlcroorg~nisms such as bacterla, viruses, fungi. and parasites. Protection is provided primarily by the cell-mediated and antibody-mediated (humoral) anns of the immune system, Tbe other two oth,,r major components of tbe immune system are complement and phagocytcs. The cell-mediated arm consists primarily ofT-IymphocyiLos whereas the antibody-mediated arm consists ofB-lympbocytes.

Anaphylatoxin is a fragment (C3a, C4a or C5a) ofthe complem~nt system that rromotes Mute inflammation by binding to specific cell swface receptors tbnt ~tlmulat~ neutrophil ch~motaxis and activate degranulati011 of (release o.f substances jiom) mast cell~ or basophils, 1'his mechanism is an imponant part of the immune system in aU kinds of inflammation and especially as part of deftmse against par~ites. CSa is the most powerful; apprnximately I 00 times more etl'ective than C3a, and I000 times more effective than C4a. Anaphylatoxins indirectly mediate: Spasms of smooth muscle cells, sucb as brouchospasms Increase iu the penneability of blood capillaries Chemotaxis - receptor-lllediated movcm~nt or leukocytes in the direction of the incrca~in g concentration of nnapbylatox.ins I. If the degranulation is too strong, it cn cause alJergjc reactions. An~pbylilX is N~t">> OIUScd by these complement components is less common thun anaphylaxis eaused hy Type 1(lgE-mediated) byperseositivity. 2. Compl ment fi)Calion is tho binding of complement as 11 result of its interaction with immune complexes (lire c/as.ical patlnvny) or particular surfaces (altenmtiw pathway), It is used in diugnoslic tests, such as the Wasserm. unu test Oo .~vp!rilis). to detect lhe presence of a specific antigen or 11ntibody.

( MlCROBIOLOGY I PATHOLOGY

Immun)

(
Rhinitis
Jaundice

The three principal kinds of atopic allergies include all of the following EXCEPT one. Which one is the EXCEPTIO/I'?

AI

Atopic dermatitis

Allergic asthma

183 Copyrigtll (l 20092010 tkntal Deets

(MICROBIOLOGY I PATHOLOGY

Immun)

Which of the following is the most frequently employed diagnostic laboratory technique for the microscopic detection of antigens in tissue secretions or in cell suspensions?

Immunofluorescence (fluorescent antibody) Agglutination Radioimmunoassay (RIA) Precipitation (Precipitin) Enzyme-Linked lmmunosorbent Assay (ELISA)

184
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.J au mJin.

Atopic allergies result from a localized expression of Type I hypersensitivity re~ctlons. The interaction of antigens (al/ergells) with cell-bound lgE on the mucosal membrrutes of the upper respiratory tract and conjunctival ti<sues lull iates u localized type 1 hypersensitivity reaction. Most allergy >'Uffcrcrs arc said to be atopic. An atopic allergy i~ one where lte...,dity plays an impOrtant tole (i.e., allergies 11111 in jlunllies). Atopic Individuals are genetically programmed to produce an abtmdance of lgll (fmmomoglobulin ) Mtibodies. The.~e lgEs strongly react against allergens in the enviroomtent (pol/ell, moulds, household dtw, etc.). It is possible to become allergic without being aropic, but mopy increa.o;es the risk! Note: A child lvith one parent who has suffered from ullergics J'UllS a 30"A risk of also becoming allergic. If both parents have suffered fmm allergies, the risk doubles to 60"A. However, aUergies can 1)urnp" a generation. AUeglc rhinllls: also known as hay fever, It takes place wueu tile aUcrgcu interacts wi!h sensitized cells of the Upper respiratory tract. Symptoms include cougbing, sneezing, congestion. tearing eyes, and respiratory difficulties. Note: The primary mediator is bbtamine, which is released lfom sensitized mast and basophil cells, Allergic usthrua: t.he .Uergic reaction primarily affects tlJe lower respiratory tract. lL ls commo11 in chUdreu and is characterized by sbortnes. ofbreatb and wheezing. Note: Specific lgB autibodiL-s or n!>nspccific inhaled irriWtts provoke mast cell degmnulation; biswmine, leukotrlones (SRS.A.s), ru>d otlt.er mediators are released to can..'\e bronchospasm aud brunchisl mucus secretion. Atopic demlatitls: commonly referred to ~s eczema, is a chronic skin disorder categorized by scaly and itching rashes. Eczema is most common in inf.mts1 and at leasr half of those cases clear by age 36 mouths. ln adults, i1 is generally a cbronk or recurring condition. A hypersen;itivity reaction occurs in t~e skin, causing chronic inflammation.

l m mununuun'<..:e('lln'

fjltull't''~ t'll/ tmlihm~l')

In this technique, fluorescent dyes, such as nuorescein and rh()(lamine, are ~<>valently auachod to antibody molecules and are made visiblt by ultraviolet light in the fluorescence microscope. Such "a labeled antibody" can be used to identify antigens on the surface of bact tria. Radjoimmunoassay (RiA): Thls mctltod i used for the qnanrificmion of aotigeosor haptens that can be radioactively labeled. Enzymc-linked-immunosorbent assay tet./SA): This method can be used for the quantification of either antigens or amibodics in patient specimens. Precipitation (Precipitin); ln this test, the antigen is a solution. The antibody cro"links antigen molecules in variabl proportions and aggregates (precipilotes) tbelr
fonn,

Agglutination: In !his test. the antigen is a particulate (e.g.. bacteria and re.d blood cells), Antibody (agglutinins). because it is divalent or multivalent, cross-links the antigenically multivalent particles and forms a latticework, and clumpi ng (agglutilwllon) Cllll be seen, Note: If the antigens are located on tlte surface of red blood cells und the addition of antibody leads lo clumping of the cells, it is called bemagglulinalion. Hemagglutinatiou is the basis for blood typing nod distingllishing the presence ofA typo antig~n or A type a.ntig(n 011 tlte surface of human red blood cell;;.

neRO BIOLOGY I PATHOLOGY

Immun)

Defects in the complement system could resull in:

Failure to produce complement-fixing antibody Increased resistance to viral infections Impaired elimination of microbial antigen and circulating immune complexes Marked increase in bleeding time

185
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(MICROBIOLOGY I PATHOLOGY

lmmun)

Passive immunization:

Provides protection without hypersensitivity Employs attenuated bacteria or toxoid Provides long-laSling protection Provides immediate protection Employs sensitized T-cells

...
Copyri""'O 20091.010 "'""' Ob

lmp.tirld dimin:11inn of microbial anti~l'n and

drculatin~

itnlliUIIl' nunph.'\l'S

The complement system plays an essenrial role in host defense against infectious agents and in the innammatory process. It consists of abouttwemy plasma proteins (tlesignated Cl. C2. C3, and so forth) that function either as enzymes or as binding proteins. ln addition to these plasma proteins, the complement system includes mulriple distinct cell surface recep1 ors Lluu exhibit specificity for the physiological fragments of complement proteius !bat occur on inllammatory cells and cells of the immune system. Jmportant: Complement activation is a feature of type UJ hypersensitivity reactions. There are three major pathways of complemem activation: The classical pathway, which is activated by certain antibody isotypes (antigen bound fgG or fgM) binding to Cl. The alternative pathway, which is activated by C3 binding to microbial cdl sllrfaccs. The lectin pathway, which is activated by plasma lcctins which bind to mannosc residues on bacterial cells. The alternative and lectin pathways ore activated in an antibody independenl fashion and appear to be of major importance in host defense against invading microorganislllJ;. l\ll1hree pathways resuli in llte production of C3 couvertase. The protein properdin com piexes with C3b and stabilizes altema<e pathway C3 convertase. C3 convenase initiates activation of tbe late components of llte complement system resulting in the fonnation of the membrane attnck complex (MAC) and ultimate lysis of the target ceiL ~ I. Cytolysis refers to the lysis of bacteria otof cells such as rumor or red blood cells Notes by insenion of the membrane att>lck complex derived from complement activa lion. 2. Characteristics of Cl : lt is a constituem of the classic complement pathway. Composed of1bree pro1eins (Clq, Cit; and Cis). Calciom is required for activation ofCl.

Prm ides immediate p rntcctinn

Acquired immunity occurs naturally 11tld artificially. It can be active or passive. Naturally: Active: person is exposed to an antigen and the body produces antibodic:. Passive: antibodies (fgG) passed from mother to fetus during pregnant) rnd lgA passed from mother to newborn during breast-feeding. These "tlbodies disappear between 6 and 12 months of age. Artificial: Active: vaccination with killed, inactivated, or auenuated bacteria or toxmd. Passive: injection of immune serum or gamma-globulin.

/Nor~

-. I. In active immunity, the host actively produces ru; immune response

consisting of antibodie.s aod activated helper and cytotoxic T-lymphocyte.~. The main advantage is that the resistance is long-term (years); the major disadvantage is its slow onset. 2. ln passive immunity, antibodies are preformed in another host It is not as permanent and does not last as long as active immunity. The main advanu.ge is the immediate availabi lity of antibodies; the major disadvantage is the s hort duration (months).

ncROBIOLOGY I PATHOLOGY

Immu~

A smaU molecule, not antigenic by itself, that can react with antibodies is called a (an):

Epitope Hapten Plasmid Immunogen

187 Cop)Tigbl 0 2009-2010 Dtnt.a.l Ded:s

EucROBIOLOGY I PATHOLOGY

lmmun)

Natural immunity (innate immunity) is resistance:

Acquired through contact with an antigen Not acquired through contact with an antigen

188

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u ..,,,...
Haptens have antigenic detenninants, but are too smaU to elicit the fonnation of IUltibodies by themselves. They can do so when covalently bound to a "carrier" protein. Many drugs (e.g.. ptmicillins) are haptens and the catechol in !be plant oil that causes poison oak is a hapten. Haptens are uot immunogepie because they cannot activate helper T-ce)ls. Important: Antibody production iovolv<>s activation of 13-lymphocytes by the hapten and bel per T-lymphocytes of tbe carrier Remember that an antigen is any substance !bat cau specifocally bind antibodies or tbe T-ceU antigen receptor. Thoso antigens that can stimulme an immune response are immuoogcns; therefore aU immunogens are antigens, but not all antigens are immunogcns. A large variety of biological molecules (i.e. proteins, carbohydrates, lipids and 11ucleic acids) are able to bind to antibodies, while only peptidcs are recognized by T cells. In order to b~ immunogenic, antigens must be foreign, with a high molecular weight, a certain degree of chemical complexity, and. forT-cell antigens must be able to interact with tbe 11osl's major histocompatibility complex (MNC). Not~ Epitope is the spec[fie portion of an antigen to whicb the antibody binds. I. l'lasmids are extrachromosomal genetic structures that can replicate t Not.. independently within a bacterial cell. These molecule.< of DNA are separate from the bacte.rial chromosomes and detennioe traits uot essential for the viability oftbeorganism but in some way change the organism's abDity to adapt. R (resistance) factor Is an example. Most antibiotic resistance in bacteria is caused by genes that are carried on plasmids. Plasmids may be passed from ono bacterium to another, and they are replicated in later generations of any bacterium carrying tltcm.

~ut

acquired through rnnt.art '' ith an antigt.n

NahJral or innate immunity is immunity that occurs. naturally as a result of a person's genetic constitution or physiology and does nut arise from a previo~s infection or vaccination. An example is th.e phagocytosis of bacteria by neutroph ils and macrophages.

In contrast to acquired immunity, naturol immunity: Is nonspecific: acquired immunity is specific. Docs not improve after exposure to the organism: acquired immunity improves upon repeated exposure. Proc~sses have no memory: acquired immunity is characterized by long-term memory.
- _ 1. Acquired immunity occurs after exposure to an antigen, improves upon Notes repeated exposure, and is specific. [t is mediated by antibodies and by Tlympbocytes (Ire/per and C)rotoxic T-cells), The cells responsible for acquired immunity have long-term memory for a specific antigen. '2. Hypersensitivity is an exaggerated immunological response upon reexposure to a Specific antigen (i.e.. positive skin test ajier having a disease).

(MICROBIOLOGY I PATHOLOGY

lmmun)

(....

All of the following statements concerning complement are true EXCEPT one. Which one is the EXCEPTION'/

It is a collective term for a group of plasma proteins that is the primary mediator of antigenantibody reactions
These proteins participate in lysis of foreign cells, inflammation, and phagocytosis
It consists of about twenty plasma proteins

The proteins are synthesized mainly by the kidney

It is present in normal human serum

It is not an immunoglobulin It is heat labile

1a9
Copyrighl 0 20092010 Dental Dks

(MICROBIOLOGY I PATHOLOGY

lmmun)

A group of compounds derived from unsaturated fatty acids which arc extremely potent mediators of immediate hypersensitivity reactions and inflammation are called:

Histamines Leukotrienes Cytokincs Bradykinins

190
Copyrigh1 0 2009-2010 l)cntal Ooc;k$

I hr prnll'ln"'

:Hl'

"nfhl"'itcd m;.~inh '" fht (..ldnl\

*This is fal!e; complement proteins are synthesized mainly by lhe U\'er. Some are made in mucropbages. Note: Cl is made in GJ epithelium. The imrouue system is composed of ceUs and soluble ~ubstances. The major cells of the immune system are the white blood ceUs (mat'ITJphllges, newmp/rils. and lymphocyres). Soluble substances nrc molecules that are not contained in cells but are dissolved in a liquid. such as plasma. The major soluble substances are antibodies, complement proteins. and cytokincs. The soluble sub$tances aetas messengers to attract ond activate other cells. The complement system comprises about tw<nty plasma proteins. These protns oct in a ca_<eade, with one protein activating ~ next protctn. There are thrte major pathways of complement activation: The classltul 1 1sthway, which is activated by cenain antibody iSOIYJl".' (antigen bound lgG or lgloJ) binding to Cl Tbe llcrnurlve pnthway, which i> acthated by C3 binding to microbial cell surfacus The lectin flRihway which is activated by 11 plasma lectins that bind 10 monnose residues on baclertul cells r l. Tite complement system functions to destroy foreign substances. either Noteo dircetly or in coojuoctioo with other componentS of the immune system. 2. The membrane attack com pies Is the end product of actiation of the complement cascade, "hkh contains CSb, C6, C7, C8, and C9. This complex mak<s holes in the membranes of gram-negou\'e bacteria, lolling them and, in red blood cells or other cells. resulung in cytolysis.

cid and Leukotncnes are btologicaUy active comrounds formed from arachidonic Q other palyun.saturated fall)' acids. Leukotrienes are of imponance 10 hO'ol defense reactions aod bavc a pathophysiologtcal role 10 tnflammntion and allergic reactions. Once arschido111c acid is genernted (by mjlummutorl! c-ells and i'!fllred tusues), ir is me1abolized through two pathways: I. Cyclooxygennllon: produces prostaglandins aud rhromboxanes. 2. Lipo~ygenation : produces leukotncnes us well ~~ liETEs and dil IETI!s. Leukmr1enes C4, 0 4, and E4 are collectively known ns slow-rcacliug su b<lances of

ooapbylaxls (SRS-A. <) and are responsible for the development of much of the clinical symptomatology nssocinred with allergic-type reactions. The lrukolnenes are 100 to 1,000 times more potent tbsn a histamine or the prostaglandins in constrlcttng bronchi.
~OitS

Remember: I. In asthma, the allergen reaction occurs m the bronchioles of the lun~ The rnosr imponsnt producL~ released from the mast cell are the SRS-As (Iiley are tile primary mediators of asthma), which causes spasm of tlte bronchiolar smooth mtl~clc . 2. Au~phylocllc shuck (anapilylax/s) s physiological shock rcsultiJ1g fmm llll anaphylncric hypersensitivity reaction (/'or example, lo penicillin or hee hilas). ln severe cases. deatb can result within minutes. This nnaphylacllc reaction involves the degranulation of llUlSI cells and the release of histamine:. heparin, platelci4Ctivating factors, SRS-As. and serotonin into the bloodstream. 3. Risramlne is responsible for the principal symptoms of anaphylaxis.

ICROBIOLOGY I PATHOLOGY

Immun)

The predominant antibody in external secretions is:

E
A.

191
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~UCROBIOLOGY

I PATHOLOGY

Immun)

Wblcb blood group has neither antigen A nor B?

192

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Polymeric lgA secretions saliva, tears, and breast milk-- especially colosmml). Therefore, st-<:retory JgA is often abbreviated as slgA. It is
compo-~ed

of two lgA monomers linked by two additional polypeptides: a J

(joining) chain and a secretory component. The secretory component protects slgA from
hydrolysis by microbial proteolytic enzymes and keeps it on the mucosal surface by binding to mucus. The primary function of lgA is to collect microorganisms and prevent their colonization. Monomeric l gA exists in se.rum. lgA is important in the respiratory, Gl, and urinary tracts, where it plays a major role in protecting surface tissues against invasion by pathogenic microorganisms. lgA provides the primary defense at mucosal surfaces such as the bronchioles, nasal mucosa, vagina. prostate, and intestine. The lgA molecules bind with surface antigens of microorganisms, preventing the adherence and ingress of antigen through the mucosa of the respiratory, Gl, and urinary tracts. Remember: lgA is one of the most prevalent humoral antibodies (second only to lgG) produced by the bQdy.

:.:::::J I. In the primary humoral immune response, the predominam immw10globulin is

No"' lgM, which appears first in the serum and is followed by lgCi

2. During the secondary humoral immune response (a second exposure to the same antigen, .for example when a person receives a third immunization with tetanus toxoid), a more rapid and greater response ensues, which is predominantly composed of lgG, not lgM, as the major class of antibody. 3. As the severity of an infection increase.< (for exmnple, periodontal disease), there is an increase in plasma cells that produce lgG 4. No function is yet known for lgD other than as a membrane receptor. 5. l gE is the immunoglobulin responsible for allergic or anaphylactic reactions.

Type AB indicates both antigens (alloamigens); type 0 the absence of both. Corresponding antibodies, anti-A, and anti-8 agglutinins, can be found in the plasma of type 0 blood. The plasma components of type A and type B blood are, respectively, devoid of anti-A and anti-B agglutinins; both agglutinins are absent from type AB b lood plasma. Both the ABO as weU as Rh (RhesltJ) antigens have to be considered during a blood transfusion. If blood that was incorrectly cross-matched is tmn.sfused, it wi ll cause agglutination of the donor's erythrocytes.
Blood Group~

Anllgent (AgglutlnugQrs)
on Erythrocylt"J

Anlibtrdics (Agglntinitts)

In Ptn_,ma
ArulA11ndA.oli8

0
(Unlvtr~al

Dnnm)

Anti"B
An1iA

ll

8
A wid B

All
(Unlr~rsal

Rcclpi4!r1U)

( MICROBIOLOGY I PATHOLOGY

lmmun)

All of the following are Type IU hypersensitivity reactions E XCEPT one. Which one is the EXCEPTION?

Rheumatoid arthritis Autoimmune hemolytic anemia SLE Serum sickness

Arthus reaction

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Enc ROBIOLOGY I PATHOLOGY

Immun)

,
I

\..

All of the following statements concerning the innate immune response are true EXCEPT one. Which one is the EXCEPTIO/\'?

It is non-specific Exposure to foreign antigen leads to a response within hours ItS activation does not rely on prior exposure to antigen hs activation may produce an anamnestic response It has cellular and humoral components

194 Copyright 0 2009-2010 lkntaJ Deets

\ulnimmunc

htmul~ tic ~10("01ia

( 111\<oitk:~tion ur lh j)t..'t''>t'll'\ilh '" H:t.f(liun ..

'l'ypt

Jmmunolot:ic: MN.'hanlsms

enmplt:s:

rypc I (allflplrylaaJ~ type): lm

mediate hypersensitivity

lgE anlibody medi;ued-mnsl~:eU acl.i- Atopic-aiJetgit:$. hay fever. asthma, --nftll valion ll.nd d~gn'lniJI :nion p.bylmds
Cyt~o!Ot (lgG. Jg_M) anlibodie!S Autoimmune hemol)"ie -al'femto., :mli formed against <:ell surface 11n1jgcns. bod)Klcpendcnt cellular cytotoxicity Comp!emc'a is usually involved. tAJJCC). Gcodpasrurc disease

Cy1otoxic anDbodics

Type Jl (cytot;,< 'I'P")'

rype 111 (immune-comple.'t- t)'~)! AOitibo<Hes (lgG, JgM. fgA) fonn<d

Immuoe complex disease

against exogenous or cndogtno\IS antigens. Complement and lculc<>C)'IC$ (neutrophils) aJon,g with macrophages arc involved. Monoauclcar cells ( T lympltocytes, m<tcrophag~s) wilh lnterleul..in and J)'ttlpbokine prodU<:tion

Autoimmune disease."$ (SLE, rlteJmtaiO/d urilrritis). serum sie~c.<;.<;., Artbus reac

tion. 100$1 typcs of alomeruJonephrihs-

Type IV (cc/l-4',('dlotcd type) Delayed bypenensllivity

Con13 hyptrscnsitivit)' (c.<>nt(J.('I dcr matili:;J, tuberculin hypersensitivity, SfiU~IJiorw.lOU$ hypersensnfvily

Its :lcthatiun

ma~

prutiUCl' an anamnestic

r{'~(lUD~l '

An anamnestic response refers to the development of immunoJogical memory via the production of memory cells. 'nJese cells are producc<l as pan of the adapth" immune response. The compooeots and mechanisms of the immune sys[em are categorized into the innate immune system aud the adaptive immune system. Exposure to foreign antigen activates the innate and/or adaptive immune system. This activation generates eithe.r an innate or an adaptive immune resr>Onse, conferring the organism with either innate or adaptive immunity.

Innate immuniry is conferrc<l by those mechanisms that arc always present and ready to rec ognize. fight and eradicate microbes by mounting an innate immune response.
Characteristics of the innate immune response: Elicited by a first-time encounter with an antigen Being nonspecific, it recognizes mici'Qorganisms by their conserVed constituents (such

as LPS on the membrane ofgram-negative bacteria) Ex.posure to pathogen.ic antigen leads to immediate response Produces no ananlnestic response Humoral components include complement, cytokines (inte1[eron. interleukins. and chemokines), defensins, lysozyme, etc. Cellular components inlcude macrophages, neutrophils, eosinophils. and natural killer (NK) cells
Epithelial barriers ioclude unbroken skin and mucous membranes lining the gastrointestinal tract~ respiratory tract, and genitourinary trsct

Found in nearly all fonns of life

The inn,a te immune response ls important and necessary because:

I. Jt ''buys" the organism time to tailor a response that is specific to tbe invading pathoge-n: an adaptive intmune response. 2. It establishes local inflammation that serves to recruit, initially, phagocytes and t11en activated T and 13 cells.

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( ' All of the following statements concerning the adaptive immune response "'\ \.. arc true EXCEPT one. Which one is the EXCEPTION?

It is highly specific

Its activation leads to the development of immunological memory

It supplements the protection provided by innate immunity

It is mediated by lymphocytes
It has cellular components but no humoral components

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All of the following sentence.s regarding the major histocompatibility compte;'~ D II" \.. (MHC) molecule are true EXCEPT one. Which one is the EXCEPTION? ..4

1t plays a role in the acute rej ection of transplanted tissue.

It assists T cells in the recognition of intracellular pathogens.

It is a glycoprotein secreted by activated plasma cells.

It is able to interact with the Toell receptor. It is coded by a group of highly polymorphic genes.

196 Copyright 0 2009-2010 Ooud Del "b

It h;.1s cellular compmll'Uis hu f no humnnlll'umpomuts This is false; the adaprive immune system response has hotb cellular and b\lllloral components. The adaprive immune system evolved in vertebratl<s as a response to pathogens that evolved resistance to the innate immWle response. 1ni1iatlon oftbe adaptive immune response relies on the activities oft he innate immune system. Characteristics of the adaptive immune response: ft is a<;tivated by the actions of the innate immtme sy.stcm. ft supplements the pro~tion provided by innate immunity. ft is NOT activated immediately after exposure to an antigen. Slow response. ft is a tailor made response that is bigbly specific to the invading pathogen: it is able to recognize a specific pathogen. It leads to the development of immunological memory (allanmestic respouse): re~XJ)o sure to the same antigen will result in a faster, more intense response. It adapts to mount a fuster, stronger response with subsequent exposuru to a panicular pathogen. There are two types of adaptive immunity: !. Bumorallmmunil)': Designed to provide immunity ag-dinst exttacellulut pathogens. Mediated by antibodies produced by B-cclls. Amibodies neutralize and eliminate pathogens and toxins from the blood, from muc.os al surfaces and from the lumen of mucosal organs. 2. Cell-mediated immunity: Designed to provide immunity against intracellular pathogens. Mediated by T-cells which activa~e macropbages to kill phagocytosed microbes (1' helper cells) kill infected cells, hence eliminating reservoirs of infection (cy/fJtoxic 1' cefls).

MHC moleeules are membrane glycQtlrOlCoins that arc not se:(.roted by any cell type. The major histocompatibility complex (MHC) genes are a highly t><>lymorphc gr<>UJ> nf gene: thotls to say thnt many different v!U'iants (~1/el-s) exist simultaneously in a popultion. In human>. th~ MHC genes arc loc;1ted on the short ann ofchr~mo>ornc six . They uro divided into three subtass 11 and MHC class Ill. Classus I and II code for membrane glygroups: MHC class I. MHC Q coprotcins {.te(! ludmV) whlll.! class 111 crnles for proteins of a be complement system (Cl, C4 OIJd factor B). Tltc m~jo r histocompntibility complex (MHC) molecule IS a hetcrodimcric membrJnc glycoprotein encoded by tl>e major bisfocompntihlllty ~omple genes, Their primary !\merion is to present (display) antigenio peptldes for rocognitiun by T-lympbocytes. Upon interaction wiU 1an MHC/jJeptide complex. the T-tcll can "decide" whether the peptide IS self or foreign, and lake oppropnate action. n1crc rc two structurally distinct types of MHC molecules: 1. MHC class I Encoded by MHC class I genes Comrosed of one ~lpha chain Md one beta 2-microglobolin chain HxproJ;sed by all nucleated cells Recognized by CDS+ T-cclls Binds -and presents peptides deri'V ed rrom C!yro.soiJe protein) 2. MHC class II Encoded by MHC class II genes Composed of one aJpha and one beta chaifl Expressed only by professional amigen pr<."Scnting cells (Af'C), macrophage. and 6-cells Recognized by CD4+ T-cclls Binds and presents pcpttdes derived from endocytoscd protein> Note: In humaos.. the MHC molecules arc referred "'as Humoo Leukocyte Anttgeos (HLA). HLA lissue typin_g i$ LL~d 10 mal(.h donutcd rissuc/organslbonc marrow with transplant reci1Jients. A mis111atch rt.'5ulls in acute ~rcctioo of the transpla.~u ed tis,(jue.

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( \...

Freund's adjuvant is a mixture composed of all of the following EXCEPT one. Which one is the EXCEPTION?

Mineral oil Lanolin Formalin Inactivated and dried mycobacteria

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~

A bacterial toxin that bas been weakened until it is no longer toxic but is strong enough to induce the formation of antibodies and immunity to the specific disease caused by the toxin is called a (an):

Antitoxin

Toxoid

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Formalin

Freund's adjuvant is an antigen solution emulsified in mineral oil and lanolin, used as an immunopotentiator (booster of the immune system). The so-called complete fonn (FCA) is composed of inactivated and dried mycobacteria, usually Mycobacterium tuberculosis. Tbe so-called incomplete form (FIA) is the same adjuvant, but without the mycobacterial components. This adjuvant is used to elicit stronger T- and B-cell mediated responses when antigens alone do not evoke sufficient immunogenic responses. The role of adjuvants: Used to enhance antibody response To enhance t.be uptake of the antigen by antigen-presenting cells (e.g., macrophages) They are added to vaccines to slow down the absorption and increase the effectiveness of the vaccine Eumple: Wben protein antigens are mixed with aluminum compounds, a precipitate is fonned that is more useful for establishing immunity than are the proteins alone. Alum-precipitated antigens are released more slowly in the human body, enhancing the stimulation of the immune response. Important point: The use of adjuvants eliminates the need for repeated booster doses of tbe antigen and penn its the use of smaller doses of the antigen in the vac-

cine.

l noid

A toxoid is a bacterial toxin whose toxicity has been weakened or destroyed by either chemical (formaldelzyde) or heat treatment. Although they have lost their toxic properties, toxoids still retain their immunogenitity; therefore, they are able to induce the prO duction of specific antitoxin antibodies. Toxoid vaccines are usually administered with an adjuvant and are useful against diphtheria, tetanus, pertussis and other diseases. Antitoxin is an antibody formed in response to a specific toxin. A serum containing antitoxins can be used for either the treatment or prevention of certain bacterial diseases. The antitoxin can neutralize an unbound toxin to prevent the disease from progtessing. Tetanus antitoxin is used both io the treatment of tetanus and in its prevention (prophylaxis). Botulinum antitoxin is used in the treatment of botulism. Diphtheria antitoxin is used in the treatment of diphtheria.
:-:----, I. As with other inactivated vaccines, there are disadvantages with toxoid

Notl!$' vaccines. Even with an adjuvant added, these vaccines do not produce a full immune response. Booster shots are needed to maintain the immunity. 2. lmmune globulins refer to antibodies used in passive immunization. 3. Toxoi ds arc used to induce active immunization.

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Human HBIC (human serum containing a high titer of antibodies against HBV) to prevent hepatitis B in those not actively immunized with the HepB vaccine is an example of:

Naturally acquired passive immunity Naturally acquired active immunity Artificially acquired active immunity Artificially acquired passive immunity

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Which disease Is prevented with a vaccine that contains an inactivated virus?

Smallpox Varicella (Chickenpox) Mumps Hepatitis A

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\rlificiall~

aC(JUir('d IMssiH immunit\

Remember: Acquired Immunity occurs naturally and artificially. Tt cao be active or p3$Sive. l. Naturally: Active: person is exposed to an antigen and the body produces antibodies. For example, rec<Jvery from an infection with mumps virus confers Ufelong immunity. Passive: antibodies (lgG) passed from mother to fetus during pregnancy and lgA passed from mother to newborn during breast-feeding. 2. Artilicially: Active: vaccination with killed, inactivated. or attenuated bacteria or toxoid. Passive: injection of immune serum or gatnnll!globulin. Important: I. The purpose of the rabies vaccine and tetanus vaccine (examples ofartifi cially acqllired active immu11ity) is to eUcit an immune response before tb.e onset of disease symptomatology. The effectiveness of this type of vaccine depends on the relatively slow development of the infecting pathogen prior to the onset of disease symptoms and the ability of the vaccine w initiate antibody production before the active toxins are produced and released to the site where they can cause serious disease symptoms.

llcpatitis \ Viral vaccines can contain either an attenuated live virus (one that exhibits decrease</ virulence); an inactivated vi rus that is no longer capable of producing disease but still retains the immunogenicity of the live virus; or parts of the whole virus (purified or syn thetic). Vaccines containing attenuated live virus are more effective because they elicit all the innate and adaptive immune responses that the live virus would.
Some ( urrent \ira I \'accinls

Diseases
Smallpox Yellow fever (lepatitis B Measles Mumps Rubella Polio Polio
Influenza

Type of Vaccine
Attenuated Jive virus Aueouated Jive virus

Purified HBsAg: Recombinant HBsAg

Attenuated live virus Attenuated Jive virus Attenuated live virus Attenuated live virus (Sabin) oraJ

lnac1ivated virus (Salk)- injection

Inactivated virus Inactivated virus

Rabies

VaJicella (Chickenpox) Attenuated live virus Hepatilis A

Inactivated virus

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The Clostridium tetaoi vaccine is an example of a (an):

Capsular polysaccharide vaccine Inactivated protein exotoxin {toxoid) vaccine Killed bacterial vaccine Live attenuated bacterial vaccine

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The classic lesion of rheumatic fever is the:

Aschoffbody "Target" lesion Koplik spots Bullous skin lesions

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l nacti\alcd protein ('\otoxin (toxoitl) \accine

Caps ula r polysaccharide vaccines {these vaccines contain polysaccharide capsular material from the bacteria. usually corifugated to protein for greater imm11nogenicity): Streptococcus pneumonia vaccine (for pneumonia) Neisseria meningitides vaccine (for meningitis) Haemophilus influenzac vaccine (for meningitis) To~ oid vaccines: Corynebacterium diphtheriae vaccine (for diphtheria) Clostridium tetani vaccine (for tetml)l) Killed bacterial vaccines: Bordetella pertussis vaccine {for whopping cough) Salmonella typhi vaccine (for typhoid fever) Vibrio cholerae vaccine (for cholera) Live attenuated bacterial vaccines: Mycobacterium bovis vaccine (for TB) Francisella tularensis vaccine (for tularemia) CoxjeJia bumetti vaccine (for Qfever) ***Active Immunity is induced by vaccines prepared iiom bacteria or their products. Passive immunity is provided by the administration of prefonned antibodies in preparations called immune gl.obulins. Passive-active Immunity involves giving both immune globulins to provide immediate protection and a vaccine lo provide long term protection.

\o,;chnt1

hod~

Rhewnatic fever occurs mostly in school age children (between 5 and 15 years ofage) with untreated streptococcal pharyngitis. It is a mUltisystem inflammatory disorder with major
cardiac manifestations and sequelae.

Rheumatic fever usually occurs I to 4 weeks after an episode of tonsillitis or other infection caused by group A beta-hemolytic streptocotti. Note: An elevated titer of antistreptolysin 0 (ASO) is evidence of a recent streptococci infection.
Acute Rhe umatic Fe\'Cr:

Major Jones Criterja

- Occurs I to 4 weeks after tonsillitis - Group A beta-hemolytic streptococci - ComJt> oo in children 5 to 15 years
Cardi'is of rheumatjc feyer; - Peticardjtis -- serous effusions

Polyarthritis Erythema
Subc.utaneous nodules

- Myocarditis - -- heart failure - Endocarditis -- valvular damage

::::::Jo I. Aschoff body:

'Notes

Chorea Carditis Rheumatic Beart Disease: - O<:curs many years after rheumatic fever - Often asymptomatic - Fibrotic, deformed, calcified lines of closure on valve leaflets - Mitral valve > aortic valve - Pulmonary valve is rarely involved

- focal interstitial myocardial intlammnrion - large monocytes (A11itscllkow cells) -multinucleated giant cells (Aschoffcells) 2. The most common clinical presentation of rheumatic fever Is migratory pol yarthritis, lasting 2 to 3 weeks, accompanied by a fever.

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All of the foUowing are characteristiC$ of Addison's disease EXCEPT one. Which one is the EXCEPTION?

Hypertension Increased pigmentation of the skin Decreased serum sodium, chloride, glucose, and bicarbonate Increased serum potassium

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Osteoarthritis is most often related to:

Autoimmune dysfunction Mechanical trauma to the affected joints ("wear-and-tear ") Urate crystal deposition Staphylococcus aureus infection

Cop)Tigh1 0

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pcrh'nsiun

* This is f&l5t!; Addison's disease is: characterized by hypottnsion.

Addison's diseuse (primal")' atii'I!IIOcorticol dliftt:iell/:)1) is a liCe threatening condition caused by partial or complete filur< of adrenocorllcnl 1\mctlun. It is most commonly d\le to IdiopathIc udreutll utropby (aouolmrmme /ymphcx:ytic adrenaliris). It can also be caused by tuberculosis ((onner6rnm.vf ronumm car;.se). metasmtk tumor. and va.riOllS infections. It is characterized by the ii\Sidiouo onset of wealmess. fatigue, depression, hypotension and brollling of the <ntire skin. Orul signs consist of diffuse pigmentation of the gingiva. tongue. hard palate, and buccal mucn>a. Although cutaneous pig)llentation \viii "'ostllkely disappear followmg thernpy, pigmentation of the onlltissues tends to persist. Tbe adrenocortic:otropf~ hort"one re.st (also A1rowtt a.r an ACT/I ft'J't or a corlltolroplll ltsl) measm es pituitary gland function. The pilllimry gland ~ra4uces the bomione ACTB. which stimuiMCS 1he outer layer of the adrenal gland (the adrenr1/ cone.<). ACTH causes the release ofO>e hormones hydrocortisone (cqrtisul), aldoSt<'t<>nc. and androgen.The mostimportnt oflb,'liebormones released is cortisol. The ACTH test is used to determine if too much cortisol is being produced (Cushing'ssyndlt~me) or if not enough conisol is beins produced (Addi,a!l'$ 1/L<eose).
1 ~ - l. Secoodury adrenal insufficiency c.au rcsull from prolonged or improper w::e Qf'glu/ Notct cocorticoid bomtones, which are used to treat rheumatoid arthritl~ aslhma, and other
2.

inflammatory illnesses. Addison's disease is treated by administering cortisol (hydrocorti.mlle).

3.
Watel'bOU$~1~'riderichsen

syndrotne. is a catastrophic adrenal Insufficiency and

vascular collapse due to hemorrhagic necrosis of Ule ~dronal cortex. h is charnoteristically due t o meningococcemia, mosr often in association with meningococcat menin

gitis. 4. The adrenal glands are located on top or each kidnoy. 'rl>ey consist of the ourer portion (called the cortex) and the inner porrion l'calld the meciullll). The conex produces
three types of bonnones: se.x hormone~. glucocor~i ooid honnones, and mineralocorti

coid hom10nes.

Osteoarthritis (degenerative joint diseiJSe) is tlte most common fonn of arthl'iti~. It is a chronic inflammatory joint disca~c eharactetized by degeoerdtioo of at1icular ciD'Iilugo accompanied by oew booe foMalion subcbondrally and at the margins of the affected joinl 111e )ncideuce is grealer in women, moM I)!len o~ginning after 50 years of age. Tbe inflammation is accompanied by pain. swelling, and sriffness. Most commouly it affects joints constantly exposed to wear sud tear. The joiots mot ol'lon affectd ioclnde the intel'vertebral joints, the phalnngenl joints, the knee&, and the hips. Cbsractcrislic morphol<lglc c)tanges include: Eburnation of bone1 polished, ivury-like appearuuce of bone, resulting from erosion of overlying cartilage: Osteophyte (bony spur) formation: at the perimeter of the &J1icolar surfsce aud at points of ligameutal attacluneut to bone, - Osloophytes fract~ring ROd floating into synovial fluid along with fragments of separated cartilage are called joint mlce. H eberueu nodes: osttQphytes al the distal interphalangeal joints of the fingers. Bouohard nodes: osteophytes at the proximal interphalangeal joints of the lingers. Types of osteoatthritis: Primary osteoa rthritis: occur. withoot knowu cause. ls mostly re1ated to (lging, Secondary osteoarthritis: is cam;ed by another disease or condition. Conditions that can lead to secondary osteoanJiritis include obesity, repeated ln!Wll.u or surgery to the joint structures, abnormal joints at bir1h (collgeTiilal abllormalities), gout, diabetes and other bormone disorders.

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Which of the following has the worst prognosis?

Letterer-Siwe disease (acute disseminated Langerhans cell histiocytosis) Hand-Schuller-Cbristian disease (chronic progressive histiocytosis) Eosinophilic granuloma

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Primary hyperparathyroidism is most often caused by:

Liver disease
Parathyroid adenoma Bronchogenic squamous cell carcinoma Hypocalcemia of chronic renal disease

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Hi5tiocyJosls X (Langerllan>cell ilistlocyro.ls) is a tenn used t<> describe a group of dofferent typeS of illn=s th3t >hate a com moo origin. Langerhans ~lis (rol/ud hi>toocytt.t) are incrnsed in number nd invade vanou~ rissues of the body. Histiocytcs arc cells normally found throughout tbe body and are most often found in the spleen. lung. liver. ond bone marrow. The rrigger for the inc""""" of Langerhans cells and their mvaMon is not known. Histiocytosis X includes: Eosinophilic Granuloma: the most benign ur mild form of histiocytosis X. characlcriud by a solitarY lesion of the bone, which can result in pain and swelling. - 60-80% of histiocytosis X - ageS- 10 yrs Hand-Christlan-Schullcr Olscast: usunlly refers to children with the cla&sic triod of ~kull lesions. diabetes insipidus. nd exophthalmos caused by involvement of Uoe orbit. -age 1-lyrs Letterer-Siwe Olsease: ~fers 10 u a;encralo:wl diseuse that has a vrY aggressive, often fatal ending_ Organs that may be onvolved include bone, lung.<;. skin, li>er, !Splccll, und
boot: marrow.

-agcO- I yr - worst prognosis

The outcome of LCH is extremely variable. The t\VO main factor.o which inOueoec a child's prognosis appear to be age at the time of diagnosis. and bow many organ> ol't' in,olved. Children younger than 2 ycaa 31 the time of diag~~osis have a higher death rate than do older children. Punhermore, the presence of maJor organ problems (liwtr. lung. bone marrow) has been shown to be an indicator of poor outcome. The involvement of multiple organ systems is also a poor progno.,tic sign,

PrimarY hyperparathyroidism is common. Primary HPT can be drvided pathulogicaUy into adenoma, byperpla.'iia, and ean:inoma. Adenomas clearly are the mOSI prevalent entity representing 81J..85% of eases. Hyperplasia tS the >etond most common diagno>ili coostituung IS,., . of eases. Carcinoma represents <I% of toud eases. Laboratory findings include: Hypercalcemia lnOffased serum alkaline phospluttast Dec:reased serum phosphorus lncrt!ll<ed <erum I'TH Clinical characteristics include: Ostrllis libros cystlea (also .tnow11 <IS 1'011 Recklinglrausen disea.fc of boll): cystic changes in bone due to osteoclastic resorption. Replacement of resorbed bone muy !COld to the formation of non-neoplastic tumor-like musses called ubrown tumor.n Ncphrocolcinos!s: tnetaswtic calcoficotionaffecting the kidneys. Renal calculi Peptic duodenal ulcers Dental finding: There is a loss of IU!ninu dura around multiple teeth. Hyperparathyroidhm can be clossifitd iulo three distinct entities: Primary hyperparathyroidism ia the result of an adenoma, glandular hyperplasia, or car-

cinoma.
Secoodal') hyperparathyroidism os u reactive hyperplastic phenomenOn in n:sponse to decreased conceniiarion of serum calcoum. Tutiary hyperposathyroidism is a t<nn used to desaibe the insumce "!Kn secondary hyperparathyroidism has become autollOOlOO!I." I. In taNo instanres, hypoparathyroodism is associated with cougenual thymic 1 Notes hypoplasia (DiGeorge'$ S)'lldrome). 2. Kem~mbrr: Osteoporost<. central t;i"nl cell granulomas, and metastatic calcifienrions are all marufe;tations of hyperparathyroidism.

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30% of patients \lith polyarteritis nodosa have serum antibodies to:

Hepatitis A virus Herpes simplex type I \irus Cytomegalovirus Hepatitis B virus

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Bacterial Viral Unknown
Fungal

The cause of multiple sclerosis is:

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Collagen is a tough. glue-l ike protein tlwt represents 30% of body protein.lt shapes the stntcture of tendons, bones, and connective tissues. Problems with the immune system can affect 1hese sm.tcmres. Tills is known as collagen vascular disease-. Collag~n \asoular disell!le.< include; Polyarteritis nodosa: a serious blood vessel disease ufunkoown cause characterized by necrorizing immune complex inJliUnmatiun ofsmall and medium sized aneries. There is an association whb hepatitis B vlral intectlon Dermatomyositis: a muscle disease that causes inflammation md a skin rash. It is a type of inflammatory myopothy. -The cause is unltnown Stleroderma: a v.idespread connective tissue disease that involves changes in the skin, blood "csscls, muscles, and intemal orgaus.
-Common m young women

- Wide,<pread connective tiSS\le tibrosi~ -Tight and mask-like tacial skin, raynaud's phenumenon, pain, stiffness. and swelling of fingers and joints, GERD, increased clmnce or BaJTells esoph11gus Systemic lupus ~rythematosus (SLE): the prototype connective tissue disoase SLEl (/tJpus) is an uutoimmune disease. - 80% of SLE patients are women, usually those of childbearing age. - Fev<r, malai$e. lymphadenopathy. and weight loss - Clmracteristic butterfly rash over the cheeks and bridge or the nose (50%. ofpotients). joint pain and anhritis, raynaud's pheoom.,lOil - Extensive immune corup1ex.medi3ted infla1nmatory lesions. th<~ lesions of greare."t ctinicallmportance In SLil are lbo$e in the ~idney. Rheumatoid arlhrifls (RA)t a long.tcrm discas~ that ca\lses inflammation of the joints and surrounding tissues. It can also aJlcct other organs.

Multiple sclerosis is a disorder of the brain and spinnl cord (cenirol nervou. sy.lem) caused by progressive diUOage to the outer covering of nerve cells (myelin). This results in decreased nerve functioning which can lead to a variety of Synlptoms. Although the cause and pathogenesis of the disease remain to be elucidated, there is evidence that suggests an auloimmune GOmpQnent to the disease wilh CD4+ and CDS+ T-cell involvement. The disease involves repeated episodes of inllammation of nervous tissue in any area of the central nervous system (braitt a11d spllw/ cord). These episc)ck-s occur when the body's own immune cells attack the nervous system. The location of the inflamed areas varies from perSon to person and iron\ episode to episode. The inflammation destroys the covering of the nerve cells in that area (myelin slteatlt), leaving multiple areas of scar I issue (sclerosis) along tl.1e covering of the nerve cells. This results in slowing or blocking the lransmission of nerve impulses in Ibat area, leadiug to the symptoms of MS. Common symptoms of MS include visual disturbi\Dces. speech disturbances, parestbesias (tingling. priokling, or tlllmbness:), depression, mood swings, etc. I. Moderate amounts of protein and a smoU number of lymphocytes in the cerebrospinal fluid are charscteristic ~r MS. 2. lnjectable interferon, a relatively nC\V ll'CtltniCnl, red\lces the freq1teocy of relapse. or MS. 3. Multiple sclerosis (MS) affect;; approximately I out of 1,000 people. 4. Women 11re affected more commonly !han men. S. The disorder most commonly begins between 20 10 40 years old. but can nappen at any age.

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Primary amyloidosis is associated witb abnormalities of:

Macropbages Erythrocytes
Hemoglobin
Plasma cells

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(
Edema

Urticaria is commonly known as:

Hives
Bleeding

Itching

210 CopynJbl C 200920 I0 Dental l>b

Pl:tsma cdl.,

"Amyloidosis" [s a generic tenn used to describe various conditions in which proteinaceous material (amyloid ) abnonnally deposits and accumulates in tissues and/or organs. These amyloids are primarily composed of Insoluble libroo. proteins (sclervprotein). Amyloidoses are classitied according"' the physical and chemical nature of the amyloid protei II it is composed of. as well as to the extent oftbe deposits; systemic (more than one orgcm or bod> system is invclved) or localized (.<ingle orgo11 imolwmtent). Clinically, the systemic and localized designations are further categori7_ed into either primary or secondary, depending ou whether the amyloidosis is related to an immune disease (primary) or a complication of some other chronic inflammatory process (secondary). Primary amyloidosis: cause is unknown; it is related to abnormal production .,r immuooglubulin.< by mati&>nant plasma cells (i.e. as in multiple myeloma). It is usually systemic in distribution. Typical sites of amyloid buildup are the heart. lungs, skin, tongue, thyroid gland, Intestine.<, liver, kidney, and blood vessels. Secondary (reactive) systemic myloidosi,<: the amyloidosis is a complicsion of another disease suoh as TB, rheumatoid arthritis, or familial Meditermnean fever. Amyloid tends to build up in the spleen, liver. kidneys, adrenal glands, and lymph nodes. The heart is rarely involved. Hereditary amyloldosb: mostly rare and limited to spt:dfic geogrephic areas, these amyloidoses are the result of genetic mutations. l'or example, Familial Mediterranean fever, systemic senile amyloidosis and sever. I types of familial amyloidotic neuropathies. Note: Alzheimer's disc:ase. diabetes meUitll-< type 2 and Parkinson's dise'l.5e are some other examples of amyloid associated conditions as they are all chardcterized by deposits of amyloid. For example, diabetel< mellillls type 2 is characterized by deposits of amyloid (refonwl toM amy/itt) in islet cells.

Hives, also called urticaria, is a reaction in the skin characteri<ed by small, pale. or reddened swellings (VIIeals). ln most cases hives are the result of a typo I hypersensitivity reaction in wbicb exposure tt a v~riety of antigens such as foods, drugs, venoms 01 other substances, leads to lgt:: dependent degranulation of mast cells. Related to and sometimes e<>existiog witlt hives is a conditiotl known as angioedema, which involves larger areas and deeper tissues beneath the skin. Hives and angioedema are anaphylactic-type reactions that arc limited to the skjo and underlying tis.~ncs. Both hives and angioedema are of rapid onset and c~o either be simply anooyi.ug or li fe threatcrung. Therapy includes the use of epinephrine. antihistamines or steroids.
Itching is usually the first symptom of hive$. quickly followed by whl'llls --smooth, slightly elevated area.s that are redder or paler than the surrounding skin and usunlly rem.aio smalL

Will> angioedema, the swelling often covers large areas and extends deep beneath th~ skin. It may involve pan or ali of the band-', feet. eyelids, lips. or genitals or even the lining of the mouth, throat, and airways, making bre~thing difficult. Important: The release of histamine and otbdr chemicals into the bloodstream (allergic respotrse) causes the itching, localized swelling, and other symptoms.

E_fiCROBIOLOGY I PATHOLOGY

Di~

All of tl:e following are true concerning Type I diabetes EXCEPT one. Which one Is the EXCEPTION?

It is usually diagnosed in childhood

It is far more common than Type 2 nod makes up 90% or more of all cases of diabetes

The body makes little or no insulin

Cataract formation, glaucoma and/or retinopathy are possible long-term cornplieations Daily injections of insulin are required to sustain life

211 Copyrlab0 2(109.l010 Dental Decks

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Dis)

(
Viral Fungal
Bacterial

The cause ofrheumatoid arthritis is:

Unknown
Environmental

212

Coclrrlah.' o 20092010 DmtaJ Dls

It h far more common Uum T~ pc 2 and mal\es Ufl 90"'u nr more of :lll ca..,c.~ of

diahchot

Diabetes is the most common pancreatic endocrine disorder. lt is a metabolic disease involving mostly carbohydrmes (glucose) and lipids. It is caused by absolute deficiency of insulin (7jlpe I) or resistance to insulin's action in the peripheral tissues ('l)'Pe 2). The classic triad of symptoms includes polydipsia, polyuria, and polypbagia.
( 11111JI:Jrhun (If I' JlL' I .tnd I \IH' 2 l>iallrll"\ \ldlhu'

Cbaracteristfe
Level r'lflosuiJo srerelton
Typltal'l:ge of oo,tt Puccntage of diabetes
Basic. dtfect

Type I
Noae or tdmost none
Cllndhood Adulthood
B0-90%

Type2
May be normal nr exceed 11C)I"n)ii.l

1 020%
Oestru<:tion ufbem cells

.Rrduecd SCllS!liytt)' af in.sulin'~ l~rget cells

Associated ~1Ut obe31~y

No
ContmQtl if untrtotcd

Usually
Slaw

Speed otd~:VHopmtnt ur ymptonn Rapid Devdqprue.nt or keto51s

Trtarm~nt

Rut

InSulin injcctiof\S, dietary mansgcmcnt

Pitwy coaltol aud \Wight reduction, OCOI.

~it.uUy oral hypoglyecmi<l. drugs

l nkno\\U

Rheumatoid arthritis is a chronic (long-tenn) in.Oammatory disease that primarily affects the joinis and surrounding tissues, but can also affect other organ systems. The cause of rheumatoid arthritis (RA) is unknown, but !here is a genetic predisposition. RA involves an attack on the body by its own immune cells (some resenrd1ers suggest it may be an amoimmune disease). The disease can occur at any age, but it begins most often between the ages of25 and 55. The disease is more common in older people. Women are affcctcrl 2.5 times more often than men. Approximately 1-2% of the total population is affected. The course and the severity of the iII ness can vary considerably. Stlll's disease is a type of RA !bat occurs in young people. The onset of the disease is usually gradual, with fatigue. morning srifTness (lasting more than one hour), diffuse muscular aches. loss of appetite, and weakness. Eventually, joint pain appears, with warmth, swelling, tenderness, and stiffness of the joint after inactivity. Note: Rheumatoid anhritis typically involves small joints of !be bauds and feet most severely, and there is a destructive pannus that leads to marked joint deformity. --. 1. Important: The condition is marked by a proliferative inllammation of the
; Note_.. synovial membranes, leading to deformity, ankylosis, and invalidism.

2. Remember: Osteophyte (bony spur) formation is a cardinal feature of osteoanhritis, not rheumatoid arthritis. 3. Rheumatoid anhritis, systemic lupus erythematosus, polyarteritis nodosa, dermatomyositis, and sclerodenna arc all classified as collagen diseases. They all have in common inflammatory damage to connective tissues and blood vessels with the deposition of fibrinoid material.

(MICROBIOLOGY I PATHOLOGY

Dis)

Immune complex diseases are those In which the tissue deposition of circulating Immune complexes initiates tissue injury and inflammation in multiple sites. Which of the following is the prototype immune complex disease?

Systemic lupus erythematosus (SLE) Serum sickness Sjogren's syndrome Polyarteritis nodosa
Glomerulonephritis

Rheumatoid arthritis (RA)

21) Copyri.gbl c 2(109.2010 Dental De<:ks

(MICROBIOLOGY I PATHOLOGY

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- - - - - . , . - hypersensitivity reactions arc caused by specific antibodies binding to antigens on the patlent's own ceO surfaces.

Type I Type n Type m Type IV

21.
Cop)Tip. 0 l0092010 Dtmll Ded.s

Immune complex diseases ore classified as type ill byptrsensitiviry rroctions tiW occur when eXt.'iS circulating immtme COOlJ>Iexes (llllfibudy bountlw nntigen) depm~it ln Hssus. The glomerul:lr lesions in immune c.omplex disesses resull from 1M deposition of lgG. Note: Normally, immune complexes arc effectively cleared by lile reticuloendothelial system. These deposited irnmuM complexes activate the complement cascade. resulting in local btllamma!ion. Remember: Histamine docs not play a major role in these Typo III hyprseu sitivity' te>~Otions. Systemic lupus erythcmstosus (lupu) s au autoimmune disease d. >Ut result< in epc<o~e; of inflammation in joints. tendons, and ofhercmmective tissues and organ.s. About 90% of tho people who have lupus are young women iu their late teens to 30s. Seruru sickness appears some days after injection of a tbreign strom or serum protein. with local and systemk re-Jctiot>s such a< urticsria. fever, general lymphadenopath~. edcmu and
arthritis.

Sjog111u's syndrome is the ~<md most common autoimmune rlteumatic disorder fler rheumato[d arthritis (RA). lt is characterized by diminished lacrimal ond salivary gland secretion (.<icca complex). This syndrome occul'6 mainly in women (90% ll[patfents) and the mean
ag~

rs so.

wbicb "ll. llll und mediumsi~od arteries become swollen and damaged when they are attJJckcd by cenoin immune Ct'lls, Glomeru.louephriU describes inflammation of tho l(idney's glonruli. hlltderins removal of waste products from the blood. Jt can occur by a type 1T reaorion (Goodp~.<tlll'l! ~ synt!rrun<), u lyJ)e Ill reaciiuu (immune complex glomemlrmepilriti~) or as pan of a multisystem -vssouliric process (vu.w.:rllific: glomeruloneplu-iris). Rbeumtoid artbrith is a tlu-Qn\t, systemic, inflammatory disease. lt primarily attacks peripheral joinrs and surrounding muscles., tendons, ligaments. and blood ve.>sels.
l'olyorteritis nndosa is a serious blood v..sel disease

rn

I \ ' jll' II

J lyper$t-u~tiv{ly rotors to undesl.roble (dunragjng, <li:rt:QJtl{(m-:Pro<luclug ond sonwtlmcs folal) teactil~nli' prod,uc~d bylhQ nomml immunesyste:m, llyp~..-r~'41liti\'1ty 1\."1\ction~ ~quire a pre~sellSit.Ued liflm'u''2) s.r.ate. of fhe :hQ$l, JfyPerscnslhvity R'actious- etu1 be.divid(.-tl into !Our l)rpcs: type I, l}?lf Jl, type IH ~.n d type lV, b~ on the. mochanisms involved und lime hsken for the ~ac1ion. Classl(ic.~:Ulon of hyp~ntnsiltvlly rt.arUous: 1)tpe l (alGI) kml'1w1 11s immeJfnte Qr aflpphylcu::Jh /Jyper:tttJ/l/ttft)') ur<.\ rellclions fn which antigens (allergens) combine \Vitb specific lgE antibodies tluu are bo\md tiJ membrane recepto~ on tia-suc

nWit cella and btood hnsnphils. Tbe antigetHUlllbodr n:a.;lion CllillSe& the rnpid ~ll:wse of potent v~oactive and inflamm:uory medi:uors. wbitl! may be preronned (e.g.. histumit:~. trypwse. klnilltJgttflU.'ft) or newly gcll'leml~d ftom menlbhl.lle lipids (e,g. , rhe leukotrletlcS- 84, C4 (utd 04, pro.stagfantiin.s D21 tmd PAF'). Examplos iocJude! AUergie rMniti~. asthma, and ams.phyla:~: ts. Type 11 an:. GYlb~o~ic tcpcrions- rcs~1lling when uutibod)' re~c:t.s wilh antig.enic compMeoli of u cdJ or rissue element~ (FJr with mtliget, or /wpt~t) that is coupled to" cell nr li!isllc. 'l'hc :mtigcn-:mtibod}' rcac1ion may e.clivtH e cer13.lo '"')'loto;o,;ic cells (kifler 'r.1.:tdl:t or mucrophtJgtM) to prorluoe antibody dependi!nt eell~medJarcd cyrotoxidt.,v. T.:ypt- 11 brrcr::;cmsltivl()' is peiuulrily UH.. 'diatcd by !UitibodiC!I or the lgM or lg(.i '-IJSS3 anll e:ornpJemt.'-nL Bxamples include: Ooodpa~1urt's syudrumc:, erythroblsLStosis fe1slis. autoirrunuu.e ht-moJ)1l"'.tnt.11liq, and hyp('racu1c tnmspluut rejection.
~rype Ill Bre iotmude C'Oil.lplex (JC) rtacliontt (t'float(v (Jj fltt !1-,V c/ru\1, rtflhm1gh lgM may nlso fu.> rcsuhlng from deposition of "olubl~ e-ireulatmg amigeLH'IHl1body fC11 in vesscl01 or tissue-. Primary components aro soluble itnJoun~ OOmplcx.;s- nd contplcm{'m ((3u, 4a tmd S1d. The damage i!; cau~d by. pltuclets Rnd neurropbils.. Tlie l~iion contains primnrily ncu1rupbih und depo:.itA of immune comph:xe-5. and complement Macrophages: iofiltntlint' in atcr ilagcs mn)' bo- iuvolvcd in the
lm'fll~ed)

healing process. Cxample~ include: Strum $ickne~s. s_ys~emic lupt,LS ~;ry,hem~tos.us, and Arthu:: reaction, 'l)'pe rv hypersensitivity rs also known as-cell m((lhHl'.d or delayed type hypt!r!\tlll'HiVily. TIH!. clsssicsl example Qf t,hi~ hyPersensitivity is tubfrt:ulht (~fmuoux) rt!AC:tion. Mec:banlsms-of damage in ddayed byp\:rscnsitiviry mclude Tlym,,hacyt(':$ and mouocyres-andlor omcropbagc~. Circ.ulating antibodies afe not involved in nor arc they necessary for developm111 of tissu~; irtiury, E~ttmplc-s include! ConUI.ct denuulilis, tuberculin test1 and chronic trantophtnt rc:actton.

(MICROBIOLOGY I PATHOLOGY

Dis)

Which of the following autoimmune diseases displays the characteristic "butterDy rash" over the face?

Rheumatoid arthritis Sjogren's disease Scleroderma Systemic lupus erythematosus (SLE)

21 S Qlp)Tiihl 0 2009-2010 Den1 aJ Decl;s

(MICROBIOLOGY I PATHOLOGY

Dis)

_ __ is an autoimmune disorder caused by the production of antibodies against the acetylcholine receptor which results in the Inhibition of neuromuscular transmiss ion and eventual paralysis.

Eaton-Lambert syndrome Systemic lupus erythematosus Myasthenia gravis Graves disease Addison's disease Hashimoto's thyroiditis
216 Copyri.gbtC 2009-2010 Odlttl Detk.s

S) Mtntic lupus

l'f) tht'mato\U'I (.\1,/:J

Lupus is a condition characterized by "hrouic inflammation of hody tissues c~used by autoimmune dis~ase. Patients with lupus produce abnormal antibodies in rl1eir blood that target tissues within their own body rather than foreign infoctious agenL,. Because the antibodies and accompanying ctlls of inflammation can involve tissues auywhcre in the body. lupus has the potential to afl'c-.:t a variety of areas nf the body, Sometimes lupus can cause disease of the skin, hC8rt. lungs. kidneys, joints, and/or nervous system. When only the skin is involved, the condition is called discoid lupus. When internal organs are involved, the condittcm is called systemic lupus erythematosus (SLE). Both discoid and systemic lupus are rnore corrtmon in women than men (alum/ eighlllmes more common). The disease can affect all ages but most commonly begins berweeo tbe ages of20 to 45 years. At its onset, only ooe orsan ~yslem may be involved. Additional organs may become Involve'<.! later. Renal !'allure <;ommonly occurs and is the usual cause of death. Severe CNS involvement may appear, AorncyonosiJ (R~yna..d J' phenomenon) is on en associated with
SLE.

'\ I. Many autoimmune discnses arc associated wich chnracteristic

nutu~an tibudh.-s.

Not"' Anti-ONA (also known asauri-nuclearauribodies) and anti.Sm antihodies nppear

to be specific for SLE. 2, Th.e characteristic "butterfly" rash over tho cheeks and bridge of ihe nose affects about half of tltose with SLE. Tbe rash is usually worsened by sunlight. 3. The proise reason for the abnormal autoimmunity that causes lupus is not known. 4. Do~en.s of medic~tions have been reported to trigger SLE; however, more than 90% of this "drug-induced lupus" occurs as a side effect of one of the following siJ< drugs: hydralazine (used for high blood presSIIre). quinidine and procainamide (used for abnormal heart rilytlwt), phenytoin (tiSed for epilepsy), isoniazid {(Nydrazid, Laniazid), used for mberculosisf. penicillamine (use</ j'or rlteumllloid arthritis). These drugs are known ro stimulate the immune system and cause SLE.

i\ 1ya~ithenia J.!r:J\ is

Myasthenia gravis (MG) is a neuromuscular disorder chamcterized by variable weakness of voluntary muscles, which often improves with re<t and worsens with activity. Tlte condition is ~used by an abnonnal immune t'C.~ponsc. The immune system produce.~ antibodies that attack the acetylcholine receptors that lie ou the muscle side of the neuromuscular junction. Tbis decreases the responsiveness of the muscle fibers to acetylcholine released from motor neuron endings. Patients with myasthenia gravis have a higher risk of having other autoimmune disorders like thyrotoxicosis, rbeUUlatoid anhritis, and systemic lupus erythematosus. Eaton-La mbert syndrome is similar to myasthenia gravis in that it is al~o an autoimmune disease that causes weakness. However, Eaton-Lamben syndrome is ~used by tlte inudequate release of ucetylcholine ruther than by abnormal antibodies to acetylcholine receptors. ,... - "l MG affects about 3 of every 10,000 people. ILcan strike at any age; however, Nortf" it is roost common in young women and older men. About I0% of MG patients develop a life-threatening we.akness of tbe UlUscles needed for breathing (a co~tdirion ca/led "my!IJrhenic" ~risis). About J% ofMG patients present 1vith a lhymoma (a 111mor origi11oli11gjivm the thymus).

(MICROBIOLOGY I PATHOLOGY

Increased melanin pigmentation is seen in:

Addison's disease Jaundice Albinism and vitiligo Hemosiderosis

217 Cop)'liJh'l 0 2(109.2010 Den1al Ocd:s

c
Knee

MICROBIOLOGY I PATHOLOGY

Disord)

Gouty arthritis most commonly affects the:

Ankle

Wrist

Big toe

211
Cop)'rip! 0 lOOP-2010 l)e$alllec\s

Accumulations of endogenous pigments Melanin is fonned from tyrosine; synthesized in melanocytes. lncrc~~Sed melanin pigmentation is seen in Addison's disease. * Decreased melanin pigmentation is seen in albinism and vitiligo. Bilirubin is a catabolic product of the be me moiety of hemoglobin. II accumulates in blood and organs producing jaundice. Jaundice is most often call'ed by hemolytic anemia, biliary obstruction, and hepatocellular disease. Hemosiderin is an insolttble, iron-containing protein derived from fcrritiu. It normally occurs in small amounts \\~thin macrophagcs of the bone marrow, liver, and spleen. It can accumulate in tissues in excess amounts: * H.emosldero.~is occurs when hemosiderin builds up in tissue macropbages. UsuaUy doesn't cause tissue or organ damage. Often associated with thalassemia major. * Hcmochrnmatosis (also called bro11zed disease) is more extensive accumulation of hemosiderin througb011t the body. There is tissue and organ damage. Most often is a hereditary disorder that develops in men over 40 years old.

Gout is an Inherited disorder of purine metabolism occ.urring predominantly iu men. H caused by a defect in metabolism that results in an overproduction of uric acid, or a reduced ability of the kidney to eliminate uric acid (almost 2 5% ofall people wlro lltlve gouttlevelop ~idney stones). Ute exact cause of lhe metabolic defect is unknown. The condition may also develop in people with diabetes. obesity, sickle cell anemia, and kidney disease, or il may follow drug ther.1py that interferes with uric acid excretion. Gout is characterized by the deposition of monosodium urate crystals in joints and otber tissues as a result of hyperuricemia. The disorder occurs must frcquemly in the metatarsophalangeal joint of the. big toe. Acute gouty arthritis is this characteristic location is known as podagra. The instep, ankle, knee, wdst an~ elbow are common sites. sometimes even the spine. Bouts may vary from days a pan to several attacks~ year; the first at~cks may be in only one joint, lasting for days. Later attacks may aiTect morejoints; there may be joint deformation if unattended. Limitation of joint movement is precipitated by stress or wrong diet. Symptoms include a sharp, needle-like pain on movement ofjoints: skin is tense, ho~ shiny and dusky red or purplish; systemic reactions may include fever. bcurt rate increase, and chills and malaise. Primary gout: most common form, hypen~ricemia without evident cause. - most common in middle-ages men - a marked familial predisposition Secondary gont: much less common. Characterized by 1\yperuricemia with evident cause, such as: -Leukemia, multiple myeloma, and myeloproliferative syndromes - Lesch-Nyhon syndrome: hyperuricemia with severe neurologic manifestations - Pseudogout (cltnmfrocalcinosis) - caused by calcium pyrophosphate dihydrntc crystal deposition, which elicits an inOammatory reaction in cartilage. Pseudogout clinically resembles gout.

(MICROBIOLOGY I PATHOLOGY

Disord)

Acute cbolccyslllls is:

Acute inflammation of the liver Acute inflammation of the appendix Acute inflammation of tbe gallbladder Acute inflammation of the pancreas

21t CopyriaJ>o0 2009-2010 o.n,.l O..kJ

(MICROBIOLOGY I PATHOLOGY

Disord)

(\..
Myxedema

Which of the following results from Inadequate secretion of thyroid hormones during fetal life or early infancy?

Plununer disease Gigantism

Cretinism

Z20
Cop)'I'IJbl 0 20($.2010 Dcae&l Ocds

\l"Ul(' in ll.lOIIH,ltiOII uf lh~ CUIIhJ:ufth:r

Acute cbolecysUti.s is a <u~den fntlammatiOII oftbe gallbladder that causes severe abdominal pain. In 90% of cases, acutecholecystitis is caused by gallstones (cholelithiasis) in the gallbladder. Acute cbolccystiti.s causes bile to become tra~ped in the gallbladdcr.llJC build up of bile causes irritation and pressure in lbc gallbladder. This can lead to bac.terial infec. tion and perforation of tbc organ. Chronic cholecystitis is rhckening of dte g.'lllbtaddcr wall which <>ccllT$ a a result of extel1slve fibrosis, It is frcqu~ntly complicated by gallstones. Gallstones (chole/llhlasLt) occur rilOI't frequently in women than men and i; ofteu assndnted widt obesity und multiple pre!,'UJlDCies. Gal lstones become more common with oge in both sexes. Not~: Narive Americans have a higher rote of gaUstoues. Stone types: Cholr<tcrol stou ..: ""'oflcu soliiary and too large to enter the cystic duct or th~ common bile duct. Pigment .stones: - Ptetipita.tion of excess insoluble unconjugated bilirubin results in Iheir ftJro1at.ion. -Association often includes hentolytio anemiA and bacterial infection. ll<ri:ted $tones: most common (7.1%-80%) - Mixture of cholesterol and calcium salts -... I. Cholesterolosts (strawberry gallb/addu) is ch;lfact<n?.e<l by small, yellow, } Notes cholesterol cQntaining flecks that are highiigji!Cd against a red background in the lining of the gnU bladder. 2. Diverticulosis of the gallbladder: small, finger-like ou1-poucbiugs of the gallbladder lining, may develop as " person ages. This may catL<e inflammation and require gallbladder removaL 3. Gallstones that bl<>ck the COIIllDOO bile duct result In obstrurtive jaundice (yellow skin color cart.ved by blfe pigments bet.-omlng cleymsUttlln the skin).

("rl'fini~m

Cretinism is a condition of stunted body growth and impaired mental development. The symptoms, which upptar during early inlltncy; are the gradual development of a characteri,... tic coarse, dry skin, a slightly swollen face and tongue, umbilical hernia. and an open mouth that drools. The baby is usually lbtless, slowmoving. con;'lipated. and a slow feeder. Cretinism is the rest~! of a tortgcnital defieicncy in lbc sccrchon of the hormone thyroxine from tl1e tl1yroid gland. In cretinism, the base of the skull is foreshortened, the face is wide and short, the mandible .be ma:dUo ovordcvelopcd, The eruption of primary and permaunderdeveloped, 811d 1 nent teeth i.s delayoo.The loug bones may be thickened and short, the epiphyses appenr late and are often irregular and deformed. Myxedemu (hJ1> 0thymidism in (ldu/ts), or uuderaclivity of lbc thyroid gland, mHy cause a variety of symptoms nd may affect all body fuuciious. The body's normal rate of functioning slow~ oau.,;ng mental and physical sluggishness. This conditiou is consitle.rably more common in wom~n than in men. ll is characterized by a puffiness of1he filce ond eyelids and a Slv~lling of Lhc tongue and laryn. The skin becomes dry ond rough aud he halr becomes sparse. The affec.tcd individuals also have poor muscle.loue, low mengtb, and gel tired very easily. Mentally th~y an: very luggish. This condition can be alleviated by admiuisteling thyroid hormones. Risk fuctors include age over 50 years. femule gender, obesity, thy1'0id surgery~ and exposure of the neck to xray or radiation trea1111en.1s.
J. The secretion of T3 (triiodot/lyronfne) and T4 (lh.vro.ine) is controlled by the pituitary gland and the hypothalamus, which is part of the brain. 2 . Thyroid diorders may re!;ult not only (rom defects \1) the thyroid gland itself, but also from abnormalitie.' of the pituitary or hypothalannts. 3. The lllJ!jority of the metabolically-active T3 is formed in the pcripbernl tissues by con von; ion of StlCretcd T4.

(MICROBIOLOGY I PATHOLOGY

Disord)

Hematuria is the presence of:

White blood cells in the urine Red blood cells in the urine Bilirubin in the blood

Glucose in the blood

221

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A subdural hematoma is 'enous hemorrhage underneath the dura, resulting from a laceration of:

The middle meningeal anery The middle cerebral aneries A berry aneurysm in the circle of Willis The bridging veins

222 CopyriJba C 10091010 Dm:alt>ecb

fted hlund cell\ in tlw urinl

Blood in the urine should never be ignored I Blood in the urine is usually caus..J by kidney and urinary tract diseases. I lowever, thcte arc a couple of e.tceptions: In women, the blood may appear to be in the urine 'vben it's actually coming !Tom the vagiua. In meu, the urethra cruTillS both urine and semen out of the body a nd whllt m.ay be mistalccn for urinary bleeding is sometimes a bloocly ejaculation usually due to a prostate problem. In ebUdreu, cougulntion disorders (such as h<?JIIophllia) or other hematologic problems such as sickle cell disease, renal ve.in thrombo<is, or tl1e thrombo.-ytopenias can be underlying rensous for uewly discovered blood in the urine. Note; Kidney dis. ease following strep. throat iss cluss1c cause of blood in U1e urine in qhildren.
, - - I. I.Jematcmesl~ is the vomiting of bright red blood, indicaring ropid upper Gl Jl'lote> bleeding. ll is commonly associated with esophageal varices (rommon in ~lco/ofics) or peptio ulcers. 2. Rmoptysis ls the coughing lip of blood 11om the respimtory tract. Bloodstrealced ~pulum often occurs in minor upper respiratory inJections or in bronchitis. Patients suffering ftoro t:UbercuJosis, pneumonia. or bronchogenic carcinoma ma.y ulsu experience hemoptysis, The main symptom of idiopathic pulmonaty hc'lllosider<1Sis (iron in the lungs) is hemoptysis. 3. Gluco$uria is the presence of glucose (sugur) in the urine; common in diabetics. 4. Ketonuria is the presence of l(etooes itt the urino: produced by starvation, uncontrolled diabctc'S, and occa\inn:Uiy alcohol intoxication. 5. Proteinuria is the pn.'Sence of protein in the 11rine; usually a sign of kidney disease.

Tlw

hrid~inl.! \dn~

Subdural hematomas (SDH) occur between the durn and the arachnoid membrane, most often due to venous bleeding from the "bridging" subdural veins which connect the cerebral cortex to the dural sinuses. Patients with SOil commonly present after acute dccclcmtion injury from a full or motor veWcle accident, but arc rarely associored wtth skull {ht~lur. Subdtmll hematomas are charCttri<ed clihioolly by gradual signs of cerebral compression occurring hours, day$, or weeks after injury. An epid ural hematoma (EDH) is an arterial hemorrhage between the dura and the skull, most often resulting fmm skull fractures and laceration of the oniddle meningeal 9rtcry. EDI! [s charocte.rized clinically by a short period of consciollSness (111cid i11lervo/) followed by loss of consciousness and signs of cerebral compression. S11baruchnoid hemorrhage is commonly associated with mpture of a berry aneurysm in the tlrele ofWiJJis, The mpture is most likely to occur in young to mfddle age adults. 1--. I. In comparison to SOH, EDH is often associated withsk\1ll fracture' (85 95rc ' Not.. ofadu/1 mses) which dismpts the middle meningeal artery. 2. A transient ischemic attack is a brief episode of impaired neurologic function caused by a brief disturbance in cerebro1 circulation. 3, A brain concussion is the immediate and lempornry disturbance of broil: functlon as manifested by dizziness, cold perspiration, visual dismrb~nces. anc loss of consciousness. Most people recover complctoly within <1 few hours m days. One compUcation is poslconcussion syndrome. 4. A m~ningioma is an intracranial tumor nrisiug from arachnoid, usually occurring in adulls over 30 yearS of age.

(MICROBIOLOGY I PATHOLOGY

Disord)

( \..

Match the appropriate fat-soluble vitamin deficiency on the left with the clinical manifestation on the right.

Vitamin Deficiency Vitamin A VitaminD VitaminE VitaminK

Clinical manifestation Osteomalacia Neurologic dysfunction Tendency to hemorrhage Night blindness

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\..

Which of the following is defined as calcification in previously damaged tissue?

Calcinosis Metastatic calcification Dystrophic calcification Abnormal calcification

22.
Cop)Tiiht 0 2009-201 0 Dc01al Occl;s

\ita min A- ~i:,.:ht hlindnl'ss \ it:unin U - Ostromalacia \'ihlmin E- '\jlurologic d~sfunction \ it.tmin I\.- llndt.m.~ tn ht.mnrrh1 1ge

~unun;.tn

nf I at-'inluhll \ lfamin'

Vitamin
A

Pb)'Siologltal functions

Rts11llt ot O<'Ocitnty

Helps ma.intatn normal body growth and Niaht blin<.loess; Squ3.100us met:.plasia in many li$$uea. healtb of .specitdized tis.sue5-. especially most ~mportantly in e)'e$, wJ!ere blindne$S may l'tSt.il~ retin~. Produ(..tion of rbudupsin
(/lhtHvpigmenf)
ES$enti~

1)

in fornw.ioo ofbolle

Ritkets in c:bUdrcn. osteomalacia in aduiiS

POS$IbJe neurologtc. dysfunction

t:
K

Antioxidant ln"olvcd in c:Joning ofblood

rendeno)' to hemorrhage

0~ struphic

r:lriticntiuu

Pathologic calcification of sol\ tissues occurs when calcium and other mineral salts are deposited in a tissue or in a passage. There arc three types of pathologic calcifications: 1. Dystrophic calcification is !hat which occurs in degenerating and previously damaged tissues, such as areas of old trauma, tuberculosis lesions, scarred heart valves, and atherosclerotic lesions. The cause is not hypercalcemia; typically the serum calcium coocentmtioo is nonnal. 2. Metastatic calcification is that in which calciwn (and othe1) salts are deposited in previously undamaged tissue as a result of an excess of salts in the circulating blood. Hyperparathyroidism is an example of metastatic calcification which occurs in kidneys and blood vessels. 3. Calcinosis is calcification that occurs in or under the skin. Sclerodenna, dermatomyositis, and multiple miliary osteomas are exam ples of calcinosis. 1. A s ialolith is a stone (salivary calcu!u.v) within a salivary gland or dueL The formation of a sialolith is called sialolithiasis and occurs as a result of precipitation of calcium and phosphate salts around a nidus of mucous or bacterial debris. Sialolitbs occur as single or multiple stones and can cause swelling and pain. The pain is experienced during salivary stimulation and is intensified at mealtimes. Most stones are found in the submandibular duct (Wharton's) and gland than in the parotid duct (Siensen's) and gland. 2. Kidney stones are calculi occurring in the kidney. Calculi too large to pass spontaneously range in size from 1 em to the staghom stones that occupy the renal pelvis and calyces. Bilateral renal calculi cause additional problems, with infection a common occll!Tencc.

neRO BIOLOGY I PATHOLOGY

Disord)

A deficiency in Vitamin B 12 is manifested clinically by (as):

Pellagra
Cheilosis Scurvy Megaloblastic anemia with prominent neurologic dysfunction

22S CopyrigbtO 2009-20t0 Dtrual Dccb

(MICROBIOLOGY I PATHOLOGY

Disord)

Conjunctivitis is most comm only caused by:

Adenovirus infection

Herpesvirus infection Picornavirus infection Retrovirus infection

226
CopyrightO 20092010 l)enQI Deck$

:\lt':,!alohlastic anemi.l ''ith promim 'n( nrurologic d)sfuncliun

SUIIIIIIUr) uf
\\~l tt.r-Suluhlt

\ il:lnlill'

Vftamln
B,
(thlamlnt)

Pl1ysiulogica.l functiuns
Cocnzytnc thi.:unine pyropf'l<)l)ph:ue

Res:ulis orDefidcncy
\V~1 beriberi: dry b~-riberi:

Wcmicke-.Korsa):ofhyndrome

plays a b:)' role incsrbobydtate and amin() acid in1mnetliary me~aboJism

Compon<:ntofF,\Oand fMN aod is 01-1.-llusiJ;: glbssitis; dmuatitis reduction pi\)CtSSes-

a,

(rlbofia'f1n) esscmi-al in a \ariety ofoxidali<m

(olAdo]

"'

Componen1 ofNAl) and NAOP, PellhllJU esscntia1 to Glycol>sis, tile citric acid cycte, -and to a varit()' of oKi~ion
reac~ons

Rcqt~ired tOr transanio31 ioo, p<>TPfY Owrilosis; gtb ssitis; anemia (pyrldmrfne-) rin ~nthesiS, sytUhcsiS- of n.i8cin

R,

from tryptophan
Bu
(~obalamio)

1-ca.rboa transfers required ror fofalc Meg-JJoblastic anemia: neurol~giedy&functioll' synthC$is and ~ivarion offfL I.embon trans(en; in a number of metabolic reactions Requimi r-llr the hydroxylation of proline nnd lysine~ wbicb are essen li<'!' (or c:ollagt."n :S)'QtlleSis; hydroxyl:.lion of dopamine lD syt~tbesis or nortpincpluir'u: Mega1oblasric antmW~ nc:Lu'(llugi.e dysfuoettioo ts oot a l..:a
t\1~ (M if I.$ hi "fiDmln Duil~fidcmcy ) Scutvy~ def:,ive wound bealir..g

f'olitlc:ld

c
(ftsl"'rbie

Add)

\tlt ~no\ irus

inft:!.:fion

Conjunctivitis is one of the most common and treatable eye iofec.tions in children and adults. Often called "pink eye,'' it is au inflammation of the conjunctiva, the tissue that lines the inside of the eyelid. Conjunctivitis can be caused by a virus, bacteria, irritating substances (shampoos, dirt, smoke, and especially poaTchlorb1e), allergens or sexually transmitted diseases (STDs). Pink eye caused by bacteria, vintses, and STDs can spread easily from person to person, ::--, l. Trachoma is an eye infection caused by Chlamydia tr~chomatis, It is tbe }Notes most common cause of preventable blindness in underdeveloped areas of tbe world. 2. Retinopathy of prematurity (retrolental fibroplasia) is due to toxicity of therapeutic oxygen, most often administered because of neonatal respiratory distress syndrome (hyaline membrane disease).It leads to blindness. 3. Diabetic retinopathy is a major cause of blindness. 4. Retinitis pigmentosa is characterized by hereditary nigbt blindness with progressive loss of central vision. It is caused by early loss of rods and later loss of
cones:.

5. Macular degeneration of the aged (senile macular degeneration) is a major cause of impaired vision in the elderly. It is often bilateral. 6. Glaucoma - two forms: - Open-angle: most common fom1; characterized by gradually increasing ocular pressure, leading to visual impairment and, eventually blindness. - Angle-closure: caused by narrow anterior chamber angle; increase in intraocular pressure on dilation of pupil. 7. Retinoblastoma is a malignant retinal rumor of childhood.

(MICROBIOLOGY I PATHOLOGY

Disord)

The enzymes lipase and are elevated in the blood of a patient suffering from acute pancreatitis.

Alkaline phosphatase Glucose-6-phosphatase Acid phosphatase Amylase

227
CopyriabiC 1009201 0 Ot:ntal Detb

(MICROBIOLOGY I PATHOLOGY

Disord)

Neurofibromatosis is a (an):

Sex-linked dominant disorder Autosomal recessive disorder Sex-linked recessive disorder Autosomal dominant disorder

m
Cos>Yri8M 0 2-2010 D<no.l llks

Pancreatitis is an inflammation or infection of the pancreas. The pantre11S is an elongated, tapered gland ilia! is located behind the stomach. ft secretes digestive enzymes and the hormones insulin and glucagon. Pancreatitis is often caused by ibe digestion ofparu of the organ by pancre.1tic enzymes that are oonnally ~rried to !he small intestine within the pancreatic duct:;. In acute pancreatitis, which is caused by obstruction of the nonual pathway of secretion of pancreatic juice into the intestine, the zymogeos of the proteolytic enzymes are converted into their catalytically active fonns prematurely. inside the pancreatic cells. As a resul(. these powerful enzymes snack the pancreatic tisS11e itself, causing a painful and serious dcstn1 ction of the organ, which cao be fatal. II is associated with alcoholism and biliory disease. Note: Manife.iutions or consequences of acUte pancreatitis include enzymatic bemorrhagio fat necrosis with ealcium soap fonnmion and resultant hypocalcemia. Physical findings of acute pancreutitis: No~ The child wiU ofteu walk into the olfrcc bent over, li1 nping. ~nd holding their right ide. The child will look ill and lay quietly There is often diffuse abdomutlll teod~mess. Point tenderness at McBurney's point which lies half-wny belween a line drnwn from the umbilicus to tbe ~nterior ili&c spine. Rebound tendernes, - pressing the abdomen at McBurney's point cau'"'s tenderness in a patient with appendicitis. When the abdorueo is pressed, held momentarily, and then rapidly released, the patient may experience a momentary incre~se in pain. This " rebound tenderness" suggests inllammation has spread to the peritoneum.

Autmmmal domin<int disnrdl'r

Neurof,bromatOsis (sometimes known as Elepham Marl $" di>eilse) ) is a genetio ncurulogicat all'ccl$ ee]J growth in nerve cls;,ue. NF produces n1mors of the skin,intcmnl al disorder tb. organ.1, and nerves that may become malignant. It also can affect bnnes, causing severe pain and debilitation and may result in learning disabilities, behavioral dysfunutiou, and hearing and vision loss. Distinguishing fcQturcs include: Moltiplc neurofibromas in skin and other locmious Schwannomas of the VUhh cranial nerve Cafe-au-Jail spots (lighi brown-colmed birthmarks) Lisch nodules (pigmcntod iris hamartomas) Skeletal disorders such 1!S scoliosis and bone cysts, and increased incidence of other tumors, c-.~-ciully pheochromocytoma and malignancies such as Wilms tumor. rhab~omyosarcoma. and leukemia, also occur. Other autosomal dominant disorders: FamiUal bypercbolesterolemla: characterized by anomalies of receptOrs1or low-density lipoprotein receptors. Hereditury hemorrhagic telangiectasia (Osler-W eiler-Rerrdu S)'ndrome): charactorncs ond by recurrent hemorilcd by localtclangieetnses of the skin and mucous membrs. rhage from these lesions. Common in Mannon fauillics of Utah. Matfan syndrome: characterized by defects in skeletal, visual. and cardiovascular structures. Patients are mil aud thin with abnomrally long legs and anns. spider-like fingers (arochnodactyl)'}. and hypcrcxtensible joints. Hean problems include: aneurysm of the proximul aorta, mitral valve prolapse and dissecting ancul)'l>m of the aona. Adult polycystic kidney disease: is characterized by numerous bilateral cy& ts that replace and destroy the renal parenchyma.

(MICROBIOLOGY I PATHOLOGY

Disord)

(
An autoimmune disorder

Hashimoto thyroiditis is:

Most often caused by a parathyroid adenoma Caused by an iodine deficiency Caused by diffuse toxic goiter

229
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(MICROBIOLOGY I PATHOLOGY

Disord)

A somatotropic adenoma with hypersecretion of growth hormone that develops before epiphyseal closure results in:

Cretinism
Acromegaly Gigantism Myxedema

230 CoP)'rigl'ltC 20-2010 Oetual Oetk5

\u autninuuum disorcflr

The most common cause of hypothyroidism in adults is Hashimoto's thyroiditis (also called chronic rilyroiditis ar Hnshimoto~ disease). It is a common thyroid gland disorder that can occur at any age, but it is most oflco seen in middle aged women. It is caused by a reaction of tbe immune system against tho thyroid gland. Clinical cbaractcrislics include: The onset of the disease is slow. and it may take months or even years for the condi tion to be detected. The symptoms of hypothyroidism arc evident (fatigue. sfo1ved speech. < 'O ft/ intoler anee, diJ' skin. coarse lwir, pl~ff>' face. elt;:.). Though the thyroid may initial ly lla\'e been painlessly enlarged, over rime the inflammation leads to atrophy of the thyroid with hypothyroidism. r I. Hashimoto's thyroiditis is associated with various autoantibodies, most l t/Qtu notably aotitbyroglobulin, antithyroid peroxidase. anti-TSH receptor, and antiiodine rcocptor antibodies. 2. Histologic characteristics include massive infiltrates of lympbocyr~s with germinal center formation. 3. Autoimmune disease refers to a disease resulting from an immune reaction produced by an individual's white blood cells or antibodies acting on the bod)"s own tissues, In the case of Hashimoto's disease, there is the production of anti bodies in response to thyroid antigens and the replacemen of normal thyroid structures with lymphocytes and lymphoid germiual oentcrs. 4. Primary hyperparathyroidism is most often caused by a parathyroid adenoma. 5. llypothyroidism (cretinism and my.~edema) can be caused by an iodine dcfi. cioncy. 6. Gravi'.S disease is hyperthyroidism caused by ditiuse toxic goiter.

Anterior pituitary hyperfunction ls usually due to benign slow growing ll1mors. Prolactinoma with hype prolactinemla: - Mos common pituitary tumor (30"~ - In women it results in amenorrhea and galactorrhea (t)mpprvprlate milk secretion) Somatotropic adenoma with hypersecretion of growth hormone Second most common pituitary tumor Gigantism resuhs if sdialoma develops before epiphyseal closure Acromegaly results ifudenoma develops ofter epiphySA:al ~losuro Common findings include: Gradual marked enlargement of the head. fuce, hands. feet, and chest Excessive perspiration and an offensiw body odor Prognathism (mandible prot/'!Ides) Enlarged ton&'l!e Deep voice:: Corticotropic adenoma with hypersecretion of ACTH - CusWng disease: refers to hypercorricism due to a toni> tropic adenoma of the pit uitary {lnosl often o basophilic adenoma) - Cushing syndrome: refers to hypercorticism regardless of the enusc. It is most oflen of pituitary and less often of adrcmtl origin. ,I, De!ieicncy of growth hormone: - Tn children, this results in pituitary dwarfism /Notes - Tn adults, this may result in increased insulin sensitivity with hypglyccmia. decreased muscle strength, and anemia 2. Deficiency of gonadotropins: In preadolescent cblldren, this r<'Suhs in retarded sexual maturation. ln adults, this results in loss uflibido, impotence, lo'" ofmu.< cu1ar mass, and decreased faci_ al hair in men, and ameuoorbt~ in women.

(MICROBIOLOGY I PATHOLOGY

Disord)

Erythema multiforme (EM) manifests as a diverse group of lesions: ""\ macules, papules, and vesicles. The most characteristic of these is the:}

Butterfly rash
"Target'' lesion

"Pasted-on" pJaqucs

Hill-Sachs lesion

231
o,p)Tigh.t 0 20092010 Dental Dccb

(MICROBIOLOGY I PATHOLOGY

Disord)

impetigo is an infection caused by:

Group A beta-hemolytic streptococci or coagulase-positive Staphylococcus aureus

Herpesvirus

Adenovirus
Influenza virus

232 CopyrigbtC 2~2010 lkntal Df'tks

Erythema multifonne (EM) is a type of hypersensitivity (allergic) reaction that occurs in response to medications, infections, or illness. Medications Msociated with erythema multiforme include sutfonamldes, penicillins. barbiturates, and phenytoin. Associated infections include herpes sfmplex and mycoplasma infections. The exact cause cs unknown. The disorder is believed to involve damage to the blood vessels of the skin with subsequent damage to skin tissues. It is a fairly common disorder, with a peak incidence in the second and third decades of life. Erythema multifonne may present with classic skin (target, hull:, eye shape or iris) lesions over the dorsal aspcet of the bands and forearms wit.h or without systemic (whole body) symptoms. to SteveASJobosoo syndrome, the systemic symptoms are severe and the lesions are extensive. involVing multiple body areas (especinlly the mucous membranes). Toxic epidermal necrolysls (TENsyndrome, or Lyell's syndrome) involves multiple large blisters (bullae) that coalesce, followed by sloughing of al l or most of the skin and mucous membranes. Important: The cla.~sic lesion is characterize by a central lesion surrounded by concentric rings of pallor and redness, thfs is commonly referred to as a "target", 11 iris"_, or "bull's eye" shaped lesion.

The organisms are thought to enter through damaged skin and are transmitted through direct contact. I! is a highly infectious skin infection tltat is most common in pre-school-aged chit drcn (aged lto 5 years) during warm weather. Impetigo usually appears on the face, csJ cially around a child's nose and mouth. It starts as a red sore that quickly ruptures, oozes for a few days and then forms a ycllov.-ish-brown crust that looks like honey or brown sugar. It tends to grow and spread. Impetigo is contagious. The infection is carried in dte fluid that oozes from the blisters. Rarely, impetigo may form deeper skin ulcers.
!-~ldn

D1waw.. or ( nndiliun'

rcmphigus
Pm~phigold

. . .

Key featurt$

Vesicles on mucosa Auto antibodies ugamst intcrocUular junctions ofkcratinocyh~S

Lil<e pemphigus. but ta~cr bullae on abdomen and groin Honey co'ored crust. !IUpcrtidal skin infection Sraphyloecus u.ureus Clr Group A beta-hemolytic SuqHQoocci
Muy be of vunJ ongin Henlld ptUch - spreads !!long Hexurallincs Lnrge, red nose Jiyperlipidcmiil. roemy hililioc:ytcs
"Salmon pu.lchcs" .and stork bites- spontM\OO~Isly tegr\!SSCS "Strawberry hemangiomas...- -initially grows. later regresses
"P011-wint stain" -$Ccn in

lmpetiao
PilyriiJ{IS

ROS3Cc3
XMthoma

Capilhuy hemruagio~

C-av.:mow: bcnwsgtorna
Cn.f~-llu-lnil spocs

. . . .

. .

Sturg.e-Wcbcf syndrvn~- docs not IUOh'c

spontanc::oulil)'

SClCtt in Ncurofib"'malosis (\'Ill/ Rtcltlinglw1uen di~r-ase)

lm:t,'Ular dqli gmcnt:uiCin

Vitiligo

(MICROBIOLOGY I PATHOLOGY

Disord)

Recurrent peptic ulcer or peptic ulcer in aberrant sites such as the jejunum Is suggesdve of:

Cushing syndrome Acromegaly Sipple syndrome Zollinger-EIIison syndrome

2))

Copyriabl 0 2009-2010 Da1tal Deck$

( MICROBlOLOGY I PATHOLOGY

Disord)

Diabetes ins ipidus results from a lack of:

ACTH Somatotropin

Prolactin

Zollinger-Eilison syndrome (l.ES) is a rare discrdcr that causes tumofli in the pnncrea.< and duodenum 11nd ulcers in the stom~cb and duo<lenum. The pnnc=s is a gland located behind tb" stomach. It produces ~nzymes that break down fat, protein. and carbohydrate.< from fuod, and hormones like [nsulin that ~reak down sugar. Tbe duo<lenum is the lii'St part of the small intestine. Peptic ulcers (circumscribed le.lon. ill the mucosal membro11e) can develop in lb.., lower esophagus, stotnach, pylorus, duodenum. or jejunum. About 80% of All peptic ulcers Me dundena! ulce.rs, and occur most commonly in men between the ages of 20 aud 50. Cnstrlc ulcers, Which affect the stomach mucosa. are most common in middle-aged ~nd elderly tllen. Esophageal ulcers are caused by the repoatcd "'b"'rgitotion of stomach acid (HCl.J imo th~ lower part of !be esophagus. Except for pep1ic ulc.ts of the stomach, peptic ulcers are al.ways as.~o<ialcd with hypersecretion of gastric acid and pepiu, Ulteratloo is closely related to gasrric T:lellcobaolc.r pylori infection, \VIticb affects ~'liSentially all patient with duode)18l ulcers and tbe majority of patients with gastric ulcers. Peptic ulcers are sometimes ossociatrd witb: The tL'e of a1plrin andNSA IDs Primary hyperparathyroidism Smoking Mul1iple endocrine neoplusla (MEN) typb l Zollinger-Ellison syndrome (Wet~11el' syndrome) n,e mon common syntptom of a peptic ulcer is pain. If the erosion is sufficiently severe, blood vessels in the stomach wall urc damagt!d, and bleeding occurs into rhe stomach itself (/his is called" b/eedh1g 11/cer). In cxtr<mc case.<. a peptic ulcer""" lead to perforation, which is a hole entirely through the wall of the Gl!t!lCI. This will calL<c an acute peritonitis wbich can lead to death. Important: The most common complication of peptic ulcers ls hemorrhage. It is most likely with duodenol ulcers. Ma~llgnant change Is uncommon.

\ D II

Diabetes insipidus (Dl) is a rare condition caused by damage to the hypothalamus (specifically /he supraoptic m<clei) or pituitary gi!Uld (puslerior pari) iu the bralli. Tills is due to !be lack of ADH (autidill/'l!tia hormone. vasopressin), which is produced in the nuclei but secreted by the posterior pil\litnry. ADH promOtes water retention through action on the renal coUecting ducts. Diabetes insipidus is charncteri7.cd by polyuria, with subsequem dehydJ'atiou aud insstiable thirst. Causes may include twnurs, trawna, inflammatory processes, lipid storage disorders. ond other conditions characterized by damage to the hypoth~lamus. Note: l11 diabetes insipidus, !be body fluid volumes remain pretty cloe to nQ rmal so long 11S the pron drinks enough water to make up for the increased clea.rMce of water in the urine. 01 should not be cooi\sed with di$betcs mellitu.!, which results from insulin ddicieucy or resi~tance leading to high biood glucose, Diabetes insipidus and diabetes mellitus are unrelated. although tltey can have similar signs and symptoms, like excessive lhirst
sud excessive urinadou,

Oialnlles mcllih1s (DM) is far more common than OJ. DM ba.< two fonns, roferred to as type 1 diabetes (/onnerly <ll!lcdj !lve!rile iliabereo. or iltsu/in-depende/11 diabetes me/IIIIlS. or JDDM) and type 2 diabeles (fomwr(v called adu/1-rmse/ diabetes, or nrmin.wllndependenr dlaheles me/lilliS, or rVLDDM). 01 is a different fonn of illness altogether. Nephrogenic Insipidus is a rare disorder in which lhe kidneys' abiUty to respond to ADR is impaired by dmgs (ll~e filhium.jor example) and by chronic disorders including polycyslic kidney dis~ase, sickle cell disellSe, kidney failure, parthll blockage or the urcle<j;, and inheriled genetic disorders.

(MICROBIOLOGY I PATHOLOGY

Disord)

Infectious mononucleosis is a benign, self-limiting disorder caused by:

Varicella zoster virus (VZIQ Herpes simplex virus type I (HSV-1) Cytomegalovirus (CMV) Eps_!ein-Barr virus (EBIQ

235 Copyright 0 2009-2010 Otnotal Deets

(MICROBIOLOGY I PATHOLOGY

Although asthma can strike at any age, half or all cases first occur in:

Middle age adults

Teenagers
Elderly persons Children under age I0

236 Copyright 0 20092010 Deo1eJ ~

Infectious mononucleosis i~ a Vital infection causing high temperature, sore throat, generalized lymphadenopathy, and often hepatosplenomegaly. Tt ls caused by Lhe EpsteinBarr virus (8 V), which has an affinity for B lymphocytes. The infection is ofleu transmitted by saliva. While it happens most ofieu iu 15 to 17 year-olds, the infection may occur iu any ge, b"ing most often diagnosed between the ages of l 0 and 35. Hematologically, there is relative lymphocytosis with al)pltal lymphocytes (re(lclive CD8+ T lymphocyte.,). lnfeetious mononucleosis is marked by a number of serum antibodies: Anti-EBY antibodies tleterophO antibodies (hererophil agglutinins) This antibody eventually appears in Lhe serum of more than 80% of the patfcnt$ wilh infectious mononucleosis, hence ft is highly diagnostic of the disorder. "') 1. Spontaneous recovery usually oceurs in 2 to 3 weeks. No llntiViraJ therapy JNotrs is ncce.~ary tonmcomplicated infectious mononucleosis and there is oo EBV vaccine. 2. The spleen is especially susceptible to traumatic rupture. 3. Remember: EBV is associated wilh Burkltt's lymphoma and nasopharyngeal carcinoma. It is also associated with hairy leukoplakia. 4. Patients with an acute infectious diseuse will have a rising antibody titer.

Astbma is a chronic reactive ainvay disorder tbat causes episudic ainvay obstru~tion. Such obstruction resuJL, from bronchospasm, increased mucus sec.retion, and mucosal gic asthedema producing the characteristic wheedng sound. There are hvo types: allet ma (most common form) and idiosyncratic a.'thmu. In asthma, bronchial linings overreact to various stimuli, causing smooth muscle spasms (bro11cltospasms) that severely constrict th~ !lirways. When Ute hypersensitive individual inhales a triggering Sttbstance (extrinsic alltNgen). abnormal antibodies stimulate mast cells in the lung interstitium to release both histamine and the slow-reacting substance or anapbylaxls (SRS-A). Both of these substances cause swelling of the bronchial smooth muscle thereby nattowing the bronchial lumen. On inhalation, the narrowed bronchial lumen can still expand slightly, allowing air to reach the alveoli. On exnalatiOtt- increased intralhoraotc pressure closes the bronchial lumen complete.ly. Mucus fill~ the lung bases, inhibiting alveolar ventil.ation. Blood. shunted to tbe alveoli in other lung parts. still can't compensate for diminished ventilation. ] . lmportaot: Nil'rous oxide is safe to administer to people with asthma and is No especially indicated for patients whose asthma is triggered by anxiety. 2. l f patient is laking steroids, consul t physician fOr the possible ne~d for corticosteroid augmentation. 3, The inhalation of a short-acting selective heta 2-agnnist (terbutoliue. albuteml) is the preferred treallnent (or an acute asthmatic attack. 4. Status asthmaticus is a paniculatl}' severe episode of asthma, usually .reqlliring bospitaUzation, that does not respond adeqUBtely to ordinary thcrapelll[o me3$u.r<s. Chronic partial airway obstruction may lead to death from rcspi ratqry acldosls.

(MICROBIOLOGY I PATHOLOGY

Disord )

Which disease produces diffuse enlargement or the thyroid with Increased thyroid hormone production from the onset?

Diabetes Graves' disease

Parkinson's disease Paget's disease

237
Copyright 0 20091010 Demal Deets

(MICROBIOLOGY I PATHOLOGY

lnfl & Nee)

(
\..
Basopbils Eosinophils

T he first white blood cells on the scene during tbe acute or early stage of innannnatlon are the:

Neutrophils
Monocytes

231 CopyrllliiO 20092010 [)meal Ded:t

Hyperlbyroidism (or thyrotoxicosis) is an imb~lance of metabolism caused by overproduction of1hyroid honnone (thyroxine-T4 and triiodotllyronine-1'3). Excessive production of the thyroid homwue thyroxin produces the symptoms of ~penhyroidism. The primary r~le of thyroxin is to S1imulate cellular metabolism, growth, and differentiation of all tissues. In ''>cess, therefore, it leads to htgb basal metabulism, fatigue. weight loss, excitability, elevated 1emperature, and generalized osreoparosi:;.. Oral ruonifestotlons are not too remark .. th blc, but ifthedislurbance begins in the early ye~rs of life, p...m~ture eruption or the tc nd loss or the deciduous cleutition are common findings, Two types of hyperthyroidism:
1. Graves' dlsc~se (most Commouform, occurs mm~t jrequeutly in women uges 4060) is

a tbyroid-spedfic autoimtn\Jnc disorder in which tile body makes antibodies to the thyroid-stilnularing hormone n'Ceptor (TSHR), leading to hyperthyrOidism, or an aboonnaily strong release of hormonos ITom the thyroid glnnd. Nonnally, the relensc of thyroid hormon~>S i. s mediated by thyroid-stimulating hormone (TSH), a honnone secreted by the pituitary gland th~t binds to TSHR to stimulate the thyroid to release thyroid honnones. This nonual cycle is-<elf- regulating~ the )lormoncs seer~ ted by the thyroid keep 111ore TSII from being produced, The uutoanllbodles produced in Uravos' disease are not suhject to neg:Hive feedboek, so they contin~e to be produced and bind to TSHR even when thyroid hormone levels rise t~o high. These ~ntibodlcs act as agoni>t~, stimulating mare hormones to be rele;c<ed and thus leading to hyperthyroidism. There are a wide range of rymptoms from anxiety and restlessness to insomnia aod wei~tloss, In addition, the eyeballs may begin to protrude (exopltllwlmus) causing irritation and tearing. 2. l'lummrr's disease (roxie nodular goiter) arises from a long-standing simple goiter and occurs most often in the elderly, Symptoms are those ofhypcrlhyroidism, but the pronuding eyeballs seen in Graves' disease do not occur. Risk (tctors include being female and over 60 years old. This disorder is never seen In thUdren.

:\l'ulrophiJs .... :Jisu c.tllcd pnl\ mnqlhonurlr~Jr l('ukttC) It's ur P,'\l ~s.

Neutrophils. tbe most numerous of the white blood cell& {50-75%), increase dramatically in number in response to infeotion and inflammation (in fact, they are the primary < 'mrstiluent nf ptls). These highly mobile ceUs arc lllructcd U) lll't'1ls of inflruruuatiou by chemotaxis and they identify the foreign antigen .and auach to it. They 5tan engulfing the invading organlsms and allcmpt to contain the infection io a smoU space. If the infection continues, rnonocytes, another type of white blood cell with even greater abiUty to engulf Qtganisms, arrive in increasing quamities.
J N'utc.,

I. 'Numerous substances have been identified a.~ chemotactic for neurrophils. These inclllde tbe complemeur system proto ins C3a "'ld C5a which ure Known as anapbylutoxlns, thul is, they induce a physiological response that results in blood vessel dilation: h)lpOtcnsion, increased vascular penneability. etc. 2. Remember: Chemotaxis is a proces~ of attracting and recruiting cells ln w~icb a cell mows toward~ higher concemralion of a chemical substance. 3. In order ro destroy its target, neutrophils use oxygen-depeudem ki ll ing roecbauisrus as weU as dcfensin molecules. 4. The o~ygon-depeudent killing mcchani~ms involve the 11se of supcroxide, rnyeloporoxide, hydrogen peroxide, aud NADPH dehydrogenase. 5. Defensins are small (I 5-2U amin<> acid$), cy$tein-ricb cationic proteins. 'fbey exblbit lllltimicrobial, amimycotic and allliviml properties.

(MICROBIOLOGY I PATHOLOGY

lnfl &

Nee)

An accumulation of pus, usually caused by a bacterial infection, is called a (an):

Granuloma

Tumor
Abscess Cyst

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Infl &

Nee)

Gas gangrene occurs as a result of infection by:

Clostridium tetani Clostridium perfringeos Clostridium botulinum Actinomyces israelii

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\h!\ttss

An abscess is a confined collection of pus. A creamy substance, which consists of dead white blood cells (mostly neulrophils) and necrotic tissue, it is the end result of suppurative inflammation. A wall of proliferating fibroblastS that produce collagen surrounds it. This is the body's attempt to prevent the fnrther spread of infection.

A cyst is an abnormal sac within the body containing air or fluid. It is lined with epithelium.
A granuloma is a tumor composed of granulation ti$suc that is usually associated witb ulterated inrections. Epithelioid cells and giant cells are derived from macrophages and are characteristic cells found in grunulomas. Lymphocytes, plasma cells, and fibroblasts surround the nodule of epithelioid cells. A tumor is a growth
~1:ow11

or tissue that forms an abnormal mass. In general, tumors (also as 1reop/asms) appear to be caused by abnom1al regulation of cell division.

Tumors generally provide no usefitl fitnction and grow at the expense of healthy ti$sues.

< "1m~ Iridium

pl'rrrinJ!l'"'

Gas gangrene results from local infection with tbe anaerobic, spore-fort:rUng, grampositive rod Clostridium perfringens. These bacteria tmder anaerobic conditions produce toxins that kill nearby cells. This rare infection generally occurs at the site of tratuoa or a recent surgical wound. The onset of gas gangrene is sudden and dramatic. Inflammation begins at the site of infection as a pale to brownish-red and extremely painfill tissue swelling. Gas may be felt in the tissue as a crackly sensation when the swollen area is pressed with the fingers. The margins of tbe infected area expand so rapidly that changes are visible over a few minutes. The involved tissue is completely destroyed. Remember: Gangrene is the death of tissue, usually associated with loss of blood supply to the a-ffected area. It is a fonn of necrosis combined with putrefaction

(decomposition or rolling).
Systemic symptoms develop early in the infection. These consist of sweating, feve r. and anxiety. If untreated. tbe individual develops a shock-like syndrome with decrease<! blood pressure {hypmension), renal failu re, coma, and finally dl!llth. Note: It is prevented by proper wound care.

:::J I. Clostridia are obligate anaerobes. gram-positive bacteria capable of 'Note<~ endospore production. 2. Closlriiliwn bacteria produce many different toxins (i.e.. alpha, beta, epsilon, iora). TI1e most important is tl1c alpha toxin (lecitlriiiOse), which damages cell membranes, including those of erythrocytes, resulting in bemolysis. 3. Remember: Clostridium tetani causes tetanus (also known as lockjaw). Clostridium botulinum causes botulism. Actinomyces israelii causes actinomycosis.

(MICROBIOLOGY I PATHOLOGY

Infl &

Nee)

Death of a portion of tissue or an organ in the body is called:

Hypertrophy

Necrosis Apoptosis
Atrophy

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lnfl &

Nee)

EpitheUoid cells and giant cells are derived from macrophagcs and arc important in the development or:

Initial inflammation
Granulomatous inflammation

Acute inflammation
Subacute inflammation

2<2 Cop)Ti&:h10 2009-2010 Denial Otcks

\:t.crosi\

Necrosis refers to a set of morphologic changes that accompany cell death within a living body. The morphologic appearance of necrotic cells is the result of enzymatic digestion and protein denaturation taking place within the cell. Autolysis takes place when the source of the hydrolytic enzymes is the dying cell's own lysosomes. Heterolysis occurs when the hydrolytic enzymes come fi-om other infiltrating cells. Necrosis may manilest in different ways, depending on the tissue or orgaos involved. Note: Coagulative necrosls is the most basic and most common type of necrosis. 1t develops when denaturation of-proteins is the dominant process, whereas liq uefactive necrosis develops when enzymatic digestion is the dominant process. When larger areas of tissues are dead, the tissue is called gangrene.
1 ~ pc uf '\l'crnsis
Causl's
~ l ust l.ikcl~

Sites lm ohtd

Coagulation Liquefaction Caseous Gangrenous Fibrinoid fat

Ischemia (loss ofblood s11pply) Heart or Kidney Suppuration, abscesses and ischemic injury to the CNS Brain or spinal cord Gmnulomatous inJJammatory sites Lower exU'emities or bowel Arttrial walls Adipose tissue, pancreas

Granulomatous inflammation (typical ofTB)

Putrefactive bacteria acting on necrotic bowel or extremity hnmulle mediated vascular damage Injured pancreas. trauma to
adipose tissue-

(;ranulomatnu" inOamm::~lion Granulomatous mflammation is subtype of chronic inflanunallOJl and IS charactenzed by granulomas, which are nodular coUections of specialized macro phages referred to as epithelioid cells. A rim of lymphocytes usually surrotmds granulomas. Granulomas arc produced by multinucleated giant cells (wngerhans giant cells and foreign body giant cells). All the other cell types characteristic of chronic inflammation, including plasma cells, eosinopbils, and fibroblasts, may also be associated with granulomas. Note: Granulomatous inOamm.ation is characteristically associated with areas of caseous necrosis produced by infectious agents, particularly Mycobac.t crium tuberculosis. Etiologic agents associated with granulomatous inflammation: I nfectious agents - TB and leprosy, whicb are mycobacterial diseases - Fungal infections (blastomycosis, histoplasmosc<, and coccidiodomycosis) - Spirochetes (Treponema pallidwn, which CatL<es syphilcv) - Cat scratch disease (caused by 011 unnamed gram-negative organism) Foreign material (e.g., suture or talc) Sarcoidosis (wrA?Jown etiology: it is nOIIIIecrori: illg} Crohn's disease (it is non-caseating)

(MICROBIOLOGY I PATHOLOGY

Intl & Nee)

- -- - - describes a tissue response to injury where there is an accumulation of mononuclear inflammatory cells (lympilocytes, plosma cells, and macropilages) and the production of fibrous connective tissue.

Acute in flammation Chronic inflammation Edema Gangrene

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---,----,,...ls a clear straw colored Uquid produced by the body in response to tissue damage.

Plasma
Serum

Exudate Transudate

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('hronic inOammatinn

Chronic inDammatlon tleve1ops Ill a siH.! of injury thot persists longer tl1an several days. [t is more proliferative than exudative. Necrosis commonly occurs and recurs. Examples of chronic intlammolion include chronic hepatitis, chronil' pyelonephritis, and autoimmune diseases . .1'/ote: Granul.u mutous inflammation is a subtype of chronic inflammation characterized morphologically by granulomas (examples would be TB, sarcoidosis, tmd silicosis). Acnte inDammntiou is the initial response of tissue to injury. paniC\tlar}y bacterlul Infections, involving vascular and cellular responses. 1'hree major phenomena occur: Increased vascular permeability with tissue e.'tudate fonued, leukocytic ccUolar infiltration (mai11ly neutroplrils by chemotaalic agents C5a mrd C3a), and repair (either by regeneration or replacement). Local signs of acute inflammation include redness (mbor), heat (col01), swelling (tumor), pain (dolot), and loss or function. Systemic effects include fever. tuchycanUa. and leukocytosis (especially neraroplri/s). Remember: O ther cells involved in acute inflammation (spec(/iCitlly the V(tScrlior phase) include bawphlls, tissue mast cells, and platelets. These c~lls release hlstsmloe.
M~crophages

appear late in the cellular phase and represent a transition between acute and chronic inflammation.

*"*The edema resulting from inOummution is caused by increa>cd capillary pen11eability. The edema Nuid is cllcd an exudate (commonly called ''pus'?. The easiest way to see exu date is to puncture a blister, the Ouid dun esc,,pes is exudate. If the fluid is cloudy or discolored it is a strong indication ofthe presence of an infection in the wound. Exudate is characterized by being protcln-rlch, cell-rich, glucose-poor and having a high spociOc gra,lty (t.\'ceedl~rg J.OZ0). 1'ypes of inflammatory exudate.~ include: suppurative, purulent. fibrinous, snd pseudomembranous. lo addition to water, c.x.udnle comoins varying amounts of nutrientS, oxygen, antibodies and white blood cells (>wutrophlls). The first role of e:rudate is to flush away any foreign material from the site of the injury. lt also nets as the carrier medium to bring fibrin and other repulr materials to the site of the injury. Later in the inllammatory rcspoose it acts 35 01e carrier for leukocytes (prl~rcipully PMN's) and monocytes and supplies them whh oxygen untl nutrient~ while they ingest bacteria and other debris in the wound, The presence of exudate also enables the mov~ment of these phagocytic cells within the wouud. Later in the healing proces. the nutrients in the exudate are used by the new tissue to help in lhe generation of gmnulation tissue. Finally the exudate acts a lubriea.nt speeding up che migmrion of epithelial c<:ll across the wound surface to complete the initial repair of che wound. Transudates result from increased iut.rovnsculor hyctrosmtic pressure or from altered osmotic pressure. This fluid Is thin and watery and is characterized by rew blood cells, lo1Vprotein content, and a low specific grnvity (less than 1.020). It is present in non-lnOsrnmatory conditions. I. Oeuemlly most of the common acute inflammatory reactions contain large Note amounts of .neutrophils and are termed uppurative (nwmling to produce prll'ttlem nwtter). 2. This suppunuion is the result of tissue necrosis. protco1ylic enzymes~ WBC'S, and a buildup of rissue fluid.

EucROBIOLOGY I PATHOLOGY

lntl & Nee)

The hallmark of the acute cellular phase of acute innammation is the appearance of:

Macropbagcs in the tissues

Granulocytes, particularly neutrophils, in the tissues Lymphocytes in the tissues Epithelioid cells in the tissues

205
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(
Vitamin A deficiency

Beriberi is a sign of:

Vitamin 82 (riboflavin) deficiency Niacin deficiency

Vitamin Bl (thiamin) deficiency

(;ranuln.:~ tt.s, pltrticnl.lrl~

neutrophil'\. in lhc tissUl'"i

Acute inflammation is the immediate, loe<~l response to tissue injury. It is designed to bring leukocytes to the site of injury. The two phases of acute inflammation are: I. Vascular phase Vasoconstriction (tempormy): narrowing of blood vessels caused by contraction of smooth muscle in the vessel walls, which can be seen as blanching (whiteni11g) of the skin. Vasodilation: widening of the blood vessels to increase the blood flow to the infected area. I ncreased vascular permeability: which allows diffusible components to enter the site. 2. Cellular phase Leukocytes (predomi11ately polymorpho/luclear /leutropldls) are the first defense cell to migrate to the injured tissue by chemotaxis. Titese leukocytes engulf particulate maner by phagocytosis. This cngttlfcd matter becomes a phagosome. and then combines with lysosomal granules to form a phagolysosome, in which digestion of the engulfed particle occurs. Cells involved in acute inflammation include; Basophils, tissue mast cells, and platelets are important in the vascular phase. PMN's predominate in the cellular phase. Macrophages appear late io tbe cellular phase and represent a transition between acute and chronic inflammation. Note: oslnopblls arc the predominant inflammatory cells in allergic reactions and parasitic infections.

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. fats. vitamins. or Rtmember: Malabsorption can cause defieu:oc1c~ of aiJ nutncnts or of protems, minerals selectively. The symptoms vary depending on the specific deficiencies. The absoJlltion of the ratsoluble \ri.tamins (A.D.E.K) is affected 10 the greatest extent. Vitamin B12 malabsotption occurs in pernicious- anemia due to the absence of intrinsic factor. This is c.ausod by the destn1ction or malfunction of gastric parietal cells. The term "pemicious" is cUJTcntly a misnomer since the disease ts no longer fatal due to advances in trearment with pan;otcral administration ofvitamin 812. Note: Vitamin Bt2 malabsorption also occurs with Crohn's disease.

Oatlbc:ini!IKWQ:r-idit~ll.;. fliWf#flf:}HJfl\k~'bm&~

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(MICROBIOLOGY I PATHOLOGY

Syndr)

Which malabsorption syndrome Is caused by a sensitivity to gluten in cereal?

Tropical sprue Celiac disease Whipple disease None of the above

247

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(MICROBIOLOGY I PATHOLOGY

Syndr)

Which of the following is autosomal recessive?

Familial adenomatous polyposis Gardner's syndrome

Turcot's syndrome
Peutz-Jeghers syndrome

2.8 Copyriibt 0 2009-2010 Derual Dcd:s

Malabsorption means !be failure of the Gl tract. usually the small intestine, to absorb one or more substances Jiom the diet. The most common symptoms of malabsorption syndromes are steatorrhea (.rtool tlrat is a liglu-colored. sojl, bulky and foul-smelling), diarrhea, bloating, flatulence, cramping and weight loss. Malabsorption syndromes: Celiac disease: is a condition where the mucosal lining of the small intestine is damaged by ingestion ofgMen. One factor thought to play a role in when and how celiac appears is whether a p"rson was breastfed and bow Jong. Tbe longer a person was breastfed, the later the symptoms of celiac disease appear, and the more atypical the symptoms. Persons with this disease have to avoid wheat, rice and corn. Note: lt can be latal in adults due to the development oflympltoma in the intestine. Tropical sprue: the cau.~e of this disease is toknown, but it may be related to an infectious organism. Tile condition affects residents of or visitors to the tropics. Typical symptoms include s teatorrhea, dlanbea, weighl loss, and a sore tongue from vitamin B deficiency. Treatment consists of antibiotics, often Tetracycl ine, for up to 6 months. Whipple Disease: is a systemic bacterial (Trophety ma w/lippelii) illness usually a ll'ecting middle age men and presents diarrhea, anem ia, arthritis, fever, weight loss, swollen lymph nodes and skin pigmentation. It ls diagnosed by t;tk ing a small bowel biopsy through an endoscope, and the treatment is antibiotics (penicillin or tetrac_vcline) for one year or longer. - - . I. Symptoms of malabsorption syndromes are due to: Not..- Osmotically active substances remaining in the GI tract (diarrlrea, and bloating) Nutritional deficiencies (weight loss, glossitis, and meguloblastic mwnlo)

furcut~ s~

ntJrumr

A Gl polyp is defined

as a mass of the mucosal surface protruding into th~ lumen ol' the bowel. Gl polyposis is characterized by multiple polyps within the Gl tract. A variety of polyposis syndrome.< cati affect the Gl tract: Fanlilial adtnomotou polyposis: - Cau~ed by the absence or APC (a fill/lOr suppressor gene).
~

AutosomaJdominant

- Characterized by tho presence of numerous ~denomatous polyps - The oisk ofmaligonnt transformation approaches 100% Gordner's syndromet Autosomal dominant -Characterized by the presence of numerous adenomatous polyps along with skin and
bone tumors

- The risk of maligJ~ant translbrmation approoches 100% 1\U'Cot's syndrome:

- AutosomaJ recessive

- Characterized by adenomatous polyps along with C:-IS (brain) tumors - The risk of malignant transformation Is hlglt Peutz~Jegbers syndrome: -Autosomal dominant - Characterized by hamartomatous polyps (non-neoplastic) nf the colon anrl sonnll in.testine (especially in the jejwwm) Characterized by melanin pigmentation in the mouth and 011 the lips, hands, o11d gen.\(alia These polyps have no malignant potential themselves - However, this syndrome is associated with iocrelUcd risk for sdonocarclnorn of tbtt colon, wd malignancy at other sites, such Ill; the stomach. breast, lung, or ovaries.

(MICROBIOLOGY I PATHOLOGY

Syndr)

Patients with Down syndrome are at an increased risk for:

Osteosarcoma Lymphoblastic leukemia Berry aneurysm of the circle of willis Fabry disease

249
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(
Infectious disease Metabolic disease Autoimmune disease Metastatic disease

Sjogren's syndrome is a (an):

m
Copyrijht 0 10W20JO Deotal Ok$

L~ mphohla~oltc ft.U~l'uti.l

Abnonnalitics of autosomal chromosomes:

Down syndrome:
- Mosl frequently occurring chromosomal disorder: caused by trisomy 21; incidence increases with maternal age Charncterl5tic5: Menta] retardation

Large forehead, broad nasal bridge, wide-spoced eyes, epicanlhal folds, large protrud Jog rongue, and small low-sol ears Short. broad bands with curvature of the fifth finger
Complications of Oowu syndrome:

Coogcnillil heart disease lncreosed risk of lymphoblastic leukemia; increased susceptibilil)' elf infection With advance<! age (older Ihalf 3.5), show clinical sib'llS and symptoms of Alzheimer disease Crl du cbar syndrome -Caused by deleciuu ofhe. shon ann ofchromosome 3; characteristiC$ nre severe mental rerordation, microencephaly, aod ao tmusual catlike cry
OIGeorge syodrome

Caused by deletion o( a portion of chromosome 22 Characterisrics include: CATCH 22 (cardiac abnormalities, abnormal facies, T-<:ell dcficicnl because of rhymic hypoplasia, clef\ palate, hypoealcemill and nricro<lelerion of
l2qll

Edwards syndrome (trisomy 18)

- Chari!Cterislics include menial retardation, face bas a pinched appearance, micrognathia (small jm..~. head ls small witb low-scl cars, and congenital heart disease

Patau syndrom~ (t risom y 13) Characteristics include menial rerardation, microcephaJiy, microphthalmia, clef\ lip and palate, brain abnormaliries, polydactyly, and congenital hean disease

,\utnilllntll0(. ' di<\(',)S{'

Sjogren's syndrome is a condition that is most Likely of autoimruuue origin. It is marked cruelly by chronic inllammation (cariSed by white blood celllnjilrratioll} of the salivary glands and lacrimal glands. This usually progre_<;ses to fibrosis and atrophy of these glands. The triad of findings found in Sjogren's syndrome includes: Keratoconjunctivitis sicca (tlry eyes) Xerostomia (dry eyes) Associated connective tissue disease (most ofleu rheumatoid arthritis) All three symptoms rarely occur in one patient. A definite diagnosis can be made only when at least two of the symptoms are present. It is less common than rheumatoid arthritis and more prevalent in women than in men. 1. The clinical presentation of diminished lacrimal and salivary gland secretion 1- J Not.. is often referred to as sicca complex. 2. Sjogren's syndrome that results from a rbeumatic condition is classified as secondary Sjogren's ~drome. Primary Sjogren's syndrome occurs by itself. 3. Sjogren's syndrome is associated with an increased incidence of malignant lymphoma. 4. Occasionally, the lymphocytic infiltration is massive and causes enlargement of tlte glands {this is called llfikullcz 's syndrome). 5. The decrease in salivation may cause rampant caries reminiscent of radiation caries. This is a result of a shift toward a more acldogenic mlcronora. 6. SSA (anri Ro) and SS-B (anti Lll) antibodies, which are directed against two extractable nuclear antigens, bave beeu dcrected with high frequency in patients with Sjogren's syodrome,

neROBIOLOGY I PATHOLOGY

Syndr)

Chvostek's sign and Trousseau's sign are rcUablc indicators of:

Bell's palsy
Botulism Rickets

Tetany

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( \.

The thymus gland and parathyroid glands are malformed and dysfunctional or missing altogether in:

Sjogren's syndrome

DiGeorge syndrome
Sby-Drager syndrome Pcutz-Jcghers syndrome

252 Cop)TiJht 0 2009-2010 Dc!lta1 Dttl:s

1t'l :&II\

Tetany is a clinical neurulogfoal syndrome characterized by muscle twitches. cramps, and carpopedal spasm. When sever~. laryngospa.<m and seizures de~elop. All of these signs and symptoms reflect irritabi liry of the cenlnll 110d peripheral nervo11s systems. It is usully asso oisted witll calcium dcflclcncy (l>'fX'f'llrl!lhyroidism). vitamin .D deficiency or alkrtlo,is. Nott: Acute hypocalccmin in lhe human being ordinarily c;auses no other si~nilie~~nt effects be.'ides tetany because tetnny kills the patl<nl before other effects can dcvclqp. Tetanus: Toxin enters the CNS along the peripheral nerves Incubation period of 5 to I0 days Stiffness of the jaws. difficulty swllo,ving, fever, headache Risus sardonicus: fixed "smile" and elevated eyebrows Severe spasms of lhe neck, back and abdominal muscles &tullsm: C. Botulinum !;pores arc higl~y tesislant to beat, but tolins arc nol Proper canning and heming of food l'revcub botulism Nausea. vomiting and abdominal cramp& usually pr:edo lhc no urological sympt<lms~ dry mouth, diplopia, loss of pupillary reflexes, followed by descooding paralysis and tO!;piratoty failure
Not<~ appro~imately

I. Tetany nom>ally will occur when the blood concentration of calcium reaches 6 mg% (nomwl is abolll /0 mg?.{,). his lethal al ;bout 4 mg%. 2. Chvostek's sl~n: to cheok for Chvostek's sign. tap rhe facial nerve above the mandibular angle. adjacent to the earlobe. A facial muscle spll<m dun causes the patient's upper lip to twitch, confums tetany. 3. Troussenu's sign: to check for 'frottsseau's sign, apply a blood pressure cuff to the patient's arm. A carpopedal spasm that causes thumb adduction and phalangeal extension, confirms tetany.

DiGeorgu yndrome is ~ rure immunodeficiency disorder characterized by various cougeniml abnormalilk~ that develop because of defects tbat occur during early fetal developmeoL These defe<:ts occur in areas ~oowo !IS the 3rd and 4th phflryngeul po~tches, which later develop into tlte thym utand parathyroid g)ands. Developmental abnorrnalitie. may also occur in the 4th brsncblal arch. Normally the thymus gland is located midline in the upper pan of the chest cavity. It ties below the sternum and above the trachea aJJd we heart. ln a baby, the thymus is relatively large (as compQtY!d ro the rest of the baby~ body). It then continues to grow until puberty at the end of which it begins to shrink (inolme). It is we primary gland of the lymphatic system, which is ntwss~ry for the normal functioning of the [mmune system. The parathyroid glands, located on the sides of the thyroid gland, are responsible for the maintenance of nonnal levels of calciwn in the blood. The thymus and parowyroid glands are missing or underdeveloped in children wi1h DiOeorge syndrome. The symptoms of this disorder vaty greatly, dep~nding upon the extent of the missing thymus and parathyroid tissue. Tbe primary probl.ctn caused by DiGcorge ~yn<.lrome is the repented oe<ourrcucc of various lnftelions due to a diminished immlme system. , I. Tho absence of the thymus results iu T-cell defioiency. The.~e ~;hildren buve , Not# normal B lymphocytes and fonn antibodies. but they have decreased or absent delayed-type hypersensltiv[ty. 2. These children develop tetany duo to hypocalcemia (from the absence oftile panrthyroids). 3. Up to 75% of myaslheniu gravis patients present with lUI abnormal thymus such as a thymoma (11 lumo uf the tl1ymu.v).

ncROBIOLOGY I PATHOLOGY

Syndr)

\,.

Which immunodeficiency disorder is sometimes called "bubble boy disease~?

)
A

Wiskott-Aidrich syndrome Severe Combined Immunodeficiency Disease (SCID)

AtaxiaTelangiectasia

Hyper-IgE syndrome

253
Cqpyri,Sh1 0 200920 1 0 l)en!~l Dcc;k$

neROBIOLOGY I PATHOLOGY

Syndr)

A tall, infertile male with small testes most likely bas which of the following conditions?

Adrenogenital syndrome Klinefelter's syndrome Testicular feminization Turner's syndrome

254

Copyriibl 0 2009-2010 Dcnttl Oteks

!'tt'Vt.'H'

Cmubim.'d I mmunodrlirh.nc~

lliHa!;~ (S('/1))

The most dangerous type of congenital (inherited) immunodeficiency, severe combined irnmunodetioioncy disease (SCID), results from a fullure of stem ~ells to dH'ferentiate properly. Individuals 1vitb SCID have neither B nor Tlymphocytes and arc lneapahle of auy immU1lo1og)cal response. Titese children generally die before age two. Note: SCJD became more 1videly known in the 1970s wheo the world learned of David Vetter, a boy with SClD who lived for 12 years iu a plaStic, genn-frce bubble. The Wiskott-Aidrich syndrome (also coiled tnummodejlcie!lay 1vith ~c=~mu and llrrombocytopenia) affects only boys and is chatactctiztd by defective B-cell and T-ceU functions. Its clfnical fearures include thrombocytopenia with severe bleeding, cc~oma. recurrent infection, and an increased nsk of lymphoid 1.'1l0cers, Ataxia-tclangicctasia is an inherited disorder that affects many tissues aud systems in the body. Multiple symptoms may include telangic..:~is (dilarion qf'mpl/lati~s), ataXic (unaot>rtlinated) gait. proneness to infection, defective humornl and cell1lar immuoil)' and increased risk of malignancies. The mosr obvious symptoms of the disease are multiple telangiectases tbot are easily visible in the 1Vhite oft he eye and skin areas sucb as the...,. and n(),';e along with graying of the hair. nnd irregular pigmentation of the areas exposed to sunilght. In addition, there is decreased coordination of movctnen~s (ql(l);ill) in late chlldhood. Aypel'immunoglobulin E syndrome (al.viJ known as Jr>h .vyndrome) is ao immunodeficiency disorder characterized by very higb levels uf lgl! antibodio:s and repe>!ted infecrioos, most commonly by Stnphyloonccus aureus. Treatment conshts of taking 811tibiotics continually for the infections.

1\:lincfrlh. rs s' nttrn11U. '

KIJ.uefelter's yndrome is a chromosome abuonna1ll)' that affects only men and causes hypogonadism. A person's sex is detemtined by 1he X andY chromosomes. Normally, men bave au X and aY and women haw two X':;, fn Klinefelter's syndrome. a male bas two X's and a Y.

Th'' condition i common aod affects

I in SOO meu. Tb~ infant appears norrnal at birth, bm the defect uslllllly becomes apparent in puberty when secondary sexual characteristics fail to develop (or develop late). ThcS individuals have small testes, eularged br<asts, a feminine distribution of pubic bair, and 11-"''uently mild retardation, Titese boys tnd to be taU, with long legs. Titis disorder is associated v.~th advanced maternal and patt mal age.

1\m~r's syndrome is a birth de feel caw;td by the absence or defect of an X chromosome, which i.nhtbit3 sexual development and usually causes infertility. The incidence is I out of 3,000 live births. Girls with T11mer's syndrome usually bave sbo11 sta1ure, webbing of the .skin of the neck, absent or retarded development of secondary sexual characterisrics at puberty, absence of menstruation. coarctation (narmwing) of the nona and abnonnalities of the eyes and bones. Tbe condition is eitber diagnosed at binh because of the associated anomalies, or at pubeny when there is absent ot d~layed meuses and delayed development of normal secondary sexual charncteristics.

.Examples of disease.~ that can be <liagnosed by karyotyping: Klinefelter's syndrome: XXY Trisomy 18: extra chromosome 18 Down's syndrome: e"tr chromosome 21 Turner's syndrome: XO

ucROBIOLOGY I PATHOLOGY

Syndr)

A male infant Is born at term. No congenital anomalies are noted at birth. A year later be now has failure to thrive and bas been getting one bacterial pneumonia after another with both Hemophilus lnfluenzae and Streptococcus pneumoniae cultu red from bis sputum. Which of the following diseases is he most likely to have?

DiGeorge syndrome Selective lgA deficiency Epstein-Barr virus (EBV) infection Acute leukemia X-linked agammaglobulinemia {Bruton~; agammaglobulinemia)

255

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(MICROBIOLOGY I PATHOLOGY

Hemody Dys)

(
Pulmonary edema Peripheral edema Lymphedema Cirrhosis of the liver

Right-sided heart failure results in:

256
CopyriJh! 0 2009201 0 DeraW Dks

Xlinkcd

a~olmmas,:Johulinlnti:t

(Bruton\

ngammtt~lolmlim~miu)

Agammaglobulinemia is a rare disorder characterized by the absence of the serum immunoglobulins. lt is associated with an increased susceptibility to infection. Tb.ree forms: I. Transient: common in infancy before 6 weeks of age. Matw-c B-cells are temporarily unable to produce antibodies. 2. Congenital (Bmton's): rare, SC><linked, and results in decreased production of antibodies. Tile treatment of this disorder involves the repeated administration oflgG to maintain adequate levels of antibody in the circulatory system. 3. Acquired: usually occurs in association with a malignant disease like leukemia, myeloma. or lymphoma.
In Bruton 's agammaglobulinemia aU fiYc immunoglobulin~ and circulating 8-cells are absent or deficient but T-cells are intact. It affects males almost exclusively aud

C<Juses severe, recurrent infections during infancy. Patients with litis disorder are deficient in antibodies aod susceptible to repeated infections (mo.vtly barterial and fungaij. TI!is results from the failure of Bcells (8-/ymplwcytes) to mature and to differentiate into plasma ceUs which produce antibodies. Note: Th(s failure to m:Uure is caused by a mutation in lbe B-cell protein tyrOsine kinase. Important: The disease is caused by a mutation on the X chromosome and it is coD-<idered a primary immunodelkiency.

Ed~roa is an abnonnal accumulation of fluid in (he interstitial sp:1ces or body cavities. Causes of c.-dcma: Joc.reased capillary permeability (prin cipal jflttot~: occurs in inflammation or with

injury to capillary endothelium

locreascd hydrostatic pressure: is exemplified by congestive hean failure - Right-sided hean failure rL-suHs in peripheral edema

Left-sided heart failure results in pulmonary <dema

De-creased oncotic pressure: is from hypalbumi"nemia, whf~h res\J.hs from: - Increased loss of -prolcin (seen in mp/Jrolic $J'Itclmme) - Decreased produ~tion of albumill (see, hr tirrhosis of tile liver) Increased sodium retention lllockllge of tymp. hatics: rcs1o1ts in lymphedema 1)'pes of edema: Anasarca: generalized edema B.ydrutbora.x: is -an accuntulatioll of fluid in the; pl~un'd cavity Hydrocephaly: is no accumulation of cerebrospinal fluid in the cranial C3Vity

Hydroperlc~rdiumt

is an accumulation of Ouid in the pericardia! cuvity

Hydroperitoneum (ascites): is an accwnuJa1jon of fluid i:n Lhe. peritoneal cavity '1 "-r&I1Sudatc: noninflammatory edema Ouid that results from altered intravascu1ar llydroslalic: or osmotic pressure. 1l ha~ a low prolcin cont.:nt and a sp!.!cific gravity of less

than 1.012
"Eudate: edema fluid resulting from incl'eased vascular permeability caused by inflammation. It has a high protein cunlenl and a specific gmvity exceeding 1.020 1 Edema may be generally described in one of two ways: Notes 1. Plttln.g edema~ when )10U press a swollen area for 5 secouds und then quickly remove tt. an iodcnuuion is J aft thai fins slowly. Seen in acute disc.asc. 2-, Non-pitting edema: when you press a swollen area for 5 seconds and then quickly remove ft. no in,dentation ts len in lht skin. Seen in chronic disease.

(MICROBIOLOGY I PATHOLOGY

Hemody Dys)

The main risk factor$ for arterial thrombosis include all of the following. or these, the 3 major risk factors are: Smoking

Diabetes
Increasing age High blood pressure Family history

Poor diet
Increased levels of cholesterol
Excess body weight

Physical inactivity
257 CopyrightC 2009-2010 Ot:ntal l)ed:s

(MICROBIOLOGY I PATHOLOGY

HemodyDys)

( Which stage of sbock is cbaracterizied by cells functioning on anaerobic) \.. metabolism, wbicb is causing a buildup of lactic acid?

Initial
Compensatory Progressive Refractory

258
Copyright 0 2009-2010 Den1al Dccb

.Smuldnl!, llich hlmull1tllimn.:

llll' lt'.f'il'tl thul (<ill'llllll' \l'l \

A blood clot within an Rncry is known as an arl,rlal chrorubo,sls. Arterial thrombosis is rcspoq:;ibte for he-an auacks", stiOkes aud perfpbcrnl vascular disc:s:sc (thmnrhosis ;,. leg nnerlt:S). ,\rrerial throl.tlbosis usu~lly alftt.l$ mdtVtdu:tl$ who p;lread:y hZ\vc. athero.stltrusis. or narrowing ufth~. anerit:l!. AtheroJiclcrosi~ CI!IUSi the W311! af tht -arttri~ ltt 'rur up' with d<:PQSits of atheroma. a porrldgeIt" .:.'Ubst3nt'f. A t~rombus is a solid muss of cloth.. -d blood th1u forms w1u:n an altemtio.n in the- epi1helial lining causes pla1elct aggregation and eon~' fibrin e.n.tropmem of red Alld whit~ blooil cells 'lloug with 11ddiliom11 platele.rs. Thronlb~ formation is more rupid (Jl tt.reas w1wre blood flow is slower. bccauw l'OCIIICt tx:1Wl'el1 platelets in.:rCBscs and rhrombin -acttumuJatr:s.. Tllror'l:lbus furmculoo ts-enhanG1.1 by endotbeha.J tnjury, o.n -ahct11tiun in blood flow, 'l11d hYJ)Cfl!glllibility of the blood. Typesof thrombi: .. Agonal thrombus rorm~ 1n .Ch he-art during tbe pmce:s~ l)f dylog <lfiCT p.ro10nged heast fiulun:.. Munol thrombus: fOl'l'OS as tl te.>~uJI of damah'l: tb lM ventrh,:-ular CfldOC:il(dium tlts,..a/6 lt}f ..-enirh.:Jtt follrttt~ing mynf:nrdhtl i;tfiwe~}. A majorcomplica~lloo of tt nlut.tJ t.hromhu.~ tt u tc:n:brnl embo1ism. Tt complicates myOOtsrJial inffirction, tttrittl fib:i lllltion, and athcro!lolcto!i1~ nfthcaomt. Whitt 1hrombus: a throo1bus eoroposed datil) of bluod pJ::u""l~l!i- Red d1rombuJS: fUm1ed n1pidly by the- cmt~u l aUon of stagMting blood, com)'~.o~ed of l'ed blood cells
Fibrin lhl'ombus: tbuued by repcnied depusib of fibrin fron1 the cin:ulalint; blond, It u!lut~lly does not com"ph:lely oct;l\ld1! the ve.itf:l. I. Morpthtloj.iclly. tw ilrttrial tJifombus- 1\hows ahtmaring red it!ld white lnmimuiotiS (limJYQf J\'111 "' lolm). Ve-nollS thrombi are more tln.ifbnu.Jy ted; the lines are d:islmct. 2, I' Jllebitb Is ihe- fnOsmmation ofB vein. Congestion is the :!Ccumul.niou ofexcesstve blood with~ in the blood vess!!IS. Tbrtuuolys:l j!; the. brenk in g. up of u blood clot 3. An embolm '' a blQod clot the.~ moves 1hrougb dtc. blood$ttUIH until it lodge$ iu a IHtm:>wetl vessel ruld block$ ~ireUlatiob. Mosl~:mbOii t1.re thrtunboc:mbofL 4. Utotp nnuu!l thrmnhO"iiJ~; (OV'If alfccu m:\intyth~veins m tbe lo\Vet leg -and 1be rbigb. Jt Lovol\~ the tbnnmion uf D. clot fi/JronWu;) 1u \hl IDJt,trt 'ltin!> of the area This throlTtbU!I may interfere with circulation of the .afCil. 1UJd it mlf)' break off and travel lhrou_&b the Nood Stream (emlwlt:t9. The embolUs Ol~ creattd uan lodg.c 10 the torniq_, lungs/publfi)Jarye.'flbo/ismJ. ha~n. or other area. cans ing, .severe-damage to lhaf organ.

nnher th<UJ phndets.

Shock is complex by its very nature. Thtpsthupl\)'Si6logy of !thoek mAny times inVtt~vcs !.he multlpJe f:tiJ ..
ures of organs and cv~u death. Shock at Its UlUi'l bltl!.ic ltwelli' rhe bttk or t!fJIillbrinm between the cell's P\!ed fur oxygen :md the body"s tnabOity lO provide thut cellular o'ygen. l'he bodys response to 'Shock U!>.uaUy tK;CUrS' in sitlgcs. Thcs~ sltlgcs arc iult1al, cotu~uwtc~ry. pmgrt!Uih'l'- and ~fnciory. The cllology bf o;h~,ck Cllfl be elnsstfied In thn.-eattcgonos with one cu:tcgory hDving thttc scpAratc.!l.ttb<:nlegorics. 1 he three main catts(lrics arc hypovolemic. c.rdiocenic Mud dbtribuHvc t hock. Dlstribtniv~ shock can he fu.rth'-'1 delinc:a1cd M !it:ptic. ncurogcmc and anaphylactlc ~hock.

The tagcs nr shock:

Initial tlngt': here lhe curdiac output i:s- seen to dccK-asc-, CIIU.!Iing an iml,airouml of the tis$U e perfU-

sion, This acliou 11 ip:~ Ote ~llto c:onver4 because- or la.c~ of suffick'lll o>:_ygcn, from aerobic to anaer~
bic mctaboJism. The mechunism l}f unsm)hil: metabolism c:nnS<."S ~t sudden i:tlcrcas.e ib waste products ~lied lactic ~cid lhat jlJrtJ.I tt injure~ lh*" c:ell~:wllich o:tuse!l further cell d<..~th in-n cyetic:ll f3s.l.lion. Aller tht body cnu:rs: lhe initial al;~gc:, if tho prOblem is 11ut ~uiv!!d tlun tihook will progress 10 rhc compcnsa~ tory stage.. Cumpc:matory s-tag~; where. the- body tries to CO!l1)')~:tlS.bU: lOt th.t lack of equUibnum. tn th'$ stasc Ote body will aller ills ht.'modymunic fun~linnli to compcnsale for poo,. tissue perflt:>ion. 'The heurt-nuu Will increase, d1e ve:s~ls of lhe body wiU b'-''g_ln constricting and the body \ViU be-gill 1 0 retm sodiUm and water. Addirionully as fhe stt1ge VfO!tl't'ISSC!i 1h1.' blood glucose levels will begib to rise and tJte ~ pifll.tory rate w!U iucr~asc (hypcn~nfi/tJiioll) in an l!Ucm,pt to blow ofr the cnt<:ts of lootlc acfdo!lh. which oc(!Ufl'red in the inhl;:al st-a.ge whcu lhe budy ;;witcMd over from !lcrobltlO :m-ntrrobic metubotism.. These changes se1 ihe ~Lage for the progre~ivr stage. Prugrc."i~lvc. stage: dmrl!cterizcd by the be!l)Jwih~ of Ciiilu:n: or the-compen-satory ~1~gc to bring 1hc body lMtck lu ~uilibriu1u. 1 h~ failure nf the comPf>USatory $l&c- signals- !he bcginni11g or the shock ~yt'lc. beiug perpetuated, Basicully, the cycle bc.-p;in!i 10 sclfpeTl)'tl\late a down..v.utd .spinll whit;h oftn enJ 1.0 death. Ouri11,g this stage lhc cells e~ f\mt:tioning on t!nat-robJc metabolism which is cau.o;ins: a.buildu.p I~~.ttl& 3CJd, AMerobic: JUt:lilboilsm dOt."!!. no-t prodUCe' enough encrg} to SUS:laih CtiiWJU-life dnd ctlB begin to die. R(tfr::u..tory rtag~: where Ihe patient will reach a point of 1~0 retum. Th;s p(,nnt l5 wbe.n: no hl!roit:; mca.sures win .s~:wc: thC' patient. 1'hi!l i~ because every organ oeed:~ ru. basic building bt~lt. lha C4.!ll, to survive. if file ccllli ofM urgu.n die- then the organ dies. Onceone oftb..: O'rgdiru. di~ tbenod1crJC wiU follqv; suit P.Od nwhiple oe-gan tl:liture will occur cndins 1n d~tn.

or

(MICROBIOLOGY I PATHOLOGY

Hemody Dys)

(
Cardiogenic Neurogenic Hypovolemic

is the most common type of shock.

259
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(MICROBIOLOGY I PATHOLOGY

The standard prophylactic regimen for a nonallergic patient Is:

Adults : 2.0 grams Amoxicillin one hour before procedure Adults: 2.0 grams Penicillin Vk one hour before procedure Children: 100 mg I kg Amoxicillin one hour before procedure Children: I 00 mg I kg Penicillin Vk one hour before procedure

210 Cop,Ti,hl 0 2009-2010 OtmaJ ()c(!b

Tbt: stages of shock rcfleeta process. Tbc 1ypc.s ofshock rdc:r to different initial mechanisms of 111:1ion tlt&l lrip those stages. The three msin categories are hypovolemic, cardiogtnic and distt1butive shock, Distributive shock ean be-further delineated as scpric, Ot"UI'Qgcni e. ~tnd anaphylactic shock. ITypD\'Oiemic Jllctck is the most common type- of shock. It occurs frqm a lack or suffieiem Ouid in the intravascular :;pace. 1"hc etiology of this is thatlhe llypovulemic shod can occur one oftwo ways.. fhe firs t way Is an extemnJ loss of body lluid such aJt blood or plasma. An arterial l<lcmtion that Is bOt stopped or df)CS not .stop on its own. A.noctn~r form ur hypovolemic shock 1s when Ouid in the body is moved to an Area where il is nOIUSt:d )'llch as wbatls called ''third., spacing. An ex.nmple of extrucdlular Ouid loss ili severe sodium deficiency. ......Tbe pathOphysinlogy ofhypO\'Qiemic shock IS tha\ when nard volwne goes down 11 dec.n:ase In the circulating volume of blood is seen. When the circulating v-olume of blood oecu:rs d!e preload ~o 1t'!c hean Is dec.reascd. A decrease in prtload c-auses a decrease in stroke ''ol~ ume whic-h causes o dttrtast in tbe cardiac Qat-put~ With ceduc-ed e~rdlac output decreased cellular oxygen perfusion will occur. Whco ctlls do om receive c.moush oxygen they die. Cardlogtnk Jlbotk is when:- the hean is unable to pump forWArd ll1e tunount of blood in one stro);c to suppon life. This can occur for several rea!lon:s. The e1iolc>gy of cardiogeu.ic shock is shown 10 be onetlf scvc:ml problems. t.h~ ultimately affect cardlac.ourput. 1l1ese examples include isc-hemia of the loft ..,.entriclc, strocruraJ probll!tm, IUld dys:thythmias. Anything that hiadcrs the now of blood out of U!e htarl can cause c.a.rdioget~ic shock. When blood flow om ofttle heart is decteasod, there will ben &.-crt."8Sc in oxyge-n milabilicy to the cells. Thfs- decrease in oxygen available to the ccll will cause cbo cells to S\Yhcb O \'Cr to anaerobtC- meaabolism. aud the whole cyd~ of shock is started. ~ Distributive thock is a C(lnditiun where the. flow of blood is nm evenly distribulcd. If is acmalty an umbrella for throe o'ber fonns- of shock. They are septic, anaphylactic and neurogenic shock. - Anaphyl11dic shuck is when the body's aatibodyanligen response i !i triggered by something the person is aUerglc: to, - Nturuge.nic .shork il> eau..~ed b)' the= suppressi.on or outright loss ofsyrnpat11etic. tune. It is-lhe rarest form of shock. The ctioli)gy is illlytbing whicb c.awse!l any di!>ruptlon of the sympathetic nervous system. Some: examples of 4his arc spinal injury, spinal anesthtsia, drugs 1md emotional stress Sepsis is the iuvasion urthe body by bacteria which t"<tus.es an immune response. The resulting filllout is Lhat tiss-ue periuslon Is impaired and the cycle of shock ls begun onct: again at the cellular lc:v~l. The-: dassic example of -St-ptic shock lsTSS or to,x.~c shock syndrome wlJicb is an invasion of the body by ll toxin prodUcing gram.posilive bacreri.o..

Adulh: 2.U }!rams Anunil'itlin Ulll' hmn heron prucedurr The standard prophylactic regimen for a nonallergic patient is: AmoxiciUin - Adults: 2.0 g orally l hour prior to appointmont - Children: 50 mg I kg orally 1 hour prior to appointment
Allergy to nmoxicillin: use Clindamycin, Cephalexin. or Azithromycin a.~ follows: Clindamycln - Adults: 600 mg orally I hour prio r to appointment - Children: 20 mg I kg orally 1 hour prior to appointment Cephalexin -Adults: 2.0 g orally I hour prior to appointment Children: 50 mg I kg orally 1 hour prior to appointment Azitbromyciu - Adults: 500 mg orally 1 hour prior to appoin~nent - C hildren: 15 mg I kg orally 1 hour prior to appointment

*** Azithromycin can also be used lo treat a periapical absce.'s in u patient who has a
history of hypersensitivity to penicillin.

(MICROBIOLOGY I PATHOLOGY

Which of the following conditions may predispose a pallent to candidiasis?

Honnonal disorder Coronary condition Immune deficiency disorder Chronic respiratory condition

281

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(MICROBIOLOGY I PATHOLOGY

The only drug that a patient can take Is clindamycin, so the patient ntust be Instructed to notll'y the dental office if be I she:

Develops a hearing problem Has 5 or more watery stools per day Has trouble sleeping Develops headaches

282 Cop)<riclMO 20092010 Dental Ded:i

Candidiasis is an infection, usually of the oral CA~\ity or vagina. with a candida species, usually C. alb leans, which causes an inflammatory, pruritic infection . Deficiencies in the immune system (either pathologic or therOJH!tttic) allow opportunistic organisms (e.g., Candida albicans) to proliferate. It is common, especially in patients who have a deficiency in T-lymphocytes, or who are receiving chemotherapy, and in immunosuppressed individunls (AfDS patients). This yeast-like fungi is a normal inhabitant of the oral cavity and vaginal tract; however, its growth is normally competitively inhibited by the indigenous bacteria of these areas. Remember: Nystatin and clotrimazole are the two antifungals that arc used as "swish and swallow" to treat oral candida infections. Nystatin (Mycostatin) is taken as an oral suspension to be swished around the mouth and swallowed. Clotrimazole (Mycelex) is taken as a trOChe (lozenge) which is slowly dissolved in the mouth and swallowed. They work by binding to sterols in the fungal cell membrane, increasing permeability and pennitting the leakage of intracellular CQmponents. This leads to the death of the affected fungal cell.
Note

- , I. A vaginal candidiasis infection can produce a thick, wl:tite discharge. 2. Angular cheilitis (bilaJeral ulcers otthe corner of the mouth) has been

linked to C. Albicans.

' u m m .tr'\ . of l m p ..rt ~nt \ r111hlu hL'

Dnoa
Pn~kiDint:

Aolikdaial Atdoe

AodbN'fMal \1fdaaobal lmpoi'IUt Achtnt Effa

lnhibicsceU ..-.II syulbooj!

Bllft<ricid>l

H)-penc~U!I1\"Ity

Pc:ruclllm VK

Amcu..xallm AtnOltl(ilhniCiawl.nMe
(AugnwuJ")

Ampieitlin
CtpbalosPQrint:
Inhibit$

oen w:Lil.synth~IJ

Bu.c1encidaJ

ll)'pt:r!l~ntllivhy

Cepb;alcx10 (Kcj1ex) Cef>ctO< (Crt/0') Oth.tr: Clindafi))'C1n

~tauvlidn:

..........,)..,. (1../'oiQ
au;tJrom)'C'Ift {Bilttflf)

,.........

tntulnts SOS nbosoma

~.-.

8Ae~il:

P-->>os
"\one sipfK*!C

Bactic:tatic:

Glltypcncti>'ll'
GI~1Yil)'

El)1hromyeon
Tetnt)'elln~:

lnbibi"ts 305 ribosomcti

OX1tric.'lQttic
Supc:"nof~1ons

T euacycline Oox)cyc:hnc (Vibnllfl)'<'/11)

None Sgf\lfic:nnt

(o..tioocycllne (M(IIQCJ,,)
Anllnogl)'(lldet:
S~ttptornycm

Not)e Signlficrmt
lnbibils 30S ri~

611C(OW1d3.l

Ototoxicil)', NcptnQtO~icic,y

CcDlam)'t1n
~lbllaDftiVJ!

Ciprolloutm (C,ol
Baci~n<m

llhibits. ON,\ tl\biba..oli'O..U..,..._.ts

Cblot ipllai!COI

t,.,,,.. !OS~

-Banmcodal Ban<ri<idol

, _ _II<

0-d"~-

~CROBIOLOGY I PATHOLOGY
Which of tbe following antibiotics Is considered a broad-spectrum anllblollc?

Penicillin VK Cefaclor (Ceclor) Penicillin G

283

Copyrigbt O 20091010 Otn.tal Detb

(MICROBIOLOGY I PATHOLOGY

Tbe penicillins act to:

Weaken the bacterial cell wall to !he point that the cell dies when it ruptures Inhibit protein synthesis and suppress bacterial growth Disrupt bacterial protein synthesis des1roying the bacterial cell Disrupt specific biochemical reactions destroying the cell

{ cf:.tdur (( ec lm)

Cefaclor is a member of the cephalosporin family of antibiotics. The cephalosporins behave like penicillin in fighting bacteria. They are bactericidal antibiotics and act like the penicillins in that they affect the bacterial cell wall during cell division such that closure does not occur. Bacteria eventually lyse, resulting in death of the cell. Cephalosporins act against a wide range of gram-positive and gram-negative bacteria. Currently there are four generations of cephalosporins. Progression from first through the fourth generation is associated with a broadening of action against more gram-negative bacteria and a decreased activity against gram-positive bacteria. Important cephalosporins within each generation: First: cephalexin (Kef/ex), cephradinc (Velosej), cefadroxil (Duricej), cefazolin (Ancej) Second: cefaclor (Ceclor). cefuroxime (Cejlin), cefoxitin (.\1/efoxin) Third: cefixime (Suprru:), cefoperazooe (Cefobid) Fourth: cefepime (Maxipime) Important: Approximately 10% of indi,iduals expressing allergy to the penicillin family of antibiotics will have cross allergenicity to the cephalosporins.

\\c~tk.cn

the hach:ri:.tl

ct~ll \\:til

to lhc point thai the Cl'll dils \\hen it ruptures

Basic mechanisms of actions of antibiotics: Agents affecting bacterial cell wall: -Penicillin family - Cephalosporin family Agents affecting bacterial DNA: - Quinolooe family (i.e. ciprojloxacill) - Metronidazole (Fiagyl) Agents affecting bacterial protein synthesis: -Tetracycline fatni ly -Erythromycin family - Clindamycin - Chloramphenicol Agents interfering with bacterial metabolic pathways: - Sulfonamide-~ (sulfa dmgs)

(MICROBIOLOGY I PATHOLOGY

Which two antibiotics are usually prescribed in the treatment of rickettsial diseases?

Tetracycline Polymixin B Erythromycin Chloramphenicol

265 Cop)'ti&ll1 C 20092010 Dental [}red:$

neRO BIOLOGY I PATHOLOGY

Which penicillin is prescribed primarily in the treatment of severe penicillinase-producing staphylococcal infections?

Methicillin Ampicillin Penicillin VK Carbenicillin

266
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lll n1c~ clinl Chlnr:tmphlnkol

1'he rickettsia are small, gram-negative, aerobic, coccobacillary bacteria that are obUgate intracellular parasites. They contain botb RNA and DNA, while viruses contain either RNA or DNA. Human rickensial infection results from insect bites. n1e human target cell for all rickettsiae is the endothelial cell of caplllaries and oU1er small blood vessels. Human rickettsial infections present as systemic symptoms of headache, myalgias, and fewr, follo,~ed by a rash. They are traditionally divided into two groups as seen below.
Diseases
Spott~d-Fcvcr

Tr ansmission Ticks Ticks Ticks Ticks Mites Lice Fleas Mites Inhalation

Gr oup: Rocky Mountain spotted fever Queensland tick fever Bouronncusc fever, Kenya tick fever Siberian tick fever Rickensialpox

l)'Phus Group: Louse-bontc typhus (epidemic typh~ts) Murine typhus (endemic typhus) Scrub typhus Qfever

\lcthicillin Methicillin is not frequently used because of the incidence of interstitial nephritis and the availability of equally efficacious alternatives (nafrillin and oxacillin). It is given througb rv in severe penicillinase-producing staphylococcal infections .. Remember: Penicillinase is produced by certain bacteria (e.g.. some , <trains ofsrapltylococci) that render penicillin inactive. It degrades rhe beta-lactam ring structure of penicillin. Structural modification of penicillin G (for example. merhicil/in), cau render the molecule resistant to penicillinases, but may also narrow the spectrum of action, limiting tbe primary use of such antibiotics to the treatment of infections caused by Staphylococcus species. Other penicillinase-resistant penicillins include clo~acil lin, dicloxacillin, nafcillin, oxacillin, amoxicill in I c lavulonate potassium (Augmentin), ampicillin I sulbactin {Unasyn), piperacillin I tazobactam (ZoS)II), and ticarcillin I clavulouate potassium (Timentilt}.
L Methici llin-resistant Staph. aureus (MRSA) is a group of resistant Staph.

Not"' bacteria that can be life-threatening. These bacteria are resistant to all the peni-

cillinase-resistant penicillins and cephalosporins. Such strains are usually resistant as well to aminoglycosides. tetracyclines, erythromycins, and clindamycin. In the past, vancomycin has been used against MRSA. However, microorganisms resistant to vancomycin have been reported and its use bas been curtailed. 2. Penicillin will work only on growing cells that contain peptidoglycan in their cell wall. This is why penicillin shows its greatest bactericidal activity ~gainst growing gram-positive bacteria (Tiley have a thick peptidoglyca11 or mrrrein layer itt their eel/wall.). Remember: Penicillin inhibits the terminal step in peptidoglycan synthesis.

neRO BIOLOGY I PATHOLOGY

Which antibiotic is not only effective against most staphylococci, aerobic and anaerobic streptococci, but is most effective in treating infections due to bacteroides species?

Penicillin VK

Erythromycin
Tetracycline

Cephaicxin (Kejlo:)
Cliodamycin

217
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Which of the following is classined as an antifungal agent?

Bacitracin

Amphotericin-a Polymyxin-B Neomycin

c.,.,.., 0

218 2009-2010 , , . , Dc<b

lind:un~ l'in

Clindrunycin binds to the 50S ribosomal subunit, blocking bacterial protein synUtesis. Its use is restricted by irs side effects such as severe diarrhea and pseudomembranous colitis. These side effects are caused by the overgrowth of the bactcriwn known as Clostridium difficile. Clindamycin is bacteriostatic and is active against most gram-positive and many anaerobic organisms, including the anaerobic gram-negative bacteria Bacter oides fragilis . .In dentistry, clindamycin is an al ternate antibio tic in the following situations: When amoxicillin cannot be used for the standard regimen for prevention of bacterial endocarditis in patients undergoing dental procedures. For treatment of common oral-facial infections caused by aerobic grampositive cocci and susceptible anaerobes. For prophylaxis for dental patients with total joint replacement. Important: Clindamycin can be given to patients allergic to penicillins since there is

no cross aUergeoicity.

\ mphuh.ril'in-B

This is an antifungal agent given intravenously or orally for the treatment of severe systemic fungaJ infections caused by fungi such as Candida species. Bacitn'lcin, polymyxin-B and neomycin are antibiotics. Antibiotics in general do noi have antifungal properties. Amphotericin B and Nystatin are polyene antibiotics which impair ergosterol synthesis. Ergosterol is the major sterol of nmgal membranes.
Sumtll.lr\ u( Smm \nttl un:,:.ll \:,:enh

Topical Agents (dluol\'t. & swallo'l'l')

Cl(ll.f'truawlt
(l>.fyco/e:>.'t'rO<Ihe) Xy&hltin

lite
Oropharyngeal Cat~didiasis
} Oral Caviry Candidiasis

Mectumh:m (In

f(lrm

Fungl Ctll
Allm<:eU

~mm'bratlt

"""'"'

()ra) suspen$ion

(Afyoostatifl)

'fopi< Agtnb (a-tam I ointmc:ot)

Antpbo(t-rki.nR B (Funghone)
Ktt~on!WIIe

c....m

(N'Wa/) 1'\)'3-lttlio (Mycostailn)

$ystemlt:A{(t-ntll
t"' ucon~olt

CutatlOOUs" & Muc;;u tanoous Candidiasis

} }

AJtccscell

n-.embrnne

er..m

c....m
TableiS
Alttl'SCC11
n~tnbr.me

(Dif7ucan) Kttl)ton_ a:z.ole(Na.r.Q

AmpltOteritln8

} Oro!, EsophagW, Ompharyr~ge31

Candidi:M;is

Tablets

(FuJtgizum:)

Sy$temic Ctndtda

JV injection

Important: Antifungal drugs affect cell membrane permeability, causing leakage of cellular con stituents. whic h leads to the death of the affected cells.

l'iote. ly. ' Systcmtc amphotcncm .. B ts assocmted w1th a lugh mc1dencc ofktdncy COxiCJ

(MICROBIOLOGY I PATHOLOGY

Oral Cav)

I' All of the following bacteria may b e etiologically related to dental carle; ' \ \.. EXCEPT one. Which one is the EXCEPTION ? }

Streptococcus mutans Actinomyces viscosus Actinobacillus actinomycetemcomitans (AA) Streptococcus sal ivarius Streptococcus sanguis Actinomyces naeslundii
Actinomyces israeli

Lactobaci llus casei

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( \..

Which of the following has been shown to be the most effective antimicrobial agent for reducing plaque and gingivitis long-term?

Stannous fluoride Phenolic compounds Chlorhcxidine Quaternary ammonium compounds

270 CoPYJ'i&btCI 2009-2010 Dental Dcdq

Aclinoh;trillus

aclinnm~

ct.h.rncumiloiOs ( I IJ

u Streptococcus mutans is the primary etiologic agent initiating dental caries.

The bacteria that initiate caries must have the ability to produce extracellular insoluble glucan s. Dextrans and mutans are types of glucans (/hey are both polymers of glucose) . These are produced by Streptococcus s anguis, mutaus, sa livarius, and Lactobacillus species. Lcvans (fruclans) are polymers of fructose and are produced by Streptococcus s alivarius, mutans, and sanguis as well as Lactobacillus easel and acidopbilus. Actinobacillus species are gram-negative coccobacillary rods. Actinobacillus acdnomycetemcomitans {AA) is found as part of the normal flora in the upper respiratory tract. It is a rare opportunistic pathogen, causing endocarditis on damaged heart valves and sepsis. Important: AA is most commonly implicated with the etiology of the localized aggressive (juvenile) periodontitis and periodontitis in juvenile diabetes.
~ I. Actinomyces viscosus and naeslundii cause root-surface caries. ' Notes 2. Dextrans, mutans, and !evans are synthesized from dietary sucrose by cariogenic and plaque bacteria primarily as extracellula r polysaccharides.

( 'h lurhl'\itlhu.

Its effectiveness may be explained by the fact that it leaves the greatest residual conce ntration in the mouth after its use. It is rapidly absorbed onto the teeth and the pell icle; and it is slowly released. It is approved by the ADA as an antimicrobial and antigingivitis agent. Examples include Peridex and PerioGard- The most common side effect of chlorhexi<line is temporary. superficial staining of oral structures. Other topical an timicrobial agents: Stan nous fluoride: antimicrobial action appears to be related to the stannous (tin) ion rather than to the fluoride ion. It is available in gel form (e.g.. Stop, GeiKam). Tbe ADA accepts stannous fluoride for anticaries activity but not for antiplaque or antigiogivitis purposes. Phenolic comp ounds: approved by ADA as an antimicrobial and antigingivitis agent. Example is Listerine. Quaternary ammonium compounds: not as effective as others in reducing plaque or gingivitis, seems to be best at eliminating bad breath {halitosis). Examples include Scope and Cepacol.

(MICROBIOLOGY I PATHOLOGY

Oral Cav )

Which species has been implicated In the dental caries process'/

Staphylococcus Bacteroides Escherichia coli Streptococcus

271 Ccp)Tigbl 0 201-1010 Denial Ok$

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(
\..
Saliva Calculus

The principal oral site for the growth of spirochetes,

fusobacter ia, and other gram-negative anaerobes is:

The gingival margin The gingival sulcus

m
Copyn.Jbl 0
~20 I 0

Dtntal Oc!rtks

Stn:plucuccu\

Specifically, S. Mutans, S. Sanguis (which is the most frequently Isolated Streptococcus in the oral cavity), and S. Salharius. These bacteria produce dex.ttan sucrase (also called glucosyllransferase). which catalyzes the formation of extracellular glucans from dietary sucrose. Glucan production contributes to the formation of dental plaque. This dental plaque holds the lactic add which is produced by these Streptococci against the tooth. This acid dissolves the hydroxyapatite crystals which fonn the enamel of the tooth, creating caries. Note: The major cariogenic property of S. mutans appears to be its ability to produce the enzyme glucosyltransferase. Streptococci have these essential properties necessary for caries formation: They adhere to tooth surface (cQionlze on tooth swface). They produce lactic acid, which will dissolve tbe enamel of the tooth. They produce a polymeric substance (from tire metabolism of carbohydrates), which causes the acid to remain in contact with the tooth. Remember: Prerequisites for the development of caries: I. Cariogenic bacteria 2. Susceptible host 3. Supply of substrate for lactic acid production

*** The gingival sulcus is an area of s tagnation and

bacterial proliferation. Factors that contribute to this are I) an increase in crevicular (gingival) fluid. 2) desquamation of epithelial cells, and 3) bacterial acid products. The normal healthy mouth consists mainly of obligate and facultative anaerobu, and aeidogenlc bacteria. It is essentially these some bacteria which are found in the normal healthy gingival sulcus that become opportunistic and influence the course of periodontal disease. Important: Streptococci found in dental plaque: S. Sanguis (produces hydrogen peroxide) } Predominantly S. Mutans (it i< aciduric and produces lactic acid) S. Salivarius (it is found consfslently In saliva and 011 oral soft tissue) S. Mitis (produces hydrogen peroxide) I. Lactobacillus casei is also acidogenlc (produces lactic acid). INottt 2. Remember: Streptoco<:ci are gram-positive cocci tl:tat are facultative nnncr obes and are the most numerous group of bacteria in the oral cavity.

(MICROBIOLOGY I PATHOLOGY

Oral Cav)

\..

All of the following s tatements concerning bacterial plaque a re t rue EXCEPT one. Which on e is the EXCEPTION?

It is the key etiologic agent in the initiation of gingivitis and periodontal disease

It is an accumulation of a mixed bacterial community in a dextran matrix

It forms on a cleaned tooth within minutes It is composed of solids (80%; 95% of which are bacteria) and water (20%)

There are two categories: supragingival and subgingival plaque Different bacteria may be found in plaque (cocci. rods. and filaments). and their proportions change with time, diet, and location
273

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(
Gram-positive cocci Gram-positive rods Gram-negative rods Filaments

Young plaque i5 dominated by:

27<
CopynlfltO 20092<110 Dental Drcb

 This is falst; it is composed of water (80%) and solids (ZO%: 95% of which are bocteria). Stages In plaqu e formation: I. Formation of the pellicle (acquired pellicle): The pellicle is a surface coatin g of sallvary origin, which Is primarily protein In nalure, with some carbohydrate complexes. It is essentially Slructureless and baclcria-frcc. It will form on a clean tooth surface wilbin a maner of minules because of ils sali vary origin. II also will form on crowns, dentures, porcelain teeth. etc. 2. Bacterial colonization: The bacteria are deposited upon the pellicle in a somewhat orderly fashion. The first group to appear on the surface of the acquired pellicle is streptococci (grom-po.irhe cocci). They colonize in tremendously large numbers. Following establishment of 1he coccal forms of bacteria, rod-shaped microorganisms (Bacteroides and Fusobacterium) auach to and colonize tbe tooth surfaces. As lhe plaque matures, 1he baclerial morphology shifts 10 include filamentous lyJles (Actinomyces). 3. Ma turallon s lage: Sativa continues to provide agglutinating subslanccs and other proleins 10 the intercellular rnalrix, and bacterial intercellular adhesion results. The crystalline structure will increase and eventually calcfy (calclllus).

*** Streptococcus sanguis is usually one of the first colonizers of plaque.

Dental plaque is tbe key etiologic agen t in the initiation of gingivitis and periodontal dis=e. II is an accumulation of a mixed baclcrial community in a dextran malrix. Young p laque is composed of: Gram-positive cocci (40-50%): Streptococcus spceics Gram-positive rods (10-40%): Lactobacillus species Gram-negative rods (J0- 15%}t Fusobacterium species Filamenls (4% or less): Actinomyces and Vclllonella species As plaque ages: The composilion changes: SO% gram-positive and 30% gram-negative The number of cocci decreases and the number of filaments increases The number of aerobit bacteria decresses and the number of a naerobic bacteria Increases due to reduced oxygen tension (decrease in aailoble oxygen) because of its consumption by the early grom-posilive colonizers

EncROBIOLOGY I PATHOLOGY

Oral Cav)

r
I
\..

All or the following statements concerning calculus arc true EXCEPT one. Which one Is the EXCEPTION?

It is calcified or mineralized bacterial plaque

It forms on natural teeth, dentures, and other dental prostheses

The surface is very rough and is covered by a layer of bacterial plaque Inorganic material makes up about 10-15% of the composition while organic material and water make up about 70-90% of the composition Its main role in periodontal disease is to serve as a collection site for more bacteria

275
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neRO BIOLOGY I PATHOLOGY

Oral Cav)

I r Which of the following s tatements are tru e concerning supraglngival and')

\.. subgingival plaque EXCEPT one. Which one is the EXCEPTION?
~

Subgingival plaque can be attached or loosely adherent {epithelium associated) Supragingival plaque is attached or tooth associated Subgingival plaque is dominated by gram-negative rods Supragingival plaque is dominated by gram-positive cocci Supragingivai plaque bas more anaerobes than subgingival plaque

276 Copyripa 0 l009l:OI 0 Otlbl 01:

lnoq~o111ic

matlrial makes up about I0-15';o ol thl cumpositiun nhile nreani

matlrial and \\ahr nwkl' up ahout 70-90/o nr the l'OniJ10Sition

This is false; inorganic material makes up about 7090% of the composition wbile organic material and water make up the remainder of the composition. Three phases of the formation of calculus: I. Pellicle formation: it begins to form within minutes. 2. Plaque maturation: microorganisms grow together ro form a cohesive plaque layer. 3 ..Mineralization of the plaque: both supra and ~ubgingivally. The average time for this whole process to take place is 12 days. Inorganic components of calculus (70-90%): calcium and phosphates with small amounts of magnesium and carbonate {these are derived almosr entirely from saliva). Hydroxyapatite and fluoride are also present. Organic components of calculus: microorganisms (same as plaque), desquamated epithelial ceUs, leukocytes, and mucin.
---. I. CaJculus is mineralized plaque. It is formed by bathing the plaque in a / Note$ bigbly concentrated solution of calcium and phosphorus (i.e., saliva). 2. Subgi ngival calculus is dark due to pigments from blood breakdown,

Supra~in:,!,hlll

phHfUC ha' mnrc

~lll<tcroh{'s

than

suhgin~hal

plaque

*** Tltis is false; subgingival plaque bas more anaerobes than supragingival plaque
Supragingival plaque: saliva and diet alter bacterial composition: Is attached or tooth associated Consists primarily of gram-positive facultative anaerobic cocci Streptococcus sanguis, Actinomyces viscosus, and naeslundii predominate. As this plaque ages, vibrios, spirochetes, and gram-negative bacteria predominate Supragiogival platrue: saliva and diet alter bacterial composition: Can be attached or loosely adherent (epithelium associated) As pockets form, gram-negative anaerobic rods tend to prevail Bacteria found includes Actinomyces species, Fusobacterium nucleatum, Treponema species {spirochetes). and Veillonella
~

I. Important: The progression from a healthy gingival sulcus to gingivitis is l'lotd associated with a shift towards gram-negati,e anaerobic rods. 2. In creased bacterial plaque= Increased gingival inflammation 3. Decreased bacterial plaque= decreased gingival inflammation

(MICROBIOLOGY I PATHOLOGY

Oral Cav)

Which one of the following organisms is commonly implicated with the etiology or acute necrotizing ulcerative gingivitis?

Streptococcus sanguis Actinomyces israelii Prevotella intermedia Streptococcus uberis

277
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Ic)

( \..

Quaternary ammonium compounds, which arc widely used for skin antisepsis, are classified as:

Nonionic detergents
Anionic detergents

Cationic detergents

278
Copyright 0 10W2010 Deotal Decks

ANUG is a condition which presents rather pathognomonic (characteris tic of a si11gle disease) clinical signs and symptoms. The two mo5t important clinical signs are: I. Interproximal necrosis and pseudomembrane formati on on marginal tissues. 2. History of soreness (pain) and bleeding gurus caused by eating and brushing. Other signs and symptoms include a fetor oris (offensive od01), a low-grade fever, lymphadenopathy, and malaise. Note: The dominant WBC noted in the inflammatory infiltrate of ANUG is the neutrophil. ANUG occurs most often io adu lts between the ages of 18-30. Factors which seem to predispose someone to ANUG include a history of gingivitis, tobacco smoking, gross neglect (poor oral hygiene), fatigue, and stress. The following bacteria are associated with ANUG: Intermediate-sized spirochetes PrevoteUa intermedia Fusobacterium species Selenomonas species Remember: According to the American Association of Periodontics (AAP), ANUG is now correctly referenced simply as "Necrotizing Ulcerative Gingivitis" without the '' acure" qualifier. The National Boards may or may nor reflect this change.

Detergents are "surface-active'' agents composed of a long-chain, lipid-soluble, hydrophobic ponion and a polar hydrophilic group, which can be a cation, an anion, or a nonionic group. These surfactants interact with the lipid in tbe cell membrane (through their lrydrophobic chain) with the surrounding water through their polar group and thus disrupt the membrane. Quaternary ammonium compounds (e.g.. benz alkonium chloride) arc cationic detergents. They are used as disinfectants and antiseptics. Gram-positive bacteria arc the most susceptible to destmction. These compounds are not sporicidal, ruberculocidal, or viricidal and are inactivated by anionic detergents (soaps and tire iron in lrard water). Anionic surface-acting substances include synthetic anionic detergents and soaps. These substances alter the nature of interfaces to lower surface tension and increase cleaning. Their primary value appears to be their ability to remove microorganisms mechanically frorn tin~ skin surface.
-~ I. Nooionlc chemicals do not possess any antimicrobial properties. Note! 2. Disinfection destroys all tbe microorganisms in a certain envitomncnt except for spores. Therefore, objects that have been disinfected may still transmit a pathogenic microorganism. Sterilization, bowever, is the complete elimination of aU organisms including spores.

(MICROBIOLOGY I PATHOLOGY

c)
~

Which of the following is a powerful oxidizing agent that Inactivates bacteria a nd most viruses by oxidizing free sulfhyd ryl groups?

Alcohol Chlorine Formaldehyde Phenol

278 Copyright C> 20092010 Dental Ded:s

(MICROBIOLOGY I PATHOLOGY

IC)

(\..
I hour

How long does it take to kill bacterial spores when a dental Instrument is placed in a 2% solution of glutaraldehyde?

10 minutes

IOhours 24 hours

Chlnrinc

Chlorine is the active component of hypochJorite (bleach), which is used as a disinfectant. Disinfectants are antimicrobial agents that kill (gemticide) or prevent the growth (microbiostatic) of pathogenic microorganisms. Disinfectants are not considered safe for usc on living tissue (as opposed to antiseptics which are) and are applied only to inanimate objects (counter tops, light handles, headrestS, etc.).

I. Phenol was the original disinfectant used in hospitals, but is rarely used as a disinfectant today because i.t is too caustic. 2. Formaldehyde (37% solution in water = Formalin) denatures protein and nucleic acids. 3. Concentration and contact time are critical factors that determine the effectiveness of an antimicrobial agent against a particular microorganism. Any or aU of the three major portions of microbial cells can be affected: the ceU membrane, cytoplasmic contents (particularly enzymes), and nuclear material.

10 huun

2% glutaraldehyde is an alkalizing agent highly lethal to essentially all microorganisms if sufficient contact time (10 hours) is provided with an absence of extraneous organic material. Note: Alcohols, chlorhexidine, and quaternary ammonium compounds are disinfectants. Advantages of glutaraldehydes: Most potent category of chemical germicide Capable of killing spores (after 10 hours) EPA registered as an immersion sterilant Can be used on heat sensitive materials Disadvantages of glutaraldehydcs: Long period required for sterilization AJJergcnic Not an environmental disinfectant Extremely toxic to tissues R emember: In hospitals, glutaraldehydes are used to sterilize respiratory therapy equipment.

(MICROBIOLOGY I PATHOLOGY

c)

The proper time and temperature for autoclaving is:

350"F (1 nq for I hour 250"F (J21C} for 15-20 minutes 450"F (232C) for 5 minutes 89"F (3 1q for 30 minutes

231 CopyrigbtO 2009-2010 Ocntal OkJ

(MICROBIOLOGY I PATHOLOGY

1c)

The proper time and temperature for dry heat s terilization is:

320F (160"C) for 2 hours 250F (1 21C) for 20-30 minutes 450F {232"C) for 5 minutes 89F (31C) for 30 minutes

232

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Z~II'T

(/J/"CJ for

l~-20

minutt'

***These conditions will yield IS lbs. pressure of steam per square inch. Moist heat destroys bacteria by denaturation of the high protein..:ontaining bacteria. The autoclave provides sterilization when used at 2SOf for 15-20 minutes because it applies the heat under pressure, which greatly speeds up the denaturation process when compared with boiling water. Usually only ten minutes is required to destroy all of the bacteria, but the increased time is allowed for penetration when the instruments are wrapped in thick towels.

I. The effectiveness of autoclaving is best determined by culturing bacterial spores. 2. Spore testing of autoclave units is recommended weekly. 3. PredeanJng is the most important step in instrument sterilization. Debris acts as a barrier to the sterilant and sterilization process. 4. Ultrasonic instrument cleaning is the safest and most efficacious method of precleaning.

J.2W'I (/60 () fnr 2

huuror~

Note: 3400F (JJOC) for I hour is also effective. Items which are usually sterilized by dry heat can be autoclaved. They should be removed immediately after cycle to diminish the possibility of corrosion of the instruments and dulling of sharp points or edges (carbon steel instruments). Dry heat destroys microorganisms by causing coagulation of proteins. Advantages of dry beat: Effective and safe for sterilization of metal instruments Does not dull or corrode instruments Disadvantages of dry beat: Long cycle Poor penetration Will ruin beat-sensitive materials

Important: Instruments must be dry before both dry heat steritizauon and ethylene oxide sterilization. Water will interfere with tbe sterilization process.

(MICROBIOLOGY I PATHOLOGY

c)

Which type of pathogen provides !be ultimate test for efficacy of sterilization?

Bacteria Spore-fonning

Vrruses
Fungi

213 CosJ>-riJht 0 20092010 DcmaJ Ottl:l

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c)
}

{ An of the following statements concerning ethylene oxide sterilization ar:'\

\.. true EXCEPT one- Which one Is the EXCEPTION?

It is used extensively in hospitals for the sterilization of beat-labile materials such

as surgical instruments and plastics

It kills by alkylating both proteins and nucleic acids

It is a fast process (20-50 minutes) depending on the material to be sterilized It is very toxic to humans and is also flammable

2..
CopyriJ}It 0 200920 10 Dmcal DecO

Spm l'~rormin~

Because bacterial spores are resistant to boiling (JOO"C at sea level), they must be exposed to a higher temperature; this cannot be achieved unless the pressure is increased. For this purpose, an autoclave chamber is used in which steam at a pressure of 151b./in. reaches a temperature of 12J'C and is held for 15-20 minutes. T his kills even the highly heat-resistant spores of Clostridium botulinum, the cause of botulism. witll a margin of safety. Saturated steam (amoclave) has proven to be the most practical, the most economical, and the most cunent.ly effective sporicide. It is also tile most efficient method for destruction of viral and fungal orucroorganisms. The steam autoclaves are made to operate in d1e following ranges: 12 1'C (250'F) at a pressure of 15 pounds per square inch (psi) for 15-20 minutes. 134'C (270'F) at a pressure of 30 psi for a orunimum of3 minutes {''flash cycle") Important: To positively destroy all living organisms, the minimum required temperature is 121'C (2SOFj.

r-.,

I. The autoclaving time will vary directly with the type of the load placed into Not<$ the chamber. 2. The 3-minutc "flash cycle" is best indicated for unwrapped instmments. 3. When instruments are wrapped, a longer sterilizing cycle is required to permit adequate penetration of steam for proper disinfection.

II h ~I ra~l

(JI.f)Cl'S\ (!()~5()

minute\) dl'(ll'IICiin~ on tlu lll:lll'l"ial to

hl \tcriliz~d

This is false; sterilization with ethylene oxide is a slow process (10-16 hours) depending on the material to be sterilized. Ethylene oxide gas bas been widely used as a sterilization agent, panicularly for prepackaged, disposable plastic ware in hospitals. This gas is very toxic to humans and is also flammable, making its general usc limited. Exposure of materials to ethylene gas must be performed in special sealed chambers. Jtems must be deaned and dried thoroughly before the sterilization process. Advantages of ethylene oxide sterilization: Highly penetrative Does not damage heat-labile materials (rubber. cotton. plastic, etc.) Evaporates without leaving a residue Works well for materials that cannot be exposed to moisture Important: Ethylene oxide functions as an alkylating agent by i.rrcversibly inactivating ccUular nucleic acids (DNA) and proteins.

(MICROBIOLOGY I PATHOLOGY

c)

The killing or removal or all microorganisms, including bacterial spores, is called:

Disinrection Cleaning

Sterilization
Wiping

285
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All or the rollowing arc advantages or using alcohols (70% isopropyl and 70% ethyl alcohol) as surracc dlsinrectants EXCEPT one. Which one is the EXCEPTION?

They are bactericidal They are sporicidal They are tuberculocidal They are economical

Sll'rilinilion - refers tn the .lh<scncC' of alllh ing forms

Disinfection is the killing of many, but not aU, microorganisms. It does not include the destruction of spores. The tenn 'disinfectant' is reserved for chemicals applied to inanimate s urfaces (lab tops, cou!llerrops, lzeadresrs, light handles, etc.). They are not considered safe for use on living tissue. An tiseptics are chemical agents similar to disinfectants., but they may be applied safely to living tissue. Note: Soap only removes microorganisms.

Important: Remember the doctrine of stedlizatjon -- Do not disinfect what you

sterilize!

I. The immersion of dental instruments in cold disinfectants wiU not destroy spores or the hepatitis viruses. (They are resistant ro physical and chemical agents) 2. Liquids are generally sterilized by filtration. The most commonly used fi lter is composed of nitrocellulose and has a pore size of 0.22 urn. This size will retain all bacteria and spores. 3. Filters work by physically trapping panicles larger than the pore size.

'I

h{'~

an. \fJOril'idal

This is false; they are not sporicidal. Alcohol is probably tlHl most widely used antiseptic and is used to reduce the number of microorganisms on the skin surface in the area of a wound. Alcohol denatures proteins, extracts membrane lipids and acts as a dehydrating agent, all of which contribute to its effectiveness as an amiseptic. Even some viruses (lipophilic viruses only) are inactivated by alcohol. The drawbacks of alcohol are that it evaporates too quickly and has diminished activity against viruses in dried blood, saliva, and other secretions on surfaces. (This is due to the presence oftissue proreins and glycoproteins which render alcohol ineffective) For the above reason, alcohols are not regarded as effective surface cleansing agents {i.e., cleaning a denral operatory following patienrrreatment).

I. Isopropyl alcohol (90'Y..-95%) is the major form in use in hospitals. 2. E thanol (70%) is widely used to clean the skin prior to inmmnization or verupuncture. 3. Iod.inc is the most effective skin antiseptic used in medical practice. It acts as an oxidizing agent and combines irreversibly with proteins.

flcROBIOLOGY I PATHOLOGY

tc)

The greatest occupational health care worker risk for bloodbornc infection is:

Hepatitis C virus Human Immunodeficiency Virus Hepatitis B virus Tuberculosis

287

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Antimicrobial chemical agents which destroy microorganisms when applied~D llf' \.. onto Inanimate surfaces, such as counter tops or lights, are called: _.

Antiseptics Sterilants Disinfectants

None of the above

288

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The basis of the current standard (formerly "universal") infection control precautions was first recommended by the CDC io 1987. The purpose was tO protect health care workers (HCW) from occupational transmission of all bloodbome infectious diseases during provision of patient care. While many health professionals focused on the Human Immunodeficiency Vmts (HIV) as the major risk, accumulated evidence clearly demonstrated that the hepatitis B virus (HB.V) was responsible for infection in 10-30% of exposed, susceptible HCW. Concentrations of HBV in the blood of a chronic carrier can range between 1,000,000 to I00,000,000 virions ~r ml, in contrast to significantly lower viral loads demonstrated for both HIV-infected persons and persons with aids. VIral concentrations detected in hepatitis C virus (HCV) infected individuals range between those noted for ~mv and HJV. Thus, we target tlte most infectious bloodborne pathogen with our infection control standards. Precautions that minimize potential HBV spread, also by inference, prevent cross-infection of less infectious microorganisms.

1, """"1' transmit HIV. Accumulating evidence suggests that ~nv is not transmitted by
casual household or social contact. 2. Important: Contact with saliva, tears, or sweat bas never been shown to result in transmission of HIV.

r:;:::-., I. Remember: Semen, serum, amniotic Ouid and breast milk are fluids that can

Uisin reel :.mts

Sterilization is defined as the use of a physical or chemical procedure to destroy all microbial life, including bacterial endospores. Disinfection is less lethal than sterilization, aod involves a chemical process of microbial inactivation which destroys vinually all pathogenic microorganisms on inanimate surfaces {i.e., courtier tops, light handles, bracket trays) , but not necessarily aU microbial forms (i.e., spores). The use of antiseptics involves chemical agents applied onto living tissues (i.e., handwashing) to both remove accumulated transient microorganisms, and temporarily lower the concentration of normal, resident Dora.

(MICROBIOLOGY I PATHOLOGY

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Which of the following is used as a handwash agent?

Chlorhexidine gluconate Triclosan Isopropyl alcohol Both cblorhexidine gluconate and triclosao
All of the above

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~ICROBIOLOGY I PATHOLOGY
An antibacterial solution which directly kills bacteria is said to be:

rc)

Bactericidal Bacteriostatic Substantive

290 Copyriab!CI2()09.2010 Dental Decks

Both t.'hlurhl\idinl' :,!lucnnah and triclos:1n

Both cblorhexidinc gluconatc and triclosan have been shown to exhibit an antimicrobial effect when used as handwash agents in health care settings. In addition to a broad antimicrobial activity, they have the property ofsubst,.nth1ty; that is, a residual action on washed tissues for extended periods. Isopropyl alcohol is also used for hand hygiene procedures, but products containing 6080% alcohol DO NOT use water, hence the term waterless hand hygiene.

ll:tl'f(rilid:t I

The use of bactericidal chemicals is preferable to those which are "static." The latter do not directly kill or inactivate microbes, but instead inhibit their metabolism and replication. These affected organisms can remain viable but inactive for extended intervals. Application of"cidal" agents or processes are designed to ensure microbial inactivation. Important: Bactericidal agents work best during the log phase of bacterial growth.

(MICROBIOLOGY I PATHOLOGY

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The marker microorganism for intermediate surface disinfection is:

Bacillus stearotbermopbilus Pseudomonas aeruginosa

Hepatitis B virus
Mycobacterium tuberculosis

~1

CopyrigbtO ~20 1 0 !)ental Dk..s

(MICROBIOLOGY I PATHOLOGY

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( \..
Proteins
Accelerators

The antigens most responsible for an immediate Type I reaction to natural rubber latex are:

Com starch powders Anti-oxidants

292
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\I~ cnh:tl"tlrium

tuiHrc:ulolii\

Antimicrobial achvtty against Mycobacterium tuberculosis is recognized as a significant benchmark criterion for disinfectant effectiveness. While tuberculosis is not transmitted via inanimate environmental surfaces, the morphology and structure of the tubercle bacilli make them relatively resistant to penetration by a number of low-level disinfectant chemicals. Intermediate level agents, such as phenols, iodophors, hypochlorite, and cettain preparations containing alcohols plus other cleaner disinfectant chemicals are able to penetrate the wax and lipid outer layers surrounding mycobacteria.

Prnttirt\

Only a few of the more than 250 proteins found in the sap from the rubber tree He,ea bras iliensis are responsible for causing the Type I, immediate, IgE-mediated reactions to natural rubber latex. These are water-soluble macromolecules that can leach out of latex gloves when a person perspires, or be detected on the surfaces of other products containing natural rubber latex (NRL).

(MICROBIOLOGY I PATHOLOGY

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Cleaning surfaces prior to disinfection in clinical settings is required to:

Destroy all pathogens Inhibit pathogen growth Reduce the concentration of pathogens Weaken the virulence of pathogens

Copyrial~t 0

283 20092010 Dental lkd:s

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)

(
Cold sterilizarion

The most efficient way to kill microbes is:

Proper bandwasbing with sterilizing antiseptics Heat sterilization Immersion of contaminated items in chemical sterilants

214 Cofl>'rllhl 0 20092010 DtmaJ Ocds

H.cdun tht tonnnlratiun nt poltiHif!.t'ns

The simplest way to approach environmental surface disinfection is to adhere to a basic premise of aseptic technique -- clean it first. All disinfectant products include specific label instructions for cleaning prior to disinfection. Cleaning is defmed as the physical removal of debris. Two effects result from efficient cleaning: I. A reduction in the number of microorganisms present. 2. The removal of blood, tissue bioburden, and other debris which can interfere with disinfection.

fll':l1 sttrilizatiun

The use of beat has long been recognized as the most efficient, reliable, biologically monitorable method of sterilization. During a routine cycle using an autoclave, unsaturated chemical vapar sterilizer, or dry heat unit, cell death is accomplished via heat inactivation of critical enzymes and other proteins within microbial cells. The recommendation stating that all reusable items that come in contact with a patient's blood, saliva, or mucous membranes must be sterilized using beat is now routinely accepted and used in dental facilities.

(MICROBIOLOGY I PATHOLOGY

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\.

The most common form of an ad\'erse epithelial reaction noted for health-care professionals is:

Irritation dermatitis Type I immediate latex allergy Type IV, delayed latex allergy Superficial fungal infections on the fingers

295
Cop)'risht 0 '20092010 Dcolll Deets

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The term "antiseptic" BEST relates to a (an):

Autoclave Dry heat sterilizer Chemical used on contaminated counter tops Handwash agent

Copyriibl 0

296 20092010 IXo~t.l Dks

lrrilaliun dcnnatiti'

A number of published reporrs have cited data suggesting that between 20-30% of health care workers suffer from occasional or chronic dermatitis on their hands. The most common manifestation of the condition is irritation dermatitis, a non-s pecific immune reaction often caused by contact with a substance that physically or chemically damages the skin. The condition can be aggravated by frequent hand washing, residual glove powder left on hands, and the harshness of repeated use of some antiseptic handwash agents. Health care workers located in colder climates may also experience chapping during the winter months.

The term anti.septic is used for antimicrobial agents that are applied onto living ti.ssues. Liquid antimicrobial preparations for handwashing, such as chlorhexidine gluconate, parachlorametaxylenol, iodophors, and triclosan are examples. Chemical solutions, sprays, or wipes applied onto inanimate counters or other other environmental surf.>ces are termed disinfectants.

(MICROBIOLOGY I PATHOLOGY

IC )

A patient develops a Type I, Immediate allergic reaction to latex. When treating him and wearing gloves from now on, you can:

Wear vinyl or nitrile gloves Wear hypoallergenic latex gloves Get an exemption and not wear gloves Refuse to treat him

297 Cop)Tigbl C
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Denial O.ks

(MICROBIOLOGY I PATHOLOGY

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\.

The complete destruction of all forms of microbial life, including spores, BEST describes:

Disinfection Sterilization Pasteurization Sanitization

\\ l'ar

\in~ I nr

nit rih gin\ l'S

A wide variety of latex-alternative infection control items have appeared in the marketplace within the last 10 years. The most widely recognized are newer generations of vinyl or nitrile gloves which do not cross-react with latex allergens. Products with the designation "hypoallergenic" are no longer to be labeled latex alternatives, as they contain latex with a chemical coating over the latex. Note: Studies over recent years have shown that not all latex-allergic persons are able to use hypoallergenic gloves, since many Type I allergic individuals still develop allergic manifestations when using these gloves.

Stlrilitalinn

Sterilization: the destruction or removal of all forms of Ufe, with particular reference to microbial organisms; the limiting requirement is destruction of heat resistant spores. Disinfection: the use of chemical agents to accomplish the destruction of pathogenic microorganisms, but not necessarily all pathogen or resistant spores. on inanimate surfaces. Pasteurization: the treatment of dairy foods, such as milk, for short intervals with heat, to kill certain disease-causing microorganisms; the target of pasteurization is the destruction of Mycobacterium tuberculosis. Sanitization: the treatment of water supplies to reduce microbial levels to safe public health levels.

(MICROBIOLOGY I PATHOLOGY

IC)

Which of the following statements Is true?

Human Immunodeficiency Virus {HJV) is the most infectious target of Standard (universal) Blood Precautions Hepatitis B VIrUS (HBY) is the most infectious target of Standard (universal) Blood Precautions

There are no Standard Precautions for health care

289 Copyrigbl C 20092010 Dental Decks

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A particular kind of antimicrobial treatment, such as that for our drinking water, which lowers the total microbial load to safe pubUc health levels is called:

Antisepsis Sanitization Disinfection Sterilization

)00

Cop)'ricb' 0 2009-lOIO Dental Oecb

Jlt.potlitis B \ irtl\ (1//JJ) is lht. mo\1 inft.'l'fious tar;.:rl of Sland:trd (uni,er\tli) Rlood Pnrwlinns

HBV is the most infectious bloodbome pathogen known, and infection control precautions aimed at preventing this viral tmnsmission have also been shown to be elTective in preventing HIV and HCV cross-infection.

Sanitizatinn

Antiseptic: a chemical tbat can be administered safely to external body surfaces or mucous membranes to decrease microbial numbers. Antiseptics cannot be taken internally. Disinfectant: a chemical agent used to destroy microorganisms on inanimate objects such as dishes, tables, and floors. Disinfectants arc not safe for living tissues. Disinfection: the process of reducing the numbers of or inhibiting the growth of microorganisms, especially pathogens, to the point where they no longer pose a threat of disease. Sterilization: the process of killing (or removing) aU microorganisms on an object or in a material (e.g., liquid media).

(MICROBIOLOGY I PATHOLOGY

c)

(
\..

Which phrase describing an aspect of infection control is not appropriate?

Exposure is not synonymous with infection Do not disinfect when you can sterilize Sterilization of ali clinical instruments and inanimate environmental surfaces is mandatory Known AIDS patientS can be treated using Standard Bloodbomc Precaution

) 01
Copyri~t () 20092010 Oen~llll)ecb

(MICROBIOLOGY I PATHOLOGY

1c)

Which of the following situations have led to the transmission of Hepatitis C?

Accidental needlesticks Blood transfusions Drug addicts sharing contaminated syringes All of the above

302 Cop)Tight C 2009-2010 Oen!~l Ok$

Stlrili.tation ofallllinical instruments and inanimah. cn\ironml'lltal surfans is mouuht tu r~

It is not possible, nor necessary, to sterilize all environmental surfaces which become contaminated during patient care. In many instances, because of the relatively low risk of microbial transmission, thorough cleaning of the surfaces is sufficient to break the cycles of cross-contamination and cross-infection.

\II nl thl' ahn\l'

Hepatitis C virus (HCV) is transmitted primarily in infected blood (blood transfusions). Historically, parenteral drug abusers, persons receiving transfusions, organ recipients, and hemophiliacs receiving factor vm or IX were shown to be at high risk ofHCV infection. More recently, persons receiving tattoos or undergoing body piercings have been infected via contaminated, unsteri lized needles. I. The most likely route for a dentist to be infected with Hepatitis C from a patient is from a contaminated needlestick (as opposed to saliva or the inhalation ofaerosols). 2. Important: Hepatitis C is a significant risk factor for the development of hepatocellular carcinoma.

(MICROBIOLOGY I PATHOLOGY

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"''I
~

An infection caused by normally non-pathogenic microorganis ms in a host \.. whose r esistance bas been decr eased o r compromised is known as a (an):

Nosocomial infection Secondary infection Opportunistic infection Medical infection

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Cot>)'l'laht 0 201-2010 Denial Deets

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I t is recommended thai face masks be changed:

Between patients Daily Twice per day

Opportunistic infl'rtion

The percentage of people living with a wide variety of immune compromised conditions continues to increase. Along with the clinical manifestations of those types of diseases there can be accompanying deficiencies in aspects of host immune defenses. The severity of deficiency can range from mild to life threatening, and predispose the compromised person to infections by organisms which would not usuaUy occur in other people with intact innate and specific immunity. Nosocomial infections are those that originate or occur in a hospital or ltospital-like setting. Nosocomial infections are primarily caused by opportunists, panicularly by: Enterococcus spp. Escherichia coli Pseudomonas spp. Staphylococcus aureus Secondary infection that occurs during or after treatment of a primary infection. It may result from the treatment itself or from alterations in the immune system. For example, a yeast infection that occurs after antibiotic treatment of a bacterial infection is a secondary infection. The development of bacterial pneumonia following a viral upper respiratory infection is another example.

Face masks should be changed at least with every patient and more often if heavy spatter is generated during treatment The CDC recommends that masks be changed between patients or during patient treaunent if the mask becomes wet or moist from within or outside. BFE (Bacterial Filtration Efficiency) measures the percent efficiency at which the face mask filters bacteria passing through the mask. PFE (Particulate Filtration Efficiency) measures the percent efficiency at which the face mask filters particulate matter passing through the mask. Fluid resistance is defmed as the ability of a face mask's material construction to minimize fluids from traveling through the material and potentially coming into C()Dtact with the user of the face mask. Fluid resistance helps reduce potential exposure to blood and body fluids caused from splashes, spray or spatter.

(mcROBIOLOGY I PATHOLOGY

1c)

(
\..

Latex allergy risk factors Include all of the following EXCEPT one. Which one Is the EXCEPTION?

Persons with multiple surgeries Atopy Rubber industry workers Persons with an allergy to pollen Persons with an allergy to bananas

305 Copyri_gtu C 2(1(19.20 I0 Otntal l>ects

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---::-:- -- - - - - - is recommended for all instruments that are used in the mouth.

Disinfection High-level disinfection Sterilization involving the use of beat Both disinfection and sterilization involving the use of heat

Published studies have demonsrrated an increased risk of developing an allergic reaction to either latex protein (type I) or certain chemicals used in the latex manufactur ing process (type IV) in certain groups of people. Current infonnation bas not shown a cross-reaction between pollen allergies and water-soluble latex allergens. Individuals who appear to be predisposed to readily developing type I hyperseositivity reactions (i.e., who are atopic), however, can become sensitized to latex allergens more readily than people with few or no allergies.

1. Atopy is the genetic tendency to develop the classic allergic diseases V. atopic dennatitis, allergic rhinitis (!ray fever) , and asthma. Atopy involves the capacity to produce lgE in response to common environmental proteins such as house dustmites, grass pollen, and food allergens. 2. Remember: THl & TH2 cells are subsets ofT-helper lymphocytes, involved in cell-mediated immune responses. 3. THl cells secrete IL-l and gamma interferon, which enhance cell-mediated responses and inhibit both TH2 subset cell activity and the humoral immune responses. TH I is inflammatory, produces IL2, IFNgamma, TNFbeta. provides help to B-oells in IgG2a production, activates macrophages and CTL and stimulates delayed-type hypersensitivities (IYpe IV hypersensitivity). 4. TRl cells, the other subset ofT-helper cells, are also involved in cell-mediated immune response<!>. TH2 cell activity and secretions are thought to inhibit cell-mediated responses and to erlhance the httmoral response. TH2 cells pro duce IL4 , lLS, TL6, JL IO and IL13, which provide help to B-cells and induce class switch to lgE and lgG I, as well as s upport eosinophils and mast cells.

Sleriliz~ltion

irnnh in:.e the usc of heat

The use of beat has long been recognized as the most efficient, reliable, biologically monitorable method of sterilization. During a routine cycle using an autoclave, unsaturated chemical vapor sterilizer, or dry heat unit, cell death is accomplbhed via heat inactivation of critical enzymes and other proteins within microbial cells. The recommendation stating that all reusable items that come in contact with a N tient's blood, saliva, or mucous membranes must be sterilized using heat JS now routinely accepted and used in dental facilities.

MICROBIOLOGY I PATHOLOGY

1c)

Rapid heat transfer sterilization provides:

A very fast cycle time No dulling of cutting edges Dry instruments after cycle
All of the above

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(:Qpyrijbl 0 10092010 Dental Dks

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Personal protective equipment clinic jackets should be

Short sleeve, high neck Long sleeve, high neck Long sleeve, turtle neck

Whatever your preference

3Cla CopyriJM 0 20092010 Deotal Dks

\II of tht aiWH'

FDA-approved, forced air, dry heat convection ovens are appropriate for sterilization of heat-stable instruments and other reusable items employed in patient care. They use a higher temperature than other dry beat units, and there is controlled internal air flow within the chamber. In contrast to the traditional type of dry heat sterilizers, a rapid heat transfer unit can achieve sterilization of items in substantially shoner times, while still offering the advantages of dry heat. Advances in the design of the dry heat oven have resulted in the development of the dry heat convection unit, which uses forced air at higher temperatures. This method of rapid heat transfer achieves sterilization in 12 minutes at 375F ( J9(f'C) for wrapped items and in 6 minutes for unwrapped items.

For optimal protection, clinic jackets or coats are required to be long sleeved and high necked. This requirement was developed to minimize the potential for exposed skin to contact, and therefore become contaminated with, a patient's blood, saliva, or other potentially infectious material.

(MICROBIOLOGY I PATHOLOGY

c)

In heallhcare, what is the primary disease prevention measure?

Wipe-wipe Spray-wipe-spray Handwashing

Vaccines

301
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Sterilization is the elimination of all microbial organisms including spore formers. Disinfection is the destruction of disease-causing microorganisms not Including spore formers.

The first statement is true and the second statement is false The first statement is false and the second statement is true Both statements ore tnte Both statements are false

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Hands have long been recognized as one of tbe most Impor tant vehicles for microbial spread of disease. More than I 00 years ago. Semmelweiss and Uster suggested that the hands of medical professionals were sources of cross-Infection with pathogenic bacteria and nosocomial infections. For health care workers, handwnsbing is a primary disease prevention measure. The simple act ofhandwashing can significantly reduce the number of transient and normal microorganisms that colonize host tissoc. thus limiting the potential for spread of infection between health care providers and patients. For routine handwasbing, a vigorous rubbing together of all surfaces of lathered hands for at least 10 seconds, followed by thorough rinsing under a stream of water is recommended. The aim of bandwashing is to remove microorganisms from the hands, preventing their potential transfer. It is known that organisms survive and multiply on ltuman hands, creating the opportunity to infect others or the hosl liandwashing reduces the number or transient organisms on the skin surface. Although hands cannot be steriHzed, most transient organisms can be removed by 30 seconds of proper scrubbing with soap and water. Proper scmbbing would include vigorous motion with tl1e hands rubbing together and lingers working in between the finger web space and inclusive of the dorsal and venin\] ~Ur faces of the hands. Microbe.~ that reside in sweat ducts and hair follicles of the skin, however, cannot be dislodged readily. Surveys show that one in live medical professionals canies potentially pathogenic antibiotic-resistant pathogens on his or hc.r hands. Handwashing by medical professionals occurs ar only 30% of the ideal rate. Failure to wash one's hand.~ before and after each patient contact is probably the most important contributor to the spread of infections. These microbt.>s pose a threat to patients with reduced defenses, so scrubbing with an antiseptic prior ro contact with Lhese patients i~ usually recommended.

Both stah.mt.nts <tl"'-' lrtn

Sterilization: the destruction or removal of all forms of life, with panicular reference to microbial organisms ; the limiting requiremeot is destruction of heat resistant spores. Disinfectlon: the use of chemical agents ro accomplish tlte destruction of pathogenic microorganisms, but not neces_~arily all pathogen or resistant spores, on inanimate surfaces. P asteurization: the treatment of dairy foods, such as milk, for shon intervals with heat, to lo11 certain, disease-causing microorganisms; the target of pasteurization is the destruction of Mycobacterium tuberculosis. Sanitization: the treatment of water supplies to reduce microbial levels to safe public health levels.

MICROBIOLOGY I PATHOLOGY

c)

Because - - - - - are the hardiest microbes, their destruction Is required before the defined parameters/levels of sterilization have been met.

Hepatitis B viruses Bacterial endospores Mycobacteria Vegetative bacterin

,,.
CopynibtO 10092010 Dnltal Dccb

(MICROBIOLOGY I PATHOLOGY

c)

{ According to the Spaulding Ciusification System for contaminated Items an;;'\ \ surfaces, critical items should be decontaminated after cleaning by: ..J 0

Intermediate or low-level disinfection High-level disinfection (by heat or chemicals) Sterilization and holding io sterilized state

All of the above

312
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Uarlcrial cnduspnn.s

Even when steriliur gauges display correct values for internal conditions and chemical indicators or integrators indicate that appropriate chamber conditions have been reached to achieve sterilization, the use of calibrated biological indicators (Bl) remains the main guarantee of sterilization. These preparations contain bacterial spores which are more resistant to heat than vegetative bacteria, viruses, and other described infectious microbes.

Stc.-riliz:Jtinn and holding in \h'riliZl'd 'Iotti.'

AU instruments to be disinfected or sterilized must be thoroughly cleaned to remove all organic matter {blood tissue) and other residue. This must precede disinfection and sterilization procedures as organic matter shields organisms from destruction and may inactivate some disinfectants.
~Jl.lllldm:.:,

( la\\lrk:JIIOII o f lh\1\\\ \ftdl\' ,11

hhlrUIIII'Ilh

Objoct 1nd
Cl~tssiOc:atioo

Useofitrm

F.:rample

Oeconr.aml~taflon

Required After Cleaning

Critical

Enters vascular Scalpel$ and other surgical system or sterile body tissues ill$trurncntS such 3S biopsy forceps Comes in contact with intaCI Thermomctet, vaginal mucous membranes speculum. sigmoid $COpe

Sterilization and holding in

sterilized Slate. Ui&b le\'el

disil\feetjon is not sufficient. High Je,el disinJect~n (1>y heat or ('.ltemicals)

Semi-Crilical Non-Critical

Comes in conlact with intact Examining table top, blood lntermedia1e Ot low level skin pressure cuff, baby weight scale disinfection

(MICROBIOLOGY I PATHOLOGY

1c)

Each of the following is characteristic of alcohol-based hand hygiene antiseptics, EXCEPT one. Which one is the EXCEPTION?

Broad antimicrobial spectrum Removal of organic debris from contam inated hands Rapid antibacterial action Greater antibacterial effect than anionic detergents

313

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1c)

Which of the following items is considered regulated medical waste and cannot be disposed of with general dental office trash?

Gauze soiled with blood, plaque, and saliva used in a denta l prophylaxis procedure Blood-saturated gauze used in oral surgical procedures Visibly contaminated environmental surface barriers Plastic saliva ejectors and high-volume evacuator tips

314

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J{('JUO\

al of organic dl'hris from cuntunin<lt('d hand\

Hand hygiene agents which contain high concentrations of alcohol denature and dehydrate proteins instead of accomplishing the removal of proteinaceous bioburden.

Blnncl-'i.ltnrah. d g~lll/t' 11\(.'(l in :m ur:tl ~mrgical prundun

Blood-saturated gauze is considered infectious, not merely contaminated, and meets the OSHA Bloodbome Pathogens Standard criteria for regulated waste. It requires special handling and disposal.

(MICROBIOLOGY I PATHOLOGY

Ic)

Iatrogenic Infections resulting from the provision of dental care may be induced:

By failure to perform band hygiene between patient procedures By performing treatment procedures In patients with debilitated or compromised immune defenses. All of the above

315 CopyriabtC 2.009-2010 l'.k1!tal Decks

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Occupational exposure incidents involving saliva and/or intact skin in dental settings typically:

Require special evaluation and prophylaxis by a qualified health care professional Have a low risk of transmitting HIV disease Have a >20% risk for subsequent HCV transmission All of the above

316 CopyriJht 0 2009-2010 Dental Dttb

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Iatrogenic infections can be initiated by any activity related to the provision of health care, including medical or dental treatments and diagnostic procedures. regardless of whether they are performed properly and regrudless of host immunity. These infections are also called opportunistic if they could not normally develop in perwns without compromised host immunity.

ll.t\l' .tlu\\ rhk

oflr;m,nullin~

Ill\ cli'l'il'l'

Since the first HIV serologic assays were developed in mid 1980's, there have been 57 documented occupational HJV infections in U.S. health care workers. At the present time there have been no dental care providers who were determined to have contracted HIV disease following occupational accidental exposures.

~ICROBIOLOGY I PATHOLOGY

1c)

,
Persons vaccinated against btpatllls 8 virus wbo ba,e developed Immunity arc also immune to: Hepatitis A virus Hepatitis C virus Hepatitis 0 virus Hepatitis E virus

311
Copyn,abl 0 2009-2010 Dental Decks

flcROBIOLOGY I PATHOLOGY

c)

,
Which ofthe rono,.ing statements is correct regarding

\.

tbe cleaning of lnstrumenrs afrer patient care?

Use of a washer-disinfector eliminates the need for subsequent wrapping and hem sterilization Using automated cleaning equipment, such as an ultrasonic unit, is less time-efficient than hand- instruments Using automated cleaning equipment is more rime-efficient. improves cleaning effectiveness, and is safer than hand-scrubbing instruments

All of the above apply

318 CG,)nabl 0 2ootl010 Dmtal Decks

Hepatitis D virus (HDV) is an RNA virus, which is incapable of completing its own replication within infected host cells. It requires and uses excess hepatitis B surface antigen (HBsAg) molecules from an existing or concurrent hepatitis B virus (HBV) infection as its major capsid protein. As a result, HDV has been sometimes referred to a "parasite" of HBV. When a person is immune against hepatitis B, HBV replication does not occur and HBsAg is undetectable. That protection is believed to extend to prevent HDV infection. Remember: It has been well established that HBV is the most infectious known bloodborne pathogen. The development and implementation of universal, and now st81ldard, infection control recommendations and regulations continued to use this DNA virus as their primary occupational bloodborne target.

l sin:,: ~tutom;H<"d d<<~ning tquipmrnt is nwre time efficient. imprm cs dean in~ ctrclliHncss. and is safer than h;;md-scruhhing

When automated cleaning equipment, such as an ultrasonic unit or a washer-disinfector, is routinely used in instrument reprocessing, cleaning effectiveness improves and the potential risks from accidental sharps exposures with contaminated instruments decreases. Cleaned instnunents must still be wrapped and heat sterilized prior to use on subsequent patients. Heat sterilization remains the "gold standard" for destruction of microbial pathogens. Note: Disposable, or single-use items, are not intended to be cle.ancd and sterilized for reuse on another patient, because they are usually not heat-tolerant and cannot be readily cleaned.

flcROBIOLOGY I PATHOLOGY

r According to the <Xcupatlonal Safety and Health Administration (OSilA) ~

Bloodborne Pathogens Standard, disposable gloves that have been contaminated shall be replaced: Immediately As soon as possible As soon as feasible As soon as practical

31t
Cop)'riabl c 2009-2010 Dmtal Docks

flcROBIOLOGY I PATHOLOGY

One major difference between eurnnt "standard" infeetion control p recautions and previous "'universal preeautions,. recommendations, is that the latter:

Primarily targets protection against respiratory infections Provided specific precautions to protect against all known microbial pathogens Was designed to primarily protect against bioodbome pathogens Addressed infection control precautions to eliminate opportunistic pathogen risks

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Contamination of the outside surface of gloves during patient care does not require urgent action. The OSHA Bloodbme Pathogens Standard states: "Disposable (single use) gloves such as surgical or examination gloves, shall be replaced as soon as practical when contaminated or as soon as feasible if they are tom, punctured, or when their ability to function as a barrier is compromised."

\\a\ drsignC'd In

primaril~

prull'CI against hlundhornc patho;.:{'ll\

Standard Precautions: A set of combined precautions that include the major components of universal precautions (designed to reduce the risk oftransmission of bloodbome pathogens) and body substance isolation (designed to reduce the risk of transmission of pathogens from moist body surfaces) Similar to universal precautions, standard precautions are used for care of all patientS regardless of their diagnosis or presumed infection status Standard precautions apply to all body fluids except perspiration. They also apply to non-intact skin and mucous membranes Universal Precautions A set of infection control practices and procedures based on the concept that aU blood and other body fluids that might be contaminated with blood should be treated as infectious

ucROBIOLOGY I PATHOLOGY

c)

Using cassettes to process and re-circulate instruments in clinical settings can:

Make instrument processing more efficient Increase organization of dental instruments Decrease handling of contaminated instruments during cleaning procedures Reduce the potential for accidental sharps injuries All of the above

Copyrijbl 0

321 10W2010 DenW Decks

ucROBIOLOGY I PATHOLOGY

rc)

rI. Used latex gloves, masks, and gauze that are contaminated with saliva and ~
blood after patient care should always be placed in a medical waste container. 2. Contaminated waste is routinely considered infectious.

Both statements are correct Both statements are incorrect The first statement is correct and the second statement is incorrect The fii'St statement is incorrect and the second statement is correct

322

Cop)Tigbl 0 20092010 Deor.l Det-kt~

\II nf IIH ahn\ r

Cassettes provide an alternative approach for reprocessing instruments that addresses a number of occupational issues encountered by beahb professionals when handling sharp, contaminated instruments. requires less handling of contaminated instruments decrease the risk of sharps injuries during reprocessing capacity to bold a complete set of instruments for a single procedure can save time by keeping all instruments for a specific procedure together through the reprocessing cycle.

Buth stalt.nHnf<i, an incorrrrf

Contaminated waste includes items that have contact with blood or other body secretions: gloves, masks, disposable gowns bibs used gauze with saliva and blood used barriers and covers Important: Contaminated waste is generally oot regulated and can be discarded with general office trash. Infectious waste is a subset of medical waste capable of causing an infectiou.~ disease. blood and blood-saturated materials pathological waste: tissue; extracted teeth (without amalgam) sharps used in patient care Important: Regulated waste is infectious waste that requires special handling, neutralization and disposal.

Sh.'p rdarion'iohlps

The primary molar rdt.tionship shown in the figurt-above is a mesia)-s-tep relationship, as the distal surface of the lower second primary molar is mcsi~J to the distal surface ofthe upper second primary molar. The mesial-step molar rdadonship-allows for the fi'rs:t pennanent molars to erupt into a nonnal occlusion immcdintely on eruption. Note that the pennancnt mobrs are in ~t nonnal Class Tocclusion.

The primary molar relationship shown in the figure a:OOvc is chc nush-ter-min_ al-pl9ne relationship for
primal)' motars (al.so known as tht! jl(ll~plane rt.latio11.ship m1d the tndtO..end n.>larionship). As shown

in the fig1,1re. the nush-tcrminal i>lane reJ:njonship d<."scri be~ a siruation where the distal surfaces oftbc maxillary and m:mdibu)ac second primnry molars arc in an end-to-end rdarionship. ln these cases, ~he: first pennanent molars do nol erupt immediately into a normal relationship. As you can sec, the first pcrmaneni molars are in a Class II relatiDnship. The Class n relationship is \Lt;llally temporary, wnil dle sec-. ond primary molars arc lost and the permanent molars move into a Class I relationship. Tbis occurs at approximately age 10 or ll and is called the late mesial shift.

{lass I molar occlu~iun

***Although the flusb-tennioal plane relationship can result in a Class IJ permanent molar relationship if the late mesial shift does not occur. Another step relationship involves a situation where the distal surface of the mandibular primary second molar is located to the distal of the distal surface oftbe maxillary primary second molar. This is tenned a distal-step relationship. In these cases, the permanent molars erupt into a Class II relationship. The primary molar relationships are as follows: Mesial-step relationship Flush-terminal-plane relationship Distal-step relationship The Angle Classilicatioo of permanent molar relationships are as follows: Class I relationship Class II Division I relationship Class 11 Division II relationship Cla.~s Ill relationship Primary molars should be assigned tenninology according to step relationships, and permanent molars should be assigned terminology according to the Angle Classification system.

ENTAL ANATOMY & OCCLUSION

Primary)

Primary molar relationshlllS are known as:

Class relationships Step relationshops Primitive relationships Occlusion relationships

105
Cl)py."igbtC 2Mt 2010 l>cntOll 0-ks

ENTAL ANATOMY & OCCLUSION

Primary)

Both the mesial-step and nushtcrminal-plane relationships usually result in the development of a:

Class I pennanent molar occlusion Class I I pennanent molar occlusion Class Ill permanent molar occlusion

10!1
co.~)::'!" ~ft' '1('~\tfttal

Ooekt:

mandibular st.runllmolar -*** The permanent mandibular first molar has a morphology lhat < primary mandibular second molar. The ditTercnees includl!: Relative size of the dlstol Cll.sp. The primary molar has its mesiobuccal, cusp almost equal in size. The distal cusp of the pcm1anent molar, howevc
other two ousps

Primar~

From lhc buccal aspect, the pl'imary mandibular second molar has a nan 'V1cal portion of the crown when compared with the calibrati ation at the ce1 crown at tlH~ conlac.~ leve1. The mandibular tirst pcnnancnt molar, accon cervical portton Groon putttrns are different on the occlusal surface The primary tootlt has more divergent roots to allow for the ~owption of 1 premolar The primnry tooth bas a more prominent t3cial crest ofcontour

r::::;:::::::;;:,_, r---.;P.;r.;im;;;;;a"'!ry Mandibular Right Second Molar

,.-..~..-...

Buc-eal Lingual 1. Prlmary second molars have the greatest facio lingual diameter Note 2. 11tc primary teeth that present ihe most noticeable- morphologic d nent teetl1 are the first molars.

P('rOIOIWIII m:ailhu~ first molar - but the) :1rc small{'r

rn general. the pnmary second molars a~ larg~.:r than lhc primal)' first mala~ a the permanent first molan;.

Other d~arncteristic.<:o or the fJrimRr)' maxillary second molar: The t3ciQiingu.al measun:mcJ'II oftbc crown is gruter than the m!.'ltiOtlisml My have a fifth cusp (q(Curabelli! Has a prominent mesiobuccal cervical ridge Has an oblique ridg(' The MB <:U!i.Jl i.s almost equal in size to oc slightly larger than the ML c\lsp The largest and longest pulp hnrn il> the mesiobuccaJ - .

&1.....,. l

~ENTAL ANATOMY & OCCLUSION

Primary)

A neophyte dental student, only about two weeks into the program, gets """ scared when her 10-year-old cousin gets hit In the face and looses a tooth. She calls you up and says that her cousin lost his permanent mandibular nrst molar. Once she tells you more about the root morphology of the tooth, you realize It is primary and the child simply lost his ...

Primary mandibular first molar Primary mandibular second molar Primary maxillary first molar Primary ma:<illary second molar

203
Copyn&M C 2'0092010 Dtntll Dks

~ENTAL ANATOMY & OCCLUSION

Primary )

Morphologically, the primary maxillary second molar strikingly resembles the:

Permanent maxillary third molar Permanent maxillary second molar Pennanent maxillary first molar Pennancnt mandibular second molar

204 Cop)-n,gbl C 20092010 DrMIIII)c.cU

The

primar~ maxillar~

fin;t molar

Characteristics of the primary maxillary llrst molar: In all dimensions except labiolingual diameter it is the smallest molar. Basically the. crown of this tooth is bicw;pid (t.tYJ cusped) There are two mai_ n cusps - a wide mesiobuccal and a narrow mcsiolinguaJ. Indistinct cusps are the distobuccal nod distolingual The MB cusp is always the longest. The ML cusp is the second longest, bot sharpest The cervic.alline is higher mesially than distally The cervical ridge staods out very distinctly on the mesiobuccal portion of this tooth The occlusal pit-groove pattern is most frequently H.,;hap~ The number of roots (three) and ~te fonn of the roots closely resembles the pennanem maxillary first molar On the crown, the rnesial surface nonnally is larger than the diStal surface The Primary Maxillary Right First Molar

Primate

Prima1c spaces appear in the deciduous dentition. The spaces appear between the maxillary lateral incis ors and the maxillary canines . T11cy also appear between the mandibular canines and !he mandibular first molars. Spacing is nonnal throughout d1c anterior part or the primary dentition. but is most noticetable in these two loouions. Th~e primate spaces arc nonnally present from the time the teeth c11.1pt. Developmental spaces between the indsors are often present from the beginning, but become sorn<.."Whal larger as the child grows and the alveolar processes expand. Generali7.ed Spating or the primary tocth Ls a requirement for proper alignment of the pe.nn.anen~ incisors. This spacing is most frequently cau.sed by the growth of Ihe dental an:.bes. l,rinulf)' Maxillary Right Lateral Incisor

r
1.--

1--

II

Labial

Ltngual lnc.isal Mesial PrJm.ary Mand_ ibular Right Latera1lncisor

~
~
Incisal

Distal

\
Labial

1'--

\
Lingual

u
M-esial
Oista.l

E~TAL ANATOMY & OCCLUSION

Primary)

Which primary molar is the most atypical or all the molars, prlrnury and permanent, and appears to be intermediate In form and development between a premolar and a molar?

The primary mandibular first molar The primary maxillary first molar

The primary mandibular second molar

The primary maxillary second molar

201 Cop)TightO 2()09.2010 DcntIIX.d:s

ENTAL ANATOMY & OCCLUSION

Primary)

A preschool child is shown below with a normal dentition. Note the

spaces between the maxillary lateral Incisor and canine and the mandibular canine and lirst primary molar. These spaces arc termed spaces, and their presence allows for the SI>Ute to be filled by permanent teeth as they erupt.

Primitive

Private
Primate

Hawley

4 to 6 months in utero
Dcddutlflli
T~lh

Ftnt t vklt-.nu or
C~f\Ndo11

Amouttt or 1.-:"t~md f'ormrd at Birtb

Eennnel
fM(Nellr$
4/ff'r Birth}

Compkled Compltttd
(Ww.J"J)

Roo

Mxiltsry

C<oOBlLatml (DC:Jsor
~

monlbs. in \ltcro

(:iV04u:thJ.-

llf.l 2112
9
6

llf.l
1
J 1/4

lfl momfn in uh:ro

'l't.'O-thitd'
One-lhitd
OceluW compkldy fficl&td plw !/2 1o

C:Mbe Fin.1 M~>l"t

S lr l monthfin loflero

.S lf!OftlM in uu:ro

l it:!

lJ.t (1"0'9,'11 hdgbl St.a'!nJ Ml),lu

6 mc~th1 in ulrfQ
()c(:l~ looompletdy

II

ealtlBoo: valed'lcd
h:mle CO\'C'IS liS 10 )/4
crown~

1\bncJibubr Coun.lltt.:i.k!t
La~ 1ncilo0f

4 4

lfl months inu!cro

Tl!n.'~>iil'dss

:2 1'2

lit:!
IIi!
J lf4

1/2lt)Qntb$ in U!tfl)
S mQ~:~tb~ in ui(JO
S mCX~~S. in uto'O

'Thnfi!W
Ocd~ wrnplet.cl)'

Canine Fit!4Mo!ot
Sond Molnr

.,.......

5 112
In

'

2ll2
l

c:aleilied 6 month$ in uiiCfO Occlusal ~plerdy

aldfiNI

)) I. On anrage primary teeth roke I0 months ror completion of calcdicahon. Nott1 2. The primary teeth begin to form in utero at about s:lx w<:cks. Hard ti5$UC fonnarion occurs in all primary teeth by the 18th week in utero, 3. The pel'manent teeth begin to d~vdop at appr oximately !our months of age in utero. Maxillary and mandibular firsl molars begin to c.alcify at bJrih. They are the llrst to begin calcification. Tile mandjbular third molars arc gcncrnlly the last teeth to begin calcifying.
This happen$ at aboutS-10 years ofgc.

(0, 4): .\nnit (2, 6) Sally willl have lost no teetl1 yet and have all her permanent first molars. Annie will have lost her lower ccntml incisors and have all permanent fust molars pl ~s her pennanent lower centrals
Sail~

Ordinarily, a 6-year-old child would have the following teeth clinically visible in the mouth: All (20) primary tcelh and four permanent fir~1 molars--- ("' 6 year molw:< ''). Remember: Mandibular ceotmls erupt between the age of6-7 Maxi llary centrals erupt between the age of7-8 Ordinarily, a 7-ycar-old child would have the following teeth clinically visible in the mouth: 18 primary and 6 Jlermaocnt teeth. The 6 permanent teeth include the: Mandibular ljrst molars (2) --- right and left Maxillary first molars (2) --right and left Mandibular centml incisors {2) --- right and left All of the primary L eeth are present except the two mandibular central incisors (20- 2
Note;, 2. The mandibular lateral incisor is the smallest primary tooth.

L The largest primary tooth is the mandibular second molar.

3. The la rgest permanent tooth is tbe maxillary first molru. 4. The mandibHiar central incisor is the smallest permanent tooth.

~ENTAL ANATOMY & OCCLUSION

Primary

The crowns of all 20 primary teeth begin to calcify between:

I to 2 months in utero
2 to 3 months in utero
4 to 6 months in utero
8 to 9 months in utero

Cop)ngb1 C> 20092010 rknul Decks

'"

~ENTAL ANATOMY & OCCLUSION

r

Primary)

Sally and Annie, ~:es six and seven rcspccllvely, come into your office and get their picture llUI up on the "Cavity-Free Board." On the back of each picture, your ussistantwriles bow many baby teeth they have lost and how mnny adult teeth they have. Which numbers are correct?

Sally (0. 4); Annie (2, 6) Sally (2, 6); Annie (4, 10) Sally (2. 6); Annie (2, 6) Sally (0, 4); Annie (4, 10)

200
CopynptC 2009-1010 Dtnta1Dedt

Uon't \\orr~. th(' pnmolnr Creth llwt rqJiotce these prima') molars take- up flo!l-s space in the arch. 'OO 'H' cun <\p<ct to 'l'l.' more room in a fe'' ~ears Remember: The swn or the mesiodjstal widths of the primary molars in any one quadrant iSgreater than the pcm1anent teeh that succeed them (premolars) """' 2 :5 mm greater. Some differences between primary and permanent molars: Primary molars have crown~ that are shorter and more bulbous. with pronounced buccal and Hngunl cervical ridges and a constricted cervical area Primary molars have .an occlusaJ table that is narrower faclolinguaiJy Primary molars have anatomy that is s haii0\\1 (i.e.. the cusps arc short. the tidges are nor

pronoum:ecl, and tirefo.\.~ae are not O.'i deep)

Primary molars have a prominent mesial cervical ridge (makes it easy to distinguish rights from lefts) Primary molars. hav..: roots that arc longer and more slender than the roots of the pennaneot molars. The roots arc ext~mely narrow mesiodistally and very broad buc:coJinguaJiy Primary molars have roots that are very divergent and less curved. There is little or no root trunk

SneUe-r

overall
Prominent ccrvkat

,,.

ridge
Narrower

roots

l'hc distal tlan of thr root Is grratcr

The primary -incisors (celllrals and laterals) are very similar to tbe permanent Incisors.
btll differ in one important t rait the newly erupted primary incisors do not show

mamclons. The most characteristic feature of the primary maxillary incisor ls the mesiodistal width of the crown. Jt is che only primary or perttlaneut incisor with a mesiodistal diameter greater than its crown height .
....., I. Tbe primary maxillary centro! incisor has a shorter length incis<rcervically than

Notes the pem1aneot maxillary central incisor.

2. Also, compared to ~1e pem1nnent central incisor, the. incisal edge of the primary

cenrral incisor is straighter.

3. Labial and lingual cervical ridges arc prominent on all primary central and lateral
incisors.

4. Remember: \Vhen extracting primary incisors (cemrals and laterals) where the
root' have been panially resorbed due to pressure from the developing permanent teeth. the facial pan of the remaining pri111ary root will usually be the longest and the most se<:urely attached to the gingiva. Primary Maxilla ry Righi Central Incisor

!
v'

ll
Labial Lingual

G
incisal llfesial Distal

~ENTAL ANATOMY & OCCLUSION

Primary )

A 16-year-old patient comes into your office wllh his mother. They are concerned about atTordlng orthodontic treatment for his slighCiy crowded anterior teeth. Be bas not lost his primary molars yet. From this information alone, you tell his mother ...

Don't worry, the premolar teeth that replace these primary molars take up less space in the arch, so we can expect to see more room in a few years Get a second job, the premolar teeth that replace these primary molars take up more space in the arch so we can expect to see even less room than there is now The premolar teeth that replace these primary molars take up tbc same amount of space in the arch. Based on this we cannot tell at this point whether your son "ill need onhodontic treatment
tt7
COJ!rnsM C l()(l9.2010 Ocnt11l Dki

~ENTAL ANATOMY & OCCLUSION

Primary)

Although it usn ally Isn' t much of a problem, which of the following criteria would not be used to distinguish primary maxillary central incisors from their permanent counterparts?

They are shoncr inctsoccrvically They are wider mesiodistally There arc no mamclons present The incisal edge is straighter The distal flare of the root is greater

Copyns,bl 0 20092tl0 lkmal Dttb

...

\hmdihul:1r first molar

This transverse ridge separates the mesial pOrtion from the remainder of the O<:Ciusal
surfhce.

Other characteristics of the primary mandibular first molar: It does not resemble any other primary or permanent tooth The mesiobuccal cusp is always the largest and longest cusp, occupying nearly twothirds of the buccal surface The mesiolingual cusp is larger, longer, and sharper than the distolingual cusp The crown is wider mcsiodlstaUy than high cervico-occlusaUy The mesial marginal ridge is very well developed and resembles a cusp It has a prominent mesiobuccal cervical ridge Class ll cavity preparations are diOicult due to morphology It has no central fossa

Buccal

Lingual

Occlusal

All canines (permanent and primary) have four lobes. lhrec on the facial (mesiofacinl. midfacial.
and distofocio/) and one on the lingual. The cusp tip is located on the mid facial (centra/facia/) lobe.

- -,. l .The pulp cavities of canines when viewed in a mesiodistal section normally appear j Notes pointed at the incisal tip. 2. When viewed fron'l the facial, canines resemble a f,entagon (five-sided).

Labial view

Lllbial view

Primary Maxillary Right Canine

/" r
Labial view

Labial \'iew

\
l'ermanent Maxillary Right Canine Ptrmaneot Mandibular Right Canine

ENTAL ANATOMY & OCCLUSION

Primary)

When attempting a MO Class II amalgam preparation and filling on a primary tooth, you encounter a very large mesial marg,lnal ridge that resembles a cusp. You also notice a transverse ridge from mesiolingual to mesiobucc.al cusp thai is rather large. This tooth often proves difficult to restore, wbicb toolb is it?

Mandibular first molar Maxillary first molar Mandibular se<:ond molar

:\<la.<illnry se<:ond molar

1t5
Copyngtlt C Z0092010 Dtmallkcb

ENTAL ANATOMY & OCCLUSION

Primary)

How n1any lobes de,elop to form a primary canine tooth?

COfi)Tisf'll 0 20(19..2010 Defttal Dtocb

'"

I hl na,pnn lht primar~ 111:1\.illan ,111111\' 1' mud1 lnn:.:,tr .md ~harper lh:Jn lht 'U\fl nn lfw ptrm.menl m:l\.lllan. canim

11h! mos1 signif~.nt difftrtn! ht'r"~ rhe prinwy maxillary c:anine and lbe pmnanenl

rnax.illuy camne are~ I The C'usp on the primary c:anmc JS mu(h kmgtr and sharptf' 2. The mesial ""'P ridge is longtr INn the d1s11l cusp ndgc (this is the opposit< ofo/1 otMr comn<!S ... 00\iousty tbey difftr in otht:r WI)'$. bul tbe<e IYIO dlfl'trences arc lhe most signi(ttanL 'riott: The primary ma."<.illuy canine also appear.,. especially Yl ide and. short.. .----T""h.,e Primary Mulllory Right Can.ri.:.:.:.....- :- ,

Ungual lntiJtl MHial Tbo Primary ~landlbular Rigbt C-;:::in::; ~~--.

(f)
I'"

()
.....
\

....... )

f\

G
hu:ls~t l

\
Mesial

l.ab1al

Lmgual

l)lstl

I ht' primar~ ma\.illar~ llfl lir't rnular

The Primary Moxlllary Righi Second Molar

Buccal

Occlusal

Mesial

Distal

~ENTAL ANATOMY & OCCLUSION

r

Primary)

A 10112 year-old patient comes into your office. You are not sure whether his maxillary canines are permanent or primary. Which or the following statements will help you determine which they are?

The cusp on the primary maxillary canine is much sboner than the cusp on the permanent maxillary canine The mesial cusp ridge on the l'!imary maxillary canine is shorter than the distal cusp ridge; this is the opposite of all other canines The cusp on the primary maxillary canine is much longer and sharper than the cusp on the permanent maxillary canine The primary maxillary canine is much narrower and longer than the permanent maxillary canine

tn
COJ))Tigln C 2009-2010 lkntol Ded.s

~ENTAL ANATOMY & OCCLUSION

(
Which primary tooth Is shown below?

Primary)

1..
CopynJI~O 20()9..2010

JknL&I OrocU

~otll'

ol llll'

~-thoH:;

their anatom~ is unlikt an~ othrr tooth in the mouth (primary m

f'l'I'IIIUII('Ill)

The general shape of the occlusal surface is oval (wider mesiodistally than buccolingually). It has four cusps (Note: The primary mtmdt'bular second molar has five cusps), witb the mesiobuccal. the largest and the mesiolingual next in size. The distobuccal and the distolingua\ are much smaller. The buccal surf.1ce is longer than that of the lingual and bas a very prominent cervical ridge across the gingival area. directly above where the tooth constricts at the cervix. The tooth has two roots: a mesial root. which is much longer and wider. and a distal root The apex of the mesial root is flattened or squared off. Looking at it from the occlusal, the mesiobtu:cal angle is acute and prominent because of the mesial cervical ridge on the buccal surface. The DB angle is obtuse. The shape of the occlusal table is that of a rhombo. id. Note: The primary finiland second molars first show ca1cificmion m five to six rnonths in utero. In general. the root of a deciduou.; tooth is completely fonned in just about one year aflcr entption ofthattootll into the mouth. The Primary MandibularRight First Molar

r\1nndihul:1r

n~ntrlll

i1u.:ism

(1-112 months old

This tooth usually erupts at around 6-112 months of age. 11te root is fully fom1ed and calcified by about 18 months of age. Remember: This tooth is usually bilaterally symmetrical when viewed from the facial and incis.1J. The Primary Mandibular Rlgbt Centrallncisor

I l

r-Labial Lingual Incisal Mesial Distal I. The first permanent tooth to erupt is the mandibular first molar ("six year Not<f molars"), followed shonly thereafter by the maxillary first molar. 2. The first permanent tooth to begin calcifYing is the mandibular ftrSl molar (at
birth).

3. The ftrSt succedaneous tooth to erupt is tlte mandibular central incisor (around six to sl!l"'!' years old). (Remember: The mandibular fll'St molar and the maxillary first molar are not succedaneous teeth). 4. The permanent maxillary central incisors erupt at approximately seven to eight years of age. The permanent maxillary lateral incisors erupt at a,pproximateJy eight

to nine years of age.

DENTAL ANATOMY & OCCLUSION

Primary

Stainless steel crowns are often used In Jledlalric dentistry. Also common in pediatric dentistry are kids throwing temper tantr ums. One day a 4-ycur-old patient throws a tantrum and knocks over your case of stainless steel crowns. When picking out the mandibular first molars you remember which of the following statements?

"

They resemble D te pennanent mandibular first premolar They resemble the permanent mandibu Jar fina molar They resemble the pennanent max.iUary second molar They resemble the primary mandibular second molar None of the above; their anatomy is unlike any other tooth in the mouth (primary: or

pennanenl}
1i1 Copynjtlt 0 2009201 0 Dtmat Decb

DENTAL ANATOMY & OCCLUSION

Primary

A fra ntic mother calls you on the phone asking what to do about her child's

first tooth. You want to impress her. Before she can say it, you tell her what tooth ills. It is a:

Mandibular centml incisor Mandibular first molar Maxillary central incisor Maxillary fir..t molar

You got that right, and now you really Impress ber and tell her how old her child Is. S he is about:

4-Y, months old 6-Y, months old 8-Y, months old

1 year old
1t2 CoP}Til!fiiO 2:009-1010 Otlll&ll)ed.'

l 1ppcr (mmu/ihularftll.i"ia- anintlar tfj~;,J rompartmrnt

The TMJ are considered the most complex joints in the human body because they must provide for rotational movements, sliding movements (tramlatOJ-y motion) and au infinite t1l1lge of combined movements and functions, unlike any other joint in the body. When ~1e mouth opeus, two distinct motions occur at the joint. The first motion is rotation around a horizontal axis through the condylar heads. The second motion is translatlon. The condyle and meniscus move together anteriorly beneath the articular eminence. In the closed mouth position. the thick postetior band of the meniscus lies immediately .,rd, the thinner intermediate zone of above the condyle. As the condyle translates forw lite meniscus becomes the articulating surface between the condyle and the articular eminence. When the mouth is fully opel\, the c.ondyle may lie beneath the anterior band of the meniscus. tn the lower (coudyle-cll'licular disc) compartment, only a hinge-type or rotary motion can occur. This rotational or terminal hinge-axis opening of the mandible is possible only when the mandible is retntded in centric relation with the conscious effort by the patient or by the dentist's control. Note: During mouth opening, the articular disc moves anteriorly in relation to the articular emu1ence. In tho upper (mandibularfossa- artkulardisc) compartment, only sliding movements or tnnslatory motion can occur. When the lateral pterygoid muscles contract simultaneously. the discs and condyles can slide forward, down over the articular eminence (protrusion), or move backwards together (retrusion) during opening and closing of the mouth, respec-tively.

b~:low.

More comp:trisons of prin1ary and perma.nent tooth: The c~wns of the primacy anterior teeth are "'ider mesiodista.lly aod .shoner incisocervically
than then pci'OUI.ncol counft'T)>Hns

!he crowns or the primary molars are shorter a11d more narro''' mesiodlstally at the cervical
thtrd s,s compared to the pennancot molars

~ The roots of the primary anterior teeth taper more rapidly 1.han do those of the pennanent antertors
The roots nf tbe primary molars are longer and more s1l!nder than those of the pennaoen[ moJars ~be tname.l ends abruptly at Lhe ~;crvk-al Hoe on primary teeth, rather than becoming thinnt:r wh1ch occurs on pcJ ruancm leel.h '

Ptllp horns

l'rlmary M ~tndlbuJar
First ~~~In

Pt-m1aner1f MandlbuJtr
Firsr 1\')QI~r

~ENTAL ANATOMY & OCCLUSION

Translatory movements take plate in which compartment of tbc TMJ?

Upper (mandibular fossa articular disc) compartment Lower (condyle articular disc) compartment Both the upper and lower compartments

119 Copyrifhl 0 2009-2010 l)entoll)ts

~ENTAL ANATOMY & OCCLUSION

Primary)

All of the following statements arc true EXCEPT one. Which one is the EXCEPTION?

The primary teeth are lighter in color than the permanent teeth The pulp cavities are proportionately smaller in primary teeth In general, the crowns of primary teeth ore more bulbous and constricted than their permanent counterparts The crown surfaces of all primary teeth are much s moother tban the permanent teetb (in oriter words. there is less evidence of pits and grooves)

110
Cop)'tigbl 0 2009-lOIO DM~I Deda

 The retrodiscaltissue is lhe highly vasculor lfs.ut of the bilaminar ~one.

Important points bout tht TMJ: It is a combined hinge and ~:lidingJOint th3t connects tile mandible to lhe ttmporol bone It is a dlr1hrodial joiot (rt actuaii)LT the mtl)' mmYiblejoinr ill the skull) that has dense fibrous conn..:tive tissue (/ibro<artllag~J on tl articular surfaces The libroeartilaginous articular disc ltes b<l\,.,.,n the aniculating bollt$ of the TMJ (the condyle ofthe mandible wrd th mandll,mlar jos.<a afthe "mporal bone). lt divide; the jmnt into two cavities, each of which is fumishe<l wilh a synovial membrane, which is a specialized connective tissue 'hat secretes the synovu\1 fluid Rcme111ber: When the mou~ opens, the mAndibular condyle rotmes on a hortzontul altis. At the same tune, lhc condyle and disc ~lidc forward and downward ou the orUculnr erninf'nce. I. The deep temporal and rna$Seteric branches of the maxillary anery and the Not~ branches of the superficial teroporol ttrttry, which arise. from the external ~aroud artery, supply lbe TMJ. The blood ves;els surround the joint m a network of fine branches Venous draulllgc is vta the S<tperficial temporal. maxillary, and pterygutd pleus of 2. The fibrous capsule of the TMJ is tMtl' ated from a huge branch of the amiculotempural nerve (branclt ofVJ}. The anterior regton of the jointts mncrvated from the OlllSSeteric """e (rJlso o imJn<h o/1'J) aod &om the posterior deep temporal nene (ali> u branch o{VJJ, Thcscn.o;ory tMenationoflhe TMJ is via the trigeminal nene as well. The nerve fibers primarily follow the va.scwar supply and tenninalc as free nerve endings. Thus. ~1e Cllpoule. syno.,al ussue, and extreme periphery of the disc are mnervated. The nn icuhtr c1u1ilngc and the tenrr3l pan of lhe dasc conta1n no nerves. Both myelinoted and nomnydinatc-d nen es are seen in the 1'MJ. The retrodiscal bilammar zone has a rich neurovascular >UJlply and is the source of pruprioccprion.

lniLrn.ll o;;~nmiall.l~l'r nt tlu. fihruu' l.'ilfl\lllt The fibrous capsule (jornt capsule) 1> u heel of fibrou; tissue that coveTS the temporomilndtbular JOint Think of ita> a bag that contains thtJOrnt. It '"'lares the C.IJIIL-nts of the JOtnt nd aUows free !nOVi!Jnent O[ the condyle and dnJCUlar db.c Wtlhin a .!mtaH ~wimmin_g pool,. ~ynovial Ou&d h

or

'' fatrly thin except bternlly. "'here 11 forms tho tcmpoMtnandtbular ltg:Jr.t<nt (also ca/1,,/thlutra/t~poromandilrJ/ar ligament). Medtally and laterally, lhe capsule i> firm. to "abtli>e tho mandtble during movement. Antenorly and PQ'ttnorly, the capsule ts loose to aiJow ntan<ltbular mocments. Usually. only a thin bnmg uhynovtal Outd tS present on d>e articular surfaces Larger amount ofjoiru fluid usually arc auoetated wuh rmful internal dernngem.:nt The JOint capsule 1nd ligaments restrict excessive dis,placcmcn1 of the numdible. Th~ Obrous capsule consists of "'10 la,tc": I. Internal syno\iallayn (s}7IO\'ial nwmbro11c)- tiH:s 1hin layer secrete5 synovial nuld lhCillu bnCAh."S lhc joint 2. Outer fibrous1aycr- a thicker loycrornbMUS: l1S:,uc wh1 ch s reinfnn::ed by accessory liM.t
rncnt~ (,tJylomandibtdar t.i11d Jpln:ffumllmlllmlarllgamellls)

ENTALANATOMY & OCCLUSION

,
All of tbe following struttul't's make up the articulating parts of each \... temporomandibular joint EXCEPT one. Which one is the EXCEPTION!
~

Mandibular condyle Anicular fossa and articular eminence

Retrodiscal tissue
Anicular disc (meniscus)

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Whlcb of the following structures Setl't'tes the Ould which lubricates the T.)IJ?

Retrodiscal tissue lntemal synovial layer of the fibrous capsule Outer fibrous layer of the fibrous capsule Anicular disc

180 Qlp)'tiJhl 0 10092010 Dc11UIII>ccks

\ull'runu.tlial

healthy temporomandibular joint (IMJ). the articular disc is seated on the condyle and is held in place by the collateral ligaments (medial and lateral. also called "disco/ ligament<") that are otract1ed to the medial and lateral poles of the condyle. Attached to the anterior ponion of the anicular disc are muscle fibers from the lateral pterygoid rnll'>cle. When the collutemlligaments become elongated or torn, they become loose and, allows the lateral pterygoid muscle to pull the articular disc out of place. When this occw:s. it is ca11ed a elise displacement. Because of the anteromedial direction oflbe 1atral pterygoid muscle. the articular disc is usually displaced anteromedlaUy. Note: When the anicular disc is displaced antcromcdially to the condyle, a click sound is usually demonstnm:d whe-n the mouth is opened ~n~ the condyl~ moves past the thick posterior band of the articular disc. There can also be a clicking sound when the mandible moves to the opposite side. as the condyle again moves past the thick posterior band of the anicular disc. Often another cliek will be demonstmtcd wh~n the mouth i~ 'Ubscquently closed and the condyle moves from the thin central area of the disc and then past the thicker posterior band as the articular disc once again be<:omes displaced. A crepitation sou ad (also A11o1wr as crepitus) is usually associated with a degenerative process (osreourtlrritis) of the condyle, the dull thud is usually associated witlt a self-,..,ducing subluxation oJ'the condyle, and tinnitus is described as ear ringing.
In~

Al11tuill'
L..-!tnlr_.ltult rlll

1 11 t n!tlnJ!-wllll

tdt~ of llutrtl p1 tor')'CoOid

tntudt., \Uj)Uiurand l11f~rie;r 1 \e.lld

Gin1!l,\ mu:1rthrmliul joint

The TMJ is 8 ginglymoarthrodial joint (meaning I!rut It glltle:r mrd rmatl!.v). penn11tiny bmh hinge.lih rm.ation and !llfding (gliding) mO\'IWH'nts. Nule: Ginglymus means ro~:,.tion, aud arthrodial means freely rnovablc. Compon<nt of lh' T~1J: Maodjbul'lr c.ondyle (somttimi!!J cullt'ilthe condyJnlc/ prnce~.v (Jj JIJe ma~tdihlt) the anic\rhtling surface or functioning pan or the condyle is luc<~h:d on the .sup<."fior ;1.nd :mtcrior surfaces oft he head uf1he condyle. Thi!i surfac~:. is covered with a dcnstIAycr of fibrc m.s ronneclive ti.ssue Arlfcular fossa~ 1his fossa is the anterior throetOurt.hs of the Jars~ mi\ndib\llar (t;~ssa, It i.; consid ered to be a non~functJonlng porLiod ofthe joint. Rt mcmbl'rt The mandibular fossa (g!l'troMjoJJa) i.; rhl.' lcmp(l!'lll componcnc of rhc TMJ~ it is bounded in front by the articular emiuence. and behind. by the ()'Jnpanll' pa11 of the tempursll>one. which scpamtes it from the external auditory meatus Articular en1iutnee (tl /.t(i calltd tlu. tmtc:rJiur luJwrrle) l!i 11 ridge thl'lt extends mcdiolatcrnlly just. ill nunt ofihe numdibuhsr fi:~ssa. lt is cunsid~rt:d to be tbe runclional portion oflhc joint. It is lined with n thick dense lay~r of fibrous connective tbsue Articuhtr disc (ol,tfl ~a/Jed rhe lmmisctu) is :1 bi'-'Onc:~vc fibrorartilllfinous dJsc inte1 -posed benvee.n fhc condyle oft he mandible-and the mandibuJar (gJ(mul(l) foss:n or the ternro~l bon~.:. whi~h pro,idcs the glidins surfilce for lhe mandlb\llar tondyh.\ resulting in smooth joim n10vcm~nt. The cemrul ,,art iS .avaS'Cular and devoid orncne nsruc: only the eJttreme periphery i!i sligJuly ~nu~r\'.:ued
4

ENTAL ANATOMY & OCCLUSION

A patient with temporomandibular disorder comes to the dental office for treatment. He has bilateral "clicking" of the condyles upon opening and tenderness on palpation of the joint. An MRI shows damaged collateral ligaments. The most common direction in which the articular disc in the TMJ will be displaced in this patient is:

Latcrdl

Medial

Posterior Anteromedial

185
~right

c 20092010 Oc:nul Decks

ENTAL ANATOMY & OCCLUSION

(
Arthrodial joint Ginglymus joint Ginglymoarthroidal joint

The TMJ is a(n):

186 Copyrisflt Cl 2009-20 I0 Dental Db

\Ja:,:nl'lil-

n ..uu:llll"\' im:J~in~

(\IR/)

:\1agnetic resonance imaging (MRJ) is considered to be the gold standard for providing an image of the soft tissue of the temporomandtbular joint. especially the position of the alticular disc. The MRI utilizes a magnetic field to alter the energy levels of primarily the water molecules of the soft tissue, which results in good visualization of the different soft tissues, including the anicular disc. Note: The mujor advantage of the MRi tcchnique is that there is no exposure of the patient to x-ray radiation. Currently. no harmful effects of MRI have been demonstrated. The other imaging modalities (i.e. pa11oramic radiograph. CATScan, lateraltranscranial radiograph) are best used for evaluating the bony smtctures of the temporomandibular joint.

(lick When the antcular disc is displaced anterior to the condyle. a click sound is usually demonstrated when the mouth is opened and the condyle moves past the thick posterior band of the anicular disc. Often another click will be demonstrated when the mouth is subsequently closed and the condyle moves ftom the cemral area of the disc and then past the posterior band as the anicular disc once again becomes displaced. A crepitation sound (also known as crepirus) is usually associated with a degenerative process (osreoartilritis) of the condyle, the dull thud is usually associated with n self-reducing subluxation of the condyle, and tinnitus is described as ear ringing.

~ENTALANATOMY & OCCLUSION

A patient with chronic TMJ lnOununatlon is being treated by a dental TMJ expert. To supplement his examination, the dentist wants to image the soft tissues of this patient's TMJ. Which oft he following is the bes t Imaging modality for Identifying tbe position of the articular disc of the temporomandibular disc?

Panoramic rndiogroph Magnetic resonance imaging (MRJ) Computerized axial tomography {CAT Scan) Laternl transcrnnial rndiogrnpb

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r
On extra-oral examination of his patient, a dental student notices that when his patient OJlens his mouth the condyles move at different times. This leads to a slight de,latlon of the maodible to t11e right and then back to center. The patient is asymptomatic, but the deviation is also associated with disc displacement, with reduction of the articular disc of the temporomandibular joint. What type of sound best describes this disc displacement?
~

Crepitation

Tinnitus

Dull thud
Click

eo,.nsm o J.009.1o1o o...., """

...

The articular disc (mMi<cus) is composed of dense fibrous connecthe tissue, and it is positioned in between the condyle and the fo>so, thereby dividing the joint UltO >Upcrior and

1nferior joint spaces.

The articular disc (melliSCUSJ varie. in thickness; the thiMer central intcnnediate .GOne separates tbe thicker portions, which are the unrcrlor nnd posterior bands. The po>terior band of the articultu disc is the thickest of the two bands, and it is attached with posterior loose connective ttssues called retrodiscal tissues (hilominar zone; poste,.tor alfllclunellt). The less thick unterior band of the articular disc is contiguous with the capsular ligament, the condyle. and the superior belly of the lateral pterygoid muscle. :\ole: The retrodiseal !Issue is highly vascularized a.nd iMervated. whereas the articular disc for the most part is noc. Only the extreme pcnphery of the articular disc is slightly tnnervated.

nt'n'tt'

fihflltl"! \UIIIIl'\'11\l' th'iriU('

The most suporli<iallayer of the arti<:ular surfaces of the T\1} (condyle ondfOJJa) tS made of dense fibrous connr<the tissue and not hyahne canilage. Underneath tht> >uperficial layer IS a layer offibrocanilaginous tissue that ofTeN; ...,;stance against both compressive and lateral forces. Articular surfaces of most dianhrodial joints are co'ered by hyoline canilage. but the TMJ as un typical dianbrodial joint m that its anicular surfaces are covered w1th a dense nbrous tOniH~CtiYe tissue. The TMJ is the nnculmion between the condyle of the mandible and the squamous ponion of the temporal bone. The condy le is elliptically shaped with its long axis oriented mediolaterally. '11te articular surface of the tcrn)l(i<al bone is composed of the concave articular fossa (wltich is the anterior three{o11rrhs nf the larger mandibufllr or glenoid fossa) and the conve' articular emintnce (tulwrdt).

Sat~ttal ~ Ollbt ~dibular joiDl. IIX ~~~- tllr 1!1KII-1attnc 1U\'a or tht tcmpQfal bcl"'t,

rM rtiNlawsg surface" oftbt OOI'ld)'k. 1114 tho 4e;co anda~k or fue Jum\.

~ENTALANATOMY & OCCLUSION

Which component of the TMJ has the most vasculature and innervation?

Anicular fossa Anterior band of the anicular disc Posterior band of the anicular disc Anicular eminence Retrodiscal tissue

Capyrl&htC 20(19..201 0 Dtmal Dtd.s

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~ENTALANATOMY & OCCLUSION

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A relathely unsurress ful treatment option for Individuals suffering from osteoarthritis is to inject or Implant hyaline eartilage into areas of articular cartilage degeneration. If osteoarthritis were to involve tbe TMJ, this treatment modality would deUnitely be unsuccess ful because tbe articular surfaces of the T MJ are covered \\1th:

Dense fibrous connective tissue

Periosteum
Elastic cartilage

112
Copyn~l 0

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I \tlrnalh n\er thl" po"trrinr

"II' f;tn ut llw l."nnci~ ll \\ifh I he numth OIJNI

The tempo r om andibular joint sbould be ealuated for tenderness and noise. When checking for joint noises (chcking o11d Crt'pitus). the joint is palpated laterall) (tn front of the external auditory mcallls) while the patient opens and closes the mandible. Tenderness can be assessed by palpating the lateral aspects of the joints when the mouth is closed and during opening of the mouth. The joint should olso be palpated for tenderness while the patient opens maximally, and the fingertip should be positioned slightly posterior to tbe condyle to apply force to determine if there is inOammation of the retrodiscol tissue. Note : P lacing fingertips in the patient's external auditory meatus, can prod uce litlse joint sounds d uring mandibular function because of pressure against the thin car cunal cartilage. Remember : I. The posterior aspect of the condyle is rounded and convex, whereas the anteroi nferior aspect is concave 2. The condyles are not symmet r ical nor identlr al

\nllriorl~

and occur" \\lull-lauchinl! m \annm).!

Olsloration of eitller or both TMJs can occur when the condyle translates anterior to the crest of the anicular eminence. and the condyle becomes trapped in front of the eminence, resulting in the patient's inabilit)' to close the mouth. When the mouth is opened to us fullest extent, such as with laughing or yawntng, the condyle will tranSlate to irs antenor limu. Sometimes the mouth is opeocd beyond tiS normal limit, and the llJOutb locks open because the condyle becomes trapped in front of tl>e anicular eminence. Dislocation is also called an open lock. Reduction of the dislocation is done by stmdtng behind the patient with the thumbs tnsidc ~te mouth and the index fmgers below the chtn. Tite thumbs depress the back of the mandtble. and the chin is elevated by the index fingers. The head of the condyle will then slide into the anicular fossa. Note: The tenn subluxation refers to hypermobility or hypertranslation of the mundiblc. When there is natural laxity or looseness of the ligaments associated with the TMJ, the mandible is able to open beyond the usual onterior limit and can appear to be a dislocation, us previously described. l~owever. wtth n subluxation, the patiem can self-reduce. or return, the mandible to its nonnal position without the assistance of a dentb1.

Oosed po$1 tion

Optn potltlon

AnltriQr dWC!~ti{ n

~ENTAL ANATOMY & OCCLUSION

,
A patient with constant, unexplained headaches is referred to a TMJ specialist by his physician. In order to check for tenderness, the specialist must palpate the joinl. What is the best way to palpate the posterior aspect of the mandibular condyle?

Immorally Externally over the posterior surface of the condyle with the mouth open Through the external auditory meatus Any of the above

178
C<lp)'rl$bl c 10092010 IXntal Oec.kJ

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A 56-year-old man comes into the ER with his mouth "ide open. His \\lfe explains that be can't close his mouth. The resident on-call quickly djagnoses this as a bilateral dislocation of the TMJ and treats it promptly with reduction. Dislocation of the TMJ is almost always:

Posteriorly and occurs wbile sleeping Anteriorly and occurs while laughing or yawning Anteriorly and occurs while chewing food Posteriorly and occurs while laugbmg or yawning

C09)'1'1JI'I't 0 20092010 Dc11tal ~ks

...

Splwnumandibul:itl" liJ!amt>nl
The spbenoma_ ndibular and stylomandibular ligaments are considered to be accessory Hga..

mcnts. The former is attached to the Hngula uf the mandible and Ute- latter at Lbc angle of tJte mandible. Titc_sc li.gamc-nt<; arc responsible for' Hmita1ion of mandibular movements (tlt~y limit e.t<'essivc opening). ~ote: The sphenomandibular ligament is mosl oficn damaged in an inferior alveolar nerve blook. lhe temporomandibular ligament (also called the lateJalligament) runs from the artlcutar emInence to tJtc mandibular condyle. II provides. lateral reinforcemem for the capsule. This ligament prevents posterior and infetior displacement of the condyle (it Is rlre main stabiUl.i"g ligamem of the TMJ). Note: l1tis ligament keeps the head of the condyle in the mandibular fossa if the condyle is fractured. CollareralligamtntS (medial am/lateral) also referred to as ~-tdiscalligaments," are ligaments that -arise: fro1n the periphery oftJ1e disc. are attached to lhe medial and Ja1eral poles of the condyle respectively, and stabilize the disc on the top of a he oondy1e. TI1esc ligaments restrict movement of tbe dl~~ away from ~te condyle during functio n. Note: They are composed of collagenous connee live !issue; thus lhey do nur stretch.

Sphe.nom-ancllhnlar-+--.1.
lis:ament

SJ,toid pn1etss or
temporal bOIIt! Stylomandibular flgamtnt

On protrusion. the mandible will deviate to the same direction as the damaged lateral pterygoid muscle. The lateral pterygoid muscle is actually comprised of the sup<:rior belly and the inferior belly. The htferlor belly originates. ti'om the lateral pterygoid plate nnd inserts on the neck of the condyle. The superior belly originates ti'om the greater wing of the sphenoid aod infratem poral crest, and insens 011 the joint capsule, the articular disc. and the neck of the condyle. :>ore: Each belly has ditTerc nt functions. Wheo the right nnd left inferior bellies contract simultaneously, the mandible is prorruded, whe reas unilatentl contraction results i n a lateral movement of the mandible to the opposite side. When the right and left inferior bellies contract along with the mandihular depressor muscles, the result is mouth opening. The function of the superior belly is to assist in stabilizing tbc position of the articular disc during mouth closure.
u

tin \)usdL''Ht \lastH:-alinu ullh \ssucmtrd \lmrnu.-nhot th<' \landihk

1\tusdes of ~fastlcatlan
Ma.. ~o;sete-r

MoYemeots of MandJbJe

Temp0r111is

Medial pterygoid Lat.,.! pterygoid

. .

Elevation of the mandible (druingjawclosing) Elevalion of the mandible (tlm i pgjaw closi~rg) Rerraction of the: mandible (lower jaw backwarcl)
Elevation of the rnandiblc (dlm'ngjaw clwilrg)

Inferior be-ads: slight deprtssjull ofdtc mandible (duringjaw OJXming)

One muscle: lateral devjation of the mandible (to

Jhifi 1/Je lower jaw to t1J4 opposite side) Both muscles: protrusion of the mandible (lower fow forward)

ENTALANATOMY & OCCLUSION

A dentist is performing a routine restoration on the left mandibular first molar. He is giving an inferior alveolar nerve block injection, where he deposits anesthetic solution right next to the Ungula and mandibular foramen. Which ligament is most likely to ge.t damaged?

""'

Sphenomandibular ligament Stylomandibular ligament Temporomandibular ligament

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~ENTAL ANATOMY & OCCLUSION

r
A patient comes into your dental office complaining of chewing difficulties. When you ask him to protrude his mandible, the mandible markedly deviates to the left. Which muscle, which inserts fibers into the capsule and articular disc of the TMJ, Is most likely damaged?

""'

Temporalis muscle Buccinator muscle Right medial pterygoid muscle Left medial pterygoid muscle Right later. I pterygoid muscle Left lateral pterygoid muscle
178 Copyrigllt<l 20092010 Dental Ottb

Remember: The crown 1s not as bilaterally symmetric:al as the mandibular central mcisor. The crown is tilted distally on chc: root. The dist.oincisal angle is more rounded lhat~lhe me:soincsal angle.
It is broader lablollngually 1han mesiodistally The lingual s urface is smooth. The cingulum is s lightly off-center to the distol. The mesial marginal ridge is slightly longer than the dist"l mnrginol ridge

Mandibular Left Lateral Incisor

F~:------,.......,

lncisaJ

Mesial

Cf'r''kM

......

0 ......

~
,ttl lOri

Mandibular Right Lateral lncltor Pulp Ca,lly

L11blotln1l

I ht. pt. rm .tntnl m.uulihul~r ll'ftn: ntr:tl int.'l\n r

Remembtr: The manchbula.r ccntn.ltncisor is lhe Just' arilbl~ toolh 1n the mouth. his also the smalltstlooth in lhe denhtton. his smaller than the mandibular literal. which is noc.lbc: case in the maxillary arch The ero"-'11 s ,.Cf)' smooth and Jacks anaton"'leal fean.trfi. Tbe tncisat outline is sb'l.atht and perpen-dicular to the long axi~L The mesial and dis.tal inCl5a.l angles are almost 90
The cingulum IS c-entered Mandibular Left Central

Lnblol

Incisal

Mesial

r-

C~l .....
\letlodiil.J

......

~
IAW.Itrnl

Mandibular Right Ctntrallncbor Pulp Cavity

......

~ENTAL ANATOMY & OCCLUSION

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,
The photo below Is a labial view of wbat permanent mandibular tooth?

175 CopynaJ'ItO 2009-2010 DentD11)b

~ENTALANATOMY & OCCLUSION

Pict- T)

The photo below Is a lingual view of what permanent mandibular tooth?

171
CO())TiJM 0 20092010 Dt:fttal Decks

llu: [ll'fnl<tnC"nt mandihul:tr llH 'l'\'HntiJHl'I11Uhtr Remember: This tooth resembles other premolars from the burral aspect only The apex of the root approximates the mental foramen Most frequently has a single central pit. There is no mesiolingual groo'e or tranS\' elSe ridge {both are common on the first premolar)

Mandibular Left Second Premolar

Lingual

Occlusal

1 Mesial

Distal

I ht fll'l"nl:Jnt'nt numdihular riJ,!h1

l':tnim

Remember: It may he bifur cated into labial and lingual pans. A developmental depression may appear on the mesial root surface. In cross-section, the root is ovoid, but wider mesiodistally at the labial.

@
Ctf"\lctl tron stetlon
\1n:iocli,ul

sdon

Labioliogusl 51ioo

Pulp Cavity

~ENTALANATOMY &

OCCLUSION

Pict -T )

Th e photo below is buccal view of what permanent mandibular tooth?

173
Copyright C 2009201 0 Den111 Deets

~E~TAL ANATOMY & OCCLUSION

Pict - T)

T he photo below is a labiollnguai section of the pulp cavity of which permanent mandibular tooth?

170
Cepyn.sbl c 2009-:010 Or:ll" ..l Dla

Remember: The crown resembles the maxillary central incisor: h<mcver, it is smaller in all dimensions except the root (root lengths are equal). The mc~1ochstal measurement is greater than the labi-

olingual measurement
A linguAl pit Is common (more pronounced th(ln moudlbular lateral). Tho lingual surface is the most coru::a,~e of any of the incisors (nra.ti/l(lry and numdibu/ar) Maxillary left Lntcral l ncisor

''

Incisal

Maxillary Right Laterallnris:or Pulp Cavity

l.l,.oii"IU I
\110"

Remember: The crown is the longest and widest ante-nor tOCMh. h tS 1he most prominent tooth in the mouth. The crown outline is wider meslodiJ:taUy than (ado lingually The mes1al cul"\iaturc of the cervical line is larger than any other tooth. The cmaulum IS "ellde,eloped and is located oiT-ttnter toward the distal The maxillary central incisors have the narro~est incisal embrasure$ MaxiUary Left Ctntral l ncisor

lingual

Incisal

'--'

\fn:iodirtl

~ -
Conkol

i\ (
.l

I1 \

.,_

Rigbt Ctntral ln<isor 'MaxiUary Pulp Ca>it)

Lab~fiiOII
~to

ENTAL ANATOMY & OCCLUSION

Pict- T)

The photo below Is a lingual view of what permanent maxillary tooth?

171

Coro'"Shl 0 20092010 Dental Oks

ENTAL ANATOMY & OCCLUSION

Pict- T)

,.

The photo below Is a labial view of what permanent maxillary tooth

172 CopyrighlC 2(11.2010 ~~ De<:b

Tht plTill:tnent m:".:ill:u' ldt second pn.mnlar Remember: The crown is smaller than the firs t prcmol~ r. from the occlusal, it is much more symmetrical and less angular (more ovoid) than the first premolar. The crown is wider fa.cioli ngutlly than mesiodistally The buccal and lingual are almost equal in height Thtre is me.siaJ inclination of the lingual cus-p (sam~ as first premolar). The distal buccal cusp ridge (DBCR) is longer than the mesial buccal cuSp ridge (MBCR) the opposite of the maxillary first premolar.

Uft Second Premolar

Max:illary Right Second

Premolar Pulp Cavity

M rsiodit:tad

lluccolin~v l

tlion

M'<'llon

fhe permanent maxi liar~ leU caninl' Remember: The crown has a prominent labial ridge. The cingulum is large and centered mesiodistally. It is wider labio-lingually than mesiodistally. From the proximal view, they appear to be positioned vertically in the arch It is the longest root. The heavy root results in a bony labial ridge called the canine eminence When viewed from the incisal, the cusp tip is located on the mesial-facial of the crown. The mesial cusp ridge is s horter than the distal cusp ridge
Maxillary Right Canine l,ulp Cavity

Maxillary Left Canine

l .biotlngliS\ stlon

ENTAL ANATOMY & OCCLUSION

Pict- T)

Which permanent tooth Is shown below?

Cop)'liJhtC> 20092010 lkflg,l Dttla

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~ENTAL ANATOMY & OCCLUSION

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The photo below is a labial view or what permanent maxillary tooth?

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Dtr!L&I Ded.s

1 hl'lll'rnt:tnl'nt m:mdihul.u left

~econd pr~.nwlH

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Ill' of ocdu'>alsurf<ll't" p.1ttern

Remember: This tooth most frequently bas a single central pit Resembles other premolars from tbe buccal aspect only lt is nearly square in shape, with little of the lingual convergence that is seen on the mandibular To determine the right from the left for this tooth, the occlusal view will show a slight

mesial concavity
I. The lingual surface is much wider mcsiodistally than the lingual surface of 1I Not.. the first premolar. 2. The interdental papilla between the mandibular second premolar and the first molar is shorter (cervico-occ/usally) than any other in the mouth. Mandibular Left Second . P remolar Mandibular Right Second Premolar

c~nirlfl

rross slklfl

Pulp

Cavity

Butrol ngual .swJoft

l'lu. distal 'il'\\ of <1 permanent m:mdibul~1r lt'ft first molar The key to the sketch is the distobuccal developmental groove on the facial. You need to know this tooth from every view (mesial, distal, facia/, and lingual).

Mandibular Left First Molar

-~

Mesial

Occlusal

Buccal

0E~TALANATOMY & OCCLUSION

Which permanent tooth Is shown helow?

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Copynght 0

20092010 Otmat Dctlt

0ENTALANATOMY & OCCLUSION

Pict- T)

The photo below is:

The mesial view of a permanent mandibular len first molar

The distal view of a pennaneot mandibular len first molar

The mesial view of a permanent mandibular right second molar

The distal view of a penn anent mandibular right second molar

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CopyncblC 2009-2010 ~I J)c(:b

'I ht rwrmam~ nt mandihuk-tr ll'l.t firsl pnmolar Remember: T his tooth has a mesiolingual developmental groove This tOoth has a large buccal cusp that occupies. a lmost two-lhirds of the occlusal surface This tooth has a very prominent trans,erse ridge with no central groove~ but 0\ay have mesial and distal pits h is the only posterior tooth in which the occlusal plane is tilted lingually in relation to L hc horizontal plane Distinguishing features: Has an extreme lingual taper for a posterior tooth. II has the greatest lingual inclination of the crown from its root of all mandibular teeth. Has a meslollngual de,elopmental groove, The mesial marginal ridge is shorter in length and less prominent In height tban the disllll marginal ridge. Occlusion: the bucc-al cusp contacts the mesial marginal ridge area (specificafly tlte mesial triangular fossa) of the maxillary fi rst premolar and the distal marginal ridge of the canine. Note: The attached ging iva is l'cry narrow on the facial (co mpared to any other mandibula,.

rooth),
Mandibular Left First Premolar Mandibular Right first Premolar

.Pulp cavity

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Mt.S odlstal
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Buteo fnaual
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nu pcl'nuncnt mandibul:tr l<'n rir\f nwlar *** This tooth presents a pentagonal "home plate" occlusal outline that is disti nct ive fo r this tooth. There are live cusps. Of them. the mesiobuccal cusp is the largest, the distal cusp is the smallest. Remember: This tooth i~ largest of the mandibular teeth fi is the firs t permanent 1ooth to e rupt 11 has five cusps {three buccal, MO lingual) The mesial-distal d imension is slig htly greater tha n the facio lingual d imension of the c rown 11 is important to properly restore the lingual cusps of this tooth because these cusps are involved in working movements NMe: \Vhen a protrusJvc mandibular movement is achieved~ the mand ibular first molar bas the potential io c ontact the second premolar and the first molar. Mandibular Left First Molar Mandibular Rivht First Mola r
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Mcslodlrtt S:ttllon

Buc~&&ltal
3t c:lloa

Pulp Cshit-y

Mesial

Distal

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ENTALANATOMY & OCCLUSION

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Which permanent tooth is shown below?

115 Copyn,ah10 10092010 De-ntal Db

ENTAL ANATOMY & OCCLUSION

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Which permanent tooth is shown below?

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Copynah 0 20092010 lkMal Dlr.t

llu. perm.ml'OI nmndihular llft canim To distinguish a right mandibular canine from a left mandibular canine: remember: T he distal cusp ridge is longer thaJl the mesial cusp ridge The mesial surface of the crown is almost parallel to the long axis of the tooth Occlusion: the cusp tip opposes the incisal embrasure between the maxillary canine and the lateral incisor, while the racial surface opposes their marginal ridges. lmporlaot: In a Class U relationship, during a protrusive movement they contact the maxillary canines and lateral incisors. t I. The cingulum of a canine is similar to the lingual cusp of a mandibular first Note:s~ premolar. 2. When viewed from either proximal surface, the facial outlioe from cusp tip to root apex is made up of one continuous arc (from the facial, the proximal surfaces from the comact to apex look Uke a straigh/Ji,e). 3. One variation of this tooth is that orl occasion, the r001 is bifurcated (facial a11d lingual roors) near its tip. The double root may. or may not be accompanied by deep depressions in the root.

Mandibular Left Canine

lingual

Mesial

*** The key to determining right from left is lhe mesialmarginaJ groo"e.lt extends onto the mesial surface. but firsl it crosses the mesial marginal ridge. Remember: This tooth has a pronounced cervical concavity on the mesial surface of its crown This tooth is the premolar that has a mesial buccal cusp ridge (MBCR) that is longer than its distal buccal cusp ridge (DBCR) When viewed from the lingual, the lingual cusp is inclined mesially MaxiUary rught First Premolar Maxillary Left First Premolar

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Pulp cavity

ENTAL ANATOMY & OCCLUSION

Pict- T)

The photo below Is a labial view of what permanent mandibular tooth?

1&3
CopyrigbtO 20092010 De:m1l Dlu

ENTAL ANATOMY & OCCLUSION

Pict- T)

Which permanent tooth is shown below?

Copyn,lbl 0 20092010 Dtnul DU

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Tlu. pl'rm:.tnlnt mandibular left second molar

Remember: It is the most symmetrical molar (two buccal and two lingual cusps) oc.clusal pattern looks like a plus sign (+) Tbe faciolingual dimension is broader at tbe mesial than at the distal The l.i ngual height of contour is located in the middle third Mandibular Left Second Molar

Buccal

Lingual

Mesial

Distal

I hl' hurcal 'il'n of a prrmanrnt mandibular ll'fl Sl'Cund moh1r

***

Keys to distinguish between the buccal aspect and lingual aspect: On the buccal, there is a slight cervical dip of the CEJ; there is no dip at all on the

lingual
The buccal developmental groove exlends almost halfway down the buccal surface and ends in a pit: on the lingual, 1he groove only extends slightly onto the lingual surface

Mandibular Left Second Molar

Lingual

Mandibular Right Sewnd Molar Pulp Cavity

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Midrool

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nttion

Jllon

EENTALANATOMY & OCCLUSION

Pict- T)

Which permanent tooth Is s hown below?

111 Cop)'rithl 0 20092010 Ot"UII [)e.c:k$

ENTAL ANATOMY & OCCLUSION

Pict- T)

Tbe photo below is:

The buccal view of a permanent mandibular leO second molar The lingual view of a permanent mandibular left second molar
The buccal view of a permanent mandibular right first molar

The lingual view of a permanent mandibular right first molar

1&2
Cop)Tiih1 0 2009-2010 ~tal [)ec;kJ

I fu. distal \ k" uf m :l\ill:1r~ ll'ft fin;t molar

The key to the photo is the distal concavity (represented by rhe dotred line). This concavity needs to be taken into account during root planing (it is lrard to remove calculus in this area} and when adapting a matrix band. Note: The distal facial root is the shortest; therefore when viewed from the distal, the mesial facial root is sometimes visible. The mesial facial root is flattened mesiodistally and has root depre$sions oo both mesial and distal surfaces. Maxillary Left First Molar Maxillary Right First Molar
Pulp c.:wity

Me-siodistal section

Ouec:olingual section

Mesial

@
Cervical cross section Midroot cross section

I'IH' pt.:rmanl'nl rna\illar~ ri~ht wcond molar Remember: This tooth resembles the maxillary first molar except: h's smaller The buccal is broader than 1 he lingual due to the absence of ihe fifth cusp (of Carabelli) fis more angular DL cusp may be absent. When this occurs. the occlusal otnline takes on a "heart shape.. as opposed to the more common rhomboidal occlusal outline (true/or all maxillary molars) ~u, xwnry Left Second Molar

Mesial

Maxillary Right Second Molar Pulp Cavity

ENTALANATOMY & OCCLUSION

Pict -T)

The photo below is:

The mesial view of a maxillary len lirst molnr The distal view of a maxillary rig ht first molar The mesial view of a maxillary len second molar The distal view of a maxillary right third molar

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CopyriJlltC 2009-2010 Dent01l Dks

ENTALANATOMY & OCCLUSION

Pict- T)

Which permanent tCHlth is shown below?

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eop,n1t.e 100920to De-r~t~l Deeb

\I andihular cenlral im:i,nr

Labial Lingual I nclsal M~lal Distal The mandibular central incisor is the least variable tooth in the mouth. It is also the small est tooth in the dentition. It is smaller than the mandibular lateral which is not the case in the maxillary arch. Crown: very smooth; lacks anatomtcal features. The incisal outline is straight and perp<:ndi cular to the long axis. 11le mesial and dtstal mcisal angles are almost <xr. Root: one: tapers evenly to a sharp apex. Vtry narro" mesiodistally, wide labiolingually, and concave on both the mesial and diStal surfaus. Surfaces: lingual surface (oonco-e) and lingual fossa arc very smooth. The cingulum, MMR. DMR. and ioeisal ridge come together. forming a shallow lingual fossa. The cingulum is ten tered. The labial surface is con,ex. Pits and groo,cs: few if any developmental lines and grooves. Occlusion: in the interclL>pal position, each one occludes with only one tooth. tbe opposing maxillary central incisor. I mportant: In an ideal imercuspal position. the distolnclsal aspect of the mandibular central incisor opposes the lingual fossa of the maxillary central incisor.

ll

I ht ptrnmtunlma\illan ri:,:hl nr,l uwlar

Remember: It is the largest permanent tooth Broader lingually than buceally Cu5p of Carabelli is found hngualto the ML cusp The total number of pit5 on the oc:clu<al surface of the maxillary fmt molar is the same as found oo the occlusal surface of the mandibular second premolar {Y-I)pn) From a buccal \i l.'l, the buccal roots present a "plier handle" appearance with the large lingual root centered between them Occlusally, the tooth is somewhat rhombolda~ with four distinct cusps. The cusp order according to size is: mesiolinguol, mesiobuccal, distobuccal, and distolmgual

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Maxillary Left First Molar

Buecal

Lingual

Mesial

Distal

ENTALANATOMY & OCCLUSION

Perm-T)

The smallest tooth in the dental arch is the:

Maxillary central incisor Maxillary lateral incisor Mandibular central incisor Mandibular lateral incisor

157 Copyri.ghl 0 2009-201 0 Dtn1 111Dk.s

ENTALANATOMY & OCCLUSION

Pict- T)

Which permanent tooth is shown below?

158 Copyngt11 10 20092010 l)cnlnl Dt:tb

Butta! Lingual Occlusal -'lesial Dl tl Cro,n: sceond molor is s maller than fuM molar, pan.cularly in its width on tbe linaual side, which has a smaller or nonexistent O_ l cusp flootlt may only hO!.'t 1hree cusps} and IS also small<r mostodlstally. Wh<"' viewed from the occlu>al. the rnt'siodislal li11c angle ts the moSI acute. Buccal is broader rhan lingual due 10 obscnte oft he llflh cusp (Car,helli). IllS more ongular than tho first molar. Roots: tl>rco; they ore as long as first molar but arc less spread apan mcsiodismlly and f.~Ci olingually. They bend more to the distal and have o longer root trunk (as comporl'd JQ Jhejirs/ molar). Cusps: cusp or Carabclli I! absent. The ML cusp" the larsest, DL cusp is the smallest (sam a.<maxmuryjint molar). The primary cusp triangle lS fonned by 1be :">IL, MB. and DB eusps (some for all nuwllar)' molars). :oiole: The DL cusp as not a part of this lrianil<. Occlusal pattern: smaller oblique ridge and 1 more vaned pll and groove pancm compared to fin.1 molar. The tnmsverse groove of the oblique ridge connects the central and distal pits (same for all maxillary molars). Not~ : The buccal groove is <horter and docs not b11ve u pit !COmpared to firstmolm). DLcusp
may also be ltbstnf on maxilla[)' third rnolars.

\landihular wt.;mul molar: it i\1 thr nw't "nmu.trh:al molar

Buccal Lingual \lesial Cro" n: rc:.cmblcs the mandibular first molw ex<ept, 11 bas no tifth cusp Md it ts smaller Occlusal outline is rectangular. The greatest fatlolingual diameter cs located tn the mesial third of the crown. Root: two; they are closer together and straighter Lhan the first molar roots and are in clined more distally. Mesial root is not as broad faclnlingually compared to ti rst molar. It has a longer root trunk. Cusps: four (two buccal and two lingual). This contributes to symmetry. Occlusal pattern: looks like plus sign(+). Facial and lingual grooves form right angles witb the central groove. Central groove is s traight. Has more secondary developmen cal grooves (thre<' ofthem) than the first molar. lias rwo tranS\erse ridges and three fossae with pits. Dislingui~hlng fealliTCs: bas only one buccal groove and one buccal pit.

E~TALANATOMY & OCCLUSION

Perm-T)

Whicb molar is least likely to need a buccal pit restoration?

Maxillary first molar Mandi bular first molar Maxillary second molar Mandibular second molar

155
Cop)rit ht 0 2009-lOIO OcnUIII:)eQks

ENTAL ANATOMY & OCCLUSION

Perm-T)

You buy a batcb ofpre-fabrltatt d temporary crown restorations for your office for the first lime. Your assistant drops the entire box on the ground and they all get mixed up. The hardest tooth to distinguish left from right will be the:

Maxillary second molar Maxillary first molar Mandibular first molar Mandibular second molar

154 Copyna,htO 2009201 0 Demel Db

Mandibular Right Canine

Labial Lingual Incisal Mesial Distal Crown: Labial surfac..e is smooch and convex. Labial ndie b not as prom1nent as tht- maxillary cantnc. The ~!~""lest factoltMiJual measun:ment is gr.. t<r than the I!I""ICSI mcsoodiSIOI measun:mcnt

Koot: one; may be bifurcated mto lobtaland lingual ports. A developm<nlOI dcprc<sion may appear on the mesial root surfact. In cross-scclion. the root is ovoid, bur wider mtslodlnally at the labial. Cusps: the cu.<p tip is displaced lingually. The mesial cusp ridge is shorter than the distal cusp ndgc (m(Jre ~(')than on ma.ril/(1')' canines). Surface<: the m.,;ial >urrace or the crown is almost paralltl to the long aJtiS or the tooth. The ciogulum ~~ ltss bulky and 1tS) prominent than the nw"llary canine. Comparisons: it appearS mort slender and is smoother than lhe maxillary canme 1n otll respects; the labtal and lingual ridge> arc ltss well developed llus fcoture allows them to be ,.,., tarits re-

shtanc.
"'"*All canines ha\e a rneslot11blnl de\1elopmental dtprtsslon lhat is found on the labial crown surface in the incisal lhird,just mesial to the labial r1dge.

\l.uu.h hul:tr "l" i,:ond prl mul:lr

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1 /

Ut~ceal Llngunl Mesial Dlshtl Crown: usu<tlly develops frorn f1ve lobes (tlte Y-lyJX!) and has three cusps.. one buccal and two lingual. From the buecal. it is shorter and wider than tbe lirst premolar. from tbe occlusal, it has a squa"' outline. It resemble> other premolars from the buccal OSJ>f"t only. Root: one~ ape.' approximates the mrnral foramen. h t.; thicker and longer th:m the: root of the mandtbulsr firs1 prtmOiar. Cusp: buccal cusp i; shorter, not as sharp, and the cu>p slopes arc; less steep thon the mandibular first pn:molar. Mesiolingual eusr IS always larger lhnn the PL. cusp which moy be absent. Buccal me lines of the lingual cusps arc runctional. From a distal view. it is usually po~~iblc to see the outline of alllhree cusps. Pits and grooves: central drvelopmental groove ts somclimcs oaU''- shaped or looks like acres-cent. It end> in the mesl31 and distal fossae. where tt ollcn join; a MB and a DB >upplcmental

groo"e
Ocolussl pattern: largt r ocdu'"l <urfacc than fiN pmnot:u-. Wid<r on hngu>lthan buccal. :.lost frequently has a .single central ptt. There is no me)tohnaual gtOOvc or transverse ndg.: {both are commor~ on first premolar).

ENTAL ANATOMY & OCCLUSION

Perm - T)

Tbe anterior tooth mos t likely to have a bifurcated root is the:

Maxillary central inc isor Mandibular canine Mandibular central incisor

Maxillary canine

153
Cop)'ri$hl 0

20092010 Drnl.ll l)rc.:l:J

ENTAL ANATOMY & OCCLUSION

Perm -T)

\..

Wbich teeth may show three types of occlusal surfaces (or pit and g roove patterns)?

Maxillary first premolar Mandibular second premolar Mandibular firs t premolar Maxillary second premolar

154
Copyntbl 0 20091010 Denal De<:b

 ll is not untomrnon to find a deep dcvelopmen,al groove a.t the side oflhc t'ln~uhJIIl. This is usually found on lhc distol side. which mny extf!l1d up on the root for part or :111 of its length,

1'\

~l uiUry lti~ht

lntbal M.,il Olstal Cro" m resembles chc nu~xmar~ ctntral incisor": hu~cvcr. Ills sntallc-r In :.111 dimensions except the T'QOt (rootlrnp.llt.'t tul! equal). Th.: mesiodistal measu~ent Is greater than the lnbiolingual mcas.. urement. Root: one: lhe apex i~ pointed and wually deviates to lhc distal. Surfaces: lingual pit Is common (MOlY pttmowu:edthan mQiftlifH,JariDieral). LtniJUal surface is the m~l t'ODta' t of an) of the inei.sors (ma.rfiiDI)' ami nramllblllar}. The lingu01ncu;.al ndge is weU d~ 'tlopf'd. The distofntisal comer or a.ng)t is more rounded (ron,oex) than thai of lhc centra) tnclSOr. Pits and groo~~s: may h11ve a radi(ular groo,e which ~tend~ from d1e cingulum onto the: root sur r~1ct (ii is prone tn dc.eay). DL groove nHL)' complicate rom pinning. Ocduslon: in the intcrcuspaJ posiuon. il opposes the incisal edge of the rnandibultlr Intern I and the , Jn ine~ his the tooth th:u is most often in an abnormal rdauon 110d con1a.ct wub adJacem teeth :n the hlmc: 3J'ch.. Ol.stinc,aisbin.g fnturet: may bt. c-ongtnllaU~ abstol fnmu qftffl ofthe J"miOIH!nt onrerior :ntlt). It i ~ the Ji.\.1 antalor rood1to begln t.alclflutlon 110 mmrth..fJ, Da"J)t:sys greater~ artallon in form than t.tn)' other pc:nnancru coOth, excep11he tlurd molars. It ma> urpear ...pegshapcd'' or numifc~~t1 as ..dens
Labial
tO dcnte,"

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l..aterdl fntlsor

\lt>.,io-~ Jcdu,a l

Oh,..i:ll ('OSI(';I\ih

ul .1 ma\illidn tir'l pn,.rnol:rr: lin tu""'i:al 'urfa('t' h n' u lh ~ t \:!0 h (' h :1rd Ill :ui:Jpllo \\ilh ~~ JUD1rh h~md

1unmwn~~d

**""'mmediately cerviCal to tbt mcs1al contact area. c.ctnekd on Ihe mc.siaJ .s.ur(ace, ill a marked dep~ " IDn., called the: mcs1DI dt\'tlopmerual depression\ which tonunucs UJJ l<' and in clude.~ the cervical line.

1)
Bucul Lingual O.:clusal Mtllal Distal Cro" o: ""idrst or all prt-mo.brs (IJ'Id.Xtllat') aM MtzJ,dlltctlar}. The oblong cro~n outline is grrattr buttolinguaU) thM mcsiodistally. fboy 011' longer <rl" lcCH>tclusaUy than the ..cond premolar,
fir~t roolar. or second molar.

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"

MO>illa!') Rij()lt

first premolar

Roo1s: two roots, one buccal anJ one lingual, each with one tonal. This is the only JU'\'111olar that ha.~
1" o

rootS. When viewed from 1hc proximal, the-axial incliruuion ufrhc roots UJ)pcar5 "ertic:al. Cusps: rwo; rhe lin;ual cusp Is shorrtr than lhe buccal cusp. The buccal cusp tip is sh31p and Is r tJc<d shg.hrly to the disllll. The m.,tal buccal cusp ridge b lon~er than the d!Sial buccal cusp 1'1dge. The lingual cusp tip as located "'"llld the m,.ial balf of the hng,ual surface. Cusp oncliru:s .,.. <rf') Surfaces: mesial surface has a pronounced (dNp) ccn ita! conca1ty (de~eloprn<IIIDI dtpl'<mon)that l't'qlrire.(O special consideration when periomung periodontal moinrenanc:c. Has a pmmlncnt bu ~c:al
ridge.

UH'p.

Occlusal patttrt.: h3S a deep sulcus ond tong central groo Usually few supple.nental groo"" and
r.ll pits.

Comparison: ""'mbl.. the second pr<molar. h<ept II is larg..- and more anaular; the '1BCR II longer man the OBCR.lhe buccall'ld~e is more ptomllltnt and 11 has a longer central groove.

ENTAL ANATOMY & OCCLUSION

Perm - T)

You hate to sec it, but this patient has a carious lesion on an anterior tooth. You sec carious lesions in this location more than you would like because this tooth occasionally exbibits a li11gual groove that extends from the enamel onto the cementa I area of the root. Which tooth is this?

Maxillary central Mandibular central Maxillary lateral Mandibular lateral

151

Cop)TiJbiC 2000..2010 1'.>enl:lll)ed:s

ENTAL ANATOMY & OCCLUSION

Perm-T)

I"
\.

Wbcn filliJlg a Class II amalgam you arc having trouble fitting the matrix band perfectly and keep getting an overhang in the cervical area. Wbat surfaces arc you preparing?

Mesio-occlusal of a maxillary first premolar Disto-occlusal of a maxi llary first premolar Mesioocclusal of a maxillary second premolar Disto-oc.clusal of a maxillary second premolar Mesio-occlusal of a mandibular first premolar Disto-occlusal o f a mandibular first premolar
152

Copyri. glu e 2009-20 1 0 Otnul Dk..~

:\Ja\illar~

first mnlars

Buccal Ung11al Occlusal Mesial Distal Crown: it is the largest permanent tooth. It is broader lingually 1han buccally (unlike any other pemmnent tooth). From the occlusal, all maxillary molars are rhomboidal, with obtuse angles at the M Land DB (the other two angles are acute- MB. and DL) . Roots: <bree; MB root often has two can au (MB and ML). These pulp homs are often higher dtan the dlstal and palatal. Cusps: four, IWO buccal (MB is usually longer and "'ider than DB) and two lingual (Ml. and DL). ML is always the largest and highest on any posterior tooth. The cusp of Carabclli (t hen present) is seen lingual to the ML cusp. Occlusal partcro: has an oblique ridge (as do all maxillary molars) which runs from the ML cusp to the DU cusp and meets near the center on a level v.ith the marginal ridges. Note: The distal surface has a pronounced cenical concavity that needs special attention when root planing. It is the second permanent tooth to erupt (after the mandibular first molar). These two teeth fonn the cornerstone of the arch. It has a long buccal groove which has a pit.

J\la\illar~

c:mine- tlu. roufs arC" ~enl'rall~ Ihe longest in the dt.>ntal tuch

ENTAL ANATOMY & OCCLUSION

Perm-T)

\,

Which of the following teeth often have a fifth cusp uod a rhomboid shape when viewed from tbe occlusal'!

Mandibular first molars Mandibular second molars Maxillary fi rst molars Maxillary second molars Two of the above

..8
C6ron,hl 0 2W92010 lknUII I)eeh

ENTAL ANATOMY & OCCLUSION

Perm -T)

rWhen performing a root canal on a patient, you ask your assistant to take back ~
the 25 mm nics and get out tbc 30 mm mes because "this tooth Is long." W hat tooth arc you most likely working on?

Maxillary central incisor Maxillary lateral incisor Maxillary canine

Mandibular canine

150 Copynchl c 2009-2010 De:!Wial Occb

:\1:1\ill:lr~

lirsl nmlar\

Buccal Lingual Occlusal Mesial Distal Crown: it is the largest permanent tootlt. lt is broader lingually than buccally (u111ike any other pemumemtoolh). From the occlusal, all maxillary molars are rhomboidal, with obtuse angles at the ML and DB (the othettwo <mgles are acute- MB. anti DL). Roots: three; M B root often has two canals (MB and ML). These pulp horns are often higher than the distal and palatal. Cusps: four, two buccal (MB is usually longer and wiikr them DB) and two lingual (ML and DL). ML is always the largest and highest on any posterior tootb. Tbe cusp or Carabelli (when presem) is seen lingual to the ML cusp. Occlusal pattern: has an oblique ridge (as do (11/maxi//(Jry molars) wbich runs from the ML cusp to t he DB cusp and meets near the center on a level with the marginal ridges. :-lotc: Tbe dis.al surface bas a pronounced cervical concavity that needs special attention wbeu root plauing. lt is the second permanent tooth to erupt (after rile mandibular first molar). These iwo teeth form the cornerstone of the arth. h has a long buccal groove which has a piL

\ 1 :n:.illar~

canine - thl:' l'not\ arc ~rncra ll~ lht:> longt~t in thl' tlenlal arch

Labial

Lingual

Tncis;tl

Mesial

Distal

Crown: has a prominent labial ridge.. The cingul\IJll is lare and centered mesiodistally. h represents a transition from anterior to p<)sterior teeth; the mesial resembles the incisors and the distal resembles the premolars. It is wider labio-lingually than mesiodistaHy. From the proximal view, it appears to be positioned vertically io the al'(:h. Root: one root with one canal. II is the longest root. The heavy root results in a bony labial ridge called [he canine emin('nce. Cusp: when viewed from the incisal, the cusp Up is located on the mesial-facial of the crown. The mesial cusp ridge is shorter tban tbe distal cusp ridge. Surface: the lingual surface contains all of the followi ng: a pronounced cingulum. lingu al ridge (located between mesio and tlislolingulllfossa), mesio and distolingual fossa. and mesial and distal marginal ridges. Pits and grooves: has a liogual-gingivaJ g roove fnq mher tooth has this I. Disting uishing features: least often extracted (together wirh tM mandlbulaJ canine).

~ENTALANATOMY & OCCLUSION

Perm-T)

(
\.

Which of the following teeth often have a fifth cusp and a rho mboid shape when viewed from the occlusal?

Mandibular first molars Mandibular second molars Maxillary lirst molars Maxillary second molars Two of the above

,.g
Copynshl c 20092010 Dental DU

~ENTAL ANATOMY & OCCLUSION

Perm-T)

When performing a root canal on a patient, you ask your assistant to take back the 25 mm files and get out the 30 mm files because "this tooth Is long." What tooth are you most likely working ou?

Maxillary central incisor :O.bxillary lateral incisor Maxillary cnnine

Mandibular canine

150 Copynght c 2009-201 0 Dtml tkdJ:

\1arKld tJi,tal inclinalion ollhl ruul trun"

Buccal

Occlusnl

Mesial

Distal

Most mandibular third molars have two roots, one mesial and one distal. These roots nrc usu:olly shorter, generaUy with a poorer development than the roots of the first and sec ond molars. and their distal incliunuon in relation to the occlusal plane of the crown is greater. This is the most distinguishing feature of the mandibular third molars. Characteristics of mandibular third molars : Bulbous erowns that taper from mesial to dtstal The crown can resemble the mandibular second molar (four cusps) or the mandibular first molar (five cusps) The mesial-distal dimension of the crown Is greater than the buccal-lingual dimension Short roots that are ofien fused. Long root trunk M 8 cusps are usually wider and longer than DB cusps l rrcgular groow pattern with many supplemental grooves and pits {very ,,Ira/low) Note: Oversized aoomaUes are more common with the mandibular third molar. while undersized anomalies are more common with the maxillary third molnr

I hl' numhlr of rooh

Occlusal Me. ~inl Ohtat Maxillary second premolnr: C rown: smaller than fin;t premolar. Prom ~1e occlusal, it is much more symmetrical and less angular (more ooid) than tlle fttst premolar. Tbe crown is wider faciollngually than mesiodistaUy. Root: one C usps: two, the buccal and lingual are almos t equal in height. Mesial incUnation of lingual cusp (same as first pnmolar). The distal buccal cusp ridge (DBCR) is longer than the mesial buccal cusp ridge (MBCR)- opposite ofmaxiUary fliSt premolar. Surfaces: has no mesial developmental depression (as seen on maxillary first prmtolars). Less prominent buccal ridge; maxillary first premolar has prorrunent buccal ridge. Occlusal pattern: shorter central groove witlt more supplemental groo\es (compttred with maxillary first premolar).

~ENTAL ANATOMY & OCCLUSION

Perm-T)

You are sifting through extracted teeth to practice a root canal. Since you will rarely do a third molar root canal in practlce, you throw those out right away. What is the most reliable distinguishing feature ofthe mandibular third molar?

Fused and compressed root system Short, bulbous outline of the crown Marginal ridge forming a smooth circle Marked distal inclination of the root trunk Great morphologic resemblance to the first molar
147 Cop)'ri$b1 c 20092010 lk:ntal Ob

~ENTALANATOMY & OCCLUSION

Perm-T)

\,

The most distinguishable difference between the maxillary first and second permanent premolars is:

The s ize of the crown The number of roots The curvature of the facial surface The length of the lingual cusp

148
Copyngl'lt C 2009-2010 Den1al [)c(ks

:\budihular lir'l molar

Buccal Lingual Occlusal Mesial Distal Crown: It is the lorgest mandl~ular tooth. It has the largest mesiodistal dimension of any tooth Mesiodistll dtmension isslightly greater than the facio lingual dimension. This tooth P"'<ent< 3 pentagonal .. home plate" occlusal out lone that is distincll'c for this tooth. Roots: '"o roots "'th three canals (a second canal is in tht e<ialroot). The roots are " ldely separoted and the r<>Oitrunk i> relatively short. Cusps: nve CU$p$ (three bucctll - MB. DO. and dis/a/: two lingtllll - DL an</ ML). The ror;tobuccal cusp is the largest of all and the distal cusp is the smollest. Lingual c:usps arc hi~hrr and more poln lrd !bon the buccal cusps Qlalttned h11ccal ""'I" atT typical of all

mandth11lar molars). Ocdusnl pattern : two transverse ridges. thn.:c fossae wnb phs. l11e cen1ral groove. is crooked
'" us mesiodistal course.
Oi~llnguisbing fea,urts: ;tdr~ the ~cornerstone of the pennanent

first pcrmanC!nt IOOih tO erupt fknO\,n d.t .tix-y~ormo/ar). it IS COn dentition. Has t\\O buccal grooves (MB anti DB/.

;\ote: The mandibular first molar is the most oflon restore.!. extracted and ,..,placed tooth.

\l:wchhular fir,l JJn.molar

\)
Buccal Lingual Occlusal Mesial Distal Crown: from the buccal. it;, lont:cr and has a more prominnt bucul ridge than lhe second premolar. It tS bell-shaped and the cervical is very constricted. Root : one; it is shorter and has a poimed apex (the second premolar is longer 1.-ltft a blunt Ofli'X). It is broader racially than lingually. has no diStal curvanre. and may have slight con caiues on the mesial and distill. Cu~ps: has a large pointed buccal cusp "'btth occupies almost two-thU"ds of the occlusal surface and has a prominent triangular ridge. It has a small (about two-thmls the height of btl<' ::ill cusp), non functioning lingual cusp (does no/ occlude w;riJ {mytlting). Occlusal pattern : small, non-runctloning occlusal surface which converaes toward the lin gu.~l The prominent triangular ridge of the buccal rusp and the small buccal ndge of the lin gual cusp unite to form a trans>trse ridge. Usually there tS no central ~roove (may ha1e <>in/ and distal pit.r). The mestal marginul ndgc is more cervical than the distal marginal
4

mlge.
'>ole: The masticatory fuuctlun uf a mandibular first premolar is similar to that of a n andsbular canine.

ENTAL ANATOMY & OCCLUSION

Perm-T)

Which tooth is the most often restored, extracted and replaced?

Max illary canine Maxillary second molar Mandibular first molar Mandibular second molar

,..
Cop)Tigbt 0 2009-2010 Dental Oeek.1

ENTAL ANATOMY & OCCLUSION

Perm-T)

A patient walks into your office holding three crowns in her hand and claims that they fell out during fight club. You notice that one of the crowns bas a mesio-lingual developmental groove. This is a dead giveaway that this tooth is a:

Maxillary first premolar Mandibular first premolar Maxillary second premolar Mandibular second premolar

146 Copyrislu 0 2009-20U) [}r(ontal Dks

\Ja\ilbn third mnlan

Ocdusal

Obtai

Characteristics of maxillary third molars: They h.-e gre11ttr morphological variance than any other tooth They are the s hortest permanent tooth. They are often congenitally missing or non-functional may be present but unempted (this is also Inti! ()jthe mandibular third moltw)

Crown tapers mol'e from buccal to 1ingual They frequently hnve only three cusps. h is sometimes difficult to identify them individually (MB, DB. and llng11al cusps). The Olcusp is frequently absent. Oblique ridge is poorly
dev.loped and often absent Roots are unpredictable (usually shon and fiud) Som.;timt> a small founh molar (poromolar/ will be fused to this molar They O<clude only wtth the mandibular tblfd molars (all orher Ieeth occlude nth two teeth except tlte mmulihular Cl'lllraf incisors) R emember: 11\e mandibular third molar as often anomalous as well, but not as oft en as the maxillary third molar.

I h( cin~uhuu

j, dinltl~

in thl~ l'l"nhr nl tht lina,:u:.J I 'urfacc

I\~

Mandibular
Right l.nteral

Incisor

Labial Lingual Incisal Mesial Distal Crown: no I a~ bilaterally symmetrical as the mandibular central incisor. 11>e crown is tilted distally on the root. The distoincisal angle is more rounded than the mcsioancisal angle. It is broader lublolinguaUy than mcsiodistally. Root: one root; a small percentage will have two canals. It is very narrow me>iodistally. Concavities are evident on mesial and distul surfaces. Surfa ces: lingual surface is smooth. The cingulum is slightly off-center to the distal. Mesial marginal ridge is slightly longer than the distal marginal ridge. Important: The mesial and distal contact areas of the lateral incisor are not at exaelly the same level. a condition differeD! from that found on the ceotntl incisor. The m<sial and distal contacts are both in the incisal third: however. the distal contact is sligbtl) cervical. :'>ote: In an anter'ior cross-bite relationship (Cia.u Ill), as tbe mandible retrudes. the maxillary lateral con111cts the mandibular canine and lateral.

~~~~~

~ENTAL ANATOMY & OCCLUSION

Perm -T)

Which teeth have th e most va riable crown shape of all permanent teeth?

Maxillary lateral incisors Mandibular lateral incisors Maxillary third molars Mandibular second premolars

,.,
Copyri&}ll Cl 2~20 I 0 t>tn1a1 Decks

~ENTAL ANATOMY & OCCLUSION

r

Perm -T)

All of the following statements concer ning the mandibular lateral Incisor arc true EXCEPT one. Which one Is the EXCEPTION?

The mandibular lateral incisor is a little larger in all dimensions than the mandibular central incisor The crown of the mandibular lateral incisor is not as bilaterally symmetrical as the mandibular central incisor The cingulum is di rectly in the center or the lingual surface The root is very narrow mesiodistally

144
CopynJbl 0 20091010 ~ Dk.s

These spaces or embrasures aUow chewed food to escape from the occlusal surface. They also make the natural hygienic factors in the mouth more effective by exposing tooth surfaces to oral Ouids and the mechanical cleansong action of the tongue. lips. and cheeks. I. Pronounced developmental grooves are usually associated with embrasures Xotes between pcm1anent maxillary canines and first premolars, and between pcnnanenl mandibular canines and first premolars. 2. The largu t incisal/occlusal embrasure is found between the maxillary canines and first premolars.

\Ja\ill.\n nnlral

iltl"I\Or

f'
v ..;-

"
[r; '
I1

Maxillary Right Central htcl<or

Labl Lingual Incisal Mesial Distal Cronn: the longut and widest anterior tooth. The distal outline is more cooex than the mesial outline. It ts the most prominent tooth in the mouth. The crown outline i) '' ider mesiodistaU~ than fatlolingua.Uy. Root: one root with a single root canal. It is comcal with a blunt apex. This root is the only maxillary tooth that is as thick at the cervix olC>iodistally as faciolingually (the otlt<Ts are tlu'ckerfaciolingually tllfm mesiodisrally). It is not unusual to find defmitc pulp horns in the incisal region of the tooth. Surfaces: the mesial curvature of the cervical line Is larger than any other tooth. The dis-

[Q]~~

toincisal corner is more rounded (c:onvex) thnn the mesioincisal comer. The mesial and distal contact areas are centered faciotinguaUy (as are all permanent incisors). The cingulum is well-developed and is locatro off-<:enter toward the distal. Octlusion : occludes in centric \\-ilb !he mandibular central and lateral lndsors (same in
protniSi-e and /here is no contact in retnlSil-e} .

Distinguishing features: the maxillary central inctsors hl\e the narrowest in <Is I embrasures. Compared tO other incisors, they ha\c the gnatest axial inclination relati\e to the occlusal plane. They usually have three mumelons and four developmental groo,os.

~ENTAL ANATOMY & OCCLUSION

T-Term~

Which of the following functions as n spillway for food and also as a self-eleansing mechanis m for the teeth?

A contact area An occlusal curvature A gingival space An embrasure

,.,
CoprnsM C 2009-2010 [)m1.1l Oeds

~ENTAL ANATOMY & OCCLUSION

Perm -T)

Which tooth in the mouth bas the greatest axial inclination relative to the occlusal plane?

Maxillary canine
Maxillary lateral incisor

Maxillary central incisor

142 Co,..tn 0 2009-2010 Demol De<b

Fnur

A point angle is an angle fonned by the junction of three surfaces. The point angle derives its name from the combination of the names of the surfaces forming it. For example, the junction of the mesial, buccal, and occlusal surfaces of a molar is caUed the mesiobuccal-occlusal point angle. All teeth have four point angles. A line angle is an angle formed by the junction of two surfaces. They are named according to the surfaces which fonn them. Note: The mesiobuccal and distobuccalline angles protect the interdental papilla by their deflective nature. The tine angles (8 of them) of the posterior teeth are: mesiobuccal mesiolingual mesio-occlusal distobuccal distolingual disto-occlusal bucco-occlusal linguo-occlusal

Because tbe mesial and distal incisal angles of anterior teeth are rounded, mesioincisal line angles and distoincisal line angles are usuaUy considered nonelistent. They are spoken of as mesial and distal incisal angles only. The line angles (6 ofthem) of the anterior teeth are: mesiolabial mesiolingual labioincisal distolabial distolingual linguoincisal

\ rid:,!l'

A ridge is any linear elevation on the surface of a tooth that is named according to its location and fom1, such as a buccal ridge. incisal ridge. or marginal ridge. Remember: Two ridges that are present on all teeth are the mesial and distal marginal ridges. They fonn the mesial and distal margins of the occlusal surfaces of premolars and molars and the mesial and distal margins of the linb "'al surfaces of the incisors and canines. Note: The marginal ridges are more prominent on the lingual surface of the maxillary lateral i.ncisors as compared to the maxillary central incisors or mandibular incisors (cennals and lai-

ernls).

Cusp ridge: Each cusp has four cusp ridges railiating !Tom its tip. They are named according to the direction they take away from the cusp tip (for example. mesial, distal, buccal. or lingual)

Lingual ridge: The ridge of enamel tbat extends !Tom the cingulum to the cusp tip on the lingual surface of most canines

UiJtal cu$p rid~ or bnccnlctHp

ctnl rida~ ur
CUJp

Lfnguet ~.sp rlda,e Mbuccal cusp (b~~ttaJ

Ctotnl

Permanent Maxillary RJgbt Second Premolar

Occlusal view

~ENTAL ANATOMY & OCCLUSION

The number of point angles a tooth has is:

T-Term~

Four

Eight Not enough infonnation; anterior and posterior teeth have a different numbel' of point angles

138 CopynsM 0 20092010 Dtnul Decks

~ENTAL ANATOMY & OCCLUSION

T-Term~

Any lin ear elevation on the s urface of a tooth is called:

An incline
A prominence

A ridge

A tuberosity

140
Cop)Tiglll 0 ~0 1 0 lXall.l lkcl:s

second premolar Tooth development begins with increased cell activity in growth centers in the tooth genn. A growth center (lobe) is an area of the tooth gem1 where the cells are pat1icularly active. These lobes are primary centers of calcification and are primary sections of formation in the development of the crown of a tooth. They are represented by a cusp on posterior teeth and mamelons and cingula on anterior teeth. They are always separated by developmental grooves, which are very prominent in the posterior teeth and fom1 specific patterns. With anterior teeth, their presence is much less noti;:cable and these lobes are separnted by what are known as developmental depressiont Summary of number of lobes: All anterior teeth: three labial and one lingual (cingulum) Premolars: three buccal and one lingual Exception: The ma.n dibular second premolar bas three buccal and two lingual lobes. First molars (maxii/OIJ' and mandibular): five Jobes, represented by five cusps, one lobe for each cusp. Second molars (maxillary and mandibultu): four lobes, one for each cusp Third molars: at least four lobes, one for each cusp. Variations are seen.
\J~truJihular

Important: The minimum number of lobes from which any tooth may develop is four.

1ulu.'rcll It is an extra formation of enamel. The most common example would be the cusp or Cara-

belli, which is located on the lingual surface of the mesiolingual cusp of the maxillary first permanent molar. Note: 11te maxillary primary second molar may even have a cusp that resembles the cusp of Carabelli. Dens evaginatus is an extra cusp. usually in the ceo1.rnl gr oove or ridge of a posterior tooth and in the cingulum area of the central and lateral incisors. to incisors. these cusps appear talon-shaped and can approach the level of the incisal edge. This extra ponioo contains not only enamel but also dentin and pulp tissue, and therefore pulp exposure can result from radical equilibration.
:-:::: . ~-

~-

A cusp is an elevation or mound of enamel (larger than a wberr:le) found on the occlusal surface of molar and premolar teeth and on the incisal edge of canines. A cingulum is a bulbous elevation of enamel (lager rh011 a /uberc/e) rhat constitutc.s the lin gual lobe of an anterior tooth. It is found on the cervical third of the lingual surface.

ENTAL ANATOMY & OCCLUSION

T-Term0

Which ofthe premolars is characterized by development from five lobes?

Maxi llary first premolar Maxillary second premolar Mandibular first premolar Mandibular second premolar

m
CopynabtO 2009-2010 Oen;~l De<:k.s

ENTALANATOMY & OCCLUSION

T-Term0

,
~

A young patient comes to the clinic complaining that he gets too much food stuck behind his front tooth when he bites. On examination, the dentist notes an anomalous, claw-shaped cusp which projects from the cingulum of tooth # 9. This small elenlion of enamel found on the crown portion of a tooth would be elasslfied as a:

Tubercle

Mamelon
Ridge Developmental depression

,,.
Copynahc0 20092010 Dtmal Dttb

\ tr:ms\l'l""it.'

ridge

Triangular ridges descend from the tips of the cusps of molars and premolars toward the central part of the occlusal surface. They are called triangular becattse the slopes of each side of the ridge are inclined to resemble two sides of a triangle. They are named after the cusps to which they belong (e.g., the triangular ridge ofthe buccal cusp of the m(l)(il/ary second premolar). A transverse ridge is the union of the buccal and lingual triangular ridges. This ridge crosses the occlusal surface of most posterior teeth in a buccolingual direction. They occur between the M L and MB or between the DL and DB cusps on molars or between buccal and lingual cusps on premolars. Important: Transverse ridges are very common on mandibular molars and maxillary pre molars. Remember: Maxillary molars have a characteristic oblique ridge. An oblique ridge is the union of two ridges running obliquely across the occlusal surf.1ce. Oblique ridges always run between tbe dis{obuccal cusp and the mesiolingual cusp. They are formed by the union of the distal cusp ridge of the MLcusp and the triangular ridge of the DB cusp.
rt'lllnf\'tnt

fldtt

l.kls:ullrlll)l. lr rid~

8U<AIIrl!lq~ln

ri

Olstobuttll1

:Meslobueeal

Mt-.J nrtlllaltfOO<rr
)h:o~..l fiU~I rldf t.

Maxillary Right First Premolar Occlusal view

Permanent Maxillary Molar

OcC-lusal view

Occlus:1l surfac('

It consists of cusps, ridges, and grooves and is bounded mesiodistally by the marginal ridges and buccolingually by the cusp ridges. Note: Incisors and canines do not have an occlusal surface. -. 1. The incisal edge is the cutting edge or biting surface of anterior teeth. Notes 2. The anatomic crown is that part of the tooth covered by enamel. The anatomical crown and root are separated by the CEJ; the anatomical crown does not include cementum, and the anatomical root does not include enamel. 3. The clinical crown is that part of the tooth that is visible in tlte oral cavity. It may be larger or smaller than {be anatomic crown. The clinical crown and root arc separated by the gingival margin; the clinical crown or root may be composed of both enamel and wmentum.

~ENTAL ANATOMY & OCCLUSION

T-Term~

Any union of two triangular ridges produces a single ridge which Is called:

A cusp ridge

A marginal ridge A transverse ri dge A proximal ridge

135 Cop)n,sbl 0 2009-2010 Dtn11l Dks

~ENTALANATOMY & OCCLUSION

r

T-Term0

A 7-year~ld patient comes Into your pediatric practice for a routine prophylaxis. When conducting an intra-oral exam you comment to him that you notice that he has just eaten something sticky like gummy worms or fruit snacks. The chewing surface of posterior teeth, and the likely location of sticky food deposits In this patient, Is referred to as the:

Clinical crown Incisal edge Occlusal surface

Anatomic crown

,,.
Cop)'tls:hl 0%009-2010 Dtfl~otl Dccb

Porliun uf lht. ::!ingha thai fills I Ill' inhquo\irnal 'IHil"l'

This interproximal space is triangular. The sides of the triangle are the proximal surfaces of the adjacent teeth. the ope< of the triangle is the an:a of contact of the two teeth. and the base of the triangle is the aheolar bone. The interdental gingiva which occupies this space (papilla) between the facial and ling lual papillae conforms to the shape of the contact area. I. The ginghal margin is the occlusal {incisal bo!Yier) at which the gingiva meets otn the tooth. 2. The free gingiva (marginal gtngl\'a) is the collar of tissue that ts not attached to the tooth or alveolar bone. It surrounds the root of each tooth from the gingi val margin to fonn tbe collar of space or gingival crevice or sulcus (where den to/floss ca11 jit). 3. The attached gingiva is a band or zone of gray to light or coral pink kern tiniLcd masticatory mucosa that os fll1llly bound down to the underlying bone. It IS present between the froe ging1va and the more movable alveolar mucosa.

\n nhhtflh ndgt.

It crossel 1he occlusal surface obliquely and is fonned by thC' umon or lhc distal cusp ndge of the me51ollngual cusp and the rriangular ridac of the di~tubu cc:al tusp. It nonnally fonns the dl~t>t31

boundary of the central fossa.

A labl.al ridge is a ridge running CCC'<II(."'oiDCI.sally in appni:(lmately the CtUICf of the labi.al surfc~

of lbe unints A bu(lttl (tusp) ridge,,. ndg~ numma ctfVtcO-ocdusally 1n approxim1tely the: center of tnt- but cal surfue of premolars (nroi'E' pronoum:t!d on the.first prcmolnrs 1han ucortd pf't.'molar.f) A c:enltal ridge is a ridjjC running mesi()distally on the cerv1calthird of the bucc.al surface of the crown h is found on all primary te.e.th. but only on the pernuwtnl molars A marglnll ridge; on lncl$or and c.anint llh. it is Jocaacd on the mesial and d1stal border of the hngm.1 \\lrface: on posltrior rttth. it IS kx:ated on. rhc: mcsJal and distal boldcf of th.: otclusal sur

rae.:

IS a ridg<: 1ba1 projcct:t from 1he cw1p tip 10 the centr&l gf'OO\'C. )( is found on post tr-Ior tetth. Note: The ML cusp on lfUlxillary molars h"~ lwn 1riangular ridges A crani\'trse ridge is a ridge fonncd by che union of a liugualcriangu1ar ridge ora buccal c-U!tflllnd a buccalcriangu1ar ndgc or a lingual c:usp It runs from the bucc.al sofratt: to the lingual 5urlare aerO\> the occlusal surface ofmost postmor teelh

A triangular ridge

"'

..
Dhll t..p rtdi
......N .. ti"P

Prtmolar

ENTAL ANATOMY & OCCLUSION

T -Term0

In many older individuals, gingival recession leads to an unaesthetic problem affectionately known as "black triangle disease." This is caused by the loss of gingival tissue in the interdental space. The interdental space is the:

Occlusal (incisal) border at which the gingiva meets the tooth Portion of the gingiva that tills the interproximal space Collar oftissuc that is not attached to the tooth or alveolar bone Band or zone of gray to light or coral pink keratinized masticatory mucosa that is firmly bound down to the underlying bone

133
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ENTAL ANATOMY & OCCLUSION

T-Term0

"'

Which of the following types of ridges is unique to permanent maxillary molars?

A labial ridge A marginal ridge An oblique ridge A transverse ridge

134
Copyri&}lt 10 2~2010 l>enllll l>b

.\ nterior open bite

Mamelons usually develop in groups of three. They resemble rounded protuberances and they arc found on the incisal edges of newly erupted incisor teelh, bQth maxillary and mandibular. When each of the anterior teeth develops. they originate from four lobe. Each one of these Jobes terminates fom1ation incisa11y in these rounded eminences. They are usually !he most profound right after eruption, but with time they usually wear down after the tooth comes into functional position. Note: The presence of mame1ons in a teenager or adult is indicative of malocclusion. Most likely there is an anterior open bite relationship where the incisors do not touch. See photo below. Pm of the reason that the mamelons are so noticeable is because these cxtertsions are made of pure enamel with no dentin layer underneath. This and their thitllless contributes to their tmnslucent appearance as opposed to the rest of the clinical crown wbich is almost always more opaque than the mamelons. With this translucent qualitY, they often appear to be a different shade than the rest of !he tooth and lherefore are sometimes much more distinct. Remember: MaxiHary and mandibular incisors characteristically have three mamelons which arc centered beneath the three facial lobes.

Photo shows mamclons present on maxillary and mandibular incisors as well as an anterior open bite.

l'hl'} <trt.' broad, tleep. limar depressions

Tills is false; developmental grooves are sharply defined, shallow, linear depres-

sions.
These grooves separate lobes or cusps of teeth and mark the boundaries between adjacent cusps and other major d ivisional pans of a tooth (marginal ridges. etc.). Buccal and lingual grooves are developmental grooves found on the buccal and lingual surfaces of posterior teeth. Remember: Pits are located at tbe ju oction of developmental groo,es or at terminals of these grooves. Supplemental groo,cs are small, less distinct, irregularly placed grooves. They are supplemental to developmental grooves and do not demarcate major divisional pans of a tooth.
D.:wklpmcnt:al

'""""
Octlu$111
d(lvt-IOpftlthlaJ

ridge

pi!

SuppltMf'ntAJ
jtntl;ll't'

Occlusal View of a Permanent First Molar

~E~TALA~ATOMY & OCCLUSION

T-Term~

rA 16-year-old patient Is referred to the orthodontist's office needing work to Ox ~

her malocclusion. Before the patient's first appointment, the orthodontist

reviews the clinical photographs or the patient and notices mammclons. Mammeions are unusual in older patlenl'l and would indicate that the patient most llktly has which or the following malocclusions?

Posterior crossbitc
Posterior open bi te Anterior open bite Edge-to-edge Class I II dental occlusion

131
C4>P)'nJITI 0 200920 1 0 Dtntal Okll

~E~TALANATOMY & OCCLUSION

r

T-Termv

All of the following are true concerning developmental grooves EXCEPT one. Which one is the EXCEPTION?

They are broad. deep, linear depressions They are formed during tooth development They usually separate the primary pans of the crown or root They arc important escape ways for cusps during lateral and protrusive jaw motions and for food particles during mastication

1l2
Cop)Tight 0 2009-2010 Deflt&l 0-\t

t- ou r

Embrasur<S are lnansularl) shaped spaces lo>ealed b<:IWetn lh<: proximal surfac:cs or adjacent te.."lh. They dl\ervc buccally, cen-ieally.lingually, and occlusally from tho area ofcon18cl ~o re : for C)\hcucs and fl.lnttion. embrasures mu.\l be symmetrical. There are four cmbrAiures for every contact area: I. Facial, lllso called labial or buccal 2. L>ngual (Qrt/lrwrl(y larger tlruu tire facial) 3. Occlusal or incisal 4.Cervical or gingival; this region is filled by the mterdentol papilla Three functlons of cmbrnswes: I . Funcuon as splll\\t)S IO direct food away from the singiva 2 ~lake the Ieeth fTi<ln' self-<leansing 3. ProtKt tht amJI\ II tissue from undue fricuonal uauma, but at the same 11me pro\ ldt the proper deif' of stimulation lo the tis.ue The lingual t mbra>urt> are ordinarily larger than the facial embrasures because mo>llceth are OCUTO\\ cr on the hngunl s1de than on Lhe factal side. and also because their con1act poan t~ are
located in the i;acwl third of 1he crowns.
Otthual

\II nf tlu.. ahm l' ''''"'mlnh co ncC"rninj:! pro\iiiHII cunlotct area' an t nil'

Contact areas are areas in which the mesial and distal surfaces of adjacent teeth in the same arch make COOI8CL ~ole: Four te<lb have mesial surfaces tllal contact each other. They arc the truUtllary and mandibular een trallncisors. In all other instances, the mesial surface of one tooth contacts the distal surface of its neighbor, cxce111 the distal surfaces of permanent third molars and tbe dislal surfaces of primary second molars. ac1 may result ln periodontal disease, malocclusion, food The loss of proximal con1 impaction, or drifiing of teeth.

\\111
Proximal contact areas of maxillary teeth, \iened from the occlusal

Proximal contact areas of maxillary anterior teeth

 ENTAL ANATOMY & OCCLUSION

T-Term~

A seeond-year dental student is creating a temporary bridge for a competency examination. She is graded on the quality of her embrasures. If the connector between the pontic and the retainer is the anatomical equivalent of a contact area, hOl\'' many embrasures are associated with that contact area?

""

One

Two
Three Four

1211
Cal)yn,htC 200..2010 Dtn1al Ikd:s

ENTAL ANATOMY & OCCLUSION

T -Term~

A 11)-year-old patient comes into the dental office and presents "ith gtnerallted sparing. Tbe mother tells you she is conetrntd that be will netd braces because of all the gaps. You assure her that the spaces ttnd to work themselves out when the larger permanent teeth come ln. But in the back of your mind you are thinking about this patient's lack of proximal contacts. Which statement concerning proximal contact areas Is true?

""

They support neighboring teeth, which thereby s tabilizes the dental arches They prevent food particles from entering the interproximal areas They protect the interdental papillae of the gingiva by shunting food toward the buccal and lingual areas They form embrasures All of the above statements concerning proximal contact areas are true
1)0 Copynthl 0 2'0092010 Denul Oecb

-\II 'limuli to lh\ pulp n."\nll,;; in a Jl:lin "'11\,llinn

The only type of nerve ending found in the pulp is the free nerve ending, which is a specific receptor for pain. These pain receptors arc located m the plexus of Raschkow. Regardless of the source of stimulation (heat. cold. pressure), the only response wi II be pain. The pulp contains both myelinated and unmyelinated nerve fibe rs. They are afferent aJtd sympntheric. The myelinated fibeos tore sensor y, and the unmyelinated fibers are motor (they play a role in the reguiMian of the lumen .vize tif the hlood ,essels). Note: Proprioceptors (wlrich respond to stimuli regarding moveme111) are not found in the pulp. Important: As the dental pulp ages. the followmg changes take place; however, in general the amount of cells decrease, and the amount of fibers increase. -- intercellular substance, water, and cells D ecreased { . o f the pu1p cavtty denun d ue to secon dary or tert,.ry -- soze 1 as pu P ages --number of reticulin fibers Increased us { -- number of collagen libcrs - - calcifications within the pulp (called denticles or pulp .<IO!ICS) pulp ages : True denticle - complete with tubule and processes false denticle - amorphous m structure Free denti<le - unattached to outer pulpal wall A ttached denUde - attached at dentin-pulp interface :-.lote: Cementi<les are calcified bodies that are sometimes found lying free within the periodontal ligament or fused with the cementum of the tooth.

Sulru\

The inclines of a sulcus meet in a developmental groo>-e or extend outward to the cusp

tips.
A fossa is an irregular depression or conc.1vity. Examples include:

Lingual fossae: found on the lingual surface of incisors. Central fossae: found on the occlusal surface of molars. They are fomted by the converging of ridges terminating at a central point in the bottom of the depression. Trinngu lur fossae: found on molars and J>remolars on the occlusal surfaces slightly mesial or distal to marginal ridges. They are sometimes found on the lingual surfaces of maxillary incisors. I. Pits arc small pinpoint depressions located ot the junction of de elopmental :'\ote.s grooos or at terminals of those grooves. 2. A fissure is a narrow channel or ere icc, sometimes d eep. fonned at the dep<h of a developmental grooe. 3. Dental canes (decay) often begins on deep fissures or pits.

Mr.stt>bllrHI
triiUIJtlllllr IV"'tlY"

m......,,.,

lrllfiC\Ihr Q_roon

M~

m.e.l m-,rcf:uJ

.......
r....
'taxlllary Ct.ntrtllneisor
Llngutl
~ I t \\

""'"
MeN.~

fissure

Su lcus

pit

Ma:ndibullr SKOnd Prtmolat

OtC'Junl rltl\

~Buccal pit

~ENTAL ANATOMY & OCCLUSION

T-Comp)

T he application of excessive beat to a tooth results in pain beca use:

Excessive stimulation of a be.at receptor always results in pain Heat receptors in the pulp have a low threshold to pain All stimuli to the pulp results in a pain sensation Blood vessels of the pulp expand and cause strangulation of the tissue

127 CopynghtC 20092010 rkrnl Decks

ENTAL ANATOMY & OCCLUSION

T-Term0

The arrow is 110inting to a long depression or a V-shaped valley on the occlusal surface of a posterior tooth between the cusps. This is called a:

Fossa

Fissure

Sulcus

121
C'op)TIS"' C ~2010 Dtrlta.l 0\s

l'triluhul:tr d('ntin

l)'pes of dentin: Mantle deotjn: is the peripheral ponion of the dentin adjacent to the enamel (DEJ) or cementum (CI::J), consisting mostly of coarse fibers (Korff:t fiber.<) . h is the first layer of dentin deposited. The remaining primary dentin is called clrcumpulpal dentin. There is also a small layer intefPOsed between these two dentin layers ofless mineralized dentin called globular dentin Intra (peri) tubulr denlln: lines each dentinal tubule. It is the most highly mineralized dentin (has a grt>arer <'onl'111 of inorganic salts) Intertubular dentin: surrounds the intratubular dentin. less mineralized (has a
/011 er content of inorganic salrs)

Interglobular d entin: lm1 >erfectly ea lcilicd matrix of dentin situated between the calcified globules ncar the periphery of the dentin I. Eacb dentinal tubule cootains the cytoplasmic cell process (Tomes' fiber) Not.. of an odontoblast. 2. Dead tracts constst of groups of empty tubules due to the death of the odontoblasts whose processes fonncrly filled them. These tracts have been anributed to the aging process of the dentinal tissue. They may nlso be caused by caries, erosion, cavity preparation. or odontoblastic crowding.

l hnlinmnamel junrtinn (/>1 ../J

The DEJ is the interface between the dentin and the enamel. It tS the remnant of the onet of enamel formation. During amelogenc~>ts (enamel formarioll), ameloblast$ enter their first formative slate after the first layer of dentin is fonned. ntey secrete enamel matrix as they retreat liom the DEJ. This matrix then mineralit.es. f,namel is produced in a rhytlunicul fushion. The odontoblasts begin dentin formation (dentinogenesis) Immediately before enamel formation by the ameloblasts. Deotinogenc.is begins with the odontoblasts laymg down a collagen matrix. mo,ing from the DEJ inward towards the pulp. The most recently formed layer of dcmin is al\\ays adjacent to the pulpal surface.

No' 2. The morphology of the DEJ is determined at the bell swge.

I. The DEJ is also the area at which colelfieatlon of a tooth begins.

3. The oldest enamel in a fully entptcd molar is located at the DEJ underlying cusp. 4. Research bas shown that in order for ameloblasts to form enamel, cells from the stratum lnlermedium must be present.

~ENTAL ANATOMY & OCCLUSION

T he most highly mineralized dentin is seen in:

T- Comp)

Pcritubular dentin Intertubular dentin Interglobular dentin Mantle dentin

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~ENTALANATOMY & OCCLUSION

T- Comp)

Tbe calcification of a tooth begin! at wbicb structnre below?

Pulp horn Cusp tip Ccmentoenamel junction (CI:."'J) Dentinoenamel junction (DEJ)

12<1
Copylljhl 0 10091010 OC'Mal Deeb

\ lurl' rt'sistanrc. tu re~m ptinu

Cementum Is tbe bon~like mineralized tissue covering th~ anatorntcul rootS of teeth. II has the follo,.ing eharacttrislics: It IS slightly softer and lighter in color (,vel/ow) than dentin. It is fonncd by cement oblasts from the POL, as opposed to demin, which rs fonncd from odontoblasts of the pulp. Mostcloscl) resembles bone (more so than dentin). ncept there arc no Haersran systems or blood vessels: itts avascular. It is 50% inorganic (hydroxyapatite), 40% organic and 10% wntcr. The organic ponitm is primarily composed of collagen and protein. Has oo ocne Innervation. It is 1mpona111 in onbodornics. It 1s more resistan t to resorpuon than alveolar bone, pellllilling orthodonuc movement of teeth wtthout root rcsorprion. Two types of cementum: fun ctionally there is no difference: 1 Acellular: contains no cells; usually predominate> on the coronal two-thirds of the root. Thinnc>t at the CEJ. 2. Crllular: contains cementoblasu,, inacrive cementocytes, fibroblasts from the periodontal ligament, and c~mentoclaStS. It occurs more frequently on the ~pica! third of the root. It is usually the thickest 10 cotnptlt.Sate for onouonal wear of the occlu.<allinci~al surface and passi,e eruption of the tooth.

~dlroric

dtnrln

When dentin ts damaged, oduntoblastic processes di~ or retract. leaving empty demlnal tubules. Areas with empry dentinal tubules ore called dead trncts and appear as dark areas m ground secuons of tooth. With tune, these dead tracts can become completely filled in with mmeral These regions are called blind tracts ond appears white in sections of ground tooth. The dentin io blind tracts is called sclerotic dentin. Sclerot ic dentin results from aging Md from slowly advMcing dental caries. The d~'ntin tubules become calcified and obliterated. wbich blocks access of irritants to the pulp by way of the tubules. ~Reparative dentin" is deposited locally in response to rnjury. It fonns rapidly (3.5 mi<'I'OIIS per day): as a cou$cquence. tho dentinal tubules are very irregular. grvtng rise to the synonym "irregular dentrn." Sometimes, odootoblasts are trapped in this reactive dentin. produc1ng "osteodentin. Other synonyms are "reactive dentrn" and "tert1ary

demin...
The tcnn "primary drntin" refers to dentin formed luring the development of the tooth. This dentin tYPe forms at a relauvcl) mpid pace; its formation ends when root formation is complete. Secondary dentin, on the other hand, is deposited after t:omfJietit>n of tooth development. 11 is deposited at a s lower uniform pace and is slightly less mineralized than primary dentin. hs deposition is ~ot ossociated with stress. Secondary dentin is re>ponsible for narrowing of the pulp chamber and root canals w1th age. It ts l= permeable than primary dentin. ~oCet The j unction between primary and secondary dentin is charJclerized by a sharp clumgc in the direction and density of dentinal rubules.

~ENTAL ANATOMY & OCCLUSION

(
Cementum has than alveolar bone.

T-Comp)

More innervaaion
More vasculature More resistance to resorption Fewer Sharpcy's libers

123 Cop)TiJbt () 2009-lOIO Dcnt&l DK::b

~ENTAL ANATOMY & OCCLUSION

T - Comp)

Dentin which is seen as a result of aging or advancing dental caries, and calcifies and obliterates dcntlnaltubules is known as:

Primary dentin Secondary dentin Reparative dentin Sclerotic dentin

12A
C<lp)Ti5h1 0 2(109.2010 Oeflt&ll)rec\.

lkntal pul1> Odontoblasts are located in the pulp, NOT in the dentin. The primary function of the pulp is to form dentin. Remember: The dental pulp is the sofHisstLe component of the tooth. It is a connective tissue originating ITom the mesenchyme of the dental papilla and performs multiple functions throughout life. In addition to being the formative organ of the dentin, it also has the following functions: Nutritive: the pulp keeps the organic components of the surrounding mineralized tissue supplied with moisture and nutrients Sensory: extremes in temperature, pressure, or trauma to the dentin or pulp are perceived as pain Protective: the formation of reparative or secondary dentin (by the odomoblasts) Important clinical information: Pulp capping is more successful in young teeth because: The apical foramen of a young pulp is large The young pulp comains more cells (odontoblastic) The young pulp is very vascular The young pulp bas fewer tibrous elements The young pulp has more tissue fluid Note: The young pulp does lack a collateral circulation.

C{'mentum

Cementum is the bonc-lik~ rigid connective tissue covering the root of a tooth from the cementoenamel junc.tion to the apex and lining the apex of the root canal. Jt serves to anchor periodontal ligament fibers. It is classified into acellular and cellular cementum, depending on whether it is cell-free or contains lacunae witb cementocytes. The functions of cement1un include: Provide rough surface anchorage for attachment of Sharpey's fibers Compensates for the loss of tooth surface due to occlusal wear by apical deposition of cementum throughout life Protects the root surface from resorption during vertical eruption and tooth movement

Has a reparative function; allows reattachment of connective tissue following periodontal treatment I. 1-listologically, cementum differs from enamel in the following ways: 'Notes (I) It has collagen fibers. (2) It has cellular components in the mature tissue. 2. Ccmcntoid is the peripheral layer of developing cementum that is uncalcified. Remember: Sharpey's libers are the terminal portions of the principal fibers of the PDL that are embedded in the cementum (run perpendi<'ular to the cementum) on one end and alveolar bone on the other end.

~ENTAL ANATOMY & OCCLUSION

T-Comp)

,
A 14-year-old boy comes Into the dental office for a prophylaxis.
A diet evaluation reveals that he oonsumes 3-4 cans of soda a day and

eats a box of fruit snacks every week. Radiographs show multiple incipient interproximal carious lesions and one cavitated carious lesion in his premolar. The cavitated lesion in the premolar is beginning to encroach on the pulpal tissue. Reparative dcnt.in Is usually formed in response to injury. The cells which form dentin nrc located in which tissue?

Enamel

Dentin
Dental pulp

Cementum
121
Copyn;Jlt 0 2009-20 I0 l)entllll)ed:$

ENTAL ANATOMY & OCCLUSION

T-Comp)

The dental tissue nhlrh most rtoseJy mimics bone is:

Enamel Dentin Dental pulp Cementum

122 Co,)'n.aht C 20092010 Dtn~l Docks

When a tooth is nely erupted. the dental pulp is large; it becomes progressively smaller as root fonnation is completed. The entire pulp and apical foramen are relatively large'" pnmary Ieeth and also in young pcnnanent teeth (see picture below). For this reason. the t~cth of children and young people are more sensitive to thennal change and dental o perative procedures than the teeth of older people .

.\1axlllary Central Incisor (young person)

Composition of the pulp: Loose connective ussuc (collagen and ret/culillfibers) Blood vessels. lymph vessels and nerves Cells: Obroblasts, odontoblasts. bistiocytes, and lymphocytes Ground substance (water and long carbohydrate chai1tt a/lac/red to prounn back bones) Undifferentiated mesenchymal cells that serve to replace injured or destroyed odontoblasts (a reparathe function)

Six stages of tooth development (odontogen~.rLr): I. lniliatlon stage invol\'es the physiological process of induction. Occurs at the beginning of the lifth week ofgesitation. lniual mteraction between oral epthehum and mesenchyme (ectomesenclryme), fonnation of dental lamina l. Bud ~!age involves the physiological process of proliferation. Occurs at the beginning of l.hc ttgllth week. Growth of the dental lamina into I 0 buds per arch. Underlying mesenchyme also undergoes prollferntioo and the shape of the tooth becomes evident. Enamel organ starts to form. 3. Cap stage involves the physiological processes of proliferation and differentiat-

ion, which occur in two ways

(I) 1\lo rphodiiTerentlalion: 10 cbaoge into other shapes } OcCIJI$ from me Chh (2) HistodiiTerentiation: to branch into different tissues to lbo lOll> ~~oe.:l

-**By the eud of the cap stage. the tooth germ 1 complete and consist~ of the enamel organ, tbe dental papilla, and tbe dental sac. 4. Bell stgc: differentiation occurs to its furthest extent, resulting in four dtffcrem ceU types in the bell-shaped enamel organ: OEE . cuboidal. lEE- columnar, Stellate reticulum _.. network of star-shaped cells, Stratum intcrmcdium ... Out to cuboidal. Tbe denial papilla also diO'erentiates into two layers: (J) outer cells } Oocurs between the ltth and t2 weeks (2) central cells. The dental sac increases in collagen liber..

5. Appositional stage: ceUs that were differenuuted into specific tissuefonnmg cells
begin to deposit the specific dental tissues (enamel. dentin, cemen11m1, and pulp) 6. Maturation stas:e: mineralization begin~ at the DEl :1nd contmue. until total development is accomplished. taking approXImnttly two years to complete

ENTAL ANATOMY & OCCLUSION

T-Comp)

A 3-year-old boy is being rushed by his mother to On ish up his ice-cream. He is unwilling to bite into it because it burls his teeth. The reason the teeth of children arc more sensitive to thermal changes than those of an adult is that:

Newly erupted teeth have more dentin than older teeth Newly erupted teeth have larger dental pulps Newly erupted teeth have more differentiated mesenchymal ceUs Newly erupted teeth have less ground substance

111
Cop)'rigbl c 2009-2010 f>tn~jl OcekJ

ENTAL ANATOMY & OCCLUSION

T-Comp)

The stage of tooth development in which the physiological process of proliferation occurs and the enamel organ begins to form is called:

Initiation
Bud stage Cap stage Bell stage Appositional stage
Maturation srage

120 Cop)Tigbt C> ZG09.JOIO Dtr.t~l Ocod s

lkntal papill.t The dental pulp is the soft-tissue component of the tooth. It is a connective tis>ue originating from the mesenchyme of the dental papilla, and perfonns multiple funct ions throughout life. lltS the formath c organ of the dentin and the wurce of nutritton and maintenance of the dentin. Anatomy of the pulp: Co ronal pulp: located in the pulp chamber and pulp horns (crown portion of tooth) Radicular pulp: located in the pulp canals (root portion of tooth) Apical foramen: communicates with the POL Accessory canals: extend from the pulp canals through the root dentin to the POL The central zone or pulp proper conUlins large nerves and blood vessels. This area is lined peripherally by a specialized odontogenic arc.' which bas the following zones (from innermost to omermost): Pulpal core: similar to the cell-rich zone Cell-rich zone: contams fibroblasts Cell-free zone or ~one of Well : tbe capillary and nerve plexus (Plexus of Raschkow)are located here. Odontoblastic layer: which contains odontoblasts and lies next to the predentin and mn1Ure dentin. If cold relieves the pain, then there is almost alway' partial necrosis of the dental pulp.

( oll:tt:t'lt

Dentin is the speciali1cd connective tissue that makes up the bulk of the tooth, extending for almost its entire length. Dentin is hard, elastic. 70% inorganic and 20% organic. The remaining to ;. represents the retained water and other untrace.>ble minerab. Note: Tile organic subStOircc (2()"/,) in dentin cons1>ts primarily of collagen fibers. Dentin is more roinernltzed than cemenntm or bone but Jess mioernh7-Cd than enamel. The mineral phase (i11organic mol/er) of dentin is composed primarily of calcium bydroxyapntite and mnkes up the bulk of the tooth. Morphologically and chemically, dentin has many characteristics in common with bone. Remember: The main cdl type in dentin is the odontoblast, whtch is derived from ectomesenchyme. Dentin is much softer than enamel but harder than bone. It is more Ocxible (/ower modulus of elasticity) than enamel. Its compressive strength is much higher than its tensile >trengtb. I. Unlike enamel, which is acellular, dentin has a cellular component which is retained after its fonna tion by odontoblasts. 2. Dentin and pulp tissue arc both formed by the dental papilla. Pulp tissue is n loose, very vascular. and noncalcified connccti\.'e tissue. while dentin os nn avascular and calcified tossuc.

~ENTAL ANATOMY & OCCLUSION

r

T - Comp)

A patient comes Into your dental clinic holding a bag of ice to the side of his face and a sliver of ice tucked between his check and teeth. He says the cold relieves the pain in bis tooth. This is almost indicative of partial necrosis of tbe structure which Innervates the whole tooth. This structure is a connective tissue that develops from the:

Enamel organ Dental papilla Dental sac

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ENTALANATOMY & OCCLUSION

T-Comp)

T he organic Mmponent of d entin Is primarily composed of:

Hydroxyapapntitc Calcium
Water

Collagen Neural tissue

C'<lp)TI,thl C zoa9-2010 lkfll.ll Ol.J

...

Tooth development is dependent on a series of sequential cellular interactions between epithelial and mesenchymal components of the tootb germ. Once the ectomesenchyme influences the oral epithelium to grow down into the ectomesenchyme and become a tooth germ. the above events occur. I. Some texts include the deposition of root dentin and cementum as #5 in the Notes histogenesis of a tooth. 2. Korrrs fibers is a name given to the rope-like grouping of fibers in the periphery of the pulp that seem to bave somerhing to do with the formation of the dentin matrix~ Remember: llistogeJtesis means the formation and development of the tissues of the body, in this case the tooth.

lnnC'r ('narul'l epit helium Fo~tr layers of the enamel organ: I. Outer enamel epithelium (OEE): the outer cellular layer of the enamel organ (very thin).

2, Inner enamel epithelium (TEE) : the innermost cellular layer of the enamel organ (ve1y tlrin).The cells in this layer will become ameloblasts and produce enamel. This layer is essential for the initiation of dentin formation once enamel is formed. 3.Stratum intermedium: this area lies immediately lateral to lbe inner enamel epith eli urn (thicker than both the 06E and lEE). This layer of cells seems to be essential to enamel fom1ation (prepares nutrients for the ameloblasts ofthe lEE). 4. SteUate reticulum: this area is the central core and fills the bulk of the enamel organ. It collains a lot of intercellular fluid {mucous type jlu;d rich in albumin) which is lost just prior to enamel deposition. After enamel formation is completed, all of the above structures oftbe enamel organ be come one and form the reduced enamel epithelium. This is important in the formation of the dentogingival junction, which is an area where the enamel and epithelium come together as the tooth erupts into the mouth. n1is forms the initial jnoctional epithelium (epithelial attachment), which later miyatcs down the tooth to assume its normal posi tion.

E~TALANATOMY & OCCLUSION

T-Comp)

'

Below are the usual events In the histogenesis of a tooth. Place them In their correct sequence, -- from what happens first to what happens last.

Deposition of the first layer of dentin Differentiation of odontoblasts Deposition of the first layer of enamel Elongation of the inner enamel epithelial cells

115
CopyngluC
~00920 10 Dtnu11

Decb

ENTALANATOMY & OCCLUSION

T-Comp)

The cells In which layer of the enamel organ will differentiate into ameloblasts?

Outer enamel epithelium Inner enamel epithelium Stratum intermedium Stellate reticulum

Cov.rnJM 0 20092010 De:ntal Dcd:-

'"

C ulla ~. n
Enam~l IS a highly mineralized SltUcture contaming approxurunely 96~. tnorgan1c mmerals. IJydroX)Apatite, which IS a crystalhnc calciUm phosphnte. 1> the lnrg~t mmeml Cllnsriruem (90-95%) or thts inorg:~~~ic maner. Fluoride and ZinC arc minor con"ituents. :-lote: Due to its high inorga nic conten~ it appears opticall~ clu r oo a histologic section of huiUJill toot b.

Enamel also consisls of au organic matr ix (I%) and wa ter (3%). Thos organic matrl~ and water content d ecreases as enamel matures. AI the same time, tht inorgantc content increases. Note: T~e organic por1ion of enamel does not contain collagtn. whereas dentin and bone do. Instead, it has two unique classes of protcms called amclo~enins a nrl cnamclins. The I'Oie of these proteins is not understood 1\tlly at this time. b ut it ts believed that these protein> aid in lhc develo pment of euuwel ns o framework suppon and other mcchunisms. Ennmel is ettremely b r ittle but can endure crushing preS-'>urC of approxomutely I00,000 pounds per square inc b. A laycnng 11fdentin and periodontium. coupled with the hardness of tbe enamel. produces a cushiomng effect on the tooth's lliO'erent structures. enabling it to endure the pres;.urt.'S or mastication. Enamel is semitransluc:ent and IS yellow to woyish white in appearance II is a selectlvely permeable memb r ane, allowing water and certain ions to pass voa

osmosis.

Enamel formation begins al the futur~ cusp and >prcaJs down the cusp slope. As the ameloblasts retreat io incremental steps, they create an artifact in the enamd called the lines of Ret nus. Where these line~ tcnninote at the tooth ;urfac<- they en:a.tl' tiny valleys on the tooth surface that travel eon:uonfercnually around the crown, known as periky mal2. One of the lines or ReiZIII$ accentuated and is OJOn: Ob\~OUS than the others. ltts the neonatal line, wrueb ma~ the ilivtSion betwe<:n enamel fonned before binh and that which is produced aflcr binh. Tins neonatal line is found in dectduous teeth ~nd tbe <USpS of pcnniUICOI lin;t ll10IBI'6. The fu ndamental murpbuloglc unit of enamel is the enamel rod. Each enamel rod i~ fonl\cd 111 iucrcmc.nts by n single enurnel-formins cell . the amelo bla!t. Each rod uavcrscs uninterrupted through the entire thickness of the enamel. In genera l, enamel rods lire llligncd per pendicular ly to the DI!J. except in the cervical regions of J>crmnncnt Ieeth (miemed someov/1(1/ <ipicill/y) . .'lote: The term Hunter-Schrcgcr bnnds refers tu the alternating light and dark line~ >CCn in dental enamel that begin 3t lite Ol'J and end before they reach the enamel !nlrfncc. Titcy represent areas of enamel rods cut in eros& ;cction dispersed between areas of rods cutlongirudinally.
I. Enamel t urts are fan-shaped. hypocalcitled stnu:nores of enamel rods that 1\otOJ project from the denttnocnameiJuncrion into the enamel proper (/heir jimctlon
is tlllkll.n.n ).

2. Enam~l spindles are elongated odootoblasuc (hair-like) processes 1hat trav= the DEl from the underlymg odontoblasL May serve as pain receptOr>. 3. Enamel la.mei!Jie are defects on the enamel resembling crack.~ or frac1ures whlch traverse the entire length of the crown !Tom the surface to the DF1. They contain mostly Ofllanic mnlerial Md may pnll~dc an area for decay lbllcterln/1<> enter.

ENTAL ANATOMY & OCCLUSION

T-Comp)

The inorganic component of mature enamel makes up 96% of the structure. The other 4% contains all of the following EXCEPT one. Which one is the EXCEPTION?

Water Amelogenin Collagen

Enamelin

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'

An elongated odontoblastic process which traverses the OEJ from the dentin into enamel is known as an:

Enamel tuft Enamel spindle Enamel rod

Enamel lamellae

114

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Important informlttlon to remembe: 1 During u fiO h we~k. or embryOniC development, the ornl epithelium lttlnderm) thickens along the futun: dentRforc hc~ tO f0m1 the denta.l Jant(nll.
2 Around lhe ~o."1hth week of cmbr)'Onle de\clopmcnt. the mtsencb) mal nt-unJ crest

ft,/tich romarns tomesmch)ntcJ lnduces the dcvclopn'll!f'll of tooth buds at ten locations in tht upper and lo\\er dentallamma. l. During the bud ~rage, the dental lamina grows IntO the rnc~cntbymc m Ibe: shape or n bud . .... During the llllllh week or cmbryon.c dovclopmenl, the tooth bud diffcrcntialcs Into il Cl:lp shaped enamel organ extcndin frorn 1hc dental lammu. A ''estibular lumlno develops to separate the gum frum the Jip.ltbcck During the cap srtgc. on uncquaJ ~ro\\1h or eptthchal cttls gro\\S do"'n co form a conca' uy around 1he mesenchyme. fanning the dental papilla. Other mesenchymal celts enctrcle the enamel organ, fonmng tile dental ur. B) the end of tht cap stage (111/rd stage of odontogeii<SIS) the tooth g<rnt is complete and conststs of: I. The enamel orgno, which IS fomu:d from orol cruthclium._ It 1 !. dcr1ved fron1 th~ ectoderm. h has rour distincc cell layers; (1) Outer ennmel eptthelium (2) Inner enamel epllhelium (3) Slratum 1ntermcdium (4) Stellate n:llculum -* The enam~l orga n will g1vt ri~ 1 0 enamel and will e\entuaJly form Henw1g's epnhel .. tal root shealh, l. The denrnl uc surro~m<b 1he dcvclopang tooth ~crm und will give nsc w the cementum, the l'DL, and the alvolar bone proper. 3. the dentnl papilla will gi'c nsc to the dentin and dtntol pulp. ' otr: Tite out~r layer of ccU.. of tht dental papilla dtlTcmtllatcs into lhc odontoblastS !d~nlin:formJng ails). Both the denud papilla and dental sac s.n: formc:d from the mesc.nchymol neural crest fu'llidJ COIJiol!tf oclome,enchyme).

\I

the IU.J

Ulllll'l :J Cll\[lllp

Enamel is the hardest tissue in the human bod~ and the ncbest in calcium. It is highly mineralized nnd is totally acellular. It consists ofappro"mately 96% morgnnic minerals 1.-alciwn tmcl piiOS{Jiloms as ilydro.<yapalite). I% orgnntc materials, und 3% water. It is of ectodermal origin. The organic matrix conststmamly of protein, which is rich in prohnc. The fundamental morphologic un11 of enamel is the enamel rod or prism, bound together by an interprismatic substance (mlerrod substance). Each is formed in mcrements by a single enamel fanning cell, the ameloblast. Each rod begins at the DEJ and extends to the outer surfnce of the crown. Each crown consis1s of 5 to 12 million rods. The rods increase in diameter ((itJfll 4 "" to 8 miCI'OIIS) ns they narc outward from the DEJ. Note: The oldest enamel in n fully erupted tOOth is located at the DEJ underlying a cusp or cingulum. Other important facts about enamel: It has no power of regeneration; the ameloblast> lose tbeir funcuonal ability when the crown o f the tooth has been completed It has no IJOWer of metabo lism II has no means of CQmbuting bacterial invasion; the susccpubtlity of the mtn eral componcnl 10 dissolution tn an acid environment 1s tho basts for dental decay. It has no nerv supply It is a good thennal insulator

ENTAL ANATOMY & OCCLUSION

T-Comp)

,
I

\.

During the fifth week of embryonic development, which of !be foUowing thickens to form !be dental lamina?

Basement membrane
Epithelial nerves Ectomesenchyme Oral epithelium

Copynaht 0 20092010 Oen~l Dks

'"

ENTALANATOMY & OCCLUSION

T-Comp)

Tbe oldest enamel (the first enamel deposited) is located:

At the CEJ At the DEJ under a cusp tip At the cusp tip At the OEJ on the buccal side

112 Cop)n1 htO 2009-lOIO Dental 0-.ts

The maxillary first and second premolars are more alike than the mandibular premolars and. unlike the. mandibular premolars, the ma.,illary first premolar is larger than the second. nte mandibular first premolar is usually the s mullcst of all premolars. Remember: Both maxillary and mandibular premolars have their long axis most perpendicular to the horizontal plane when the teeth are in maximum intercuspation. In other \\OTd>.they are the most dosely venicaUy aligned ofalltbe teeth.
:\tu:. Rjght

, .... Rlgbt
Second rremolar

{\land. RJght

flnt Premolar

Firsl Premolar

Mind. Right Second Premolar

Importa nt : In a l.atcrotrusivc movement (working. right or left), the lingual cusp of a ma.xillary second premolar passes through the facial embrasure between the second premolar and the first molar.

l'n'\l'IH."t'

nf

mc,io-lin~:,mtl dl' \

l'lopmenlal

grno\ t'

Tbts is found on the mandibular first premolar. not on either maxillary premolar. The maxiUary second premolar has lhe foUowing characteristics compared to the maxillary first premolar: One root: the first premolar has two roots Much more symmetricnl and less angular (more ovoid) than the first premolar DBCR (disto-buccalcriSp-ridge) is longer than MBCR: opposite of lirst premolar Buccal and lingual cusps are almost eq ual in height; on the first premolar they are not Ha> no mesial developmental depression; first premolar does Ha< a less prominent buccal ridge; first premolar bas a prominent buccal ridge lias a shorter central groove with more supplemental grooves; fir!<t premolar has a long central groove with minimal supplemeotai grooves

r :...-..
~1

---- ~

..

~ Buccal

l A
Lingual

---

DENTALA:'IIATOMY & OCCLUSION Premolar- lnf

The largest of a lithe premolars are t h e - - -- - and the smallest are the - - -- -

Maxillary first, mandibular first Maxillary first, mandibular second Maxillary second, mandibular first Maxillary second . mandibular second

1ot
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DENTALANATOMY & OCCLUSION Premolar- Inf

,
A hockey player comes into your office with both of his maxillary right premolars In hand. Which or th e following characteristics would you not usc to distinguish the first from the second maxillary premolar?

Number of rooiS

Symmetry (one is more symmetrical than the other) Mesial to distal cusp ridge ratio Presence of mcsio-lingual developmental groove Central groove si~e and supplemental groove number

110 Copyris}ll 0 ~2010 DentA-l Ded:l

Remember: Maxtllary first premolars: Often times-- both the root outline and pulp chamber are kidney-shaped Tbey are the only premolar -.ith two roots and two canals (one buccal and one ling11al) Buccal root and canal are the largest

..,.....,...._

___....,.

MuiUary Right First Premolar

Mesial view

I. Premolars are most difllcult to do root canal treatment on because they are Notes easy to perforate {especially maxillary firsr premolars). 2. Maxillary premolar roots occasionally penetrate the antrum.
~!axillary

Right first Premolar

The key to dctennining right from left is that there is a more pronounced developmental groove on the mesial.

Mesial Developmental Croon

\l.nillar~

tir'l 1nmu lar

Remember also: That this tooth bas a pronounced cen ical concavity on the mesial surface of its crown, as does the distal surface of the maxillary first molar. Maxillary Right First Premolar

P---------------.r---~--------~

~Inial

lkpnMI

"''..,..._taJ

Buccal features

ENTALANATOMY & OCCLUSION Premolar-

In~
)

The pulp cavity shown below is the:

Maxillary right first premolar Maxillary left second premolar Mandibular riglll first premolar Mandibular left second premolar

) fts:lodlstl

$tl:don

Buccolinjlua d section

107
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Dcntul Ob

DENTAL ANATOMY & OCCLUSION Premolar- lnf

Which premolar is the only one that has a mesial buccal cusp ridge that is longer than its distal buccal cusp ridge?

Mandibular first premolar

Mandi bular second premolar

Maxi llary first premolar Maxillary secood premolar

108

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\ l <~~u.l ihul:.tr li~t

premolar

The distal marginal ridge follll> a prominent ele,arion on the distal ponioo of the crown and measures nearly twice the length of the mesial marginal ridge. Both mesral and distal margmal ridges of thrs tooth have lillie or no contact in the rdeal intercuspal rdationship. The contacts are rdeally on tbe mesial or distal triangulor fossae. which are found slightly mesial or distal to the marginal ridges. Tbts tooth has a small, nonfunclioning lingual cusp. For this reason. the masticatOI)I function most closely resembles that oftbe mandibular canine. I. The mandibular first premolar shows evidence of crown completion at 5 to 6 :\'oles years of age. 2. The mandibular $ccond premolar shows evidence of crown completion nt 6to 7 years of age. 3. The maxillary premolal'll show crown completion at the same approllirnutc time as the mandibular premolars.
''~blr~

M,..,W ...

..v ..a _,_.,_.. I

......

:\landibular Rijtht First Premolar

Lingual ,ie"

1-'rnm

prnximal \it.\\, lln mandihular pn:mnlarcro\\ns tilt 13hi:.tll~

Four characteristics of mandibular premola.rs th3t cle-arly distinguish them from their

ma"llary counterpans:
l . From a proximal view, the mnndabulnr prcmolarcro\\n.~ tilt liaguall~ From a pronmal view, the outline of the m:rn..lrbu13r premolaiS is rhomboidal The outline of the maxillary prtmolar.. is lrape-toidal 3 On mandibular premolars, the lingual cusps are much smaller than the buccal cusps. On
~

maxlllary premolar.~. the lingual cusps are smaller: howe>er, they are only slightly smaller an occlusal vi"" mandibular premolars are more square, while maxillary premolars are more rectangular (m thor they ore wider brwcolingually) I mporlant: The characteristic common 10 all mandibular first premolars when 'rewed from the occlusal aspect is that the buccal lobe makes up the majority of the tooth. Remember: A lobe is one of the primrll')' sections of fonnntion in the development of the crown of a rootlt. It is represented by a CtL'ip on posterior teeth, and mamelons and cingula on
J , From

anterior teeth.

\ landlbular Right first Premolar

Maxillory Right First Premolar

Oedusol

Occlusal

DENTAL ANATOMY & OCCLUSION Premolar - lnf

Which tooth has a mesial marginal ridge that is distinctly shorter in length and Jess prominent in height than the distal marginal ridge?

Maxillary second premolar Mandibular first premolar Mandibular second premolar Maxillary first premolar

105

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DENTAL ANATOMY & OCCLUSION Premolar I lnf

A mandibular first premolar crown and a maxillary first premolar crown fall on the ground. At first you cannot distinguish them because you know the biggest difference is the number or roots. But then you figure it out when you decide to usc all of the following criteria, EXCEPT one? Which one is the EXCEPTION?

From a proximal view, the outline of the mandibular premolars is rhomboidal, while the outline of the maxillary premolars is trapezoidal On mandibular premolars, the lingual cusps are much smaller than the buccal cusps, while on maxillary premolars, the lingual cusps arc only slightly smaller From an occlusal view, mandibular premolars are more square, while max illary premolars are more rectangular (in that they are wider buccolingually)

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The collagen fibers (connective tissue fibers) tllat support the gingiva and auacb it to the tooth and alveolar bon~ nrc called gingival fibers. TbeS<: fibers arc continuous with th~ periodontal ligament. The POL is also considered to be connective tissue. h surrounds the root and connects it wtth the alveolar bone by its principal fibers (a/.<o collagenous

fibers).
The collagen fibers of the gingiva are further classified into four groups as fol lows: circumf~rential (circular), dentogingival. dentoperiostcal, and alveologingival fibers. ~ott: Transseptal fibers are sometimes classified as a separate group of gingival fibers. I. The gingival apparatus is a tenn used to describe these gmgival fibers and :-<ott. the epithelial anachmeut. 2.The gingival ligament includes the dentogingival, alveologingival, and circ umferemial fibers.

\1t.Jndihuktr \t.~cnntl

pnuwlar

:-<ote: When \iewiog an x-ray of this area. the mental foramen is sometimes misdiagnosed as a premolar abscess. Therefore, before perfonuing root canal therapy, make sure all diagnostic tests confirm your ftnding. Important: When performing endodontics on this tooth. care must be taken to avoid 311 o'erfillthat may impmge on the mental foramen. Remember: This tooth can show three types of occlusal surfaces (pit and groove patt ems) . The three types of occlusal surfaces (pil and groove pal/ems) nrc: I. Y-t) pc = 5 lobes. 3 cusps (most common type) ~ . Ht) pe = 4 lobes. 2 cusps 3. li-type = 4 lobes, 2 cusps; central developmental gi'OO\'e will appear crescent shaped.

"""' 1!01"
Ulypc

......

11-type

Y-type

ENTAL ANATOMY & OCCLUSION

(
Attached gingiva Free gingiva

Gingival fibers arc found within the:

Mucogingival junction Attached and free gingiva

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DENTAL ANATOMY & OCCLUSION Premolar- Inf

Which tooth is most likely to be unnecessarily endodontically treated by a novice dentist who sees a radiolucency on the radiograph?

Mandibular canine Mandibular second premolar Mandibular first molar Maxillary first premolar

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The ptrlodontlum refer$ to the functtonal unit of ttssucs that surrounds and suppons the teeth. It

.. 'Om~IM~ of '''o sections:

(I) Glnp.lval unit1 composed of the frte and attaclltd gingavn and the nh'eolar mucosa. (2) Anachment :.pparatus, which includes the cerntntum, periodontal ligament. and the alveolar

bon I! proper. Important information to remember

l The lnltrdut.al ginJ:a' 1S lh211 part of du: ftcc JIDilV3 that occupits rbe inlerdcntal spac:es rrws wbkb is sanwed bd-.'CCD the teelh In the area beneath the tooth contact pomts. It COt'ISISI~ O(l\\'0 papillae (one huccol cmd one lingua/) that are connected by the eoncavc..-shaped fnttrdtntRI col. Th1s col confonns to the s;ha~ of the
to ronal to the ahcolar c~t. h " the- tnangutar gang.val

.n' uuues and helps to fonn the sides of

roorh fonn pre~t.
A)lt'Oiar mtlh
(UnJna mu ('ll,l~)
)tuwttl~tll.h'al

contact are~ and is not prcsc:m nt all when Ieeth .-.re nor in cont~ct. ~.The nttached gingiva IS thnt ponion which is firrn. d<.:usc, stippled. and bound 1 0 1ht underlying pcriosu~um, tooth, and bone. lc ex1end.~ from the mucoalns,:i..,al junction to the frt~e g_lngl..,ial groon. 3. The rr~ gingjYa (also called tht murgfnal gingim)1s lhat portion which is unauach.t:d to underty

the gin~1val crrviee (sulcus). lt cxcrnds from the fr~ ginghl ~rooYt to the gjngJul mt~reio . .a 1n the bseoce or penodonlal di.)(tSe.., abc configurauons of the crest of lhc lnll:rdcnlalahwl:ar 'CJ'I'' a~ d~erm1ned by the rel1ti\'c positions of the adjactnt CEJs. The width 15 ck1mnined by the

jUIK'fiGD

::;;;.-- \la~ilul

zia-D

1 1-.'1..' 1-:hl:.!,l\;1

Components of the Gingiva: I Free gingiva (wruuach~d or margma/ gingn"t1): the collar of tissue that is not attached to the tooth or alveolar bone. It rs approximately I 10 3 mm wide and fonns the oft tissue wall of the gingival sulcus next to the tooth. Other structures of the free gingiva include: Gingival margin : the I nun narrow band of gingiva that fonns the immediate collar around the base of the tooth. ThiS area is first to show symptoms of ging-

a,itis.
Gingi,.,.l sttlcu~: area bet\\een the unanached gingiva and the tooth. Popcorn hulls get trapped in this area. Epithelial attachment (junctional ~pllltelium): joins the gingrva to the tooth surface. 2. Attached gingiva: is that pan of the gingiva which is attached to the underlying periosteum of the alveolar bone, and to the cementum by connective tissue fibers and the epithelial anachment. It IS present between the free gingiva and the more movable alveolar mucosa. I. The mucogioghol junction separates the attached gingiva from the alve.:.Jar
Note,- mucosa.

2. The free gingival J(roove separates the free gingiva from the auached gingiva.

~ENTAL ANATOMY & OCCLUSION

,
Tbe col is a non-keratinl~ed, eonca\'Cshaped structure which is most specifically port of which gingival division? Interdental gingival Attached gingiva Free gingiva

t Ot C0$')'1'1Jht0 2(109..2010 lkntal Dttl:s

~ENTALANATOMY & OCCLUSION

A 42-year-<>ld female patient who has a history of impeccable ond hygiene comes into your office for a maintenance appointment. Tbe dentist notices that she seems stressed out and also disco,ers moderate plaque buildup. The patient doesn' t ban any clinical or radiographic demineralization but Is starting to show signs of gingivitis. The first area to show clinical signs of gingivitis would be tbe:

Attached gingiva Free gingiva Mueogingival junction Free gingival groove

ID Z Co,)nJM C> 20092010 rkntal Dks

0.2 mm '' idt

The thickness of the POL ''aries deptnding on: The person'> age -- it decreases to 0 ,1 mm in old age; this happens most hkcly a.< a result of the deposot oon of c.:menrum ami bone (this is most 11oliceable ;, th~ regio11 of the mandil>lllor callille), Stag~ of crup11on Function of the tooth-- the PDL becomes very thin and loses the regular urrllngcmeot of its fibers when a tooth loses its function. This also occurs in areas of tension as opposed to nrens of compression. POL and tts hard tissue anchorage in tenns of resisting occlusal force. I . Anterior teeth have slight or no conUICt mthe totereuspal position 2. The occlusal table is less than 60"/o of the overall faciolingual Wtdth of the tooth. 3 . The occlusal table of the tooth is generally 111 right angles to tltc long axis of the tooth . .1 Crowns uf mundibular molars are inclined about 15-20" toward Uoe lingual. For this reason. the root apices of mandibular molars arc positioned more lilcially und the ~rowns arc positioned more lingually.

I Tbe POL os derived from the dental sac. 'looes 2. The tl>>lll'S immediately adjacent to the I'OL are cementum and alveolar bone. 3. Rernn3nts ofHenwig's epithelial root sheath found in the POL of a functional tooth are called Rests of Jl1alasscl (gmup< of epithelial cells). Some rests become calcified (cemen!ic/csj.

u They project into the cementum ~"'een groups of cemeotoblasts, and lie pe~ drcular to the surface of the cementum. The dtanteter of these fiber.\ is constderably grtater on the bone side than on the cementum >Jde. The PDL s u complex, soft. fibrous connective tissue that surrounds the root of a tooth, separating it from and attaching it to the alveolar bone. h extends from the base of the gingival mucosa to the fundus of the bony socket. It contain~ numerous cells, blood vessels. lympluotio~. and extracellular substance consisting of fibers (glng/v(l/ and principal) and ground substance. The majority of the fibers are collagen, and the ground >ubstnnce os composed of a variety of proteins and polysaccharides. Functions of the POL: Ph~sical - attachmem of the tooth ro the bone via principal fibers and the absorptiOn of occlusal forces Formath e -- t'ormanon of connective tiS!;ue components by activties of conneethe tissue cells (cl!memohlasts.jibroblasts. amJ o<tl!(lb/asts). Remodel inc - by activities of connectove tissue cells that are uble to form as 11ell as resorb cementum (cementobla.rts or cemcmoclosts), periodontal ligament (fibroblasts orji!Jm,lflsts), and alveolar bone (osteoblll.f!S or osteoc/asts). Nutritive- through blood vessels that maintains the vitality of its various cells. Sensory- carried by the trigeminal nervo, llr<lprioceptive and taclllc scnsitovity is imparted through POL (sen.<atfo11 of colllact between teeth). The POL is richly supplied "ith ntr\'C endings that are primarily rc<:eptors for pain and pressure,

ENTAL ANATOMY & OCCLUSION

Your new patient reveals to you during a health history that she has scleroderma. During the general appraisal you did notice a purse-string mouth, and when caking radiographs realized the difficulty of performing dental work. Tbe radiographs also showed generalized widening or the periodontal ligament. The periodontal ligament in an adult is about:

0.002 mm wide 0.2 nun wide 2.0 mm wide 20.0 mm wide

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E~TALANATOMY & OCCLUSION

The periodontal ligament is made or large collagen fibers tbat course between the cementum and the alveolar bone. The porlion of tbe principal fiber that Is embedded into tbc cementum is called a:

Cementa} fiber Sharpcy's fiber

Dentinal fiber
Gingival fiber

[pilhl'lial :tll.u:hmcnt

The epirbelial auochmenl is provided by the surface cells of lhc: junctiorull cpllhelium, via a basal lamina and bemldesmosomes. It fmm~ rhe actual anachmeru to the toorh surface. Remember: The juncrional epithelium is rhc epithelil collar rhat providell lb< epithelial attachment to the tooth surface continuous with but stnocrurally distinct from the sulcular epithelium (cwicu/a,. epi1helium), which is the epithelial liniog of ~te gingivnl sulcu$, extending from tho gingival~~~~~~:!.':~~~~~

IIIC!rnlll hAUII~mllll

r..,,.,"t ba,.al lamln;

\h enlar hmw pnptr

The lllveolar pr~ess is that pan of the maxilla and mandible !hat forms and suppons the sockets oftbe teeth. h consists ofmo main parts I. Alveolar bone proptr: a thin layer of compact bone that is a specialized contmuation of the conical plate aod forms the tooth sockeL Note: Tbc lamina dura is a horseshoe-shaped white line on a dental radoograph that roughly correspond to the alveolar bone proper. It has minute openings which provode passages for vascular and nerve compuncnts. It is composed of compact bone, but is sometimes called bundle bone due to the presence of bundles of perforating collagen fibers. :!_ Supportlngolvcolar bone: that bone which surrounds the alvcolnr bone proper and gh cs suppun to the socket. It consists of: Cortical plate: structurally. the conocal plate is composed ofhn!,'llal and facial plates of compact bone. It is dense in nature, provides strength and protecuon, and actS as the attachment for skeletal muscles. The mandibular corucal plate is more ucn>e than the maxillary conical plate and has fewer perforations for the passage of nerves and blood vessels. .'lote: The alveolar crest is the highest puitll of the :olvcolar ridge and join~ the facial and lingual coo 1ic:ol plates. Spongy bone (concellou.s bo11c): fills in the area between corttcal plates and alveolar bone proper. This type of bone is not pr=nt in the anterior region of the mouth: here the conic:~! plate is fused 10 the al\'eolar bone proper. This ts also uue over the rndicular buccal bone of the maxillary posteriors. :-lote: The alveolar bone proper is the only essential part of the bone socket. The suppaning alveolar bone is not always present.

~ENTALANATOMY & OCCLUSION

,
Whicb structure is the inner layer or tells or the junctional epithelium and attaches the gingiva to the tooth? Mucogingival junction Free gingival groove Epithelial attachment Gingival col

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ENTALANATOMY & OCCLUSION

,
A patient presents to the endodontist \\ilh a severe toothache wblcb Is radiating throughout the entire right side or his fa~e. The upper right molar bas a large, cavitated lesion and is negative to a cold test. The radiograph shows widening of the PDL and disruption or the lamina dura. The lamina dura roughly corresponds to which component of the alveolar process?

Alveolar bone proper Supponing alveolar bone Conical plate Spongy bone

Copyni!bt 0 2009201 0 rkMIII Decks

..

\pica I

Th< prn>c:tpJI fiber< of 1~ PDL arc primanly romposcd of bundles of cy po I rolllgen fibrils.

n...e

fiben t"'nnl the tcmetttUm f(l thr:~lvcolu bone. 1bc m:un princl)Xt.l fibtt group r!l> thr: ahtolodrntal liga~mN11, whatb COI1XIl'l)l. or fht fiber groups:: Aht'olod.:niHIIIgnnlro:

Tbe alvtolnt'l"t''t gr'Oup ofchc alvcoludenhlllignment: origtnnlcS in the alveolar crest tho alveolar bt.me proper and lbns uut tu m~;crt into the <:cf\lreal~:t.:m~:n,um .:n various BJlgJeot.. The func:lion of thi$ group IS co te~i~t llhing1 mlmswe; exhmlvt. And rou.tion~l torcc:~~. Th~ DJilUI group Of lhe t\l\'tolo..kntal ligament; r"oldllle5 rrom the npical regrOI\ O( the ~cmcntum 1 0 inscn Into the surroulldlng l\1\eol~rbonc Pf01}4::1 rhe t\mcuon orrhis tP'OUp i~ 10 n:.,~,, tAmi.,IVC ft>rccs. \\hich tty to pull tkt lo<rth oor.-ooud1 and rol;ulonal f()(Cts 11te obHqut group o( 1hc lh'CUloc:Jental hprnc:nl tk 0\0'!.1 nUJ'Den)u,s of lhc fibc:r ~!and CO\'ctS lh api<al N-o-lhtn!. of1h< rooc This group on~tnal<> '" 111< alvrolar bonr propor and nen<J, apo<all~ \D u1sro nKWt:' wrtnfl)" rno 1he t'ementu.m 1n.., \'lbhq\tc tniMtr TI1c function oftbts ,wp h h) n:;.tst lnr:rw.i\>C forcct. \\hrc:h 1ry IC'I ~})the tooth mwania Wt0 .U rolati<maJ (Ofl~ts. The horiLontlll &roup (lr th~: aheotodema1 Jigan~em; orijliMtts ID tJ1t tl\'to1ar bone pi'<IJloe UIJ.CI!l to lts alveolar ~r.tnnd IO,t:ns inlO Ihe eementwn hnri70011tlly. The filnt:hQO or lhis group b: 10 rcJIUit tilting force~ Wht(:h work (0 fo~c d'c tip eithe-r mo.o;1!1lly, dbtally, llnb'lulll)'. or O.cially. uml to rctu!lt nmuional
il)o.!l'$,

or

The inferrndkular )troup of the alvcolodet~llil1l~ttmcnr. found ouly iu multirOOted tcctlt 1 h1~ ~rrttUJI i;; in~ened on the ccmentUJl1 of tm9 reo to lhe cementum or the other root (or tuaL') ;;upcrnct:.lco the intemdku.lat .!!eptum .ln~ thus has no bony anuehmcnt The funclton of thl$ ~up ij to work tOgtthC'r \\itt\ the uh tOioH Cf'eSl a'Jd apical WOUfs 10 l'e11~U lotni\1\e, t\lt\l)t\lc. tilting. and NCI.Iion:aJ (on:c..'t ' olt: .~\nolher pr1ncrpal fiber otbrr dt...n the ahC(.IIOI.kntll ligament j$ !.he inttrcltnltlllt:mtnl. or
l,..ftlsrpll llgamtnl. ThiS fiber ~toup fcallf'd lrtlfiiUpl~l fl!vnl in.s~m mts&ally oc lOie:nlc:nblly mro rhe tc:rvicftl ceo'!Cflt\&n\ of' ncig:hhoring, 'c:db tner Ihe h col:&r c.:rnl of the sheolat bun.: rro~ \he fiber$ tra\'t~ from l cmem:um to ec:menrum " nhoot An) bon~ anachm&:nt Tt.e function of dus !UOIJP ~~

nnas.

tu lf-')1.;1 rt11tltiU1l~J rortr:5 and lh~ huJd ibC: U:tlh lD !nl(1prlJ\ImSI1 C\-mlact

Remember: The lenmnal ponions of lhese collngttl t1bers 1ha< inaen iulu lhc ccmenlum and bon< are C.1lled Shorpcy's fibers.

lh.nlf.!n~i'

ulli:_:.1mcnl

Gingival fibe~ 3rc coUogen fibers thai suppon onl) 1he marginal b~ngial lis.,ues 10 maintain thctr relauoosbip to the tooth. The glns;hal lib<>r group (olsn Ctlfled the gillgi\YJI/igaflwnl) ts the name given to St:panuc but adj~eru fiber goups thai are round wuhiu1he luminu prupria ofrbe marginal gingt\0 Nule: S<me biSiologisiS consider the gingival IIJ:nment to be pan oftltc rnnc1pal fibers (also <ailed t/J~ aloclllllflillgivalligamenl) or the PDL . Gingivolllgumcnl (or ~;.Tingiva/ fiber group): Ci rcnliU' Ugnmnt - thi~ tiber subgroup of 1he gingival fiber ~'Totop is ii)(!Rttd in the lamina propnn of lhe mnlb>in~tl gingiva. The circular Ugnrucnt c'ltcirctes the lOOih and helps maintain gmgivol iutcgrily. Oemoglnghol ligament - this fiber subgroup uf the gmgwol tiber lltOUP Ul"'ns m lhe cnnenJUm on lhe 1\Kl\, apical lo lhe eptlhelial anscbmc'ltl, and ~tends tnto tb~ lamina propnu of lhc marginal gingiva. Thu.~. tbis ligament bas only one min<'TIIhzed auacbmc'ltt 1<1 d1e cementum. Tite dcntol!ingwal ligament works wilh the crcular ligamenl \u mnintum gingival imegrny. Alveologiugival llgam~nt - this tiber subi!!Ollp of lhc gingival fiber group cxtcuds from lhe -ulvtolnl ~rest of U te alveolar hune tll'nper Hod radiates cumnully o olo 1he ovl.'rlying laminu propria of the marginal go ngtvn. Th<se fibers may pos.<ibly help 10 attach the gin11ivu lo the alveolar l>tlne because of their one mincmli~ed ot1uchmen1 ro bone. Denlop.rlost<ll ligament- this fiber subgroup of 1he gtnglval fibef ~roup courses from the ccmenJUm. near the cementoenal1ltl JUnction, across the alcolar The<e fibers posstbly anchor tbe tooth 10 1be booc und protect the deeper penoclon1l hgn

-=t.

menL

~ENTAL ANATOMY & OCCLUSION

r
An oral surgeon Is extracting a patient's second premolars In order to create more room In the arch for orthodontic treatment. She is always fascinated at the resistance a healthy tooth bas to extraction. Which group of fiber$ of the alveolodentalligament resist tilting, intrusive, extrusive, and rotational forces?
~

Alveolar crest roup Horizontal group Oblique group Apical group lnterradicul:tr group
as
Cop)'ritM C 20092010 l>c'lt.~l ~ks

E ENTAL ANATOMY & OCCLUSION

Which nbcr subgroup of the gingival nbcr group (gingiva/ligament) inserts In the cementum on the root, apical to the epithelial attachment, and extends into the lamina pro11rla of the marginal gingiva?

Circular ligament Deotogingivalligament Aivcologingivniligamcnt Dentoperiostcnl ligament

CopynglnC !009-2010 """'' O..b

"

*** The cranium is fhed and !he mandible IS moable.

In this system (Cia.rs Ill): Fulcrum condyle Force ~ muscles Work load teeth In a Class Ill lever system the workload is located between !he force and the fulcrum.

The oral caity IS lined by a mucous membrane "hose maJor functions are lining and protecting. It also serves as a mobile tissue that permits free movement of the lips and cheeks.
I' Jh' nl ( lr.ll \lmo"a

Ttll<f

Regions

Gtural Clln1ul Appearanc-e

CC'nC'ral ~1kro.trOplt
ApptaN~~ncr

Linins
MUC0$3

- --M~tiUtiOry

Softer turf~ texture, moist surfu<:c:. nnd ability to :~tretch rosa. floor of the: mouth, and be compressed, accing as vtntrttltongue surface. a cushion and soft ptlau~

Buccal muc~>sa. labial mucosn, alveoln.r mu

Thin nonkerallnlted

stratified squnmous cpilhelium, f1.'W rete pegs, thm lamina propria

t ~M gingiva.. attached Rubbc:ty surftce cexturt and Kentinlud epnhchum. pn&Jv.. Interdental giD- RS.~lieocy. J(tvtng as tirm many rete pep. ttuck

, ..... lwd palate. and

Dorsatoongueourfaee

.......

lamina propna

SpoaaJ....S

Assoc&ated With linglW

muc:osa

popolloe

Mostly ktf'ltanlltd. Nolt: 'The filifom~ and circumvallate pap1lla~ are keratinized. but the run&ifcmn a.nd foliate papillae arc nonkemti nized.

I. The crevicular (.<ulcular) ep1thellum and gmgtval col a1e nonkerallnlzed gingiNotes va] tissues. 2. The lllling of a healthy gingival sulcus is composed of nonktratinlzed epithelial tissues with no rete pegs. The presence of rete pegs is inditathe of the presence of
inflammation.

3. The junction of the lining mucosa with the masricatory mucosa is tbc mu<Ol:lngl~ljund~n.

~ENTAL ANATOMY & OCCLUSION

(
Class I lever Class II lever Class Ill lever
The mandible functions as a:

Occl-Term0

t3
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20092010 Den1ol Decks

ENTALANATOMY & OCCLUSION

Pdl /G)

Whicb type of mucosa co,ers the gingivallissue and bard palate?

Masticatory Specialized mucosa

Lining or reflective mucosa

CopynafltO 20092010 Denial De<b

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 Overbite: the vertical distance by which maxillary incisors overlap the mandibular incisors. Normal = incisal edges are within the incisal third of mandibular incisors Overjet: the horizontsl distance between the labio-incisal surfaces of the mandib ular incisors and the linguo-incisal surt1ces of the maxillary incisors Underjet: maxillary teeth are lingual to mandibular teeth Open bile: lack of occlusal or incisal comact between maxillary and mandibular teeth. The teeth can not be brought together

Vertical Overlap

-r-

OVERJET

OVERBITE

Cur\t.' ofSp"r

There are two curves of the occlusal plane observed from a buccal and a proximal view: I. Curve of Spec- refers to the anteroposterior curvature of the occlusal surfaces, begin oing at tbe tip of the lower canine. following the buccal cusp tips of the premolars and molars and continuing to the anterior border of the ramus. An ideal c11rvc of Spec would be aligned so that a continuation of its arc would extend through the condyles. For mand ibular teelh the curve is concave and for maxillary teeth it is convex. 2. Curve of Wilson - refers to the me.diolatersJ curve that contacts the buccal and lingual cusp tips on each side of the arch. ft results from inward inclination of the lower posterior teeth. making the lingual cusps lower than the buccal cusps on the mandibular arch; the buccal cups are higher tl1an the lingual cusps on the maxillary arch because of the outward inclination of the upper posterior teeth. For mandibular teeth the curve is also concave and for maxillary teeth it is convex.

Curve of Wilson

Remember: Combined, the Curve ofSpee and Curve of Wilson fonn a plane termed the '"Sphere of Monson or the Monson Curve." Note: From a fi'ontal view, the plane of occlusion of the mandibular arch in a nonnal dentition is a concave curve, while the maxillary arcb is a convex cu"'e.

DENTAL ANATOMY & OCCLUSION

Occi-Terms

A patient's mother comes in to complai n that her child's upper front teeth rest in front of his lower lip. You explain to her that this is called - -- - -

Overjet

Overbite
Underje t Open bite

t1 Copyngbt 0 20092010 Dental Oks

E ENTALANATOMY & OCCLUSION

occl- TermV

Which curve or the occlusal plane is depicted below?

Curve of Spee Curve of Wilson Curve of Monson

- ....,,,,
t2

CopynJht 0 20092()10 OC'n.tal OU

The LESS the \'ERTICAL mcrlap, I he SHOIHEH I he <11'1" \ll'S I he

*** Notice that cusps :'\'l AY be tall but nevt>r MUST be tall: and that cusps MUST be short, but never MAY be short. See notes below. Anterior guidance (sometimes called anterior coupling) is a tightly overlapping relationship of the opposing maxillary and mandibular incisors and canines, which produces disclusion of the posterior teeth when the mandible pro1n1des and moves to either side. Anterior teetlt have a mechanical advantage over posterior teeth because they are farther away from the fulcrum (condyles), giving them better levemge to offset the closing musculature. This is apparent when one tries to occlude maximally wfth anterior le"'lh as opposed to occluding maximally in the molar region. The further away from the site of muscle action, the less force is exerted. Important point of all this: If anterior guidance can he accomplished, the least amount of force will be placed on the Ieeth during muscular contraction. I. The les< ' 'ertical overlap of the anterior teeth. the shoncr the cusps must Notes be. With little incisal guidance from this end-to-end relationship, tbe shorter the cusps must be to allow smooth protrusive movements. 2. The greater tbc vertical O\'erlap of the anterior teeth, the longer the cusps must be. The anterior teeth contact immediately and disocclude the posterior tcetl1. 3. The greater the horizontal overlap of the anterior teeth, the sltoner tlte cusps must be lo allow for a smooth proU'tlsive movement uno1 the anterior teeth contact. 4. The Jess horizontal overlap of the anterior teeth, the longer tbe cusps may be. since the teeth contact immediately and disocclude the posterior teeth.

In a lateral movement. the nonworking side condyle moves downward, forward, and medially. The working side condyle moves laterally. Since the mandible is a solid bone. the amount that the non#working condyle moves mcdtally determines how far the working .side condyle moves laterally, The Oenncu movement is. sometimes called the lateral shift of the mnndiblc- or immediate side s hift. Important: This movemenl influences the lingual concavity of the maxillary an(erior h.:eh and dir ectional placement of the ridges and gr<>ov(.'"S on the mandibular
JlOSierior 1 ec1b.

Right lateral ruoveml!nl of the- mandible viewed from above (horizo,(al plane). 11\c condyle

Juring a si~c shift on the working side lrom \V 1 to w2 . On the l>a1ancing side, the c'Ondylc may move ITom C to point B. The angle (BG) niJide by I he sagillal plane and a line drawn from point Cto point Bis called the Sennett angle. Bilateral stmighl forward movcmcol of the condyles (CP) is protrusive.

ENTAL ANATOMY & OCCLUSION

occl-Termv

Which of the following statements is TRUE regarding anterior guidance?

The MORE the VERTICAL overlap, the TALLER the cusps MUST be The MORE the HORIZONTAL overlap, the SHORTER the cusps MAY be The LESS the VERTICAL overlap, the SHORTER the cusps MUST be The MORE the HORIZONTAL overlap, the TALLER the cusps MAY be

89
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ENTAL ANATOMY & OCCLUSION

occl-Termv

In the early stages of lateral movements, the condyle appears to rotate with a slight lateral shift in the direction of the movement. This movement is called the Bennett movement. This Bennett movement refers to the:

Non-working side condyle only Working side condyle only Both the non-working and working side condyles

90
Copyright C 2009101 0 1>tnta I Db

The fottl:UC and buccal mucosa po\ition Determinants or occlusion: I. The right temporomandibular joint and itS suspensory ligaments as well as the right condyle of the mandible

2. The left temporomandibular joint and its suspensory ligaments as well -as the left condyle of the mandible *** I and 2 are the posterior detenninants of occlusion and are fixed. 3. The teeth -- consist of the inter-occlusal contacting points and inclines of cusps of the opposing arches: they are variable *** 3 is the anterior detenniuant of occlusion. 4. Tlte neuromuscular system is programmed by the third determinant (the teei/1 and what nature and man <lo to them) The mechanical equivalents for the reproduction of occlusal determinants: I. Articulators 2. Facebow recordings 3. Mounting the lower cast on the articulator 4. Setting condylar guidance 5. Setting the Bennett angle 6. Transferring anterior guidance values to the incisal guidance plate

mandibular fu,sac I hones I "ithont I arc uol

The centric relation (CR) (also called tile ret-uded contact position) is the most unstrained, retruded anatomic and functional position of the beads of the condyles or the mandible in tbe mandibular (glenoid) fossae of the temporomandibular joints. This is a relationship of the bones of the upper and lower jaws without tooth contact- The presence or absence of tcelh, or the type of occlusion or malocclusion. are not factors. Important: Centric occl.usiou is typically slightly anterior to centric relation. :"iote: Tbe mandible cannot be forced into centric relation rrom the rest position because lhe patient's reflex neuromuscular defense would resist the applied force. The mandible should be relaxed and gent.ly guided into centric relation. Centrlc occlusion (also called the inlercuspal position) is U1e relationship between maxillary and mandibular occlusal surfaces chat provides the maximum contact and or intercuspation. Functional occlusion: Functional occlusion consistS of all contacts during chewing, swallowing, or normal

actions
Functional cootacts: nonnal contacts made during chewing and swallowing Parafunctional contacts: those made outside tbe normal range, may create wear , bntXism, clenching. nail biling. thumb facets or attrition and result from habits (i.e_ s11c~ing, cheek biting. etc)

~ENTAL ANATOMY & OCCLUSION Occi-Term~

The determinant factors of occlusion include all of the following EXCEPT one. Which one is the EXCEPTION?

The temporomandibular joint The masticatory muscles The tongue and buccal mucosa position The biomechanics of the temporomandibular joint The dentition and the occlusal table

87 CopynJ)ll 0 20092010 Dental DU

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Occi-Term~

The centric relation (CR) is the most unstrained, retruded anatomic and functional position of the heads of the condyles or the mandible in the _ _ of the temporomandibular joints. This Is a relationship of the _ _ of the upper and lower jaws _ _tooth contact. The presence or absence of teeth, or the type of occlusion or malocclusion, _ _ factors.

mandibular fossae I bones I without / are not mandibular fommcn I teeth I with I are mandibular fossae I bones I with I are mandibular fossae / teeth I with I are mandibular foramen I bones I without / are not
Cop),gbl 0 20092010 ~UII Dcc'b

..

The four theoretical determinants needed to ~store a complete and functional occlusal surface of a tooth arc: I. The amount of venical overlap of the anterior teeth

2. The contour of the anicular eminence

3. The amount and direction of lateral shift in the working side condyle 4. The position of the tooth in the arch

\\ htn hum ( K Co J( P j, natur.1l. il ,twuld lll'\er he mnrlititcl Occlusal adjustment (equilibration) is the reshaping of the occlusal surfaces of teeth to create harmonious contact relationships between the maxillary and mandibular teeth. Occlusal adjustment enhances the healing potential of tissues affected by the lesions of occlusal trauma. It may involve: Disking Odontoplasty Enameloplasty Coroooplasty

a'"'"'

The basic principles for occlusal adjustment include: The maximum distribution of occlusal stresses in centric relation The forces of occlusion should be home as much as possible by the lona axis of the teeth When there is surface-to-surface contact of Oat cusps, it should be changed to a point-to-surface contact Once centric occlusion is established. never take the teeth out of centric occlusion

ENTAL ANATOMY & OCCLUSION

Occl-Term~

There are four theoretical dcterminanl5 needed to restore a complete and functional oeclual surface. They Include all of the following EXCEPT one. Which one Is the EXCEPTION?

The amount of vertical overlap of the anterior teeth The contour of the articular eminence The relative strength of the muscles of mastication The amount and direction of lateral shift in the working side condyle The position of the tooth in the arch

85
Cop)TIJht~ 2009-ZOIQ

Dcnul Oeelt

0ENTAL ANATOMY & OCCLUSION

Occl- Term~

Tbe basic principles for occlusal adjuSimeot include all of the follo,.in g EXCEPT one. Which one is the EXCEPTION?

The maximum distribution of occlusal stresses in centric relation The forces of occlusion should be borne as much as possible by the long axis of the teeth When there is surface-to-surface contact of Oat cusps, it should be changed to a point to-surface contact Once centric occlusion is established. never take the teeth out of centric occlusion When a slide from CR to ICP ts natural, it should never be modified

II
Cop)'n$bl 0 20092010 Dental Deets

\Lnill.tr~

hucc;1l cu'P' \landihubr lin~o:u:tl \ u'J>"

These cusps are Blso called balancing, oon5upporting, non-ceniTic or s hearing cu.~ps. These cusps do not occlude or fit into fossae or marginal ridge areas on the oppo~ne arch. They allow the dentition to move apart, out of occlusion. Tbey allow tbe tcctlt to " unlock" and move back and fonb and side ro side. Supporting cusps are the maxillary lingual cusps and the mandibular buccal cusps. These cusp> are also called working, stamp, or centric cusps. Centric ~tops are areas of contact that a supporting cusp makes with opposing teeth. For example, the mesial lingual cusp of the maxillary first molar (o sr1pporring cusp) makes contact with the cenual fossa (cenrrol stop) of the mandibular forst molar. Supporting cusp~ contact the opposing teeth 111 their corresponding faciolingual center on a marginal ridge or a fossa. Non-supporting cusps overlap the opposing tooth without con1acuns it. Note: In posterior cross-bite situations. the supporting and guiding cusps are OllllOSite. The maxillary buccal and the mandibular lingual would be supporting and the maxillary lingual nod the mandibular buccal would be guiding.

Examples: I. The mt>iolingual cusp of the mand1bular first molar op~s the lingual embruure between the maxillary forst molar and second premolar 2. The mesiolingual cusp of the m3Jidibular second molar opposes the lingual embrasure between the maxillary second molar and lin-t molar Note: The dlstollnguul cusp ofthe mandibular tlrst molar fits into (opposes) the lingual groove of tho maxillary first molar. Remember: The lingual cusp of permanent mandibular forst premolars does not occlude with anything. Important: During mandibular movements (working. liOn-working, etc.). the outer aspects of the lin~:ual cusps of tbe mandibular molars "ill not contact thelf maxillary aotagonists. All other areas of buccal and lingual cusps may contact during mandibular movements- this is asswning that all occlusal relationships are normal. Note: In unilateral balanced occlusion, conuet between mandibular buccal cusps nnd maxillary buccal cusps, along wiih simulwneous comact between mandibular lingual cusps and maxillary lingual cusps, wiU most likely occur in laterotruslve movements.

ENTAL ANATOMY & OCCLUSION

Occl-ln0

~ A dental student Is finalizing the temporary crown he fabricated for his patient. The patient's occlusion is in an ideal relationship, and the crown has Ideal centric contacts. The student has a bad habit offorgetting about working and balancing contacts. He docs remember the rule that be should avoid laterotruslve conlllcts on tbe guldln& cusps on posterior te<-th. Which of the following ar e considered to be guiding cusps?

Maxillary lingunl cusps Maxillary buccal cusps Mandibular lingual cusps Mandibular buccal cusps

n
Copyt'llbl 0

20092010 Dental OU

ENTAL ANATOMY & OCCLUSION

Occl-

lnf)

In an Ideal intercuspal position, the mesiolingual cusp of a JICrmanent mandibular molar opposes:

The opposing central fossae The lingual embrasure between their class counterpan and the tooth distal to it Tile opposing distal marginal ridge The lingual embrasure between their class countcrpan and the tooth mesial to it

Copyngbl C 20092010 DMtal Docks

..

( ont;lrh in lhl lnh.n:u,pal f'o,itinn

.Mandibular Buccal Cusps First premolar Second premolar first molar Mesiobuccal Distobuccal Distal Stcond molar Mesiobuccal Distobuceal

Ootludes Into Area of Maxillary Teetb

(Class counterpart or ~ounterparr and tooth meSilll to it)

Mesial triangular fossa of ftrst premolar and distal marginal ridge of canine Mesial triangular fossa of second premolar Mesial marginal ridge of first molar and distal marginal ridge of second ptcmolar Central fossa of first molar Distal fossa of first molar Mesial marginal ridge of second molar and distal marginal ridge of first molar Central fossa of second molar

'IL\iohunal

Classilicatjon oUiumun Occ!ysion f.4ngle~) Class 1: most common (about 70% oj tht population). The mesiobuccal cusp of the max tllary first molar lioes up appro.,mately "11h the me,tobuecal gJOOve of the mandibular first mol~r. The maxillary central tnctsors o erlap the mandibulars. Maxillary canine lies ben\een

h~---~--T~I
Cla<s II: less common (abotJtlJ%). The mestobuccal cusp of the maxillary fli'St molar falls approximately between the mandibular first molar and second premolar. l'he lower jaw and <hin may also appear small and withdruwo. The mandibular incisors occlude even more pos ttrior to the maxillary inch.ors so that they lnllY not touch at all. Maxillary canine is mcslol to mandibular canine. The subclassilications of the Angle Class IT relationship are based on the position of the incisors in individuals with Class 1.1 relationships, and are referred to as Class II Division 1 and Class II Division II relationships.

Class Ill : the least common (less tlra11 Jo/o). The mesiobuccal cusp of the maxilla!) first molar falls approximately between the mandtbular fii'Sl molar and sec<lOd molar. The chin may aho protrude like a bulldog's does. The mandtbular incisors ovtrlap anterior to the maxtllary

mci~. Th< =m><MO~ ~f"""

1~1

ENTALANATOMY & OCCLUSION

Occl-ln0

'\,.

In the intcrcuspal position, where does the distohuccal cusp of a permanent mandibular first molar occlude?

The interproximal marginal ridge area between the maxillary second bicuspid and the first molar Central fossa of the maxillary first molar Central fossa of the maxillary second molar The interproximal marginal ridge area between the maxillary first molar and the second molar

81 CopynghtC 20092010 t>cnm1 Decb

ENTAL ANATOMY & OCCLUSION

Occl- In0

A dental student is completing a MW patient screening and the dental chart asks for the Angle's Class occlusion. He tells the patient to smile wide while keeping his teeth together. Which cusp of the permanent maxillary first molar serves as a reference point in identif)ing Angle's Class I, II, and Ul occlusion?

Distobuccal Mesiobuccal Mesiolingual Distolingual

82
CopyrightC 2009-2010 Dtntallkcb

1- achtllmhr.l\urt. hehu~en rhe mandihular wc.und premolar and l hl' mandihula fir\t mnLtr

Remember : The facial cusp tips of permanent maxillary premolars oppose the facial embrasure between ~teir class counterpart and the tooth distal to it. Examples: I. The facial cusp tip of a maxillary tlrst Jlremolar opposes the facial embrasure between the m11ndibular first and second premolars (see 1101e be/01~ 2. The facial cusp tip of a maxillary second p remolar opposes the facial embrasure between tbc mandibular second premolar and mandibular first molar

.' \ote: During lateml excursive movements, the facta! cusp ridge of the maxillary first premolar on the working side opposes the distal cusp ridge of the first premolar and the mesial cusp ridge of ~te second premolar.

( ontach in th, lnllnu,palJ'u,itinn

;\l UiUI J'}

Occludes into Area of :\landibular Teetb

(Class counterpart or counterpart and tooth distal to it)

Lingual Cusps First premolar Se<:ond premolar First molar Mesiolingual Distolingual Stcaod molar
~1esiolingual

Distal triangular fossa of first premolar Distal triangular fossa of second premolar Central fossa of first molar Distal marginal ridge of first molar and mesial marginal ridge or second molar Central fossa of second molar Distal marginal ridge of second molar and mesial marginal ridge of thind molar

Distolingual

ENTAL ANATOMY & OCCLUSION

Occl- Inf)

In an ideal intercuspal position, the facial cusp tip of the permanent maxillary second premolar opposes the:

Facial embrasure between the mandibular first and second premolars Facial embrasure between the mandibular second premolar and the mand ibular first molar Opposing central fossa Opposing mesial marginal ridge

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Occl-In0

( \...

ln the iotercuspal position, where does the distolingual cusp of a permanent maxiUary first molar occlude?

Central fossa of the mandibular first molar Central fossa of the mandibular second molar The interproxi mal marginal ridge areas between the mandibular first and second molars The interproximal marginal ridge areas between the mandibular second and third molars

80 Copyri_ght C 2009-2010 Dtntlll Dtcks

Su1rortin~

and \\ur"in1!

Five common char2deristics of supponang cusps: I. They contact the opposing tootb in the intercuspal position 2. They suppon the n rtiul dimension of the face 3. They are nearer the fadolingual center of the tooth than the non-supporting cusps 4. Their outer incline bas a potential for contact 5. They have broader, more rounded cusp ridges than non-supponing cusps Remember: The supporting ctlSps nre the maxillary lingual cusps and the mandibular buccal cusps. These cusps do grinding work because they occlude in a fossa or marginal ridge and are also called working cusps. They are sometimes culled centric cusps because they bold the occlusion in n middle position (centric position). The non-supporting cusps are tbe maxillary buccal cusps and the mandibular lingual cusps. These cusps do not occlude or tit into fossae or marginal ridge areas and are called balancing or non-centric cusps. These cusps allow the dentition to move apan. out of occlusion. They allow the teeth to "Unlock"" and move back and forth and side to side Supporting Cusps MniUary Right First ~tolar l\1ondlbular Right First Molar

Non-supporting Cusps

\l<tndihular C't'nlr~d im.+.ur'

Oppose the maxillary central incisors only (right or left) Will also contact the mnxillary incisors in protrusive and lateral protruslvt mo,ements Important: In an ideal intercuspal position. the distoin<isal aspt of the mandibular central incisor opposes the lingual fossa of the ma.'tiUary central incisor. Normally a tooth has contact with two teeth in the opposing arch. The only excepUons arc the lower central incisors and the upper third molars. In the mandible. a tooth is situated more mesially and Lingually than its counterpart in the maxilla. Accordingly. each mandibular tooth in the intercuspnl position contacts two maxillary teeth its class counterpart and the tooth immediately mesial to it. For example, the mandibular first molar makes contact with the maxillury Grst molur and second premolar.

ENTAL ANATOMY & OCCLUSION

Occl-ln0

An archoeologlst consults a dentist about some findings he had ou 11 dig. The teeth the archeologist finds have four cusps- two of them taller and pointed, two or them shorter, rounded, and dull. The dentist tells the archaeologist that these teeth are similar to our human molars. Tbe broader, more rounded cusps are:

Non-supponing and working Supponing and balancing Supponing and working Kon-supponing and balancing

17
C09rrighl e 20091010 Dcnl&l D-b

ENTALANATOMY & OCCLUSION

Occl- In0

Which permanent teeth occlude with only one tooth in the opposite jaw, assuming Ideal relations exist?

Maxillary canines Maxillary central incisors Mandibular central incisors Mandibular third molars

71 Cop)ngbl 0 20092010 Otti~AI Docb

ton porta nt: The llltjfobuccal cusp ~vptdjic(l/lv, tlw ~r/anxular rldg' oflhe M8 cusp) of the nur~lll nry first molar oppo>es the mesiobuccal groove of the mandibular fir< I molnr. Tlus relationship is a key fuctor in the definition of Clas. I occlu!lion. Th~ di.<tobucuJ cusp of the m:ulllry Orst molar opposes the dlstobuccol ~ roovt uf tho mandibular nnt molar. ~ote: Thos distobuccal groove also serves as ao e5(Jlpeway for the ML CU SJI of the ma.tiltwy ftm molar dunng non-working excursivemovements. When the mandible move> to the right, the MI. cusp of the masllla ry right Orst molar passes through ~ lingual grooH of the mandibular right first molar. The oblique ridge of th< mu:lllal') Ont molar oppo.o;os the de' clopmental groo,e betweeo the dlstobucul and dlslai cusps of the mandibular llrsl molar. Remember: The ma.<illary buccal (fat"IOI/ and the mandibular lingual cu.<ps are JtUitlln~ cusps. l'he inner occlusal inclines leading to the;e cusps""' called guiding inclin<os because 111 contact movemems they guide the supponing ~usps away from the midline. Thus. there are bucco-occlusal inclines (lin~ua/ ilrcline< o{th bll<'<:al msps) of the maxillary posterior teeth and lin guo-occlusal i11cli11eS (biiCCIII inchne.r o( rile liugual <'usps) of the ma11dibulnr posterior teeth.

In the Closs U relationship. the ma.xillnry ar<h "pvs!lloned me<>ially, with the mesiobuccal the cmbrasu~ bem etn the mandibular first molar and the .e<:ond premolar. In addition. the DlliAillwy camn< os ~ned anterior to the 1oandibular canine. The \ngle Class U Division II inci;ors""' t;<nemlly more upright and ha' e I= antmor Olottjct, 1M a deeper enical overbite. than Cia,.; U OivbtOn t
<US]) abov< or approaching

II < hm Ill

In the Class Ill relattonship, the mand1bular firtt mol"' rs mesial to the maxillary fiflil mol liT And there is concomitant mandtbular prognathiSm reflected in the patient profile. The mandtbular arch is displac.d mesially or the maxillary arch is displaced distally, with Otc mestobuccal cusp of me mru<illory first mol"r occluding distnl to the buccal groove oftbe mandibular iirst molar. In the Class I relationship, the mandibulur first llcnnanent molar is sllg.bUy anterior to the "'" <~llary first pennanent molar. If there are no trregularitie. elsewhere, this would be tenncd a Clnss I occlusion. If there were ~rn:~uluriuc$ elsewhere, it would be termed a Class I mal ocdu~ioo. The Class lrclationship is nonnal pennanent molar relationsbip. ln this condition the me5robuccal cusp uf the maxiilnry fil'l<t molar Is placed over the buccal grooe or the mandibular flrSl molar. In addition, tht maxillary canine tS plared in th< embnosure bel"'"''" the mandibulur canine and the first premolar in a nomul canine ~lationship.
( C Ia" II llh I

In the Class II relationship, the maxillary arch i~ posuioncd mesially, with the m"l>tobuccal Ctl<p abo e or approaching the embrasure betwe<n the mundibular first molar and the sccond rremolar. In addition. rhe maxJI\31)' canine is ~eated antenor to the mandibular canme The Angle Class II Division I mcisors nonnaily display excess1ve anterior ovecjet.

ENTALANATOMY & OCCLUSION

Occl- In~

In an ideal intercuspal position, the mesiobuccal cusp of the permanent maxillary second molar opposes:

The distobuccal groove of the mandibular f~rst molar Tbe buccal groove of tbe mandibular second molar The mesiobuccal groove of the mandibular second molar The developmental groove between the distobuccal and distal cusps of the mandibular first molar

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Occl- In~

,
Identify the following pictures of dental arch relationships as being either Class I, Class ll Div I , Class II Oiv. II, or Class Ill. A

76
Cqp)TightQ ZOO?-'lOIO Dental ~ks

Remember: Lateral excursions (movmg the jaw sideway<) result from the contraclton of one lateral pterygoid muscle on the opposite side. For a righln orldng-side movement. the prime mover is the lefllaleral pterygoid. Note: ProtrusiYe movement is produced when both lateral pterygoids simultaneously contraet.
rill'
\1m~clr-'\

of \Jot,fil':tliun \\ilh \"udatl'<l \111\tnu.nl\ ufthl' \bndihlt

Movements of Mandible

Muscles of Mastication
Masseter Temporalis.
Medial pterygoid
Lateral pterygoid

l!levntion of chc mandible (duringjaw closing) Elevation of che mandible (during jaw closing) RCt111CIIOn of the mandible (lower ja"' back>wrd)
Elc>otion of the mandible (duringjaw c/osmg) Inferior htads: sligbt depression of the mondoblc
(duringJO" opening)

One mu5ele: late111l deviation of the maochblc (to shift th# loner jaw ro the opposire side) Both muscles: protrusion of the mandible (lower jawforn ord)

( :mine'

This is called canine or cuspid protected occlusion. It is an occlusal relationship in whtch the vertical overlap of the maxillary and mandtbular canines produces a disclusion tuporation) of all of the pOSterior teeth "hen the mandible moves to either side. All other teeth, once they move from centric relnuon. do not rontacL If there is contact of other teeth, it is termed a "worldng side" or "non-norldog side" interference dependong on which side the mandible moves to"ards. Croup function (sometimes called mu/ateral balanced occlusion) is an occlusal relationship in which there is contact of all of the teeth on the worldng side during a 13teml working movement I. Some relationship> arc not conducive 10 cuspid protected occlusion. sucb as Notes Class II or end to end relationship. 2. Some relationships are not untenable to group function, sucb as Class 11 , deep vertical overlap. 3, Regardless of what lal~rul concept is used, it is essential to have no nonworking s ide contacts becaus-.;: ( I} They are damaging (2} They are difficull tO control due tO mandibular flexure (3} They deliver more force to the teeth than other contactS

ENTAL ANATOMY & OCCLUSION

While chewing gum on the left side of your mouth the mandible deviates to the left. This is left working movement. Which muscle is responsible for the left working-side movement?

The right medial pterygoid muscle The lefl medial pterygoid muscle The right lateral pterygoid muscle The lefl lateral pterygoid muscle

73
Copyri& bt

e 20092010 Den1aiDccb

ENTALANATOMY & OCCLUSION

Occl -

In0

A 22-year-old female dental student comes into your dental practice for a regular check- up. She states that she has never had any problems with her teeth, and upon examination you notice that only one pair of teeth seem to have contact during lateral movements of the mandible. Which teeth should ideally provide the predominant guidance through the full range of movement in lateral mandibular excursions?

Premolars
First molars

Incisors

Canines

74
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Lateral excu,.,lons (moing the jaw sidt!IO)'S} r~suh from the contraction of on~ lateral pterygoid mu.cle on the opposite side.
I hl \1 U\t." ll'\ ur \Ja,ticatiun '' ith h\tu;nlllt.l \lm tmLnh of lhL \I :uulihll

Museles or Mastication Masseter I<'tnponllis

~ledtal ptei')'Oid

Movrrnents of MandibJ.:

Elevation or the mandible (duringjaw closing)

Elevation or the mandible (duringja" dosrng) Retmcllon or the mandible (lowerja>~ bockwarrl)

Elevation or the 11l3ndible (duringjall' dosmg) Inferior htod<: slight dcpressioo or the mandtble
(tlurml{JCfh openillg)

Latml ptaygord

One mustle: lntcral deviation of the mandible (to

shtfi the /oli'Cr jaw 10 the opposite side)

Both muscles: pr01rusion of the mandible (lower

jawf(m~t:tlrd)

Retrusion (retrudi11g tire jaw) rc.sults ftom tbc bilateral contra(:tion of the posterior ihori= ontal) fibers of the temporalis muscle. They nrc assisted by the suprahyoid muscles. specifically the anterior and postenor bellies oftbe digastric muscles. Closing the mouth (elemting the mandibltl re>uhs from tbe bilatenol contrnction of tbnoe pairs of muscles: 1. The anterior (wmical) fibers of the right and left temporalis muscles 2. The right and lefl masseter muscles 3. The right and lcfl medial pterygoid muscle>

Doth

lall'r:IIJth: r~f,!Hitlmu\cle~

Important: Protrusion (protruding the jal results only from the simultaneous contraction of both lateral pterygoids. llus produces forward movement of the condyle from the mandibular fossa (articular fossa). They do not need assistance for this

mo,ement.
Unilateral contraction deviates lhe mandible to the contralateral (opposite) side. Contraction oftbe muscle on alternating sides produces ~te side-to-side motion required for grinding food. Opening of tbe jaw (depression of the mundible): The lateral pterygolds do this by pulling the articular discs and the condyles Qntcrlorly and down onto the nnicular emmences (sec picwres below). In opening the jaw or depressing the mandible. tbe lateral pterygoids are assisted by the anttrior bellie of the digastric muscles (which are <uprahyoid muscles) and the omohyoid muscles (which are infrahyoid nuJSrles). These muscle help ftX or hold the hyoid bone.

CtoS< position

Opto positio11

ENTAL ANATOMY & OCCLUSION

After seating a new crown on tooth # 30 you Med to check excursive movements. You ask the patient to sUde their jaw to the left to make sure there are contacts on 30 during this movement. What muscle does the patient use to move her jaw like this?

Right medial pterygoid Left medial pterygoid Right lateral pterygoid Left lateral pterygoid

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Both lateral pterygoid muscles Both medial pterygoid muscles Both masseter muscles Both tcmporalis muscles

72 CopynghtC 10092010 Den:111Dlcs

n. nucdn;ttor
This muscle compresses tbe cheek. holding food under lbe teeth. The muscles of mastiCJ&tion are the muscles responsible for the movement of the mandible in the chewing of food. There are four pairs of muscles (righr and left): Masseter Temporalis Medial pterygoid Lateral pterygoid These muscles have the major control over all of the movementS of the mandible (elevation, depression, retraction, prolrtiGtion, and lmeral excursions). Mastication is the breaking down or chewing of food so that it may be easily attacked by the digestive enzymes. The function of mnstication is as follows: Incision offood: by the incisors (cemrals and larerols) Prehension of food: by the canines Trituration of food: by the premolars and molars The incisors. and canines. masticatory function is primarily biting.

ll'fllaleral

pttr~~oicl

Important: The mandible will ahU)S dt\ iatt co che side of injury.

Remember: If the hypogtosut ne"e become< damaged from injury or a tumor, the tongue will
al~o de\iate noticeably to~a rd

lh\: arfc:cted "i1de.

'ott: W1th a fracture of the condylar neck. the eondylor head remains in die ma><hbular fo.sa due
to the temporomBndibular ligament. Th!.S ligamenlts the main Slabilizing ligament oflhc TMJ.

h ong10ates from the lateral surface of the Z) gomallc arch and a rubercle on liS lo"er border. and " duec1ed obliquely downward and boekward to insert into the J10$terior border and lateral
'Urf3te of the neck of the mandible. This ligament restricts down\\'3J'd and posterior mo"emcnt of
I he

mandible and guides the f01ward mo11on of the eondyle during opening.

ENTALANATOMY & OCCLUSION

Which muscle labeled below plays a subsidiary role in mastication?

~1axilla

""'"''"''''''oris muscle

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ENTALANATOMY & OCCLUSION

A new patient comes in with a history of malignant cancer. When the patient opens, the mandible deviates to the left. You suspect a tumor blocking nervous innerntion to which muscle?

Right medial pterygoid

Left media.l pterygoid

Right lateral pterygoid

Left lateral pterygoid

70 Copytls!u.C 200?-2010 Dcn~ll)ccks

\. \ h lnh\ nitl mu":ll H. (ol"ntUh\IIHIIIIU,dl

As a group, these muscles raise the hyoid bone dunng swallowing. They also asstst the lateral pterygoid mu.<clel in depressing the mandible (opeuiug rhe mowh) and the postenor fibers of the tcmpornlis muscles during retraction of the mandible. The suprahyoid muscles include: Stylohyoid Pulls the hyoid superiorly and posteriorly during swallowing 2. Fixes the hyoid bone for infrahyoid action lnn~rvallon: cervical branch offacial ncr,;e (CN VII)

I:

Digastric

1. Opens mouth by depressing mandible (Anrerlor bellyI

2. Fi>.es b)oid bone for infrahyoid action (Po.rtrior ~11>1
Innervation: anterior belly-mylohyoid nerve, a branch of the inferior al,eolar ne"e, posterior belly-facial nerve (CN VII). Mylohyoid I. Elevates the hyoid bone 2. Raises floor of mouth (for swallowing) 3. Depresses mandible when hyoid is fixed Geniohyoid I. Elevates the tongue 2. Dcp= the mandible 3. Works with mylohyoid Innervation: Cl via the hypoglossal nerve !C. Xlf/ Tbe gemohyoid and mylohyoid muscles form the floor of the mouth.

Utrinsit mu.sclts of the lOngue: Genioglossus: ongtnates from genial tubm:le or maodtble and insem on dor<um or tongue. Acts to protrude the tongue and retrael the tip of tongue. Hyoglossus: onginatcs from the greater and leo><.'f hom of1bc hyoid bone. ln.cns on lateral a.~pec:l of tongue. h octs to depress the tongue. StylogJossu.s: originates from Styloid process, mserts on latef31aspect of tongue. lis mam fimction is 10 retract and cle\atc the tongue. Palatoglossus (glossopalatine): originates liom the J >alatinc aponeuroses and inserts on the side of the ton~;uc. II acts to elevate the posterior tongue and closes tbe oroph11ryngent isthmus. Nole: It aids i" the initiation of swallowing. Intrinsic musdu (/ibt!rs) of the tongue an: named according to the throe spatial planes '" which they run Longitudlnol: <honen> tongue (curls hpJ Tranntrse: narrows longue } alter the shape of the ronguc Vertltal: flattens end broodens tongue

~ENTALANATOMY & OCCLUSION

Identify the suprahyoid muscles labeled A and B, shown from above the floor of the oral cavity.

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~ENTAL ANATOMY & OCCLUSION

A young brother and sister are in your waiting room bickering as they frequently do. The sister sticks out her tongue at her brother. What muscle is she using?

Genioglossus Styloglossus Hyoglossus Intrinsic longitudinal

68 Cop)'tiJbl c 2009-2()10 lkntal (};k~

rhree rouls I. Tbt palatal. which is the longest 2. The me~iobuccal 3. The dtstobuccal, wluch is the shortest Maxillary Right First Molar

Buccal View

The two buccal roots are well separated and bent in such a way that they look like the handles on a pair of pliers. The axes of the roots are Inclined distally. This is in contrnst to lhe roots of a second molar, which are often close together and less curved. The palatal root often bas conca\-ities both facially and lingually. Remember: Molar roots originate as a single root at the base of the crown (called a roor rnmkj near the cemcntoenamel junction. The furcatlon is the place on multi rooted teeth where the root trunk divides into separate roots (bifurcation 011 two-rooted <llld trif urcation on rhree-roor~d reeth). I. The mesial furcarioo is closest to the cervtcal line. while the distal is lhe ~otH fanhest from the cervical line. 2. There is a deep developmental groove buccally on the root trunk of the maxillary lirst molar. It stuns at the bifurcation and terminates at the cerv~cn l line. Remember: The distal surface of the root trunk has a concavity which rcqum:s special auention when root planmg. 3. Duri11g surgical removal of the maxillary first molar, be careful not to force root tips into the maxillary sinus.

Stern nih\ rnid

The infrahyoid muscles are depressors of the larynx and tbe hyoid bone. The.~e muscles are often referred to as strap muscles due to their ribbon-like appeamnce. They lie between the deep fascia and the visceral f11scia covering the lhyroid gland, trachea and esophagus. They are innervated by the ansa cervicalis (a motor plexu< from the -entral rumr ofC 1.1, and J). The infrahyoid muscles include the: Thyrohyoid muscle: pulls m ehyoid downward and raises the larynx lnnenation: Cl via the llypoglossnl nerve (CN XII) Sttrnohyoid muscle: pulls lhe hyoid downward lunen ation: Cl , C2. C3 from ansa cervicalis Sternothyroid muscle: pulls the larynx downward lnnermtioo: C2 and CJ by a branch oftbe ansa ccrvicalis Omohyoid muscle: pulls the hyoid downward lnnenation: Cl, C2. C3 by a branch oftbe ansa cervicaijs :'\ote: ntese muscles anchor lhe byord bone and depress the hyoid nod larynx dunng swallowing (tleg/uririo11) and speaking.

ENTAL ANATOMY & OCCLUSION

Mol-Inv

How many roots arc visible from the buccal aspect of a maxillary first molar?

One root
Two roots
Three roots

Four roots

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ENTAL ANATOMY & OCCLUSION

Which infrahyoid muscle puUs the larynx downward?

muscle (c:ut)

66 Copyriaf'll 0 2009-2010 Dental Decks

Important: As a result of this decided lingual inclincation: I. The height of contour of the crown is lowered apically to the middle third. 2. The placement of instruments subgingivally is more difficult oo the lingual side.

\ l ;nillar~

'l'l"uncl mular

The parotid duct is the duct that conveys sali'a from the parotid gland to the mouth at the level of the maxillary second molar. It is also called Stenson's duct.

Palatine Gland

Sublingual Gland

Submandibular Gland

 ENTAL ANATOMY & OCCLUSION

Moi-In0

Relative to the long axis of the tooth, mandibular molars are inclined to the:

Facial and mesial Facial and distal lingual and mesial Lingual and distal

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Mol -

In0

Calculus buildup is associated with the location of salivary ducts. Since the sublingual glands open Into the oral cavity by the lingual surfaces of the mandibular incisors, we find buildups of calculus here as well. Likewise, we would expect to find calculus on Ibis molar since the parotid gland opens on the oral surface of the cheek opposite the:

Maxillary first premolar Maxillary second molar Mandibular first molar Mandibular second molar

eop,.;p.c 2(1C)t.20IO o.m. Db

14

\1~hll

mar!,!inal

ricJ~t

of the ma\illan ,,.,;und molar

The marginal ridges of a tooth (M or D) are the same height as the tooth in proximal contact to it (M or D). Important: When restoring the marginal ridges of posterior teeth, remember to round them off to fonn occlusal embrasures and keep them wide enough for sn-ength. Remember: Marginal ridges are elevations of enamel that form the mesial nnd distal margins of the occlusal surface of the molars and premolars. They also form the mesial and distal margins of the lingual surfaces of the incisors and the canines.

lo\\ard thl' th\tal --if .ll all

I. :\1axlllary teeth seem to sbo" the least statistical variation in root
~otH

inclination.
2. Mandibular central incisors and canines usually present the greatest

variation.

~E~TALANATOMY & OCCLUSION

Molar -

In0

r
\.

A dentist is completing a disto-occiusai restoration on a permanent maxillary first molar. He is carving the distal marginal ridge. He makes sure to give it width for support and must round it to create an embra~ure. In order to get the correct heig)lt ocdusocervicaUy, be should match the distal marginal ridge of the maxillary fiJ'St molar to the:

Mesial marginal ridge of the maxillary second premolar Mesial marginal ridge of the mandibular first molar Mesial marginal ridge of the ma;tiUary second molar Distal marginal ridge of the maxillary second premolar

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~ENTALANATOMY & OCCLUSION

r

Mol -

Tn~

A crying 4-year-old boy is brought Into the dentist's office by his mother. She has his two maxillary central incisors in a glass of milk. They were avulsed when the boy fell down and hit his front teeth on the edge of the coffee table. Unfortunately for the dentist, the crowns of the teeth look virtually identical. He needs to use the roots to determine which tooth is left and which I~ right. As a general rule, root tips tend to curve:

Toward the mesial Toward the distal Toward the mesial on maxiUary teeth and toward the distal on mandibular teeth Toward the distal on maxillary teeth and toward the mesial on mandibular teeth

From a mesial or distal view. lbe crown outline of a maxillary posterior tooth is rrapezoidal in shape. Notice !hat !he ttapezoidal oulline has iiS longest uneven side at the base of the crown (see picture below).

From a mesial or distal view, the crown outline of a mandibular posterior tooth is rhomboidal in shape and tills towards the lingual. Because of this Lingual inclination, the mandibular molars have long axes positioned with their root apices facial and their crowns lingual. Note: This design encourages cusp fracture.

I alon cu'p

The distolingual cusp on permanent maxillary molars generally is the ooe that gelS progressively smallr as you go posterior in the arch. This is the most ob\10us characteristic lbat distinguishes permanent first. second, and lbird molars from each olber. Remember: For maxillary molars, the primary cusp triangle (also called tire "trigon") is formed by the ML, MB, and DB cusps. The DL cusp is called the talon cusp and is not a pan of this primary cusp triangle ("rrigou "). The talon cusp might be absent on maxillary second and third molars. Note: A cusp present abnormally is also called a talon cusp.

Primary Cusp Triangle

~E~TALANATOMY & OCCLUSION

Mol-In~

From either proximal view, maxlllnry molar crowns have a:

Triangular outline Rhomboidal oulline Trapezoidal outline Square outline Rectangular oulline

St
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~ENTAL ANATOMY & OCCLUSION

Mol- In~

(
\..
Cusp of Carabelli

The distolingual cusp on the permanent maxillary molars is also called a:

Talon cusp Dens Evaginatus Trigone

60 Cop)rieh<O 2-2010 0....1 Db

I r-ian~ul:1r

Maxillary Right first Molar

Ctnk.-1 rross Sf'<'tion

Cervical

cross section

Whether there arc three ro<>t canals or four root canals (as seen somellmes with the maxillary first molar), !he orifice of each major canal serves as a comer of the pulp chamber. Therefore, the shape of the floor of the pulp chamber is roughly triangular. The base is formed by the buccal canals and the apex is formed by the palatal canal. :'\ore: The line connecting the mesial canal with the palatal canal is the longest.

\ mandihul.1r u:,:hl flurd

~

mul:~r

) ~ ~
1>-<

'"

'f.nit61111

-- -

'\

u ..., ....

~h'Skldl lll ~KiiOft

Buct<~U.nJtlll
~ll<1n

:\landibular RIJ:I'It Third Molar

Ma.xiJJa.ry Righi Third Molar

~ENTAL ANATOMY & OCCLUSION

Mol-In0

A dental student is performing root canal therapy on an extracted maxillary molar in her preclinical endodontics course. Her pre-operative radiograph shows four canals (two canals in the MB root). She should expect the shape of the floor of the pulp chamber in this maxillary molar to be roughly:

Square Rhomboidal
Triangular

Circular

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Mol-In0

The photo below is a mesiodistal section of the pulp cavity of a:

A mandibular right first molar A mandibular right second molar A mandibular right third molar

58 Copyriillt 0 2009-20 I0 DcmaJ Deets

in~ual

\urface uf ma\illar~ mul.u'

It is called the distolin gual d evelopme ntal groove. Due to its presence. occlusal cavity preparations usually need to be extended onto the lingual surface.
This groove originates at an occlusal pot and tenninates in a pit on the lingual surface.

M axillary Right Second Molar

Oistolingual developmental groove

Lingual view

\hlndihular fir,t mula..-

Important points about mandbular molnr roots:

Two pulp canals are usually, if not aha)>, found in the mesial root. The dosiJII root usually has only one canal If a cross section is made jU5! apoc:al to the bofu~a11on of the roots ofa mandibular molar. !he large.-, kidney-shaped canal is found tn the dist al root and the smaller. more cin:ular canals are

found in ahe mesial rool

The MB canal eurves more than lhe ML canal

'The mesial root is typically very thin m~iod 1 slally, much wider facio1ingually, and conca\e on both the mesial and distal surfaces
The distal pulp hom is the smalle.>l han that on the diSIJII (this ~~etds The pulp hom on the mesial (facially a11d il11gual/y) s higher o robe kept in mind dur;ug ope.rati\'e procedures)

( ~\) ......

~
'A
\tt.tSodbuJ
JH"t M)n

;;:::::
.......

~ ~ But~nzual
~(o/
Mid fOO l

Mandibular Rlgbt first Molar Pulp Cavity

{)
Crnical r.r ou Jt('fion

rron stC'tlon

~ENTAL ANATOMY & OCCLUSION

A fissured groove is most frequently found on the:

Moi-In0

Facial surface of maxillary molars Lingual surface of ma>tillary molars Facial surface of mandibular molars Lingual surface of mandibular molars

55
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~ENTAL ANATOMY & OCCLUSION

Mol-

1"V

The photo below is a cervical cross section of the pulp cavity of a:

Maxillary first molar Mandibular first molar Maxillary first molar Maxillary second molar

56
CoPYliJbt 0 2009-2010 Dental Decks

***The distobucul is the smallesL The palatal root of a maxillary fll'St molar is the third longest root of any of the maxillary teeth, aflcr the maxillary canine and second premolar roots. It is wider mcslodlstally than faciolingually and has a longitudinal depression on the lingual. It is concave on its buccal surface. When viewed from the f.1eial, this root apex is in line with the buccal groove. Remember: On the maxillary s~ond molars, the roots are much less spread npan than the rootS of a first molar. The palatal root b straighter tban the palatal root of the first molar. Note: Dunng oral surgery if a root is forced into the maxillary sinus it is usually the root of a permanent nta~illary first molar. Maxillary Right First Molar ;If axillary Right Second J\lolar

Pennanent mandibular molars can be distingutshcd from pennanent ma~illary molars by the following: When viewed from the occlusal, mandibular molars appear rectangulor, maxillary molars appear rhomboidal. Mandibular molars have two roots, maxillary molars have three roots Mandibular molars have pits and grooves on the occlusal and buccul surfaces; maxillary molars have pits and grooves on the occlusal and lingual surfaces Mandibular molars are much wider meslodlstally than faciolingually: this is the opposue of DW<illary molars, which are much "ider faciolinguaJJy Mandibular molars have two nearly equal-sized lingual cusps; maxtllary molars have one large and one small lingual cusp Mandibular molars have a transverse ridge; maxillary molars have nn oblique ridge, which extends from the mesiolingunl to the distobuccal cusps Remember: The oblique ridge is formed by the union of the distal cusp ridge of the meslolingual cusp and the triangular ridge of the d.istobuccal cusp.

ENTAL ANATOMY & OCCLUSION

Mol-lnv

During a surgical extraction of the maxillary Orst molar, a rough oral surgeon accidentally perforates the maxillary sinus. If he perforated the sinus with one of the roots of the Orst molar, which root is the most likely candidate, given that it is the largest, longest, and strongest of the three roots?

Mesiobuccal Distobuccal

Palatal

53 Copyright C 2009-201 0 DentaJ Deets

ENTALANATOMY & OCCLUSION

Mol- In0

( From a developmental viewpoint, all mandibular molars have how many "'\ \ . major cusps, as compared to how many major cusps on maxiUary molars?

4:6

5:3
5:4

3:4

54 Copyright 0 20092010 Ocnu l Dol:k.s

I hl' nh,iuhun:al run l

The maxillary fust molar usually has three roots and three canals. Tbe palatal root usually has the largest dimensions. The mesiobuccal root is onen very wide buccolingually. In approximately 15% of maxillary first molar teeth, a fourth root canal is present with its orifice being just lingual to the ori fice to the mesiobuccal canal. The canal is located in the mesiobuccal root and may join the mesiobuccal canal or exit through a separate foramen. The pulp horns are usually prominent in this tooth. The mesiobuccal and mesiolingual (if pre>ellt) are higher than the di"ofaeial and palatal pulp horns. This should be kept in mind during opcrati,e procedures. l'iote: In all molars, root canals join the pulp chamber apical to the cementoenamel junction.

MC".t:ludllital

Bue eo lln ~ull l

Mu111ary Right First Molar Pulp Cavity

stttlon

Httlon

@
Ctn lu l
<'1'0~1 ~cc:thn

ca

'lktroot
t'rO(f ~e<tlon

\l.l\ilf.ln tiNt pr('Olnl.lr'

*** Btfurcahoos tD the mandtbular molars usually occur in the cervical or middle third of
the root. Th rcc root types: I. Single or one root: maxillary and mandibu lar incisors, maxillary and mandibular canines, maxillary second premolar, and mandibular first and second premolars 2. Bifurcating or two roots: maxillary fors t premolar (buccal a11d palatal) and mandibular molars (mesial and distal) 3. Trifurcation or three roots: maxillary first and second molars (mesiobuccal, disur buccal, and palatal). l'lote: Some maxillary third molars have trifurcations, but they vary too much to predict nil of the time

ENTALANATOMY & OCCLUSION

Mol- In0

An endodontist is performing root canal therapy on a permanent maxillary first molar. Since be is a very thorough endodontist, be knows he should look for a fourth canal. Which root of a maxillary first molar commonly has two root canals?

TI1e palatal root The distobuccal root The mesiobuccal root

51 CoP)'ri_ght e 20091010 Den1ol ~b

ENTAL ANATOMY & OCCLUSION

Mol-ln0

In which teeth will we most likely sec a bifurcation io the

apical third of the root?

Mandibular molars Maxillary first molars Maxillary second molars Maxillary first premolars Maxillary second premolars Mandibular premolars

52 C()p)rigbl 0 20092010 [)enu \ OcckJ

l'l-otrusive mo\ em em is accomplished when 1he mandible is moved slrn1gl11 forw11td until the maxollary nnd mandibular incisors con1ac1 edge-ao-edge. Tins movement is bilaterally symmelrical m !hat both sides of the mandible move m !he same direc1ion. Note: Incisors nre mosl likely to frac1urc (i.e. res1arotions in\JOiviug 1/te incisal edge break oj!) during protrusive movements.

I. Occlusal contact possibil itics occur on maxillary dlsla I mclines nnd

:-/ole> mandibular mesial inclines.

2. AnltriOrl) the facial surface of !he lower incisors will contncl the gu1ding mclint> (lingual) of lbe upper inc1sors nnd canones. 3. In prolrusi'e movemen~ lbe "Ondylcs of the mandible have moved in a do"o"o rd and forward direcllotL Note: Translation is perfonned as the mand1blc moves from a pure protrushe movement from maximum intcrcuspal posotion to a ma;um\Un protruded posiaion.
tmportnnt: Retrusive movement l'equires the COI 1dyles to move bckwurd and upward -the arrow on lhe front oflh< card would be pointing auteriorly lfahis were
<1

reuush e muvemcnt.

\ery important: For the :-lationaJ Board &am. make sure you are aware of what the arro"; arc indianing (i.e direcJion oj mmemem oj 11hich teelh "'"" wlrich Ieeth). For '<ample. for tho< quesaion the arrows indicate ahe dt~cuon of movement ofahe maxillary u'elh over the mand1bular Ieeth. l f abe arro" ~ were indicating the mollentcnt of the mand1bular teeth ocr the maxillary t<etb dunng a protrusive movemeDt, ahe arrows would have been pointing anteriorly.

I. Rit:ht lahrnt, '"nrking '\idr

'lnte: An easy way to rent~mber tf:urows are indicaung \\Orking side mocmenas is to remember abnl arro" >will be ~lativcly sanight, pomting buccal (r/ rrg/11 worki1rg) or lingual (!(left 11orking)

:-/ole: The puthway of the maxillary cusps on the mandibular posterior teetb IS toward the distofnclnl. In these movements ahe mandible is moving aoward$ tJ1c right or lefi side. !'he side towurds wbich Ute mandible moves is refemd to as the working side. The side from "hich the mandible is movrng is rcfcrr<d to us abe non-working side. \\orking sidt contacl- cusp lips pass bel\\ctn opposing cusp tips. :'\on-\\ orkiug side con1ac1 (illleifering ~ontoc1) - the conaac1 lakes place on the distal of ahe maxiUary Inclines and on the mesial of the mnndibular inclines. Tbe contaca area posstbilities here are unique because they involve the tnncr agpccts of supponing cusps only. This is the only time thai the inner inclines of 1he supporting cusps can conaac1 omsidc lltc inlcrcuspnl position Lalerotrusive mo\cmcnt: contacts of teclb mndc on tbe side of the occltL~ion toward "hich lhe mandible has been moved. Also called working movement. :\!edlolrushe movement :contacts of the Ieeth on d1e side oppositc 10 the stde aoward \\ llicb the mandible moves in aniculatioo. Also called non-working movement.

~ENTAL ANATOMY & OCCLUSION

Mand- M & P)

IdentiFy the mandibular movement indicated by the arrow on the drawing below.

The arrow indicates the direction of movement of the maxillary teeth over the mandibular teeth during this mandibular movement.
49 C.oprright<: 20092010 Oeou.l Dttb

~ENTAL ANATOMY & OCCLUSION

Mand- M & P)

Identify the mandibular movements indicated by the arrows on the drawings below.

Figure I. The arrows indicate the direction of movement of the mandibular teeth over the maxillary teeth during this mandibular movement.

Figure 2. The arrows indicate the direction of movement of the maxillary teeth over the mandibular teeth during this mandibular movement.
50 CopyrightCil0091010 Dcmal Decks

lnt('rcw~pll po~ilion

(/()- alsu called ctntrk

ordu~ion

Empty mouth swallowing occurs frequently throughout the day and is an important function that rids the mouth of saliva and helps to moisten the oral structures. The hourly rate of non-masticatory swallowing is apparently related to the amonnt of salivary Oow and, in most instances, may be an involuntary reOex activity. I. The masseter muscles contract and the tip of the tongue touches the roof of I the mouth during normal swallowing. 2. Tooth contacts are of longer duration in swallowing than in chewing, but there is wide variation in frequency and duration from one person to another.

IJistnhurtal

\Uiru~

Remember: I. In the intercuspal position, t11e mesiobuccal triangular ridge of the maxillary first molar opposes the mesiobuccal groove of the mandibular first molar. 2. In a working side movement (right or left), the mesiolingual cusp of the maxillary first molar passes through the lingual groove of the mandibular first molar. 3. In a working side movement (righr or left), the mesiobuccal cusp of the maxillary second molar passes through tbejacial groove of the mandibular second molar.

ENTALANATOMY & OCCLUSION Mand- M & P)

A 7-ycar-old male patient with a history of thumb-sucking comes into the orthodontist's office presenting with an anterior open bite. Doing swallowing tests, the orthodontist discovers tbat the patient needs to involve bis tongue to close the freeway space between his teeth. During typical empty moutb swallowing, the mandible i.s braced In which jaw posit.ioo to aUow for proper stabilization?

Centric relation (CR) lntcrcuspal position (!C) RetiUded contact position (RCP) Protruded contact position (PCP)

47
Copyrigtn 4:1 2009-2010 Dtn111l Dcclcl

ENTAL ANATOMY & OCCLUSION

Mand- M &

~
~

,
\.

A 53-year-old female bas a rclatiYely large occlusal D I carious lesion in ber maxillary right first molar. The dentist restores it using amalgam and has to build up the oblique ridge. A few days later, tbe patient comes back complaining of sharp pain in the mandibular and muillary right first molars. The dentist disconrs a high spot on his restoration which is causing the occlusal trauma. During a working side moYemcnt of the mandible, the oblique ridge of a maxillary first molar passes through which sulcus of a permanent mandibular ftrst molar?

Mesiobuccal sulcus Distobuccal sulcus Mesiolinguai sulcus Distolingual sulcus

48 Cop)TightC 2009-2010 Dcnt:ll Dttb

Here are tbre~ basi( jll'~ po.itions:

I. Centric occlusion or the intcrcuspal (IC) position i> defined as maximum inter cuspation of the teeth. It os a tooth-guided pooition.

2. The rest position or the mandible or the postural position is detennined mostly by the musculature. The usual reflex cited as the basis for the postural pooition of the mandible is the tonic stretch reflex of the mandibular levators (i.e., the myotatic rejle.<). It is a muscle-guided position. 3. Centric relation or the retnodcd contact position (RCP) is a position (or path of opening and closing wlthollltrlmslation of the conclyles) of the mandible in which the condyles arc in their uppermost. midmost positions in the mandibular fossae and related anteriorly to the distal slope of the anicular eminence. Because the mandible appears to rotate around a transverse a.is throu&h the condyle in centric relauon movement. guidance of the jaw by the denti.t in opening and closing movementS that do not have tmnslation i~ referTed to as binge axis movcmenL In this pooition (C/1), the condyles arc consodered to he in the terminal hinge position. It is a ligament guided position.

La1eral movement of the mandible is referred to a~ crnnstrusion. This movement has

1wo components:

I. Latcrotruslou - the lateral movement of the working or rotating condyle

2. Mediotrusion lhe medial movement of the balancing or nonworking condyle

In a lateral movement the balancing nonworkinjl eon d) le goes downward. forward. and medially. The " ork.ing condyle moes laterally (generally rotating about a wmrca/ axis and tran.slatmg laterally). Since the mandible is a Mllid bone, the amount that the non-working condyle mo'es medially determines how far the wort.ing condyle moves laterally. This latml movement is known as Bennett J\lo,ement or Side Shift of the mandible.

Remember: 1. \\'orking side is che side that the mandible move5 towards in a laleral excursion.
2. Non-working side is the side that the mandible moves away from during a lateral

excursion.
3. The balancing !!Ide condyle refers to the left condyle during a right lateral jaw moement and the nght condyle during a left lateral jaw moY<ment.

ENTAL ANATOMY & OCCLUSION Mand- M & P)

Which jaw position is a muscle-guided position?

Centric occlusion (CO) Centric relation (CR) Rest position of the mandible

45
CopynghtO 2()0?..2010 Den~ll)(d;s

ENTAL ANATOMY & OCCLUSION Mand- M & P)

A dental patient is complaining of unilateral jaw pain when chewing. You notice that she only chews on her right side. When a mandibular movement to tbe right is performed, which condyle moves forward, downward, and medially?

Working condyle (right) Non-working condyle (left)

Cop)'titbt C 2009-2010 lml\31 Ded5

""

-1 -- h ma,ticated primaril\ in I: .Jitral nwHnunt'

l. Border movements of the mandible recorded in the horizontal plane. The incisal point is at point CR when the condyles are in centric relation. and at pomt CO when the teeth are in centric occlusion. The smaU dark area, MR2. is the approi mate region of function during the Iauer stages of mastication. The huger stippled area, MR 1, extending to point !EC (incisal edge comacr) is the approximate region of func tion in earlier stages of mastication. CR

2. PosseIt's enve.l ope of motion

Mid-sagittal plane 3. The envelope of motion Frontal view the peak (top) of this dtagram defines the point where posterior tooth contact occurs. 4. The chewing stroke Viewed anteriorly S. A straight line

This position results when the mandible and all of its supporting muscles (eight m<tfcles of mastication plus the s11pra and infrahyoids) are in their resting posture. The term used to describe this absence of contact is rreeway spate" or '"interocdusal distance.~ It usually averages between 26 rum. Remember: When the teeth are in centric occlusion (inrercuspal position). the position of the mandible in relation to the maxilla is determined by the intereuspalion of the teeth.

ENTALANATOMY & OCCLUSION Mand- M & P)

Viewed anteriorly, which diagram represents a chewing stroke?

43
Cop)'l'lgbtC 2009-201 0 Dentul Oed:s

E ENTALANATOMY & OCCLUSION Mand- M & P)

An Internet urban legend states that the average human being swallows seven spiders a year while they sleep. During sleep, the mandible i.s in its physiologic rest or postural position. The contact of teeth is:

Maximum

Not present
Premature

Slight

44

CopyrightCI ~00920 10 DecnaJ Ded:s

Frontal
Sa~itlal

The mandible is mo'ed in a number of planes: I. Up and down (frontal plane) 2. Side tO side (ltorizontol plane) 3. Forwards and backwards (.<agittal plane) Five factors or mandibular movement: I. Initiating JIOSilion (centric relation) - Most stable and most easily reproduced position 2. Types or motion - Rotation - Translation 3. Direction or motion (planes) -Frontal - Sagiual - Horizontal -1. Degree of movement 5. Clinical signincunce of movements - Each patient may have different relationships

F = prutrudt.d t.untact (lO\ilion. PCP nr CO :: nntrk ut.~o: lu,iun. hahilu:d n nlric

intc-rcu~p:d

111~1\imum

prutru,ion
n ntri~o:.

pu,itinn. tuuth poo,.ition. acquind

or

en.= rt.nlril'

rdotfiun.

ll'rmin~tl

hil11!l' pn... iliun. ur ntrudcd cnnlarl pn,ition

R = rc"il (W\itiun ur pustural posit inn

E
=

m:Himum

npt.nin~

('10 }

Remember: I. If the mandible is held back and up by either the patient or the operator, a hinge mo' ement can be traced for the lower incisors from CR to B. This movement, called the terminal hinge mO\'ement of the mandible, maintains a slationary rotation axis througb tbe two temporomandibular joints; this axis is usually located in the condyles. 2. The anterior border movement oftbe mandible is from F-E. Xote: Food is masticated primarily in lateral contacting movement.

ENTAL ANATOMY & OCCLUSION Mand- M & P)

Pure rotation of the mandible involves which two planes of movement?

Frontal
Horizontal Saginal

CopyriJhl c 20092010 l>eJ'Ital Decks

..

ENTAL ANATOMY & OCCLUSION Mand- M & P)

Identify the positions of the mandible recorded in a sagittal plane labeled below.

42
Cop)Tigh: 0 2009-2010 Dctltal OttJ:s

 Enamel bypocaleolic:uion is. bemlitary dental defeet in which lhe enamel orthc llh 1$ son and undcrc:a1e1fied 1n context yet nonnal in quantity. This condition is eaused by defecthe maturation of ametoblasts (deject in mintrall:arfon (Jj tlte (om.ed matrlr). Tho o cclh are chalky in consiso ency, lho surfaces wear down rapodly. and a yellow m brown stain appears as the underlying dentin is exposed. This condition n. m."Cts both the dccid
uous and permanent teeth. Enamel hypoplasia is a developmental dental dcfcc:tln \!Jhich the enamel or the teeth IS ht1rd in con text bUI thin and deficient in amount II is caused by dcfectht enamel matrix fornuatJon with a deficiency in lbC' cementing substance~ Then: 1s ll lack of contact between teeth. rnpid breakdown o( occlusai>Url'accs. and a yello" ish-brown stain thai appc:11> I'here !be dentin is exposed The conduion. "hoch affects boob lhc deciduous and pcrmancnlocclh, con be uansmiucd geneucally or tJ~ by em troncm~cal factors, as with vnamm dcfit1tncy. nuoros1s, or metabolic djscur'b3nccs dunng the prenatal period. It is a common sequela 1n a ch1ld wuh a history or generaUttd gro~tb failure in tht: li~tllix months oflife. Hypoplastic areas on lccth are seen if a child hit) 11lncsscs in
earl~

childhood.

Sott: Hypoplastic enamel, which is a dental monifcsunion of hypoparalhyroidism, can be pr..:vemcd by early treatment wiLh vitamin D.

Fluorosis i~ the condilion thai rcsuhs from excessive, prolonged ingestion or nuoridc. Typically causes monied dl$coloration and pitting of the enamel ofpcnnanenl and deciduou; occoh.

Enamel hypoCIIIcllltatlon

Fluorosis wich mottled enamel

l .inf!Uoll :md fa\'i.ll uf all lt.>eth

:\ole: Ma;cillnry posterior crowns when ''iewed from either proximal surface are shaped like a trapezoid. the longest uneven side bemg at th( ce" ical line (see picn.N! below).

Distal View or Maxillary

Right First Molar

ENTAL ANATOMY & OCCLUSION

Mise)

A patient of yours bas enamel hypoeaklficJition. Y ou would expect _ __ quantity of enamel and would describe it a s - - - - --

Less than normal, hard Less than normal, soft Normal, soft Normal, hatd More than normal, batd More tban normal. soft

38
Copytif.ht C 2009-lO I0 Dtntll I Ded.s

ENTAL ANATOMY & OCCLUSION

Mise)

Which surfacts have a trapezoldJII outline?

Lingual and labial of posterior teeth Lingual and facial of all teeth Lingual and buccal of anterior Ieeth Proximal surfaces of anterior teeth Proximal surfaces of all posterior teeth

o
Copynf.ht 0 201)9..20 10 DtntaJ Ded:s

-\nntlnnlia

Two forms: I. Complete true: is n mre condition in which aU oft he teetb are missing. It may inv ol\c both the primary and permanent dentitions. II is usually associated with heredi tary ectodermal dysplasia.

2. Portia I anodonti (commonly referred ro as congenirally missing reerh): is rather common. Teeth usually affected include the third molars (maxillary more often rhan mandibular). maxlllar~ lateral incisors, and mandibular second prtmolars.
:o;ote: As n general rule. if only one or a few teeth are missing, tlte absent tooth will be the most distal tooth of any given type (ifnwl(//: tlten it would be the third molar). Other terms that are sometimes used include: OIIJtodontia: refers to the coogerutal absence of many, b ut not all, teeth HyiJodontia: refers 10 the absence of only a few teeth

rhum h .. u d\in~

or

: til \ uth~r ~uckinl: h~tbil

The pressure of the thumb agaonst the platc ond maxillary teeth during the growth and development of the. teelh and orul covity can cAU!tC anterior open bile and ovel)ea,lnbial nare of the max illary anterior teeth. and n high palau~l vuuh. ' ott: Most of lhe lime the anterior open bite is asymmetrical with nonnal po~tcriorocclu,lon. Open bue rclauonsbips are cl\aracleriz<-d b) follure or the Ieeth in bolh arches 10 mee1 proporty. Open bn~ may be observed 1n the anterior or pos:tenor rcion and may be attnbuiable to supmcruptJon oft he ndjac~nl iCcth or infraeruption of the teeth in the: lU'CU in q1.1estion. In addition to thumb sucking. open bites may be caused by dcvinlll growth pattcms or a forward tongue posilion .
.' ote: Anterior open bites art much more common in African Americans than Caucasi~ whtrt.as

deep bitts are much more commoo in Cau~ians. Pm1:.tetU longterm thumb sucking may also result in: Protru:,1on of maxa11ruy meisors Con,triC1ion of the mnxilhuy arch Lingual inclination of mandibular incil;Ors RoU~hon of maxillary llueraJ incisors Cl> II malocclusions Rtmembtr: Mouob brtothing typically presents clinically as 1he gingi'a ofohc facial aspec of lbc ma.>.ltary an1erior being red, edematous ond bleeding cosily. The afToetcd orca is widcsl in 1he rmdlinc tmd tapers laterally. the remaining gingiva are nonnol.
Antmor open bite can tlso be associated wuh tongue thrucoL The patient shown here has a \'ty pronuntnl open bite secondary 10 a tongue thru~l swallowin& pattern ("ott Jilt posilio, o/the
IOIIgue).

ENTAL ANATOMY & OCCLUSION

Mise)

,
A developmental abnormality characterized by the total absence of Ieeth Is c.alled:

Hypodontia Anodontia Diphyodontia Hypsodontia

37
CopyriJM 0 20092010 On'ltal Ol:s

ENTAL ANATOMY & OCCLUSION

Mise)

,
A child has maxillary incisor protrusion, an anterior open

bite, c.rowded lower anteriors, and a high palatal vault. Which of the following ntostlikely caused this problem?

Mouth breathing Thumb sucking Tongue thrusting

Using a pacifier
Nocturnal bruxism

,.
Copyn,lltO 20()9..2010 Dtntl Dls

\ita min

I)

t.'\Cl'\S

Possibly, a deficiency palate.

or the B

vitamin folic acid may be involved in cleft lip/

Agems (clremicals) that are capable of causing developmental abnonnalities in utero are called teratogens. The particular type of fetal development problem is related to not only the type of teratogen but also the time at which the teratogen interacts with the ferus. Since most organogenesis occurs during the first three months of gestation. this first trime"er is the time of greatest sensitivity to teratogenic activity.
Tlraln~t.ns

\fflr1ing llt.ntofadal Ut\t.'lnpmt.nl

Teratogcns Aspirin, alium. dilantin, and cigarette smoke (hypoxia) Cyton>cgalovirus, toxoplasma Ethyl alcohol Rubella virus X-radiation Cleft lip and palate

Effect

Microcephaly, hydrocephaly, microphthalmia Central mid-face discrepancy Microphthalmia. cataracts, deafuess Microcephaly
Premature surure closure

Vitamin 0 excess

lll'll'rmlun t

Hetero means "different;''-- odont means "tooth" ~ ' 'different teeth" Humnn dentition is also described as diphyodont to produce two sets of teeth
fprimor}' and pemJancm).

Other terms to know: "~lonopbyodont dentition"= having one set of teeth " Polyphyodont dentition" =teeth contioually being replaced (fish. amphibians. and reptiles) Homodont dentition" teeth are all alike " llypsodont" = long teeth Carnhore" = OI.'Sh eating

""Herbivore" vegetable eating

"O mnivore"= mixed diet

ENTAL ANATOMY & OCCLUSION

Mise)

A young child is born wilh cleft lip and palate. You tell the mother that all of the following could be the cause of the child's problem EXCEPT one. Which one is the EXCEPTION?

Drugs (including several different anti-seiz ure dmgs)

Infections

Vitamin D excess
Maternal illnesses Maternal smoking and alcohol use

35

Copyright C 2009 20 I0 Dcnrol Oec:ks

ENTALANATOMY & OCCLUSION

Mise)

As you know, there are several kinds of teeth in the human mouth. They all serve different functions. You are in an argument with your friend, a law student, and you test his vocabulary. You can him a , which simply means he bas teeth with different morphologies and functions.

polyphodont monophodont

omodoot
heterodont diphodont
36
CopynafltO 200?201 0 Dc1 ual Dccb

Remember: The sum of theM- D diameter of the maxillary teeth is approximately 128 mm. The sum of theM- D diameter of the mandibular teeth is approximately 126 mm.
In general, the primary arch is more circular than the permanent arch.

Types of abrasion: TootbbruJh abrulon: most often results on \ '.,haped \\Odges at the cervical """i'n in the uoin. .nd premolar areas. It is caused by the u<e of a hard toothbrush andiora honzontal brushang stroke and/or tiiJliiY dcntimce.
Occlusal abrasion: results ;n flattened cu~p) on all posterior teeth and worn 1ne1sal edges. II IS caused by chewing or biting hard foods or objects or chewing tobacco. Arition is the wearing away of enamel and dentin from the normal function or. more commonly, from exce~sive grinding or gritting together of teeth by the patient (bnLt:lsm). The most noticeable enects of attrition arc polished facets, Oat incis:a l t:dgcs, discolored surfaces of to'Cth, and exposed drntin. Facets usually develop on lhe linguoincisal of the maxillary central incisors, the faeioincisal of the mand1bularcnnines, and tbc: linguoincasa1 of the maxillary canines. Erosion is the loss of tooth structure from non-mtcha nlcal means. It can result from drinking acidic liqu1ds or eatang acidic foods. It is common rn bulimic individuals as a result ofreprgtt:attd s10maeb ""ids. llafTeciS smOOth (especially lmgual) and occlusal surfa<:cs.

ENTALANATOMY & OCCLUSION

Mise)

How does the maxillary arch generally compare in length with the mandibular arch?

It is exactly the same It is slightly longer It is slightly shorter

33
Copynght 0 2009-2010 Dcn1al Decb

ENTAL ANATOMY & OCCLUSION

Mise)

The abnormal or pathological wearing away of tooth structure by a mechanical means is referred to as:

Erosion
Abrasion

Attrition

3.
CQpyri;ht 0

2009-20 I 0 Dental ()ffi(s

In lhl' inci,alrhinl

<ontact
Maxillary Mandibular

\rea' bor \nll'rinr f eeth Central

IJ

Lateral

Canine

JM
II

JM IM

11

;>;ote: lJ means that the mesial contact is located in the incisal third (I) and the distal contact is located at the junction (J) of the incisal and middle thirds. These are all from the facial aspect (mcisocen:ical or occlusocenical dimension). When viewed from the o~clusal (or incisal), all anteriors have their contacts in the middle third (M or D); thus they arc centered faciolinguaUy. Remember: Although the mesial and distal contacts of the mandibular lateral are in the incisal third. the distal contact is slighlly cervical to the mesial contact. On the mandibular central Incisor they arc both at exactly the same level.

It may be initiated by an infection or trauma 10 the periodontal tigao1ent. The ankylo~d

tooth has lost itS periodontal ligament space and is trul} fused to the alveolar process or bone. Ayper~emcntosls is the excessive fonnation ofcem~ntum around the root of a tooth after the tooth has erupted. It may be caused by trnumn, metabolic dysfunction, or periapical inflammation. Concrescence is a fusion or growing together of two adjacent teeth at the rooi tl11'ougb the cememum only. Meslodens is a supernumerary tooth between the maxillary ceotrnl incisors.

Ankylosis

Uypcreemcntosis

Concrescence

Mcsiodens

~ENTAL ANATOMY &

OCCLUSION

etc)

,
The mesial contact area of a permanent mandibular lateral intisor Is usually located: In the incisal third In the middle third At the junction of the incisal and middle thirds

31

Copyn'aJ!I Cl 20W.l010 Dent11l Deets

ENTAL ANATOMY & OCCLUSION

Mise)

A 17-year-old patient walks into your office with a maxillary second molar stlll ln place. Upon din leal and radiographic observation you determine that the root is fused to the alveolar bone. This is called:

Ankylosis

Hypercementosis
Concrescence

Mesiodens

32 Copynjb1 0 20092010 Dtmall>t.s

( untuur ln\\ard' thl :t)Jl'\ on lhl' ftll"ial .nul linj.!ual \urf:IC'l''; :uut
thl' tnl,i.ll :wd di,lal 'url.ll'l''

~1\\a~

on

Rcmcrnher: The cemento-ennmel j unction (cervical line) of teeth curves towards the apex on the facial and lhtl(ual surfaces and away from the apex on mesial and distal surfaces.

HHHKMKH

Facial

HHHHHNN
2nd Molar
Jst

Mesial

Molar

lnd 1st Cnine Premolar f'rcmola.r

Lateral

Central
Incisor

Incisor

I. The CEJ (also known as rhe cervical line) separates the enamel of the Not., anatomic crown from the cementum of the anatomic root. 2. All teeth generolly have a greater proximal cervical line curvature on the mesial than on the distal.

'll).!hll~

huccal of flu milldk third

When viewed from the fadal (in the incisocenical or occlusocervical dimension). the proximal contacts of all the teeth are as follows: Maxillary teeth: IJ. JM. JM, MM, MM, MM. MM, M Mandibular teeth: II, II , IM, MM, MM, MM, MM, M

***I incisal third J junction of the inciSitl and middle third .\1 middle third
For example: The maxillary central incisor can be labeled IJ to indicate the location of tts mesial contact l in the incisal third and its distal contact J at the junction of the incisal and middle thirds.

 ENTAL ANATOMY & OCCLUSION

etc)

Which of the following be$1 describes the proper margin contour on a crown 11rep on tooth #19?

Contour towards the apex on the facial and lingual surfaces: and away on the mesial and distal surfaces Contour towards the apex on the mesial and distal surfaces; and away on the facial and lingual surfaces Contour towards the apex on the mesial and lingual surfaces; and away on the facial and distal surfaces Contour towards the apex on the facial and distal surfaces and away on the mesial and lingual surfaces

ze
Copynallt ~ ~009- lOIO Dental f>ts

ENTAL ANATOMY & OCCLUSION

You are fabricating an interim bridge to span from 18 to 20. The contact areas on the pontic, as viewed from the occlusal, should appear where in the buccal-lingual direction?

In the middle third Slightly lingual of the middle third Slightly buccal of the middle third

)0

CopyrigblC 20()9..2010 Dcm11 Deds

Sl'l'nnd (lfl'I11Uiar.
< "*

lin,l mnl.tr, <tnd \l'l'nnd molar

Stc pil1un hdo\\.

Remember: Contacts are all slightly buccal of the middle third (including mesial and distal contacts ofall teeth).

:-lotc: The mesial surface of the maxillary central hus the greatest curvature.

HHH KHHH HHHHH \'1~

2nd ) l olar 1st Molar 2nd 1st Canine Premolar Prtmolar Lateral lndsor

Fncinl

Mesial

Central Incisor

Remember: All teeth generally have a greater proximal cervical line (CEJ) curvature on the mesial than the distal. Also, the proximal cervical line (CEJ) curvatures are greater on the Incisors and tend to get smaller when moving toward the last molar, where there may be no curvature at all.

ENTALANATOMY & OCCLUSION

etc)
~

,
~

Which three mandibular teeth are so aligned that, when viewed from the occl usal, a straight line may be drawn that will bisect all contact areas?

Central incisor, lateral incisor, and can ine Canine, first premolar, and second premolar Second premolar, first molar, and second molar Lateral incisor, canine. and first premolar

27

CopyrishtC 2001>-2010 lkntallkd:J

ENTALANATOMY & OCCLUSION

etc)
~

,
~

CervicJllline (or CEJ) contours are olosely related to the attachment of the gingiva at the neck of the tooth. When doing a crown prep, your margin will slope "itb tbe contours of the cervical lines and gingival attachments. On wltich surfaces will your greatest contour be found?
~

Distal surfaces of anterior teeth Distal surfaces of posterior teeth Mesial surfaces of anterior teeth Mesial surfaces of posterior teeth

28
Cop)TI&ltt C 200t-l 0 I 0 txft1al Dttb

\Jiddl third When viewed from the facial, all posterior teeth have prQximal contacts in the middle third. The more posterior teeth --the molars -- have contacts lower in the middle third than the premolars. Also, each posterior tooth bas the mesial conlact slightly more occlusal than the distal con1act. Summary of contacts in the incisoccnical or occlusoccrvical dimension: :\!axillary teeth-- U, JM, JM, MM, MM, MM, MM, M :\land ibular teeth-- IJ, IL IM, MM, MM. MM, MM. M *** 1 :Incisal third J = at the junction of the incisal and middle third .\I = middle third Remember: L The more anterior the tooth, the more iocisaVocclusal are the locations of the prQximal contacts. 2. For any tooth, the mesial contact area is more toward the incisal/occlusal than 1> the distal contllct area.
:\otes drift. These contact areas create wear pnnems that

I. Coolactareas between posterior teeth aid in pre,enting rotation a nd mesial will eventually cause reduced interproximal embrasure areas. 2. Contact surface area increases with age as a res ult of proximal attrition.

Fadallwit:hl nl (.'ontuur locah.d in the ccn ira I third Th< height of contour (also called the crest of cur-.'Ohlre} is an imoginary curved line encircling a tooth at its greaiest bulge or circumference.

nn:pao.r .
l he functions of the height of contour are: lt forms the contact area on the mesial and distal surfaces. lt protects the gingiva surrounding the tooth. Summa!)' of the location for the heightS of contour; L located in the middle third of the crown on the: lingual urfau of all maxillary and mandibular posterior teelb 2. Located in the cervical third of the crown on the: facial surft~ce of all teeth lingual surface of all anterior teeth, on the cingulum 'iote: There is clinical evidence that smooth and properly contoured (IIOtto<> convex or too JfiTOI a conto11r) ctown surfaces promote tooth cleansing and gingival health. In other words. "ht'll fubricating a crown for a p:ltient. make sure the height of contour is taken into
cons-ideration.

--

ENTALANATOMY & OCCLUSION

cJc)

All posterior teeth have proximal contacts in the:

Middle third Junction of the occlusal and middle third Occlusal third

25 Cop)TitMC 2009-2010 Otnl310 ed:s

ENTALANATOMY & OCCLUSION

What do all teeth have in common?

Facial height of contour located in the cervical third Lingual height of contour located in the middle third Lingual height of contour located in the cervical third Facial height of contour located in the m iddle third

26
Q,.pyrigb1 0 20092010 Ocnl.lll Dk.s

 The mandibular seeond molnr erupiS between 11 and 13 years of age.

( hrnnnlnc\ ut lhl t'nm.tm:nl llLnlllmn

Tooth
:\1axHian

First Evidenee of CaldOcation

Enamel Complete 4-5 years 45 years 6-7 ye"rs S-6 years 6-7 years 3-4 years 78 years 12-14 years

Eruption 7-8 yea"' 8-9 years 11-12 years 1011 years 10-12 years 6-7 years 12-13 years 17-21 years

Root Completlon 10 years II years 13-15 years 12-13 years 12-14 years 9 LO years 14-16 years 19-21 year..

Central Lateral Canine

First premolar Second premolar

First molar Second molar Third molar

.3-4 months 10 months 4-5 months I 112 -l 3/4 yenrs 2 2 1/4 years Atbinb 2 112 -3 years 7-9 year!

) l andlbular Cenual Lateral Canine rust premolar Second premolar First molar Second molar Third molar

J-4 months 3-4 months 4-5 months I M-2ycars 2 1/4.2 112 years Atbinh 2 112 -3 year.. 8-10 year>

4-S )ears 4-S years 6-7 )'eRrs S-6 )'ear> 6-7 years 2112-3years 78 years 12- 14 years

6-7 years 7-8 years 9-IOyears 1().12 years 1112 years 6-7 years 11 -13 years 17-21 years

9 yean 10 ye~r; 12-14 )Ut$ 12-13 years 13-14 years 9-IOyears 13-14 years 19-21 years

:\pproximately 50% of root formation is completed at the time of eruption. Apex is fully developed two to three years al\cr eruption.

\H:t-fo-:tr(':\

The character of occlusal contacts in the unworn dental arch are all of the following: Point-to-point Point-to-area Edge-to-edge Edge-to-area Important: In bruxism, however, the direet tooth-to-tooth eontact may result in non physiological area-to-area contacts. The character of occlusal contacts makes chewing easier to perform, since there arc abundant food spillways on the occlusal table.

~ENTAL ANATOMY & OCCLUSION

Es)

,
8

A pediatric patient of yours complains of severe pain on chewing. On clinical exam, you see an eruption cyst in the place ofthe mandibular second molar. What is the most likely age of this patient?

12
1 4

23 CopyrigbtC 2000-2010 Dtntallkd:s

EENTALANATOMY & OCCLUSION

etc)
~

A patient comes in with a chief complaint of, " My wife says I wake her up at night with scraping noises from my mouth." On clinical exam you will expect to find which of the following characteristics of his occlusal contacts?

Point-to-point

Edge-to-edge Edge-to-area

Area~to-are.a

24
O>p)riJhl 0 2()09.2010 !k'ltal Dttl:s

Pcrmancnl fir,l mul.tr'

The earliest lndl~allon of mixed denution consists of the primary dentition and the permanent first molars (usually the mandibular permanent first molars). The mixed dentition period ends with the exfoliation of the last primary tooth (normally rhe maxillmy carrirre). There are three periods of dentition in man : I. The prim11ry dentition (approximately 6 mom/~, to 6 years) 2. The mind dentition (approximately 6 to 12 years) 3. The permonent dentition (12 + years) Remember: Aller the permanent teeth have reached full occlusion, small tooth movements occur to compensate for wear at the contact areas (by meswl drifl) and occlusal surfaces (by deposirlon ofcemerrfum at the rool apex).

l,riman '-'.lllllll'' and wcond molar' Rule of four: This simplified rule will enable you to determine the number of teeth present at any gi-en time. It implies the eruption of four teeth every four months beginning with four teeth at age seven months.
l~u l l

ul I nur

Age
(in monlb5)

Number orTetth Er-upted

4

Spetlfie Teeth
4 =mand. incisors

7
II

8
12 16
20

IS
t9

8 mand. and max. central and lateral inc:ison 12 mand. .net mu. central md latcralocjOf'$,. row
first moW.

16 mand. and max. eenrral and lalcnl incuon_ four first molan and four caninet

23

20 mand. and max. ceoual and later~.lmcsors. four firsc molnrs, rour canines. and f'our seoond molars

Example from IJUCstion on front of card: AI age 15 months, !2 teeth are erupted -four centrals. four laterals, and four first molars.

ENTAL ANATOMY & OCCLUSION

As soon as a child gets her she is considered to be in mixed dentition.

Pennancnt canines
Permanent firs t molars Permanent firs t premolars Permanent second premolars

21
Copyrigb~ CI 2009-20 10

Deotal Ottb

ENTAL ANATOMY & OCCLUSION

A 15-month-old child walks into your office and begins to cry and hold his mouth in pain. Which teeth have probably not been traumatized, as they are not usually present at 15 months of age?

Primary lateral incisors and canines Primary canines and first molars

Primary canines and second molars

Primary central and lateral incisors Primary first and second molars

22 CQp)Tiglu 0 2009-2010 Dcntallkel:s

J~C
2

1M :1. S ner quadrant ~ 10 per arch _ 2ototal teeth 1 2 5 J>Cr quadrant = J0 per orcb

I a Incisors C = Canines M =Molars :-lote: There arc no premolars (bicuspids) in the deciduous dentition. For primary dentition, the crowns of all 20 teeth begin to calcify between 4 to 6 months in utero, and on 3\'erage take I0 months for completion. In general, the root of a deciduous tooth is completely formed in just about one year after eruption of that tooth into the moutl1.

I ~

<!

II

I
2

\I .!_ I o

>~ P

'

I ~ C 1 B :1. .M l 8 per quadrant = 16 per arch f t 32 total teeth 2 I 2 3 8 per quadrant = 16 per arch I = Incisors C =Canines B = Bicuspids (premolars)
~I= Molars

ENTALANATOMY & OCCLUSION

Es)
)

The deciduous dental formula of man is:

None of the above

It

CopynJbt 0 20091010 Dtn11l Dk:s

ENTAL ANATOMY & OCCLUSION

Es)
)

Tbe permanent dental formula of man is:

I ~ C 1 B ~ M 1 = 16 x 2 2 I 2 3 .

= 32

None of the above

20
Copyrlaht C l009l0 I0 Dt"11l Dccb

9 12 ~ear~ old

~U :JII

\ fuli.lt inn \ J!l' uf I ht

l'r i m :t~

I <'l~ th

Muillar) TO<tb

Shod

Ceolral ln<:isor Lateral Incisor

Canine

6-7 years 7-8 years 1012 yean 91 1 years 1012 ycors

Shed

First molar

Second molar

Mandlbulor Teeth
Second molar

1012 ycors 911 years 912 years 78 years 6-7 )<:US

First molar
Canine

Lateral 1ncisor

Cenlral tncisor

Primary teeth are exfoliated by the phenomenon called resorption of the primary root. The permanent tooth in iiS follicle aucmpts to force iiS way in to the position held by its predecessor. The pressure brought to bear against tl1e primary root evidently causes resorption of the root. which continues until the pnmary crown bas lost its anchorage, becomes loose, and is fmally e><folinted.

Cirl"i h.cth usuall~ t.'rupl fwfor,lm~o,; h:l'lh of the same a~e \landibular teeth u~~;uall~ ,rupl hl'l-un. nul\illary trrth 1 ht' h.cth of 'llndc r r hildnn 11\Ualh ''rupt btfon thl' tCLth of o,;toc~~ f.:hildn.n
110

Note: You will probably never find these cardinal rules in a book '"'"'have tried bmto avail!!!); however, if you see this question or something similar to it asked on the boards, answer as above. Also remember: I. Teeth usual ly erupt in pairs. 2. Often the permanent mandibular nmerior teeth erupt lingual to the primary teeth and give the appearance for awhile tbut there are two rows of teeth. Universal Tooth Numbering
P..-mn.,l T. . th
upperlflt upper right

16 15 u 13 12 11 10 ~ ~ 7 6 17 18 19 20 21 22 p3 p4 ps 26
, _ ... ,eft

p7 pa

3 2 1 29 30 31 32
4

,_.,..right

Deolduous t.eth (b8bv te.th)

upperlfl J

upper right

,_.,., ...
K

H M

G F
N

E
p

c
R

B A

, _ _ right

~ENTAL ANATOMY & OCCLUSION

Es)

Tommy, a pediatric patient of yours, says be lost his vampire tooth last week and the tooth fairy gave him a dollar for it. What is Tommy's most likely age of when be lost his mandibular canine tooth?

6 - 8 years old 7 - 9 years old 9 - 12 years old l4- 16yearsold

17
COJ!>nsh~ C 20092010 Deo~IDc<:ks

0ENTALANATOMY & OCCLUSION

Es)

Which of the following are the three cardinal rules regarding the eruption of teeth?

Boys, teeth usually erupt before girls, teeth of the same age Girls, teeth usually erupt before boys, teeth of the same age Maxillary teeth usually erupt before mandibular teeth Mandibular teeth usually erupt before maxillary teeth The teeth of slender children usually erupt before tl1e teeth of stocky children The teeth of stocky chi ldren usually erupt before the teeth of slender children

18
CoprrisM o 20()9.2010 Oc:ntal Dks

I hl' pnmanent

m:t\ill:tr~

.uul mandihular 1nnw1a,-,

A permanent tooth that moves into a position fonnerly occupied by a primary tooth is called a succedaneous tooth. In each quadrant, live pemtanent teeth. the incisors, canine, and premolars, succeed or take tbe place of the five primary teeth. Nonsuccedaneous teeth include: The permanent maxillary nnd mandibular first molars The permanent maxillary and mandibular second molars The pemtanem maxillary nnd mandibular third molars These teeth do not move into a position formerly occupied by a primary tooth.

\ 1 ~tntlihular-

and

m~nill.tf"~

inchor'

Primary Dentition Eruption Chart Upper Teeth Central lnclSO< La1erallnciSO< Cani~ (cuSPid)
First molal

Erupt 812 mos. 913 mos. 1&-22 mos. 13-19,..,. 25-33mos.

Shed
67 yrs. 78 yrs. 1012 yrs. 9-11 yrs. 11).12 yrs.

Second molar

lower Teeth
Second molar
Fhtmolal
Canine (cuspid)
Lateml ineiSOf'

Erupt 23-31 mos 1418 mos. 17-23 mos. 10-16 mos.

6-10 mos.

Shed

ID-12yrs. 9-11 yrs. 9-12 yrs.

18 yrs.

Central Incisor

6-7 yrs.

Eruption dates are variable. Some infants get teeth early, others do so late. I. Calcification of the roots is normally completed by the age of 3 or 4. ~.... 2. Active eruption of teeth occurs after one-half of the root is formed.

 ENTALANATOMY & OCCLUSION

Es)
)

Wbkh leech are succedaneous teeth?

The permanenl maxillary and mandibular premolars The permanent maxillary and mandibular first molars The permanent maxillary and mandibular second molars The permanent maxillary and mandibular third molars

15
Cop)TishtC 202010 Dcnt~I
!Xcks

ENTAL ANATOMY & OCCLUSION

Es)
~

A mother brings her one-year-old lnlo your office the day after his firsc birthday. She says the pediatrician said to have che firsc dental check-up by this time. What primary teeth are you expecting to see when the child opens?

Mandibular incisors only Maxillary incisors only Mandibular and maxillary incisors All incisors and maxillary canines All incisors and mandibular canines All anterior teeth
1e
COC'I)'nJt.O 20Q9.~0 10 lk!lul Db

Ctwac:aerisucs thai d1stanguish 1 mandibular can1ne from 1 masiUar)' canine: On the mand1bular canine. the mesial border as much straighter (l7e'Kwl/odol(l') Contact are.tS are located more indsally (rcmcm~r: JM): for the maxillary canine it is JM
The cusp tip 1$ disJ)Iaeed lingually on the mandibular canine, "'hereas on the maxillary c:uune the

cusp is on or labial to the root axis line (\'iewed pro:'Cim~rlly ami incisally) The mandibular canine has a comparatively n nrrower mesiodistal dimension (viewe<lfllclally) The mandibular Cfllline has a continuous convex facial surface when viewed from the mesial o r
distal
The mandibular canine has a cinguJum that is ltu pronounctd and often slightly 10 che dtSUll, whc:rca.s lhe maxtllary canine has a cingulum that 15 more pronounced aod centered mesodstaHy (vin.<Ji lmguolly) lingual ndges wuh mmal and disul fossae an: ltss promln on mandibular un1ncs (>ln.~

in<isolly).
Maxillary Right Canine Mandibular Right Canine

\
l---'"

r
.--.,

'

~ ~ ......

l\

~d

'

labial

'
f'"

Llngul'l

~~
Incisal Incisal

~t
Lab1 al Lingual

\1 t'\ia l ( \t' t'

tur, hdou)
.\l a ndibular Right C anine

The most prommcnt labial ridge on the pcrtlUlnent canines is the mlddle.
Maxillary Right Canine

Cu~p

1 fp

Cusp lip

Labial \'lew

Labial
v iew

@ENTAL ANATOMY & OCCLUSION

Can - In0

A hockey player comes into your office holding his friend's right canines (maxillary and mandibular) in his hand. His friend, a lacrosse player, got hit by a ball flying under his mask. Whkh of the following would you look for in the ma:dUary can.ine as compared to the mandibular canine?

It is narrower mesiodistally

It bas a less pronounced cingulum

It is wider mesiodistally

It has a shorter root

13
CQp)TightCl20092010 Denl~l Offi;s

~ENTAL ANATOMY &

OCCLUSION

Can- In0

Which cusp ridge is the shortest on the permanent canines?

Labial Lingual Mesial Distal

14
Cos~rn,m

o 2.009-2010 Do'~~I >e<;k$

I ;~hial ridcc.

Th<: labial (facial) surface of canines is marked by a pronounced labial ridge (Su fat:al >'i"'' lwlow). Shallow developmental depressions he mesial and distal to the lab1al ndge. On the mandibular canines, the lab1al ndge and the de\elopm<ntal depressions are not u pronounced. Important: The canines (bo<h ma.rillary and mandib11lar) are the only tusped ttetb whth featUre a funttlonallingualsurfate rather than a funttional occlusal surface. I. Looking at the maxillary canine from an incisal view, the distal ponion of Notes the facial surface is convex '" the middle third and slightly concave 10 the cervical third. The mesial ponion is convex in the middle third and nearly flat

in the cervical third. 2. From the incisal view. the cervical line is often nor visib1e, This is due lO the convex..ity of the crown. )1axillnry Rigbl Canine Mandibular Right Canine

c....
Up

.......

bbbl

Labial

Labial

I hl ~ oun~lst child i' I 0 and h:.1' :ulull mandibular canines on I~ Going by the known eruption ages, the most plausible scenario is that the I 0-year- old has her mandibular canines but not her ma.~illary canines. Re member: Maxillary canines erupt between the ages of 11-12 (after the premolars) .M andibular canines erupt bet"een the ages of9-10 (before the premolars)
Permanent Teeth Eruption Chart

"!%::--- IAMHI.....
Y.OA--

-7::- - c..t........

- ""'"'"""" ..............

-..........
.....

---

..._
t.,_

.........................~

...... ~

,.,,.....
10.12-

..,_
"Q-

--~

--- ................. ..... ........

n.,..

._..._ ,__..,._...,.
.__..

.,.,. ,,..,,_
11U!-

n.-,.,_

.........._. ..,.._

,..,...

.....

..,._

@ENTAL ANATOMY & OCCLUSION

Can

-In0

Which or the following terms is specific to canines?

Labial ridge Lingual fossa Mamelons Cingulum

11 Copyright C 20092010 l>tntal Deets

~ENTAL ANATOMY &

OCCLUSION

Can-

ln0

\.

A mother brings her three kids to your office for their annual check-ups. Which of the following statements is most likely?

The middle child is I I and bas no adult canine teeth

n 1e youngest child is I 0 and has adult mandibular canines only

The oldest child is 12 and has maxillary canines only

n 1e youngest child is 10 and has adult maxillary canines only n1e oldest child is 12 and has mandibular canines only

12
{Ap)'fisM C lQ09.l010 Dnu.al 0-ks

( an in(' : Jnd nr,l prt.nwlar

There is no contact on the cusp rip. It falls in direct alignment with the facial embrasure between these mandibular teeth. This anterior tOOth Is unique in that it has antagonistS, in the intercuspal position, in both anterior (canine) and posterior (first premolar) segments of the opposite arch.

Also remember that: The cutv.lture of the cervical tine is greater on the mesial side than on the dostal side The mesial surface is srraigbter than the distal surface The distal cusp ridge is longer than the mesial cusp ridge The mesial contact point is at the junction of the incisal and middle third It usually thicker labiolingually than it is mesiodistally The tip oft he cusp is displaced labially and mesial to the central long axis of the tooth The distal contact is in a more cervical position (middle ofthe middle third) Maxillary IUght Canine ~----~------, ~-------,~----~

Lingual

~ENTAL ANATOMY & OCCLUSION

Can- InV

The permanent maxillary canine is most likely to articulate with which of the following mandibular teeth?

Lateral incisor and canine

Canine only Canine and first premolar First premolar only

9 Cop)nghl C 20092010 Dentlll OkJ

~ENTAL ANATOMY &

OCCLUSION

Can-

In0

A hockey player comes into your office with his six upper anterior teeth in his hand. How can you distinguish the right canine from the left canine?

The root always curves to the distal in the apical one-third The distal surface is fuller and more convex than the mesial surface Labially, tbe cusp tip is placed distal to a line which bisects the crown and root Lingually, the cervical line slopes mesially

10 Cbp, ri,gh! 0 20092010 Dental Dks

The base of the 1riangle will be lbe facial. The apex will be the lingual. If i1 is nol 1riangular, then il will be oval.

T he cervical cross sections of 1he anterior Ieeth below show the relationship of the crown oudine to the pulp chamber and the roo1 canal.

Maxillary Central Lateral

Canine

Mandibular Cenlral Lateral Canine

I riangul:.i r uutlinr

Distal view of the Mandibular Right Canine

I. The mesial and distal aspects of all maxillary posterior teeth have a
Notrs trapezoidal oudinc. T he shonest uneven side is 1oward the occlusal surface. !;(le Figure I.

2. The mesial and distal aspects of all mandibular posterior teeth have a rhomboidal oudine. See Figure 2. ;\!axillary Right First Molar Mandibular Right First ;\1olar

Mesial Figure I

Distal Figure 2

Distal

ENTAL ANATOMY & OCCLUSION

Ant- JnV

A negligent hockey player comes into your office after taking a puck to the face. The entire crown of a tooth bas been knocked off and the pulp chamber is open. The incisal view of the tooth shows a triangular shaped pulp chamber. Which tooth got knocked out?

Maxillary central incisor

Mandibu1ar centrdl incisor

Maxillary lateral incisor Mandibular lateral incisor

7
Copynjht 0 2009-2010 Demel Decks

ENTAL ANATOMY & OCCLUSION

Ant- InV

The mesial and distal aspect (or surface.~) of all anterior teeth have a:

Trapezoidal outline Triangular outline Rhomboidal outline Square outline

Copyrijht C '2009-2010 Dental Deets

\n elliptical ,h.tpt. '''der in Ihe nu...... irulht:tl dtn.:lwn in the pulp ch ..lmhtr, hut \\ idt~ r in the f.tctnlin~u :tl direclion in lht> muJ .ruul :tn-.t

Near the roof of the pulp chamber, the elhptical form of the pulp cavity is" idest in the mesiodis

raJdirec.:hon; however, near midroo Ihe elliphcol ronn is wide$t in the faciollngu:~t dircc1ion. A small percc.nta~c have two canals. l. Compared to the mandibular centrdl incisor, the mandibular lateral incisor's 1'001 is NottS Jarg~r In all diruensious.
2 . The crown or the mandibular laterul Incisor tips >lightly to the distal rolntic to the rooc: thus. the cingulum is slightly off-<:cnccr to 1he distal. like that of the ma"tillury ceo tral wnei~r and mandibularcantne, but unllkt> that of the mandibularcentralmci~r. ) , The onct<al edge of the ma.n dibular lot era l os slightly curved or rotated on the dostal. For thiS roason Il lS possible to- a small ponoon of this distal-inctsal edge when .;.,.. ong thos tOOth &om the mesial aspect, Mandibular Right Lateral Incisor ~lan dibular Right Cent rallnri<or

Ccnicel Cress mdN

\I)
~1 estodlstl

$t'etlon

Labiolin2ua..1 sec: lion

~h:~iodjrtaJ

Lbiollngual
$L 't110 n

' <'c:Uoo

The distotllctsal angle of most anterioor ttb ts more rounded coo~ to the mestoincisal angle. Another way to say this is that the n>e>toinco<al angles are more S<JUart (or orotel than the distoinci>al angles, which are more obtuse, Hint: Disllll is rounded like the letter "0"'; mesial straighter like the lener "M",

l. lmportnnt: The mandibular tenlrnl ls the only anterior tooth in which the dis NotCJ !oincisnl angle is as sharp and distinct os the mesioincisa l angle. AU other incisors show a more or less rounded disto incisol ang le. 2, An terior teeth are highly important aesthetically and play an iruporttiJlt role in the tomtallon of many speech sounds (" V", "F ", and " TH''). When viewed from the sagmal plane, the axial inclination of the anterior teeth inclines facially.
l\1adllar) Right

Ct ntral lndsor

\1andlbular Right l, a te.-.l l ndsor

Mandibular Right Ceotrallntl>or

j
Labial Labial Lllbial

~ENTAL ANATOMY & OCCLUSION

Ant- InV

Which of the following statements best describes the pulp canal of the mandibular lateral incisor?

An elliptical shape, consistently wider in the mesiodistal direction

An elliptical shape, consistently wider in the faciolingual direction

An elliptical shape, wider in the mesiodistal direction in the pulp chamber, but wider

in the faciolingual direction in the mid-root area

An elliptical shape, wider in the faciolingual direction in the pulp chamber, but wider

in the mesiodistal direction in the mid-root area

s
CopynafuO 2009-2010 Dem:d Deets

~ENTAL ANATOMY & OCCLUSION

Which of the following line angles is least "square"?

Ant- InV

Mesioincisal of the mandibular lateral incisor Distoincisal of the mandibular lateral incisor Mesioincisal of the mandibular central incisor Distoincisal of the mandibular central incisor

Copyflih! 0 2009-2010 Dtn1al Dtd:s

Oifferenn in rnl,tliu n uf

llu~

rnmn un lhl rnul

... The mandibular lateral indsor crown tips slightly to lhe dislal relative to lhe ro01 (facial l'il"'l'}. Other ways to di>tingush lhc mandibular lateral from tl1e mandibular central: The lateral is larger oerall (especit~lly meslodisrally) The lateral Is not as bilaterally symmetrical as the central incisor The cingu lum on the lateral is slightly dlshll to the center Oo tl1e lateral incisor, the mesial marginal ridge Is longer than the disllll marginal ridge. Oo cenl.nlls, they are the same length Lateral incisors have the dislal proximal contacr,. more apical than the mesial contaCIS. Centrals are at the same level Lateral incisors have the diStoincisal angles more rouoded than the mc.~ioioctsal angles. Oo centrals, the angles are nearly lhe same Note: Bolh the mandibular central and lateral have a lingual cervical line that is positioned more apically than the facial cervical line.
Mandibular Right Lateral locisor Mandibular Right Central I nclsor

L.abiul

I ncisal

Labial

l nclsnl

(anna"'

When viewed from the lab1al (buccal) and lingwtl,the 1001h crowns of the followtngtecth hS\e a trape201dal outline All cenual and lateral incisors (maxillary and mand1b11lar) All po>lcnor teeth (marillao and mamJ.Imlar) II'\ole: The trapczodal out1ine has its longest uneven &Ide coward the occlusa1 or inetsol ~urfacc on all theso ICcth.
~1nxillnry

IUgllt Central Incisor

[I'

,
Labial

~/
' -~

.,
1, '

Mandibular Right C<ntrllllncisor

I
Lingual

..._
Labial

' ' J !>Lingual

Maxillary Right L.lllernl l ncisor

Mandibular JlightLlltCral Inclsor

,.
1.

.;

1
Labial
Lingua1

Labial

Lingual

ENTAL ANATOMY & OCCLUSION

Ant-Inr)

A clinical examination of your patlent reveals two lower incisors centered on the midline. The patient gives a history of a car accident when he was young where he lost two of his lower front teeth. He says I bat his dentist used braces to fill in the gaps. Which of the following criteria would be most reliable to decide if the remaining teeth were lateral or central incisors?
~ ~

Difference in root length Difference in ratio of crown length to root length Degree of slope of the incisal edge when viewed facially
Di fference in rotation of the crown on the root

Copyrighte :ZOo<J.ZOIO Dentall)eck$

ENTAL ANATOMY & OCCLUSION

Ant-

In~

All of the follo\\1ng teeth have a trapezoidal outline when viewed from the labial or lingual aspect EXCEPT one. Which one is the EXCEPTION?

Maxillary incisors

Mandibular incisors

Canines
Mandibular molars Maxillary molars Two of the above

4
CopyriS:h1e 20092010 Dcnt.JI 0-ks

\Jandihular l:lhral incl\or

A cingulum is a large, rounded eminence on the lingual surface of all pcnnancnt and primary antenor teeth. Anterior teeth that have a cingulum which is located in the c.e nter of the cervical third of the lingual surf.1ce: Maxillary lateral incisor Maxillary canine Mandibular central incisor Anterior teeth that have a cingulum which is located off center to the distal in the cervical third of the lingual surface: Maxillary central incisor Mandibular lateral incisor Mandibular canine Note: The total number of cingula in each dentition is twelve (six maxillmy amerior teeth aud six mandi/)lllar alllerior teeth). Mandibular Right Lateral Incisor Mandibular Right Central Incisor

Incisal

lncsial

( nntintlflll'

\. ' 1111\ l'\11~ md\oapirall~

nn tlw farh1l 'urfare

Three charactcr'lstlcs common to all mandibular anterior teeth: I. I ndistinct cingula with smooth lingual anatomy without grooves and ptts 2. Incisal edges lingual to the root axis hne 3. Continuous convexity incisoapically on the facial surface Specific inforntalion pcnaining to mandibular cenlral incisors: Occlusion: they only occlude with one olher toolh -- the maxillary central incisor (in cell/ric, protrusive, and ltae~al pmtmslve as well) Nole: The alveolar procc,~s is thinnest facinlto both central incisors (for tltls reasou. local iufiltratlon may be effective for tmestlretizltrg these teeth). *** Remember: The canines (both maxillary and mandibular) are the only Ieeth with labial ridges. Mandibular Rlght Central Incisor

~
'

\
Labral

II
Lingual

@
lnctsal

~ENTAL ANATOMY & OCCLUSION

Ant-

"V

A stray crown is found in your office. rt is an anterior incisor and has a cingulum that is offset from center. What tooth is it most likely to be?

Maxillary central incisor Maxillary lateral incisor Mandibular lateral incisor Mandibular central incisor

~ENTAL ANATOMY & OCCLUSION

Ant-

"V

Which characteristic below is common to all mandibular anterior teeth?

Distinct cingula with grooves and pits Incisal edges that are facial to the root axis line Facial surfaces that are marked by pronounced labial ridges Continuous convexity incisoapically on the facial surface

Copyright C 2009 20 I0 DtlltaJ f>td:s

Dental Anatomy and Occlusion Legend

Major Topic Anterior teeth information Canine teeth information E ruption sequence Heights of contour & contacts Mandibular movements and positions Miscellaneous Molar teeth information Muscles Occlusion terms Occlusion
information

Abbrc,iation Ant-Inf Can-Inf

Major Topic Permanent teeth (16 individual teeth) Picture of teeth Premolar teeth
information Primary dentition

Abbreviation Perm-T Pict-T Premolar-! nf Primary TMJ T-Comp

Es
C!C

Mand-M&P Temporomandibular joint Misc. Mol-Inf Msl Occi-Terms Occl-lnf PdV G Tooth terms Tooth components (or formation of) Pulp Dentin Enamel Cementum

Periodontal ligament/ Gingiva

T-Tcrms

Notice
Medicine is an ever-changing science. As new research and climcal experience broaden Otlr knowledge, changes in treaonent and drug therapy are required. The authors and the publisher of this work have checked with sources believed to be reliable in their eft'orts to provide infonnation that is complete and generally in accord with the standards accepted at the time of publication. However. in view of the possibility of human error or changes to medical sciences, neither the authors nor the publisher nor any other party who has been involved in the preparation or publication of this work warrants that the information contained herem is in every respect accurate or complete, and they disclaim all responsibility for any errors or omissions or for the results obtained from use of the information contllilled in this work. Readers arc encouraged to confm11 the in formation contained herein with other sources. For example and in particular. readers are advised to check the product information sheet included in the package of each drug they plan to administer 10 be certain that the information contained in this work is accurate and that changes have not been rnade m the recommended dose or in the contraindications for admmistration. This recommendation tS of particular importance in connection with new or in!Tequently used drugs.

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Cottone, James. Geza T. Tere2balmy. and John A. Molinari. Prncoical lpfccuoo Conupl in Denti:rtry, Scepnd Edition. Baltimore: Williams &: Wilkins Company, 1996.
~-StLouis:

Darby, Michele Leonardi. Mosb~'s C2WilBlUi:D~~~ R~vi~ g(C~DIIll:b&i'D~. fguQb Mosby, 1998.

Dawson. Peter E. Elm~rionaJ Qcc)ysiQD f[QDl IMJ JQ Smils: 12~i2D. St. Louis: Mosby, Inc., an affiliate of Elsevier Inc., 2007.
Dorland's !l!u.gnted Me!lical Dictionary. Philadelphia: W.B. Saunders Company. 1994. Dox,lda, B. John Melloni, and Gilbert M. Eisner. The HarperCo!ljns l!lustmled Me!ljcal Dictionarv. New York: Harper Collins Publishers, 1993. Doyon, Dominique, Kathlyo Marsot-Dupuch, and Jean-Paul Francke. IbG Cmoiol

Nerves,
Teterboro: Icon Learning Systems LLC, 2004. Dunn, M3rtin J.. and Cindy Sbapiro. l:lDlml All&illarv Practice Bi!!l!!ii~DI fl~i~ Dod ~lini~;d Aanli,ali2DS Ms:HJyles l 4 and 6. Balti1110<e: WU!iams & Wilkins Company, 1975. Fehrenbach. Margaret J.. and Susan W. Herring. !llumte4 Anatomy of the Head and lS~<~:k, Ihial ~ili!!D. St. Louis: Saunders, an tmpriot of Elsevier Inc., 2007.

References
Ih~ Amm~o llmlli&G Stedman~ MG!Iieal lli"i!!l!l!!X .Boston: .Houghton Mtffiio

Company. 1995.
Albertine, Kun II.
18a2n'~

d,na!Qm)! fll$b Curds Hauppauge: .Bruroos Educational

Series, Inc.. 2007.

Aoa1czm~ ~od l!bx~iolou. Health care Professional Guides. Springhouse, PA: Springhouse Corporation, I998.

Ash, Major. and Sigurd Ramljord. as;,IUr1i~:to fourth Edition. Philadelphia: W.B. Saunders Company. I99S.
Ash, MaJor. ~"I'['~ Ih:DIBI Ai!~lllWX f!b~iQIQ~ Philadelphia: W.B.Saunders Company. 1993.

ami Qcc1J,iQDa S~Y~Ib fdiljQD.

Alias of Human Annmwy. Pennsylvania: Springhouse, 200 I. Atlas Qf PaJbophvsjoloey. Pennsylvania: Springhouse, 2002. Atlas. Ronald M. Princinles of Microbiology. St. Louis: Mooby-Year Book, 1995. Barnes. Carcn, and Margaret B. Waring. Appleton & I !!Pge's Reyjcw of Dental Hyiim' Ellllnh ~ili!!!l- Norwalk, CT: Appleton&. Lange, 1995.

Groer, Maureen W.. and Maureen E. Skeleton. C.V. Mosby Company, 1983

Oa~i~ Pi1lbsmb;,;:~iolo~.

St. Louis: The

Guyton, Artlmr C. Billii~ l:lnmao ~~~~~iolog)!: Nonnal Fyu!Oii!lo and Mechanisms of Disease. SecondEdition. Philadelphia: W.B. Saunders Company, 1977, Guyton, Arthur C., and John B. Hall. Ie~t!lnok of M!:!Ji~all'bx~iUI!!g~, l::!iotb ~i!i!!D Philadelphia: W.B. Saunders Company, 1996.

HaJTUff. Richard C. Pathology Facts. Philadelphia: J.B. Lippincott Company, 1994. Johnson, Arthur G., ei al. Mi~ml!i!!IQg:t 8n~ Immunology. Board ~iQ: S".i!:J!, Third Edition, Baltimore: Lippincott. Williams & Wilkins, 1996.
Karst, Nancy Shobe. and Sarah K. Smith. Dental Anatonl~C A S~lf-ID~WI,IfgnoJ Program. Ninfl1 Edition. East Norwalk, CT: Appleton-Century-Crofts, 1982. Kooiman, Jan, and Klaus-Heinrich Roehm. ClliQ[
&!Ia~

of -aioch~rnisttv

Se~oml

:EWJillo., New York: Georg Thieme Verlag. 2003.

Kraus, Bertram S., Ronald E. Jordan, and Leonard Abr'ilms. Dental Occ!usjoo. Baltimore: Williams & Wilkins, !969.
Anatornx and

Kuchel, Philip W., and Gregory B. Ralston. Schaum's Outline ofTbeO[X and Problems
Qf Bi~b~mistey. SC!lQDQ E!liti!ln. New York: McGraw-Hill, 1998.

Bath-Balogh. Mary, and Margar"t J. Fehrenbach. lllus!ll!t~d Histology. and Anatomy. St. Louis: Elsevie.r Inc., 2006.

Q~n!l!l embrvQJQ~

Baum, Lloyd, Ralph W. Phillips, and Melvin ll.. Lund. Text!lQok ofOoeratjye Demjstcy Third Edition. Philadelphia: W.B. Saunder.; Company, 1995. Shushan, Vikas, and Tao Le. Ei[~! Aid f2t I!Je ).!SMLE Sten 1 2005: A Student TQ Stydent Gyjde, New York: McGraw-Hill, 2005. Bun, Brian. and Stephen A. Eklund. l2!1Dii~ttx Qen!!}l Practice~ and the CommYni~ Fourth fidjtion. Philadelphia: W.B. Saunders Company. 1992. Cawson, ll..A ,, and E.W. Odell. Q~w22o's as~'Dtial~ g( Qllli fntb!!l!lllX ao!l Qllll Medicine SeventhEdition. Philadelphia: Churchill Livingstone. 2002. Cbampe, Pamela, <md Richard A. Harvey. J3i!:u;;bmlim - l~illRiD~t!U'~ lllusrmttd Reviews Secon<!Edition. Philadelphia: Lippincott. WiUiams & Wilkins, 1994. Chung, Kyung Won. Q~~ 1\,oatomy BQard Revi~w S~ri~s Lippincott, Williams & Wilkins. 1995.
Jbit~

E!liligu. Baltimore:

CQI!!t!~h~a:zi~ ;&}!iSC>X C~u Q~n.Yd H~gienists f'ounh EditiQn. St. louis: Tbe C.V, Mosby Company, 1980.

Costanzo, Linda. b~~jgjggy & Wilkins, 1998.

flQ!Jr~

Review Series. Baltimore: Lippincott, Will iams

Lehninger, Alben L .. David l. Nelson, and Michael M. Cox. PrioillhiS !!C Bjocbemistn Seg>nd Edjtion. New Yod. Wonh Publishers. 1993. Levinson. Warren, and Ernest Jawetz. M!:!li~al Mi~llll!i!!l!li!X 1100 Jmmuoolo~m Eillb Appleton & Lange, 1999. Liebgott, Bernard. The Ao>JQmlcal Bam of Deotistrv- Philadelphia: W.B. Sauode~ Company, 1982.

Elliliwl- SI8IIlford, CT:

Marks, Dawn B. BjocbemjsiN a~uu s,~i~\~ Si:C~.

Lippincott, Williams & Willcios, 1999.

Ibi!ll Edition. Balli more:

Ill' Mr~k Manual QL M"licaiiD[Q[IDUli!lD. l:l!lw~ fl!iti!lD Whitehouse Station, NJ:

Merck Research Laboratories, 1997.
~-

Moore, Keith L. The DeyelooiDR l:lumao Clioi~ll:t Philadelphia: W.B. Saunders Company, 1992.
fQ[

Q[i,ow.l

Emb~Qh;~~

Ibitd

MQ5b:fs R~~,
Inc., 2007.

lhc ~BDE eao 1 St Louis: Mosby. Inc., an affiliate of Elsevocr

ExmniDiUi~o B'griol:t Distributed by the Amencao SIUdent Dental Association (ASOA). with permission from the American Dental Association (ADA), Chicago.

iSAtimud B2iml

NetT, Peter A. Qs.:clu~iQD !mel 1975.

:Euns;JiDD Georgelown Univ<'fSity School of Dentistry,

Shafer, William G, Maynard K. Kline, and Samet M. Levy. A Textbook of: Oral Patbologv, E<>urth Edition. Philadelphia: W.B. Saunders Company, 1983. Snell. Richard S. !;;linical Anall!lllli: [Q[ M~ical Sll!llcnts, Fifth P..diti!!n. Boston: Little, Brown and Company. 1995.

Spence, Alexander P.. and Elliott B. Ma;on. Huwao Ana1omy and Phvsjolm, Eourth f.W!ilm. St. Paul: West Publishing Company, 1992. Slryer. Lubert. Bjocbewisrry. San Fruncif!l: \V.H. Freeman and Company, 1975.

ll!!ili!ln. St. Louis: Mosby-Year 13ook. 1995.

Sturdevant, Clifford M., el nl. Ibt 80 an~ S~i~l'~ g( Qoerativ Dnris!!)(

Ibicd

SUQ~[ Review Qf ADDI!!WY {& ~bYiil!ill~ Piscataway. NJ: Research & Education Association, 2000. SUD:'[ Review of Microbjg:)Q~. Piscataway, NJ: Research & Education Association, 2000.

Van de Gruff, Kent M., el al Eiuwaa ADIISUDX: imd ~b~21aev Srudx Hightstown, NJ: McGraw-Hill. 1999.

Carel~.

Van De GraafT, Kent M .. and R. Wnrd Rhee.. Schaum's Outline of!heorv and Problems
!I( ~IUIDiDAPil!lmY ami flu!~iiii!!~X SGI;!lml Ellili!lo. New York: McGrawHill. 1997.

Netter, Frank H. A!la Qf Human Anatom:r: Se~Qnd Editi2D Novartis, 1997. Norton, Nei I s. N~n~r's l:l"d C.od ~~k Anatom!l FQr Saunders, an imprint of Elsevier Inc., 2007.

East Hanover, NJ:

D~ntisto:,

Philadelpb.ia:

Pansky, Ben. R~vjew Q[ Q[Q~S C.Omomx, Fifth Edition. New York: Macmillan Publishing, 1984. Patton, Kevin T., and Gary A. Thibodeau. M!.lsbt~ Handbook of AnatQm!l ,\'! Pbysiologv. Mosby, Inc., 2000. PDR Medical Dictionary. Montvale, NJ: Medical Economics, 1995. Pbagpacy Review. Baltimore: Williams & Wilkins, 1989. Pinchuk, George. ~ha~m~ Qutlines of TheQQ: and PmbiUJ~ g( lllllll11D212CX New York: McGraw-Hill, 2002. Profeysjgnal Guide to Diseases. Seventh Edition. Pennsylvania: Springhouse, 2001. Rubin, Emanuel, and John L. Farber. PathoiQ!::i Second Edition. Philadelph.ia: J.B. Lippincott Company, 1998. Schneider, Arthur s., and Philip A. Szanto. fatbQlogx Baltimore: Williams & Wilkins, 1993.

- BQard Review

Series.

Wilkins, Esther M. Clinical Practice of the D~11tal Hygienist Seventh Edition. Malvern, PA: Lea & Febiger, 1994. Woelfel, Julian B., and Rickne C. Scheid. Dental Anatomx: Its Relevance to Dentisrrv. Baltimore: Williams & Wilkins, 1997. Wolf-Hejdegger The Color Atlas gf Human AnalQillY, NewYork: Sterling Publishing Company Inc., 2006. Yotis, William W. et al. Appleton & l&nes Reyjew of Microbiology and Immunologv. Third EditiQn. Stamford, CT: Appleton & Lange, 1997.

( PROFESSIONAL ETIDCS I PATIENT MANAGEMENT)

The m easure of the quality of care provided In a particular setting Is called:

Quality assurance Quality evaluation Quality assessment Quality inspeetion

PROFESSIONAL ETIDCS I PATI ENT MANAGEMENT

Dentists are:

Morally obligated to report child abuse Ethically obligated to report child abuse Legally obligated to report child abuse All of the above

Cov.rnJbt 0 2009-2010 Dtmal Detls

{)ualil\ :1\Sl'SSIJICOI

Quality assurance is the measurement of the quality of care and the implementation of any necessary changes to either maintain or improve the quality of care rendered. The differences in these definitions are important: quality assessment is limited to the appraisal of whether or not standards of quality have been met; whereas, quality assurance includes the additional dimension of action to take the necessary corrective steps to improve the situation in the future. The following concepts relate to quality assurance;

1. Structure --- refers to the layout and equipment of a facility_ 2. Process --- involves the actual services that the dentist and assistant perform for the patients and how well they perform. 3. Outcome --- is the change in health status that occurs as a result of the care delivered.

\II of Ihe ahO\ l'

Dentists are morally, ethically, and legally obligated to report a suspected case of child abuse. Once an injury of a suspicious nature is observed, the dentist's first and immediate responsibility is the protection of the child. Reports should be made to the designated state agency (wcial services or police). Dentists must familiarize themselves with the exact procedures to be followed in their own states. I. Cbild abuse most commonly involves newborns and children up to the age of three years. 2. Dentists are also ethically obligated to identify and refer cases of domestic violence. Practitioners should become familiar with the physical s igns of dome.~tic violence, especially because 68% of battered women's injuries involve the face, 45% the eyes, and 12% the neck.

( PROFESSIONAL ETHICS I PATIENT MANAGEMENT )

The role of the professional in the practice of dentistry is described In the ADA's Principles of Ethics and Code of Professional Conduct (ADA Code). The ADA Code Is, in effec.t , a written expression of the obligations a rising from the implied contract between:

The dental profession and insurance companies The dental profession and public health board of directors The dental profession and society The dental profession and the local government

3 Copyn&}ltO 20092010 OC'ntall)ecks

(PROFESSIONAL ETIDCS I PATIENT MANAGEMENT )

\..

All of the following are true concerning the Americans with Disabilities Act EXCEPT one. Which one is the EXCEPTION?

Dentists cannot deny anyone care due to a disability Dental offices must undergo structural changes to allow access for the disabled Dentists cannot dismiss employees due to a disability Patients with IllY are not protected under the Americans with Disabilities Act

1 hl' dlntal J)rofc\sion :md sudrl~

The dental profession holds a special posmon of trust within society. As a consequence, society affords the profession certain privileges that arc not available tO members of the public. In rerum, the profession makes a conunitment to society that its members wiU adhere to high ethical standard~ of conduct. These standards are embodied in the ADA Principles of Ethics and Code of Professional Conduct (ADA Cede). Members of the ADA voluntarily agree to abide by the ADA Code as a condition of membership in the Association. They recognize that continued public trust in the dental profession is based on the commitment of individual dentists to high ethical standards of conduct. The ADA Code has three main components: The Principles of Ethics The Code of Professional Conduct The Advisory Opinions Five ethical principles in the code: I. Veracity --- truthfulness 2. Justice --- fairness 3. Autonomy-- self-governance 4. Beneficence-- do good 5. Nonmaleficence ---do no bann

P:.1lienls \\ilh Jfl\' :ul' not protrctrd undrr the .\mcrir:uts nilh Disahililics Act

This is False; patients with HlV are protected under the Americans with Disabilities Act. Both state and federal statutes define disabllitv as having the following: I. A physical or mental impairment that substantially limits one or more of the major life activities of such individual. 2. A record of such impainneot. 3. Being regarded as having such impainoent.

(PROFESSIONAL ETHICS I PATIENT MANAGEMENT)

\.

When obtaining informed consent, the patient must be informed of all of the following EXCEPT one. Which one is the EXCEPTION'/

A description of the proposed treatment The costS involved in the proposed treatment The foreseeable risks The benefits and prognosis of the proposed treatment All reasonable alternatives to the proposed treatment The risks, benefits, and prognosis of the alternative treatments

5
Cop)Tight 0 20092010 Den11d !Xck$

(PROFESSIONAL ETIDCS I PATIENT MANAGEMENT)

The dentist has diagnosed and recommended specific treatment for a patient of record and remains on the premises while the patient Is being treated. This type of dental s upervision is known as:

General Supervision Direct Supervision Indirect Supervision Personal Supervision

'I he cosh iO\nhed in thl' propnsld trr-.ltmlnt

Financial information should not be kept on the treauneut record. Always use a seperate financial form. All factors (except financial) must be described to the patient in language the patient understands. Give the patient an oppQrtunity to ask questions. and provide the answers. The patient's consent can be provided either orally or in writing. although from a legal standpQint, a written agreement is preferred. The written treatment olan should include the following: a description of the patient's condition the propQsed treatment the pQssibilities that the treatment may or may not be successful the foreseen outcome of not treating the patient's condition aU of the involved risks other JX>Ssible treatment options for the patient cost of treatment estimated number and length of appointments wben payments are expected by the patient how long it will take to complete all phases of treatment signed and dated by the patient or guardian ** Both parties (dentist and patiem) get a copy

I ndin\'t Suprn isiun

Supervision is the tenn applied to the legal relationship between tbe dentist and the dental hygienist in practice. The various types of dental supervision include: General Supervision the dentist has recommended a demal hygiene procedure for a patient of record but does not have to be physically pr('Sent while that procedure is being performed. Direct Supervision the dentist has diagnosed a problem and recommended specific treaunent by the dental hygienist, remains on the premises while the patient is being treated, and appro,cs the work perfonned prior to the dismissal of the patient. Personal Supervision the dentist is treating a patient and the hygienist is concurrently performing a supponive procedure that has been recommended by the dentist. Note: Each individual state's dental practice act defines the type of supervision that is required by that specific state and also states the ~-pecific dental hygiene procedures that a dental hygienist is legally allowed to perform in that state.

PROFESSIONAL ETHICS I PATIENT MAl'iAGEMENT

(
Physical abuse Sexual abuse Physical neglect Emotional abuse All of the above

Abuse of a child csm mean:

7 O:lprria:ht 0 20092010 Dental Oed;t

PROFESSIONAL ETHICS I PATIENT MA~AGEMENT

Ir

In the code (Principles of Ethics and Code of Professiot~af Cond11ct), '-under the definition of beneficence ("do good"), the dentist is obliged to j

"I

Give the highest quality of service of which he or she is capable Preserve a healthy dentition unless it compromises the well-being of other teeth Participate in legal and public health-related maners All of the above

Qlp)'f\iiJI 0

2~2010

Dmt.al ~k$

All nf the "IHI\0 General signs of ch ild abuse: Very fearful and cry excessively or show no fear at all, unhappy and withdrawn Behavior may be different when parent is present Developmental delays in language or motor skills Malnutrition, untidy appearance Long-sleeved shirts and long pants in warm weather to possibly cover bruises or ftnger marks on arm, legs, or neck Wounds at different stages of healing inconsistent with parent's explanation. Bums, bite marks, and trauma to neck, eyes, and ears Oral signs of child abuse: Lips may be swollen or bruised, scars may indicate past history of trauma Marks around comers of mouth, possibly due to child being gagged Injury to the teeth -- fractured, premature loss, darkened appearance Fractured jaw Injuries to the tongue Evidence of ignoring child's dental needs Tom or lacerated oral frenums Note: Dental personnel should also be aware of possible signs of spousal and elder abuse (rmusual behavior or physical sig11s).

\II nf t lw .lllO\ r

Principle: Beneficence--- "do good." The dentist has a duty to promote welfare.

th~

patient's

Tltis principal expresses the concept that professionals nave a duty to act for the beoeftt of others. Under this principle, the dentist's primary obligation is service to the patient and the public. The most important aspect of this obligation is the competent and timely delivery or dental care within the bounds of the clinical circumstances presented by the patient, with due consideration being given to the needs, desires. and values of the patient. The same ethical considerations apply whether the dentist engages in fee-for-service. managed care, or some other practice arrangement. Dentists may choose to enter contracts govemiug the provision of care to a group of patients; however, contract obligations do not excuse dentists from their ethical duty to put the patient's welfare ftrst. Important: The patient is expected to be responsible for his or her own preventive practices. The dentist is responsible for providing information and supportive care, but the patient bas the ultimate responsibi lity to maintain his/her oral health.

PROFESSIONAL ETHTCS I PATIENT MANAGEMENT

Which principle in the code refers to "self-governance?"

Veracity

Justice
Autonomy Beneficence Nonmaleficence

8
CQP)Tl&ht 0

10092010 Oee i1al l:>tctt

(PROFESSIONAL ETIDCS I PATIENT MANAGEMENT)

In the code (Principles of Ethics and Code of Professional Conduct), under the definltlon of justice ("fairness'?, dentists:

Shall not refuse to accept patients into their practice or deny dental service co patients because of the patient's race, creed, color, sex, or national origin. Have the general obligation 10 provide care to those in need. A decision not to provide treatment co an individual because the individual is infected with Human Immunodeficiency Virus, Hepatitis B Virus, I lcpatitis C Virus, or another blood-borne pathogen, based solely on that fact, is unethical. Shall be obligated to make resonablc arrangements for the emergency care of their patients of record. All of the above

10 CopyriJbiO Z009201 0 ~I Db

\utn11nm~

Principle: Patiem autonomy --- "self-governance." The dentist bas a duty to respect the patient's rights to self-determination and confidentiality. This principle expresses the concept that professionals have a duty to treat the patient according to the patient's desires, within the bounds of accepted treatment, and to protect the patient's confidentiality. Under this principle. the dentist's primary obligations include involving patients in treatment decisions in a meaningful way, with due consideration being given to the patient's needs, desires, and abilities, and safeguarding the patient 's privacy. Important: A dentist bas an ethical obligation on request of either the patient or the patient's new dentist to furnish in accordance with applicable law, either gratuitously or for nominal cost, such dental records or copies or summaries of them, including dental X-rays or copies of them, as will be beneficial for the future treatmem of that patient. This obligation exi.s ts whether or not the patient's account is paid in full. Note : According to the code, if a patient refuses to let you take X-rays of his/her teeth, the dentist's only recourse is to usc informed consent about the risks and benefits of an incomplete exam and the possible consequences of such a decision. The respect of the patient's right to choose (auronomy) prevails.

All uf lhl' IIJO\ ~

Principle: Justice- "fairness." The dentist has a duty to treat people tairly. This principle expresses the concept that professionals have a duty ro be fair in their dealings with patients, colleagues, and society. Under this principle, the dentist's primary obligations include dealing with people j<Lstly and delivering dental c-are wltbout prejudice. In its broadest sense, this principle expresses the concept that the dental profession should actively seek alties throughout society on specific activities that will help improve access to care for all. Important: Dentists shall be obligated when consulted in an emergency by patients not of record to make resonable arrangements for emergency care. If treatment is provided, the dentist, upon completion of treatment, i ohliged to retum the patient to his or her regular dentist unless the patient expressly reveals a different preference. Note: Dentists shall be obligated to report to the appropriate reviewing agency as detennioed by tb< local component or constituent society instances of gross or continual faulty treatment by other dentists. Patients should be informed of their present oral health status without disparaging comment about prior services.

PROFESSIONAL ETHICS I PATIENT M.AJ.~AGEMENT

1 ' Which principle in the code expresses the concept that professionals hav;;'m
\.. a duty to be honest and trustworthy in their dealings with people?
~~

Autonomy Justice Beneficence Veracity Nonmaleficence

11

Copyrigbt 0 20091010 OC'Mal Jktb

(PROFESSIONAL ETIDCS I PATIENT MANAGEMENT)

, j\.

Which principle in the code expresses the concept that professionals have a duty to protect the tlatient from harm?

Beneficence
Autonomy

Veracity Nonmaleficence
Justice

12
Copyn"" 0 ,_20I 0 0..1>1 """

\ l'nH:il~

Principle: Veracity-- " truthfulness.'' The dentist has a duty to communicate truthfully. This principle expresses the concept that professionals have a duty to be honest and trustworthy in their dealings with people. Under this principle, the dentist's primary obligations include respecting the position of trust ioherent in the dentist-patient relationship, col)llllun icating truthfully and without deception, and maintaining intellectual integrity. Important: Based on current scientific data, the ADA has determined that the removal of amalgam restorations from the non-allergic patient for the alleged purpose of removing toxic substances from tbe body, when such treamlent is pcrfonncd solely at the recommendation or suggestion of the dentis~ is improper and unethical. The same principle of veracity applies to the dentist's recommendation concerning the removal of any dental restorative material. However, it is not unethical to replace amalgams cf a patient requests this treannent. Note: A dentist who represents that dental treatment or diagnostic techniques recommended or pcrfonned by the dentist have the capacity to diagnose, cure or alleviate diseases, infections, or other conditions, when such representations are not based upon accepted scientific knowledge or research, is acting llnetbically.

'I H u mall'fh t.' 11 n

Principle: Nonmalcficcoce --"do no harm." The dentist bas a duty to refrain from harming the patient. This principle expresses the concept that professionals have a duty to protect the patient from harm. Under this principle, the dentist's primary obligations include keeping knowledge and slcills current, knowing one's own limitations and when to refer to a specialist or other professional, and knowing when and under what circumstances delegation of patient care to auxiliaries is appropriate. I mportant: Demists shall be obligated to seck consultation, if possible, whenever the welfllte of patients will be safeguarded or advanced by utilizing those who have special skills, knowledge, and experience. When patients visit or are referred to specialists or consulting dentists for consultation: 1. Tite specialists or consultating dentistS upon completion of their care shall rentm the patient, unless the patient expressly reveals a different preference, to the referring dentists or if none, to the dentist ofrecord for future care. 2. The specialists shall be obliged when there is no referring dentist and upon the completion of their treannent to infonn patients when there is a need for further dental care.

PROFESSIONAL ETIDCS I PATIENT MANAGEMENT

A disciplinary penalty that may be Imposed on a dentist found guilty of unethical conduct that consists of a disciplinary sentence written to express severe criticism or disapproval for a particular type or conduct or act Is considered a:

Suspension Probation

Censure
Revocation of license

13
Cop)Tight 0 20092010 Dee.tlll Dedr;5

(PROFESSIONAL ETHICS I PATIENT MANAGEMENT)

Which of the following statements are true? A dentist who accepts a third party payment under a co-payment plan as payment in full without disclosing to the third party that the patient's payment portion will be collected, is engaged in overbilling. It is unethical for a dentist to increase a fee to a patient solely because the patient is covered under a denial benefits plan. A dentist who submits a claim form to a third party reponing incorrect treatment dates for the purpose of assisting a patient in obtaining benefits under a dental plan, which would otherwise be disallowed, is engaged in making an unethical, false, or misleading representation to such a third party. All of the above statements are true

CopyriJbt 0 20092010 Dental DcdJ

Ccnsun

Types of disciplinary penalties that may be imposed on a dentist found guilty of unethical conduct: Censure: a discip linary sentence written to express se,ere criticism or disapproval for a particular type of conduct or act. Suspension: a loss of membership privileges for a certain period with automatic reinstatement. Probation: a specified period without the loss of rights in lieu of a suspended disciplinary penalty. A dentist on probation may be required to practice under the supervision of a dentist or other individual approved by the dental board. Revocation of license: absolute severance from the profession. Acts that would result in a dentist being charged with unethical conduct: -A guilty verdict for criminal felony. - A guilty verdict for violating the bylaws or principles of the Code of Ethics.

\II ot lhl' ahO\t' stahmlnts arc trm

All of the statements (issues) on the front of the card are considered in the code under the principle of veracity ("trwhfulness"). The dentist has a duty to collltllunicate truthfully. Overbilling is the misrepresentation of a fee as higher than it is. A dentist cannot accept a co-payment from a dental insurance company as payment in full for services and not request the patient's portion. This is considered overbilling and unethical without full disclosure to the insurance company. A dentist cannot charge different fees to different patientS for the same services. A dentist who recollltllends and performs unnecessary dental services or procedures is engaged in unethical conduct.

( PROFESSIONAL ETHICS I PATIENT MANAGEMENT )

True or False Although any den list may advertise, no dentist shall advertise or solicit patlents \.. in any form of communication in a manner that is false or misleading. ..J

us

15
Copyri.gbt c 2009-2010 l>nltl Dcl.:ks

PROFESSIONAL ETHICS I PATIENT MANAGEMENT

Since the name under which a dentist conducts his or her pr actice "' may be a factor in the selection process or the patient, the use or a t rade name or an assumed name that Is false misleading in any material respect Is unethical. Use or the name of a dentist no longer actively \. associated with the practice may be continued for a period not to exceed~

I year

2 years 3 years
4 years

11 Copynhl 0 20(19..2010 Oml.al Oeelr.t

I rut

Infringements of the standards involve statements that include: -Inferences of a specialty by a general dentist -Use of unearned degrees as titles to enhance prestige A dentist may use the title Doctor or Dentist, DOS, OMD, or any additionally earned, advanced academic degree in health service areas in an announcement to the public. An advertisement to the public of HN negative test results, without conveying additional infonnation that will clarify the scientific significance of this fact. A dentist could satisfy his or her obligation to convey additional information by clearly stating in the advertisement or other communication. "This negative HIV test cannot guarantee that I am currently free of HIV."

With permission of a departing dentist, his or her name may be used for more than one year, if, after the one year grace period has expired, prominent notice is provided to the public through such mediums as a sign at the office and a short statement on stationary and business cards that the departing dentist has retired from the practice. Dentists who choose to announce specialization should use "specialists in" or "practice limited to" and shall limit their practice elclusively to the announced special area(s) of dental practice, provided at the time of the announcement such dentists have met in each approved specialty for which they annowtce, the existing educational requirements and standards set forth by the American Dental Association. Note: Dentists who use their eligibility to announce as specialists to make the public believe that specialty services rendered in the dental office are being rendered by qualified specialists when such is not the case are engaged in unethical conduct.