Transcribed by Jazmin Lui May 15, 2014

CRANIOFACIAL BIOLOGY MASTICATION DR. SPIELMAN

1. Mastication and Swallowing: Flipped Classroom component
Good morning. How is everybody this morning? You dont look too fresh.
Yawning, sitting in the back, you guys are not really involved. So, an honest
hand, how many have actually looked at the posted slides? Alright. So were
going to have some difficulty in getting through but well try. So today were
going to apply that knowledge that you did not review. So well talk about
mastication, obviously you will have to know the muscles of mastication, start
and insertion, and how do you actually use it? You will see these patients
actually come to your office and you will have to figure out what are the
muscles that are involved? So we have a couple of textbooks on The
Vitalbook. One book, called Clinical Oral Physiology is not The Vitalbook, but I
have access to the book and I posted the chapters from those books, that
book, on swallowing and mastication. So you have access to the information
and images. You can use it read it, read up on it and also

2. References
- this is the Timothy Miles book that was published. There is actually in that
book a chapter on saliva and theres a chapter on taste, the one I have
written. A colleague of mine, if any of you have want or need of access of
that I would be more than happy to post those as well. There is the essential
medical physiology textbook you have, the Johnson. And that has a section
on swallowing. Its the images that are posted on the slides that are actually
from the Johnson textbook. And finally there is the Anatomical Basis of
Mastication which is, I believe that you have it on the Vitalbook. And you
have also a section, not a long section, on mastication. So you have
something to talk about.

3. Conclusions and Concepts
Transcribed by Jazmin Lui May 15, 2014

So before you fall asleep I just wanted to give you the conclusions. Because
thats also, the take home message, you know, what do I need to know. And
afterwards if you are not with me thats fine, you can fall asleep. So what are
the concepts you need to know? Not just for the comprehensive exam but
beyond you need to clearly know mastication issues that are associated with
your patients ability to open and close. Now this is not just for you to
examine a patient. Patients speak, eat, and for each of these processes they
need to open and close their mouth. And you will see some complaints from
patients following procedures, traumas, whatever it is they will not be able to
open or close. You need to figure out what is wrong with them. Is this
something associated with the muscle, is this something associated with the
joints that allow you to open and close? What kind of movements are
hindered? That will allow you to narrow down to the area. Palpation will allow
you to figure out whether this is superficial, is this deep. You need to ask the
patient to bite and see where the pain occurs or the hindrance occurs. So you
need to do some detective work. Its not gonna be list the muscles.
Nobodys going to ask you maybe on the boards. But your patient is not
going to be concerned about that. They will be asking you Whats wrong
with me? and you will have to figure that out based on your knowledge. So
applied knowledge is the key. You will see trauma, see dislocation as a
potential. Infections, very common. And very important about infections
infections dont stay in one place. You need to know how the various layers
allow spread of infection. What is the direction? You need to know the
drainage of the facial lymph, on the facial and neck area. Because if you see
an infection and someone cannot open or close his or her mouth, you will
have to figure out Are there lymph nodes involved?. Where do you actually
palpate the lymph nodes? So I urge you to go back and look at that anatomy
textbook because what you will find is that infections occur in the lip and
lower jaw up to this point. And you have submental lymph nodes involved.
When you move beyond the molar and into the molar area, you will have
submandibular. If its deeper you will have cervical around the
Transcribed by Jazmin Lui May 15, 2014

sternocleidomastoid muscle. So those will be hints for you Oh this is
probably an infection. Trauma rarely involves lymph nodes. It has to be an
infection. So you need to figure out infection, trauma, dislocation.
Inflammation if you have a patient that you worked on very clear that
cause/effect. And its traditionally associated with procedures that take a long
time. Wisdom tooth extraction. As easy as it sounds. If you work on that
patient 1 minute, you will have far less swelling, almost none, because you will
not have traumatized that tissue. Patient comes back swelling, not because of
infection, its because of the tissue reaction to trauma. The longer you work,
the more swelling thats going to occur. You need to work on your technique.
And patients will essentially come with this inflammation which is the sign of
the body essentially reacting to what you have done the previous time.
Fractures. You may see these during your rotations in general practice
residencies. You have to remember something about how the mandible or
what muscles are attached to the mandible. And well see some fractures that
move the pieces and you will have to figure out what muscles are involved
and what functional deficiencies the patient is going to end up with.
Mastication, speech and swallowing. Again, the nuts and bolts of the process
Im not going to go over them. Its very simple, you can go over it on your
own. I dont have to repeat it to you.

3. Why?
So why do you need to know? These are pretty much the inability to chew
pain, infection, you will also have some patients who are taking medications.
Bisphosphonates. Its a very recent development because patients with
osteoporosis take bisphosphonates. And theres an interesting correlation
between bisphosphonates and osteonecrosis of the jaw. You might be the
first one to actually see osteonecrosis of the jaw and say Are these patients
on bisphosphonates?. We just briefly talked about it. Im going to show a
gun shot case that I have treated many many years ago. Theyre pretty
dramatic pictures but this is what a patient might come into an operating
Transcribed by Jazmin Lui May 15, 2014

room. And you need to figure out when this patient is repaired, what kind of
functional problems are they going to face? Will they be able to open, close?
Will they have sensory deficiency? Its a very complex case, but were gonna
see and maybe apply some of the knowledge you have gained in anatomy
and physiology. The inability to open. Trismus is a quite common, especially
if the posterior, the masticatory muscles such as the medial pterygoid and the
masseter are involved. Subluxation. Ill give you a case that I have seen many
many years ago. Fractures. TMD. Then understanding swallowing. You will
have to pretty much understand how does the gag reflex come into play. You
will be taking impressions on your patients. Anyone who has an upper
edentulous area will have to have an impression taken. And you need to
understand how to position that patient; all of a sudden the patient starts
gagging. What are the steps you have to do in order to stop, short of
removing, and is the patient going to be reclined, are they going to sit up?
Are there any ways other than removing the stimulant that activates the gag
reflex? Is there anything else you can do? And this is the impression taking
exercise. I mentioned GERD here because in many instances the reflux will
also, may activate some of the gag reflexes and gag reflex will lead to
vomiting. So you have to understand what is the process of swallowing and
what is actually the process of vomiting. Which is literally in reverse the steps
we understand as swallowing. And then of course, we covered this topic of
halitosis but it has implications here.

5. Case 1
So case number 1. This particular patient tried to commit suicide. He was
rushed to the emergency room and I happened to be on call, on duty. The
patient took a gun and clumsily tried to shoot himself. And somehow the
angle of the gun was parallel to his face. So what happened is he shot a piece
of his mandible, and that grazed through his eye, and ricocheted off the
upper portion of the eye socket.

Transcribed by Jazmin Lui May 15, 2014

6. [case picture]
So this is with the flap pushed back. Im not sure, actually lower the lights so
you will be able to seeI think this is better. So this is the left side of the face
but you can see even with the tissue being covered completely there is a
deficiency of tissue. So the question you have to ask

7. [case picture]
- so this is after a surgery that lasted approximately 4 hours. I had to remove
his eye, and it was, a piece of his upper lip was missing, the jaw was missing,
so you needed to stabilize the mandible.

8. [case picture]
And this was approximately a month after his surgery. So his eye is gone and
part of the maxilla was gone.

9. [case picture]
And this was after 8 months. We did a number of corrective surgeries. But the
question is if you use this particular case to try to figure out what kind
muscles and tissues are being eliminated.

9. [case picture]
So this is a side view. We did and artificial eye, we did an additional
corrections on the lip and vestibular deepening to allow room for a denture.
He needed to get a bone graft because mandible was missing a piece, which
was initially just stabilized. But that was brought out in order to fix the
mandible position so you could do something to the rest of his face. So there
are temporary measures you can take. So Id like you to talk it over with your
neighbour, try to figure it out: What anatomical structures are involved in
chewing and facial expression? So were not going to get into bone and
everything else. Just, well to the extent that these muscles need to be
anchored. So try and figure it out. You can use any book, you can talk it over
Transcribed by Jazmin Lui May 15, 2014

with your neighbour. Lets try to do this exercise.

10. Describe the anatomical structures affected in this patient
Because this is a different angle than youre used to. Tell me muscles or the
nerves. This is an applied application. Ok. Open your books. You can open
any anatomy text. You can look at structures, tissue, lets try to do some
applied knowledge. You in the back, do you want to join the other lonely
student in the other back? Ok? Just team up.

Ok, why dont we start with perhaps the simplest. What are the bones that are
being affected? Ok Pedrum ok lets take it sequentially. So the mandible is
the first piece thats being affected. Lets hear from someone else. Yes.
Maxilla. What else is being affected? Palate. Yes it was affected, part of the
palate, youre right. Anything else? [Zygomatic?] well its part of the
maxillayeah youre right. It probably did come out. [Frontal?] It was actually
there was some leakage of cerebrospinofluid. The orbit, yes. It was affected. It
was everything you can think of. What nerves were affected? That would
involve mastication and facial expression. Let me just get a few other
opinions. Charles, what do you think? The mandible is gone, or at least a
piece of it. Lets start with the sensory nerves. Inferior alveolar, and what
branch is right there? Its the mental nerve. So what covers the mental nerve,
what kind of sensory deficit would this patient have right away? Or even after
surgery? What does mental cover? It covers this lip this portion of the lip, the
inside of the lip and the gum. Its very simple. You dont need this kind of
trauma to get this kind of deficit. Youre doing any kind of flap, contract, and
you push that nerve I guarantee you the patient is going to come back with a
sensory deficit. You dont have to cut the nerve you just have to compress it.
Its very very sensitive to compression. Yes? [lingual nerve]? No I dont think
that the lingual nerve was affected, the branch is actually way back if you
remember your anatomy. When you inject have you guys done any local
anaesthesia? When you inject all the way back to the inferior alveolar nerve,
Transcribed by Jazmin Lui May 15, 2014

the lingual branch actually comes off and enters the tongue, all the way back.
This is where the chorda tympani is associated. But lingual is part of the
trigeminal, and chorda tympani is part of the facial nerve. Buts its attached
as a separate fibre. Its all the way back, its not affected. So moving up, what
kind of sensory nerve would have been affected further up as you move in
the anatomy? Maxillary branch of what nerve? Its the V2 which is, its actually,
when you say V its really the Latin number for the fifth nerve. You may call it
V3 but its really second branch of the trigeminal nerve, the fifth cranial nerve.
What does that cover? If you were to demonstrate on your own face what
area does that maxillary branch. Ok? You were showing that. Take off your
glasses and show me what would be the deficit. Ok so which part of the nose
do you feel would be affected. Put your finger on it. Well this is both sides,
this is just one side that was affected, the left side. Its the side of the nose,
the ala of the nose. What about the eye? If this patient had a whole eyelid
what area would be covered by that branch? Its the area below, its the lower
eyelid would be affected. Its like a butterfly but only one side would be
affected. So clearly this lower side. If you had to anesthetize that nerve, lets
say in an intact person, what area would you inject? Yes infraorbital foramen.
Does everyone know where the infraorbital foramen is? You can actually tap
on your face and you may occasionally feel an electric tingle, which is where
that nerve is, below the orbit and in some instances further down. So that
area was completely gone. What about further up, what about the orbit?
What other sensory nerve would have been affected? Look at this area. What
kind of nerve is there? [ophthalmic] its not the ophthalmic, this is called the
supraorbital branch which is the first branch of the trigeminal. Can you
actually palpate that notch? On the upper, on both sides, if I take off my
glasses. Can you palpate that notch? This was an area that was affected in this
patient but its also the area where the supraorbital comes out and covers the
entire frontal area of the skin. This is also an area that you can use when you
happen to be in public or a place where you cannot sneeze. You know what
you need to do in order to stop the sneezing? You just push the supraorbital
Transcribed by Jazmin Lui May 15, 2014

nerves and it will stop the sneezing. Any pressure on either the base of the
nose or the supraorbitals will inhibit the sneezing. Its sort of this gesture, you
know where you look like youre really deep thinking. You just push it hard
and you avert the sneezing. So lets look at, so what else.

11. [muscle pictures].
So what muscles are there. Take a look at this. You can actually see very
clearly what are the masticatory muscles and facial expression. So you would
have in terms of masticatory muscles -

12a. [skull pictures].
- we talked about the mandible, mental nerve, mental foramen, part of the
maxilla, the infraorbital, and supraorbital would be affected by this. Entire
orbit, part of the zygoma, part of the maxilla. The orbit and of course, that
means the eye is completely gone. There was just no way to support that in
this case.
12b. [side view of facial muscles]
When it comes to muscles, the patient would not have the facial nerves, sorry
the facial muscles. Interestingly the facial nerve was not affected, at least the
terminal branch. The facial nerve comes right here and it was located
between the superficial and deep lobe of parotid gland and you can clearly
see that was not affected in this patient. But the muscles receiving the
innervation by the facial would be affected.
12c. [front view of facial muscles]
You can see the depressor angulis oris would be affected. The levator angulis
oris, that means the patient was not able to rise or lift the corner of the
mouth. The superior the upper lip was not able to lift. The eye was gone
and the disruption of the muscles around.
12d. [back view of oral cavity]
Transcribed by Jazmin Lui May 15, 2014

When you look at the back you can clearly see the pterygoid was affected
and of course part of the mandible was gone. You can actually see part of the
genioglossus was affected, teeth were gone, part of the mandible was gone.

13. list of affected structures.
This is a list of muscles, nerves, and bones, and of course all of the functions
associated, both the motor and sensory functions associated.

14. Case 2
This is the second case. Somebody who walks into your office and has no
capability of closing her jaw. So imagine yourself sitting with a mouth half
open, shifted to the right. What do you think is happening? Lets take some
other opinions. [left condylar dislocation]. Ok. So what is really happening to
the condyle when you open your mouth? Just take me through, as if you
were sitting on the condyle. On both sides, what is happening? So the
condyle does what? [goes down and forward] Ok, and? So there is a slight
movement forward in the fossa. What happened in this patient? If you were
sitting on the condyle, what is happening? Let me get some other opinions.
[are you talking where its displaced] yeah what is happening with the condyle
when you have somebody like this? Exactly, so everyone has this articular
eminence in front of your mental eyes. So the condyle moves forward and
somehow gets stuck in front this articular eminence. So lets bring up this
image and you can see what Im talking about. So normally this condyle is
supposed to sit inside the fossa. Why would the condyle or mandible do this?
What are the conditions? [if jaw is open and gets hit] so Ill give you the that
case I had. It was my last year of dental school. This old lady came in
completely edentulous. Like this, no trauma. She just yawned and two o clock
in the night. While your first reaction is why dont you sleep, why are you up
at 2:00? But she got stuck. And I had no idea how to deal with that. Some of
you had seen, when we were talking on Saturday when we went to the
Metropolitan Museum of Art. We were talking about the Evans papyrus that
Transcribed by Jazmin Lui May 15, 2014

4000 years ago they described this procedure, how to put a displaced
mandible back. Egyptians knew how to deal with it. I didnt know, but Im
going to tell you. Unless someone can actually help me and guide me. What
would you like to do in order to put this mandible back? [wrap your thumbs
around?]. Very good, well not with my patient who was edentulous, it was a
lucky situation. When they snap close, the teeth, your fingers will get caught
between the teeth so you make sure your patient is edentulous or in a case
like this you have to do something. Well my first reaction was Well this is
open, Im just going to try to shut it. And pushing from the mental area does
not really help because youre pushing it against the eminence. So what you
need to disengage this condyle, which means it has to come down and
before it can go back. So what is the easiest way? You have to go as far on
the mandible, as far back as the last molar or even the pad, the retromolar
pad. Wrap your fingers and go all the way to the retromolar pad and push
down. Then you can disengage and then it can essentially go back. So the
movement is down and slide back. What is the reason that people end up
with - what is holding the condyle in place? [ligaments]. Yes you have a host
of ligaments that under normal circumstances are tight and do not allow this
to happen. But if those ligaments become lax, patients will become what is
called a habitual subluxation. So you will need to engage the mandible all the
way back and push it back and then ask the patient, you have to wrap or
close the tooth, ask the patient to open, you have to ask the patient not to
start chewing, just give time for ligaments to relax. But you cannot prevent
this from happening. Now there is an alternative. If this is a very powerful,
strong young man you may actually do one side at a time. And then the
other side. Because theres a huge amount of biting force you have to
overcome. Someone with big mastication muscles will not be able.

15. Case 3
Case number 3, what do you see? Observe this patient and describe and
describe what do you actually see? Because half the diagnosis is going to
Transcribed by Jazmin Lui May 15, 2014

come from you observing this patient. Anyone. Yes. It was a car accident, that
is correct. It was my patient and was a car accident. So what do you think,
where did the trauma occur? I mean obviously not the location in the city but
where on this face did this occur? [potentially floor of the orbit]. You see that
if you put a line here, the eye is dropped. Thats very good. What is holding
the eye up? You said the orbit, the left orbit. What bone is that, maxilla
andthe orbit is actually made of several bones. You have the atlas?
Zygomatic bone which has 3 legs is affected. The eye is completely dropped.
Now what does this tricking blood indicate? [cribiform plate broken?] well I
hope its not. I dont think this is blood actually, this is not cerebrospinal
fluid. If that were cerebral spinal fluid, yes then somehow the orbit has been
breached and there is a huge chance for infection. Thats a major emergency.
So this blood means that the 3
rd
leg, the maxillary portion of the zygomatic
is broken so obviously the nose is broken. And thats where the blood is
coming. So I asked the patient to do some kind of opening and closing. And
she could not open her mouth past 1 cm. It was better on the right side but
the left side got stuck. So what do you think is happening? Why would the
patient not be able to open her mouth on the left side because of this
trauma? What do you think is happening? [tmj got damaged?] no. [lateral
pterygoid?] you mean the muscle? When I palpated it, it felt that there was a
depression on the face but the blockage was sudden. It was not like an elastic
blockage, when you have muscle pain or damage you will have a certain
amount of elasticity in that movement. This was like hitting something very
hard. Lets think about the mandible for a moment. So think about the
coronary process. Where is it sitting? Sitting in space between the zygomatic
arch. If you have temporal- if the zygomatic arch is broken and you have
green stick fracture, which is the indentation, the green stick fracture
essentially blocks the movement of the coronary process. We talked about
the condyle moving forward, but the coronoid process needs a smooth and
clear path to move. If you block that, a patient with this kind of fracture will
have instantly have a problem opening her mouth.
Transcribed by Jazmin Lui May 15, 2014


16. image of arch
And in fact you can see in this image, this is not the best image. This is an
image taken below the chin. And you can see theres a fracture here -

17a. labelled picture of skull
- which this picture can show. Now look at this coronary process. This actually
goes all the way up and a fracture at this point will block the coronary
process.

17b. picture of fractures
This is actually one of those fractures on the same patient. So what do you do
actually? What is the process? There are several ways of doing it. You do an
incision on the skin and you go deep enough to reach the facial. You dont
go below the facial that covers that temporal muscle. Because thats the plane
in which you have to move down and free up the area so that the coronary
process can move. Obviously the muscle is already on the surface on the
bone, but the facial essentially covers that space. You take one of these U-
shaped metal instrument and you go down behind this broken mandible and
lift it. So you literally push out to make space. Now the outer handle allows
you to see how deep you are and you just lift it. Now the patient obviously
cant sleep on this or else it will go back so there are balloons you can insert
to keep it in and the patient has to sleep on the other side. But this
mandibular, sorry zygomatic arch fracture is typical of inabilityso this is what
you would do, you would go behind it and lift it.

18. Zygomatic fracture
This is not the best x-ray but I can guarantee you that it was restored and the
patient could open her mouth.

19. Case 4
Transcribed by Jazmin Lui May 15, 2014

Lets talk about this particular case. Very common, typical. What do you see in
this case? [abscess?] well lets put it this way, in order for you to see abscess,
abscess means there is pus. So what are the 4 cardinal signs you need in the
case of pus for instance, you would have inflammation, you have heat, you
have lack of function, you would have pain, and redness. Those are signs of
inflammation. In this particular case it turns out there was no actual pus. Pus
means the infection has gone beyond a certain point and you feel fluctuation.
Thats when you have pus. This patient actually underwent and extraction
that lasted 2 hours. It was a surgical extraction and the surgeon was
inexperienced and took a long time pulling the tooth. So that causes this
kind of swelling. What would the patient complain about? What would you
expect before the patientthey just sit in your audience, your waiting room.
What kind of complaints would you expect. Pain? [heat?] Im talking about
subjective symptoms. What would they complain about? Cannot talk, cannot
eat, cannot open! This patient cannot open her mouth. So what kind of
muscles would you involve? What is the area that you would expect? Lets just
hear from somewhat are the muscles that actually open the mouth? [gravity
and infrahyoid, sometimes] yeah. [lateral pterygoid] Pterygoid. It would
obviously the patient would have inability to chew or open or close because
of the trismus. It would have inflammation of the joint, it would have
inflammation of lateral pterygoid. It was part of the wisdom tooth and, both
open and close would be affected. So they would have a problem chewing so
the masseter was affected, the lateral pterygoid was affected, and you
would essentially have injuries with these kinds of symptoms. What about
submandibular area? If you put your fingers, what would you find? Would you
have lymph nodes involved in this case? Well this is actually one of those
cases where you would involve lymph nodes, because this is the reaction,
the tissue reaction. When you have trauma, you dont have lymph nodes
involved. But in the case of infections or inflammation, and then leading to
infection, depending on how sterile you are, you would lymph nodes involved.
Particularly you would have submandibular, even the ones adjacent to the
Transcribed by Jazmin Lui May 15, 2014

sternocleidomastoid muscle. You have to make a distinction in the case of
tristhmus with tetanus. Of course, these are far rarer conditions.

20. Vitalbook picture of mouth
Now well talk about the last case which is a fracture. In case of fracture you
have dislocation of mandible depending on the kind of muscles attached.
Some fractures are what you call a favourable fracture. This particular piece,
this is not the same case but you can see in this case the mandible is pulled
up and this piece is pulled down. What happens is because the masseter
muscle is pulling, theres a contraction, fractures that allow this piece to move
up will have a dislocation. This type of fracture is called an unfavourable
fracture. Why? If this would be in the opposite direction, the piece, essentially
the mandible, would be pulled in position and you would not have
thismalocclusion if you wish. This type of fracture requires open reduction
which means you need to have braces or plates to open it up.

21. Favourable and unfavourable mandibular farctures
The fracture is what is called, sorry this is favourable and this is unfavourable
fracture. This fragment is pulled into position as opposed to away from
position. So when you have a dislocated unfavourable fracture this is
would require an open reduction. This muscle of mastication, the masseter,
and the medial pterygoid are overreacting and pushing the fracture, the
fractured piece. In the case of a favourable one all you need to do is closed
reduction, meaning you can just wire the teeth and keep them in occlusion
because the occlusion is going to allow you to hold the teeth in place.

22. common mandibular fracture sites

The last piece, sorry I wanted to show this slide on common fracture sites.
And Im going to skip the next 2 slides. I wanted to show you a case on
swallowing.
Transcribed by Jazmin Lui May 15, 2014


24. Case 5
So imagine a patient that has complaints of eating and swallowing. And in
terms of the medicalits about 8 months old. Cannot swallow or eat hard
food. Has high blood pressure, arthrosclerosis, high cholesterol. Was
diagnosed with pharyngeal cancer a year ago and received chemotherapy
radiation. What do you think is wrong with this patient? What is causing the
swallowing difficulty? Think about it. Just take some time, look at this case
and think about the reason. [lower salivary flow, radiation of parotid gland?]
well this patient actually has pharyngeal cancer, not oral cancer. So the way it
works is that they collimate the beam. So most likely the parotid glands have
been spared. They can actually pinpoint the pharyngeal area. [pharyngeal
muscles?] good thinking, possibly. What other areas are affected? Youre
stretching or youre thinking? [survery affected nerves involved in swallowing].
How would you distinguish that? What kind of question would you ask this
patient? [did this swallowing problem occur after surgery?] exactly. So Im the
patient and Im saying No it wasnt after surgery, I had some problem but
not of this magnitude. [the cancer came back and the tumor is preventing
swallowing?] no, I dont, they cleared it, there is no reoccurance. [radiation of
submandibular gland?] no I think they spared the submandibular gland as
well. This is further down. No. So I want you to put your tongue on your
cheek and just feel the smoothness. What do you think is that smoothness.
Why is your cheek slippery? Mucus! Where else is mucus? Throughout the
entire GI system. The esophagus, the pharynx, its covered by mucin
secreting glands. You guys are talking about salivary glands only. Yes its
important to form the bolus but the mucin that comes from the pharynx,
which was not spared the radiation, is affected. Once you cut that down they
complain about dry throat.

25. Case 5
Transcribed by Jazmin Lui May 15, 2014

So the issue is really that the patients dont have a vehicle for moving the
bolus, which is happening in this particular patient. Inability to move the
bolus. So think mucin is an absolutely important component, not just in
the oral cavity. Its easy blame the salivary glands, perhaps, but in this case
they spared them.

Major concepts
These are just some of the things we touched upon. But I want you to think
about not only the physiology and the anatomy and the listing of these
components, but how they actually apply to your patients. Part of the testing
is going to be a case. And you would have to kind figure out what is going
on, you have to figure out what muscles are involved. You have to know the
background information and apply it. Questions. Ok.

I guess I wont see you until the next academic year. We have one lecture
coming up in August with you on nicotine, on addiction nicotine. And of
course well have integrated seminars with a number of you in various group
practices but okay, thank you.