practical dental Flashcards by Argyro Mouzouraki

dental anatomy

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amelogenesis imperfecta

HEREDITARY ENAMEL DYSPLASIAS !! = AMELOGENESIS IMPERFECTA (A. I.)

Ectodermal anomaly – dysfunction of the adamantine organ (of the ameloblasts)

It doesn’t involve the dentin (mesodermal origin)

Genetically inherited: AD (most frequent), AR, X-linked

Involves the enamel of all the teeth

HYPOPLASTIC A.I. – two forms:

ENAMEL APLASIA :

The teeth which remain included are often resorbed

If the teeth erupt :

No enamel deposits (Rx)

Covered with dentin

Yellow-brown colour

Rough surface

ENAMEL HYPOPLASIA :

Reduced production of protein matrix

Normal degree of mineralization

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dentinogenesis imperfecta

NTINOGENESIS IMPERFECTA = Dentinogenesis imperfecta (DI) is a genetic disorder (AD) of tooth development. This condition is a type of dentin dysplasia that causes teeth to be discolored (most often a blue-gray or yellow-brown color) and translucent giving teeth an opalescent sheen.[1] Teeth are also weaker than normal, making them prone to rapid wear, breakage, and loss.

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Internal resorbtion

NTERNAL RESORBTION:

Rare

Causes:

Pulp traumas

Pulpitis secondary to caries

Pulpotomy

Starts in the pulp and evolves towards the surface of the cementum or the crown => until it produces a communication between the pulp and the periodontal space or the external surface of the crown

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external resorbtion

RESORBTION= Loss of dental tough subtance on the surfaces which are not exposed to the outside.

In contact with the pulp region (crown, roots)

In contact with the periodontal ligament (roots)

EXTERNAL RESORBTION:

Much more frequent

Starts at the surface of the tooth, in contact with the periodontal ligament

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enamel carious lesion

Enamel caries: white plaque, cavitary lesion

Enamel 95% of hydroapatite – very hard tissue. Due to the action of proteolytic enzymes and cariogenic acids > succession of demineralization and remineralization phases. The enamel caries start below the bacterial plaque. Plaque… strep lactob…

Cavitary lesion due to a slow dissolution of the enamel, along the prisms and the interprismatic areas.

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'’white spot’’

demineralization

Enamel caries: white plaque, cavitary lesion

Cavitary lesion due to a slow dissolution of the enamel, along the prisms and the interprismatic areas.

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enamel caries

Enamel caries: white plaque, cavitary lesion

Cavitary lesion due to a slow dissolution of the enamel, along the prisms and the interprismatic areas.

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tubule invasion by bacteria

dentinal caries

DENTIN CARIES:

Secondary to enamel caries (coronal caries) or cementum caries (cervical caries)

Evolves more rapidly

Large amount of organic substances in the dentin -30%

Dentin is injured

Initially by the bacterial cariogenic acids

Different bacterial species than the ones for enamel:

Role of anaerobes (lactobacilli) is more important

Later, bacteria penetrate the dentinal tubules

As a result, the organic component is demineralized and then liquefied

Dentin caries are cone shaped, with the tip pointing towards the pulp chamber

LAYERS:

NECROTIC (surface)

INFECTED / AFFECTED

SCLEROTIC (DEEP)

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infected layer

bulbs and caves

DENTIN CARIES:

Secondary to enamel caries (coronal caries) or cementum caries (cervical caries)

Evolves more rapidly

Large amount of organic substances in the dentin -30%

Dentin is injured

Initially by the bacterial cariogenic acids

Different bacterial species than the ones for enamel:

Role of anaerobes (lactobacilli) is more important

Later, bacteria penetrate the dentinal tubules

As a result, the organic component is demineralized and then liquefied

Dentin caries are cone shaped, with the tip pointing towards the pulp chamber

LAYERS:

NECROTIC (surface)

INFECTED / AFFECTED

SCLEROTIC (DEEP)

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dentinal caries

transverse view

DENTIN CARIES:

Secondary to enamel caries (coronal caries) or cementum caries (cervical caries)

Evolves more rapidly

Large amount of organic substances in the dentin -30%

Dentin is injured

Initially by the bacterial cariogenic acids

Different bacterial species than the ones for enamel:

Role of anaerobes (lactobacilli) is more important

Later, bacteria penetrate the dentinal tubules

As a result, the organic component is demineralized and then liquefied

Dentin caries are cone shaped, with the tip pointing towards the pulp chamber

LAYERS:

NECROTIC (surface)

INFECTED / AFFECTED

SCLEROTIC (DEEP)

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reactive tetriary dentine

rtiary dentin is dentin formed as a reaction to external stimulation such as cavities

ENTIN CARIES:

Secondary to enamel caries (coronal caries) or cementum caries (cervical caries)

Evolves more rapidly

Large amount of organic substances in the dentin -30%

Dentin is injured

Initially by the bacterial cariogenic acids

Different bacterial species than the ones for enamel:

Role of anaerobes (lactobacilli) is more important

Later, bacteria penetrate the dentinal tubules

As a result, the organic component is demineralized and then liquefied

Dentin caries are cone shaped, with the tip pointing towards the pulp chamber

LAYERS:

NECROTIC (surface)

INFECTED / AFFECTED

SCLEROTIC (DEEP)

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tertiary dentin in response to stimuli

twisting tubes

ENTIN CARIES:

Secondary to enamel caries (coronal caries) or cementum caries (cervical caries)

Evolves more rapidly

Large amount of organic substances in the dentin -30%

Dentin is injured

Initially by the bacterial cariogenic acids

Different bacterial species than the ones for enamel:

Role of anaerobes (lactobacilli) is more important

Later, bacteria penetrate the dentinal tubules

As a result, the organic component is demineralized and then liquefied

Dentin caries are cone shaped, with the tip pointing towards the pulp chamber

LAYERS:

NECROTIC (surface)

INFECTED / AFFECTED

SCLEROTIC (DEEP)

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reversiple pulpitis or pulp hyperemia

REVERSIBLE PULPITIS (PULP HYPEREMIA): Reversible pulpitis is generally characterized by sharp sensitivity to cold, sometimes to sweets and sometimes to biting.

The initial stage of pulp inflammation

Closed

Partial – the tissue zone is expanded only a little

Aseptic

Acute

Causes:

Deep, but closed caries

Large, incorrect metallic obturations

Evolution :

Healing after the disappearance of irritant factors

Towards a total acute pulpitis if the agression persists

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dentinal caries

closed acute pulpitis and abcess

ACUTE IRREVERSIBLE PULPITIS: Irreversible pulpitis is generally characterized by prolonged sensitivity to cold and/or heat, and sometimes to sweets. Swelling may be present.

Etiopathogenesis:

Exacerbation of a reversible pulpitis by opening the pulp chamber

Periapical abscess

PERIAPICAL ABSCESS (ACUTE PERIAPICAL PERIODONTITIS) = collection of pus usually caused by an infection that has spread from a tooth to the surrounding tissues.

Well delimited purulent inflammation located at the apex of a tooth

EVOLUTION :

DRAINAGE OF PUS TOWARDS THE GINGIVA:

FISTULIZATION → the symptoms disappear

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opened dentine pulpitis and pulpal abcess

CUTE IRREVERSIBLE PULPITIS: Irreversible pulpitis is generally characterized by prolonged sensitivity to cold and/or heat, and sometimes to sweets. Swelling may be present.

Etiopathogenesis:

Exacerbation of a reversible pulpitis by opening the pulp chamber

Activation of a chronic pulpitis

Periapical abscess

PERIAPICAL ABSCESS (ACUTE PERIAPICAL PERIODONTITIS) = collection of pus usually caused by an infection that has spread from a tooth to the surrounding tissues.

Well delimited purulent inflammation located at the apex of a tooth

EVOLUTION :

DRAINAGE OF PUS TOWARDS THE GINGIVA:

FISTULIZATION → the symptoms disappear

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CHRONIC PULPITIS:

Can appear directly, spontaneously

After an acute pulpitis, when the pus is drained through the carious orifice

CHRONIC HYPERPLASTIC PULPITIS (PULP POLYP): A pulp polyp, also called as Chronic Hyperplastic Pulpitis, is found in an open carious lesion, fractured tooth or when a dental restoration is missing. Due to lack of intrapulpal pressure in an open lesion pulp necrosis does not take place as would have occurred in a closed caries case.

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chronic sclerosing pulpitis

CHRONIC PULPITIS:

Can appear directly, spontaneously

After an acute pulpitis, when the pus is drained through the carious orifice

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Apical granuloma

PERIAPICAL GRANULOMA

(CHRONIC APICAL PERIODONTITIS) = A periapical granuloma is a mass of chronically inflamed granulation tissue that forms at the apex of the root of a nonvital (dead) tooth. However, a periapical granuloma does not contain granulomatous inflammation, and therefore is not a true granuloma.

Etiology:

Apical defense reaction to the presence of bacteria and their toxins in the root canal

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apical cyst

PICAL PERIODONTAL CYST = APICAL RADICULAR CYST = The periapical cyst (also termed radicular cyst, and to a lesser extent dental cyst) is the most common odontogenic cyst. It is caused by pulpal necrosis secondary to dental caries or trauma. The cyst lining is derived from the cell rests of Malassez. Usually, the periapical cyst is asymptomatic, but a secondary infection can cause pain.

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Apical abcess

PERIAPICAL ABSCESS (ACUTE PERIAPICAL PERIODONTITIS) = collection of pus usually caused by an infection that has spread from a tooth to the surrounding tissues.

Well delimited purulent inflammation located at the apex of a tooth

EVOLUTION :

DRAINAGE OF PUS TOWARDS THE GINGIVA:

FISTULIZATION → the symptoms disappear

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acute gingivitis

CUTE GINGIVITIS =

Initial form of a periodontopathy

The acute nature is established by the intensity of the local irritation:

Sulcular plaque

The patient’s immune resistance

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chronic gingivitis

HRONIC GINGIVITIS = gingivitis is a non destructive periodontal disease.

An inflammatory process of reduced intensity, without symptoms

Elderly people

Causes:

A. From the start

Defective hygiene – chronic accumulation of bacterial plaque

Mechanical and chemical irritation

B. Evolution of an acute gingivitis

C. Down syndrome, diabetes mellitus, increased progesterone levels (pregnancy)

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chronic periodontitis

'’pouch’’

DULT CHRONIC PERIODONTITIS = Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by accumulation of profuse amounts of dental plaque. Redness + bleeding, gum swelling, halitosis, gingival recession, deep periodontal pockets, loose teeth.

The most frequent cause of dental loss

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chronic periodontitis suboceous pouch ## Footnote ADULT CHRONIC PERIODONTITIS = Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by accumulation of profuse amounts of dental plaque. Redness + bleeding, gum swelling, halitosis, gingival recession, deep periodontal pockets, loose teeth. The most frequent cause of dental loss

periodontal abcess ## Footnote LATERAL PERIODONTAL ABSCESS = is a localized collection of pus (i.e. anabscess) within the tissues of the periodontium. It is a type of dental abscess. Complication of a chronic periodontitis Cause: Closure of the periodontal pocket in the superior gingival region Inside the closed pocket: Foreign bodies can be found Fish bones, food Bacteria multiply, sometimes even change their composition Pus is formed = lateral abscess of the root

herpes ## Footnote Gingivostomatitis (also known as primary herpetic gingivostomatitis or orolabial herpes) is a combination of gingivitis and stomatitis, or an inflammation of the oral mucosa and gingiva. Herpetic gingivostomatitis is often the initial presentation during the first ("primary") herpes simplex infection. It is of greater severity than herpes labialis (cold sores), which is often the subsequent presentation. Primary herpetic gingivostomatitis is the most common viral infection of the mouth. HSV-1: The most frequent viral infection of the oral mucosa Involves the oral cavity, lips, pharynx, eyes, the skin of the upper body

candidosis in silver stain ## Footnote PSEUDOMEMBRANOUS CANDIDOSIS = Acute pseudomembranous candidiasis is a classic form of oral candidiasis,[6] commonly referred to as thrush. It is characterized by a coating or individual patches of pseudomembranous white slough that can be easily wiped away to reveal erythematous, and sometimes minimally bleeding mucosa beneath.[7] These areas of pseudomembrane are sometimes described as "curdled milk",[4] or "cottage cheese".[7] The white material is made up of debris, fibrin, and desquamated epithelium that has been invaded by yeast cells and hyphae that invade to the depth of the stratum spinosum.[4] APPEARS in: Newborns, Malnourished infants Adults: HIV infection, antibiotics, chemotherapy, radiotherapy, leukemia Debilitated older people LOCATION: jugal mucosa, dorsum of the tongue, palate, oropharynx ANATOMIC - CLINICAL: MACRO: White, soft, creamy aspect (like coagulated milk) They are adherent, but can be easily removed by friction or scraping The underlying mucosa is normal or erythematous Rarely with hemorrhage (in anticancer treatment) EVOLUTION : Acute After antibiotic treatment Chronic Depressed immunity

giant cell granulloma ## Footnote GIANT CELL PERIPHERAL GRANULOMA (EPULIS WITH MYELOPLAXES) DEF. : Gingival pseudotumor due to a deep gingival irritation PREDISPOSING FACTORS : Dental extraction, dental fracture Periodontal treatments Irritation given by prostheses Chronic infections EVOLUTION : Slowly, towards fibrosis

mucocel retention ## Footnote MUCOCELE : CYSTIC LESION OF OBSTRUCTIVE ORIGIN: Characteristic for minor salivary glands, rarely in major ones MUCOCELE DUE TO EXTRAVASATION : Def: retention of saliva in the surrounding connective tissue due to a traumatic rupture of the excretory canal of a salivary gland, which is: Minor Or major – in the case of ranula

mucocel extravation ## Footnote MUCOCELE : CYSTIC LESION OF OBSTRUCTIVE ORIGIN: Characteristic for minor salivary glands, rarely in major ones MUCOCELE DUE TO EXTRAVASATION : Def: retention of saliva in the surrounding connective tissue due to a traumatic rupture of the excretory canal of a salivary gland, which is: Minor Or major – in the case of ranula

chronic sialdenitis ## Footnote CHRONIC SCLEROSING SIALADENITIS: CAUSES : sialolithiasis In adults, more frequent in males MACROSCOPY/CLINICAL Swelling and recurrent pain in a gland Usually the submandibular gland, which has an increased volume and is tough – called KÜTNER’S TUMOR MICROSCOPY : In easy/medium cases : Periductal and intralobular inflammation, with a moderate acinar atrophy In severe cases : Acinar destruction with fibrous replacement + ductal ectasia

pleomorphic edenoma ## Footnote PLEIOMORPHIC ADENOMA (mixed tumor of the salivary glands) = is a common benign salivary gland neoplasm characterised by neoplastic proliferation of parenchymatous glandular cells along with myoepithelial components, having a malignant potentiality. It is the most common type of salivary gland tumor and the most common tumor of the parotid gland.

folicular ameloblastoma ## Footnote AMELOBLASTOMA = is a rare,benign tumor of odontogenic epithelium much more commonly appearing in the lower jaw than the upper jaw. While these tumors are rarely malignant or metastatic, and progress slowly, the resulting lesions can cause severe abnormalities of the face and jaw. The most frequent odontogenic tumor (equal to all the others combined)

compound odontoma COMPOUND ODONTOMA = A compound odontoma still has the three separate dental tissues (enamel, dentin and cementum), but may present a lobulated appearance where there is no definitive demarcation of separate tissues between the individual "toothlets" (or denticles). It usually appears in the anterior maxilla.

complex odontoma ## Footnote COMPLEX ODONTOMA = The complex odontoma is unrecognizable as dental tissues, usually presenting as a radioopaque area with varying densities. It usually appears in the posterior maxilla or in the mandible. Osteosarcoma is the most common histological form of primary bone cancer. It is most prevalent in children and young adults

''red tooth'' internal resorbion RESORBTION= Loss of dental tough subtance on the surfaces which are not exposed to the outside. In contact with the pulp region (crown, roots) In contact with the periodontal ligament (roots) INTERNAL RESORBTION: Rare Causes: Pulp traumas Pulpitis secondary to caries Pulpotomy Starts in the pulp and evolves towards the surface of the cementum or the crown =\> until it produces a communication between the pulp and the periodontal space or the external surface of the crown

pulp polyp ## Footnote CHRONIC PULPITIS: Can appear directly, spontaneously After an acute pulpitis, when the pus is drained through the carious orifice CHRONIC HYPERPLASTIC PULPITIS (PULP POLYP): A pulp polyp, also called as Chronic Hyperplastic Pulpitis, is found in an open carious lesion, fractured tooth or when a dental restoration is missing. Due to lack of intrapulpal pressure in an open lesion pulp necrosis does not take place as would have occurred in a closed caries case.

Apical cyst ## Footnote APICAL PERIODONTAL CYST = APICAL RADICULAR CYST = The periapical cyst (also termed radicular cyst, and to a lesser extent dental cyst) is the most common odontogenic cyst. It is caused by pulpal necrosis secondary to dental caries or trauma. The cyst lining is derived from the cell rests of Malassez. Usually, the periapical cyst is asymptomatic, but a secondary infection can cause pain.

apical cyst ## Footnote APICAL PERIODONTAL CYST = APICAL RADICULAR CYST = The periapical cyst (also termed radicular cyst, and to a lesser extent dental cyst) is the most common odontogenic cyst. It is caused by pulpal necrosis secondary to dental caries or trauma. The cyst lining is derived from the cell rests of Malassez. Usually, the periapical cyst is asymptomatic, but a secondary infection can cause pain.

apical abcess ## Footnote ERIAPICAL ABSCESS (ACUTE PERIAPICAL PERIODONTITIS) = collection of pus usually caused by an infection that has spread from a tooth to the surrounding tissues. Well delimited purulent inflammation located at the apex of a tooth EVOLUTION : DRAINAGE OF PUS TOWARDS THE GINGIVA: FISTULIZATION → the symptoms disappear

acute gingivitis-tartar ## Footnote ACUTE GINGIVITIS = Initial form of a periodontopathy The acute nature is established by the intensity of the local irritation: Sulcular plaque The patient’s immune resistance

chronic gingivitis hiv related ## Footnote CHRONIC GINGIVITIS = gingivitis is a non destructive periodontal disease. An inflammatory process of reduced intensity, without symptoms Elderly people Causes: A. From the start Defective hygiene – chronic accumulation of bacterial plaque Mechanical and chemical irritation B. Evolution of an acute gingivitis C. Down syndrome, diabetes mellitus, increased progesterone levels (pregnancy)

drug related gingival hyperplasia ## Footnote DRUG RELATED GINGIVAL HYPERPLASIA = Drug-related gingival hyperplasia is a cutaneous condition characterized by enlargement of the gums noted during the first year of drug treatment.[1] There are three drug classes that are associated with this condition namely, anticonvulsants (such as phenyotoin and phenobartibal), calcium channel blocker( such as amlopidine, nifedipine and verapamil) and cyclosporine, an immunosuppressant.

gingival fibromatosis ## Footnote Hereditary gingival fibromatosis (HGF), also known as idiopathic gingival hyperplasia, is a rare condition of gingival overgrowth.[1] HGF is characterized as a benign, slowly progressive, nonhemorrhagic, fibrous enlargement of keratinized gingiva. It can cover teeth in various degrees, and can lead to aesthetic disfigurement.[2] Fibrous enlargement is most common in areas of maxillary and mandibular tissues of both arches in the mouth.[1

chronic periodontitis ## Footnote ADULT CHRONIC PERIODONTITIS = Chronic periodontitis is a common disease of the oral cavity consisting of chronic inflammation of the periodontal tissues that is caused by accumulation of profuse amounts of dental plaque. Redness + bleeding, gum swelling, halitosis, gingival recession, deep periodontal pockets, loose teeth. The most frequent cause of dental loss

hiv related periodontitis ulcerative necrotic Patients with severe immunosuppression as a consequence of infection by human immunodeficiency virus (HIV) are at risk for a number of severe periodontal diseases. HIV-associated gingivitis and HIV-associated periodontitis (HIV-P) are seen exclusively in HIV-infected persons. In some cases HIV-P may extend into adjacent soft tissue and bone, resulting in necrotizing stomatitis of periodontal origin. In addition, acute necrotizing ulcerative gingivitis has also been reported to have an increased prevalence in HIV-infected patients.

periodontal abcess fistula LATERAL PERIODONTAL ABSCESS = is a localized collection of pus (i.e. anabscess) within the tissues of the periodontium. It is a type of dental abscess. Complication of a chronic periodontitis Cause: Closure of the periodontal pocket in the superior gingival region Inside the closed pocket: Foreign bodies can be found Fish bones, food Bacteria multiply, sometimes even change their composition Pus is formed = lateral abscess of the root

herpes+hiv linical Features of Genital Herpes in HIV-Infected Patients5,6 Lesions may appear as ulcers, “cracks,” or linear fissures Lesions may be larger and/or more numerous and may heal slowly Lesions may be coinfected with other pathogens Lesions caused by resistant virus may be especially atypical, more severe, larger, and slower to heal

minor aphthe ## Footnote MINOR APHTHS = Minor aphthous ulcers are the most common (8 in 10 cases). They are small, round, or oval, and are less than 10 mm across. They look pale yellow, but the area around them may look swollen and red. Only one ulcer may develop, but up to five may appear at the same time. Each ulcer lasts 7-10 days, and then goes without leaving a scar. They are not usually very painful.

major apthe ## Footnote MAJOR APHTHS (oral aphthosis) = Major aphthous ulcers occur in about 1 in 10 cases. They tend to be 10 mm or larger across. Usually only one or two appear at a time. Each ulcer lasts from two weeks to several months, but will heal leaving a scar. They can be very painful and eating may become difficult.

pseudomembranous candidiosis ## Footnote PSEUDOMEMBRANOUS CANDIDOSIS = Acute pseudomembranous candidiasis is a classic form of oral candidiasis,[6] commonly referred to as thrush. It is characterized by a coating or individual patches of pseudomembranous white slough that can be easily wiped away to reveal erythematous, and sometimes minimally bleeding mucosa beneath.[7] These areas of pseudomembrane are sometimes described as "curdled milk",[4] or "cottage cheese".[7] The white material is made up of debris, fibrin, and desquamated epithelium that has been invaded by yeast cells and hyphae that invade to the depth of the stratum spinosum.[4] APPEARS in: Newborns, Malnourished infants Adults: HIV infection, antibiotics, chemotherapy, radiotherapy, leukemia Debilitated older people LOCATION: jugal mucosa, dorsum of the tongue, palate, oropharynx ANATOMIC - CLINICAL: MACRO: White, soft, creamy aspect (like coagulated milk) They are adherent, but can be easily removed by friction or scraping The underlying mucosa is normal or erythematous Rarely with hemorrhage (in anticancer treatment) EVOLUTION : Acute After antibiotic treatment Chronic Depressed immunity

candidose-central papilary atrophy ## Footnote ENTRAL PAPILLARY ATROPHY : (median rhomboid glossitis) Initially considered a malformation Chronic evolution, without symptoms Macroscopy On the median line of the dorsum of the tongue, posterior region A red, swollen, rhomboid, well delineated area The surface is smooth or lobulated Loss of filiform papillae

pregnancy tumor pyogrnic granuloma YOGENIC GRANULOMA = is a vascular lesion that occurs on both mucosa and skin, and appears as an overgrowth of tissue due to irritation, physical trauma or hormonal factors. DEF. : A pseudotumor produced due to irritation and trauma in the presence of a special oral microbial flora More frequent In children, adolescents and pregnant women Appears in the first semester of pregnancy, grows until birth and then decreases in size = PREGNANCY TUMOR

giant cel-epulis ## Footnote GIANT CELL PERIPHERAL GRANULOMA (EPULIS WITH MYELOPLAXES) DEF. : Gingival pseudotumor due to a deep gingival irritation PREDISPOSING FACTORS : Dental extraction, dental fracture Periodontal treatments Irritation given by prostheses Chronic infections EVOLUTION : Slowly, towards fibrosis

squamus cell carcinoma ulcerative at mouth floor MOUTH FLOOR CARCINOMA : 35% of oral cancers Growing frequency in women Predisposing factors : Leukoplakia, erythroplakia Secondary neoplasm

squamus cell carcinoma ulcerative alveolar boarder 0% of oral cancers Location : posterior mandible On an area of keratosis In the beginning : Can mimic a dental inflammation

squamus cell carcinoma ulcerative lateral margin of tongue CARCINOMA OF THE TONGUE : 40% of all oral cancers (without the lips) Nodule or painless ulceration Location : 2/3 on the posterior margin 20% on the anterior-lateral and ventral surfaces of the tongue 4% on the dorsal surface of the base of the tongue (on syphilitic lesions) The ones at the tongue base – the most malignant

practical dental Flashcards

(60 cards)