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- Harvey M. Meyerhoff Professor of Bioethics and Medicine
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Usually through the legislative activity of the dental societies acne during pregnancy discount 0.5mg decadron fast delivery, dentists can work vnth elected and appointed officials and provide technical advice on oral health issues acne 5 pocket jeans discount decadron 1 mg fast delivery, safety acne in early pregnancy purchase decadron pills in toronto, and public education skin care solutions buy cheap decadron online. At the state and national level, dentists can engage in the work of political action commit tees and participate in lobbying for pediatric oral health. This is not an experience that many dentists have had, but in our political system, elected and appointed officials are expected to make decisions about a myriad of issues and need information to make the best decisions. Oral health is also often a low priority in legislative health matters, so accu rate portrayal of the importance of oral health is critical. Because many decision-makers enjoy good oral health and have insurance, they may not appreciate the prevalence of dental disease in their poorer constituents. Training programs in pediatric dentistry are now expected to teach residents about advocacy and are encouraged to let them participate in community-based activities. If dentists truly understand the political and health systems we have in the United States, they realize that without advocacy at all levels, the health of the children of this country is at risk. Caffey J: Multiple fractures in the long bones of infants suffering from chronic subdural hematoma, Am J Roentgenol 56: 1 63-1 73, 1946. Eaton J, McTigue D, Fields H et al: Attitudes of contemporary parents toward behavior management techniques used in pediatric dentistry, Pediatr Dellt 27: 107- 1 13, 2005. Fontana V: the maltreated child: the m altreatment syndrome in children, Springfield, Ill, 197 1, Charles C Thomas. Tagliaferro E, Pardi V, Ambrosano G et al: An overview of caries risk assessment in 0-1 8 year-oIds over the last ten years (1 997-2007), Braz J Oral Sci 7: 1678-168 1, 2008. General Accounting Office: Oral health: factors contributing to low use of dental services by low-income populations. American Academy of Pediatric Dentistry: Guideline o n infant oral health care, Pediatr Dent 33: 1 24-128, 201 1. The purpose of this chapter is to high light selected oral lesions that are most commonly found in children and pathologic entities that primarily develop in this age group. In addition, oral lesions associated with several genetic disorders and specific malignancies, which may mimic benign or inflammatory conditions, are included to broaden the disease scope. The material is outlined in tables to make this comprehensive subject more succinct and easier to review. The brief description for each entity sum marizes the most important clinical information that is rel evant to the child patient. Representative examples of these conditions are included to illustrate the characteristic clinical or radiographic features. Except for the first table on selected developmental anomalies, the other tables are arranged to capture the primary clinical or radiographic characteristics for the purpose of comparison. The sequential headings for each of the tables include the following disease categories: Developmental anomalies (Table 2 - 1, Figure White soft tissue lesions (Table White surface thickening lesions White surface material lesions White subsurface lesions & maxillof acial surgery, St Louis, 2004, Saunders. B and C, Partial ankyloglossia with lingual frenum attachment at the tip of the tongue (B). A and B, Frictional keratosis of the lateral tongue (A) and buccal mucosa (8) from chronic biting of the tissues. Colttinued 22 Fundamentals of Pediatric Dentistry R o N, Fan-shaped scar at the corners of the mouth d ue to a n electrical burn. A and B, Vascular malformation on the side of the face a nd around the lips . F and G, Erythematous candidiasis Continued of the hard palatal mucosa (F) and dorsal tongue (G). K, Amalgam tattoo of the maxillary palatal gingiva adjacent to the first premolar. L, Oral melanotic macule of the mandibular gingiva in a child with a history of oral melanoma. Continued F, Diffuse traumatic u lcer from biting the lip followIng local anesthesia for restorative treatment. H, Erythema and recession of the attached gingiva between the primary first and second maxillary molars from picking the tissues with the fingernails. P to 5, Primary herpetic gingivostomatitis of the tongue and lips (P), maxil lary gingiva and labial mucosa (Q) and mandibular gingiva and labial m ucosa (R), and vesicles on the thumb (5). U, Necrotizing gingival ulcer with a thick pseudomembrane in a child with acute lym phoblastic leukemia. V to X, Red-purple enlargements of the buccal gingiva (V), palatal mucosa (W), and skin (X) that represent leukemic infiltrates I n a child with acute myeloid leukemia. Ludwig angina and cavernous sinus Facial hematoma Plunging ranula Emphysema Obstructive sialadenitis Angioedema Acute sinusitis Acute lymphadenitis Gingiva and alveolar mucosa are most common sites Usually caused by odontogenic infection or entrapped foreign body; pericoronitis is a gingival abscess associated with erupting molars Manage source of infection; local debridement, antibiotics may be indicated; recurs if infection is not eliminated Pyogenic granuloma Oral lymphoepithelial cyst Sialolithiasis Tonsilithiasis Gingival cysts of newborn e:::!. Peripheral ossifying fibroma Second decade Female predilection Pedunculated or sessile nodule with pink to red surface; frequendy ulcerated; firm and nontender; may resorb alveolar bone; limited growth potential Emanates from interdental papilla of attached gingiva; most common site is anterior region Attached gingiva or alveolar mucosa Reactive hyperplastic lesion that contains mineralized product from cells of periosteum or periodontal ligament; may displace teeth Excisional biopsy down to periosteum and remove local irritation; 16% recurrence rate Irritation fibroma Peripheral giant cell granuloma Giant cell fibroma Pyogenic granuloma Peripheral odontogenic fibroma 0::s en. Hemangioma Infancy Female predilection Localized to diffuse, red, blue or purple lesion, 60% occur in head Hemorrhage is potential complication; may cause malocclusion; scarring is common with involution.
D acne antibiotics purchase decadron 0.5 mg without prescription, Initial fusion of the shelves at a point about one third of the way back along their length acne routine buy decadron paypal. The separation of the premaxilla from the remainder of the maxilla is shown clearly acne hormones order 1 mg decadron with visa. Note the wide separation of the eyes (hypertelorism) and deficiency of the midfacial structures skin care laser clinic birmingham best purchase decadron, both of which are characteristic of this syndrome. Because of premature suture fusion, forward development of the midface is retarded, which produces the apparent protrusion of the eyes. These are the craniosynostosis syndromes, which result from early closure of the sutures between the cranial and facial bones. In fetal life, normal cranial and facial development depends on growth adjustments at the sutures in response to growth of the brain and facial soft tissues. Early closure of a suture, called synostosis, leads to characteristic distortions, depending on the location of the early fusion. It is characterized by underdevelopment of the midface and eyes that seem to bulge from their sockets (Figure 5-12). This syndrome arises because of prenatal fusion of the superior and posterior sutures of the maxilla along the wall of the orbit. The premature fusion frequently extends posteriorly into the cranium, producing distortions of the cranial vault as well. If fusion in the orbital area prevents the maxilla from translating downward and forward, the result is severe underdevelopment of the middle third of the face. The characteristic protrusion of the eyes is largely an illusion-the eyes appear to bulge outward because the area beneath them is underdeveloped. There may be a component of true extrusion of the eyes, however, because when cranial sutures become synostosed, intracranial pressure increases. Although the characteristic deformity is recognized at birth, the situation worsens as growth disturbances caused by the fused sutures continue postnatally. Growth Disturbances in the Fetal and Perinatal Period Fetal Molding and Birth Injuries Injuries apparent at birth fall into two major categories: (1) intrauterine molding and (2) trauma to the mandible during the birth process, particularly from the use of forceps in delivery. Intrauterine Molding Pressure against the developing face prenatally can lead to distortion of rapidly growing areas. Strictly speaking, this is not a birth injury, but because the effects are noted at birth, it is considered in that category. On rare occasions, an arm is pressed across the face in utero, resulting in severe maxillary deficiency at birth (Figure 5-13). This is related to a decreased volume of amniotic fluid, which can occur for any of several reasons. The result is an extremely small mandible at birth, usually accompanied by a cleft palate can occur for any of several reasons. The result is an extremely small mandible at birth, usually accompanied by a cleft palate because the restriction on displacement of the mandible forces the tongue upward and prevents normal closure of the palatal shelves. This extreme mandibular deficiency at birth is termed the Pierre Robin anomalad or sequence. It is not a syndrome that has a defined cause; instead, multiple causes can lead to the same sequence of events that produce the deformity. Early mandibular advancement via distraction osteogenesis has been used recently in these severely affected infants to provide more space for an airway so that the tracheostomy can be closed. Because the pressure against the face that caused the growth problem would not be present after birth, there is the possibility of normal growth thereafter and perhaps eventually a complete recovery. Some children with Pierre Robin sequence at birth do have favorable mandibular growth in childhood, but a smaller than normal mandible typically persists (Figure 5-14), and a recent study found no catch-up growth during adolescence. Catch-up growth is most likely when the original problem was mechanical growth restriction that no longer existed after birth. Birth Trauma to the Mandible Many facial deformity patterns now known to result from other causes once were blamed on injuries during birth. Some children with this condition have enough postnatal mandibular growth to largely correct the jaw deficiency, but the majority do not. If the cartilage of the mandibular condyle were an important growth center, of course, the risk from damage to a presumably critical area would seem much greater. In light of the contemporary understanding that the condylar cartilage is not critical for proper growth of the mandible, it is not as easy to blame underdevelopment of the mandible on birth injuries. Children with deformities involving the mandible are much more likely to have a congenital syndrome. Progressive Deformities in Childhood A progressive deformity is one that steadily becomes worse, which, of course, indicates early treatment. These problems, fortunately, arise much less frequently than the severe but stable deformities that comprise most of the jaw problems encountered in children. Childhood Fractures of the Jaw In the frequent falls and impacts of childhood, the condylar neck of the mandible is particularly vulnerable, and fractures of this area in childhood are relatively common.
The fibril arrangement in these muscles is such that the muscle fiber appears to skin care 3-step buy decadron 0.5mg be crossbanded in alternate light and dark striations acne nyc buy 0.5 mg decadron fast delivery. Skeletal muscle fibers are long acne 20s generic decadron 0.5 mg, cylindrical skin care blog order decadron 0.5 mg fast delivery, multinucleated cells whose nuclei are located peripherally. Smooth and cardiac muscle cells, in contrast, each possess only one centrally located nucleus. Microscopic evaluation reveals no striations within the cytoplasm of smooth muscle cells. It is the contractile element in blood vessels and forms the walls of the viscera. Smooth muscle is a nonstriated, fusiform muscle con- in a fashion similar to skeletal muscle cells, but each cell possesses only one centrally located nucleus. Features unique to cardiac muscle are its branching and its anastomosing, or joining together, of the cells, and its transversely oriented intercalated discs, located at the junction of any two fibers. This muscle type is unique in that it possesses an ability to modify its contractive actions by altering the wave of impulses received from the nervous system. This involuntary muscle is the contractile element in vessel walls and forms the walls of the viscera, where it forms longitudinal and circular layers reinforcing the hollow viscera. Cardiac muscle fibers are striated Skeletal muscle is by far the most abundant muscle in the body. Skeletal muscle size varies from the large muscles of the leg to the very small stapedius muscle (only about 2 mm long), which is attached to the tiny stapes bone of the middle ear cavity. Each skeletal muscle fiber is encased in a thin connective tissue covering, the endomysium. A muscle fascicle, composed of a group of muscle fibers, is bundled into a separate connective tissue sheath, the perimysium. The entire muscle, composed of many fasciculi, is wrapped in yet another connective tissue sheath, termed the epimysium or deep fascia. Bursae form around the attachment of some tendons, providing lubrication, reduction of frictional forces, and protection. At the attachment to bone, the endomysium, along with the epimysium and perimysium, merge to form the tendon, a dense, regular, collagenous connective tissue, silvery white in color. Tendons are extremely strong and at the their attachment site on bone the periosteum is absent. In certain regions of the body, such as in the muscles of the scalp, attachment is by an aponeurosis, a broad, flat, sheetlike structure, instead of a tendon. Some attachments are provided with bursae, which lubricate the tendon as it passes over bone. Often a synovial sheath encloses a tendon, forming a tubular sac that is capable of secreting a synovial fluid, which functions to reduce friction. Because the deep fascia encloses muscles and bone in a continuous manner, it also serves to contain the spread of infection. Tendinous attachments to bone are usually described as the origin and insertion of the muscle. Generally, the muscle is described as arising from the origin, possessing a fleshy belly (the contractive portion), and inserting at the insertion site. The origin is usually the more proximal and/or fixed area, with the insertion being the more distal or movable area. Movement is usually described relative to the muscle insertion position moving toward the origin while the body is in the anatomic position. It must be stressed that these are not inviolate rules but, rather, are arbitrarily used by anatomists as aids in describing function. These rules are especially difficult to apply in the head and neck; thus, learning muscle functions in this region of the body is painstaking. Although the previous description of bone-to-bone origin and insertion is the usual occurrence, the muscles of facial expression do not follow this rule. Generally, these muscles arise from bone or fascia and insert into the skin of the face. On contraction, they produce movements of the skin that we recognize as facial expressions. Fibers entering a tendon at two oblique angles, as do the veins of a feather, are said to be bipennate. Multiples of this architectural arrangement produce multipennate muscles, which exhibit the greatest strength. However, most are intuitive, such as flexion and extension across a joint and adductors and abductors moving things toward or away from the midline. Actions about the head and neck are protrusion, retraction, elevation, rotation, and depression. Muscle size, form, and fiber arrangement is indicative of its power and direction of the movement it produces across a joint. Muscle action is described according to the movement effected in the part in motion from the anatomic position (this basic reference position was shown in.
Each can be defined by appropriate reference to acne reviews buy generic decadron 0.5 mg on-line a forcedeflection or stressstrain diagram (Figures 9-2 and 9-3) skin care zurich decadron 0.5 mg. Three different points on a stressstrain diagram can be taken as representative of the strength of a material (see Figure 9-3) acne killer buy 0.5mg decadron visa. The stiffness of the material is given by the slope of the linear portion of the curve skin care vancouver purchase decadron 0.5 mg line. The range is the distance along the X-axis to the point at which permanent deformation occurs (usually taken as the yield point, at which 0. Clinically useful springback occurs if the wire is deflected beyond the yield point (as to the point indicated here as "arbitrary clinical loading"), but it no longer returns to its original shape. The first two points attempt to describe the elastic limit of the material, the point at which any permanent deformation is first observed. Three different points, as noted here on a stressstrain diagram, can be taken as representing the strength. The slope of the stressstrain curve (E) is the modulus of elasticity, to which stiffness and springiness are proportional. Typically, the true elastic limit lies between these two points, but both serve as good estimates of how much force or deflection a wire can withstand clinically before permanent deformation occurs. The maximum load the wire can sustain-the ultimate tensile strength-is reached after some permanent deformation and is greater than the yield strength. Since this ultimate strength determines the maximum force the wire can deliver if used as a spring, it also is important clinically, especially since yield strength and ultimate strength differ much more for the newer titanium alloys than for steel wires. Stiffness and springiness are reciprocal properties: Each is proportional to the slope of the elastic portion of the forcedeflection curve (see Figure 9-2). The more horizontal the slope, the springier the wire; the more vertical the slope, the stiffer the wire. Range is defined as the distance that the wire will bend elastically before permanent deformation occurs. If the wire is deflected beyond this point, it will not return to its original shape, but clinically useful springback will occur unless the failure point is reached. Orthodontic wires often are deformed beyond their elastic limit, so springback properties are important in determining clinical performance. These three major properties have an important relationship: Two other characteristics of some clinical importance also can be illustrated with a stressstrain diagram: resilience and formability (Figure 9-4). Resilience is the area under the stressstrain curve out to the proportional limit. It represents the energy storage capacity of the wire, which is a combination of strength and springiness. Formability is the amount of permanent deformation that a wire can withstand before failing. It represents the amount of permanent bending the wire will tolerate (while being formed into a clinically useful spring, for instance) before it breaks. The properties of an ideal wire material for orthodontic purposes can be described largely in terms of these criteria: it should possess (1) high strength, (2) low stiffness (in most applications), (3) high range, and (4) high formability. In addition, the material should be weldable or solderable, so that hooks or stops can be attached to the wire. In contemporary practice, no one archwire material meets all these requirements, and the best results are obtained by using specific archwire materials for specific purposes. In the United States, orthodontic appliance dimensions, including wire sizes, are specified in thousandths of an inch. In Europe and many other areas of the world, appliance dimensions are specified in millimeters. For the range of orthodontic sizes, a close approximation of sizes in millimeters can be obtained by dividing the dimensions in mils by 4 and moving the decimal point one place to the left. Because the plastic deformation that makes a material formable also may be thought of as cold work, formability alternatively can be interpreted as the area under that part of the stressstrain curve. Orthodontic Archwire Materials Precious Metal Alloys In the first half of the twentieth century, precious metal alloys were used routinely for orthodontic purposes, primarily because nothing else would tolerate intraoral conditions. Gold itself is too soft for nearly all dental purposes, but alloys (which often included platinum and palladium along with gold and copper) could be useful orthodontically. The introduction of stainless steel made precious metal alloys obsolete for orthodontic purposes even before precious metals became prohibitively expensive. Currently, the only considerable advantage to gold is the ease of fabricating cast appliances, such as custom-fit bonding pads used with fixed lingual appliances (see Chapter 10). Stainless Steel and CobaltChromium Alloys Stainless steel, or a cobaltchromium alloy (Elgiloy; Rocky Mountain Co. A typical formulation for orthodontic use has 18%chromium and 8%nickel (thus the material is often referred to as an 18-8 stainless steel). The properties of these steel wires can be controlled over a reasonably wide range by varying the amount of cold working and annealing during manufacture. The steel ligatures used to tie orthodontic archwires into brackets on the teeth are made from such "dead soft" wire. Steel archwire materials are offered in a range of partially annealed states, in which yield strength is progressively enhanced at the cost of formability.
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