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By: Martin J. Blaser, MD

  • Muriel G. and George W. Singer Professor of Translational Medicine, Professor of Microbiology, Director, Human Microbiome Program, Departments of Medicine and Microbiology, New York University School of Medicine, Langone Medical Center, New York, New York

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He gave the West many classical learnings in readable Latin through his many translations of Greek pregnancy 31 weeks order 20mg sarafem otc, Roman pregnancy joint pain order 10 mg sarafem overnight delivery, and Arabic scholars pregnancy pact buy sarafem on line amex. Africanus described the composition and sequential development of the embryo in relation to menstruation terms purchase line sarafem the planets and each month during pregnancy, a concept unknown in antiquity. Medieval scholars hardly deviated from the theory of Aristotle, which stated that the embryo was derived from menstrual blood and semen. Because of a lack of knowledge, drawings of the fetus in the uterus often showed a preformed fully developed infant frolicking in the womb. This theory was based on the teachings of Aristotle, and it survived until the late 18th century. Cambridge, University Press, 1934; with permission of Cambridge University Press, England. He introduced the quantitative approach to embryology by making measurements of prenatal growth. He believed that the male seed or sperm, after entering the womb or uterus, became metamorphosed into an egglike substance from which the embryo developed. He also studied the development of the fallow deer; however, when unable to observe early developmental stages, he concluded that embryos were secreted by the uterus. Girolamo Fabricius (1537-1619) wrote two major embryologic treatises, including one entitled De Formato Foetu (The Formed Fetus), which contained many illustrations of embryos and fetuses at different stages of development. Early microscopes were simple but they opened an exciting new field of observation. Undoubtedly, the small chambers that de Graaf described were blastocysts (see. He also described vesicular ovarian follicles, which are still sometimes called graafian follicles. A young medical student in Leiden, Johan Ham van Arnheim, and his countryman Anton van Leeuwenhoek using an improved microscope in 1677. They thought the sperm contained a miniature preformed human being that enlarged when it was deposited in the female genital tract. The object was held in front of the lens on the point of the short rod, and the screw arrangement was used to adjust the object under the lens. The miniature human being within it was thought to enlarge after the sperm entered an ovum. Other embryologists at this time thought the oocyte contained a miniature human being that enlarged when it was stimulated by a sperm. Caspar Friedrich Wolff refuted both versions of the preformation theory in 1759, after observing parts of the embryo develop from "globules" (small spherical bodies). He proposed the layer concept, whereby division of what we call the zygote produces layers of cells (now called the embryonic disc) from which the embryo develops. His ideas formed the basis of the theory of epigenesis, which states that development results from growth and differentiation of specialized cells. He also observed embryonic masses of tissue that partly contribute to the development of the urinary and genital systems-Wolffian bodies and Wolffian ducts-now called the mesonephros and mesonephric ducts, respectively (see Chapter 12). The preformation controversy ended in 1775 when Lazaro Spallanzani showed that both the oocyte and sperm were necessary for initiating the development of a new individual. From his experiments, including artificial insemination in dogs, he concluded that the sperm was the fertilizing agent that initiated the developmental processes. Heinrich Christian Pander discovered the three germ layers of the embryo, which he named the blastoderm. Etienne Saint Hilaire and his son, Isidore Saint Hilaire, made the first significant studies of abnormal development in 1818. They performed experiments in animals that were designed to produce developmental abnormalities, initiating what we now know as the science of teratology. He also observed cleaving zygotes in the uterine tube and blastocysts in the uterus. He contributed new knowledge about the origin of tissues and organs from the layers described earlier by Malpighi and Pander. Von Baer formulated two important embryologic concepts: corresponding stages of embryonic development and that general characteristics precede specific ones. His significant and far-reaching contributions resulted in his being regarded as the Father of Modern Embryology. Mattias Schleiden and Theodor Schwann were responsible for great advances being made in embryology when they formulated the cell theory in 1839. The cell theory soon led to the realization that the embryo developed from a single cell, the zygote, which underwent many cell divisions as the tissues and organs formed. Wilhelm His (1831-1904), a Swiss anatomist and embryologist, developed improved techniques for fixation, sectioning, and staining of tissues and for reconstruction of embryos. His method of graphic reconstruction paved the way for producing current three-dimensional, stereoscopic, and computergenerated images of embryos. Mall (1862-1917), inspired by the work of His, began to collect human embryos for scientific study. For his discovery of the phenomenon of primary induction-how one tissue determines the fate of anotherSpemann received the Nobel Prize in 1935. Over the decades, scientists have been attempting to isolate the substances that are transmitted from one tissue to another, causing induction. Edwards and Patrick Steptoe pioneered one of the most revolutionary developments in the history of human reproduction: the technique of in vitro fertilization. These studies resulted in the birth of Louise Brown, the first "test tube baby, " in 1978. Since then, more than one million couples throughout the world who were considered infertile have experienced the miracle of birth because of this new reproductive technology. Gregor Mendel, an Austrian monk, developed the principles of heredity in 1865, but medical scientists and biologists did not understand the significance of these principles in the study of mammalian development for many years. Walter Flemming observed chromosomes in 1878 and suggested their probable role in fertilization. In 1883, Eduard von Beneden observed that mature germ cells have a reduced number of chromosomes. He also described some features of meiosis, the process whereby the chromosome number is reduced in germ cells. In the same year, Garrod reported alcaptonuria (genetic disorder of phenylalanine-tyrosine metabolism) as the first example of mendelian inheritance in human beings. Many geneticists consider Sir Archibald Garrod (1857-1936) the Father of Medical Genetics. It was soon realized that the zygote contains all the genetic information necessary for directing the development of a new human being. Felix von Winiwarter reported the first observations on human chromosomes in 1912, stating that there were 47 chromosomes in body cells. Theophilus Shickel Painter concluded in 1923 that 48 was the correct number, a conclusion that was widely accepted until 1956, when Joe Hin Tjio and Albert Levan reported finding only 46 chromosomes in embryonic cells. Once the normal chromosomal pattern was firmly established, it soon became evident that some persons with congenital anomalies had an abnormal number of chromosomes. A new era in medical genetics resulted from the demonstration by JГ©r Гґme Jean Louis Marie Lejeune and associates in 1959 that infants with mongolism (now known as Down syndrome) have 47 chromosomes instead of the usual 46 in their body cells. It is now known that chromosomal aberrations are a significant cause of congenital anomalies and embryonic death (see Chapter 20). In 1941, Sir Norman Gregg reported an "unusual number of cases of cataracts" and other anomalies in infants whose mothers had contracted rubella in early pregnancy. For the first time, concrete evidence was presented showing that the development of the human embryo could be adversely affected by an environmental factor. Twenty years later, Widukind Lenz and William McBride reported rare limb deficiencies and other severe congenital abnormalities, induced by the sedative thalidomide, in the babies of infants of mothers who had ingested the drug. The thalidomide tragedy alerted the public and health care providers to the potential hazards of drugs, chemicals, and other environmental factors during pregnancy (see Chapter 20). These techniques are now widely used in research laboratories to address such diverse problems as the genetic regulation of morphogenesis, the temporal and regional expression of specific genes, and how cells are committed to form the various parts of the embryo. For the first time, we are beginning to understand how, when, and where selected genes are activated and expressed in the embryo during normal and abnormal development (see Chapter 21). The first mammal, Dolly the sheep, was cloned in 1997 by Ian Wilmut and his colleagues using the technique of somatic cell nuclear transfer.

The nervous system is a complex organization of tissue women's health magazine 6 week boot camp buy sarafem 10mg with visa, ramifying throughout the body breast cancer 61172 purchase sarafem from india, functioning to women's health center udel buy sarafem 10mg otc collect information from within and from outside the environment of the body menopause one sarafem 10 mg with visa. The nervous system sorts this information, then reacts to perceived challenges imposed on it. Included within the functions of this system is the process of cognitive faculties occurring in the highest centers of the brain. The the tissue of this system is made up of specialized cells, neurons, which conduct impulses, and neuroglial cells, which serve in a supporting capacity. A neuron, the basic structural unit of the system, possesses the ability to perceive stimuli (irritability) and to transmit physiochemical impulses along its processes (conduction) to effector organs and/or other neurons. The cell body contains the nucleus and cytoplasm containing Nissl bodies (rough endoplasmic reticulum), which may be made visible by light microscopy through the use of special stains. The arrangement of processes around the cell body might vary from that described here and are thus supplied with descriptive terms. These 24 Chapter 3 Body Systems Schwann cell Dendrite Unmyelinated nerve fiber Nucleus Cell body Nissl body Axon hillock Node of Ranvier Neurilemma sheath cell nucleus Myelin sheath Axis cylinder Axon Myelination of nerve fiber Axon Schwann cell Schwann cell Axon Motor neurons possess numerous dendrites, a large central nucleus, and a long myelinated axon. Teloglial cell (shown only in part) Muscle Nerve terminal Motor end plate Junctional folds Sarcoplasm Mitochondrion Figure 3-10. These intervals, called the nodes of Ranvier, impart a linked-sausage appearance to the axon. The speed of conduction of an impulse along a nerve fiber is related to the absence or presence and the thickness of the myelin sheath. Neurons are either of a sensory (afferent) function, an intercalated (connecting) function, or a motor (efferent) function. Neurons are categorized functionally as sensory, intercalated (connecting), or motor. General somatic afferent refers to sensory function (modality) perceived from the body and transmitted to the spinal cord or brain. Sensations such as pain, temperature, and touch to the skin are perceived by neurons in this category. Also in this category is sensation from muscles, tendons, and joints, referred to as "proprioception. General somatic efferent, a motor component, serves to provide innervation to all of the skeletal muscles of somatic origin, whereas general visceral efferent stimulation provides motor innervation to smooth muscles, cardiac muscles, and glands. Certain muscle groups and the sense organs for hearing, smell, taste, and sight make this group "special. Similarly, the motor component to the "special" muscles (branchiomeric origin) is the special visceral efferent. Because no "special" category exists for glandular secretomotor function in the head, the general visceral efferent component remains for the glands, smooth muscles, and mucous membranes of this region. Note that certain of the cranial nerves carry general visceral afferent sensory components from the viscera of the head as well. Nerve endings transmitting pain, on the other hand, are free and without specializations. Dendrites of the spinal nerves are connected to their cell bodies located in the dorsal root ganglion, which is just outside the spinal cord. The axons pass from the ganglion via the dorsal root into the dorsal horn (sensory) of the spinal cord. Here they may terminate, enter the white matter of the cord to ascend or descend before synapsing on connecting neurons in the spinal cord, or ascend to conscious levels in the brain. Cell bodies of spinal motor neurons are located in the ventral horn (motor) of the spinal cord. Just beyond the dorsal root ganglion area, the sensory and motor roots unite, forming a spinal nerve that thus carries both sensory and motor components. Motor fibers destined for muscle will continue on to synapse at the motor end plate, a specialized ending between the nerve and the muscle. Sensory nerve endings located, for example, in the patellar ligament of the knee do not have their Figure 3-11. Rapid opening of the mouth as a result of painful stimuli from biting down on a piece of bone while chewing is an example of a reflex arc in the fifth cranial nerve. The central nervous system is represented by the brain, which is housed with the skull, and the spinal cord, which is housed within the vertebral canal surrounded by the divisions of the vertebrae. The brain and spinal cord are responsible for analysis, integration, and response for the body via sensory input and motor output. The autonomic system is subdivided into the enteric, sympathetic, and parasympathetic systems. The enteric nervous system is located in the wall of the digestive system and functions in the autonomic control of the digestive system. The enteric nervous system is not associated with the head and neck and, therefore, will not be discussed in this textbook. The sympathetic nervous system is that system which puts the body ready for action ("fight or flight"). Each is delicately covered by several layers of meninges and is protected by bone- either the skull around the brain or the bony vertebral column that surrounds the spinal cord. Three separate layers make up the meninges: a tough outer layer, the dura mater; an inner delicate layer closely applied to the brain and the spinal cord and their vessels, the pia mater; and an intermediate layer, the arachnoid, which is closely applied to the dura. Only a potential space exists between the dura and arachnoid, known as the subdural space. The sympathetic system generally prepares the body for action-as in the "fight or flight" response- by increasing heart rate, respiration, blood pressure, and blood flow to the skeletal muscles; dilating the pupils; and generally "shutting down" visceral activity. Neurons of the sympathetic system originate in the intermediolateral cell column of the spinal cord in the thoracic and upper lumbar segments (T1 to L2­L3). Thus, they are often referred to as the thoracolumbar outflow of visceral efferent fibers. The parasympathetic nervous system serves to "calm" the body, returning it to a homeostatic state. Parasympathetic innervation, conversely, functions to calm the body by decreasing heart rate, respiration, and blood pressure; constricting the pupils; and increasing visceral activity. Both systems innervate many organs of the body where their antagonistic actions serve to balance functioning to maintain homeostasis. Neurons of the parasympathetic system originate either in the brain in certain nuclei of cranial Autonomic System Summary Bite. The autonomic nervous system, by definition, is a motor system controlling the viscera, cardiac and smooth muscle, and glands. The autonomic (involuntary, visceral) nervous system exerts control over the viscera of the body, serving Chapter 3 Body Systems 27 Figure 3-12. The axon of this neuron will synapse on the cell body of the second neuron in the chain, located in one of the autonomic ganglia; thus, this axon is preganglionic. The axon of the second neuron is postganglionic and extends to the effector organ. The sympathetic system is served by the autonomic ganglia located along most of the spinal segments. These ganglia are known as the sympathetic chain ganglia (paravertebral ganglia) and are connected to each other by the sympathetic trunk and the several collateral ganglia (preaortic ganglia) along the major abdominal blood vessels. Ganglia of the parasympathetic system are located close to the structures innervated and are called terminal ganglia, four of which are in the head, whereas others, the enteric ganglia, are located within the wall of the alimentary canal. Preganglionic sympathetic fibers reach the chain ganglia via the white rami communicantes, a connection between the spinal nerve and the ganglion transmitting the myelinated fibers. The postganglionic fiber may enter the spinal nerve via the gray rami communicantes directly or after ascending or descending in the sympathetic trunk. Preganglionic fibers synapse only one time; therefore, those destined to synapse in the collateral ganglia do not synapse in the chain ganglia. Acetylcholine is the neurotransmitter of both preganglionic sympathetic and parasympathetic neurons and postganglionic parasympathetic neurons. However, noradrenaline is the primary neurotransmitter of postganglionic sympathetic neurons 28 Chapter 3 Body Systems Parietal distribution Visceral distribution Blood vessels of visceral structures, blood vessels, sweat glands, and arrector muscles of hairs Eye (iris) C1 C2 C3 C4 C5 C6 C7 C8 T1 White ramus communicans T2 T3 T4 T5 T6 T7 Gray rami to anterior primary rami of all spinal nerves for distribution to body walls and limbs (vasomotion, sudomotion, and pilomotion) T8 T9 T10 T11 T12 L1 L2 L3 L4 L5 S1 S2 S3 S4 S5 Inferior mesenteric ganglion Superior mesenteric ganglion Large intestine Small intestine Kidney Suprarenal (adrenal) gland Rectum Internal anal sphincter Bladder Penis (or clitoris) Gonad 4 Aorticorenal ganglion 1 2 3 Stomach Pancreas Spleen Celiac ganglion Abdominopelvic splanchnic nerves Cephalic arterial ramus Carotid periarterial plexus Cardiopulmonary splanchnic nerves Heart Larynx Trachea Bronchi Lungs Liver Diaphragm Gallbladder Sympathetic fibers Presynaptic Postsynaptic A nervous system. It receives preganglionic sympathetic fibers which synapse on chromaffin cells of the medulla, stimulating them to produce catecholamines, which give rise to epinephrine and norepinephrine, which are released into the bloodstream.

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Al-Nimri pregnancy 7 weeks ultrasound heartbeat purchase 20mg sarafem fast delivery, K women's health clinic fort hood purchase genuine sarafem online, Al Habashneh women's health center university blvd sarafem 20mg generic, R women's health clinic fort worth tx order sarafem 20 mg fast delivery, Obeidat, M: Gingival health and relapse tendency: a prospective study of two types of lower fixed retainers. Treatment for Adults Adult orthodontics has been the fastest-growing type of orthodontic treatment in recent years, going from a relative rarity as late as the 1970s to a commonplace procedure today. In the United States, adults (those over age 18 at the start of treatment) now comprise about 30%of all patients receiving comprehensive orthodontic treatment. A similar trend is occurring worldwide in orthodontic practices, trailing behind the U. This does not mean that the treatment procedures can be the same as for adolescents or children. Perhaps the biggest difference is that for adults, other types of dental treatment almost always are required, which makes interdisciplinary interaction and cooperation a necessity from the beginning. The prevalence of periodontal problems increases with age, and even young adults are likely to require some level of periodontal care by either a generalist skilled in doing this or a periodontist. As adult patients become older, orthodontic treatment must be done in the context of a used dentition with worn teeth and restorative implications, not a new one as with adolescents. The absence of growth in adults (or more accurately, the very small increments of continuing growth) means that growth modification is not a treatment option-everything has to be done with either tooth movement, restorative dentistry, or orthognathic surgery. In a sense, planning orthodontic treatment for adults can be easier because there are no uncertainties related to the amount and direction of growth, but treating adults requires a high level of technical skill, knowledge of other disciplines, and an understanding of biomechanics. There are several other considerations that are particularly important in the treatment of adults: 1Treatment planning must involve all the dentists who will play a role in the treatment. With a group of practitioners, an important question is "Who is the conductor of this orchestra? This can be accomplished with a diagnostic setup/waxup that can be used as a diagnostic and communication tool among the treatment team and between them and the patient. This has to be evaluated in the context of cost and risk versus benefit to the patient from various treatment procedures, so discussion of treatment options and genuinely informed consent are very important. As we have noted earlier in this book, this means bringing both dental and periodontal disease under control, which may add endodontics and oral surgery to the types of treatment. In the chapters that follow, Chapter 18 focuses on orthodontic treatment in interaction with other dental specialists except maxillofacial surgeons, and Chapter 19 adds orthognathic surgery to the considerations in planning and implementing coordinated treatment. Although the focus is on orthodontics in both chapters, a discussion of treatment procedures by other dental specialists has to be included in the discussion of interdisciplinary treatment. In Chapter 19, the surgical options and the surgeon­orthodontist interaction in the sequencing and management of treatment receive particular attention.? Chapter 18 Special Considerations in Treatment for Adults Adults who seek orthodontic treatment fall into two quite different groups: (1) younger adults (typically under 35, often in their 20s) who desired but did not receive comprehensive orthodontic treatment as youths and now seek it as they become financially independent and (2) an older group, typically in their 40s or 50s, who have other dental problems and need orthodontics as part of a larger treatment plan. They may or may not need extensive treatment by other dental specialists but frequently need interdisciplinary consultation. The second group seek to maintain what they have, not necessarily to achieve as ideal an orthodontic result as possible. For them, orthodontic treatment is needed to meet specific goals that would make control of dental disease and restoration of missing teeth easier and more effective, so the orthodontics is an adjunctive procedure to the larger periodontal and restorative goals. Treatment for older adults has been the fastest growing area in orthodontics during the last decade. Adjunctive orthodontic treatment, particularly the simpler procedures, often can and should be carried out within the context of general dental practice, and the first part of Chapter 18 is written with that in mind. This discussion does not require familiarity with the principles of comprehensive orthodontic treatment, but it does presume an understanding of orthodontic diagnosis and treatment planning. In contrast, the discussion of comprehensive treatment for adults in the latter part of Chapter 18 builds on the principles discussed in Chapters 14 to 16 and focuses on the aspects of comprehensive treatment for adults that are different from treatment for younger patients. Comprehensive orthodontics for adults tends to be difficult and technically demanding. The absence of growth means that growth modification to treat jaw discrepancies is not possible. The only possibilities are tooth movement for camouflage or orthognathic surgery, but applications of skeletal anchorage now are broadening the scope of orthodontics to include some patients who would have required surgery even a few years ago. Applications of skeletal anchorage are discussed and illustrated in detail in this chapter; a discussion of skeletal anchorage versus surgery follows in Chapter 19. Adjunctive Versus Comprehensive Treatment Adjunctive orthodontic treatment for adults is, by definition, tooth movement carried out to facilitate other dental procedures necessary to control disease, restore function, and/or enhance appearance. Usually, it involves only a part of the dentition, and the primary goal usually is to make it easier or more effective to replace missing or damaged teeth. Making it easier for the patient to control periodontal problems is a frequent secondary goal and sometimes is the primary goal. The treatment duration tends to be a few months, rarely more than a year, and long-term retention usually is supplied by the restorations. With the distinction made in this way, much of the adjunctive treatment discussed in this chapter can be carried out within the context of general dental practice, and the first part of this chapter is written from that perspective. Adjunctive procedures that probably should be done by an orthodontist are labeled as such. Whether one or several practitioners are involved, adjunctive orthodontics must be coordinated carefully with the periodontal and restorative treatment. In contrast, the goal of comprehensive orthodontics for adults is the same as for adolescents: to produce the best combination of dental and facial appearance, dental occlusion, and stability of the result to maximize benefit to the patient. Typically, comprehensive orthodontics requires a complete fixed orthodontic appliance, intrusion of some teeth is likely to be needed, orthognathic surgery may be considered to improve jaw relationships, and the duration of treatment from braces on to braces off exceeds 1 year. Adults receiving comprehensive treatment are the main candidates for esthetically enhanced appliances; the prime examples are ceramic facial brackets, clear aligners, and lingual appliances. The complexity of the treatment procedures means that an orthodontic specialist is likely to be significantly more efficient in delivering the care. Goals of Adjunctive Treatment Typically, adjunctive orthodontic treatment will involve any or all of several procedures: (1) repositioning teeth that have drifted after extractions or bone loss so that more ideal fixed or removable partial dentures can be fabricated or so that implants can be placed, (2) alignment of anterior teeth to allow more esthetic restorations or successful splinting, while maintaining good interproximal bone contour and embrasure form, (3) correction of crossbite if this compromises jaw function (not all crossbites do), and (4) forced eruption of badly broken down teeth to expose sound root structure on which to place crowns or to level/regenerate alveolar bone. Whatever the occlusal status originally, the goals of adjunctive treatment should be to: 1Improve periodontal health by eliminating plaque-harboring areas and improving the alveolar ridge contour adjacent to the teeth. As a general guideline in treatment of adults with periodontal involvement and bone loss, lower incisor teeth that are excessively extruded are best treated by reduction of crown height, which has the added advantage of improving the ultimate crown-to-root ratio of the teeth. For other teeth, tooth­lip relationships must be kept in mind when crown height reduction is considered. It may be advantageous to strip posterior teeth to provide space for alignment of the incisors, but this requires a complete orthodontic appliance and cannot be considered adjunctive treatment. In adjunctive treatment, the restorative dentist usually is the principal architect of the treatment plan, and the orthodontics (whether an orthodontist is or is not part of the treatment team) is to facilitate better restorative treatment. Nevertheless, the steps outlined in Chapter 6 should be followed when developing the problem list. The interview and clinical examination are the same whatever the type of orthodontic treatment. Diagnostic records for adjunctive orthodontic patients, however, differ in several important ways from those for adolescents and children. For this adult and dentally compromised population, the records usually should include individual intraoral radiographs to supplement the panoramic radiograph that often suffices for younger and healthier patients (Figure 18-1). When active dental disease is present, the panoramic radiograph does not give sufficient detail. For this patient who is a candidate for adjunctive orthodontic treatment, adequate detail of root morphology, dental disease, and periodontal breakdown is obtained only from carefully taken periapical radiographs. In some instances, the computer prediction methods used in comprehensive treatment (see Chapter 7) can be quite useful in planning adjunctive treatment. Articulator-mounted casts are likely to be needed because they facilitate the planning of associated restorative procedures. Once all of the problems have been identified and categorized, the key treatment planning question is: can the occlusion be restored within the existing tooth positions or must some teeth be moved to achieve a satisfactory, stable, healthy, and esthetic result? At this point, it is important to consider the difference between realistic and idealistic treatment planning. In older patients, searching for an "ideal" result could involve more treatment than would really benefit the patient. Obviously, the time needed for any orthodontic treatment depends on the severity of the problem and the amount of tooth movement desired, but with efficient use of orthodontic appliances, it should be possible to reach the objectives of adjunctive treatment within 6 months. As a practical matter, this means that like comprehensive orthodontics, most adjunctive orthodontics cannot be managed well with traditional removable appliances.

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Loss of one or both primary canines from ectopic eruption usually indicates lack of enough space for all the permanent incisors but occasionally may result solely from an aberrant eruption path of the lateral incisor women's health clinic calgary ne sarafem 20 mg mastercard. Space analysis women's health tone zone strength training 10 mg sarafem with amex, including an assessment of the anteroposterior incisor position and the facial profile menopause 7 dwarfs discount 10 mg sarafem free shipping, is needed to womens health tampa purchase sarafem 20 mg overnight delivery determine whether space maintenance, space management, space regaining, or more complex treatment is indicated. In some patients, this type of ectopic eruption is just a symptom of the temporary incisor crowding that is normal in the early mixed dentition (see Chapter 4) and not an indication of longterm crowding. A, these lower central incisors erupted lingually because the permanent incisors have not been lost and their tooth buds are positioned lingual to the primary incisors. This is a common occurrence in this area and is the main reason lingual arches should not be placed until after lower incisors erupt. B, this maxillary premolar has been deflected facially because of the retained primary molar. In both the circumstances shown here, removal of the retained primary tooth or teeth will allow some spontaneous alignment. For this reason, management of all but the most basic problems associated with lateral incisor ectopic eruption are better managed in specialty practice, and addressed in Chapter 12. When one primary canine is lost, treatment is needed to prevent a shift of the midline. Depending on the overall space assessment, the dentist can take several approaches. If the space is adequate and no midline shift has occurred, the position of the lateral incisor on the side of the canine loss can be stabilized using a lingual arch with a spur (Figure 11-33). If both mandibular primary canines are lost, the permanent incisors can tip lingually, which reduces the arch circumference and increases the apparent crowding. A passive lingual arch to prevent lingual tipping and maintain adequate space is indicated. If the midline has moved, even with adequate space, or the midline has moved and space has been lost, the problems rapidly become complex. These types of problems need to be resolved prior to canine eruption and are addressed in Chapter 12. Maxillary First Molars Ectopic eruption of a permanent first molar presents an interesting problem that is usually diagnosed from routine bitewing radiographs rather than clinically because it is painless. If the blockage of eruption persists for 6 months or if resorption continues to increase, treatment is indicated. Lack of timely intervention may cause loss of the primary molar and space loss as the permanent molar erupts mesially and rotates mesiolingually. If a limited amount of movement is needed but little or none of the permanent first molar is visible clinically, a 20 or 22 mil brass wire looped and tightened around the contact between the primary second molar and the permanent molar is suggested (Figure 11-35). It may be necessary to anesthetize the soft tissue to place the brass wire, and depending on the tooth position and depth of the contact between the permanent and primary molars, it can be difficult to successfully direct the brass wire subgingivally. The brass wire should be tightened at each adjustment visit, approximately every 2 weeks, so that it will not move in relation to the teeth. If the wire is not tightened to the point that the patient feels some discomfort, it has not been appropriately adjusted. A steel spring clip separator, available commercially, may work if only a small amount of resorption of the primary molar roots exists. These clips are difficult to place if the point of contact between the permanent and primary molars is much below the cement-enamel junction of the primary molar, although some are available that have greater vertical distances for just these situations (Figure 11-36). Elastomeric separators wedged mesial to the first molar also can be used to push it distally so it can erupt but are not recommended. They are well retained for normally positioned teeth, but they require substantial force to place them below the contact of an impacted molar. They have the potential to become dislodged in an apical direction and cause periodontal irritation. If this occurs, the separators are hard to locate and retrieve, especially if the material is not radiopaque. If resorption is severe and more distal movement is required than can be provided by these simple appliances, the situation becomes more complex. If access can be gained to the occlusal surface of the molar, a simple fixed appliance can be fabricated to move the molar distally. The appliance consists of a band on the primary molar (which can be further stabilized with a transpalatal arch) with a soldered spring that is bonded to the permanent molar (Figure 11-37). In lieu of using a soldered appliance that must be fabricated in the laboratory, a similar but alternative appliance can be fabricated intraorally, either a band and looped spring (Figure 11-38, A) or two bonded brackets (a first molar bracket on the primary molar and a second molar bracket on the first molar) and a looped spring (Figure 11-38, B). Using either appliance, if the movement is not sufficient in 2 weeks, the loop can be reactivated. If the permanent molar has caused extensive resorption of the primary molar, there may be no choice but to extract the primary tooth, which allows the permanent molar to continue to move mesially and shorten the arch length. Unless the second premolar is missing and the arch length is purposefully to be reduced or unless considerable mesial molar movement is tolerable and later premolar extraction is planned, a distal shoe that guides the erupting molar should be placed after the extraction (see below). Even if this technique is used, some space has already been lost and the permanent molar will have to be repositioned distally after it fully erupts using another type of space-regaining appliance as described later in this chapter and in Chapter 12. A flowchart summarizes the decision making for ectopic eruption of permanent first molars (Figure 11-39). A, the distal root of the primary maxillary second molar shows minor resorption from ectopic eruption. B, this radiograph taken approximately 18 months later illustrates that the permanent molar was able to erupt without treatment. A, this distal root of the primary maxillary second molar shows enough resorption that selfcorrection is highly unlikely. B, A 20 or 22 mil dead soft brass wire is guided under the contact (starting from either the facial or lingual and proceeding with the most advantageous approach) and then looped around the contact between the teeth and tightened at approximately 2-week intervals. C, the permanent tooth is dislodged distally and erupts past the primary tooth that is retained. The posterior bow is crimped to bring the subgingival legs together and apply pressure to separate the teeth. B, If the occlusal surface of the permanent molar is accessible, the primary molar can be banded and a 20 mil spring soldered to the band. C, the permanent molar is tipped distally out of the resorption defect and (D) once disengaged, is free to erupt. A, To make a band and spring appliance, a band with an attachment having a buccal tube is cemented on the primary second molar. Next, a large omega-shaped loop and a helical loop are bent distal to the primary molar. The spring is activated, and the wire is inserted into the primary molar tube from the distal and secured with a bend anterior to the molar tube. The helical loop is compressed during bonding to the occlusal surface of the permanent first molar. The appliance is reactivated intraorally by opening the omega loop with a loop-forming pliers with the round beak positioned superior to the wire. B, Another option for repositioning an ectopically erupting first molar is to bond archwire tubes on both the primary second molar and the permanent first molar. Then, bend an opening loop from either rectangular beta-Ti or stainless steel wire and compress it to seat from the distal into the primary molar tube and from the mesial into the permanent molar tube. The force from the activated loop will retain the rectangular wire, which can be carefully positioned adjacent to the soft tissue. Answers to the questions posed in the chart should lead to successful treatment pathways. Given the potential complications of continued ectopic canine eruption, early diagnosis and intervention are warranted to either prevent or limit root resorption. When a mesial position of the erupting permanent canine is detected and incisor root resorption is threatened but has not yet occurred, extraction of the primary canine is indicated (Figure 11-41). Ericson and Kurol found that if the permanent canine crown was overlapping less than half of the root of the lateral incisor, there was an excellent chance (91%) of normalization of the path of eruption. When more than half of the lateral incisor root was overlapped, early extraction of the primary tooth resulted in a 64%chance of normal eruption and likely improvement in the position of the canine even if it was not totally corrected.

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Nerve Supply All the muscles of the soft palate except tensor palati are supplied by the cranial root of the accessory through the vagus womens health houston 20 mg sarafem for sale. The soft palate plays an important role in closure of the nasopharyngeal isthmus and menstruation spotting cheap 20mg sarafem, therefore pregnancy vs pms order sarafem with a visa, helps in deglutition and speech women's health center abington generic sarafem 20mg with amex. The posterior free border of the soft palate comes in contact with this ridge to close the nasopharynx during deglutition. The ridge is raised by the contraction of upper fibres of the superior constrictor and the palato-pharyngeus muscle. Lymphoid aggregation in the nasopharynx and oropharyngeal isthmus have a protective role. Besides, the pharynx is a site for various reflexes and is related to the opening of the eustachian tubes. Functions of the Pharyngeal Lymphoid Tissues the exact functions of the subepithelial lymphoid tissues are not very clear. The strategic location of the faucial tonsils and nasopharyngeal lymphoid tissues suggests that these structures are concerned with sampling of air and food and thus constantly monitor the bacterial flora. Since these lymphoid structures atrophy with the growth it appears that this defence mechanism is mainly active during childhood. This process involves three stages: First stage (voluntary) After the food is masticated and made into a bolus, the posterior part of the tongue propels the food into the oropharynx. Second stage (pharyngeal stage) In this stage food passes from the oropharynx into the oesophagus. During this stage, the larynx is raised and laryngeal inlet gets closed to prevent food from going into the trachea. Retroversion of the epiglottis helps to close the approach to the laryngeal inlet. The pharynx is elevated and the pharyngo-oesophageal junction opens to receive the bolus which is pushed down by contraction of the circular muscles of the pharynx. Third stage (esophageal stage): this stage consists of passage of food down the oesophagus. The cardiac sphincter opens in response to the peristaltic waves and food thus enters the stomach. Disposal of dust and bacteria-laden mucus conveyed by ciliary action to the pharynx from nasal passages, sinuses, tympanic cavities, larynx and tracheobronchial tree. Opening of the pharyngeal ostia of pharyngotympanic tubes, to establish equalisation of pressure on the outer and inner surfaces of the tympanic membranes. During swallowing there is a transitory rise of about 40 mm Hg pressure at the pharyngo-oesophageal junction. During swallowing this pressure falls abruptly just before the pharyngeal peristaltic wave reaches this zone. Immediately after the bolus has passed, the sphincter contracts strongly with a rise of pressure to 50-100 mm Hg. This abrupt closure coincides with the arrival of the pharyngeal peristaltic wave and has the function of preventing reflux while peristalsis is occurring in the upper oesophagus. When the bolus has passed further down the oesophagus, the pressure in the pharyngooesophageal zone returns to normal, i. The first sound occurs immediately after the commencement of the act and is probably due to the fluids impinging on the posterior pharyngeal wall. The second sound resembles a bubbling or trickling noise and occurs at a variable interval of 4-10 seconds after the first sound and persists for 2-3 seconds. In recumbant subjects the second sound is replaced by a few discrete squirting sounds, each of one second duration. This is due to dehydration causing decreased salivary secretion and drying of the pharyngeal mucosa with consequent stimulation of the special sensory receptors. Impulses from those receptors are conducted along fibres in the ninth and tenth nerves. This pharyngeal component can be abolished by stimulating salivary secretion or by local anaesthesia of the pharyngeal mucous membrane. The extrapharyngeal component or "thirst drive" is supposed to be the central component (not agreed by all). Intravenous hypertonic saline or a high intake of salt with low water intake, causing intracellular dehydration and a rise in intracellular crystalloid osmotic pressure produces thirst. Pain from the oropharyngeal diseases may be referred to the ear (referred otalgia). Difficulty in Deglutition Difficulty in deglutition may result from acute infections of the oral cavity. This can result from a variety of lesions in the oral cavity, pharynx and oesophagus. Odynophagia is painful deglutition caused by inflammatory lesions in the oropharynx or supraglottis. Regurgitation occurs in paralytic lesions of the soft palate when the ingested material regurgitates into the nose. Paralysis of the pharynx may lead to dysphagia as well as to aspiration into the trachea. Difficulty in Speech Palatal paralysis or sometimes adenoidectomy lead to improper closure of the nasopharyngeal isthmus with resulting hypernasality of voice called rhinolalia aperta. Ulceration of Pharyngeal Mucosa Ulceration of the pharynx may be manifestation of systemic diseases like leukaemia, agranulocytosis or aplastic anaemia. Cervical Lymphadenopathy Enlargement of the cervical nodes is commonly due to infective or neoplastic lesions of the oral cavity, pharynx, larynx and bronchi. The patient is asked to open the mouth and an inspection of the oral vestibule is done. The patient is asked to lift the tip of the tongue and orifices of the submandibular ducts and floor of mouth is seen. Orodental hygiene is assessed and attention is given to the teeth as to the cause of pharyngeal disease. Pressure by the tongue depressor squeezes the debris from the tonsillar crypts in chronic tonsillitis. The colour of the mucosa, ulcerations and membrane formation are looked for in the oropharyngeal and buccal mucosa. The tongue depressor is used to depress the anterior two-thirds of the tongue for oropharyngeal examination. The postnasal discharge which indicates a nasal disease is seen trickling behind the soft palate. Mirror Examination A view of the nasopharynx by a postnasal mirror and that of the laryngopharynx by a laryngeal mirror is an important examination for diagnosing the pharyngeal diseases. Palpation Finger palpation is necessary to examine the inside of the oral cavity and pharynx and should be routinely done. Bidigital examination of the submandibular salivary gland and its duct is done for calculus. Palpation of the tongue (kept inside mouth) and that of the floor of the mouth is necessary for evaluating the extent of a tumour infiltration. Palpation of the tonsils and base of the tongue is necessary to diagnose certain infiltrative growths which may not show on the surface. An elongated styloid process may be felt on palpating through the tonsillar fossa. Common Symptoms of Oropharyngeal Diseases Investigations Haematological Tests Like haemoglobin estimation total and differential counts are particularly required in ulcerations of the oral cavity and oropharyngeal mucosa. Radiological Investigation A plain X-ray of the neck (lateral view) provides clues for evaluating pharyngeal diseases. X-ray of the chest, lateral view of the nasopharynx, X-ray of the mandible are the other views which may prove useful. Local Causes Traumatic stomatitis the trauma may be due to ill-fitting dentures, hot foods, corrosives, simple cut of the mouth, too vigorous use of a hard toothbrush, medicaments, fumes, smoke and radiotherapy. Infective stomatitis Inflammation of the oral cavity may result from viruses, bacteria or fungi. Viral infections like herpes simplex or herpes zoster start as small painful vesicles which later ulcerate, involving the lip, buccal mucosa and palate. Acute stomatitis can be caused by staphylococcal, streptococcal or gonococcal infections. Fungal stomatitis (moniliasis, thrush): Stomatitis caused by Candida albicans is known as thrush or moniliasis. The infection is common in debilitated patients, marasmic children and patients receiving broad-spectrum antibiotics.

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