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Another aid is the use of a prop such as a toothbrush handle to gain access to tooth surfaces on the other side of the mouth buy oxytrol 2.5 mg low cost medicine journals impact factor. Modification of existing 2.5 mg oxytrol with amex treatment kidney stones, often very narrow-handled toothbrushes or the use of specially modified brush heads can be helpful (Fig. For some children, the mechanical removal of plaque can be more readily accomplished using a powered toothbrush. Once the child has become accustomed to the sensation, results can be better than by conventional toothbrushing. Chemical agents are effective in reducing plaque in the short term, but not enough is known about the effects of their long-term usage. Many patients with impairments may be unable to use a mouthwash correctly and either swallow or spit out anything distasteful. An alternative technique is to opt for chairside application of chlorhexidene as a varnish. Originally intended for treating dentine hypersensitivity, application of the varnish has been shown to reduce the incidence of both gingival signs and dental caries. Some schools for children with special educational needs provide toothbrushes for their pupils during their learning of personal hygiene skills. However, supervising staff may be unaware of the best method of mouth cleaning, which may be more dependent on their own perceptions of oral health and the perceived difficulty than any other factor (Fig. Toothbrushing can be taught in the same way as other skills, but it requires time for the individual as well as commitment on the part of the regular carer to ensure that all areas of the mouth are being cleaned each time. However, many disabled children are intolerant not only of toothbrushing but also of toothpaste and they may gag when toothpaste, which they cannot swallow because of poor reflexes, is introduced into the mouth. Toothpaste also obscures the view for the carer during toothbrushing and they cannot always be sure that the tooth surfaces are clean. In these circumstances, where toothpaste is unacceptable to the child, parents or carers should attempt to clean around the mouth with a piece of gauze moistened in a 0. Alternatively, chlorhexidine in gel form or fluoride toothpaste can be rubbed as vigorously as possible around the tooth surfaces using a finger. Since chlorhexidene is inactivated by the traditional foaming agents in toothpastes, the former should be used at a different time of the day to the latter. Children who are tube-fed for some or all of their nutrient intake still need oral care. They will frequently accumulate significant quantities of calculus, which, if detached might be inhaled. Diet More severely impaired children may have well-regulated eating times and a reduced likelihood of snacking. The food consumed may be semi-solid or even liquidized, but those foods which are easily reduced to this form are often dentally undesirable. This will be justified by parents saying they are desperate to get the child to eat something, and so biscuits, and other snacks high in non-milk extrinsic sugars, become the norm. This pattern is further endorsed in some children with impairments where weight gain is paramount and the dental implications are secondary, if indeed they are even considered. It is not uncommon for children of 2 years of age or older still to be using a bottle containing milk, often for naps, last thing at night before going to bed and even during the night. This is an extremely difficult habit to break, but the most successful approach has been to advise the parent gradually to dilute the contents with water over a period of weeks, until eventually the child is drinking water only. This not only eliminates the undesirable habit but also gives the parent of the child, who is able to be toilet trained, some prospect of getting the child dry and out of nappies overnight. For a number of children with impairments, the use of sweetened medication has led to an increase in dental caries (Fig. Some children will be taking medication as dispersible tablets or in an effervescent form, some of which, with chronic use, may predispose to dental erosion. Months of eager anticipation are followed by disbelief, anger, denial, frustration, and guilt.

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The pulp is partially obliterated cheap 5 mg oxytrol free shipping medicine effects, appearing in the molar teeth as a small demilune buy oxytrol 5mg lowest price medicine 027. Under the microscope the coronal dentine is normal but the root dentine is not, with masses of abnormal dentine obliterating the pulp space. The short roots may cause problems because of mobility and this may lead to the condition being identified. It remains to be seen whether dentinal dysplasia (type I) is also allelic to dentinogenesis imperfecta. Affected males tend to be short in stature with bowed legs and other skeletal changes. Of the dental hard tissues, the dentine is most markedly affected with interglobular dentine being the chief histopathological finding. Radiographically the pulp spaces are larger than normal and pulpal extensions of the pulp horns may be exposed as a result of attrition of the teeth (Fig. Systemic influences including nutritional deficiencies, tetracycline administration, and chemotherapeutic agents such as anti-cancer therapy involving cytotoxic drugs can also affect the formation of dentine. Treatment As with enamel defects there may be severe psycho-social problems as a result of the appearance of the teeth. Many of the arguments presented in the consideration of enamel conditions will apply to dentine also. In dentinogenesis imperfecta, management is focused on the prevention of tooth wear, the maintenance of the vertical dimension and improvement of the appearance (Chapter 10869H ). In rickets, the treatment should be similarly directed but cases presenting late may require acute management of dental abscesses on the teeth as a result of pulp death. The consequences of alterations in cementum can have profound effects on the fate of the dentition. There are a number of rare but significant conditions associated with the early loss of primary teeth. Any case of early or spontaneous loss of teeth is a cause for further investigation. In one of these, hypophosphatasia (both autosomal dominant and autosomal recessive inheritance are known), there may be premature exfoliation of the primary teeth or loss of the permanent teeth. The serum alkaline phosphatase level is low; phosphoethanolamine is excreted in the urine. Histopathological examination in hypophosphatasia will show aplasia or marked hypoplasia of the cementum. There may also be abnormal dentine formation with a wide predentine zone and the presence of interglobular dentine (similar to vitamin D-resistant rickets). Treatment Local measures such as scrupulous oral hygiene may slow the loss of teeth in cases of hypophosphatasia but the prime focus of treatment may be the replacement of teeth of the primary and permanent dentitions as they are lost. There may be some racial variation and eruption may also be influenced by environmental factors such as nutrition and illness. Eruption times of permanent teeth in females tend to be slightly ahead of the corresponding eruption times in males; this becomes a more marked difference with the later erupting teeth. Children with high birth weight have been reported to have earlier eruption of their primary teeth than children with normal or low birth weights. Early eruption of the permanent dentition may occur in children with precocious puberty and children with endocrine abnormalities, particularly those of the growth or thyroid hormones. Natal and neonatal teeth Teeth present at birth are known as natal teeth and those that erupt within the first month of life as neonatal teeth. Occasionally maxillary (central) incisors or the first molars may appear as natal teeth. The vast majority of cases represent premature eruption of a tooth of the normal sequence. It has been suggested that this condition is a result of an ectopic position of the tooth-germ during foetal life. Natal or neonatal teeth may also be seen in association with some syndromes including pachyonychia congenita, Ellis-van Creveld syndrome, and Hallermann- Streiff syndrome. Natal or neonatal teeth are often mobile because of limited root development and may be a danger to the airway if they are inhaled. The crowns may be abnormal in form and the enamel may be poorly formed or thinner than normal.

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Severe cases of gingival enlargement inevitably need to be surgically excised (gingivectomy) and then recontoured (gingivoplasty) to produce an architecture that allows adequate access for cleaning cheap oxytrol 5mg otc symptoms mononucleosis. A follow-up programme is essential to ensure a high standard of plaque control and to detect any recurrence of the enlargement purchase 5mg oxytrol otc symptoms lactose intolerance. As the causative drugs need to be taken on a long-term basis, recurrence is common. There is no alternative medication to cyclosporin, however, and the patients inevitably require indefinite oral care. The minor form results from rubbing or picking the gingiva using the fingernail, or perhaps from abrasive foods such as crisps, and the habit is usually provoked by a locus of irritation such as an area of persistent food packing or an already inflamed papilla (Fig. The lesions resolve when the habit is corrected and the source of irritation is removed. The injuries in gingivitis artefacta major are more severe and widespread and can involve the deeper periodontal tissues (Fig. Other areas of the mouth such as the lips and tongue may be involved and extraoral injuries may be found on the scalp, limbs, or face (factitious dermatitis) (Fig. The lesions are usually viewed with complete indifference by the patient who is unable to forward details of their time of onset or possible cause. The treatment of these patients, other than the dressing and protection of oral wounds, does not lie with the dentist. A psychological or psychiatric consultation, rarely welcomed either by older children or their parents, is necessary if the patient is to be prevented from ultimately inflicting serious damage upon themselves. Key Points Gingivitis artefacta: • minor/major; • self-inflicted; • habitual; • psychological. The position of a tooth in the arch is a better guide as studies have shown that, of those permanent incisors with recession, about 80% are displaced labially. Aggravating factors such as gingivitis or mechanical irritation from excessive and incorrect toothbrushing further increase the likelihood of recession. Gingival recession is also a common periodontal complication of orthodontic therapy when labial tipping of incisors is undertaken. When roots move labially through the supporting envelope of alveolar bone the potential for recession increases. When gingival recession occurs in children, a conservative approach to treatment should be adopted. Overenthusiastic toothbrushing practices are modified and a scale and polish given if necessary. The recession must then be monitored carefully until the permanent dentition is complete. Longitudinal studies of individual cases have shown that, as the supporting tissues mature, the gingival attachment tends to creep spontaneously in a coronal direction to cover at least part of the previously denuded root surface. Key Points Gingival recession: • narrow keratinized gingiva; • local trauma; • post orthodontics; • conservative treatment approach. The variation in prevalence between studies is considerable and attributable to different methods of diagnosing attachment loss and the use of different cut-off levels to determine disease presence. Radiographic studies on children with a primary or a mixed dentition indicate that loss of attachment is uncommon under the age of 9 years. A microscopic examination of the root surfaces of 200 extracted molars, however, demonstrated a mean attachment loss of 0. Cut-off levels at which disease is diagnosed in adolescents have been set at 1, 2, or 3 mm. Larger cut-off values provide more stringent criteria for the detection of attachment loss and consequently the disease appears less prevalent. An exception to this trend was seen in a study of 602, 14-15-year-olds in the United Kingdom; 51. Additional radiographic features were also used, namely an irregular contour of the alveolar crest and a widened, coronal periodontal ligament space. Such observations may result from minor tooth movements following eruption of the second molars and consolidation of the occlusion, or from remodelling of bone after orthodontic treatment. If a cut-off value of 2 mm is deemed acceptable, the majority of studies put the prevalence of disease in adolescents at 1-11%.

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