K. Seruk. Baylor College of Dentistry.

Which of the following is the most likely recommendation for transfusing this patient? Washed red cells and platelets; avoid plasma Concept: Polyagglutination is a structural modifcation of red cell surface oligosaccharides that exposes underlying “cryptantigens buy discount careprost 3ml line. Plasma itself should be avoided if at all possible (Answer D) cheap careprost 3 ml without a prescription, but it is not necessary to avoid transfusion of all blood products (Answer A) buy careprost 3ml fast delivery. A 31-year-old group O order careprost toronto, Rh-negative, G4P3 female has a strong anti-D (4+ reaction) and is currently pregnant (approximately 31 weeks estimated gestational age). Due to the severity of the anemia and hemolysis, an intrauterine transfusion is planned. In addition to being hemoglobin S negative, which of the following is the best choice of blood product for this transfusion? Answer: D—Since the mother carries anti-D, the transfused units must be Rh-negative, not Rh-positive (Answers A and B). A 65-year-old Caucasian male with no signifcant medical history presents to his physician complaining of decreased exercise tolerance and yellow discoloration in his eyes. His physical examination is signifcant for several enlarged axillary lymph nodes and prominent scleral icterus. Which of the following is the most likely fnding in the transfusion service when his blood is sent for compatibility testing? However, the most common clinical association when one is actually found is a hematologic malignancy, such as chronic lymphocytic leukemia or non- Hodgkins lymphoma. Patients may actually present with hemolytic anemia months prior to the malignant diagnosis. Answer: B—The physical fndings are suspicious for a hematologic malignancy, such as lymphoma. Blood bank testing will most likely reveal a positive antibody screen (Answer E) with panagglutination to all cells. She tells her nurse that she has a 5 year history of chronic anemia, and insists that she has been warned that her blood “is not compatible with anyone else’s blood! The transfusion service discovers a panreactive pattern, with all testing cells reacting with microcolumn (gel) technology. Which of the following tests or procedures is the next best step to fnd blood for this patient? This can make it diffcult to detect underlying alloantibodies that the patient may also a have formed (e. Blood banks use several strategies to choose the safest blood for these patients when transfusion cannot be avoided. If an alloantibody is identifed, the patient should receive blood that is negative for the corresponding antigen. If the patient is recently transfused, then alloadsorption, which is a more complicated procedure, is necessary. Since the patient has not been recently transfused, warm autoadsorption is the best choice among those listed (molecular or serologic phenotyping would have also been equally good choices if listed). Rather, it is simply a way to choose which unit to give after alloantibodies have either been ruled out or managed by one of the earlier mentioned strategies (Answer C). Blood banks typically opt to choose the least incompatible (or “most compatible”) unit among the units crossmatched, but there is no real evidence that this strategy does anything to reduce hemolysis. A 27-year-old male presents to the Emergency Department by ambulance, following a motor vehicle accident. The patient has a history of sickle cell disease with multiple previous hospital admissions secondary to pain crises. Request directed donations from family members Concept: In urgent transfusion scenarios, communication with the clinical team caring for the patient is extremely important. This is especially true when there may be delays in the provision of compatible blood for transfusion. If the patient is hemodynamically stable, it may be most appropriate to hold off on transfusion and request antigen negative units from a blood center. If the patient is hemorrhaging or showing signs of shock (such as hypotension, tachycardia, cool extremities, and signifcantly decreased hemoglobin), transfusion is urgently needed. In these situations, transfusion of uncrossmatched or least incompatible units, lacking as many of the appropriate antigens as possible, may be necessary. Answer: B—This patient has a possible bleeding source on imaging, and the patient’s hemoglobin is below normal. However, the patient has a history of sickle cell disease and his usual baseline 15. In this situation, it would be most appropriate to speak with the team caring for the patient to assess clinical status. If the patient’s hemoglobin level is at or near his baseline and there is no evidence of hemodynamic and/or oxygen-extraction compromise, delaying transfusion while waiting for antigen-negative units to arrive from an outside facility is the best option (Answer A). Note that this patient’s antibody combination is compatible with less than 1% of donors. If there is clinical concern for active bleeding and the patient is showing signs of hypovolemia, delaying transfusion would be inappropriate and uncrossmatched or least incompatible (Answers C and D) units lacking as many of the appropriate antigens as possible should be transfused and the patient should be monitored for signs of hemolysis. If the patient will require long-term transfusion support, family members may be screened for directed donation. Blood relatives (Answer E) may be more likely than the general donor population to lack the antigens corresponding to the patient’s alloantibodies. However, coordinating a directed donation takes time and is not the frst choice in this setting. A 60-year-old female with alcoholic cirrhosis arrives in the Emergency Department with hematemesis and melena. The blood bank calls to notify you that the type and screen was positive, the antibody identifcation revealed an anti-E alloantibody, and 1 of the 4 units transfused was positive for the E antigen. No action is needed; Anti-E antibodies are not reported to cause hemolytic transfusion reactions B. Notify the clinician caring for the patient and immediately administer fuids and diuretics to keep urine output >1 mL/kg/h D. Such patients should be carefully monitored, but urgent intervention is often unnecessary. Despite this, it is appropriate to notify the clinician and monitor the patient for signs of hemolysis (Answer B). A 37-year-old woman is admitted with end stage renal disease and severe, symptomatic anemia. Counsel her that refusing transfusion means she is ineligible for kidney transplant E. Treat her renal failure with hemodialysis instead of peritoneal dialysis Concept: An adult patient has autonomy to make decisions about his or her healthcare and may refuse any therapy. Jehovah’s Witnesses generally refuse blood transfusions based on Biblical references (such as in Lev. Despite this, congregants may vary in the strictness of their interpretation of this prohibition. Offcially, the Watchtower Bible and Tract Society states that the church’s offcial position is a prohibition on the acceptance of whole blood, red blood cells, platelets, and plasma. The use of “fractions” of blood (such as clotting factors, fbrinogen, albumin, or immunoglobulins) is left to the congregant’s personal choice. Answer: C—It is important to fully discuss what is and is not acceptable to a Jehovah’s Witness patient. Some will accept fractions of blood as listed earlier, some will actually accept some primary components (such as plasma), while others will not accept any part of the blood. If the patient is an adult with the capacity to make decisions regarding her care and treatment, attempting to circumvent the patient’s wishes with legal (Answer B) or family maneuvers is not generally appropriate (Answer A). Other appropriate steps include restricting the patient to bedrest to minimize oxygen demand and providing supplemental oxygen, minimizing blood draws, and considering starting erythropoietin and iron therapy. Congregants must decide for themselves if they will accept tissue/ organ transplant, so refusal of transfusion has no bearing on eligibility for renal transplant (Answer D). Finally, hemodialysis may waste up to 175 mL of blood per session, whereas peritoneal dialysis will have no blood loss (Answer E). However, the parents are Jehovah’s Witnesses and they refuse to give consent for the exchange transfusion. Perform a plasma exchange since that treatment would be acceptable to the parents D. Treat the baby with ultraviolet light Concept: Courts recognize the right of parents to consent to treatment for their children.

The prevalence of this disorder increases with rising levels of obesity in the population cheap careprost 3ml with mastercard. In addition 2 percent of adolescents and 3 percent of children have sleep disordered breathing discount careprost online. Familial: The incidence of the disease increases in relatives of affected individuals which is due to similarities in facial structure affecting upper Fig generic 3 ml careprost. Pierre Robin syndrome order careprost 3 ml without prescription, Crouzons disease, Treacher Collins airway, myopathy and reduces chemosensitivity. Obesity: Increased weight is associated with Obstructive apneas causing increased morbidity and increase in fatty tissues in the neck, which mortality has been the subject of much debate in promote mass loading and obstruction to airway recent times. Endocrine and metabolic disorders: Hypothyroidism psychosis Deficits in thinking, perception, memory and causes myxedematous infiltration of the upper ability to learn Consequences due to hypoxemia Cardiac Consequences Table 18. Glaucoma due to increased intracranial pressure Endocrine Consequences Musculoskeletal Disorders: Myasthenia gravis, muscular Decreased libido and impotence dystrophy, kyphoscoliosis, pectus excavatum. Hematological, Consequences Neurological Disorders: Encephalitis, motor neuron disease, Secondary polycythemia Shy drager disease, bulbar polio, brainstem infarcts, Pierre Nephrological Consequences Robin syndrome, Crouzons disease, Arnold Chiari Nocturia, proteinuria. Fatigueness or tiredness may be seen particularly in Obstructive sleep apnea has been shown to cause women. History suggestive of heartburn may occur dilated cardiomyopathy, which is reversible with due to tendency to gastroesophageal reflux. Snoring is cyclic with periods of loud snoring abnormalities like hypothyroidism should be exceeding 100 decibels or snoring alternating with excluded. Obstructive sleep apnea in known as night time recording of respiratory primary care. Sleep study is required to confirm the diagnosis, ascertain the severity and to evaluate the response to therapy. Ideally should include an entire night and a second night for manual titration of pressure with continuous positive airway pressure Fig. Flow volume loops oral or nasal may show presence of variable extrathoracic airway obstruction and a saw tooth pattern has diagnostic sensitivity of 68 percent and specificity of 62 percent. This measures the tendency of the patient to fall asleep in a setting conducive to sleep, which reflects aspects of sleepiness however, does not correlate strongly with the severity of sleep apnea. Interventions for sleep apnea include behavioral therapy, specific therapy in case of mechanical obstruction, medical or surgical line of management. Medical Therapy The best available therapy consists of delivering positive pressure through the mask i. Sullivan and its coworkers first described it in 1981, which acts as a pneumatic splint in preventing oropharyngeal collapse. Side effects are usually discomfort or irritation due to mask in 15 to 45 percent of patients. Nasal Decreased quality of life and congestion, dryness, rhinorrhea may occur while Increased morbididity and mortality some patients may complain of aerophagia and chest discomfort. Rare complications include epistaxis, tympanic membrane rupture, pneumomediastinum Table 18. Optimal treatment Avoidance of sleep deprivation can be hampered due to air leaks from the mouth, Nocturnal positioning when a mask, which covers both the nose and the Specific therapy: Removal of adenoids/tonsils Treatment of nasal obstruction/nasal mouth, can be useful. Genioglossal advancement/maxillo- Supplemental oxygen and drug therapy have mandibualar advancement) limited, adjunctive roles in the treatment of 352 Textbook of Pulmonary Medicine obstructive sleep apnea. Acetazolamide, frequency volume reduction of the palate or tongue theophylline, nicotine, opioid antagonists and has been new techniques tried. Oral appliances tongue retaining devices, It is also known as simple snoring, snoring without Herbst appliance forces mandible forward. These sleep apnea, noisy breathing during sleep, benign appliances are worn during sleep and generally well snoring, rhythmical snoring and continuous snoring tolerated. Primary those with primary snoring are good candidates for snoring differs from snoring associated with a trial of oral appliance. A presurgical change in life style, maintain a healthy and athletic evaluation should be carried out aided by physical lifestyle to develop good muscle tone and loose examination; cephalometric analysis and fibreoptic weight. Tranquillisers, sleeping pills, antihistamines, pharyngoscopy to evaluate the site of obstruction alcohol and heavy meals before bedtime, should be and the type of surgery. In 1993, the term "upper perioperative death and significant perioperative airway resistance syndrome" was first used by Sleep-related Respiratory Disorders: Sleep Apnea Syndromes 353 Guilleminault and colleagues to describe a subgroup described as a "fat boy, standing upright with his of patients with conditions that were formerly eyes closed who was hypersomnolent, edematous, diagnosed as idiopathic hypersomnia or central and a very loud snorer". This resets the set- cyanosis and signs of right heart failure due to cor point of the central nervous system chemoreceptors pulmonale. In addition, symptoms of chronic respectively) Arterial blood gas show hypercapnea hypoxia (low blood oxygen level) can also occur, (and usually hypoxemic) during wakefulness while such as shortness of breath or fatigue after minimal breathing room air. Those patients without airway Sleep-related Respiratory Disorders: Sleep Apnea Syndromes 355 obstruction (e. In fact, they may have that ventilatory muscle function and chest wall failure to thrive. Obese children are also at have any validity as predictors of the occurrence of complications. In other words, on the basis of normative data, an obstructive apnea index of 1 is often chosen as the cut off for normality. The upper airway size is further narrowed in pre- The major problems in clinical practice regarding eclampsia, probably due to oedema. Further disease, failure to evaluate and diagnose potential studies are required to clarify the importance of complications such as cor pulmonale, systemic upper airway narrowing in pre-eclampsia. It is derived from With the recent advances in the understanding significant increases in slow-wave sleep (percentage of the neurotransmitters involved in the control of of total sleep time) and decreases in rapid eye sleep and the upper airway motor neurones, movement sleep (percentage of total sleep time). How to reach a diagnosis in patients who Management of Childhood Obstructive Sleep Apnea may have the sleep apnea/hypopnea syndrome. Cough is more beta2 receptor function in asthmatics leading to common when severe bronchoconstriction is present, bronchospasm. This bronchoconstriction can while prior inhalation of Beta2 agonist reduces this stimulate cough receptors present in airways side effect. Chromoglycate sodium inhalation solutions induce cough due to its hypotonic form can cause cough due to the irritation of upper which can be avoided by isotonic forms which are airways. Some amount of cough, however, 360 Textbook of Pulmonary Medicine occurs due to bromide ions. Anti-cholinergic drugs interstitial pneumonia like features which if like Ipratropium relieves such spasm. Consolidation commonly induces bronchospasm which occurs clinically mimics infective process but responds to 40 minutes after ingestion or may occur upto steroids and withdrawal of the offending etiological 24 hours. Aspirin is related with atopy as first usually associated wih skin rash, facial edema, reported as Sampters triad, i. Its transmission predominantly at the bases and are associated with is autosomal recessive and affects 20 percent of all pleural effusions in 15 percent of cases. Mechanism of bronchospasm due to dyspnea and abnormal lung function test give clues Aspirin is due to inhibition of cyclooxygenase to the diagnosis when chest radiograph appears pathway of arachidonic acid metabolism so that normal. Generally respiratory symptoms subside increased leukotrienes produced by reduced within 48 hours of discontinuation of the drug but Prostaglandin synthesis. Hypersensitivity is intolerance like stomatitis, dysphagia and nephrotic a common pathological event in interstitial pneu- syndrome. Hypersensitivity is an immunological peripheral eosinophilia and pulmonary function tests reaction from various antibodies like IgG, IgE showing obstuction rather than restrictive causing tissue injury. It is caused by free oxygen radical Radiologically bilateral reticulonodular shadows damage to alveolar epithelial and capillary endo- with bilateral pleural effusions are seen. Other than the temporal relation to the darone induced pneumonitis is diagnosed more causative drugs, there are no clinical or radiological easily by Gallium scintigraphy which helps to Drug-induced Respiratory Diseases 361 exclude primary cardiac arrythmias as a cause for thromboembolism is to discontinue heparin and radiological opacities and clinical symptoms like institution of anti-vitamin K treatment. The onset of toxicity is within few damage occurs is as follows: hours to few days. Hypersensitivity reaction: It is an immunological noncardiogenic pulmonary edema with predominant mediated lung disease presenting as pneumonitis neutrophil infiltration. Serum IgE and syndrome or alveolar hemorrhage is common positive skin tests to the offending drug confirms complication with D-penicillamine and has high the diagnosis. Oxidants: Lung damage occurs through free lazine, Procainamide, Chlorpromazine, D-penicilla- oxygen radicals and presents as pneumonitis. Altered collagen production: Collagen induced lung skin, kidney, blood involvement with antihistone damage either due to increased production or antibodies detected in the serum. The above drugs reduced degradation of collagen, clinically also cause mediastinal lymphadenopathy. Lipidosis: Crystalloid phospholipases intra-cellular iatrogenic pulmonary edema is also known.

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However this is not to say that you will always fnd evidence to underpin your practice buy careprost 3 ml mastercard. All research needs to be approved by appropriate ethical bodies prior to com- mencement and it can take years after the successful award of a research grant before the research is undertaken careprost 3 ml discount. This is because research is a complex and lengthy process that can take some time to get started buy cheap careprost. Writing in the British Medical Journal cheap careprost 3ml without a prescription, Yong describes the need to ‘fast track’ certain research projects to ensure that evidence is available at the time that it is required. Before the advent of this technology, libraries contained hard-bound indexes and volumes of the journals that were likely to be most relevant to their students. Practitioners would probably subscribe locally to relevant professional journals and even have their own departmental libraries. Consequently, there were always a large number of journals that were not available to staff and students or available only through inter-library loan. With the advent of online libraries, databases and journals, students and practitioners have access to many thousands of journals and e-books in addi- tion to websites and other sources of information and references. Whilst this is advantageous to health and social care practitioners (notwithstanding the problem of informa- tion overload), it is also of beneft to patients as social media and information technology has been used for the beneft of patient information systems. They concluded that professionals should gain understanding of the type of people using it, their preferences, and the barriers to using it so that providers can prioritize effort when using evidence-based social media in their practice. It has been found that mobile phones are ideal in reaching all demographics and that interventions using short mes- sages may be most effective as a reminder to support disease management behaviours. Research in this area and information communicated by a variety of social media formats is likely to increase. In short, as practitioners we have a duty to incorporate evidence-based infor- mation into our everyday practice to enhance patient/client care. As we have already discussed, practitioners are accountable for their practice and this requirement has grown with the increasing amount of information that is available regarding health and social care. In addition to the information available to professionals, our patients/clients are more able to access infor- mation too and so may want to be involved more in decision making. As the available information increases, it is more and more likely that there will be some good quality research available that underpins the care or treatment you deliver. Therefore if you practise as you have always done in the past without seeking to update yourself, it is likely that you will fnd that your practice is out of date and there is evidence to support a different way of doing things. You may then be called to account as to why your practice is out of date, or, if you give advice or an intervention that is not based on evidence you are more likely to be challenged by fellow practitioners or patients/clients. With the on-going information revolution, keeping up to date with new ideas and research is arguably more diffcult than it was previously. Key points 29 how can i manage the increasing information that i will come across? Smith (2010) discusses some possible responses to this information overload, including a ‘head in the sand strategy’ and reliance on information gained from other colleagues. There are ways to manage the information overload, such as using systematic reviews, good quality literature reviews and research- based guidelines and policy. We will discuss other strategies that you might use to keep up to date with the ever-increasing amount of evidence available in Chapter 7. No longer is it acceptable to say ‘this is how I’ve always done this’ and to carry on with an out-dated practice in the light of new evidence. The increase in the amount of available evidence and the ways that this can be accessed, together with the demand and drive for research evidence, have led to an expectation and culture in which practice is founded on evidence. You will as a student or qualifed practitioner need to be able to justify the care that you give. In the remainder of this book, we will explore how you can best access, evaluate and make sense of the information that is available to you. In Chapter 6 we discuss how you can identify whether or not the evidence you fnd is useful. Finally in Chapter 7 we discuss strategies for adopting an evidence-based approach, and what the realities of that are like, within the realistic context of busy professional practice. Key points 1 It is no longer acceptable to base our practice on tradition or ritual. We will discuss in greater detail how you make sense of and apply the evidence you fnd in Chapters 6 and 7. EvidEncE and dEcision making 31 In simple terms, every time you undertake a professional activity or decision, you need to ask yourself what evidence you need to act in that situation. Evidence and decision making We make decisions all the time in all professional areas. Let’s look at the decision-making process so we can see where the components of evidence based practice ft in. Hastie and Dawes (2010) state that decision making is made up of three parts: • There has to be more than once course of action. Recognizing that there is more than one possible course of action is part of making a professional judgement. Evidence is then used to consider the expected outcomes of the decision and the possible consequences. Standing (2005: 34 and 2010) has defned decision making as: A complex process involving information processing, critical thinking, evaluating evidence, applying relevant knowledge, problem solving skills, refection and clinical judgement to select the best course of action which optimises a patient/client’s health and minimises any potential harm. There are many different activities and decisions that require the use of evidence. Thompson and Stapley (2011) highlighted several decision types: • Decisions about interventions • Decisions about which patients or clients will beneft most from an inter- vention • Decisions about the best time to intervene • Decisions about when to deliver information • Decisions about how to manage a service or care delivery • Decisions about how to reassure patients and clients. We have described some of the varied decisions you may have to make and the different types of evi- dence you may draw upon in the examples below: Examples of different decisions Example: If you are a midwife, you might regularly give advice about breast feed- ing. Some mothers might be struggling to breast feed and you might be tempted to suggest supplementing with bottle feeding as you have heard others do. You need to check the evidence behind this and ensure that you give the best avail- able advice to new mothers and their babies. In this case, the evidence you need is research that addresses the best form of nutrition for new born babies. Example: If you are a social worker, you might regularly need to assess risk of depression in clients and you need to be able to suggest effective strategies to support your client. In this case, the evidence you need is research that addresses the types of interventions that are effective. Example: If you are a surgical nurse, you might regularly need to give an intra- muscular injection and you need to know the best site for the injection and the best technique to use. In this case, the evidence you need is evidence which addresses the most appropriate site for giving an injection. Example: If you are an occupational therapist, you might regularly need to dis- cuss fall prevention strategies with clients. In this case, the evidence you need is that which is concerned with effectiveness of different fall prevention strategies. Example: If you are a physiotherapist, you might regularly give advice to cli- ents with tendonitis and need to know about the effects of exercise versus rest versus alternative strategies. In this case, the evidence you need is that which has evaluated the effectiveness of various interventions for tendonitis. Example: If you are working with vulnerable people, you might regularly need to monitor the fuid intake of your clients to ensure they do not suffer from dehydration. In this case, the evidence you need is about the importance of adequate hydration. The consequences and implications of your decision Some decisions will be more important than others. This will depend on the nature of the risk or potential for harm involved to the patient/client in undertaking or omitting the intervention and the cost involved. If mothers and babies are not appro- priately supported in breast feeding, the longer term health of the baby may suffer. If the occupational therapist does not give appropriate advice regarding falls prevention, a patient or client may have a serious accident.

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Further buy 3 ml careprost mastercard, the peri- in the width of the periodontal ligament in these three odontal ligament of a natural tooth in occlusal function regions discount careprost online american express. At any age buy careprost 3ml fast delivery, the ligament is wider around both is slightly wider than in a nonfunctional tooth because 210 Part 2 | Application of Tooth Anatomy in Dental Practice the nonfunctional tooth does not have an antagonist to stimulate the periodontal ligament and bone cells to remodel purchase careprost overnight. It may contribute to destructive changes in the bone, widening of the peri- odontal ligament, and root shortening (resorption), all of which may contribute to increased tooth mobility. Some of the changes are reversible, meaning that the periodontium can accommodate. Next, view the occlusal surfaces and observe movement of the marginal ridges of the tooth being tested relative to adjacent teeth as you use two rigid instruments (such as the mirror and probe handles) to apply light forces alternating fairly rapidly first one way, then another. Observe the tooth for movement in a buccolingual or mesiodistal direction, as well as for vertical “depressibility. For simplicity, tooth mobility can be recorded as “0” for no mobility, “1” for slight mobility, “2” for moderate mobility, or “3” for extreme mobility that includes depressing the tooth. It is determined by placing the nail of the gloved Method for determining tooth mobility. Two rigid instrument handles are applied to the tooth to see index finger at right angles to the facial crown surface if it can be displaced either buccolingually or mesiodistally. For using a light force while the patient is asked to tap his teeth with severe mobility, the tooth can be depressed or rotated or her teeth, or clench and move the mandible from (which is category 3 mobility). Light, alternating (reciprocating) bucco- is felt, fremitus is confirmed and could be noted as an lingual forces are applied and movement observed relative to “F” on a patient’s chart for that tooth (as seen for tooth adjacent teeth. Functional mobility (biting stress mobility) occurs when teeth move other teeth during occlusal function. In the presence of periodontal disease, A standard, frequently used periodontal probe. To make measurements easier, there are dark bands at 1, this gingival sulcus may be called a periodontal pocket. Probing depth (referred to as pocket depth if periodon- tal disease is present) is the distance from the gingi- val margin to the apical portion of the gingival sulcus. On Probing depths in healthy gingival sulci normally range the other hand, if there is gingival recession where the from 1 to 3 mm. However, if gingival tissues are low probing depths in the presence of true periodontal overgrown (as may be seen during tooth eruption, or disease. Therefore, the critical determinant of whether as a side effect from some medications), a pocket depth periodontitis has occurred is measured by the amount reading of 4 mm or greater (called a pseudopocket) of attachment loss (to be described shortly). A, B, D, and E demonstrate the alignment of the probe against the proximal, tapering crown contours. Note that the probe is angled toward the proximal surface with enough bucco-lingual lean to engage the most interproximal aspect without catching on tissues. Notice that the depth of this midfacial sulcus is 1 mm deep, and the tissue is so thin that the probe can be seen D E through it. The probe is guided along the tooth surface, and care is taken not to engage the sulcular gingival tissues. Although not easily appreciated from this view, it is also angled 10 to 15° to reach the most direct proximal area. When the gingival recession, and the root is exposed (seen most depth of the sulcus/pocket has been reached, resilient obviously in Fig. The probe should be angled By convention, the following denotes the gingival slightly toward the crown or root surface to prevent margin level: it from engaging or being impeded by the pocket wall (seen best midfacially in Fig. There in proximal contact, the probe should progress toward is no gingival recession. The three facial readings to record are the deepest readings for mesial interproximal, mid- When recession has occurred, the distance between the buccal, and distal interproximal. On the other hand, there may be no or is subgingival, the probe should be at a 45° angle. The attachment loss even with deep pockets if pseudopock- junction between enamel and cementum can be felt with ets are present, that is, pockets due to an enlargement the probe. Periodontists also make interproximal measurements of the gingival margin level that is a more challenging D. It is a measurement that indicates how much support has been lost and is, Bleeding on probing occurs when bacterial plaque therefore, a critical determinant of whether periodontal affects the gingival sulcular epithelium, resulting in disease has occurred. Study The percentage of sites that bleed can be calculated by the example of clinical attachment calculation on the dividing the number of bleeding sites by the number of tooth in Figure 7-23 where the sulcus depth is 1 mm total sites (where total sites equal the number of teeth (Fig. When the two numbers are added together, the amount of attachment loss is determined. In this case, the probing depth of 1 mm and the gingival level of + 1 (1 mm recession) results in an attachment loss of 2 mm. In the absence of disease, furcations It is important to remember where to insert a probe in cannot be clinically probed because they are filled in order to confirm furcation involvement (summarized in with bone and periodontal attachment. Recall that mandibular molar furcations are periodontal disease, however, attachment loss and bone located between mesial and distal roots near the middle loss may reach a furcation area resulting in a furcation 28,29 of the buccal surface (midbuccal) and middle of the lin- involvement. Pockets that extend into the furcation gual surface (midlingual) as illustrated in Figure 7-28A create areas with difficult access for the dentist and den- tal hygienist to clean during regular office visits, and are a real challenge for patients to reach and clean dur- ing their normal home care. Therefore, these areas of furcation involvement readily accumulate soft plaque deposits and mineralized calculus (seen on an extracted teeth in Fig. These deposits frequently become impossible to remove and may provide a pathway for periodontal disease to continue to progress. Initially, there may be an incipient (initial or begin- ning) furcation involvement. As disease progresses into the furcation (interradicular) area, attachment loss and bone loss will begin to progress horizontally between the roots. At that point, a furcation probe (such as a Nabor’s probe with a blunt end and curved design) can probe into a subgingival furcation area. Calculus in the furcation area and root cal area) as demonstrated in Figure 7-27A. This extracted molar has mineralized deposits extreme circumstances, the furcation probe may actually (calculus) in the furcation. Once disease progresses into the extend from the furcation of one tooth aspect to the fur- furcation area, access for removal by the dentist or dental cation on another tooth aspect. The furcation probe is able to engage far into the interradicular area because of periodontal destruction. The furcation (Nabor’s) probe has a rounded point and is curved to allow negotiation into furcations. This allows estimation of how far the probe horizontally penetrates into the furcation. The furcation probe is engaging the roof of a furcation but does not com- pletely penetrate to the lingual entrance of the furcation. Note how close the furcation is to the mesiolingual (mesiopalatal) line angle of the tooth due to the wide mesiobuccal root. The probe is shown at the apical and horizontal extent of the penetration into the facial furcation. However, more cervically positioned furcations palatal and distobuccal roots as seen in Fig. The furcation probe is shown as it enters the potential furcation near the middle of the facial surface of this maxillary molar. Palatal view: The mesial furcation on a maxillary molar is accessed through the palatal embrasure since the mesiobuccal root is wider than the palatal root. Palatal view: The distal furcation on a maxillary molar is probed through the palatal embrasure here, although the distobuccal root is about as wide as C the palatal root. Divergent roots with the furcation in the coronal one third of the root with a short root trunk. Fused roots with Radiograph showing close root approxima- the furcation in the coronal one third of the root. Furcations and concavities like these are virtually inaccessible due in part to better access.

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