By N. Ateras. Occidental College.

In type E2 there was an erosion of the superior part of the glenoid and in type E3 the erosion extended to the inferior part of the glenoid (Fig best doxazosin 4mg gastritis diet 101. Radiological classification of glenoid erosion in osteoarthritis with massive rupture of the cuff order doxazosin 4 mg without a prescription gastritis symptoms how long does it last. Radiographic evidence of arthrosis was graded as mild, moderate, or severe evaluated in the anteroposterior radiograph. There have been various attempts at staging the development of the lesion to aid in understanding the process and to apply appropriate therapy. For this reason, a modification of the staging system first pro- posed by Arlet and Ficat appears to be the most worthwhile. The modification is proposed because there are therapeutic implications to Stage 5, the phase at which acetabular changes are visible (Fig. Classification of osteo- necrosis of bone modified for the humeral head according to Nov-Josseand and Basso [105a] based on Cruess 166 14 Classifications of necrosis of the humeral head n Stage 1: this is the preradiologic stage and is characterized by a total absence of radiologic features. Some patients will complain of a stiff, painful hip and there is occasionally even limitation of motion. Scin- timetry may show either absence of uptake in areas of the femoral head or (and this is much more likely) increased uptake in the femo- ral head as a whole. Such an increase indicates that the area of osteo- necrosis has already provoked a reparative response. Ficat and Arlet describe three forms (A) diffuse osteoporosis, (B) a sclerotic form, and (C)a mixed osteoporotic/sclerotic form. It is reasonable to as- sume that the sclerotic changes represent a later stage in the develop- ment-beyond that of either osteolysis or osteoporosis ±during which time the body has laid down appositional new bone as part of the re- pair process. However, with a preserved femoral head shape, this form is still classed in Stage 2. The stage repre- sents collapse of the subchondral bone with the area of collapse be- ginning characteristically in the anterolateral area of the femoral head, best seen on a lateral view or on tomograms. The relationship of the radiologic changes, symptom change, and clinical pathology would all favour the development of a subchondral fracture. This stage corre- lated with the operative findings of a separated, sometimes free, os- teocartilagenous flap lying on depressed subchondral bone. As long as acetabular cartilage remains relatively normal, hemiarthroplasty is a reasonable therapeutic choice. The differences are best explained by describing the point of maximum joint reaction force and the anatomical contour of the glenoid compared to that of the acetabulum. The glenoid is flat, and the point of maxi- mum pressure on the head seems to occur when the arm has been raised about 908. At this point the scapula has rotated 308, so that the area of the head that is placed under maximum pressure is that contact- ing the glenoid when the humerus has been elevated 608. This area of contact is the site where the humeral head consistently collapses in avascular necrosis and where maximum wear and sclerosis occur in os- teoarthritis. Avascular changes with collapse of the articular surfaces in the el- bows of two paraplegic patients, as mentioned above, confirm the im- portance of pressure and load in the configuration of avascular necrosis of the humeral head. In their discussions of the aetiology of avascular necrosis, both Cruess [149] and Springfield and Enneking [148] pointed out that the alterations in the femoral head did not match the anatomi- cal configuration of the blood vessels in the femoral head nor the ran- dom site of infarction that might occur if the infarcts were due to ªslud- gingº. Since the location of the crescent sign and the later collapse at the head correspond to the point of maximum joint reaction force on the humeral head, Neer [102] believes the consistent location of the wedge-shaped area of infarction is largely due to pressure. To assist in describing the indications and treatment of this condi- tion, Neer has adapted the excellent classifications of Ficat and Ennek- ing to the shoulder. Stage I disease shows only subtle changes that are not always definitely diagnostic. There may be slight mottling of the trabecular pattern or an area of sub- chondral decalcification. Classification of avascular necrosis of the humeral head according to Neer [102] sickle cell disease) have more very early pain.

The discol- oration on tooth surfaces is extremely tenacious order doxazosin 1 mg mastercard gastritis diet , and a Triclosan is active against a broad range of oral gram- professional tooth cleaning using abrasives is necessary positive and gram-negative bacteria doxazosin 2mg gastritis thin stool. The staining is dose dependent, of its antibacterial activity is the bacterial cell mem- and variation in severity is pronounced between indi- brane. Effects at lower 42 Drugs for the Control of Supragingival Plaque 503 504 V THERAPEUTIC ASPECTS OF INFLAMMATORY AND SELECTED OTHER CLINICAL DISORDERS concentration are more subtle. In contrast to the efficacy of fluorides in preventing car- Clinical Effects ious lesions, these formulations have relatively poor an- tibacterial properties (Table 42. Finally, of considerable interest terfere with bacterial membrane function, bacterial is the observation that triclosan inhibits gingivitis by a adhesion, and glucose uptake, thereby inhibiting the mechanism independent of its antiplaque activity. The ADA Council on this surprising effect stems from research conducted us- Dental Therapeutics endorses fluorides for their caries- ing a gingival fibroblast cell culture model. Prebrushing Rinses Essential Oils The topical application of a liquid rinse before brushing A mixture of essential oils consisting of thymol 0. Prebrushing rinses usually Essential oils may reduce plaque levels by inhibiting contain a plethora of ingredients, and it is not known bacterial enzymes and by reducing pathogenicity of which constituent is the active chemical. It has been sug- plaque via reduction of the amount of endotoxin; the al- gested that sodium lauryl sulfate acts as a detergent to cohol is probably responsible for denaturing bacterial dislodge or loosen the plaque on teeth (Table 42. The substantivity of Listerine appears to be When prebrushing rinses were tested against placebo quite low, and therefore, it must be used at least twice a rinses, prebrushing rinses appeared to have no effect on day to be effective. Adverse reac- Today gingivitis and periodontitis are prevented princi- tions include a bitter taste and burning sensation in the pally through mechanical plaque control; however, den- oral cavity. Regular use of high-alcohol rinses can ag- tition free of supragingival and subgingival plaque is ex- gravate existing oral lesions and desiccate mucous tremely difficult to accomplish and maintain. In addition to Listerine, a huge number of annual basis, Americans spend more than $750 million American Dental Society (ADA) approved generic on oral rinsing agents, although few effective plaque-in- equivalents available over the counter. The goal of future product development is not so Fluorides much an improvement in the antiplaque performance Fluorides are widely used in caries prevention, for which of the existing effective compounds but rather lessening they have been highly effective. Systemic administration of their side effects and development of better delivery of fluorides for caries prevention is available via drink- systems. Products that combine various known com- 42 Drugs for the Control of Supragingival Plaque 505 pounds with well-established plaque-inhibiting proper- vention of supragingival plaque will depend on prod- ties are under investigation. The other four compounds are substrate in the oral cavity is not cationic and do not bind strongly to tissues. Triclosan (A) is active against a broad range of (B) Absorption oral gram-positive and gram-negative bacteria. Yellow or brownish extrinsic stain of teeth is a fre- bacteria, but Streptococcus mutans and Actinomyces quently observed side effect of viscosus, two bacteria particularly associated with (A) Fluoride dental lesions, are especially susceptible to its ac- (B) Triclosan tion. Stannous fluoride (D) is widely used in caries (C) Essential oils prevention, and many studies have proven its effec- (D) Chlorhexidine tiveness. The LEAST effective chemical agent for reduction shown to decrease supragingival plaque in combina- of dental plaque is tion with the polymer in a commercial preparation. Proceedings of the 2nd involved in drug elimination, while absorption (B) European Workshop on Periodontology. Rinsing, irrigation and sustained local scribes the ability of a drug to enter a variety of body delivery. In most instances, dental plaque can cause ery- Administration was evaluating the results of a new thema and gingival bleeding, but the gingival re- drug for the treatment of periodontal disease. Her sponse can also be exacerbated by a variety of review of the phase III clinical data caused her to systemic conditions, including diabetes mellitus, visit her dentist, since she was concerned that her leukemia, malnutrition, puberty and pregnancy. For exam- revealed swollen and tender gingiva that were ple, the age of the patient, her appearance, and accompanied by erythema and bleeding upon mild questions about her diet should be enough to provocation. Her dental radiographs revealed no rule in or out issues concerning puberty and mal- abnormalities, and her physician found her to be nutrition. She reports be ruled out, an additional physical examination taking no medications and denies allergies to any by a physician may be necessary. She is concerned about her health to be requested could include oral glucose toler- because her gingiva will bleed when she eats fibrous ance test for diabetes mellitus, human chorionic foods (e. What do you think is the most likely cause of her tative and quantitative evaluation of bone mar- periodontal disease? Should an oral chemotherapeutic agent be pre- using over-the-counter toothpastes with triclosan scribed for her periodontal disease?

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