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Infection of this area raises the floor of the mouth and displaces the tongue blood pressure medication losartan purchase 5 mg enalapril otc, resulting in pain and difficulty in swallowing but little facial swelling blood pressure kidney generic enalapril 10 mg mastercard. The submental space is found between the mylohyoid muscle superiorly and the platysma inferiorly. It is bounded laterally by the mandible and posteriorly by the hyoid bone, and it is traversed by the anterior belly of the digastric muscle. Infections of this area arise from the region of the mandibular anterior teeth and result in swelling of the submental region; infections become more dangerous as they proceed posteriorly. Figure6117 Posterior view of mandible, showing the attachment of the mylohyoid muscles (A); geniohyoid muscles (B); sublingual gland (C); submandibular gland (D),which extends below and also to some extent above the mylohyoid muscle; and sublingual (E) and inferior alveolar (F) nerves. The submandibular space is found external to the sublingual space, below the mylohyoid and hyoglossus muscles (see Figure 61-16 and 61-17). This space contains the submandibular gland, which extends partially above the mylohyoid muscle, thus communicating with the sublingual space, and numerous lymph nodes. Infections of this area originate in the molar or premolar area and result in swelling that obliterates the submandibular line and in pain when swallowing. Although the bacteriology of these infections has not been completely determined, they are presumed to be mixed infections with an important anaerobic component. In general, at least a 2-mm space should be present between the coronal border of the nerve and the apex of the implant. The mental nerve must be considered during implant placement and also during mucogingival surgery because damage to this nerve results in debilitating paresthesia. The lingual nerve is most susceptible to damage when it is close to a third molar that will be extracted. In the maxilla the nasopalatine nerves and vessels are of little importance if they are included in the surgical field. However, involvement of the greater palatine artery should be avoided because significant hemorrhage can occur if it is severed. Radiographic evaluation of the position and extent of the maxillary sinus is essential during treatment planning for dental implants. Woelfel J: Dental anatomy: its relevance in dentistry, ed 4 Philadelphia, 1990, Lea & Febiger. Carranza Periodontal pocket reduction surgery limited to the gingival tissues only and not involving the underlying osseous structures, without the use of flap surgery, can be classified as gingival curettage and gingivectomy. Current understanding of disease etiology and therapy limits the use of both techniques, but their place in surgical therapy is essential. Scaling refers to the removal of deposits from the root surface, whereas planing means smoothing the root to remove infected and necrotic tooth substance. However, they are different procedures, with different rationales and indications, and should be considered separate parts of periodontal treatment. A differentiation has been made between gingival and subgingival curettage (Figure 62-1). Gingival curettage consists of the removal of the inflamed soft tissue lateral to the pocket wall, whereas subgingival curettage refers to the procedure that is performed apical to the epithelial attachment, severing the connective tissue attachment down to the osseous crest. It should also be understood that some degree of curettage is done unintentionally when scaling and root planing are performed; this is called inadvertent curettage. This chapter refers to the purposeful curettage performed during the same visit as scaling and root planing, or as a separate procedure, to reduce pocket depth by enhancing gingival shrinkage, new connective tissue attachment,or both. Rationale Curettage accomplishes the removal of the chronically inflamed granulation tissue that forms in the lateral wall of the periodontal pocket. This tissue, in addition to the usual components of granulation tissues (fibroblastic and angioblastic proliferation), contains areas of chronic inflammation and may also have pieces of dislodged calculus and bacterial colonies. The latter may perpetuate the pathologic features of the tissue and hinder healing. This inflamed granulation tissue is lined by epithelium, and deep strands of epithelium penetrate into the tissue. The presence of this epithelium is construed as a barrier to the attachment of new fibers in the area. Figure621 Extent of gingival curettage (white arrow) and subgingival curettage (black arrow). When the root is thoroughly planed, the major source of bacteria disappears, and the pocket pathologic changes resolve with no need to eliminate the inflamed granulation tissue by curettage. The existing granulation tissue is slowly resorbed; the bacteria present, in the absence of replenishment of their numbers by the pocket plaque, are destroyed by the defense mechanisms of the host.

Carter J blood pressure levels variation buy discount enalapril 10mg on-line, Saunders V: Virology: principles and applications blood pressure medication zapril order enalapril 10mg line, Chichester, England, 2007, Wiley. Ursic T, et al: Human bocavirus as the cause of a life-threatening infection, J Clin Microbiol 49:1179­1181, 2011. Doe reported that her daughter had had a mild cold within the previous 2 weeks and that she herself was currently having more joint pain than usual and felt very tired. What underlying condition would put the daughter at increased risk for serious disease after B19 infection? The biphasic nature of the disease and the slapped-face rash are notable symptoms but are not unique to B19. A somewhat similar course of disease would occur with human herpesvirus 6 induction of exanthema subitum (roseola), although the time course may be different. The child was infectious during the initial disease signs and symptoms, which resemble a mild cold. The initial nonspecific disease signs are caused by interferon and other innate responses to the infection. The rash is caused by immune responses, most likely associated with antibody and virion immune complexes. The rash of the daughter and the arthralgia of the mother are due to the presence of antibody, formation of immune complexes, and type 2 and 3 hypersensitivity reactions. Pregnant women are at risk for B19 infection, which causes hydrops fetalis and loss of the fetus. Quarantine would not be effective because the virus is spread before the onset of the classic disease signs and symptoms of erythema infectiosum (fifth disease). The family has more than 230 members divided into nine genera, including Enterovirus, Rhinovirus, Hepatovirus (hepatitis A virus; discussed in Chapter 55), Cardiovirus, and Aphthovirus. The enteroviruses are distinguished from the rhinoviruses by the stability of the capsid at pH 3, the optimum temperature for growth, the mode of transmission, and their diseases (Box 46-2). Infection could have occurred upon contact with fecal material from the mother but, just as likely, by contact with nasal secretions or an aerosol. The mother or another family member is likely to be the source of infection, since echovirus 11 causes a common cold in adults. The virus is a naked capsid virus, and the capsid is impervious to acids, detergents, heat, and dryness. It can withstand the harsh conditions of the gastrointestinal tract and even insufficient sewage treatment. As a result, the virus is transmitted by the fecal-oral route, but it can also infect the upper respiratory tract and cause common coldlike symptoms and can be transmitted by contact or aerosols. The most important immune response for protection is antibody, which will neutralize the released virus to prevent spread of the virus. If Mom had been infected at an earlier time, then transplacental immunoglobulin (Ig)G would have been provided to the infant from Mom for protection, but that is not the case. Antibody in the serum also prevents spread of the virus to the target tissue, which would be the meninges and brain. Enteroviruses are resistant to pH 3 to pH 9, detergents, mild sewage treatment, and heat. The icosahedral capsid has 12 pentameric vertices, each of which is composed of five protomeric units of proteins. The capsids are stable in the presence of heat, acid, and detergent, with the exception of the rhinoviruses, which are labile to acid. The capsid structure is so regular that paracrystals of virions often form in infected cells (Figures 46-1 and 46-2). The naked picornavirus genome is sufficient for infection if microinjected into a cell. The genome encodes a polyprotein that is proteolytically cleaved by viral-encoded proteases to produce the enzymatic and structural proteins of the virus.

Ainamo J blood pressure chart normal blood pressure range discount enalapril 5mg with mastercard, Asikainen S blood pressure of 130/80 purchase enalapril 10 mg otc, Ainamo A, et al: Plaque growth while chewing sorbitol and xylitol simultaneously with sucrose flavored gum, J Clin Periodontol 6:397, 1979. American Academy of Periodontology: Proceedings of the 1996 World Workshop in Periodontics, 1996, p 926. Brecx M, Theilade J, Attstrom R: An ultrastructural quantitative study of the significance of microbial multiplication during early dental plaque growth, J Periodontal Res 18:177, 1983. Brooun A, Liu S, Lewis K: A dose-response study of antibiotic resistance in Pseudomonas aeruginosa biofilms, Antimicrob Agents Chemother 44:640, 2000. Carlsson J: Symbiosis between host and microorganisms in the oral cavity, Scand J Infect Dis Suppl 24:74, 1980. In Lindhe J, editor: Textbook of clinical periodontology, Munksgaard, 1983; Munksgaard International Publishers. Carlsson J, Soderholm G, Almfeldt I: Prevalence of Streptococcus sanguis and Streptococcus mutans in the mouth of persons wearing full-dentures, Arch Oral Biol 14:243, 1969. Carlsson J, Grahnen H, Jonsson G, et al: Establishment of Streptococcus sanguis in the mouths of infants, Arch Oral Biol 15:1143, 1970. Chen C, Slots J: Clonal analysis of Porphyromonas gingivalis by the arbitrarily primed polymerase chain reaction, Oral Microbiol Immunol 9:99, 1994. Contreras A, Slots J: Herpesviruses in human periodontal disease, J Periodontal Res 35:3, 2000. De Soete M, De Keyser C, Pauwels M, et al: Outgrowth of cariogenic bacteria after initial periodontal therapy, J Dent Res 84:48, 2005. Evaldson G, Heimdahl A, Kager L, et al: the normal human anaerobic microflora, Scand J Infect Dis Suppl 35:9, 1982. Fletcher M: the physiological activity of bacteria attached to solid surfaces, Adv Microb Physiol 32:53, 1991. Fransson C, Berglundh T, Lindhe J: the effect of age on the development of gingivitis: clinical, microbiological and histological findings, J Clin Periodontol 23:379, 1996. Furuichi Y, Lindhe J, Ramberg P, et al: Patterns of de novo plaque formation in the human dentition, J Clin Periodontol 19:423, 1992. Grenier D, Nutritional interactions between two suspected periodontopathogens, Treponema denticola and Porphyromonas gingivalis, Infect Immun 60:5298, 1992. Grenier D, Mayrand D: [Studies of mixed anaerobic infections involving Bacteroides gingivalis], Can J Microbiol 29:612, 1983. Hultin M, Gustafsson A, Klinge B: Long-term evaluation of osseointegrated dental implants in the treatment of partly edentulous patients, J Clin Periodontol 27:128, 2000. Hultin M, Gustafsson A, Hallstrom H, et al: Microbiological findings and host response in patients with periimplantitis, Clin Oral Implants Res 13:349, 2002. Hyyppд T, Paunio K: the plaque-inhibiting effects of copper amalgam, J Clin Periodontol 4:231, 1977. Isogai E, Isogai H, Sawada H, et al: Bacterial adherence to gingival epithelial cells of rats with naturally occurring gingivitis, J Periodontol 57:225, 1986. Kohler B, Krasse B, Carlen A: Adherence and Streptococcus mutans infections: in vitro study with saliva from non-infected and infected preschool children, Infect Immun 34:633, 1981. Kononen E, Asikainen S, Jousimies-Somer H: the early colonization of gram-negative anaerobic bacteria in edentulous infants, Oral Microbiol Immunol 7:28, 1992. Lekholm U, Ericsson I, Adell R, et al: the condition of the soft tissues at tooth and fixture abutments supporting fixed bridges: a microbiological and histological study, J Clin Periodontol 13:558, 1986. Leonhardt A, Renvert S, Dahlen G: Microbial findings at failing implants, Clin Oral Implants Res 10:339, 1999. Lie T: Morphologic studies on dental plaque formation, Acta Odontol Scand 37:73, 1979. Lie T, Gusberti F: Replica study of plaque formation on human tooth surfaces, Acta Odontol Scand 37:65, 1979. Lцe H: Periodontal diseases: a brief historical perspective, Periodontol 2000 2:7, 1993. Lovdal A, Arno A, Waerhaug J: Incidence of clinical manifestations of periodontal disease in light of oral hygiene and calculus formation, J Am Dent Assoc 56:21, 1958.

They appear identical at both light and electron microscopic levels69 but may have different functions arrhythmia greenville sc discount enalapril 5mg with amex, such as secretion of different collagen types and production of collagenase arteria femoralis profunda generic enalapril 5mg otc. Osteoblasts and cementoblasts, as well as osteoclasts and odontoclasts, also are seen in the cemental and osseous surfaces of the periodontal ligament. The epithelial rests of Malassez form a latticework in the periodontal ligament and appear as either isolated clusters of cells or interlacing strands (Figure 5-7), depending on the plane in which the microscopic section is cut. Continuity with the junctional epithelium has been suggested in experimental animals. Epithelial rests are distributed close to the cementum throughout the periodontal ligament of most teeth and are most numerous in the apical area122 and cervical area. The cells are surrounded by a distinct basal lamina, are interconnected by hemidesmosomes, and contain tonofilaments. The defense cells in the periodontal ligament include neutrophils, lymphocytes, macrophages, mast cells, and eosinophils. These cells, as well as those associated with neurovascular elements, are similar to the cells in other connective tissues. GroundSubstance the periodontal ligament also contains a large proportion of ground substance, filling the spaces between fibers and cells. It consists of two main components: glycosaminoglycans, such as hyaluronic acid and proteoglycans, and glycoproteins, such as fibronectin and laminin. The cell surface proteoglycans participate in several biologic functions, including cell adhesion, cell-cell and cell-matrix interactions, binding to various growth factors as co-receptors, and cell repair. PhysicalFunctions the physical functions of the periodontal ligament entail the following: 1. Provision of a soft tissue "casing" to protect the vessels and nerves from injury by mechanical forces. Figure58 Cementicles in the periodontal ligament, one lying free and the other adherent to the tooth surface. ResistancetoImpactofOcclusalForces(ShockAbsorption) Two theories pertaining to the mechanism of tooth support have been considered: the tensional and viscoelastic system theories. The tensional theory of tooth support states that the principal fibers of the periodontal ligament are the major factor in supporting the tooth and transmitting forces to the bone. When a force is applied to the crown, the principal fibers first unfold and straighten and then transmit forces to the alveolar bone, causing an elastic deformation of the bony socket. Finally, when the alveolar bone has reached its limit, the load is transmitted to the basal bone. Many investigators find this theory insufficient to explain available experimental evidence. The viscoelastic system theory states that the displacement of the tooth is largely controlled by fluid movements, with fibers having only a secondary role. These perforations of the cribriform plate link the periodontal ligament with the cancellous portion of the alveolar bone and are more abundant in the cervical third than in the middle and apical thirds (Figure 5-9). Arterial back pressure causes ballooning of the vessels and passage of the blood ultrafiltrates into the tissues, thereby replenishing the tissue fluids. When an axial force is applied to a tooth, a tendency toward displacement of the root into the alveolus occurs. The oblique fibers alter their wavy, untensed pattern; assume their full length; and sustain the major part of the axial force. The first is within the confines of the periodontal ligament, and the second produces a displacement of the facial and lingual bony plates. The apical portion of the root moves in a direction opposite to the coronal portion. In areas of pressure, the fibers are compressed, the tooth is displaced, and a corresponding distortion of bone exists in the direction of root movement. The root apex105 and the coronal half of the clinical root have been suggested as other locations of the axis of rotation.

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References:

• https://www.asge.org/docs/default-source/education/Technology_Reviews/doc-endoscopic_mucosal_resection_aip.pdf
• https://www.dhss.delaware.gov/dhss/dph/chca/files/famplanenglishd28533.pdf
• https://medicine.umich.edu/sites/default/files/content/downloads/Student%20survival%20guide%202013.pdf