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Dentistry (Vol 2, No 1, 2010)
Bleaching and Caries Control in Elderly Patients
Professor Van Haywood examines the role of bleaching in the older patient and how it relates to caries

Bleaching teeth with carbamide the staining is a detriment to use. than hydrogen peroxide, since the urea strep mutans, one option is to both clean peroxide in a custom tray is Interestingly enough, 10% carbamide and carbopol in 10% CP allows it to the teeth and destroy the lactobacillus an exciting service to offer peroxide can be used alternately with be active up to 10 hours in the mouth, bacteria by wearing the non-scalloped, patients and a tremendous adjunct to chlorhexidine to remove those stains while hydrogen peroxide is only active no-reservoir tray overnight with restorative dental treatment. One of (Addy et al, 1991).
the side effects noticed when bleaching Although 10% carbamide peroxide The tray design used for caries control supplemented by using chlorhexidine teeth is that the use of 10% carbamide is generally associated with tooth is a non-scalloped, no reservoir tray, rinse for 30 seconds prior to bedtime. peroxide applied nightly in a custom- whitening, the material was originally which extends 1-2mm onto the gingival In addition to caries control, the fitted tray is effective to remove plaque, used as an oral antiseptic for gingival tissue (Haywood 2006, 2007). It should 10%CP can control the staining from reduce caries bacteria and elevate pH healing (Haywood, 1992). It was being not extend into undercuts to the path chlorhexidine.
on elderly patients for successful long- applied in a tray for wound healing of insertion, nor encroach on frenum The only side-effect of this treatment when the tooth whitening side effect attachments. The contact with the is that the teeth will become white. As the population of the world ages – was discovered (Haywood, 1991). gingival prevents the washing out of For most people, this may be a benefit. and is living longer and keeping more Carbamide peroxide 10 and 15% has the material, and does not generally However, since restorations do not of its teeth – there is a greater number of been has been classified by the United cause gingival irritation at the 10% change colour, there can be a mismatch people who have received good dental States Food and Drug Association as concentration (Leonard et al, 1994). between existing restorations and care in their younger years, but are now category 1, which means there are The lack of reservoirs means less bleached teeth. Some restorations faced with difficulty in maintaining sufficient data to demonstrate that material is needed per application. The may need to be replaced due to this those restorations and existing teeth these agents are safe and effective for traditional custom fitted bleaching tray colour mismatch. However, the benefit in their later years. Dentists have use in the oral cavity as oral antiseptic from an alginate impression works of saving the teeth or, having larger experienced the frustration of rampant agents (Haywood, 1993, Dental Product well, although there are some options restorations due to caries, may override root surface caries around crown Spotlight, 2001). Persons now involved with ‘boil and form’ trays in certain this concern. Teeth typically whiten margins or in virgin teeth as these in tooth whitening research report a arches (Haywood et al, 2001). The boil to a certain level, then stabilise, even patients age. This caries phenomenon loss of plaque during that time such and form tray can also be used as a with further treatment. However, it is seems to be associated with a reduction that their teeth feel ‘squeaky clean’ diagnostic test to see if the patient can unknown to what level of whitening the in salivary flow due to ageing, much like after a prophylaxis. Reports wear the tray and if the material will patient will progress, so some patients increased side-effects of medications, from a century ago cite the use of this be effective.
may have very white teeth over time.
and a decline in health. There is also a material in children with pitted teeth Carbamide peroxide for caries control Sensitivity is often associated with loss in manual dexterity and the ability to reduce caries (Atkinson, 1893). has a long history of use, except that bleaching. However, in elderly patients, to perform routine oral hygiene care. Current research on safety noted that the previous attempts did not employ the pulps have receded such that Even if these patients have access to the pH of the saliva and the material a tray application. Several papers cite sensitivity is seldom a problem. The use care from a general dentist, their ability in the tray is elevated to about eight in the use of 10% carbamide peroxide of potassium nitrate in the bleaching to clean at home around hemi-sected less than five minutes after application, as a rinse in the form of Glyoxide, tray for 10-30 minutes has been shown molars, under pontics for fixed partical and remains that for the duration of in orthodontic patients during three to alleviate this in most patients dentures, or interproximally around the application (Leonard et al, 1994, years’ treatment to prevent white spot (Haywood et al, 2001). Additionally, gingival recession or periodontally Leonard and Austin et al, 1994) (in those lesions (Fogel and Magill, 1971). It has many bleaching products now contain involved teeth is compromised, and studies, two hours). This occurrence is also been used in elderly patients as a this ingredient, and sensitivity levels often results in caries between dental related to the urea in the composition rinse for oral hygiene (Haywood, 1992). have been greatly reduced with the (Firestone et al, 1982, Wainwright and Carbamide peroxide seems to be most combination of potassium nitrate and a disadvantage is further complicated Lemoine, 1950). The pH values are effective when some type of container soft tray, as well as by pre-brushing and by the tendency of these patients to crucial to preventing the formation of or barrier is used.
use sugar-containing breath mints due tooth decay, since root caries can start to salivary flow loss, and the resultant when the pH of the mouth is between The questions of safety to the ingestion 6 and 6.8 (Hoppenbrouwers et al, 1986, have been answered in literature This technique is meant to be used prior to bleaching, as well as current for the life of the patient. Studies on What is needed is a simple, inexpensive 1987). A further study has indicated literature (Ritter et al, 2002, European bleaching teeth nightly for six to twelve mechanism to apply to better clean the that 10%CP kills one of the two bacteria Commission, 2005). Prior to bleaching months with tetracycline-stained teeth teeth. Rather than mechanical means causing tooth decay (Bentley et al, 2000). and even today, 10% carbamide have indicated no harm to the teeth alone, a chemotherapeutic approach Gingival indices in bleaching studies peroxide is used in new born infants, or pulp with low concentrations of is needed. Typically, fluoride in a tray have indicated some improvement 10 drops in their throat every two carbamide peroxide (Haywood 1997, has been used for this population. in gingival scores (Powell and Bales, hours for seven to eight days, to treat Matis et al 2006, Leonard et al 1994).
However, clinical experience has 1991), although the patient population candidiasis or thrush (Dickstein, 1964). clean mouth for the onset of treatment. Since carbamide peroxide kills beneficial with oral cancer patients Chlorhexidine can also be used, but Carbamide peroxide is preferred rather lactobacillus, and chlorhexidine kills for whom the cancer treatment has Figure 1: Moderate tetracycline-stained teeth with dark
Figure 2: Four months of nightly bleaching using 10%
Figure 3: A non-scalloped, no-reservoir bleaching
discoloration on the incisal half and slight banding
carbamide peroxide in a non-scalloped, no-reservoir
tray is used to apply 10% carbamide peroxide nightly
is an unsightly problem for this patient. Tetracycline-
tray produces an acceptable outcome. Now the patient
for caries control in elderly patients. One or both
stained teeth generally take two to six months to treat.
is interested in restoring the fractured central incisor.
arches may be treated, depending on the patient’s
Generally, lighter teeth make a person appear 10 years
One arch was treated at a time to allow comparison
needs. The disadvantage is the natural teeth will
and encourage compliance
become whiter but restorations will not change
((Vol 2, No 1, 2010)) Dentistry
reduced the salivary flow, and caries is containing carbamide peroxide on Haywood V B, Leonard RH, Dickinson Hoppenbrouwers PMM, Driessens a problem. It is also used in orthodontic cariogenic bacteria. J Esthet Dent 2000; GL. Efficacy of six-months nightguard FCM, patients to avoid white spot lesions, 12: 33–37. vital bleaching of tetracycline-stained vulnerability of unexposed human although the fit of the tray and the Dickstein B. Neonatal Oral Candidiasis: teeth. J Esthet Dent 1997;9(1):13–19.
dental roots to demineralization. J Dent amount of material needed makes this Evaluation of a new chemotherapeutic Haywood V B. Nightguard Vital Res 65(7):955-958, 1986 option more of a challenge. Typically agent. Clinical Pediatrics 1964;3(8): Bleaching: A History and Products Leonard R H Jr, Bentley C D, Haywood the ‘boil and form’ trays can be made 485–488.
Update: Part 1. Esthetic Dentistry V B. Salivary pH changes during Commission:Scientific Update 1991;2(4):63–66.
Committee on Consumer Products: Haywood V B. The Food and Drug Quintessence Int 1994 25:547–550.
Administration and its influence on Leonard RH, Austin SM, Haywood Root caries may be minimised by Firestone A R, Schmid R, Muhlemann home bleaching. Current Opinion in VB, and Bentley CD. Change in use of carbamide peroxide in a tray H R. Effect of topical application of Cosmetic Dentistry 1993:12–18.
overnight to remove plaque, elevate urea peroxide on caries incidence and Haywood V B. Considerations for Vital both cost-efficient and safe. Sensitivity Carbamide Peroxide after nearly 20 819–23.
can be treated by potassium nitrate Fogel M S, and Magill J M. Use of Years of Proven Use. Inside Dentistry Leonard RH, Haywood VB, Caplan DJ, in the tray, pre-brushing with it, and an Antiseptic Agent in Orthodontic 2006; Sept: 2–5.
using a bleaching product containing October:50–54.
Haywood V B. Extended Bleaching Tetracycline-Stained teeth: 90 months of Tetracycline-stained teeth: a case Post Treatment. J Esthet Restor Dent for caries control is for ageing patients, Haywood V B. History, safety, and report. Contemporary Esthetics and 2003;15(3):142–154.
those with physical handicaps or effectiveness of current bleaching Restorative Practice 1997;1(1):14–21.
nightguard vital bleaching technique. Haywood V B. History, safety, and MA, Jiang T. Extended bleaching of conventional brushing and flossing is Quintessence Int 1992 23: 471–488.
effectiveness of current bleaching tetracycline-stained teeth: A 5-year not proving effective. The side-effect Haywood V B., Caughman W F, techniques and applications of the study.Operative Dent, 2006, 31-6, of whitening the teeth is often less of Frazier K B, Myers M L. Tray delivery nightguard vital bleaching technique. 643–651.
a problem than the cost and medical of Potassium nitrate-fluoride to reduce Quintessence Int 1992;23:471–488.
bleaching sensitivity. Quintessence Int Haywood V B. Treating Sensitivity its effect on oral tissues. J Am Dent during Tooth Whitening. Compendium Assoc 1991;122(12):50–54.
Frazier K B, Myers M L. Fabrication of Home-Use Bleaching Agents. Dental Caplan DJ, Haywood VB. Safety and Addy M, al-Arrayed F, Moran J. The use Immediate Thermoplastic Whitening Product Spotlight. JADA 2001;132:1292. stability of nightguard vital bleaching: of an oxidising mouthwash to reduce Trays. Contemporary Esthetics and Haywood VB.Tooth Whitening: 9 to 12 years post-treatment. J Esthet staining associated with chlorhexidine. Restorative Practice 2001;5(9):84–86.
Indications and Outcomes of Restor Dent 2002; 14(5):275–285.
Studies in vitro and in vivo. J Clin Haywood V B, Cordero R, Wright Nightguard Vital Bleaching. K, Gendreau L, Rupp R, Kotler M, Quintessence Pulbishing Co, Inc. diffuse penetration of intact enamel Atkinson CB. Hints, Queries, and Littlejohn S, Fabyanski J, Smith S. Hanover Park, IL 2007:133–138 Comments: Pyrozone. The Dental Brushing with a potassium nitrate dentifrice to reduce bleaching Hoppenbrouwers PMM, Driessens Bentley CD, Leonard RH Jr and sensitivity.J Clin Dent. 2005;16(1): Solubility of Human Tooth Roots. Crawford J. Effects of whitening agents 17–22.


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