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Specific recommendation to improve access to cancer medicines Ensuring the availability of affordable cancer treatment will be a key element in efforts to expand treatment access to many people who need it generic 250mg trimox with mastercard antibiotic and yeast infection. The following recommendations for action specifically deal with access barriers to cancer medication discount trimox 500mg line bacteria 3 types smear. There is today much opportunity to expand access to cancer care with existing low-cost products buy 500mg trimox amex infection wisdom tooth extraction. Twenty percent of breast cancer patients require trastuzumab (Herceptin) that is prohibitively expensive today buy generic trimox 500mg on line bacteria 5th grade. Eighty percent of breast cancer cases can be treated with older, less costly medicines. It is essential that governments take action to ensure the price of trastuzumab comes down. Advocating for affordable trastuzumab will be more effective in an environment where breast cancer treatment and care is available to all women. It will be an opportunity to include proven effective treatments (regardless of cost) and provide a basis for further action to ensure availability and affordability of these essential cancer medicines. Once cancer medications are included in the core list, such a list can form the basis for inclusion in the World Health Organization’s Prequalification Program’s Expression of Interest, help attract low-cost quality generic suppliers and guide countries’ selection. An overview of price ranges by the Global Task (see Table 3) shows wide ranges in prices paid for cancer medications in low- and middle- income countries. Publicly available drug price and source information should be made available and regularly updated. In the cases where generic manufacturing is not possible because of a patent, licenses should be made available. Patent holders should be incentivized to license their patents of essential cancer drugs to generic manufacturers. The Medicines Patent Pool can provide a model for health-oriented licensing and licensing terms. Licenses with a large geographical scope help to create economies of scale and thus lower the cost of production. Governments should provide compulsory licenses to generic producers in the case a patent holder refuses to license on reasonable terms. It will be important to protect the flexibilities in intellectual property law that countries have to remedy the negative effect of drug patents. The use of these flexibilities to increase access to cancer drugs is completely legal under international law. Countries have to intervene when patents cause access problems and patent holders refuse to provide licenses to the patents. This may require agreements at international level on reference pricing to prevent high-income countries demanding discount levels intended for low- and middle-income countries. A very effective mechanism for differential pricing of patented medicines is through licensing. Production of lower-priced products by generic companies offers the steepest discounts. Because products produced under a license are marketed under a different brand, there is no risk of flow back to high-income markets, which has always been a concern of originator companies in implementing differential pricing. Demands for cancer treatment in low- and middle-income countries will increase and a response by health authorities in many countries is long overdue. This lack of response cannot be explained by the high cost of cancer medicines only. Many of the products used in cancer treatment are available from multiple sources at affordable price levels. To make those medicines available to cancer patients, governments should put in place, and sustain, cancer screening and treatment strategies. Those medicines are often very highly priced and out of reach of people and health systems in low- and middle-income countries. Essential cancer medicines whether old or new, should be made available in the context of cancer care. This will require action by governments and companies to ensure these treatments are affordable. In case of single-source cancer drug supply, relying on differential pricing alone does not provide the sustained decrease in price that is necessary. Where patents are barriers to access generic cancer medication, companies should offer licenses and if they fail to do so governments should use compulsory licensing strategies. However, for all of this to happen we need a vocal civil society that demands drastic change in the current situation. Grady (2009) ‘How much is life worth: cetuximab, non-small cell lung cancer, and the $440 billion question’, J Natl Cancer Inst. N (2009) ‘Limits on Medicare’s Ability to Control Rising Spending on Cancer Drugs’ Engl J Med 360: 626–633doi: 10. Wittes (2012) ‘In cancer care, cost matters’ New York Times 15 October: pA25 (http://www. Jackson (2013) ‘Gilead critic sponsors voter initiative to limit drug pricing in San Francisco’. Ford (2014) ‘Minimum costs for producing hepatitis C direct-acting antivirals for use in large-scale treatment access programs in developing countries’, Clin Infect Dis. Kumar (2005) ‘Change in the age structure of India’s population (1881-2001)’, Dialogue 6: 445–457. Nandkumar (2010) ‘Projection of number of cancer cases in India (2010- 2020) by cancer group’, Asian Pacific Journal of Cancer Prevention 11: 1045–1049. Swaminathan (2005) ‘Cancer: current scenarios, intervention strategies and projections for 2015’, National Committee on Macroeconomics and Health Background Papers: Burden of disease in India, New Delhi 52 Ibid. Mithral (1994) ‘Breast cancer screening: the case for physical examination without mammography’, Lancet, 343: 342–344. Fox (2009) Global strategies to reduce the price of antiretroviral medicines: evidence from transactional databases, http://www. Health Action International is currently carrying out a project to map external reference pricing practices for medicines with the support of Dfid. Ixabepilone is indicated as monotherapy for the treatment of metastatic or locally advanced breast cancer in patients whose tumors are resistant or refractory to anthracyclines, taxanes, and capecitabine. Research reports This research report was commissioned by Oxfam and written to share research results, to contribute to public debate and to invite feedback on development and humanitarian policy and practice. The copyright holder requests that all such use be registered with them for impact assessment purposes. For copying in any other circumstances, or for re-use in other publications, or for translation or adaptation, permission must be secured and a fee may be charged. Japan: The Advertising Department, Subscribers may reproduce tables of con- Subscription prices are available upon Elsevier K. Subscriptions are European Journal Commercial Sales, compilations and translations. Priority fax: (+44) (0) 20 7424 4433; store or use electronically any material rates are available upon request. Because of rapid Orders, claims, andjournalenquiries: please following terms and conditions apply to advances in the medical sciences, in contact the Customer Service Department at their use: particular, independent verification of diag- the Regional Sales Office nearest you: noses and drug dosages should be made. It does not include information that has necessarily been considered or approved by any drug regulatory authority and should not be used by physicians to inform the prescribing of medication.

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Afer the administration of pilocarpine cheap 500mg trimox otc antibiotic over the counter, salivary outpuincreases rapidly buy 250 mg trimox otc antimicrobial fabric treatment, usually reaching a maximum within 1 hour proven 250 mg trimox antibiotic 7169. Stimulation of the salivary glands during radiation therapy has been suggesd as a possible means of reducing damage to the glands 500 mg trimox infection in blood. The synergistic efecof anetholetrithione in combination with pilocarpine was shown [20]. The mechanism of action of anetholetrithione may be to increase the number of cell surface receptors on salivary acinar cells and pilocarpine stimulas the receptors thus, in combination, these drugs have synergistic efec[20]. Pilocar- pine is contraindicad in patients with pulmonary disease, asthma, cardiovascular disease, gastroinstinal diseases and glaucoma [20]. Cevimeline is another parasympathomimetic agonisthahas been recently approved for the treatmenof oral dryness in patients with Sjogren�s syndrome. Due to similar side efects as to those of pilocarpine imusbe prescribed with caution. Symptomatic approach Palliative treatmenremains as only choice in cases when there is no functio- nally salivary tissue presenas is in the disorders of irreversible damage of salivary secretory cells (such as in radiation-induced xerostomia). Mosremedies available today for patients with dry mouth are only symptomatic and aimed to avoid or alle- via discomforand pain as well as to prevencomplications of xerostomia. A number of saliva substitus have been developed for the palliative care of patients with salivary hypofunction to supplementhe saliva and allevia oral symptoms of dryness. These agents, in liquid, spray, or gel form have moisning and lubricating properties, and their purpose is to provide prolonged wetness of the oral mucosa. Commercial artifcial saliva should resemble normal saliva in its 80 Rad 514 Medical Sciences, 38(2012) : 69-91 M. Preetha and Banerjee [60] compared artifcial saliva based on carboxymethylcellulose and the xanthan gum and found thathe examined sub- stitus fall shorof required biophysical criria and modifcations are required to improve them. The advantages of saliva substitus or artifcial saliva are in the coating and moisturizing oral mucosa and eth, and disadvantages are their short-rm acti- vity withoupreventive efecon oral tissue. Commercialy available alcohol contai- ning oral rinses should be avoided due to their drying efect. Patients with irreversible xerostomia should be instrucd to maintain proper hydration of the oral cavity by taking plenty of fuids throughouthe day and kee- ping the mouth moist, and using artifcial saliva preparations. Frequensips of wa- r throughouof day and during the meals will facilita chewing and swallowing and may also improve the tas of food. The use of bedside humidifers may lessen discomforof dryness, especially anighduring sleep when any residual salivary secretion is physiologically decreased. Patients should avoid any cafeinad drinks (a, cofee) and sof drinks and alcohol, as well as smoking and alcohol-containing mouthwases to prevenfurther desiccation. Special denture adhesives for individuals with xerostomia also may provide some rention aid for removable dentures. Peri- odontal diseases may be prevend by using an alcohol-free, antibacrial mouth rinse, such as chlorhexidine. Professional oral hygiene procedures and instructions in home care as well as di- ligenand meticulous oral hygiene are crucial to reduce the bacrial load in the oral cavity and thus the risk for halitosis and oral infection. Mravak-Stipetic: Xerostomia - diagnostics and treatmenDecreasing dosage of psychopharmaca could be atained by psychotherapy or adding a lighxercise regimen to the patient. For a patienwith uncontrolled type 2 diabes, regular glycemic control (using modifcations of diet, exercise, and possibly oral anti-diabetic medication or insu- lin), may eliminas the hypo-salivation. Xerostomia being caused by uncontrolled diabes, can be cured by bringing diabes under control. Hydroxychloroquine is classifed as an anti-malarial medi- cation and is also used to decrease infammation in sysmic lupus erythematosus as well as rheumatoid arthritis and Sjogren�s Syndrome (all rheumatic disorders) [62]. This therapeutic approach focuses the ra- diation beams to the targetumour tissue with aim to avoid unnecessary radiation of sourrounding salivary gland. The compur-driven chnology generas dose distribu- tions thasharply conform to the tumor targewhile minimizing the dose delivered to the surrounding or contralaral normal gland tissues. Multiple studies have demonstrad thathe parotid gland sparing efecof this tre- atmenmodality resuld in signifcanobjective and subjective improve- menof xerostomia. However, in patients who have tumours thaorigina from the midline or thacross the midline, or in patients with contralaral lymph node metastais iis nopossible to use this chnique [54,63]. However, a high ra of serious adverse events, including hyponsion and ga- stroinstinal disturbances, results in discontinuation of amifostine and limits its use. Caries Fluoride preparations for control of dental caries should be prescribed to all individuals who have natural eth. Patients with signifcanxerostomia should be closely monitored for the developmenof dental caries, which may be prevend by the daily use of 1. Application of fu- oride should be adjusd accordingly to the severity of the gland dysfunction, the degree of developmenof caries and the underlying disease or the cause thaled to the dryness of the mouth. Studies have demonstrad thafuoride preparations alone are nosufciento prevencaries and remineralization of damaged eth, particularly in patients with dry mouth who underwenradiation therapy [65-67]. A study evaluad the use of calcium phospha supersaturad remineralizing rinse in 84 Rad 514 Medical Sciences, 38(2012) : 69-91 M. Fungal infections (candidosis) Treatmenof oral candidosis with topical antifungal medications from polyenic group such as nystatin and amphoricin B proved to be successful athe beginning of the therapy. During the treatment, adverse efects of drugs were observed in some patients, and in patients tread with anticoagulandrugs and antidiabetics the use of antifungal drug myconazole is contraindicad. In xerostomic patients afer cesa- tion of the antifungal therapy relapses of oral infection are common [20]. A combi- nation of antifungal drugs and application on the surface of dentures was described in patients with dentures and denture stomatitis. In recenstudy the efecof supersaturad solution of calcium and phospha (Caphosol�) on oral yeasinfection in patients with dry mouth was investigad. Su- persaturad solution of calcium and phospha increased the amounof saliva and signifcantly reduced oral fungal infection, in comparison with a solution of sodium bicarbona. Compared with myconazole and in combination with it, no signifcandiferences were found [68]. Dentures wearing In dentures wearing patients weting dentures before placing them into the mouth and spraying protheses with artifcial saliva before applying dentu- re adhesives [15] will help in reducing the discomfort. Weting dentures before meals and taking more fuids during meal- time will aid in mastication and swallowing [1-3,20,24,34]. Adapd denture fabrica- tion (splidenture chnique and fexible comple denture construction) will help in alleviating dyscomfor[55,56]. Although xerostomia is common in elderly patients iis frequently noassessed and managed on time. Due to serious complications of dry mouth which afects oral and general health the qua- lity of life of these patients is decreased. Therefore, the assessmenof salivary gland hypo-function, early recognition, prevention and treatmenof xerostomia and its complications will need to be incorporad into everyday clinical dental practice. Epidermal growth factor inplasma and saliva of patients with active breascancer and breascancer patients in follow-up compared with healthy women. Salivary biomarkers for the dection of malig- nantumors thaare remo from the oral cavity. Oral diagnostic sting for decting human immune-defciency virus-1 antibodies: A chnology whose time has come. Serum amylase isoenzymes in patients undergoing operation for ruptured and non-rup- tured abdominal aortic aneurysm. Measuring change in dry-mouth symptoms over time using the Xero- stomia Inventory. Minor gland saliva fow ra and proins in subjects with hyposalivation due to Sjogren�s syndrome and radiation therapy. Oral dryness examinations: use of an oral moisture checking device and a modifed coton method. Longitudinal analysis of parotid and submandibular salivary fow ras in healthy, diferent-aged adults.

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Trafficking It is estimated that almost 380 mt or 45% of the total via West and Central Africa would have amounted to cocaine exports from the Andean region leave for North 39 some 21 mt order 500mg trimox visa antibiotics for uti in cats. In addition cheap trimox 250 mg on line topical antibiotics for acne vulgaris, cocaine is trafficked for local America generic trimox 500mg mastercard antibiotic resistance youtube, a region with a population of some 460 mil- demand to West and Central Africa – a subregion with lion people discount trimox 250mg with mastercard antibiotic bone cement. The bulk of cocaine shipments are still by a combined population of more than 400 million people, sea across the Pacific to Mexico and on to the United which may consume some 13 mt. In addition, Central American countries have gained prominence in recent years as trans-shipment locations. Production** 1,111 Less seizures in Andean countries -254 Less domestic consumption in Andean region -13 Potential amounts available for export out of the Andean countries 844 Less losses in production and/or losses in global trafficking which cannot be attributed to specific regions -56 Actual exports out of Andean countries 788 Non-Andean South Amer- West and North ica / Caribbean, Central Central Europe America America, Africa, Asia, Oceania Amounts of cocaine leaving the Andean countries 217 378 193 Less amounts seized in non–Andean South America, -59 -98 -64 Caribbean and Central America linked to trafficking flows Less domestic consumption in non-Andean South -83 America / Caribbean / Central America 158 Amounts leaving South America, Caribbean and (incl. Considering purity-adjusted seizures of cocaine (unweighted average of all purities at retail and wholesale level reported by Member States in 2009), some 481 mt would be available for consumption and losses if the lower cocaine production estimate were used. If the higher cocaine production estimate were used, deducting seizures adjusted for wholesale purity (based on 2009 purity data or the latest year available), some 496 mt would be left for consumption and losses. The upper and the lower production estimates could be thus sufficient to cover consumption (440 mt). For the calculation shown above, the higher production estimates and seizures adjusted at wholesale purities were used. This reflects the observation that wholesale seizures account for the bulk of seizures in volume terms and would support the higher production estimates. However, one cannot exclude the possibility that seizures may be over-estimated due to possible double-counting once several law enforcement agencies within or across countries have been involved in cocaine interceptions. North America accounted for 47% and West countries - of which almost two thirds was for subse- and Central Europe 39% of the total. While the North American market shrank over the last Current value and money flows two decades – due to lower volumes and lower prices - The value of the global cocaine market is most certainly the European market expanded. United States 180 120 111 West & Central Europe 160 Cocaine sales 100 140 87 120 80 71 100 62 80 60 5654 5049 60 4344 4544 40 3635 34 363537 32 32 40 34 33 20 31 20 26 26 27 21 0 18 18 141414 1995 2008 2009 0 Fig. West and 40 Reports indicated that up to one third of the shipments Central Europe, is paid in kind to service providers in West Africa, who 33 then traffic most of this cocaine to Europe on their own behalf. Meth- the use of prescription stimulants1 is as common as amphetamine or amphetamine can be in powder, tablet, methamphetamine. In South America and the Carib- paste or crystalline form while ‘ecstasy’ is usually avail- bean, prescription stimulants are more commonly used. In Africa, especially in West, Central and East Africa and some parts of Southern Africa, the use of amphetamines- 4. This section describes the In 2009, out of the 69 Member States that reported trends in the use of amphetamines-group and ecstasy- expert perception on amphetamines-group use trends group substances in the different regions. In The type of amphetamines-group substances used in developing countries and especially emerging econo- different regions varies considerably. In East and South- East Asia, methamphetamine is the primary substance 1 Prescription stimulants may include substances such as amfepra- consumed within this group, while in the Near and mone, fenetylline, methylphenidate, phenmetrazine, et cetera. The association in developed countries increase in the use of stimulants in developing countries of synthetic drugs, especially stimulants, with moderni- where young people within the growing middle class zation and affluent lifestyles, combined with increasing may want to emulate these lifestyles. This increase in the prevalence of stim- significantly higher than the estimate in 2008 (95,000), ulants use is attributed in part to an increase in the it is still substantially lower than the estimate for 2002 number of methamphetamine users. Among secondary school students in the in the past 30 days (prior to the survey) increased sig- United States, there has been a declining trend in the nificantly from 904,000 (0. In 2009, among school students aged 12-19 in Mexico, the reported lifetime prevalence of 0 amphetamine and methamphetamine use was 1. In previous years, however, the life- Stimulants (all types) Methamphetamine time prevalence among youth aged 12-17 was reported as 0. In 2010, annual prevalence of amphetamines use rose among 10th and 12th graders while it continued to Amphetamines-group substance use in South decline among 8th graders. Use of methamphetamine, America appears to remain stable in contrast, increased among 8th graders, remained stable among 10th graders but declined among 12th There is no updated information on the prevalence of graders in 2010. Despite some increases in ampheta- amphetamines-group substance use in South America. Compared to 2008, most of the countries report- the use of prescription stimulants. Brazil, While most countries in Europe show stabilizing the Bolivarian Republic of Venezuela and Argentina trends in the use of amphetamines-group remain countries with a high prevalence and absolute substances, high levels of injecting amphetamines number of users of amphetamine and methampheta- use are reported by a few mine in South America. The coun- dents in Brazil in 2009, the annual prevalence of tries that reported data show a mixed trend from previ- amphetamines use among the students was reported as ous years. The annual prevalence was higher among female substance use in Europe is estimated between 0. In most parts of Europe, ampheta- of amphetamine and methamphetamine in Central mine is the more commonly used substance within this America, as a region, it has a high prevalence of amphet- group, while the use of methamphetamine remains lim- ited and has historically been highest in the Czech Republic and Slovakia. While in Germany, there was an increase in in a wide range and uncertainty of the estimates. Within West and Central Europe, the Czech Republic, Denmark, the United Kingdom, Norway and Estonia Among the limited number of countries that have remain the countries with the highest annual prevalence reported expert opinion on trends in the use of amphet- rates, while in South-East Europe, Bosnia and Herze- amines-group substances in Africa, nearly half of the govina and Bulgaria have high annual prevalence of countries report that the trend has increased while a amphetamines use. In most parts of Africa, prescription amphetamines In most West and Central European countries, problem amphetamines use represents a small fraction of overall comprise the primary substances used within this group. Those who report there is more consistent and recent information available amphetamine as their primary substance account for less on drug use trends. Such data – based on treatment than 5% of drug users in treatment, on average, in demand - showed a strong increase in the importance of Europe. High levels of injecting use are reported from amphetamines until the second half of 2006, followed the Czech Republic, Estonia, Latvia, Lithuania, Sweden by a stabilization or small downward trend since. The and Finland, ranging from 57% to 82% among amphet- importance of amphetamines increased again temporar- amines users. In which experts perceived the problem to have stabilized other parts of the country, the proportion has remained or decreased over the past year. This ranges from 30% of all treatment admissions reported in Niger to In East and South-East Asia, the annual prevalence of around 2% in Nigeria. The annual prevalence of amphetamines-group sub- stance use in Asia ranges between 0. The highest range and uncertainty in the estimates derive from miss- increase reported was from Lao People’s Democratic ing information on the extent and pattern of use from Republic, whereas Japan has reported a decline in meth- large countries in Asia, particularly China and India. Alcohol and Drug Abuse Trends: July trends with a particular focus on use of amphetamine-type stimu- – December, 2009 (Phase 27), South African Community Epidemiol- lants. In Thailand, injecting is the 40,000 10 second most common method for using crystalline 20,000 methamphetamine and the third most common method 14 0 0 for abuse of methamphetamine pills. In 2009, Indo- nesia reported an increasing trend in injecting heroin and crystalline methamphetamine, while Malaysia reported injecting of crystalline methamphetamine for the first time in 2009. Drug Strategy Branch, Australian Government Department of Health and Ageing, September 2009. Source: Drug Use Monitoring in Australia: 2008 Annual Report on drug use among police detainees, Australian Marshall Islands, Australia and New Zealand, with Institute of Criminology, 2010. The Pacific island states and territories in the 31 31 30 29 29 region with available data report high prevalence rates of 27 28 27 amphetamines-group substances. Although there is no updated information on annual prevalence of 10 amphetamines use among the general population since 5 2007, available information points to a continuing decline in the trends of amphetamines use reported 0 through different indicators. Among Australian students aged 12-17 there has been a significant decline in both the lifetime and past month prevalence of amphetamines use from 2002 to 2005 and The monitoring among detainees who were tested for further to 2008. The annual prevalence of ‘ecstasy’ use among the population aged 15-64 was Uruguay 1. The latest information (2008 or the annual prevalence among the general population 2009) on lifetime prevalence of ‘ecstasy’ shows the prev- remains much lower in these subregions than the world alence rates ranging from 0.

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There are some cases which will need the attention of a specialist dental surgeon (like oral and maxillofacial surgeon buy generic trimox 500mg line antibiotics for sinus infection over the counter, orthodontist e order trimox 500 mg with amex antibiotics for pet birds. Diagnostic criteria:  Inflammation of the gingival which is initially seen as discrete colour and texture changes of the marginal tissues purchase trimox 250 mg amex antibiotics for acne south africa. Prevention Instructions for proper oral hygiene care Treatment Removal of accumulated plaque and oral hygiene instructions on tooth brushing and other adjuvant means of oral hygiene (dental flossing cheap trimox 500mg otc infection types, use of mouth washes) 1. The damage of the periodontal membrane, periodontal ligaments and eventually alveolar bone leads to formation of pockets which eventually favours more bacterial growth. Note: Tetracycline should not be given to pregnant and lactating mothers to avoid tetracycline stains in for their babies. Patients usually present with soreness and bleeding of the gums and foul test (fetor-ex ore). Contact stomatitis (a counterpart of contact dermatitis) also can occur due to allergy. Choline salycilate, Benzalkonium chloride and Lignocaine hydrochloride) Note: Mouth washes should not be used at the same time with the gel. Start slowly with white spots later developing to black/brown spot and cavities in enamel, dentine and eventually the pulp. Dental caries is caused by bacteria of the dental plaque which feed on sugary food substrates producing acid as by-products which dissolve the minerals of the tooth surface. Note: The Susceptible sites are those areas where plaque accumulation can occur and be hidden to escape active and passive cleansing mechanisms e. Prevention  Proper instruction to avoid frequent use of sugary foods and drinks  Use fluoridated toothpaste to brush teeth at least once a day Non-pharmacological measures  Early lesions presenting as a spot on enamel without cavitation and softening, observe and adhering to preventive measures. The condition may be acute and diffuse or chronic with fistula or localized and circumscribed. Adult: Paracetamol (O) 500mg – 1g, 4-6 hourly for 3 days, Child: Paracetamol (O) 10-15 mg/kg 4-6 hourly  For anterior teeth (incisors, canine and premolars: Extraction is carried out only when root canal treatment is not possible. Give antibiotics: Adult A: Amoxicillin (O) 500mg, 8 hourly for 5-7 days; Children, Amoxicillin (O) 25 mg/kg in 3 divided doses for 5 days. Plus A: Metronidazole (O); Adult 400mg 8 hourly for 5-7 days 21 | P a g e Children 7-10 years, 100mg every 8 hour Note: Periodontal abscess is located in the coronal aspect of the supporting bone associated with a periodontal pocket. Diagnostic criteria  Severe painful socket 2-4 days after tooth extraction  Fever  Necrotic blood clot in the socket  Swollen gingiva around the socket  Sometimes there may be lymphodenopathy and trismus (Inability to open the mouth) Treatment  Under local anesthesia with Lignocaine 2% socket debridement and irrigation with nd rd Hydrogen peroxide 3%. The procedure of irrigation is repeated the 2 and 3 day and th where necessary can be extended to 4 day if pain persists. The condition is very painful and it defers from infected socket by lack of clot and its severity of pain. Diagnosis  Severe pain 2-4 days post-extraction  Pain exacerbated by entry of air on the site  Socket devoid of clot  It is surrounded by inflamed gingiva Treatment 22 | P a g e Treatment is under local anesthesia with Lignocaine 2% socket debridement and irrigation of nd rd hydrogen peroxide 3%. The procedure of irrigation is repeated the 2 and 3 day and where th necessary can be extended to 4 day if pain persists. Aerobic Gram positive cocci and anaerobic Gram negative rods predominate among others. The predominant species include; Bacteroides, Fusobacterium, Peptococcus, Peptostreptococcus and Streptococcus viridians. Diagnosis  Fever and chills  Throbbing pain of the offending tooth  Swelling of the gingiva and sounding tissues  Pus discharge around the gingiva of affected tooth/teeth  Trismus (Inability to open the mouth)  Regional lymphnodes enlargement and tender  Aspiration of pus for frank abscess Investigations: Pus for Grams stain, culture and sensitivity and where necessary, perform full blood count. Treatment Preliminaries  Determine the severity of the infection  Evaluate the status of the patient’s host defence mechanism  Determine the need of referral to dentist/oral surgeon early enough Non-pharmacological  Incision and drainage and irrigation (irrigation and dressing is repeated daily)  Irrigation is done with 3% hydrogen peroxide followed by rinse with normal saline. Criteria for referral  Rapidly progressive infection  Difficulty in breathing  Difficulty swallowing  Fascia space involvement  Elevated body temperature [greater than 39 C)  Severe jaw trismus/failure to open the mouth (less than 10mm)  Toxic appearance  Compromised host defenses 3. It is an extension of infection from mandibular molar teeth into the floor of the mouth covering the submandibualr spaces bilaterally sublingual and submental spaces. Diagnosis  Brawny induration  Tissues are swollen, board like and not pit and no fluctuance  Respiratory distress  Dysphagia  Tissues may become gangrenous with a peculiar lifeless appearance on cutting  Three fascia spaces are involved bilaterally (submandibular, submental and sublingual) Treatment Non-Pharmacological  Quick assessment of airway 24 | P a g e  Incision and drainage is done (even in absence of pus) to relieve the pressure and allow irrigation. Note: For this condition and other life threatening oral conditions consultation of available specialists (especially oral and maxillofacial surgeons) should go parallel with life saving measures. Impaction of food and plaque under the gingiva flap provide a medium for bacterial multiplication. Biting on the gum flap by opposing tooth causes laceration of the flap, increasing the infection and swelling. Diagnosis  High temperature,  Severe malaise  Discomfort in swallowing and chewing  Well localized dull pain, swollen and tender gum flap  Signs of partial tooth eruption or uneruption in the region  Pus discharge beneath the flap may or may not be observed  Foetor-ox oris bad smell  Trismus  Regional lymphnodes enlargement and tender Treatment A: Hydrogen peroxide solution 3% irrigation If does not help, or from initial assessment the situation was found to require more than that then; 25 | P a g e  Excision of the operculum/flap (flapectomy) is done under local anesthesia  Extraction of the third molar associated with the condition  Other means include: Grinding or extraction of the opposing tooth  Use analgesics  Consider use antibiotics especially when there are features infection like painful mouth opening and trismus, swelling, lymphadenopathy and fever. Drug of choice A: Amoxicillin 500mg (O) 6 hourly for 5 days Plus A: Metronidazole 400 mg (O) 8 hourly for 5 days If severe (rarely) refer section 3. The infection becomes established in the bone ending up with pus formation in the medullary cavity or beneath the periosteum obstructs the blood supply. In early stage features seen in x-ray include widening of periodontal spaces, changes in bone trabeculation and areas of radioluscency. Treatment Non-pharmacological  Incision and adequate drainage to confirmed pus accumulation which is accessible  Culture should be taken to determine the sensitivity of the causative organisms 26 | P a g e  Removal of the sequestrum is by surgical intervention (sequestrectomy) is done after the formation of sequestrum has been confirmed by X-ray. Pharmacological A: Amoxicillin or cloxacillin 500mg 6 hourly Plus A: Metronidazole 400mg gram 8 hourly before getting the culture and sensitivity then change according to results. Under certain circumstances candida becomes pathogenic producing both acute and chronic infection. Other risks for candidiasis is chronic diseases like diabetes mellitus, prolonged use of antibiotics and ill/poorly fitting dentures. Diagnosis Feature of candidiasis are divided according to the types Pseudomembranous  White creamy patches/plaque  Cover any portion of mouth but more on tongue, palate and buccal mucosa  Sometimes may present as erythematous type whereby bright erythematous mucosal lesions with only scattered white patches/plaques Hyperplastic White patches leukoplakia-like which is not easily rubbed-off. The condition is recurrent following a primary herpes infection which occurs during childhood leaving herpes simplex viruses latent in the trigeminal ganglia. Diagnosis There are 3 types of alphthous ulcers Minor alphthous ulcers  Small round or ovoid ulcers 2-4 mm in diameter. Healing is prolonged often with scarring Herpetiform ulcers These occur in a group of multiple ulcers which are small (1-5 mm) and heal within 7-10 days Rationale of treatment: To offer symptomatic treatment for pain, and discomfort, especially when ulcers are causing problems with eating 29 | P a g e Treatment A: Prednisolone 20 mg tid for 3 days then dose tapered to 10 mg tid for 2 days then 5 mg tid for other 2 days. Referral criteria: If the ulcers persist for more than 3 weeks apart from treatment, such lesion may need histological diagnosis after specialist opinion. Diagnosis Bleeding socket can be primary (occurring within first 24 hours post extraction) or secondary occurring beyond 24 hours post extraction. Symptoms associated with it like fever and diarrhea are normal and self limiting unless any other causes can be established. The following conditions usually are associated with tooth eruption and should be referred to dental personnel: eruption cysts, gingival cysts of the newborn and pre/natal teeth. Deciduous/primary teeth should be left to fall out on themselves unless the teeth are carious or there is any other indication. Parents should be counseled accordingly and be instructed to assist their children to loosen the teeth the already mobile teeth and when there is no success or the permanent teeth are erupting in wrong direction should consult a dentist. Diagnosis There are several forms of malocclusion Class 1 The sagittal arch relationship is normal. The anterior buccal groove of the lower permanent molar should occlude with the anterior buccal cusp of the upper first permanent molar. Treatment Rationale for treatment:  Reduce possibility of temporomandibular joint pain dysfunction syndrome especially in case of cross bites  Reduce risks of traumatic dental injuries especially in overjet  Traumatic occlusion and gum diseases and caries especially in crowing  Avoid psychosocial effects resulting from to lack of self esteem, self confidence personal outlook and sociocultural acceptability Removable orthodontic appliances are those designed to be removed by the patient then replaced back. They are very useful in our local settings especially for mild to moderate malocclusion in teenagers. Appliances for active tooth movement fall into two groups  Simple removable appliances which have mechanical a component to move the teeth  Myofuctional appliances, which harness the forces generated by the orofacial muscles. Passive removable appliances may also save two functions:  Retainers used to hold the teeth following active tooth movement  Space maintainers, used to prevent space loss following the extraction of teeth. Fixed orthodontic appliances (braces) are useful in malocclusion which have resulted in relapses of failure after use of removable appliances and moderate to severe malocclusion which can not be managed by removable appliances especially adult patients. Adolescents and adult patients requiring fixed appliances should be referred to an orthodontist.

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