By Y. Ugrasal. University of Wisconsin-Stout.

Children with severe dehydration have a fluid The detection of dehydration is based entirely on deficit equalling more than 10% of their body clinical signs buy aleve 500 mg mastercard. They are usually lethargic cheap aleve 500 mg otc, stuporous or identify children with diarrhoea who are at even comatose 500mg aleve. The eyes are deeply sunken and increased risk of becoming dehydrated, for without tears; the mouth and tongue are very dry, example, those children who are vomiting, have a and breathing is rapid and deep. Children who are fever, or have passed six or more diarrhoeal stools awake are very thirsty; however, when there is in the past 24 hours. Children who fluids or water have been restricted or could not are unconscious are unable to drink. When Page 64 Module 3 there is hypovolaemic shock, the systolic blood Column A: No signs of dehydration pressure taken in the arm is low or undetectable, If neither severe dehydration nor some dehydration the arms and legs are cool and moist, and the nail is present, the child has no signs of dehydration. Children with diarrhoea but no signs of dehydration usually have a fluid deficit, but it Severe dehydration requires urgent treatment, usually equals less than 5% of their weight. Children with no If severe dehydration is not present, look next at signs of dehydration can be treated at home, column B. If the signs in column C are not sufficient to diagnose Weigh the child severe dehydration, they should be counted as Children who are found to have some dehydration belonging to column B. This category includes both mild and moderate Weight is important for determining the amount dehydration, which are descriptive terms used in of oral or intravenous fluid to be given in treatment many textbooks: plans B and C. If no scale is available, weight • Mild dehydration (5–6% loss of body weight) is should be estimated on the basis of the child’s age manifested mostly by increased thirst and or length, and treatment should be given without restlessness. The weight taken when a child is dehydrated should • Moderate dehydration (7–10% loss of body not be recorded on a growth chart, as it will be weight) causes children to be restless, “fussy”, or lower than normal owing to dehydration. The eyes are somewhat sunken and the the child should be weighed again after rehydration mouth and tongue are dry. There is increased thirst: has been completed and that weight should be older patients ask for water and young children recorded on the chart. If possible, children with drink eagerly when offered fluid from a cup or no signs of dehydration should also be weighed spoon. The is detectable, but rapid, and the fontanelle in infants assessment of hydration status is difficult in children is somewhat sunken. This is especially true for signs Module 3 Page 65 Assessing the child for other problems related to the child’s general condition or behaviour After the child has been evaluated for dehydration, such as sunken eyes, absence of tears and other problems – such as dysentery, persistent diminished skin turgor. If Using a patient record form possible, a fresh stool specimen should also be Information on the history, examination, and observed for visible blood. If bloody diarrhoea is treatment of each patient should be summarized present, the patient should be considered to have on a “Patient Record Form”. If dehydration is present it should also of this form may be used, but they should include be treated immediately. Episodes that have lasted at least • the child’s pre-illness feeding pattern; 14 days are considered to be cases of persistent • the child’s immunization history, especially as diarrhoea. Persistent diarrhoea patients with bloody regards measles; stool or a stool culture positive for Shigella should • important findings during examination of the receive antibiotics. If stool culture yields another child, especially signs of dehydration or bacterial pathogen, for example, enteropathogenic undernutrition, and the child’s weight; E. If Giardia cysts, or findings following rehydration therapy at the health trophozoites of either Giardia or E. Similarly, no “antidiarrhoeal” drug (including antimotility drugs, antisecretory drugs, When the form is completed it provides a valuable and adsorbents) has any proven value in patients record of the child’s progress during treatment. It also with persistent diarrhoea, therefore such drugs helps remind the healthcare worker of all of the steps should not be given. Completed forms should be kept at Sometimes it is difficult to determine whether a the health facility and reviewed regularly to identify child has persistent diarrhoea or is having sequential areas where management practices could be improved. Patients with persistent Page 66 Module 3 diarrhoea usually have loose stools every day, history and an examination to determine whether although the number per day may vary the child is adequately nourished or considerably. Additionally, in areas where have normal stools for one or two days after which vitamin A deficiency is a public health problem, diarrhoea resumes. If the period of normal evidence of such deficiency should be sought and (formed) stools does not exceed two days, the illness treated. However, if the period of normal stools is longer Feeding history than two days, any subsequent diarrhoea should The feeding history should consider both the child’s be considered to be a new episode. The child’s If no longer breastfeeding, when was breast- nutritional status declines and any preexisting feeding stopped? In turn, malnutrition contributes to diarrhoea, which is more severe, Animal milk or infant formula prolonged, and possibly more frequent. When these steps are followed, malnutrition can be either prevented or corrected and the risk of Weaning foods (for children aged 6 months or older): death from a future episode of diarrhoea is much At what age were soft foods started?

Primaire preventie is gebaseerd op se- lectie van de juiste patiënten buy cheap aleve 250 mg on-line, goede planning en uitvoering van de behandeling maar ook op regelmatige controles van de implantaat-gedragen constructies en zorgvuldige onderhoud door zowel de patiënten als de mondzorg professionals purchase 250 mg aleve fast delivery. Het oppervlak van het transmucosale deel is glad aleve 500 mg without prescription, terwijl het deel van het implantaat dat botcontact maakt voornamelijk een ruw oppervlak heeft. Het verwijderen van bioflm van implantaatop- pervlakken (door zelfzorg en door tandheelkundige zorgprofessionals) is essentieel om pe- ri-implantaire ziektes te voorkomen en te behandelen. Bij de nazorg en de behandeling van peri-implantaire mucositis moet er normaal gesproken een glad (titanium) oppervlak gerei- nigd worden. De instrumenten die op de transmucosale implantaatoppervlakken gebruikt kunnen worden, mogen deze oppervlakken niet beschadigen omdat dit anders rekolonisatie met micro-organismen zou kunnen bevorderen. Dit is met name belangrijk voor die onder- delen van het implantaat die blootgesteld zijn aan het orale milieu. De hulpmiddelen die ervoor het meest gebruikt worden zijn mechanische instrumenten en chemische middelen. Bij een ernstige peri-implantaire ontsteking kan het zo zijn dat door botverlies ook het ruwe deel van het implantaat boven het botniveau komt te liggen. Dan moeten de windingen van het implantaat en het ruwe oppervlak gereinigd worden. Dit is niet eenvoudig omdat micro-organismen zich in het ruwe en het soms poreuze oppervlak kunnen verschuilen en onbereikbaar zijn voor de instrumenten van de tandheelkundige zorgprofessionals.. Instrumentatie In diverse onderzoeken van de afgelopen decennia zijn verschillende mechanische instru- menten op verschillende implantaatoppervlakken getest: metalen handinstrumenten, niet-metalen handinstrumenten, (ultra)sone scalers met metalen of niet-metalen tips, air polishers met diverse poeders, polijstcupjes/puntjes met of zonder polijstpasta en diamant-/ carbideboren. In hoofdstuk 2 werd in de literatuur gezocht naar wetenschappelijk bewijs voor de te verwachten effecten van diverse mechanische instrumenten op de oppervlaktestructuur van gladde en ruwe titaniumoppervlakken. De uitkomsten van dit review tonen dat air polishers, niet-metalen instrumenten en rubber polijst cupjes geen of minimale schade aan gladde titaniumoppervlakken toebrengen en daardoor veilig toegepast kunnen worden in de nazorg van patiënten met implantaten. Als er geen veranderingen in de oppervlaktestructuur van Nederlandse samenvatting 241 ruwe implantaatoppervlakken mag worden aangebracht, lijken niet-metalen instrumenten en de air polisher de meest geschikte instrumenten. Als het doel is het ruwe implantaatop- pervlak juist gladder te maken en bijvoorbeeld ook de schroefwindingen te verwijderen, dan worden diamant-/carbideboren aanbevolen. Dit bijvoorbeeld ten behoeve van implantoplas- tie wanneer het ruwe implantaatoppervlak is blootgesteld aan het orale milieu. Misschien nog belangrijker dan het effect van een instrument op de oppervlakte struc- tuur is of een instrument effectief is in het reinigen van het oppervlak. In hoofdstuk 3 werd bekeken welke mechanische instrumenten effectief zijn in het reinigen van het implantaat- oppervlak en het verwijderen van bioflm. De resultaten van deze review duiden erop dat air polishers de meest effectieve instrumenten zijn voor het verwijderen van bioflm van zowel gladde als ruwe titaniumoppervlakken. De literatuur laat verder zien dat de effectiviteit van alle mechanische instrumenten bij het verwijderen van tandsteen beperkt is. Bacteriële contaminatie kan de chemische samenstelling van een titaniumoppervlak veranderen. Ook kan instrumentatie een ongunstig invloed hebben op de samenstelling en oppervlaktestructuur van een titaniumoppervlak. In hoofdstuk 4 werd bekeken wat het effect van de diverse mechanische instrumenten op de biocompatibiliteit van het implantaatoppervlak is. Van alle geteste instrumenten blijkt de air-polisher het minst negatieve effect te hebben. In hoofdstuk 5 werd onder- zocht wat de invloed van de diverse poeders op de cellen die in het peri-implantaire weefsel voorkomen kan zijn. De selectie van het meest geschikte poeder lijkt van belang te zijn voor de genezing. Geen van de mechanische instrumenten blijkt alle bioflm van het titaniumoppervlak te ver- wijderen, zeker als het oppervlak moeilijk bereikbaar is. Er kan dus ook overwogen worden om de behandeling met chemische middelen te combineren. Hiermee kunnen dan de bac- teriën die op de titaniumoppervlakken zijn achtergebleven alsnog mee worden gedood. In hoofdstuk 6 werden chemische middelen geëvalueerd in relatie tot de bioflm op het titaniu- moppervlak. In dit hoofdstuk werd bekeken welke middelen effectief zijn in het verwijderen 242 Nederlandse samenvatting en afdoden van bioflm van titanium implantaatoppervlakken. Het gebruik van een zuur (etsgel) lijkt hierbij op dit moment het meest effectief. Zelfzorg Het onderhoud van de implantaat-gedragen constructies is grotendeels de verantwoordelijk- heid van de patiënt en het is afhankelijk van de dagelijkse plaque-beheersing.

Burs and metal instruments smoothen both surfaces by removing a part of the coating while non-metal instruments cause no visible changes generic 500 mg aleve with mastercard. Al- though sometimes a slight rounding of the sharp edges has been observed (Schwarz et al safe 500 mg aleve. In general proven 250 mg aleve, air abrasive devices do not seem to cause major changes on moderate rough and rough surfaces. The slight changes that can 5 sometimes be observed are dependent on the powder used, the angulation of the tip and the treatment time. Some instruments induce minimal, scarcely visible changes in surface topography while others account for more pronounced changes. The effect of me- 7 chanical instruments on the surface structure is dependent on various parameters related to the instrument used, but also to the surface itself. The degree of change that might be in- 8 ficted by an instrument is dependent on the material of the instrument, the treatment time and treatment mode (e. It should be kept in mind that what seems as a minor change after a single use may become a major change after repeated application of an instrument on the same surface. This is important for surfaces that are exposed to the oral environment and for instruments that are causing a roughening of the surface, especially since frequent maintenance is recommended for patients having dental implants. Depend- ing on the surface and its localization, the best suitable instrument for this surface should be chosen. From the available instruments the air polisher seems at this moment the most suitable instrument for both smooth and rough surfaces, when preservation of the surface structure is required. Surface decontamination The effect of mechanical instruments on the surface structure may be of secondary impor- tance, in case an instrument is not effective in removing accretions from the surface. A suc- cessive systematic review was performed in chapter 3 to evaluate the ability of various 224 Summary, Discussion… mechanical instruments to clean contaminated implant surfaces. Based on the available evi- 1 dence non-metal curettes were found to be ineffective in removing bacteria and/or bacterial products from both smooth and rough titanium surfaces. Better results have been observed 2 for sonic and ultrasonic devices with non-metal tips. These instruments were more effective in cleaning smooth than rough titanium surfaces. These devices, when used with a sodium bicar- 4 bonate powder, were found to be effective in removing bacteria and bacterial products for both smooth and rough surfaces. All studies reported more than 84% removal of deposits 5 irrespective of the surface type. Similar results were also observed when the less abrasive amino-acid glycine powders were used. These results are in agreement with another review on air abrasive devices (Tastepe 6 et al. The authors of this review reported: “In vitro, the cleaning effcacy of air-powder abrasive treatment on titanium strips, discs or implants is high”. Promising results for the air 7 abrasive were also reported in a review evaluating the decontamination of infected implants by mechanical, chemical and physical methods (Meyle 2012). This review included in vitro, animal and human studies, and the authors concluded: “For decontamination of infected 8 implant surfaces air-abrasive treatment seems to work”. In clinical situations, several factors, such as the soft and hard tissues surrounding the 9 implant, the implant/abutment design or the design of the restoration may render the ac- cessibility of the titanium surfaces more diffcult and may limit the cleaning effcacy of an instrument. The accessibility of an air abrasive device with glycine powder to clean minimal- ly rough implant surfaces was assessed in models imitating peri-implantitis with different defect morphologies. The authors concluded: “ Although a complete cleaning of the implant surfaces was not possible in any of the defect models, it was possible to clean the biggest part of the surface up to more than 95% in easy accessible defects. In broad defects of 60° and 90° defect angulations, it was even possible to get access to more than 75% of the lower faces of the implant threads”. Narrow defects (< 30o) and the area under the threads were diffcult to reach (Sarhmann et al. In a subsequent study using the same model, the air-abrasive device was compared with other modalities as a stainless-steal curette and an ul- trasonic device with metal tip. In wide defects, the differences between the in- struments were more pronounced (Sahrmann et al. The two-abovementioned studies simulated condition similar to an open-fap debridement. Recently, the same research group 2 published another study using a bone defect-model that includes a custom-made mucosa mask in order to simulate the conditions of nonsurgical implant surface debridement, which 3 made the access to the implant even more diffcult. The air abrasive with a glycine powder and a subgingival nozzle provided superior cleaning results compared to a metal curette or an ultrasonic device with a metal tip.