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Normally buy levitra 20 mg free shipping erectile dysfunction doctors in maine, the veins from the stomach purchase 10mg levitra with visa erectile dysfunction pump prescription, intestine buy levitra 10 mg online erectile dysfunction after age 50, spleen, and pancreas postmenopausal After menopause, the period merge into the portal vein, which then branches into of time after a woman has experienced 12 consecu- smaller vessels and travels through the liver. It can cause gastrointestinal bleeding, back of the nose and throat that leads to or gives the ascites, and symptoms related to decreasing func- sensation of mucus dripping down from the back of tion of the liver. Postnasal drip is one of the most common consequences of sinusitis, nasal allergies, and the portal vein A large vein formed by the union of the common cold. It can occur a the body, the attitude or carriage of the body as a few days, weeks, or even months after childbirth. A whole, or the position of the limbs (the arms and woman with postpartum depression may have feel- legs). Treatment involves counseling postural hypotension See hypotension, and/or medications. An abnormal increase in potas- sium (hyperkalemia) or decrease in potassium postpolio syndrome A constellation of symp- (hypokalemia) can profoundly affect the nervous toms and signs that appear years after an initial system and heart, and when extreme, can be fatal. Other symptoms include fatigue, joint pain, and slowly progressive muscle Pott’s disease See tuberculous diskitis. This is an (floppiness), poor sucking and feeding problems in important calculation because if delivery is delayed early infancy, and, later in infancy, excessive eating 3 weeks beyond term, the possibility of infant mor- that, if unchecked, leads gradually to marked obe- tality increases dramatically. Other sypmtoms include developmental delay, mild to moderate mental retar- post-traumatic stress disorder A psychologi- dation with multiple learning disabilities, and small cal disorder that develops in some individuals who gonads. The child can have two vived or witnessed violent crimes, or been through copies of chromosome region 15q11–15q13, but if wars. When the same Although preeclampsia is relatively common, occur- region of the maternally contributed chromosome is ring in about 5 percent of all pregnancies and more missing, the result is a different disease, called frequently in first pregnancies than in others, it can Angelman syndrome. In some cases, untreated preeclampsia can Prayer of Maimonides See Daily Prayer of a progress to eclampsia, a life-threatening situation Physician. The Pregnancy lasts for about 40 weeks, measured from aim of a preclinical study is to collect data in sup- the date of the woman’s last menstrual period. Preclinical conventionally divided into three trimesters, each studies are required before clinical trials in humans roughly 3 months long. There is little to no chance that a first- precocious puberty The onset of secondary trimester fetus can survive outside the womb, even sexual characteristics, such as breast buds in girls, with the best hospital care; its systems are simply too undeveloped. In the first trimester, some women growth of the penis and thinning of the scrotum in boys, and the appearance of pubic hair in both experience morning sickness. With the best medical care, a second-trimester fetus For example, preconceptual counseling is the inter- born prematurely has at least some chance of sur- change of information prior to pregnancy. In the third trimester, preconceptual counseling The interchange of the fetus enters the final stage of preparation for information prior to pregnancy. It increases rapidly in weight, as does the counseling usually occurs for pregnancy planning mother. Swelling of the ankles, back pain, and bal- and care, but sometimes it takes the form of genetic ance problems are sometimes experienced during counseling. See also acute fatty liver of pregnancy; prediabetes A state in which blood glucose lev- birth; birth defect; conception; eclampsia; els are higher than normal but not elevated enough ectopic pregnancy; fetal alcohol effect; fetal alco- to warrant a diagnosis of diabetes. People with prediabetes can prevent the prenatal care; prenatal development; teratogen. Many procedures are available to prevent prema- pregnancy, molar See hydatidiform mole. If prema- ture birth is medically necessary or inevitable, pregnancy, pernicious vomiting of See hyper- however, it may be accomplished via C-section to emesis gravidarum. Tubal pregnancies premature contraction of the heart A single are due to the inability of the fertilized egg to make heartbeat that occurs earlier than normal. Lifestyle changes are recommended for anyone with The premature contraction is followed by a pause as prehypertension. A battery of techniques irritability, tension, sleep and appetite changes, are available to remove or kill the tissue, thereby fatigue, and physical problems such as pain or preventing the development of cancer. Symptoms generally treatment method depends on the particular prema- begin the week before menstruation and end a few lignant tissue involved. The earlier in development that birth support of family and friends, and medications, takes place, the greater the likelihood that life-sup- including diuretics, pain killers, oral contracep- port systems will be needed and the greater the risk tives, drugs that suppress ovarian function, and anti- for birth defects and death. The next 3 weeks see intense cell differentiation, as the cell mass divides into separate primitive sys- presentation, footling See footling birth. At the end of 8 weeks, the embryo takes on a roughly human shape and is called a fetus. For the remaining weeks of develop- prevalence The proportion of individuals in a ment, the fetus continues to gain weight, and its population having a disease or characteristic. Prevalence is a statistical concept referring to the number of cases of a disease that are present in a prenatal diagnosis Diagnosis before birth. A growing number screening for hypertension and treating it before it of birth defects and diseases can be diagnosed pre- causes disease is good preventive medicine. Also Preventive medicine takes a proactive approach to known as antenatal diagnosis. Treatments include medications, anesthesia, and drainage of blood prepuce See foreskin. The first sign of presbyopia is primary care A patient’s main source for regular often the need to hold reading material farther away. All family physicians, and many pediatricians and internists, practice pri- prescription A physician’s order for the prepa- mary care. The aims of primary care are to provide ration and administration of a drug or device for a the patient with a broad spectrum of preventive and patient. A prescription has several parts, including curative care over a period of time and to coordi- the superscription, or heading, with the symbol R or nate all the care that the patient receives. A private mutation occurs and is passed to a few family members, but not to future generations. Treatment includes cholestyramine to diminish itching, antibi- indicates that the likelihood of something occurring by chance alone is less than 5 in 100, or 5 percent. Most patients die example, a proband might be a baby with Down syn- within 10 years of diagnosis unless a liver transplant drome. Also known as idiopathic sclerosing case, propositus (if male), or proposita (if female). Also known as baby teeth, milk teeth, primary den- probiotic A substance that appears to replenish tition, temporary teeth, and deciduous teeth. For example, the process of the mandible is fungal nor viral and contains no genetic material. Prognathism may cause no problems or be associ- proctitis Inflammation of the rectum. Prognathism is charac- may be due to a considerable number of causes, teristic of some diseases, such as acromegaly. Infectious proctitis is often due to agents such as prognosis The forecast of the probable outcome Chlamydia trachomatis, Neisseria gonorrheae, and or course of a disease; the patient’s chance of herpes simplex virus, all of which can be acquired recovery.
Strictly speaking buy 20mg levitra with visa impotence urban dictionary, since Aristotle’s supreme intellectual faculty 10 mg levitra with mastercard erectile dysfunction and smoking, the nous buy cheap levitra 20mg erectile dysfunction blood pressure, is said to be incorporeal and not to require simultaneous perception in order to be active,20 there is, at least in principle, no reason why we should not be able to think while being asleep. Aristotle’s negative deﬁnition of sleep does not, however, imply a negative evaluation of this ‘affection’ (pathos). Sleep is a good thing and serves a purpose, for it provides rest (anapausis) to the sense-organs, which would otherwise become overstretched, since they are unable to be active without interruption (454 a 27, 455 b 18ff. Here, again, one may note a difference compared with thinking; for one of the differences between perception and thinking, according to Aristotle, is that perception cannot go on forever, indeed if we overstretch our sense-organs, we damage them; thinking, on 19 For a discussion of Aristotle’s physiological explanation of sleep see Wiesner (1978). Aristotle on sleep and dreams 177 the other hand, does not know fatigue and the harder we exercise our intellectual faculty, the better it functions. Sleep, he argues in chapter 1 of On Sleep and Waking, is the opposite of waking; and since waking consists in the exercise of the sensitive faculty, sleep must be the inactivity of this faculty. In fact, sleep is nothing but a state of what Aristotle elsewhere calls ‘ﬁrst entelechy’,23 a state of having a faculty without using it, which may be beneﬁcial in order to provide rest to the bodily parts involved in its exercise. Furthermore, Aristotle is characteristically keen to specify that sleep is a particular kind of incapacitation of the sense faculty as distinct from other kinds of incapacitation, such as faint and epileptic seizure (456 b 9–16). He also applies his explanatory model of the four causes (which he reminds us of in 455 b 14–16) to the phenomenon of sleep, listing its formal, ﬁnal, material and efﬁcient causes, and leading up to two com- plementary deﬁnitions stating the material and the formal cause of sleep: the upward movement of the solid part of nutriment caused by innate heat, and its subsequent condensation and return to the primary sense organ. And the deﬁnition of sleep is that it is a seizure of the primary sense organ which prevents it from being activated, and which is necessary for the preservation of the living being; for a living being cannot continue to exist without the presence of those things that contribute to its perfection; and rest (anapausis) secures preservation (soteria¯ ¯ ). It is true that, in the course of his argument, Aristotle occasionally refers to empirical observations, or at least he makes a number of empirical claims, which can be listed as follows: 1. Nutrition and growth are more active in sleep than in the waking state (455 a 1–2). Some people move and perform various activities in sleep, and some of these people remember their dreams, though they fail to remember the ‘waking’ acts they perform in sleep (456 a 25). Words are spoken by people who are in a state of trance and seemingly dead (456 b 16). People with inconspicuous veins, dwarﬁsh people, and people with big heads are inclined to much sleep (457 a 20). People with marked veins do not sleep much; nor do melancholics, who in spite of eating much remain slight (457 a 26). Yet while some of these claims are interesting as testifying either to Aristotle’s own observational capacities or to his considerable knowledge of medico- physiological views on sleeping, as a whole they can hardly be regarded as impressive for their wide range or systematicity; and in the argument, most of these empirical claims have at best only a marginal relevance to the topic of sleep. They are mentioned only in passing, and none are presented by Aristotle as guiding the investigation inductively to a general theory or as playing a decisive role in settling potentially controversial issues. Nor does Aristotle explain how observations that seem to be in conﬂict with the theoretical views he has expounded can nevertheless be accommodated within that theory. Thus, in spite of his deﬁnition of sleep as the absence of sensation, Aristotle on several occasions acknowledges that various things may occur to us while we are in a state of sleep. This is obviously relevant for the discussion of dreams and divination in sleep that follows after On Sleep and Waking; but already in On Sleep and Waking we ﬁnd certain anticipations of this idea, for example in 456 a 25–9, where he acknowledges that people may perform waking acts while asleep on the basis of an ‘image or sensation’ (nos. And on two occasions, the wording of On Sleep and Waking seems to open the door to sensations of some kind experienced in sleep: ‘Activity of sense perception in the strict and unqualiﬁed sense (kurios¯ kai haplos¯ ) is impossible while asleep’ (454 b 13–14), and ‘we have said that sleep is in some way (tropon tina) the immobilisation of sense perception’ (454 b 26). These speciﬁcations suggest that more may be at stake than just an unqualiﬁed absence of sensation. Yet how the phenomena Aristotle on sleep and dreams 179 referred to are to be explained within the overall theory, he does not make clear. This absence of a teleological explanation of dreams is signiﬁcant, and I shall come back to it at the end of this chapter. In On Dreams,asinOn Sleep and Waking, Aristotle again begins by stating rather bluntly that dreams cannot be an activity of the sense faculty, since there is no sense-perception in sleep (458 b 5–10). However, in the course of the argument he recognises that the fact that sense-perception cannot be activated (energein) does not mean that it is incapable of being ‘affected’ (paschein): rì oÔn t¼ mn m ¾rn mhdn lhqv, t¼ d mhdn pscein tn asqhsin oÉk lhqv, llì ndcetai kaª tn Àyin pscein ti kaª tv llav a«sqseiv, kaston d toÅtwn ãsper grhgor»tov prosbllei mn pwv t¦ a«sqsei, oÉc oÌtw d ãsper grhgor»tová kaª Âte mn ¡ d»xa lgei Âti yeÓdov, ãsper grhgor»sin, Âte d katcetai kaª kolouqe± tä fantsmati. He goes on to say that dreams are the result of ‘imagination’ (phantasia), a faculty closely associated with, but not identical to sense perception. This time, though, Aristotle presents his account much more emphatically as being 180 Aristotle and his school built on observation of ‘the facts surrounding sleep’ (459 a 24), and his claims are backed up by a much more considerable amount of empirical evidence: 1. During sleep, we often have thoughts accompanying the dream-images (458 b 13–15); this appears most clearly when we try to remember our dreams imme- diately after awakening (458 b 18–23). When one moves from a sunny place into the shade, one cannot see anything for some time (459 b 10–11). When one looks at a particular colour for a long time and then turns one’s glance to another object, this object seems to have the colour one has been looking at (459 b 11–13). When one has looked into the sun or at a brilliant object and subsequently closes one’s eyes, one still sees the light for some time: at ﬁrst, it still has the original colour, then it becomes crimson, then purple, then black, and then it disappears (459 b 13–18). When one has been exposed to strong sounds for a long time, one becomes deaf, and after smelling very strong odours one’s power of smelling is impaired (459 b 20–2). When a menstruating woman looks into a mirror, a red stain occurs on the surface of the mirror, which is difﬁcult to remove, especially from new mirrors (459 b 23–460 a 23). Wine and unguents quickly acquire the odours of objects near to them (460 a 26–32). While in earlier scholarship the authenticity of the passage was disputed, the discussion now focuses on the following issues: (1) the problem of the passage’s obvious counterfactuality; (2) is the theory of menstruation as expounded here in accordance with what Aristotle says elsewhere? Brieﬂy summarised, my view is (1) that what seems to be underlying the passage is a traditional belief (perhaps derived from magic or midwives’ tales) in the dangerous and polluting effects of menstrual blood, and that Aristotle must have accepted this story without checking it because he felt able to provide an explanation for it; such beliefs were not uncommon regarding menstruation (although most of the evidence dates from the Roman period); (2) there is no inconsistency regarding the cause of menstruation, for in 460 a 6–7 the words di taracn kaª flegmas©an a¬matikn must be connected with ¡ diafor... When one is under the inﬂuence of strong emotions, one is very susceptible to sensitive illusions (460 b 4–16). When one crosses two ﬁngers and puts an object between them, it is as if one feels two objects (460 b 22–3). When one is on a ship which is moved by the sea and looks at the land, it is as if the land moves (460 b 26–7). Weak stimuli of pleasure and pain are extruded by stronger ones and escape our attention (461 a 1–3). Dreams occur in a later stage of sleep; they are often distorted and unclear, but sometimes they are strong (461 a 18–27). Melancholics, drunk people and those suffering from fever have confused and monstrous dream images (461 a 21–2). When one presses a ﬁnger under one’s eye, one single object appears double (462 a 1). Sometimes, during sleep, one is aware of the fact that one is dreaming (462 a 2–8). At the moment of falling asleep and of awakening, one often sees images (462 a 10–11). Young people see in the dark all kinds of appearances when their eyes are wide open (462 a 12–15). In situations of half-sleep, one can have weak perceptions of light and sounds from one’s environment (462 a 19–25). Many people never had a dream in their whole lives; others ﬁrst got them after considerable advance in age (464 b 1–11;cf.
The crude mortality of bacterial pneumonia in solid-organ trans- plantation has exceeded 40% in most series (65 quality levitra 10mg erectile dysfunction only at night,66) order 10mg levitra overnight delivery erectile dysfunction age 50. The clinical presentation and the differential diagnosis are similar to those in other critical patients cheap 20mg levitra visa erectile dysfunction trimix. The incidence of bacterial pneumonia is highest in recipients of heart-lung (22%) and liver transplants (17%), intermediate in recipients of heart transplants (5%), and lowest in renal transplant patients (1–2%) (67–69). The crude mortality of bacterial pneumonia in solid-organ transplantation has exceeded 40% in most series (66). Gram-negative pneumonia in the early posttransplant period is associated with significant mortality. In another study, opportunistic microorganisms caused 60% of the pneumonias, nosocomial pathogens 25%, and community-acquired bacteria and mycobacteria 15% (64). Gram-negative rods caused early pneumonias (median 9 days), and gram-negative cocci, fungi, Mycobacterium tuberculosis and Nocardia spp. These patients have particular predisposing factors, since the allograft is in contact with the outside environment, and have an impaired mucociliary clearance, ischemic lymphatic interruption, and abolition of the cough reflex distal to the tracheal or bronchial anastomoses. In fact, the anastomosis is especially vulnerable to invasion with opportunistic pathogens including gram- negative bacilli (Pseudomonas), staphylococci, or fungus. Lung transplant recipients with underlying cystic fibrosis may be prone to suffer infections caused by multiresistant microorganisms such as Burkholderia cepacia. In this group of patients perioperative antimicrobials are chosen on the basis of surveillance cultures. Pathogens transmitted from the donor may also cause pneumonia in this setting, though it is not very frequent (75). Pneumonia is less common after renal transplantation (8–16%), although it remains a significant cause of morbidity (67–69). Although bacterial pneumonia may occur any time after transplantation, the period of greater risk is the first month after the procedure. Need for mechanical ventilation and intensive care in this period are among the causes. The etiology will depend on the moment after transplantation, length of previous hospital stay, the days on ventilation, previous use of antimicrobial agents, and clinical and radiological manifestations (Table 3). Infections in Organ Transplants in Critical Care 393 Table 3 Probable Etiology of Pneumonia in Relation to the Type and Progression of the Infiltrates Probable etiology in relation to the type and progression of the infiltrates Radiological pattern Acutea Subacute Consolidation Bacteria (S. Pneumoniae gram-negative Aspergillus (30 days), Nocardia, tuberculosis rods, Legionella, S. A prodrome of influenza-like symptoms is followed by a sometimes “explosive” pneumonia with patchy lobular or interstitial infiltrates on chest radiograph. High fever, hypothermia, abdominal pain, and mental status changes are sometimes seen. Pneumonia is the most common presentation, but some patients have just fever (74). Other manifestations have also been described such as liver abscesses, pericarditis, cellulitis, peritonitis, or hemodialysis fistula infections (81). Infiltrate is usually lobar, but Legionella has to be included in the differential diagnosis of lung nodules, cavitating pneumonia, and lung abscess (71). Legionella infections can be overlooked unless specialized laboratory methodologies (cultured on selective media, urinary antigen test) are applied routinely on all cases of pneumonia (72). The use of impregnated filter systems may help prevent nosocomial legionellosis in high-risk patient care areas (83). Late community-acquired bacterial pneumonias are 10-fold more frequent in cardiac transplant recipients than in the general population (2. The most frequent form of acquisition of tuberculosis after transplantation is the reactivation of latent tuberculosis in patients with previous exposure. Clinical presentation is frequently atypical and diverse, with unsuspected and elusive sites of involvement. A large series of tuberculosis in transplant recipients described pulmonary involvement in 51% of patients, extrapulmonary tuberculosis in 16%, and disseminated infection in 33% (38). In lungs, radiographic appearance may vary between focal or diffuse interstitial infiltrates, nodules, pleural effusion, or cavitary lesions. Manifestations include fever of unknown origin, allograft dysfunction, gastrointestinal bleeding, peritonitis, or ulcers. Treatment requires control of interactions between antituberculous drugs and immunosuppressive therapy. Rhodococcus equi (89) and Nocardia (90–94) are well-known causes of respiratory tract infection in transplant recipients. Radiologically, they may appear as multiple and bilateral nodules, possibly due to their long-term silent presentation. The incidence of nocardiosis has been significantly reduced since the widespread use of cotrimoxazole prophylaxis. Nocardia farcinica may be resistant to cotrimoxazole prophylaxis and cause particularly aggressive disease (90). In a retrospective cohort study among 577 lung transplant recipients from 1991 to 2007, nocardiosis occurred in 1. Infection occur usually late (median of 49 months after transplantation) and the lungs are primarily involved in most cases. Rates vary according to the type of transplant recipient and are greatly influenced by the degree of immunosuppression, the use of prophylaxis, the rate of surgical complications and of renal failure among the transplant population. Fungal pathogens more likely to cause pneumonia in this population are Aspergillus, P. In lung and heart-lung transplantation, the incidence of fungal infections, most notably aspergillosis, ranges from 14% to 35% if no prophylaxis is provided, but has significantly decreased since aerosolized amphotericin B is provided to these patients (98,99). In lung and heart-lung transplant recipients, the types of disease presentation include bronchial anastomosis dehiscence, vascular anastomosis erosion, bronchitis, tracheobronchitis, invasive lung disease, aspergilloma, empyema, disseminated disease, endobronchial stent obstruction, and mucoid bronchial impaction. Retransplantation is also an independent risk factor (103,104), although aspergillosis may happen in low-risk Infections in Organ Transplants in Critical Care 395 patients if an overload exposure has occurred (39). Aspergillus may appear late after transplantation, mainly in patients with a neoplastic disease (106). Although the lung is the primary site of infection, other presentations have also been described (surgical wound, primary cutaneous infection, infection of a biloma, endocarditis, endophthalmitis, etc. Voriconazole is the mainstay of therapy; although combined therapy may be indicated in especially severe cases (108). These fungi now account for *25% of all non-Aspergillus mould infections in organ transplant recipients (109). We found that 46% of Scedosporium infections in organ transplant recipients were disseminated, and patients may occasionally present with shock and sepsis-like syndrome (110). Overall, mortality rate for Scedosporium infections in transplant recipients in our study was 58%. When adjusted for disseminated infection, voriconazole as compared with amphotericin B was associated with a lower mortality rate that approached statistical significance (p ¼ 0. Before prophylaxis, incidence was around 5%, although it has been described to reach up to 80% in lung transplant recipients. Clinical presentation was acute (less than 48 hours) with fever (89%), shortness of breath (84%), dry cough (74%), and hypoxia (63%).
Older children generic levitra 20mg overnight delivery erectile dysfunction treatment diabetes, in the same situation should use a toothpaste containing between 1000 and 1500 p buy 20mg levitra with amex latest advances in erectile dysfunction treatment. In the child where the development of dental disease would pose a real hazard to their general health cheap levitra 10 mg with amex erectile dysfunction workup aafp, and where home care in terms of oral hygiene and diet is poorly controlled, it is advisable to confer maximum protection by recommending the use of a toothpaste containing 1000-1500 p. Because of the inability of many disabled children to hold solutions in their mouths or to expectorate, fluoride mouthwashes are contraindicated; however, they can be used on a toothbrush (dipped) where toothpaste is not well tolerated, to mimic the amount of topical fluoride received from toothpaste. Key Points Fluoride advice: • supplements to give optimal caries protection; • fluoride mouthwash on a toothbrush instead of paste in cases of paste intolerance; • low caries risk: 500-600 p. Included in this general category of physical impairment are children with clefts of the lip and/or palate (Chapter 141148H ), where there may well be an associated syndrome in up to 19% of cases. This is a group of non-progressive neuromuscular disorders caused by brain damage, which can be pre-, peri-, or postnatal in origin, and is classified according to the type of motor defect: 1. There is the appearance of severe muscle stiffness and the planned movement of an affected limb results in a hypotonic tendon reflex, especially with rapid movements. Athetosis⎯uncontrolled, slow twisting, and writhing movements, which are frequent and involuntary and occur in over 16% of cases. For example, with the decrease in kernicterus (neonatal jaundice), there has been a fall in the athetoid form, but the spastic form, associated with prematurity, has increased. In addition, they may be disabled by other impairments such as convulsions, intellectual impairment, sensory disorders, emotional disorders, speech and communication defects, and a poorly developed swallowing and cough reflex. Although not confined to children with cerebral palsy, gastric reflux is relatively common (Fig. There may be an obvious aetiology, for example, a hiatus hernia, but quite often a cause for the erosion cannot be identified (Chapter 101152H ). Key Points Oral features in cerebral palsy: • gingival hyperplasia; • increased caries prevalence; • malocclusion; • dental trauma; • enamel hypoplasia; • heightened gag reflex; • dental erosion and abrasion (bruxism). Plentiful reassurance, efficient suction and skilled assistance are vital to success in these situations. Impaired ventilation may accompany scoliosis and becomes an even more important consideration if procedures involving a general anaesthetic are contemplated. Children who spend long periods in one position may be predisposed to pressure sores, therefore lengthy procedures in the dental chair without a break are best avoided. Patients can experience acute discomfort during tooth preparation or ultrasonic scaling (even when the affected teeth are distant from the operating site), merely from the cold produced by high volume aspiration. The use of a desensitizing agent like Duraphat fluoride varnish or fissure sealing the symptomatic surface can be helpful if a restoration is not indicated. Hypoplastic enamel does not have the same ordered prism structure as normal enamel and, despite acid etching, may not provide optimum retention for conventional resins. Some less severely disabled children will have little or no intellectual impairment but will have a degree of spasticity or rigidity. This may prevent them from co-operating fully with dental procedures, despite their willingness to do so, and they may be helped by nitrous oxide sedation (Chapter 41155H ). Most children require help with brushing until they are 7 years or older, but for the child with physical limitations this may be a permanent commitment on the part of carers. Limited or bizarre muscle movements prevent normal mouth clearing and food is often left impacted in the vault of the palate. This is readily removed with the end of a toothbrush handle or a spoon handle, but carers need to be aware of the potential for this, otherwise food residues may be left in the oral cavity for days. Powered toothbrushes may be helpful for a child with limited dexterity, not only because of the relative efficiency of cleaning but also because of the larger size of the handle of most of these brushes. When normal limb movement is impaired or absent and/or normal speech is impossible, the mouth assumes an even greater importance as a means of holding mouthsticks to grasp pens or to operate a variety of equipment. It is vital the dentition is maintained to the highest standard as the successful use of such mouthsticks is reliant on having a good occlusal table for balanced contact (Fig. Children with cerebral palsy, especially where there is accompanying intellectual impairment, will on occasion adopt a habit of self-mutilation by chewing soft tissues around the mouth (Fig. It is distressing for the parents as the child is obviously in pain from the ulcerated areas and may refuse all food and drink, but there is little they can do to break the habit. There are a number of solutions to the problem depending on the cause and the severity of the condition. In a child who is erupting primary teeth it may be possible to fit an occlusal splint, provided that sufficient teeth are available for retention. Fabrication of the splint may necessitate a short general anaesthetic for impression- taking. Alternatively, addition of glass ionomer cement to the occlusal surfaces of the primary molars, to open the occlusion and prevent the teeth contacting the soft tissues, may be successful. If only anterior primary teeth are present then composition, moulded over the offending tooth surfaces as a temporary splint, may break the habit and allow healing (Fig. If the problem is more severe and a splint is not feasible, it is sensible to extract the primary teeth involved. In the permanent dentition, rounding-off the pointed or sharp tooth surfaces and/or fitting a splint is usually successful. Ensuring that the child has plenty of fluids is of paramount importance as small, debilitated children rapidly become dehydrated. For some disabled children this can be excessive, although surgery to divert the submandibular flow more posteriorly may alleviate the problem. However, this is not always successful and carries the risk of increasing caries prevalence as a result of the greatly diminished salivary volume. The use of acrylic training plates that encourage the formation of an oral seal as well as promoting a more active swallowing mechanism so that saliva does not pool in an open mouth may be helpful (Fig. Concurrent work with speech and language therapists will help with the necessary therapy that is fundamental to the success of such treatment. Anecdotal case reports support the use of these plates, but few studies have been published that give objective data on their success. However, one relatively non-interventional method of reducing saliva flow is the use of hyoscine hydrobromide, a drug which blocks parasympathetic transmission to the salivary glands. Diet Considerations on dietary aspects have been covered in the section on intellectual impairment (Section 17. Some children, because of a failure to thrive, will be fed through a gastrostomy site. If the child is exclusively fed via this route, they will tend to accumulate large deposits of calculus. These need to be removed from surfaces adjacent to the gingival margins in particular. This can be difficult unless there is good cooperation from the patient; an impaired airway makes the safe removal of such deposits hazardous, with the risk of inhalation of calculus. The gastrostomy site can be useful also for sedative drugs, especially bitter intravenous sedation drugs that might otherwise not be tolerated orally. It is estimated that in 50-60% of affected children the defect is inherited and that environmental agents may be responsible for the remainder.