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Most adhesive and sealant producers will recommend the proper procedures for surface preparation erectile dysfunction treatment emedicine levitra soft 20 mg online. Some of the more common substrates and related applications for silicones are given in Table 3 erectile dysfunction quality of life cheap 20mg levitra soft mastercard. Klosowski erectile dysfunction help discount 20mg levitra soft overnight delivery, in Adhesives erectile dysfunction protocol book download 20 mg levitra soft fast delivery, Sealants and Coatings for Space and Harsh Environments (L erectile dysfunction is often associated with cheap 20 mg levitra soft visa. Shephard erectile dysfunction treatment yoga discount levitra soft 20 mg with amex, in Science and Technology of Building Seals, Sealants, Glazing and Waterproofing, Vol. Fedor, 2nd Symposium on Science and Technology of Building Seals, Sealants, Glazing and Waterproofing, Ft. This makes them ideally suited to adhesive applications in which high strength under adverse conditions is a prerequisite. Their unique characteristics include negligible shrinkage during cure, an open time equal to the usable life, excellent chemical resistance, ability to bond nonporous substrates, and great versatility. Although they were hailed as wonder products when first introduced, it has now been accepted that they will not do everything. They have, however, clearly established niches, especially in high-technology applications, and have shown steady growth, generally ahead of the industry average. Sales of epoxy resins in Europe, for example, totaled 101,000 metric tons in 1980, 150,000 metric tons in 1985, and 205,000 metric tons in 1990. By contrast, however, hardeners come in a variety of shapes and sizes, including amines and amides, mercaptans, anhydrides, and Lewis acids and bases. Choice of hardener depends on the application requirements, and the wide range of hardeners available increases the versatility of adhesives based on epoxy resins. The most widely used epoxy resins are the family of products produced by the reaction between epichlorhydrin and bisphenol A. This reacts with additional epichlorhydrin to produce a molecule of general structure Commercially useful grades are relatively low-molecular-weight products in which n ranges from 0 to about 4. When n is between 0 and 1, the product is a liquid, and this is the most useful product for adhesive applications. Regardless of molecular weight, the resulting resin has two epoxy groups per molecule. Resins of greater functionality can be produced from polyols having more than two hydroxyl groups per molecule. Thus phenol novolac resins, having the general structure can be reacted with epichlorhydrin to produce epoxy novolac resins. Because of their higher functionality, epoxy novolacs have greater cross-link density, generally yielding better temperature resistance at the expense of increased brittleness. Other products that may be epoxidized in this way include dihydric and trihydric phenols, aliphatic polyols such as glycerol, and simple alcohols such as butanol or allyl alcohol. Epoxy groups may also be produced by oxidation of olefinic unsaturation within animal and vegetable oils. The resulting epoxy resin is capable of reacting with various products, or itself, to form a solid, infusible product of considerable strength. The fact that these reactions generally occur without the production of low-molecular-weight by-products means that shrinkage during cure is negligible. This reduces stresses in the cured structure, contributing to the strength of the cross-linked matrix and eliminating the need for sophisticated clamping techniques. The two cross-linking reactions are external, by reaction of the oxirane group with active hydrogen, and internal, by homopolymerization through the oxirane oxygen. The former is typical of cross-linking by hardeners and the latter of catalyzed cross-linking. The classic epoxy curing mechanism is illustrated by the reaction between a primary amine and an epoxy group: this product can react with an additional epoxy group to continue the cross-linking process. This reaction is characteristic of hardeners having active hydrogens available, including amines, amides, and mercaptans. The reaction is catalyzed by hydroxyl groups, especially phenolic hydroxyls and tertiary amines. Because of the bulk of the substituent groups involved, steric factors have a major influence on the reaction rate. Thus low-molecularweight hardeners tend to react more vigorously and produce more cross-linked structures, while hardeners of high molecular weight tend to react more sluggishly. Homopolymerization occurs readily in the presence of catalysts, especially at elevated temperatures. In fact, reactions with resin and hardener or catalyst are very much more complex than these idealized reactions, and both reactions as well as a number of side reactions probably occur to varying extents in any cross-linking mechanism. Major suppliers of curing agents include Anchor Chemicals, Dow, Shell, and Cray Valley Products. Thus a knowledge of the number of reactive sites is needed in order to calculate correct ratios. For applications requiring low viscosity it is thus necessary to include other types of epoxy resin or to use reactive or nonreactive diluents to achieve the desired viscosity. In general, suppliers of proprietary hardeners do not furnish detailed chemical descriptions. Instead, they supply data on recommended mix ratios, and from this the formulator can calculate the correct quantities. In practice, however, the quantity used will affect both the rate of cure and the cured properties. Thus with catalysts, in practice, the mix ratio is sometimes more critical than is the case with hardeners. Mixed Product During cure of epoxies, especially systems with a short pot life or large mixes, considerable heat is evolved. Mixes larger than 5 kg can reach excessive temperatures even with systems that have relatively long pot lives in quantities of 100 g. In addition to shortening the pot life dramatically, exothermic reactions can push the peak temperature to the point where thermal degradation occurs, or at least to a level that creates excessive stresses in the curing matrix, causing it to crack on cooling. Except in certain circumstances, peak exotherm temperature should be limited by formulation to 150 C or preferably less in the mix quantities used. Cured epoxy resins may be formulated to be extremely hard, with Shore D hardeners of 80 or more, or soft, flexible products that barely produce a reading on the Shore A scale. It is a feature of the inherent thermoplasticity in cured epoxy compounds as a result of the relatively low cross-linking density, and may be any value from below 50 C to about 250 C, depending on formulation and cure cycle. These include the ability to formulate liquid systems without solvents or carriers, the ability to convert these systems to cured products without the production of low-molecular-weight by-products, the ability to bond dissimilar or nonporous surfaces, and the ability to produce thick sections without subsequent stress cracking due to shrinkage. Although epoxy resin and hardener may be used in unmodified form in adhesive systems, most systems will consist of components that have been modified by incorporation of various additives to achieve specific effects. Formulators will add catalysts or blend hardeners to obtain a specific usable life of the mix and to control the curing temperature. Various additives may be added, usually at a low percentage, to reduce aeration, improve adhesion to difficult surfaces, or minimize settlement of fillers. Epoxy novolacs, having higher functionality, increase the cross-linking density, which improves heat resistance but decreases impact resistance. Incorporation of epoxidized oils increases flexibility at the expense of heat and chemical resistance. Low-viscosity polyfunctional epoxies based on polyols or polyhydric phenols reduce viscosity and can increase functionality without impairing cured properties. Monofunctional reactive diluents will also decrease viscosity and form part of the polymer backbone, to impart a measure of flexibility without the possibility of migration. Properties of commercially available epoxy resins and diluents from various suppliers are listed in Table 1. Hardeners may be blended to achieve properties intermediate to the individual components, to reduce exotherm or accelerate cure, to modify the cured properties, or simply to arrive at a more convenient mix ratio. Several classes of curing agents each having distinctive characteristics may be used. These offer improved heat and chemical resistance and longer pot life with reduced exotherm, but poor color stability and sluggish cure. They are generally solids and require some formulating to produce easily handleable products. Reactions proceed best at elevated temperatures, where their irritancy can be a problem. Both aliphatic and aromatic amines can be adducted with small amounts of mono- or diglycidyl epoxies to produce amine adducts of medium to high viscosity that have decreased volatility and irritancy, more convenient mix ratios, and often, better reactivity. Although amides on their own are too unreactive, reaction products of polyamines with fatty acids to produce amidopolyamines provide the largest group of commercial hardeners for adhesive applications. Reduced volatility and irritancy and a convenient mix ratio offer the compounder ease of handling. Initially, amidoamines have poor compatibility and an induction period is necessary to allow the reaction to start. Its low reactivity yields a usable life in excess of 6 months, but at elevated temperatures it reacts quickly. Most mercaptans on their own are unreactive, but with catalysts produce flexible cures. Since all these products tend to degrade the performance of the cured product, it is preferable to use difunctional low-viscosity epoxies to reduce viscosity. Where applicable, functionality of reactive diluents must be allowed for when calculating ratios. They exhibit little tendency to migrate and have good compatibility with both resins and hardeners. Chlorinated plasticizers may be used to reduce flammability, especially in conjunction with antimony trioxide. The effect of plasticizer additions is generally to degrade most physical properties, although at low additions the effect is usually small. Nor is this generally a desirable attribute in adhesive applications, where epoxies are usually selected because of their great strength. Powder fillers are added to increase viscosity, improve abrasion resistance and gap-filling properties, impart specific electrical or mechanical properties, or reduce cost and shrinkage. Although most fillers will increase the density of the cured product, certain lightweight fillers will decrease density. Highly alkali fillers should be avoided, especially with acid-cured systems, as they may retard setting. Fibrous fillers may be added to impart specific rheological properties or to reinforce the system. Addition levels are much lower at 10 to 50 phr, as they usually cause much more rapid thickening. Settlement of fillers during storage depends primarily on the particle size of the filler and its density, and the viscosity of the formulated product. Fine particle fillers with relatively low specific gravity in high-viscosity products will settle much less, especially if the product is at all thixotropic. Where coarse fillers must be used, an approach toward a fully filled voidless system where the volume of liquid is such as just to fill the voids will solve the problem. Incorporation of fine fillers, use of a pigment-dispersing aid, and where application permits, use of a thixotroping agent will help to reduce or eliminate settlement. Depending on addition levels, fillers will generally increase the usable life and extend the cure time of the mix. Tensile and compressive strength usually increase maximally then decrease on further additions. Solvents Although a major advantage of epoxy adhesives is their ability to be formulated without solvents, under certain circumstances solvents may be included. On porous substrates solvents may be added to reduce viscosity and assist penetration. On certain nonporous substrates, particularly some plastics, addition of a small percentage (1 to 3%) of a suitable solvent will improve adhesion. Most commonly used additives are defoamers, antisettling or wetting agents, thixotropes, and adhesion promoters. Because of their minimal shrinkage, compressive strength of cured epoxies is very high. Since aeration will reduce this substantially, use of defoamers, especially in heavily filled systems, is quite common. Many defoamers are suitable, but silicone-based defoamers should be avoided on surfaces where adhesion in critical. Antisettling agents, pigment dispersers, or wetting agents may be included in filled formulations. Depending on the formula, particularly the selection of fillers, such products may reduce or eliminate settlement. Various thixotropes are used in epoxy formulations to reduce or eliminate flow in products designed for use on vertical surfaces, to improve gap-filling properties, or to reduce settlement of fillers. At low levels, the effect on viscosity is small except in high-viscosity systems, but settlement will be reduced. At higher addition levels, even low-viscosity products can be converted to firm pastes. To improve the efficiency of fumed silica, especially in the resin component, small quantities of polar liquids may be added. Other thixotroping agents include Bentones and Tixogels, of which a number of grades are available, and China clay or kaolin, usually added as a filler, but which imparts thixotropy to the formulated product. Formulators can select from a number of different functional groups, but generally epoxy functional types will be used in the resin component and amine functional grades in the hardener. Elastomers Occasionally, elastomers may be included in solvent-based formulations.
The level of pain perceived was found to be significantly lowerwiththeperiodontalendoscope(p<0 erectile dysfunction dr mercola purchase 20 mg levitra soft overnight delivery. Atotalof37%ofrespondentsreportednopain or discomfort with the use of the periodontal endoscope erectile dysfunction quick natural remedies generic levitra soft 20 mg line,56 impotence kegel exercises cheap levitra soft 20 mg on-line. Of those that reported some pain for Full mouth periodontal probing was completed discomfort erectile dysfunction medications comparison order levitra soft 20mg fast delivery,89 erectile dysfunction treatment medications purchase 20mg levitra soft with mastercard. Im- odontal endoscope elicited slight levels of anxiety mediately after the examiner used the periodontal orfear erectile dysfunction doctors in pittsburgh levitra soft 20 mg with visa,while1additionalsubject(6. Question 6 was consistent with comparing the pain scores of the probe and the periodontal endoscope. Overall, 75% of subjects said the level of pain felt was less with the periodontalendoscopethantheprobe,and16. There has been no previous research published examining the levels of perceived pain with the use of a periodontal endoscope. The results of this study may help expand the knowledgeanduseofthisinstrumentinthefieldsofdentistry and dental hygiene. Based on the findings from the current study, subjectsdidnotfindtheperiodontalendoscopeto elicitsignificantanxietyorpain. Earlyusersofthe periodontal endoscope advocate the use of local anesthetics to ensure patient comfort. As revealed by the literature review, studieshaveshownmanysubjectsfindaninjectionof local anesthetic to be a stressful and painful experience. This supports several other previous studies, which showed no difference in pain experience among such groups. Moredefinitivestatisticsneedtobeobtained in the future in order to determine if either of these itemsareofsignificantimpactonpainperception. Althoughthecurrentfindingssupportedtheconcept ofpredictorsofpainexperience,thefindingswere not, however, deemed statistically significant. Limitations this was a pilot study with a relatively small sample of the population (n=30). It is a preliminary step in expanding the knowledge base of how periodontal endoscopes could be more widely utilized in periodontal and general dental practice. However, further research with larger populations should be performed in the future to determine patient acceptance and pain experience of this tool among a greater variety of individuals. Achieving an accurate measurement of anxiety isextremelydifficult,andthereforemayalsoskew research outcomes. A subject may express anxiety to one aspect of treatment, but not to another - it is not necessarily a consistent level. With that in mind, although the periodontal endoscope did not elicit significant pain or anxiety during subgingival visualization, if calculus is detected and scaling and root planing 120 is recommended, the use of local anesthetics may be necessary, therefore, eliciting different levels of anxiety. An additional limitation is that this study compared the pain perception felt with simple visualization with the periodontal endoscope to that of periodontal probing. These both have similar methods of subgingival "instrumentation," however, they are not performing the same task. Also, pain measurements were taken for full mouth periodontal probing, but the pain measurements for the periodontal endoscope were obtained after use in only 2 quadrants, not the entire mouth. Due to the nature of the study, there was no way to blind the subjects or the examiners. There is no placebo for the periodontal endoscope, so both subjects and examiners knew if it was used or not. Conclusion the subjects of this study expressed the level of perceived pain or discomfort with the periodontal endoscope was significantly less than that exVol. Therefore, administration of a local anesthetic was not necessary for subgingival visualization of the pocket environment during this study. Is it the injection device or the anxiety experienced that causes pain during dental local anaesthesia The pain anxiety symptoms scale: development and validation of a scale to measure fear of pain. Endoscopic visualization of submarginal gingiva dental sulcus and tooth root surfaces. The effectiveness of in vivo root planing in removing bacterial endotoxin from the roots of periodontally involved teeth. The use of pain scales in assessing theefficacyofanalgesicsinpost-operativedental pain. A preliminary study of intra-pocket topical versus injected anesthetic for scaling and root planing. Clinicalandinflammatoryevaluationof perioscopy on patients with chronic periodontitis. The descriptor differential scale: applying psychophysical principles to clinical pain assessment. A new ultrasonic device in maintenance therapy: perceptionofpainandclinicalefficacy. Effects of two different methods of non-surgical periodontal therapy on patient perception of pain and quality of life: a randomized controlled clinical trial. The descriptor differential scale of pain intensity: an evaluation of item and scale properties. Everyday- and dental-pain experiences in healthy Swedish 8-19 year olds: an edpidemiological study. Dental and medical injections: prevalence of self-reported problems among 18-yr-old subjects in Norway. Injection pain: comparison of three mandibular block techniques and modulation by nitrous oxide-oxygen. The effect of vibration on pain during local tal fear survey among patients with dental phobia. Abstract Purpose: To evaluate educational resources used in developing and implementing an interactive infection control instructional programforfirstyear(n=26)andsecondyear(n=26)dentalhygiene students in a baccalaureate program. Descriptive statistics were used to evaluate responses on a post instructionopinionsurveyona5-pointLikert-typescale. Results: Following the instructional program, most students reported on an opinion survey that they understood infection controlprinciples(92%firstyear,100%secondyear),feltprepared toworksafelyinclinic(96%firstyear,100%secondyear)and liked working at their own pace (88% first year, 100% second year). First year students valued the online learning components and were less favorable toward supplemental textbook readings and the limited time to complete all 10 modules. Most second year students valued the interactive workshop but did not take the time to complete the online videos and did not watch all of them. Seventy-nine percent of second year students (n=20) preferred the interactive workshop method over traditional lecture instruction completedduringtheirfirstyear. Traditionally, dental hygiene students learn the didactic portion of infection control content via classroom instruction, and then they are expected to apply their knowledge in the clinical setting for delivering safe client care. Active learning happens through involvement and participation with "thoughtful fusion of face-to-face and online learnothers,andwiththoughtfulreflection. They attended a mandatory orientation session including instructions on accessing the online course materials on Moodle (an online teaching platform) and had an opportunity to ask questions. Students had 1 week to work through 10 online course modules, which included a combination of workbook and supplemental readings, online videos, and brief online post-module study questions. Students also completed an opinion questionnaire that was developed in collaboration with a statistician at this institution. Questions arose regarding which of these methods was effective in promoting critical thinking skills, preferred by students and saving time. Data previously collected and analyzed indicated course outcomes for e-learning and traditional classroom instruction in infection control was equally effective when free online modules were used. Second year students (n=26) completed their initial infection control instruction in the 2009 fall semester by a traditional classroom lecture method prior to the development of the new instructional program. These students were required to have annual refresher education in the fall semester 2010. Prior to the start of the academic year, the students received orientation letters including information on the required annual refresher. Instructions were provided on accessing and completing the online course content (10 video modules) which was required prior to the workshop scheduled 2 weeks after the start of the semester. The students attended a required refresher workshop 2 weeks after the start of the semester, and thecontentwasthesameasthefirstyearstudents (discussion and interactive activities). Respondents were provided with an opportunity tocommentonthemostandleastbeneficialcomponents of the infection control instructional program through 3 open-ended questions. The assigned readings, and particularly the supplemental textbook readings, were not well received because students perceived the information was "contradictory," "hard to understand," "unnecessary," "repetitive" and "a lot of work in a short period of time. The majority of the second year students agreed or strongly agreed that the interactive workshop was easy to understand (96%), interesting (73%)andusefulforclinic(96%). Theyalsoagreed or strongly agreed they understood infection control principles (100%), felt prepared to work safely in clinic (100%)andliked workingattheirownpace (100%). Themajority(79%)preferredthenewinteractive method to the traditional instruction used the previous year for initial infection control training. Comments and suggestions for improving the instructional program were made by both groups of students. First year students needed more time to complete the program and recommended eliminating the repetitive supplemental readings. Second year students thought the most beneficial aspect was the interactive workshop and preferred this method of instruction over the traditional method employed in their first year. These results might have been related to the fact that these students had seen the videos during initial infection control training, and/or possibly related to the nature of novice versus more experienced learners. Novice learners need detailed information and visual instructional approaches, and they are less able to apply principles in interactive case-based activities. More experienced learners, like the second year students, with the goal of attaining competence need application and synthesis for deeper meaningful learning. The students agreed or strongly agreed that the interactive workshop was easy to understand (88%) and useful forclinic(96%). Firstyearstudentsalsoagreedor strongly agreed that they understood infection control principles (92%), felt prepared to work safely inclinic(96%)andlikedworkingattheirownpace tolearninfectioncontrolcurricularcontent(88%). Open-ended comments indicated the Understanding the various aspects that worked or online videos were valued by the students because did not work for each group of students was importhey could work at their own pace and could watch tant in evaluating this infection control program and 126 the Journal of Dental Hygiene Vol. The interactive workshop with activities was most valuable to the second year students receiving refresher infection control content for application and synthesis. I feel prepared to work safely in the clinic setting after completing this material. Asafirst-yearstudentlastyear,Iunderstoodtheinfectioncontrol material and felt prepared for clinic. Which method would you prefer if you had a choice in learning initial infection control material The aspects that did not work well included supplemental readings for firstyearstudents,andtheonlinevideosforsecond year students. Class activities as suggested from the toolkit, examination items and online preparatory components may be helpful to faculty responsible for teaching infection control content to dental hygiene students. These materials have the potential to assist educators in teaching and evaluating infection control curricular content. The use of supplemental readings should be minimized as they may provide little benefit Acknowledgment for students. Recommendations for dental hygiene educators that teach infection control content inThe author would like to thank Professor Denise clude: Bowen for her assistance with manuscript preparation, Dr. Higher education, blended learning and the generations: knowledge is power no more. Introducing an online community into a clinical education setting: a pilot study of student and staff engagement and outcomes using blended learning. Blended learning on medication administration for new nurses: Integration of e-learning and face-to-face instruction in the classroom. A blended-learning course taught to different groups of learners in a dental school: Follow-up evaluation. An instructional model for web-based e-learning education with a blended learning process approach. Descriptive statistics, Chi-square and Fishers Exact tests compared personnel demographics and oral health knowledge, confidenceandpracticesatthep0. More than half of those reportingwerenotconfidentassessingforvisualsignsofdental decay and do not routinely assess for visual signs of decay. Participation, eligibility requirements and the complicated application process vary by state. A combination of bacteria, tooth in a child 71 months of age or younger, or any saliva, defective tooth about the transmission of sign of smooth-surface decay in children younger bacteria enamel, parental behaviors and attitudes than 3 years of age. The guardians and/or parents of 2 year olds results in positive behavioral and clinical outcomes displayed greater compliance with recommended for children and parents. A pea-size or smear of toothpaste should be introduced at approximately 18 to 24 months of age and hands-on parental or caregiver toothbrush instruction should be taught and reinforced. Virginia Division of Dental Health implemented a Maternal and Early Childhood Oral Health Program called Bright Smiles For Babies. Dental and medical providers are trained to increase the number of dental visits for at-risk 1 year olds. Methods and Materials After approval from Old Dominion University College of Health Sciences Human Subjects Committee, a pilot study of 15 nursing students and 32 dental hygiene students was conducted to determine reliability of a test-retest procedure for a 22-item investigator-designed questionnaire. Content validity was established involving a panel of experts (20 dental hygiene graduate students and faculty). Anonymity was insured by not requiring names on the questionnaire instrument, and data were reported in group-form among districts only. Questionnaire content was guided by the knowledge, confidence and practice objectives of the 133 the Journal of Dental Hygiene overall study and the review of the literature.
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Improving generalization of peer socialization gains in inclusive school settings using initiations training erectile dysfunction young living quality 20 mg levitra soft. Improving question-asking initiations in young children with autism using pivotal response treatment erectile dysfunction reasons discount 20mg levitra soft amex. Using pivotal response training with peers in special education to facilitate play in two children with autism icd-9 erectile dysfunction diabetes 20mg levitra soft with visa. Peer-mediated social skills instruction and self-management strategies for students with autism (Doctoral dissertation) erectile dysfunction treatment urologist buy levitra soft 20 mg without prescription. Increasing complex social behaviors in children with autism: Effects of peerimplemented pivotal response training low testosterone causes erectile dysfunction purchase 20 mg levitra soft. Multiple peer use of pivotal response training social behaviors of classmates with autism: Results from trained and untrained peers drugs for treating erectile dysfunction cheap levitra soft 20mg with visa. Using peer trainers to promote social behavior in autism: Are they effective at enhancing multiple social modalities The assessment and treatment of social behavior in autism: Towards a naturalistic approach (Doctoral dissertation). Training paraprofessionals of students with autism to implement pivotal response treatment in inclusive school settings using a brief video feedback training package. Training paraprofessionals of students with autism to implement pivotal response treatment using a video feedback training package (Doctoral dissertation). Behavioral treatment for children with autism: A comparison between discrete trial training and pivotal response training in teaching emotional perspective-taking skills. Using teacher-implemented instruction to increase language intelligibility of children with autism. Teaching symbolic play to children with autism using pivotal response training: Effects on play, language and interaction (Doctoral dissertation). The effects of sibling-implemented training on social behaviors of autistic children (Doctoral dissertation). Father involvement in parent training interventions for children with autism: Effects of tailoring treatment to meet the unique needs of fathers (Doctoral dissertation). Studies that are ineligible for review using the Children and Students with an Autism Spectrum Disorder Evidence Review Protocol Aldred, C. Mediation of treatment effect in a communication intervention for pre-school children with autism. Child demographics associated with outcomes in a community-based pivotal response training program. Parent-implemented interventions for young children with disabilities: A review of fidelity features. A meta-analysis of school-based social skills interventions for children with autism spectrum disorders. Effects of a fatherbased in-home intervention on perceived stress and family dynamics in parents of children with autism. Teaching social skills to people with autism: Best practices in individualizing interventions (1st ed. Infants and toddlers with autism spectrum disorder: Early identification and early intervention. Social compass curriculum: Three descriptive case studies of social skills outcomes for students with autism. The sequential relationship between parent attentional cues and sustained attention to objects in young children with autism. Using parent/clinician partnerships in parent education programs for children with autism. Parenting interventions for children with autism spectrum and disruptive behavior disorders: Opportunities for cross-fertilization. Evaluation of a multicomponent online communication professional development program for early interventionists. Large scale dissemination and community implementation of pivotal response treatment: Program description and preliminary data. Self-management interventions on students with autism: A metaanalysis of single-subject research. Peer interactions of students with intellectual disabilities and/or autism: A map of the intervention literature. Effective strategies for the inclusion of children with autism in general education classrooms. Social skills intervention for students with autism spectrum disorders: A survey of school psychologists (Doctoral dissertation). Parent-mediated early intervention for young children with autism spectrum disorder. Bridging the research-to-practice gap in autism intervention: An application of diffusion of innovation theory. Using evidence-based practices addressing language and communication in students with autism and developmental disabilities: Do special education teachers determine approaches consistent with characteristics of students The impact of parentdelivered intervention on parents of very young children with autism. Cross-setting complementary staff- and parent-mediated early intensive behavioral intervention for young children with autism: A research-based comprehensive approach. Teaching joint attention to children with autism through a sibling-mediated behavioral intervention. The need for more effective father involvement in early autism intervention: A systematic review and recommendations. A review of treatments for deficits in social skills and self-help skills in autism spectrum disorder. Language use in social interactions of school-age children with language impairments: An evidence-based systematic review of treatment. Social skills and adaptive behavior in learners with autism spectrum disorders: Current status and future directions. The effects of behavior skills training on correct teacher implementation of natural language paradigm teaching skills and child behavior. Effects of naturalistic instruction on phonological awareness skills of children with intellectual and developmental disabilities. The effects of teacher-implemented naturalistic intervention on the communication of preschoolers with autism. Randomized trial of an eLearning program for training family members of children with autism in the principles and procedures of applied behavior analysis. Brief report; Using individualized orienting cues to facilitate firstword acquisition in nonresponders with autism. Improving social initiations in young children with autism using reinforcers with embedded social interactions. The effectiveness of contextually supported play date interactions between children with autism and typically developing peers. Practical social skills for autism spectrum disorders: Designing child-specific interventions (p. Evaluation of a public school group-based applied behavioral analysis program for elementary students with autism (Doctoral dissertation). Communication interventions and their impact on behaviour in the young child: A systematic review. A comparison of video modeling and pivotal response training to teach pretend play skills to children with autism spectrum disorder. Effectiveness of pivotal response training as a behavioral intervention for young children with autism spectrum disorders. Early intensive behavioral interventions: Selecting behaviors for treatment and assessing treatment effectiveness. Behavior support interventions implemented by families of young children: Examination of contextual fit. Initiating and responding to joint attention bids in children with autism: A review of the literature. Impact of social communication interventions on infants and toddlers with or at-risk for autism: A systematic review. Adherence to treatment in a behavioral intervention curriculum for parents of children with autism spectrum disorder. Teaching complex social skills to children with autism: Advances of video modeling. Evidence-based practices in interventions for children and youth with autism spectrum disorders. A systematic review of training programs for parents of children with autism spectrum disorders: Single subject contributions. Rogers and Geraldine Dawson: Review of Early Start Denver Model for young children with autism: Promoting language, learning and engagement. Naturalistic language teaching procedures for children at risk for language delays. Evidence-based treatments in communication for children with autism spectrum disorders. Stimulus overselectivity in typical development: Implications for teaching children with autism. Overview of meta-analyses on early intensive behavioral intervention for young children with autism spectrum disorders. Social skills interventions for individuals with autism: Evaluation for evidencebased practices within a best evidence synthesis framework. This study is ineligible for review because it is out of the scope of the protocol. Pivotal response treatment for children with autism: Core principles and applications for school psychologists. Parent training for children with pervasive developmental disorders: A multi-site feasibility trial. Identifying critical elements of treatment: Examining the use of turn taking in autism intervention. Effectiveness of a modified rapid toilet training workshop for parents of children with developmental disabilities. Training paraprofessionals to implement interventions for people autism spectrum disorders: A systematic review. This study is ineligible for review because it does not use a sample aligned with the protocol. Interventions for toddlers with autism spectrum disorders: An evaluation of research evidence. Positive affect of parents of autistic children: A comparison across two teaching techniques. Fostering self-management: Parent-delivered Pivotal Response Training for children with autistic disorder. Training for parents of children with autism: Pivotal responses, generalization, and individualization of interventions. Alternative applications of Pivotal Response Training: Teaching symbolic play and social interaction skills. Enhancing generalization of treatment effects via pivotal response training and the individualization of treatment protocols. A review of parent education programs for parents of children with autism spectrum disorders. A review of parent training interventions for children with autism spectrum disorder and proposed guidelines for choosing best practices (Unpublished doctoral dissertation). Promoting the social and cognitive competence of children with autism: Interventions at school. Teaching augmentative and alternative communication to students with severe disabilities: A review of intervention research 1997-2003. Using pivotal response training to facilitate appropriate play in children with autistic spectrum disorders. The basic structure of community early intervention programs for children with autism: Provider descriptions. Parent and multidisciplinary provider perspectives on earliest intervention for children at risk for autism spectrum disorders. The effects of an accelerated parent education program on technique mastery and child outcome. Toward a technology of treatment individualization for young children with autism spectrum disorders. Pivotal response treatment for infants at-risk for autism spectrum disorders: A pilot study. Providing interventions for young children with autism spectrum disorders: What we still need to accomplish. A sustainable model for training teachers to use pivotal response training (Doctoral dissertation). Training teachers to use pivotal response training with children with autism: Coaching as a critical component. Examining the effectiveness of a train-the-trainer model: Training teachers to use pivotal response training. Parent training for families who have children with autism: A review of the literature. Using a self-assessment procedure to improve parent implementation of intervention for children with autism (Doctoral dissertation). Professional development needs of intervention specialists in the area of evidence-based practices for students with autism (Unpublished doctoral dissertation). An early social engagement intervention for young children with autism and their parents. Pivotal response treatment for children with autism spectrum disorders: A systematic review.
Depending on the displacement of the fragments and the compensatory posturing of the mandible being overweight causes erectile dysfunction order 20mg levitra soft mastercard, there may be deviation of the chin to the affected side or there may be no occlusal disharmony erectile dysfunction drugs and nitroglycerin levitra soft 20 mg overnight delivery. Bleeding from the external meatus may occur due to perforation of the anterior wall of the auditory canal by the condylar head (see Figure 7 erectile dysfunction pill identifier cheap levitra soft 20mg online. Bleeding or discharge from the ear should be investigated by an otolaryngologist but suctioning of the external meatus is contraindicated due to the potential for disturbance of the ossicular chain should there be a perforation of the tympanic membrane impotence low testosterone purchase 20 mg levitra soft mastercard. Displacement of the condylar head into the middle cranial fossa has been reported but is a rare event erectile dysfunction medicine bangladesh buy discount levitra soft 20mg online. Management Treatment is almost always conservative with a short period of rest followed by active movement to prevent the temporomandibular joint ankylosis impotence jelly generic levitra soft 20 mg otc. Bilateral subcondylar fractures may result in significant displacement and an anterior open bite. A short period of intermaxillary fixation with posterior bite blocks to distract the fragments may be indicated. Where there has been gross displacement of the condylar head, or in severe cases of bilateral fracture, Botox (botulinum toxin) has been used 126 Handbook of Pediatric Dentistry to paralyse the lateral pterygoid muscle, relieve the spasm in this muscle and minimize the fracture displacement. As the condylar neck is relatively broader in the child with a greater volume of cancellous bone, fractures of the articular surface are more common than in the adult. Should there be a limitation of opening or frank ankylosis, early intervention with a costochondral graft is recommended. Maxillary fractures Middle-third fractures are rare in children and usually present with other severe maxillofacial and head injures. As is common with these injuries in children, an intracapsular fracture-dislocation is present, which remodelled itself without treatment. Note the bilateral periorbital ecchymosis and swelling resulting in closure of the eyes. Despite the appearance, there was only minimal displacement of the maxilla, although external fixation was required to reduce the depressed nasal fracture. Management Conservative management is usual unless there is displacement of the maxillary complex. Simple maxillary fractures are managed with cap splints or arch bars with intermaxillary fixation. With marked displacement of the mid-facial complex, internal semi-rigid fixation or extra-oral fixation may be necessary. These children spend extended periods in intensive care units, undergo personality changes, suffer post-traumatic amnesia and may have episodes of neuropathological chewing. Tooth loss Approximately 10% of children who sustain fractures of the jaws will also have loss of permanent teeth. Intra-articular damage to the temporomandibular joint There is always a risk of ankylosis of the temporomandibular joint after significant displacement of the condylar head, intracapsular fracture or a failure to achieve early mobilization of the joint. Treatment of the ankylosis involves condylectomy and joint reconstruction with a costochondral graft in later childhood. Mandibular asymmetry with antegonial notching may occur on the affected side after Figure 7. The key to management is to correct asymmetries early to avoid secondary maxillary deformity. Luxations in the primary dentition General management considerations There is general agreement that most injuries to the primary dentition can be managed conservatively and heal without sequelae Immunization If the child is not fully immunized then a tetanus booster is required: tetanus toxoid 0. Antibiotics Unless there are significant soft-tissue or dentoalveolar injuries, antibiotics are not usually required. Antibiotics are prescribed empirically as a prophylaxis against infection, but are not a substitute for proper debridement of wounds. Luxations Up to 2 years of age, the most common injuries to the primary teeth are luxations involving a displacement of the teeth in the alveolar bone. All these teeth are tender to percussion, there is haemorrhage and oedema within the ligament, but gingival bleeding and mobility only occurs if the teeth have been subluxated. There is usually a palatal and superior displacement of the crown, which means that the apex of the tooth is forced away from the permanent follicle. D Gross displacement of all upper anterior teeth with gingival degloving and loss of the labial plate. This child had the displaced teeth extracted, and debridement and suturing of the gingiva under general anaesthesia. E An intrusive luxation of the upper right central incisor in a 12-month-old child. Note the displacement of the gingiva, indicating that the tooth has not been avulsed. Trauma Management 131 Clinical Hint Where the apex of the primary tooth has perforated the labial plate the tooth should be removed. The decision on whether to extract or to allow for re-eruption is very much a clinical one, and is based on the presentation of the injuries and the assessment of the child. More severe injuries, involving alveolar bone and gingiva, often necessitate extraction. Replacing an avulsed primary tooth may force the blood clot in the socket, or the root apex itself, into the developing permanent tooth. There are cases in which the parent or caregiver replants the tooth and it seems to be stable and viable; in these cases the tooth could be left in situ. Splinting of primary teeth may be difficult in young, traumatized children and if successfully placed, the splint must then also be removed later when the child is less compliant. There is more risk of damage to the permanent tooth than there is benefit gained by replacing the tooth. B A child involved in a motor vehicle accident resulting in six avulsed primary teeth. A chest radiograph was required to ensure that no teeth were swallowed or aspirated. A thick (2-0) nylon suture passed through both labial and lingual plates can be used to provide fixation for the fragment. Teeth usually survive this trauma and there are few untoward sequelae for the permanent teeth. Enamel and dentine may be smoothed with a disc and if possible cover the dentine with glass ionomer cement or composite resin. In these cases it is not possible to adequately restore the tooth and so it should be removed. Often the fracture is not immediately evident, but the child may present several days after the trauma with a pulp polyp separating the fragments. Management Most discomfort results from the movement of fractured pieces of enamel still held by the gingiva or periodontal ligament. If a small piece of root remains in the socket after a fracture it may be safely left in situ where it will be resorbed as the permanent tooth erupts. B Root fractures, again, require no treatment unless the coronal fragments are excessively mobile. C A complex crown/ root fracture involving the upper left primary central incisor. If, at regular review, the pulp shows signs of necrosis, with excessive mobility or sinus formation, the coronal portion should be removed. Apical root fragments are always removed by resorption as the permanent tooth erupts. It is often desirable to reposition the teeth with the bone to maintain the alveolar contour. This can be achieved with a thick nylon suture (2-0) passed through the labial and lingual plates of the bone. Teeth that are excessively mobile should be carefully dissected out of the sockets preserving the labial plate, which is then repositioned and sutured. Although it may be difficult to accurately predict the prognosis for permanent teeth, parents appreciate having an idea of possible outcomes. In cases that have been followed, up to 25% of children are left with some developmental disturbance of the permanent tooth. Damage to the permanent dentition occurs more often with intrusive luxation and avulsion in very young children. It is important to warn parents of possible problems with permanent teeth and also to reassure them that, with modern restorative materials, minor defects are easily repaired. Sequelae in the permanent dentition depend on: Direction and displacement of the primary root apex (Figure 7. Possible damage to primary and permanent teeth Necrosis of the pulp of the primary tooth with grey discoloration and possible abscess formation. Commonly, intruded primary teeth will fail to fully erupt but will exfoliate normally. In rare cases, extraction may be required just prior eruption of the permanent incisor. This film gives a good localization of the position of the primary root apex in relation to the central incisors. B the root apex is clearly visible, just underneath the anterior nasal spine, having perforated the labial plate. For example, this case of severe intrusion, and alveolar disruption, has caused little damage other than mild hypocalcification of the permanent incisors (B). C Displacement and dilaceration of the upper-right permanent central incisor, following avulsion of the primary precursor tooth, at 18 months of age. E Hypoplasia of the permanent central incisors resulting from trauma in the primary dentition. F Restoration of dilacerated teeth is extremely difficult, especially when the defect involves the gingival margin. Hypoplasia and hypomineralization of the permanent teeth can be restored with composite resin. Dilaceration of the crown or root of the permanent tooth often necessitates surgical exposure and bonding of chains or brackets for orthodontic extrusion (see Chapter 11 for details of surgical procedure). Crown and root fractures of permanent incisors Crown infractions An incomplete fracture (or crack) of the enamel without loss of tooth structure. Fractures do not cross the dentinoenamel junction and usually require transillumination or indirect light to be viewed (see Figure 7. Uncomplicated enamel and enamel/dentine fractures Uncomplicated fractures are confined to enamel or enamel and dentine but do not involve the pulp. The most common presentation is an oblique fracture of the mesial or distal corner of an incisor. Trauma Management 137 Clinical Hint It is extremely important to cover the exposed dentine of permanent incisors as soon as possible. Parents have often saved the fractured piece of permanent incisor that can sometimes be used to restore the tooth by being bonded back onto the tooth with composite resin (Figure 7. In the very immature tooth, where there is a questionable pulp exposure, an elective Cvek pulpotomy (see below) may be indicated. This will ensure normal development of the apex and prevent the need for any possible open apex endodontic procedure (apexification). A A chamfer or bevel is placed around the fragment and remaining crown and the dentine covered with glass ionomer cement. It is often impossible to re-create the subtle hypocalcific flecks in a crown with composite resin alone; the replacement of the fractured piece is a good alternative technique if the fragment can be found. It is essential that they are removed at the time of the trauma as they are extremely difficult to find once the tissues have healed. Immediate coverage and dressing will help to prevent pulp necrosis and the need for an open apex endodontic procedure. Prognosis Pulp necrosis after extensive proximal fracture: No protective coverage of dentine: 54%. Healing does not occur spontaneously and untreated exposures will result in pulp necrosis. The time elapsed since the injury and the stage of root development will influence treatment. If the tooth is treated within hours of the exposure conservative management is appropriate. After several days, microabscesses occur within the pulp, and more radical pulp amputation is required. Aim is to preserve vital, non-inflamed pulp tissue, biologically walled off by a hardtissue barrier (Cvek 1978). In almost all situations, if vital pulp tissue can be covered with a calcium hydroxide dressing, it is possible to form a dentine bridge over the defect. It is undoubtedly preferable to preserve tooth vitality rather than start root canal treatment. A non-setting calcium hydroxide is placed directly onto uncontaminated vital tissue (see step 4 below). Non-setting calcium hydroxide is placed over the pulp remnant and this is then covered with a setting calcium hydroxide. It is essential that the calcium hydroxide is placed over vital tissue, it must not be placed over a blood clot.
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