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By O. Olivier. Grace College.

Individuals with congenital heart disease are living longer and frequently require heart surgery (4) generic 20mg piroxicam with mastercard treating arthritis in your back. In addition discount 20 mg piroxicam overnight delivery rheumatoid arthritis eyes, rheumatic heart disease has essentially disappeared from the developed world generic piroxicam 20mg mastercard osteoarthritis knee diet. Change in the underlying valvular pathology: rheumatic heart disease <20% of cases b. The incidence ratio of men to women ranges up to 9/1 at 50 to 60 years of age (68). Although there are many types of valvular infections, they all share a common developmental pathway. Leukocytes adhere more readily to it and platelets become more reactive when in contact with it. As the infection progressed, the adherent bacteria were covered by successive layers of deposit fibrin. Within the thrombus, there is a tremendous concentration of organisms 9 (10 colony forming units per gram of tissue) (75). The endocardium of this area may be damaged by the force of the jet of blood hitting it (Mac Callums patch) (77). Bacterial infection of intravascular catheters depends on the response of the host to the presence of the foreign body, the pathogenic properties of the organisms, and the site of Table 5 Risk of Bacteremia Associated with Various Procedures Low (0%–20%) Moderate (20%–40%) High (40%–100%) Organism Tonsillectomy Bronchoscopy (rigid) Bronchoscopy (flexible) Streptococcal sp. Within a few days of its placement, a sleeve of biofilmconsisting of fibrin and fibronectin, along with platelets, albumin, and fibrinogen is deposited on the extraluminal surface of the catheter. This composite biofilm protects the pathogens from the host antibodies and white cells as well as administered antibiotics (86). For catheters that are left in place for less than nine days, contamination of the intracutaneous tracts by the patient’s skin flora is the most common source of infection (87). The bacteria migrate all the way from the insertion point to the tip of the catheter. It is the bacterial flora of health care workers hands that contaminate the hubs of the intravascular catheters as they go about their tasks of connecting infusate solutions or various types of measuring devices. The bacteria then migrate down the luminal wall and adhere to the biofilm and/or enter the bloodstream. For long-term catheters (those in place for more than 100 days), the concentration of bacteria that live within the biofilm of the luminal wall of the catheter is twice that of the exterior surface (88). Gram-negative aerobes such as Enterobacter, Pseudomonas, and Serratia species are the most likely to be involved because they are able to grow rapidly at room temperature in a variety of solutions. Because of its hypertonic nature, the solutions of total parenteral nutrition are bactericidal to most microorganisms except Candida spp. A wide variety of infused products may be contaminated during their manufacture (intrinsic contamination). These include blood products, especially platelets, intravenous medications, and even povidone- iodine (87,91). Up to 1% to 2% of all parenterally administered solutions are compromised during their administration usually by the hands of the health care workers as they manipulate the system, especially by drawing blood through it. Most of these organisms are not able to grow in these solutions except for the Gram-negative aerobes that may reach a concentration of 3 10 /mL (92,93). This concentration of bacteria does not produce “tell-tale” turbidity in the solution. The risk of contamination is directly related to the duration of time that the infusate set is in place. Fifty percent of these are due to their high degree of manipulation (frequent blood drawing) and the high rate of contamination of the saline reservoir of this device. Central venous catheters that are inserted into the femoral vein have a high rate of infection than those placed in the subclavian. More recent data indicates that the infectious complications of hemodialysis catheters may be the same whether placed in the jugular or femoral vein (96). This is due to displacement of the anterior leaflet to the mitral valve by the abnormal contractions of the septum or by a jet stream affecting the aortic leaflets distal to the obstruction (99). Other underlying congenital conditions include ventriculoseptal defect, patent ductus arteriosus, and tetralogy of Fallot (100). All have in common a roughend endocardium that promotes the development of a fibrin/platelet thrombus. Calcific aortic stenosis results from the deposition of calcium on either a congenital bicuspid valve correlate previously normal valve damage by the cumulative hemodynamic stresses that occur over a patient’s life span. Because of their age, these patients have a high prevalence of associated illnesses, such as diabetes or chronic renal failure, which contribute to their increased morbidity and mortality. Because the degree of stenosis is not hemodynamically significant, this type of valvular lesion is often neglected for antibiotic prophylaxis (108). The risk of infection is highest during the first three months after implantation. Mechanical valves are more susceptible to infection until their first year anniversary. Endothelialization of the sewing rings and struts of the valves decreases but does not eliminate the risk of infection. The implanted material is “conditioned” by the deposition of fibrinogen, fibronectin laminin, and collagen. Various types of infection are second only to coronary artery disease as the most common cause of death in chronic renal failure. Because of the relative lack of virulence factors of the organisms that are involved in subacute valvular infections, its manifestations are due primarily to immunological processes, such as focal glomerulonephritis that is secondary to deposition of circulating immune complexes (124). Symptoms of arthritis and arthralgias, especially lumbosacral spine pain, are the result of deposition of immune complexes in the synovium and most likely in the disc space. The dermal, mucocutaneous, musculoskeletal, central nervous system, and renal presentations are produced by the embolic phase that occurs later in the course of this disease. A history of dental or other invasive procedures is found in less than 15% of cases. Up to the point of the development of frank heart failure, the patients symptoms are almost exclusively noncardiac in nature (124) (Table 7). Congestive heart failure is the most common complication of both acute and subacute disease (15%–65% of patients) The leaflets of the infected valve are rapidly destroyed as the organisms multiply within the progressively enlarging, and often quite friable, vegetations. The infected valve may suffer any of the following insults: tearing and fenestration of the leaflets, detachment from its annulus, and rupture of the chordae tendineae and/or papillary muscles (125). The regurgitant jetstream of the incompetent aortic valve can make impact with the mitral and produce erosion of perforation of this valve’s leaflets or its chordae tendineae.

Temazepam was popular some years ago discount piroxicam 20mg with amex arthritis in dogs and cats, especially as its duration of action is shorter than diazepam order piroxicam 20 mg with amex laser treatment for arthritis in dogs uk. However piroxicam 20mg without prescription arthritis diet for dummies, idiosyncratic reactions in some children have caused temazepam to fall from favour. Recent studies using midazolam, another short-acting benzodiazepine, have reported good results. Midazolam is easy to take orally and seems to offer safe and reliable sedation, with far fewer idiosyncratic reactions than with temazepam. Onset of sedation is rapid (around 20 minutes) and recovery is also relatively quick. The preparation designed for intravenous administration is used, often mixed into a small volume of a suitable fruit drink. However, midazolam is not yet available as an oral or nasal preparation and is not yet licensed for oral sedation. Practitioners are therefore advised to seek specific training before prescribing midazolam for oral sedation. When using any sedative agent in children it is essential that suitable precautions are taken and that appropriate emergency drugs and equipment are available. These important aspects are detailed fully in Chapter 4297H and, hence, will not be further rehearsed here. Recently, the justification for such extensive use has been questioned, and it is now widely agreed that general anaesthesia should only take place in hospital and should only be employed where other behaviour management strategies have failed or are inappropriate. Comprehensive full mouth care under intubated general anaesthesia enables children with multiple carious teeth to be expediently rendered caries-free in one procedure (Fig. This approach does have a place in the management of young, anxious, or handicapped children with extensive caries, and in some medical conditions where multiple treatment episodes over a prolonged period increase the risks of systemic complications. Extractions under general anaesthesia may be preferable to no treatment at all in the management of extensive caries in young children, especially when facilities for restorative care under general anaesthesia are not available or parental motivation is poor and reatten-dance for multiple visits is unlikely to occur. In addition, general anaesthesia may be the only practical approach for children with acute infection. Where general anaesthesia is employed in the dental treatment of the preschool child, the emphasis must be on avoiding the need for repeated general anaesthesia. This may require the extraction plan to be quite radical, especially where facilities for restorative care under general anaesthesia are not available. Carious exposures of vital or non-vital teeth can be dressed with a small amount of a polyantibiotic steroid paste (Ledermix) on cotton wool covered by a suitable dressing material. It serves as a simple and straightforward introduction for the child to dental procedures. By removing soft caries and temporarily occluding cavities, the oral loading of mutans streptococci is significantly reduced. It helps to reduce sensitivity, making toothbrushing and eating more comfortable, and also makes inadvertent toothache less likely. If a suitable material is used, it can produce a source for low-level fluoride release within the mouth. Key Points Temporization of teeth: • helps to reduce dental sensitivity and prevent toothache occurring before definitive care is complete; • reduces the oral mutans streptococci load; • serves as an introduction to dental treatment; and • provides a source for fluoride release if a glass ionomer-based material is used. Communicating in terms the child can understand, and using vocabulary that avoids negative associations, is also important. Starting treatment by temporizing any open cavities as described above serves as an easy introduction to operative care. From that point on, planning to include both a preventive and a restorative component at each visit allows effective treatment to progress at a reasonable pace. It is customary to start with treatment in the upper arch first, as this is usually easier for both the child and the dentist, although this approach may need to be modified if there are lower teeth in urgent need of attention. Many preschool children are far more accepting of carefully delivered local analgesia than most dentists realize. Careful attention to obtaining adequate analgesia of the gingival tissues, both buccally and lingually, ensures comfortable clamp placement. The techniques employed for definitive restoration in young children should take into account the often active nature of the disease in this age group. The use of plastic restorative materials should be limited to occlusal and small approximal lesions. Extensive caries, teeth with caries affecting more than two surfaces, and teeth requiring pulpotomy or pulpectomy should be restored with stainless-steel crowns. Amalgam is still widely used as a restorative material, but materials including newer glass ionomer cements, resin-modified glass ionomers, polyacid-modified resins (compomers), and composite resins may be preferred. However, all the latter mentioned materials are far more sensitive to moisture contamination and technique than amalgam, so adequate isolation, preferably with rubber dam, is essential. A fuller discussion on material selection for the restoration of primary molars is given in Chapter 8316H. Composite strip crown restorations are the most effective way of repairing carious anterior teeth (Chapter 8317H ). Key Points • Plan to carry out treatment at a pace that the child (and you) can cope with. In preschool children the extraction of one or two teeth can often be accomplished under local analgesia⎯inhalation or oral sedation being a useful adjunct for anxious children. If more extractions are needed, these can sometimes be carried out at the same time as restoring adjacent teeth. However, general anaesthesia is the only practical strategy for some children, in which case referral to an appropriate dental general anaesthesia facility is mandatory. When planning extractions, it is important to consider the need for balancing (Chapter319H 14). Factors such as the likelihood of continued future attendance and co-operation of the child should also be borne in mind. In preschool children with extensive caries, extraction of first primary molars with maintenance and restoration of the second primary molars where possible is often a good plan (Fig. Not only does this limit the risk of further decay by eliminating posterior primary contact areas, but it also minimizes the deleterious effect of early extraction on the developing dentition.

Additionally purchase 20mg piroxicam with visa can you have arthritis in your neck, patients are at risk of rejection of the trans- planted organ that can be acute or chronic buy 20 mg piroxicam with mastercard rheumatoid arthritis gold. Chronic cardiac transplant rejection mani- fests as coronary artery disease cheap piroxicam 20 mg on-line arthritis in knee icd 9 code, with characteristic long, diffuse, and concentric stenosis seen on angiography. It is thought that these changes represent chronic rejection of the transplanted organ. Common alternative diagnoses in this setting include exacerbations of congestive heart failure, myocarditis, and pulmonary embolism. This patient has atypical features of his chest pain for angina: lasting for more than minutes at a time, nonexertional. In a young host, without other significant risk factors, atherosclerotic coronary artery disease would be less likely, especially if the history is atypical. However, other factors in the management of these patients have been shown to decrease risk. In several disease states, notably severe obstructive lung disease, pericardial tamponade, and superior vena cava obstruction, an accentua- tion of this normal finding can occur. Indeed, in the most pronounced cases the periph- eral pulse may not be palpable during inspiration. The most common cause of constrictive pericarditis worldwide is tuberculosis, but given the low incidence of tu- berculosis in the United States, constrictive pericarditis is a rare condition in this country. With the increasing ability to cure Hodgkin’s disease with mediastinal irradiation, many cases of constrictive pericarditis in the United States are in patients who received curative radiation therapy 10–20 years prior. Other rare causes of constrictive pericarditis are recurrent acute pericarditis, hemorrhagic pericarditis, prior cardiac surgery, mediastinal irradia- tion, chronic infection, and neoplastic disease. Physiologically, constrictive pericarditis is characterized by the inability of the ventricles to fill because of the noncompliant pericar- dium. In early diastole, the ventricles fill rapidly, but filling stops abruptly when the elastic limit of the pericardium is reached. The jugular venous pressure is elevated, and the neck veins fail to collapse on inspiration (Kussmaul’s sign). Right heart catheterization would show the “square root sign” characterized by an abrupt y descent followed by a gradual rise in ventricular pressure. This finding, however, is not pathogno- monic of constrictive pericarditis and can be seen in restrictive cardiomyopathy of any cause. Echocardiogram shows a thickened pericardium, dilatation of the inferior vena cava and hepatic veins, and an abrupt cessation of ventricular filling in early diastole. Peri- cardial resection is the only definitive treatment of constrictive pericarditis. Diuresis and sodium restriction are useful in managing volume status preoperatively, and paracentesis may be necessary. Underlying cardiac function is normal; thus, cardiac transplantation is not indicated. Pericardiocentesis is indicated for diagnostic removal of pericardial fluid and cardiac tamponade, which is not present on the patient’s echocardiogram. Mitral valve stenosis may present similarly with anasarca, congestive hepatic failure, and ascites. Examination would be expected to demonstrate a diastolic murmur, and echocardiogram should show a normal pericardium and a thickened immobile mi- tral valve. Mitral valve replacement would be indicated if mitral stenosis were the cause of the patient’s symptoms. Initial management should include high-dose aspirin, heparin, and stabilization of blood pressure. In addition, use of furosemide for the treatment of pulmonary edema is also contraindicated because of the degree of hypotension. Intra- venous fluids should be used with caution as the patient also has evidence of pulmonary edema. The best choice for treatment of this patient’s hypotension is aortic counterpulsa- tion. Aortic counterpulsation requires placement of an intraaortic balloon pump percu- taneously into the femoral artery. The sausage-shaped balloon inflates during early diastole, augmenting coronary blood flow, and collapses during early systole, markedly decreasing afterload. In contrast to vasopressors and inotropic agents, aortic counterpul- sation decreases myocardial oxygen consumption. Both dobutamine and norepinephrine can increase myocardial oxygen demand and worsen ischemia. If fluid administration fails to alleviate the hypotension, sympathomimetic agents or aortic counterpulsation can be used. However, care must be taken to avoid excess fluid administration, which would 230 V. A trans- venous pacemaker would be useful if the hypotension were related to heart block or pro- found bradycardia, which can be associated with right coronary artery ischemia. Sudden cardiac death accounts for about 50% of all cardiac deaths, and of these, two-thirds are initial cardiac events or occur in populations with previously known heart disease who are considered to be relatively low risk. A strong parental history of sudden cardiac death as a presenting history of coronary artery disease increases the likelihood of a similar presentation in an offspring. Defibrillation should occur prior to endotracheal intuba- tion or placement of intravenous access. If the time to potential defibrillation is <5 min, the medical team should proceed immediately to defibrillation at 300–360 J if a monophasic defibrillator is used (150 J if a biphasic defibrillator is used). Even if there is return of a perfusable rhythm, there is often a delayed return of pulse because of myo- cardial stunning. In these trials, patients were rapidly cooled to 32–34°C and maintained at these temperatures for the initial 12–24 h. Individuals who re- ceived therapeutic hypothermia were 40–85% more likely to have good neurologic out- comes upon hospital discharge.

There is strong evidence that muta- gene (connexin-30) in Spanish subjects with autosomal-reces- tions in this gene can also cause erythrokeratoderma variabilis cheap piroxicam 20mg with visa arthritis in upper right back, sive nonsyndromic hearing impairment (submitted 2004) order 20mg piroxicam overnight delivery arthritis diet. Finally piroxicam 20 mg line arthritis relief cream with celadrin, there has been only one report of a missense degeneration of inner hair cells. Pendrin has a highly discrete expression pattern throughout the endolymphatic duct and sac, in the distinct areas of the utricule and the saccule, and in the external sulcus region (64). These regions are thought to be important for endolymphatic fluid resorption in the inner ear. To date, 11 genes have been localised for different types of Usher syndrome, Genes involved in the structure and of which eight genes have already been identified. In the eye, cadherin 23 is thought to play a fundamental role in the organ- function of the hair cell isation of synaptic junctions. Protocadherin 15 is Adhesion molecules an important protein in the morphogenesis and cohesion of Cadherin 23 and Protocadherin 15 belong to the cadherin stereocilia bundles through long-term maintenance of lateral superfamily, most members of which play a role in calcium- connections (lateral links) between stereocilia (72). Interestingly, two types of hair-cell complexes located at specific emplacements in the plasma anomalies have been detected in this mouse mutant. In the cochlea, harmonin is restricted to the hair most severely affected mutants, the hair bundle is disorganised, cells, where it is present in the cell body and the stereocilia. In humans, 40 different myosin genes can be divided differs between the two myosins. All other myosin classes con- gene has been found to cause nonsyndromic hearing loss, i. All other mutations cause a variety of syndromes, myosin in contraction and force production in muscles is well with a decreased number of blood platelets as a common characterised, little is known about the specific functional roles symptom (96). The most abundant microfilament protein in mechanical stability to the apex of the hair cell. The exact pathogenic mammalian hair cells is espin, a calcium-insensitive, actin- mechanism of the Cochlin mutations is unknown. This Collagen fibrils provide structural elements of high tensile leads to shortening, loss of mechanical stiffness, and eventual strength in extracellular matrices. Remarkably, the amount of they can be grouped into fibril-forming collagens, fibril- espin is proportional to the length of the stereocilium (105). Interactions between collagen fibrils, other matrix cause profound prelingual hearing loss and peripheral vestibular components, and cells are likely to provide the basis for the areflexia (106). Features of Stickler syndrome include progressive myopia, vit- The contractility of their lateral cell membrane is an interesting reoretinal degeneration, premature joint degeneration with mammalian cochlear specialisation that does not occur in inner abnormal epiphyseal development, midface hypoplasia, irregu- hair cells. Addition- collagen fibrils, which leads to moderate-to-severe hearing ally, the pres -/- knockout mouse model has a 40 to 60dB loss of loss (115). These proteins share a significant similarity with cochlin, a protein that is highly expressed in the cochlea (111). Stereocilin is almost exclu- Cochlin comprises approximately 70% of all bovine inner ear sively expressed in the inner hair cells (118), whereas otoan- proteins (112) and is expressed in fibrocytes of spiral limbus, spi- corin is present on the apical surface of sensory epithelia and ral ligament, and fibrocytes of the connective tissue stroma their overlying acellular gels (119). Based on the sequence sim- underlying the sensory epithelium of the crista ampullaris in the ilarity and expression pattern, it was suggested that stereocilin semicircular canals (113). Sixteen different isoforms of cochlin may have a comparable function to otoancorin, i. Gfi1 is the first downstream target of a hair component in the cochlea that lies on top of the stereocilia. These polypeptides interact with pattern of expression, including cells that line the developing -tectorin. Half the normal amount of Genes with atypical or poorly -tectorin is probably enough to preserve the auditory function, understood function thereby explaining the lack of symptoms in heterozygous carri- ers. Mice homozygous for a targeted deletion in a -tectorin The function of several deafness genes is currently not well have moderate-to-severe hearing loss due to the detachment of known. No exact physiological role of these genes is known the tectorial membrane from the organ of Corti (122). Later on, mutations were found in two other genesis and a survival role in the mature cochlea. The two genes are lead to mechanical stress on hair cells and that this may lead to expressed in distinct cell types and at different time points. By comparing inner ear to the Caenorhabditis elegans spermatogenesis factor fer-1. This sodium channel may have a role in the mutation in this gene (Q829X) is a common cause of prelingual maintenance of the low sodium concentration of endolymph. Therefore, genetic analy- framin is mainly located in cells lining the scala media, in sis of otoferlin may be indicated in cases of auditory neuropathy vestibular hair cells, and in spiral ganglion cells (152). The severity of the dia- (Bth) mouse mutant strains segregating postnatal hair-cell degen- betic phenotype was dependent on the mouse background. A cell model suggest a role for this gene in the correct development contains several of these mitochondrial genomes. In humans, this gene is mutated in several con- mixed population of normal and mutant genomes is present, sanguineous families that are linked to the autosomal-recessive the mutation is heteroplasmic. Additionally, aminoglycosides clearly Nonsyndromic hearing loss: cracking the cochlear code 71 Table 5. To date, the responsible gene in both codon base pairing on the coding region of ribosomes. The genetic susceptibility to aminoglycoside-induced ototoxicity (961delT diversity between inbred mouse strains makes them a valuable and 1494C T). Both the 7445A G and the gene, a plasma membrane calcium pump located at chromo- 7472insC mutations have been found in families with syndromic some 6 (184). This calcium pump helps to maintain low cytoso- 2 2 and nonsyndromic hearing loss. To cause the palmoplantar keratoderma for the 7445A G mutations and early-onset hearing loss in mdfw mice, a combination of 753A neurological dysfunction (ataxia and myoclonus) for the homozygosity of the cdh23 allele must coexist with haploin- 753A 7472insC mutation. By interacting in the same or a paral- To date, more than 100 loci for nonsyndromic hearing loss have lel biological pathway as a disease gene, modifier genes can been detected, and the responsible gene has been identified for affect the phenotypic outcome of a given genotype.

Initially developed to prevent caries their use has been developed further and they now have a place in the treatment of caries purchase 20mg piroxicam fast delivery rheumatoid arthritis qof. The decline in caries observed in industrialized countries over recent decades has affected all tooth surfaces but has been greatest on smooth surfaces purchase 20mg piroxicam mastercard rheumatoid arthritis in upper back. Therefore the pit and fissured surfaces piroxicam 20mg overnight delivery arthritis lyme, particularly of the molars have the greatest disease susceptibility. This means that the potential benefits of effectively used sealants continue to increase. The technique for placement of sealants is relatively simple but is technique sensitive. Salivary contamination of as little as half a second can affect the bond and therefore the retention of the sealant. Current resin materials are either autopolymerizing or photo-initiated, and most operators prefer the advantages of demand set offered by photo-initiation. Although there are theoretical advantages to chemically cured materials in terms of retention, as these materials have longer resin tags extending into the etched surface. Filled and unfilled resins are available, the filled materials being produced to provide greater wear resistance. However, this is not clinically relevant and clinical trials demonstrate superior efficacy for unfilled materials. Irrespective of the presence of fillers some materials are opaque or tinted to aid evaluation. This is an advantage but means the clinician is unable to view the enamel surface to assist with caries detection and to detect the presence of restorations such as sealant restorations. Key Points Fissure sealing technique • Prophylaxis before etching does not enhance retention but is advisable if abundant plaque is present. A dry brush should be used rather than paste as these are retained in the depths of the fissures preventing penetration of the resin. Operator and assistant must act as a team as it is impossible for single operators to apply sealant effectively. The vast majority of trials have demonstrated cotton wool and suction to be an effective means of isolation. Rubber dam is advocated by some because of the superior isolation offered by this material. This is probably true but its use is frequently not possible because of the stage of eruption of the tooth or level of co-operation of the patient. It would be inappropriate to delay sealant application to allow further eruption to permit the application of rubber dam. The application of sealant is a relatively non-invasive technique, frequently used to acclimatize a patient. It is difficult to justify the use of rubber dam with the associated use of local anaesthetic and clamps for the majority of patients, on both clinical and economic grounds. Glass ionomers have also been used as sealants, the application technique is less sensitive, than that for resins. It is suggested that the fluoride release from glass ionomers provides additional protection but the clinical relevance of this remains doubtful. The addition of fluoride to resin sealants has been demonstrated to provide no additional benefit. Glass ionomer sealants only have a place as temporary sealants during tooth eruption, when adequate isolation to permit the application of resin is not possible or in patients whose level of anxiety or co-operation similarly prevent placement of resin. Glass ionomers have been developed specifically for this role but clinical evidence of their effectiveness is not yet available. Key Points Application of glass ionomer sealants • Clean the surface • Isolate the tooth • Run the glass ionomer into the fissures • Protect the material during initial setting • Apply unfilled resin, petroleum jelly, or fluoride varnish to protect the material. For anxious patients application can be done with a gloved finger until the material is set. Resin fissure sealants are effective; a recent systematic review has demonstrated 57% caries reductions at 4 years, with retention of 71-85% at 2 years falling to 52% at 4 years (Ahovuo-Saloranta et al. To gain the full caries preventive benefit sealants should be maintained, that is, sealants with less than optimal coverage identified and additional resin applied. Since the development of sealants there has been a question regarding the effect of sealing over caries, the concern being that caries will progress unidentified under the sealant. Given the difficulty in diagnosing caries this must be a frequent occurrence in daily practice. A number of trials have examined this by actively sealing over caries, and all have shown that sealants arrest or slow the rate of caries progression. We are not at the point where sealing of active caries is recommended by most authorities but the maxim if in doubt seal is good advice. The surface should then be monitored clinically and radiographically at regular intervals until its status is confirmed. One instance where actively sealing over caries is to be recommended is in the pre- cooperative patient where the placement of sealant may help acclimatization of the patient, with the added benefit of controlling the caries, until a definitive restoration can be placed. Sealants are also effective at preventing pit and fissure caries in primary teeth. Primary teeth have more aprismatic enamel than permanent teeth, and doubt about the effectiveness of etching deciduous enamel lead to a belief that they required prolonged etching times. This has been demonstrated not to be the case and the technique for sealant application to primary teeth is identical to that employed with permanent teeth. Although the effectiveness of fissure sealants is beyond doubt, to be used cost effectively their use should be targeted. Guidelines for patient selection and tooth selection have been published by the British Society for Paediatric Dentistry, and these are summarized below. Fissure sealing of all occlusal surfaces of permanent teeth should be considered for those who are medically compromised, physically or mentally disabled, or have learning difficulties, or for those from a disadvantaged social background. Children with extensive caries in their primary teeth should have all permanent molars sealed soon after their eruption.

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