Nursing Education and Competency Essay

Nursing Education and Competency The purpose of this paper is to explore the different paths of education to become a registered nurse. Specially, to examine the educational tracks of the Associate Degree nurse and the Baccalaureate Degree nurse. The question at hand is how do these educational paths differ in the level of competency? First, I will show the difference in educational structure and then examine how these relate to the competency of the nurse following completion of each program. The Associate Degree in nursing came about during the 1950s in an effort to combat a nursing shortage in the Unites States following World War II. An Associate Degree nursing program is a two-year program that is typically affordable and offered at a junior or community college. The focus of this program is â€Å"on the basic sciences and theoretical and clinical courses related to the practice of nursing† (Potter & Perry, 2005, p. 16). It prepares the student for â€Å"competent technical bedside† nursing in â⠂¬Å"secondary care settings† (Cresia & Friberg, 2011, p. 33). Following completion of the two-year program, the student is eligible to take the NCLEX-RN (National Council Licensure Examination) and can achieve a license as a registered nurse. The first Baccalaureate Degree in nursing was â€Å"established in the United States at the University of Minnesota in 1909† (Cresia & Friberg, 2011, p. 25). It consists of a four-year program on a university or college campus with a larger financial attachment. There are typically two years of general education requirements followed by two years of upper-level nursing education courses. In addition to the basic science, theory and clinical education the program â€Å"include courses in community and public health, beginning research, management and leadership (Cherry & Jacob, 2005, p. 81). It prepares the student to become a â€Å"professional nurse generalists for acute care settings, community-based practice, and beginning leadership/management positions† (Cresia & Friberg, 2011, p. 33). Following the completion of the program, the student is also eligible to take the NCLEX-RN to receive licensure. Do these two years of additional education make a more competent nur se? â€Å"Over the past several years, policy makers, researchers, and practice leaders have identified that education does make a difference in how nurses practice† (Johnston, 2009). The University of Pennsylvania in an issue of Medical Care released one such  study that supports this in October, 2012 (American Association of Colleges of Nursing, 2012). It states that: surgical patients in Magnet hospitals had 14% lower odds of inpatient death within 30 days and 12% lower odds of failure-to-rescue compared with patients cared for in non-Magnet hospitals. The study authors conclude that these better outcomes were attributed in large part to investments in highly qualified and educated nurses, including a higher proportion of baccalaureate prepared nurses. (American Association of Colleges of Nursing, 2012) The current healthcare environment is changing through federal policy, technological advancements, and a growing global multicultural population. These additional years of education are believed to â€Å"enhance the students professional development, prepares the new nurse for a broader scope of practice, and provides the nurse with a better understanding of the cultural, political, economic, and social issues that affect patients and influence† (American Association of Colleges of Nursing, 2012). The four-year baccalaureate program offers more education to develop these skills giving the nurse the ability to adapt and contribute to these continual changes. Let us now use the following patient care situation of a newly diagnosed patient with Diabetes Mellitus Type II to explore the differences of an Associate Degree nurse (ADN) and Baccalaureate Degree nurse (BNS). A newly diagnosed diabetic needs teaching, the focus of this example will be on how the AND verses a BSN would approach teaching. As stated previously the ADN is prepared at a more technical level, although they share the same basic science and theory as a BSN. After explaining the basics of disease process to the patient, the ADN primary focus may be on the methods of testing blood glucose levels, the correct techniques for drawing up insulin and administration. This is due to the fact that the bulk of their educational training encompassed technical nursing. They would consider proper aseptic techniques for finger stick testing while teaching. Interrupting the results and applying it to a sliding scale of insulin related to food intake and activity. Then teaching the method of drawing up insulin, administration, and sharps disposal. A BSN nurse would teach the basics of the disease process taking the patient’s learning modality into consideration before starting. What is the patient’s ability to learn? Is the patient ready to learn? What is the best method for teaching (audio, visual, written material, or discussion)? What is the  family dynamic and should the family be involved in the teaching? Are there any cultural considerations? The BSN nurse might be inclined to research the topic of teaching new diabetics and find some current evidence based literature to assist in providing the best possible care for this patient. All of these items would have to be taken into consideration before moving onto the task of blood glucose testing, interpreting results and administering insulin. The example above is just a brief look into the thought process that comes with the different tracks of nursing education. A BNS nurse has a larger knowledge base to work from applying critical thinking, evidence based research and cultural consideration into their daily practice. They also possess some of the qualifications to move toward nursing positions in leadership and management. Research is leaning toward the idea that a nurse that has received a Baccalaureate Degree makes for a more competent nurse. National nursing associations support this thought. Policy makers are privy to this information as well. What seems to be a topic of debate now could soon become a reality and change how we educate future nurses. References American Association of Colleges of Nursing (2012, October 24). The impact of education on nursing practice. Retrieved from http://www.aacn.nche.edu/media-relations/fact-sheets/impact-of-education. Cherry, B., & Jacob, S. R. (2005). Contemporary Nursing: Issues, Trends, and Management (3 rd ed.). St. Louis, Missouri: Elsevier, Inc. Cresia, J. L., & Friberg, E. (2011). Conceptual Foundations: The Bridge to Professional Nursing Practice, (5 th ed.). http://dx.doi.org/. Johnston, K. A. (2009). The Importance of Baccalaureate Degree in Nursing Education. Retrieved October 2, 2013, from http://www.peoriamagazines.com/ibi/2009/apr/importance-baccalaureate-degree-nursing-education Potter, P. A., & Perry, A. G. (2005). Fundementals of Nursing (6 th ed.). St. Louis, Missouri: Mosby, Inc.

Power Politics Essay

â€Å"†¦what is happening to India today is not a problem†¦the issues †¦are not canses. They are huge political and social upheaval that are convulsing the nation. †   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Those are the exact words that Roy (24) had used to describe what is happening to the world that is beyond the realm of common human understanding: globalization led on and operated by â€Å"experts†.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   And just how will a common human understand when every time they try to, at the end of the day, they are relegated to being â€Å"just a citizen† who are, to experts, are â€Å"too emotional† and just lack the ability to eventually understand when explained to (if the experts even try to do the explaining part).   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   It is the phenomenon characterized by experts who have acquired technical knowledge on certain matters take the matter into their own hands—not wanting to be questioned or contradicted and seemingly not encouraged to do their tasks with sympathy. They believe that they have all it takes to do it all, and be all, for all. The usual behavior of an arrogant little child who thinks he knows all he needs to know and thus scoffs at any questioning remarks on how he does his tasks, sneers at any suggestion or idea unlike his own, or flares up at any tap on his shoulder that gently reminds him that he is not of possession of every knowledge yet; a kind of behavior that is often times not tolerated.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   And that is what needed to be done. This arrogance should be broken down. And this could not be accomplished by mere taps on the shoulder anymore. A sterner reminder is needed; a reminder that even the too emotional and comprehension-challenged common citizen still has a say on how he lives his life—or at the very least, has the natural right to be made to understand.   Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Therefore, the author urges the humanity to speak, and speak loud, now or forever be made to hold their peace. Works Cited Roy, Arundhati. Power Politics (year of publication). 24-33.

Stock Market

Stock market is the place were all stocks and other securities buy and sell. Pakistan have three main stocks markets (KSE, LSE, ISE).Among these stock exchanges Karachi stock exchange founded on 18 September 1947.it was the largest stock exchange in Pakistan and oldest in the south Asia. its growing day by day. Many ups and downs are occurring in KSE due to political instability, securities threats and macro-economic issues but due to negative issues. its show a positive progress. Two types of KSE,100 and KSE 30 index. KSE 100 index rapidly growing in Pakistan indexes. 2013 is the best year in history of stock market in Pakistan on December 31 (25,261) points are occur which are great achievement. Top five companies in KSE 100 index are be capitalize and weight age.No Company Names Weightage % Market capitalism (PKR) in Million1 OGDCL 14.14 550,948,930,0002 MCB 7.17 279,583,150,0003 BOP 5.43 211,726,900,0004 Pakistan petroleum 5.06 197,201,080,0005 Standard chartered Bank 4.41 171,704,800,000 Literature Review: According to researcher's stock market in country play a vital role in economy growth. Many factors that have an impact on stock market. These factors may decrease the performance or may increase the performance. Government of every country should encourage these factors may increase the performance and should discourage these factors that have diverse impact on stock market. A study many articles and every paper about these factors but found that interest rate has a negative impact on stock market. Interest rate also decrease the efficiency of stock market.Davidson (1996) focus the relationship Between both variables and use regression analysis to define the relationship. He found that important impact of interest rate on stock market. his results are focus on long term interest rate that are play fundamental role in price dividend ratios. Knut (1996) he found that those countries with less interest rate has strong market as compere to who have high interest rate. He also says that develop countries having low rate that's way its market is extra ordinary.Kellen (2000) worked develop markets (south Africa, Zimbabwe) he says that in this market high interest rate think to huge loss market and its prices. After study the markets he found that relationship is negative in both variables. Hosing (2004) find out variables have different impact on each other. variables were interest rate, exchange rate and stock market. but at the end he found that negative relationship between interest rate and stock market.Zoran (2005) worked with macro factors i.e. World War II and he also found opposite relation between both variables. He also focused on cycle's research. For example: ten to fifteen years etc.Salahuddin (2009) study two factors that can impact on country growth and reduction. These factors are interest rate and stock exchange. Salahuddin investigate about these variables and he found that both variables have negative impact on each other.Zahid (2010) also study macro variables and stock market index and found that interest rate and inflation has negative impact on stock market.

System operation management Essay Example | Topics and Well Written Essays - 2000 words

System operation management - Essay Example This is a picture that extends to other sectors of the economy, whether it is the tourism industry, where some tourists get guidance from a digital tour guide, or one that is physically present. In the production sector, the use of computers in the process gets more prominent by the day (Katz & Koutroumpiz 2012). This section of the paper examines the importance of digitization to the manufacturing sector. The manufacturing industry forms the largest source of revenue for many economies in the world, especially first world economies (Friedrich et al. 2011). As mentioned earlier, the production industry has been privy to rapid digitization over the past few decades. This means that there is the use of intelligent machinery in place of human labour. Economists all over the world have had debates on the consequences of this. This is because, even though digitization means a more sophisticated production process, there is the fact that the introduction of intelligent equipment to the pro duction chain implies that there are fewer jobs for human labourers (Karim et al 2013). Despite this negative consequence of digitization, the positive implications of a digitized manufacturing industry are vast. ... This for the manufacturing industry means higher rates of production at lower costs (Sabbagh et al. 2012). In addition, machines can work for longer periods than human labour can; hence, the increased levels of production. Secondly, digitization in the manufacturing industry has revolutionized the method by which companies communicate with customers and stakeholders, and how they create brands (Karim et al. 2013). In the second economy, companies have learnt to rely more and more on social media for service production. One way in which this is made possible in the manufacturing industry is by providing avenues for customers to voice their opinions on certain products on social media, for example, on twitter. This enhances communication with the necessary clients and works towards building a brand. Another way in which the digital economy proves useful for communication is by providing consumers with the option to order custom-made products from manufacturers and, therefore, enhance c ustomer satisfaction (Sabbagh et al. 2012). Another advantage of a digitized economy over a physical economy is the way in which digitization has revolutionized operations. It is said that in America, one in four workers engage in telecommunication while at work (Katz & Koutroumpis 2012). Across the world, members of different companies have a means through which they reach workers in other continents. The effect that this has is that it increases competition between various organizations. In addition, companies are able to outsource some of their functions to companies in far away locations. This enhances efficiency across the manufacturing industry. Digitization is important for each aspect the manufacturing industry. In production, the

Case Assignment Example | Topics and Well Written Essays - 500 words

Case - Assignment Example In this case, competition is rife and a good image is likely to create a competitive advantage for St Margaret’s Hospital. 2. The issue related to brand name is that there is a general feeling that the name Margaret is old fashioned and is no longer commonly used. However, the brand name should not be changed for good reasons that include the following. This is a church owned institution and this should be reflected in the name of the hospital. The name itself makes the hospital distinct from other healthcare institutions operating in this particular area. If the name is changed, people may be confused hence it should be maintained for the sake of the people who identify with the catholic mission. 3. Mary should focus on the core services offered by the institution and attention should be given to the fact that this institution is not for profit. This helps to attract people if there is a clear distinction from other competitors in the same sector. Mary should also try to target competent medical personnel to join the institution so as to improve its reputation as a force to reckon with in the health care profession. The advertisements should target the less privileged people in society so as to make a distinction between the catholic hospital and other institutions that are for profit making. This differentiation strategy is advantageous in the targeted people can easily identify with their preferred institution for all their medical requirements. 4. St Margaret’s hospital should pursue activities that are socially responsible in the communities they operate so as to build a strong and positive corporate image. The institution should engage in activities that are meant to benefit the less privileged members of the society so as to appeal to the interests of many people. Since this is a not for profit organization, the institution should try to offer free medication to people with special cases who cannot afford to pay for their medical expenses.

Dow Corning Customer Value and Segmentation Essay

Dow Corning Customer Value and Segmentation - Essay Example The results of such re-evaluation are a new approach to customers and a newly formed customer segmentation. Basically, Dow Corning has classified their customers into three main categories. First, the company has clients who aim to become the first in the market to introduce certain innovative products and services. For instance, when a company wants to introduce a new product into the market, it may require the expertise of Dow Corning so as to hasten the entry of such product into the market. Such customers want specific innovations that will help them produce new products or develop new services. As cited in the case study, one such company was Reliance Industries. Through the services of Dow Corning, the said company was able to bring to the market a new fiber optic cable that that was easier to install and cost significantly less than other available alternatives in the market. The second customer segment of Dow Corning is composed of companies involved in fast-growing markets. Being involved in fast-growing markets, clients such as these require innovative solutions that will improve their own productivity and performance. These clients require Dow Corning's expertise so as to avoid being left behind by their competitors in their rapidly growing and changing industries and sectors.

A Reaction to the Article Are Poor People Responsible for Their Own Essay - 4

A Reaction to the Article Are Poor People Responsible for Their Own Poverty - Essay Example Larzelere argues â€Å"Being poor was not a choice, it was a condition brought about by the people in power.† Upon examining the substance of their individual arguments at depth, I feel disposed to prefer the side that acknowledges the truth of poverty as perceived in reality where in general, due to a number of factors that influence our state of the economy, we may not plainly put the blame on the poor. Even if the poor may, to a certain extent, be observed weak in the ability to improve themselves in terms of economy, we ought to understand that they do not merely struggle with the financial aspect of living. Poor people find it difficult to gain inspiration from a depressed environment they dwell in for evidently, the strong presence of vices, crimes, violence, and other elements that threaten to ruin or degrade the quality of life in a society bears negative impact in their attitude toward personal growth. Moreover, we may not have them take the sole accountability of neg lecting to live with decent income and shelter for most of them are either those uneducated or those who receive but an inadequate amount of formal learning so that they barely have a proper way of determining suitable professional careers or of simply employing themselves to be resourceful and persevering in finding work that matches one’s set of skills. Jensen accuses the poor of being lazy, irresponsible, and unable to handle money and the tasks of every day yet on suggesting to remedy this situation â€Å"By developing work ethics and feeling some sense of pride and ownership of the money†, we may with high-pitched voice collectively ask, in return, how? How are these less fortunate citizens able to manage at least knowing what ‘work ethics’ is about if they do not have work in the first place and how can they be proud of monetary possession if the little money they have is immediately spent on basic necessities and nothing remains to be saved for the comfort of future living? Larzelere appears as rather one-sided in suspecting ‘people in power’ when it comes to the matter of significant control over the poor which keeps the latter from advancing to a higher level of self-net worth. I agree, however, to the writer’s biased stand because, in view of the actual occurrences, it seems more reasonable to catch red-handed those who are corrupt in their acquisition of considerable wages with tax anomalies than those who are paying taxes delinquently on the ground of working in an irregular basis.  

Staff Management Essay Example | Topics and Well Written Essays - 750 words

Staff Management - Essay Example If we take these factors into consideration, we find that in hotels there is usually a respect for authority which makes the employees defer to their superiors and operate in the circle of ownership that they have over their jobs. Hence, what can be done within their purview, they do that well and leave the rest to the control system to tell them their specific duties. By empowering employees at all levels, Becker has introduced what can be called uncertainty in the decision-making the process as the case highlights how employees are unsure of what they are supposed to do and hence seeking direction on even the minute aspects. Though the intention here is not to belittle empowerment, there are places where employees need to be assigned specific jobs with clearly defined roles and responsibilities and this is one such instance (Joiner, 2001, 238). Individual behavior, in this case, is a classic example of how empowerment leads to the wrong results if not managed properly. The case ill ustrates the need for direct supervision along with clearly defined roles and responsibilities for the staff that stems from a command and control system with each level doing what they are supposed to do under strict conditions of regulation. Though the intentions of Becker are noble, he just happened to have implemented them in the wrong manner leading to the outcomes described in the case. In conclusion, it can be said that Becker was in the wrong place at the wrong time and with the wrong set of people. Organizational Culture The culture of the organization before Becker took over is an example of top-down control with limited autonomy at each level and employees at all levels being clearly told what to do and how to do it. Once Becker took over and started the process of empowerment, there was a "culture" shock in the hotel which led to chaos and confusion and loss of productivity and direction. These are all symptoms of how an organization reared in the culture of authoritarian decision making and centralized authority reacts when there is a shakeup in the way the organization goes about its business. As mentioned in the previous section, the intentions of Becker are noble but they just happened to be applied to the wrong organization (Ashkanasy, 2003, 303). The point here is that hotels can be run in autonomous fashion provided they have a culture of openness right from the beginning. And if changes to the culture are supposed to be brought in, they must be done in a gradual and graduated manner instead of introducing them all at once. This saves the organization and the employees in it a lot of trouble as culture shocks can be managed and the transition to another organizational culture done in an orderly and smooth manner. Hence, when introducing changes to the organizational culture, care must be taken to follow the due diligence process and not jump into unchartered territory (Schein, 1990, 90). The hotel described in the case was being run in an efficient manner with the culture being one of command and control with elements of delegation and role definition is clearly laid down. So, when Becker took over and started his reorganization methods, it did not go down too well with the employees who were used to a different

Quantitative Methods Coursework Essay Example | Topics and Well Written Essays - 1000 words

Quantitative Methods Coursework - Essay Example 1. Production and Transportation cost = (80000 units)(97 pence/unit) = 7,760,000 pence 2. The rest of the capacity of factory '1' (90,000 - 80,000 = 10,000) can be used for producing and transporting to manufacturer 'B' Production and Transportation cost = (10000 units)(98 pence/unit) = 980,000 pence Hence the total cost of production and transportation for factory '1' is 7,760,000 + 980,000 = 8,740,000 pence = 87,400/- 3. The rest of the demand of manufacturer 'B' (72,000 - 10,000 = 62,000) should be produced by factory '3' having lesser costs than factory '2'. Production and Transportation cost = (62000)(109) = 6,758,000 pence 4. The rest of the capacity of factory '3' (80,000 - 62,000 = 18,000) can be used to produce and transport for manufacturer 'A'. Production and Transportation cost = (18000)(107) = 1,926,000 pence Hence the total cost of production and transportation for factory '3' is 6,758,000 + 1,926,000 = 8,684,000 pence = 86,840/- 5. The rest of the demand of manufacturer 'A' (51,000 - 18,000 = 33,000) is produced by factory '2' Production and Transportation cost = (33000)(113) = 3,729,000 pence Hence the total cost of production and transportation for manufacturer 'A' order is 1,926,000 + 3,729,000 = 5,655,000 pence = 56,550/- 6. The total demand of manufacturer 'D' can be supplied by factory '2' Production and Transportation cost = (58000)(114) = 6,612,000 pence Hence the total cost of production and transportation for manufacturer 'D' order is 6,612,000 pence = 66,120/- Conclusion Total Cost of production for factories and manufacturers Factory Computer... As shown by the graph, the relationship is somewhat linear at values 13 onwards (lower part of the graph) and these are non-linear at higher part of the graph. The values for Wells Fargo Home Mortgage are non-linear with huge differences as shown by the graph.

Green Mountain Coffee Roasters Fair Trade Coffee Essay

Green Mountain Coffee Roasters Fair Trade Coffee - Essay Example Since Green Mountain Coffee Roasters is also known for investing in small coffee enterprises, their target market is therefore the main focusing on the business owner who like to entertain their consumers by providing them with the best brewed coffee so that they can understand the quality of their consumer satisfaction and hence go ahead in having business transactions with them. Even, for the employees it is very refreshing to have coffee with a good brew. Apart from the business owners, when we look towards the consumer’s point of view, it is essentially meant for the families who like to have occasional get together and plan to drink coffee during those quality moments (Rudarakanchana, 2013). The young professionals who have the aspiration to start up with their own enterprises and be professional with their approach is also a target customer for them. Based on the target market, GMCR should also look forward to tapping the regions where there do not have their presence li ke the developing nations such as India and China. The demographic profile of the normal Green Mountain coffee consumer is not promptly accessible by means of market asset information; then again, a few industry patterns may be relevant to the GMCR target consumer. It is accepted that the target consumer is Caucasian and in their initial 20s and/or mid 40s. This consumer drinks a normal of 2-4 containers of coffee every day, which is a perfect focus for a solitary mug blending framework. Coffee inclination has a tendency to change by salary, with higher wage consumers inclining toward premium coffee products. Higher wages are additionally connected to a higher ability to pay for more manageable product characteristics. Considering this, GMCR offers a few lines of natural and reasonable exchange K-Cups and entire bean/ground coffee choices and more maintainable bundling alternatives. GMCR

Business Law Essay Example | Topics and Well Written Essays - 2250 words - 1

Business Law - Essay Example This Corporate Compliance Plan version is particularly developed for the officers and directors of Riordan Manufacturing to make them aware of the existence of laws that regulate certain acts and that violation thereof not only exposes the company to fines and penalties but makes them liable for fines and/or imprisonment as well. In addition, any violation of these laws will also merit them severe sanction by the company like termination, depending on the severity of the act. This Compliance Plan also reminds the officers and directors that it is the company policy to abide by the laws of the land. A Compliance Officer is designated by the company for the purpose of ensuring that all the provisions of this Compliance Plan are implemented and supervised efficiently and rigorously. The Compliance Officer shall have the following duties and functions: Periodically review the efficacy and efficiency of this Compliance Plan and proposes changes, amendments and new measures that will enhance, improve and ensure that Riordan Manufacturing maintains corporate policies that are ethically and legally sound and correct; To perform such other duties necessary and relevant to the implementation and supervision of the Compliance Plan and for such purpose, engage the aid of subordinates, if necessary, to facilitate such implementation and supervision. An ALTERNATIVE DISPUTE RESOLUTION is any means of settling differences extra-judicially – that is without or before resorting to court actions. The term can include within its ambit anything and everything that seeks to settle conflicts between parties like negotiation, mediation, conciliation, arbitration or even mini-trials approximating that of formal judicial court trials. In the hope of resolving intra-agency and inter-agency between and among officers or directors of Riordan Manufacturing

Media Violence and Children Essay Example for Free

Media Violence and Children Essay Your children are surrounded by violence. From video games and television to the news itself, bloodshed is everywhere. Many parents and educators fear that violence seen on the media will at the very least desensitize children, and that it may even make children more likely to commit atrocities themselves. Other people claim the violence seen on the media is not real, and that children understand this. So whos right? In order to better understand this crucial issue, we need to examine the history of violence in entertainment as well as revelations made possible by modern science. Violence in entertainment is not new. Even in ancient Rome, people gathered to watch gladiators. In gladiator combats, two trained men (usually criminals or slaves) would fight each other in front of a cheering crowd. Sometimes, men would also be forced to fight wild animals. These shows were incredibly popular; in order to accommodate the huge masses of people eager to watch the combat, Roman officials built the Colosseum, which could seat 50,000 spectators, in 80 CE. The opening of the Colosseum was celebrated with 100 days of games, during which thousands of men and animals were seriously injured or killed. Long before children watched violent cartoons, they listened to violent stories. Even our most cherished fairy tales often contain bloodshed. In fact, modern versions of fairy tales tend to be a lot less violent than the originals. For example, in Hans Christen Andersons The Little Mermaid, the little mermaid has her tongue cut out, almost stabs her prince, and dies; Disneys famous version of this classic tale is significantly happier and less violent. But why is violence such a popular form of entertainment? There are several possible answers, and they are probably all true to some extent. People like watching violence because it is, at least to some degree, forbidden; all functioning societies need to have laws against murder. Seeing other peoples pain also makes your own problems seem insignificant. Finally, some violence in the media was meant to teach a practical lesson. Many gladiators were condemned criminals, so their violent and entertaining death served as a warning against would-be criminals. Public executions have served the same purpose throughout history. Fairy tales also warned children against the dangers of misbehaving. For example, the little mermaid disobeyed the rules of her father and her people, and she suffered as a result. Modern violence in the media is not that different from what occurred in the past. People enjoy watching violence because it is forbidden, distracting, and it can teach lessons about reality. At the same time, violence is becoming more and more prevalent. Additionally, much of the violence shown in video games, movies, and television is completely unrealistic; real consequences are very rarely shown, especially in cartoons. As a result, the violence may be too glamorized to teach real life lessons. Even if violence does teach a morality lesson, children may still be negatively affected. Vincent P. Mathews, a professor of radiology at Indiana University School of Medicine, discovered that watching violence on the media might actually alter brain function. Functional magnetic resonance imaging (fMRI) showed that watching violent images decreased frontal lobe brain activity in children whether or not they had previous problems of aggression. Decreased frontal lobe activity is associated with attention and self control problems. Also using fMRI, Klaus Mathiak at the University of Aachen in Germany discovered that playing violent video games and thinking about actually participating in real violent activities stimulate the same part of the brain. In other words, an individuals brain cannot distinguish between violent actions that are committed by the individual and violent activities that are purely make believe. Additionally, violent video games may be training the brain for real life violent behavior. So what does all of this mean for parents? Children, like adults, are naturally drawn to violent images, and it is possible for children to learn valuable lessons from violent stories. However, exposure to too much violence, especially glamorized violence, probably does have a negative impact of children. Although more scientific research needs to be conducted before conclusive answers can be given, children may have a hard time distinguishing between real violence and fake violence, and simply watching violence may lead to increased behavioral problems. If you are worried that your children are watching too much violence, you should monitor exactly what they are watching. Movies and video games both have rating systems, and all televisions 13 inches or larger that were manufactured in the United States since January 2000 contain V chips. V chips allow parents to control what programs are watched, even when the children are unsupervised. You could also limit the amount of time that your children are allowed to spend watching television or playing video games, regardless of whether or not the programs or games contain violent content. Finally, you can discuss the reality of violence with you children to make sure that they can differentiate between make believe and reality.

Individual Reflection Report On A Business Plan Education Essay

Individual Reflection Report On A Business Plan Education Essay Terms of Reference This report has been prepared as a reflective work of my groups business plan for MBA course. The purpose of this reflection sheet is to redirect how I and my team mates worked while undertaking the project. The point of writing this report is to include my thoughts and reactions to the experience. The reflective journal is a personal record of my learning experiences (White, 2005). I have been asked by university management to write an individual reflective journal on business plan that should consist of my critical way of thinking in an analytical way. It has been written to reflect on my work which will allow the readers to understand my achievement being a member of a team and my role as a researcher, analyser, critical thinker, reporter and presenter (White, 2005). I tried to be as specific as possible as this journal is a persuasive essay arguing on behalf of myself. It includes where my inspiration comes from, how I made use of my ideas to develop my work and my awareness of t he context in which I work. This reflective journal is an individual report that has described my work based on the business plan that I have participated in. I was chosen to work in a team of five members to build a business plan regarding launching a business in Cardiff. My team members for this assignment were Archana Ashu, Gagan Deep Singh, Nadeem Khan and Rachit Ajmera. The business plan that we have worked together, is regarding launching a multiplex cinema in Cardiff. This business plan provides a 3 year operating plan for a Multiplex cinema with a start-up capital of  £5 million. In this report we highlighted and analysed all the factors essential for a start-up. We considered market analysis, market strategy and costing, staffing and resourcing, and financial projections for the first 3 years of the business. In this reflective journal I have described objectively what happened, I tried to Interpret the events explaining what I saw and heard, my insights, my connections w ith other learning, my hypotheses and my conclusions. I also evaluated the effectiveness and efficiency of what was observed. In this journal, I have described how I tackled team issues, interpreted my role as a team member, what did I learn being a team member and How I approached challenges. Other than problem solving I have recorded and mentioned knowledge and understanding of relevant theories, synthesis of what would I do differently next time reflecting on how the workshops/meetings helped develop my study? I have been asked to reflect an analysis, taking into account aspects of my strategy formulation and explaining how I built upon and applied knowledge from taught modules. I have made sure that structure of work follows all the section headings and recognises marking scheme, language is concise and this journal is presented according to school guidelines. Problem solving I was chosen to work in a team of five members to build a business plan regarding launching a business in Cardiff. My team members for this assignment were Archana Ashu, Gagan Deep Singh, Nadeem Khan and Rachit Ajmera. Although I wanted to be in a team of my close friends, the administration allocated teams randomly and put me in a group of five students. Luckily I already had close friendship with one member and I knew one other as he was in a same study group as mine. Initially I had objections with the supervisors decision of allocation but gradually as I started to know my team members, this opposition faded away. I felt friendly and enthusiastic being in this team. Being students from different backgrounds and societies naturally raised some problems for us but we managed to solve all the issues quite amicably (Gillie, 2010). All the disagreements were resolved and we worked together harmoniously. As a contemporary management student, I understood the capability of a team is gre ater than the collective abilities of the individuals within it. As soon as I was consigned in a team, I called everyone for a meeting to know each other and discuss task in hand. For me, doing the work in a friendly environment and more casually could make the task easier. Rest of the team members did not agree and had some reservations but I motivated them and persuaded them to follow my arrangement. In the meetings, plan was discussed and ideas were revolved (Gillie, 2010). I also put forward my thoughts and plans. After careful planning, thorough discussion and constructive arguments I made them agree on the topic. We defined our roles according to our strengths in subject areas and tasks were assigned to each member. My team set its standards of ethics and behaviours to achieve positive synergy and to create effective environment (Levin, 2008). All team members were highly committed and motivated. My strong area was marketing, hence id been assigned with collecting, analysing a nd evaluating marketing aspects of the business plan. I also convinced them to work closely and stay in constant contact. Although we had to work individually on our tasks but I collaborated to help others in their work and vice versa (Levin, 2008). Apart from problems mentioned above, I and other team members faced some other problems such as lack of knowledge of how to conduct the study, inexperience of research process, lack of critical analysis during research process, less research was done on every individuals part and there were critical judgements on each others work, no involvement of critical thinking which made our presentation look descriptive, and inconsistent decision making. All these problems were solved jointly (Gillie, 2010). I have learnt that team is more successful when members within it are able to create synergy. Since our goals, objectives, tasks, and priorities were larger than any individual, teamwork was required. When team members know how to be more effective together, synergy happens and greater organizational success is achieved. I have also understood the importance of teamwork (Sugars, 2005). I considered every member of my team as important as each person brought unique skills, knowledge, and experience. Team members also brought energy, drive, passion, and determination. Since not everyone brings different amounts of all of these things, team members needed each other. Increasing the strength of each team member produced greater team success and results. I along with my team members approached all the issues quite confidently as I knew our collective strengths could tackle any problem we face (Glover, 2009). Knowledge and Understanding By conducting a research as a team, I felt that there is no doubt team theory is relevant in practice. I was confident to relate the research and the theory I have studied during my MBA course (Sugars, 2005). Previous experience in management field also came handy. The most important thing I have gained knowledge of is the effectively working in a team. In the later stages of the project, coordination among team members increased considerably. This helped in improving and polishing our communication skills. We learned that everyone can do their own part to work towards a common goal and that there doesnt need to be just one distinct leader (Glover, 2009). Although different tasks were assigned to team members, I remained in constant contact with every member and consulted on every possible occasion. This also helped me learn and understand their approach as well (Glover, 2009). As an individual, working on a business plan has helped me to understand how to make an official report. It assisted me in research methodology, how to check different sources and how to carry out research. The proposed business plan was solely concentrated on market penetration and market acquisition with its customer service, facilities, ambience, and projection technology and above all, operational benefits (Sugars, 2005). Beside this, I managed to learn different marketing techniques and got a practical experience of how to apply marketing models and theories. I considered myself an important member of a team in formulating strategy and objectives to achieve this strategy. The main purpose of conducting a market research was to identify and establish potent ial market and also to get the reliable data for product. I have learned to analyse the market and potential customers before entering the market. I understood the market analysis for business is to check the feasibility and the absorbance of product in the market and to understand the trends and behaviour of the consumers in market and to apply strategies accordingly (Dyer, 2007). All this provided crucial and reliable information. I studied to carry out market analysis; learned about market size and forecast; its share, trends and behaviour. I also assessed competitors and their strategies, targeted market segments, analysed our business core competencies and critical success factors; marketing and costing strategies. This business plan also assisted me in projecting financial position and reports along with knowledge of staffing and resourcing for business (Sugars, 2007). Synthesis Although all team members planned the business plan and divided the tasks according to their strengths but we still faced some problems. I would like to change my approach a little next time I involve myself in this type of activity. I would definitely focus on time management and motivation issues (Dyers, 2007). Others areas need to be improved are analytical skills and market assessments. The area of critics of team needs some perfection as well. Every members presentation skills were weak that resulted in lower marks. The report looked descriptive and team members just read that in the presentation meeting. Experience gained from this project will definitely help to improve the above mentioned areas in the future (Saunders et al. 2009). There are a lot of aspects and factors that helped me develop my understanding and improve my knowledge. Workshops and lectures taught me how to carry out a research in desired fields, what method to select and what approach to take. Meetings provided facilitation in problem solving and strategic planning. These also helped me in decision making and working in a team (White, 2005). Analysis and Evaluation As a student studying MBA course from a renowned university, I was expected to apply critical thinking and analyse the business plan. The modules that I have studied during my lectures helped me apply marketing tools and techniques to my research. I learned how to apply theory into practice. This was a new idea to me but I was successful in interpreting this. This helped me gained both theoretical and practical knowledge. I applied knowledge from the books and journals to formulate the strategic plan, mission and vision of the company that I was working on. I applied different models successfully such as McKenzie 7s model, Porters generic strategies, Ansoffs growth model, IR model, Porters five forces model and some others (Kotler. 2010). The knowledge from the lectures helped me how to search different sources which was useful in strategy formulation. Overall the use of theoretical knowledge in practical situation helped me understand the business plan. I used the theories to advanc e my understanding of the business plan. The practical experience was built upon the theoretical knowledge (Saunders et al. 2009). Theory asked me how to conduct a research; based on this I practically collected data and information for analysis. Theory taught me how to calculate; I practically used this knowledge to formulate a financial projection; Theory explained how to apply different models; I managed to use these theories according to my situation and constructed a whole report. I practically worked in human resource filed to staff and resource my business. Having completed this project, I have learned how to better argue a point in discussion. Using facts and example, my arguments have become much better (Sugars, 2005). The project taught me and my team members to be good team members, cooperative and helpful. I felt a change as my researching skills increased considerably. I can better understand the topic and use a variety of sources for search purposes which will help me a lot in future research process. I can create a conclusive argument that can set a tone of the entire project. Using latest techniques of researching and arguing, my paper will seem clearer and my arguments more apparent (Bryman and Bell, 2007). I have also updated my accounting knowledge by working on new accounting principles. I was responsible for quite of lot of report writing. It was good for me to get practice at writing, at proof reading, editing, etc. I did have a sense of achievement when a report was finished. And finally my computer skills have also impr oved from writing reports and through having 24-hour access to the computer. These skills are not great, but in comparison to my own skills before working on this project they have progressed well. I personally feel that business plan is viable as it helps us understand not just to apply critical thinking and analyse the information but to use the theory into practice. This is what I think MBA requires. It helps the students getting management experience and applying what they have learnt in their lectures and workshops.

Sharing Pirated MP3’s :: File Sharing Essays

Sharing Pirated MP3’s The sharing of MP3 music and its legality is a major issue in our legal system at this time. It has been a battle in the courts for several years now. It all began with the legendary downfall of the original bad boy of sharing, Napster. Despite the legal actions of the music industry, the file sharing community continues to thrive. Millions of users still log on to a handful of programs and illegally trade MP3’s and other computer programs. College students are suspected to be one of the major culprits of People to People file sharing. A survey was conducted in order to obtain an understanding of why students of James Madison University would use People to People sharing programs. More importantly, it was to gain insight into the ethical outlook of students in concern to the sharing of MP3 music files. The survey attempts to determine why, in light of the ethical issue and possible legal repercussions, do JMU students still trade illegally pirated music? The survey was composed of ten multiple choice questions and administered to twenty random students. The students were taken from various areas around the campus in order to obtain a wide variety of responses. It sought to have respondents who were of various age, race, and sex. The surveys were handed out in a classroom, a dining hall, and an events committee meeting for the University Programming Board. Students remained anonymous to the administer and their confidentiality was assured. Most of the students filled out the survey with relative ease and only had to debate on a couple of the questions. Several students were kind enough to give a few extra minutes of their time for various follow up questions. I began to ask students which questions gave them the most trouble. Many felt the last question, asking if downloading MP3’s for free is ethical, was the most thought provoking question. Nineteen of the twenty students surveyed downloaded MP3’s. Fourteen said they felt it was unethical to download the MP3’s, yet most of them continue to download. The question seemed to stimulate an ethical debate inside the respondents of which they had trouble answering. A vast majority of the students simply do not care about pushing ethics aside and continue to download pirated music.

The Impact of the Montreal Canadiens Hockey Club on the City of Montrea

The Impact of the Montreal Canadiens Hockey Club on the City of Montreal A sports team is vital to a large city such as Montreal. A sports team may have positive or negative impacts on a city. The team that will be focused on is the Montreal Canadiens. Despite the poor seasons that the team has recently endured, the Montreal Canadiens are still one of the most winningest franchises in all of sports. The team’s long history as a winning organization has made the city of Montreal reputable. For my research, the three disciplines that will be focused on are sociology, geography, and economics. These disciplines are very much evident and important to my research topic, that being, the importance the Montreal Canadiens Hockey Club for the City of Montreal. With the use of sources related to my topic, one will be able to grasp the overall context of my research. The direct question that my research intends to answer is; how has the Montreal Canadiens Hockey Club impacted the City of Montreal as a whole? Literature Review   Ã‚  Ã‚  Ã‚  Ã‚  The discipline of sociology studies groups of people in a specific area. In this case, the people we will focus on are the players playing for the Montreal Canadiens hockey team and the fans that support the team. After viewing a video on the Montreal Canadiens during the 1988-1989 season (Fisher 1989), the discipline of sociology is very much evident in this video. The video takes an in depth viewing of the team during the 1988-1989 season. It looks at the ups and downs the team faced during this particular season and how the Montreal Canadiens have over come obstacles.   Ã‚  Ã‚  Ã‚  Ã‚  During the 1988-1989 season, the Canadiens advanced to the Stanley Cup final where they lost to the Calgary Flames in six games. A few years earlier, in 1986, the Canadiens beat those same Calgary Flames to win their twenty-third Stanley Cup. The player that led the Canadiens during the 1988-1989 season was none other than goaltender Patrick Roy. The pressures that were placed on the shoulders’ of Roy were unbelievable. This pressure came from fans and media alike. The fact he was a French- Canadian that grew up cheering for the Canadiens, did not help either. As Patrick said in the video, â€Å"Hockey in Montreal is not a sport, it’s a religion.† Also interviewed was .. ... I composed my questionnaire around my research question. The results of my fieldwork take into account the three disciplines that my literature review is based on, that being, sociology, geography, and economics. From the answer(s) that was derived from my fieldwork, the impact the Montreal Canadiens has on the city of Montreal as a whole is positive. Conclusion   Ã‚  Ã‚  Ã‚  Ã‚   To explain the importance a sports team has on a city, a new avenue for future research would be the traveling to a city that lost a professional sports team and research the impact it had on places such as Winnipeg and Quebec, where the Winnipeg Jets and the Quebec Nordiques used to play respectfully. Economically, jobs are created within and around the team and city, which geographically is the reason why businesses are set up where they are, and sociologically, people come together in the supporting of their team. These three disciplines are lost with losing of a professional sports team. A sports team is vital to a large city such as Montreal. To conclude this report, the Montreal Canadiens Hockey Club has a positive impact on the city of Montreal as a whole.

parkinsons disease Essay -- essays research papers

Parkinson’s Disease and the protective mechanism of the antioxidant Vitamin E Description and Risks   Ã‚  Ã‚  Ã‚  Ã‚   Parkinson’s disease (PD) is a progressive movement disorder marked by tremors, rigidity, slow movements (bradykinesia), and postural instability. It is a chronic, progressive neurodegenerative disease caused by decreased production of dopamine, a neurotransmitter. Dopamine is responsible for most of the body’s smooth muscle movements. As a result, motor control in Parkinson’s patients is disrupted, causing anything from uncontrollable tremors to muscular stiffness to slow-as-molasses movements. (2) PD affects about 500,000 people in the United States, both men and women, with as many as 50,000 new cases each year. The disease usually begins in a person’s late 50’s and 60’s; it causes a progressive decline in movement control, affecting the ability to control initiation, speed, and the smoothness of motion. The symptoms of PD are seen in up to 15% of those between the ages of 65-74, and almost 30% of those were between the ages of 75-84. (3) Genetic Risks   Ã‚  Ã‚  Ã‚  Ã‚  Scientist identified two gene abnormalities present in PD patients whose families have a rate of the disease, indicating at least some evidence that the disease is inherited. Both abnormalities cause the body to produce an altered version of alpha synuclein, the protein that shows up in dense masses in the brains of Parkinson’s patients. (3). But in another study in the Journal of the American Medical Association suggested heredity is a significant influence on how fast the disease will onset. Researchers identified 172 twin pairs in which at least one twin had PD. If the condition was hereditary, the rate of both twins having the disease would be lower among fraternal twins, who share some, but not all of the same genes unlike identical twins who share them all. In individuals who were diagnosed after age 50, the rate of twins who both had the disease was similar among fraternal and identical twins. In those diagnosed at 50 or younger, however, the rate wa s significantly lower in fraternal twins than in identical twins (2). Researchers also think that PD has environmental risks such as increase exposure to toxic chemicals such as pesticides, herbicides, or heavy metals. For example, some studies of people liv... ...one, L., Bagala, A., Napoli, I.D., Caracciolo, M. & Quattnone, A. (2001) Plasma levels of Vitamin E in Parkinson’s disease. Archives of Gerontology and Geriatrics 33:7-12. 6. Miklya, I., Knoll, B. & Knoll, J. (2003) A pharmacological analysis elucidating why, in contrast to (-)- deprenyl (selegiline), alpha-tocopherol was ineffective in the DATATOP Study. Life Sciences 72:2641-2648   Ã‚  Ã‚  Ã‚  Ã‚   10.  Ã‚  Ã‚  Ã‚  Ã‚  Parashevas, G.P., Kapaki, E., Petropoulou, O., Anagnostouli, M., Vagenas, V. & Papageorgiou, L. (2003) Plasma levels of Antioxidant Vitamins C and E are decreased in vascular Parkinsonism. Journal or Neurological Sciences. 215:51-55. 11.  Ã‚  Ã‚  Ã‚  Ã‚  Roghani, M. & Behzadi, G., (2001) Neuroprotective effect of vitamin E on the early model of Parkinson’s disease in rat: behavioral and histochemical evidence. Brain Research 892:211-217. 12.  Ã‚  Ã‚  Ã‚  Ã‚  Vatassery, G.T., Demaster, E.G., Lai, James C.K., Smith, W.E. & Quach, H.T. (2003) Iron uncouples oxidative phosphorylation in brain mitochondria isolated from vitamin E-deficient rats. Biochemical et Biophysical Acta 1688:265-273. .

Periodontics

Tissues of the periodontium (Chapter 2) Periodontium * The tissues that surround, support, and attach to the teeth Components of the periodontium 1. Gingiva 2. Periodontal ligament 3. Cementum 4. Alveolar bone Function of the periodontium * To support the teeth and oral structures The gingiva * The visible component of the periodontium inside the mouth * Described as: pink, pink-red, blue, purple, or pigmented * It can appear much darker when melanin pigmentation is present * Factors that mask the color change of gingiva: * Food * Medications The three types of gingiva 1. Free gingiva 2. Attached gingiva 3.Alveolar mucosa Mucogingiv al junction * Appears as a line that marks the connection between the attached gingiva and the alveolar mucosa Alveolar mucosa * The moveable tissue loosely attached to the underlying boe * It is attached but moveable * The surface is smooth and shiny Attached gingiva * Extends coronally from the mucogingival junction * It is continuous with the oral epit helium and is covered with keratinized stratified squamous epithelium * It is firmly attached to the alveolar bone unlike the free or marginal gingiva * It DOES have attachment fibers, which is why on the lingual aspect of maxillary teeth the ttached gingiva will blend with the attached palatal mucosa Rete pegs * Ridges of epithelium that form the connection between the free or attached gingiva and the underlying connective tissue * If gingiva is healthy, it appears stippled, which is due to the rete pegs * If gingiva is not healthy, it will appear flat and shiny, due to a lack of rete pegs Function of rete pegs 1. Add strength to the gingiva 2. Nourish the gingiva Free gingiva or free marginal gingiva * Surrounds the tooth and crests a cuff or collar of gingiva extending coronally about 1. mm * Usually a groove called the free gingival groove demonstrates the free marginal gingiva from the attached gingiva * Appears to be attached to the tooth but maybe separated by an instrument l ike a periodontal probe Gingival sulcus or crevice * A crevice or groove around each individual tooth * Sulcular epithelium is the continuation of the oral epithelium covering the free gingiva * Healthy sulcus is 1 to 3 mm probing depth Sulcular or gingival crevicular fluid * Liquid in the gingival sulcus Components diffuse through the basement membrane and the junctional epithelium Components of crevicular fluid 1. Connective tissue 2. Epithelium 3. Inflammatory cells 4. Serum 5. Microbial flora Functions of the crevicular fluid 1. Cleanses the sulcus 2. Antimicrobial action 3. Plasma proteins improve adhesion of the epithelium to the teeth 4. Antibody activity to defend the gingiva Junctional epithelium * Separates the periodontal ligament form the oral environment * Protects the attachment to the tooth to the surrounding tissues * Approximately 15-20 cells If the base of pocket is damaged, it takes 4-6 weeks to heal Interdental papilla (interdental gingiva/gingival papilla) * The gingiva that fill embrasure spaces, which is the interproximal space beneath a contact point of 2 teeth * Shape depends on the teeth it is between but we generally consider the papillae pyramidal or triangular * In health, it should fill embrasure and the tip pointed, not blunt or swollen * Other descriptions: pointed, bulbous, blunted, absent, or cratered Col Depression between the lingual and facial papillae in posterior teeth that conforms to the proximal contact area * Usually absent in anterior teeth because of the lack of lingual facial width at most coronal portion * Often susceptible to infection because of its non-keratinization Keratinization * The process whereby keratinocytes migrate from the basal layer of the epithelium to the surface and flatten out in the process * These flattened cells produce a superficial layer that is similar to skin where no cell nuclei are present * Least common form of epithelium in oral cavityOral epithelium * The oral cavity is primarily ma de of stratifies squamous epithelium cells * The majority of cells are keratinocytes and melanocytes which produce melanin which gives the gingiva a pigmented appearance (dark brown) Parakeratinized * The epithelium appears keratinized but the cells of the superficial layers retain their nuclei * Lightly keratinized (dorsal surface of tongue) Non-keratinized * No signs of keratinization (no keratin) are present (epithelial surface) Keratinized| Non-keratinized|Palate (most)| Sulcular epithelium| Tongue| Alveolar mucosa| Attached gingiva| Junctional epithelium| Oral epithelium| Cols of papillae| Cheeks (least)| Buccal mucosa| Components Gingival epithelium 1. Oral epithelium 2. Sulcular epithelium 3. Junctional epithelium Normal â€Å"healthy† gingiva Color| Uniformly coral or light pink varying with thickness and degree of keratinization may also vary due to amount of melanin (pigment)| Size| Fits snuggle around the tooth, not enlarged when healthy| Contour| 1.Marginal gingiv a: flat/knife edged 2. Papilla: 1. Pointed and pyramidal in normal contact 2. Blunted/absent if diastema is present| Texture| 1. Free gingiva: smooth 2. Attached gingiva: stippled of rete pegs| Consistency| Firm and resilient (bounces back quickly)| Bleeding| No spontaneous bleeding upon probing| Exudate (pus)| None| Probing depth| Average is 1. 8mm (0-3mm is the normal range)| Periodontal ligament * Fills the space between the cementum and bone * Remember that teeth have a â€Å"shock absorbing cushion† space of 0. -1. 5 mm next to the bone and they are not rigidly fixed in their sockets * The attachment apparatus consists of: 1. Alveolar bone 2. Periodontal ligament 3. Cementum * The fibrous connective tissue that surround and attaches the roots of the teeth to the alveolar bone * This connective tissue is made of fiver bundles (mainly collagen) and cells * The fiber bundles in the PDL are made of collagen arranged in bundles and spread throughout the PDL Function of the pe riodontal ligament 1.Maintains the relation of a tooth to hard/soft tissues 2. Supplies nutrients and removes waste via blood and lymph vessels 3. Protect the vessels and nerves from injury 4. Resists occlusal forces (shock absorbers) 5. Transmits occlusal forces to the bone Sharpey’s fibers * The terminal brush-like fibers of the principle fiber bundles in the periodontal ligament that are partially inserted into the outer portion of the cementum at 90 degrees and then attached to the alveolar bone at the other end Five principal fiber groups of the periodontiumApical fibers| * Run from the root apex to adjacent surrounding bone * Function: to resist vertical forces| Oblique fibers| * Run from the root above the apical fibers obliquely toward the occlusal * Function: to resist vertical and unexpected strong forces| Horizontal fibers| * From the cementum in the middle of each root to adjacent alveolar bone * Function: To resist intrusive forces| Alveolar crest fibers| * From the alveolar crest to the cementum just below the CEJ * Function: to resist intrusive forces| Interradicular fibers| * Run from the cementum between the roots of multi-rooted teeth to the adjacent bone * Function: to resist vertical and lateral sources| Cementum * Outer most layer of the root of a tooth * Helps anchor the teeth * Made of a mineralized fibrous matrix (collagen and fibers) and cells (cementoblasts and cementocytes) * Attaches teeth to the alveolar bone b anchoring the periodontal ligament * No vascular or nerve connections * Cannot transmit pain, therefore not sensitive to scaling procedures * Renewable Cementoenamel junction * The junction point between enamel and cementum * Not always smooth, can be due to alterations in cemented surface and the tissues involved Three scenarios occur at the CEJ 1.Cementum will overlap enamel (60%) 2. Cementum and enamel meet (30%) 3. Cementum and enamel fail to meet leaving a narrow zone of exposed dentin (10%) Alveolar process * Su pport system for teeth * Extensions of the bone from the body of the mandible and maxilla * Lines the sockets of the teeth and provides support for the sockets * The walls of the sockets are called the lamina dura * The process also provides attachments for the periodontal ligament Components of the alveolar process * Alveolar bone * Compact bone * Trabecular and cancellous bone The alveolar process functions as a unit, as indicated by it’s gradual resorption when teeth are lostCurrent concepts of microbiology and periodontal disease (chapter 4) Microorganism * Microscopic living organisms which include bacteria, viruses, and fungi * Bacteria: single-cell * Viruses: very small and not capable of growth or reproduction without living hosts * Fungi: plant-like organisms that occur as yeasts or molds Bacterial classifications 1. Morphologic forms (shape) 2. Cell wall structure 3. Oxygen environment 4. Metabolism 5. Motility Morphologic forms (shape) * Involved in plaque biofilm formation 1. Cocci: spherical, most common form in plaque is streptococci 2. Rods or bacilli: generally rectangular or rod like 3. Spirochetes: spirals Cell wall structure Bacteriologic technique (gram staining) of using a double dye staining system to differentiate the structure of the cell walls * Two wall types: 1. Gram positive: stains purple (crystal violet dye applied first) 2. Gram negative: stains red (safranin dye applied second) Oxygen environment Aerobe/Aerobic organism| Requires oxygen to live and grow| Anaerobe/Anaerobic organism| Grows in complete or almost complete absence of oxygen| Facultative anaerobic organism| Can use oxygen when present but can use anaerobic fermentation when oxygen is absent| Obligate anaerobe| Cannot survive in an aerobic environment| Aerotolerant anaerobes| Grow in both types of environment| Capnophile| Requires or prefers carbon dioxide for growth| Metabolism The sum of total of chemical changes occurring in the body; chemical process of tra nsforming foods into complex tissue elements and or transforming complex body substances into simple ones, along with the production of heat and energy * Anabolism: The building up of tissue; maintenance and repair of the body * Catabolism: The breaking down of tissue into smaller parts from energy production and excretion Motility * Bacteria either are or aren’t motile * Flagella are long fine wavy filamentous structures used for motility * May have one or more flagella * Flagella may be located at either end, both ends, or encircling cell Microbial succession * Flora: organisms together in a locale * Oral flora: various bacterial and other microscopic organisms that inhabit the oral cavity Normal oral flora * Predominant microorganisms present in healthy state: * Streptococcus mitis * Actinomyces species Streptococcus oralis (sanguis II) Dental plaque: â€Å"The cause† * Dental plaque is THE major etiologic factor in the initiation and progression of periodontal dise ase * Epidemiologic studies have shown that poor oral hygiene increases the prevalence and severity of periodontal disease * Microorganisms other than bacteria can be found in plaque (ex. yeasts, protozoa, and viruses) * The difference between dental plaque and material alba is the strength/adherence of the deposit * Material alba is loosely adherent, soft accumulations of bacterial/cellular debris and can be removed by mechanical action (ex. strong water) The definition of dental plaque (Not on test) An accumulation of bacteria on the surface of teeth or other solid oral structures and is not readily removed Plaque formation: 3 stages 1. Pellicle formation * The acquired pellicle forms on the tooth surface * It is acellular * It is an organic and tenacious film composed of glycogen proteins from saliva * It will start to form within minutes after a tooth surface is entirely polished 2. Bacterial colonization * Bacteria from indigenous oral micro flora attach to the pellicle and for m microbial colonies in layers as the bacteria grow and multiply * An intermicrobial substance is formed mainly from saliva and from polysaccharides produced by certain bacteria from sucrose or sugar in the diet 3. Plaque Maturation As plaque ages, a change in the types of microorganisms occurs within plaque * Plaque that is up to 2 days old consists primarily of cocci * By 2-4 the filaments replace the cocci * By days 4-7, filamentous forms increase and rods and fusiform bacteria appear * By 7-14 vibrios and spirochetes and more gram negative and anaerobic microorganisms appear * Bacterial plaque, if not mechanically disturbed, produces a great proportion of those microorganisms associated with periodontal disease Dental plaque growth * After the first day of plaque growth, gram (+) streptococci decrease in number * During the next 3 weeks of undisturbed plaque formation, cocci continue to decrease because of an increase in filamentous bacteria.These filaments actually invade and r eplace many of the streptococci that inhabit the deeper levers * As plaque increase in thickness, further changes occur in the environment * When plaque is allowed to grow undisturbed, it becomes more anaerobic * The level of oxygen diminishes as a result of O2 consumption by facultative organisms * This lowers 02 level and allows the growth of obligate anaerobes * A more mature plaque harbors increasing number of obligate anaerobic organisms such as spirochetes and gram (-) rods * At this point, no additional bacterial species join the plaque, although the volume of bacteria may continue to increase * Mature plaque has the potential to invade the subgingival space and to cause localized gingival disease Page 74 (figure 4-9) The difference between supra/subgingival plaque Characteristic| Supragingival| Subgingival|Location| * At or above (coronal to) the margin of the free gingiva| * Apical to the margin of the free gingiva, between tooth and gingival pocket epithelium| Origin| * Sa livary glycoproteins form pellicle * MO’s from saliva are selectively attached to the pellicle| * Apical growth of bacteria from supragingival plaque| Distribution| * Starts on proximal surfaces * Heaviest on areas not cleaned daily by patients * Cervical 3rd * Lingual mandibular molar * Pits and fissures| * Shallow pocket * Attached plaque covers calculus * Unattached plaque extends to the periodontal attachment| Adhesion| * Firmly attached to acquired pellicle, other bacteria and tooth surfaces| * Adheres to tooth surface: calculus| Sources of nutrientsFor bacterial proliferation| * Saliva * Ingested food| * Tissue fluid (sulcus) * Exudates * Leukocytes| Bacteria | * Early plaque: mostly gram + cocci * Older plaque: increases in filaments (3-4 days) * More complex flora increase rods (4-9 days)| * Depends on pocket depth. Apical part dominated by spirochetes, cocci, and rods; coronal part has more filaments. * Environment is conducive to growth of anaerobic population| Sign ificance| * Etiology of: * Gingivitis * Supragingival calculus * Dental caries| * Etiology of: * Gingivitis * Periodontal infections * Subgingival calculus| Pathogens in plaque The virulence for pathogenicity of a microorganism is its ability to cause disease * For a microorganism to be virulent it must: * Be established in close proximity to the periodontal tissue * Must be able to withstand the forces of saliva and gingival crevicular fluid that are capable of sweeping it away * Normally cellular defense systems are able to rid the microbe from the host * However, periodontal pathogens have developed a variety of strategies to evade or overcome these mechanisms * Example: Actinobacillus Actinomycetemcomitans (AA) defends themselves against phagocytosis by: 1. releasing inhibitors of directed migration (inhibits chemotaxis) 2.Produces anti-phagocytic surfaces that prevent the polymorphonuclear lymphocytes (PMN’S) or neutrophils killing mechanisms * Has very slippery surface: slippery surface makes it extremely difficult to latch onto bacteria, therefore PMN’s cannot properly engulf it and PMN’s may be destroyed releasing toxins that produce osteoclasts * AA is a major pathogen Plaque tissue destruction 1. Bacteria themselves do not need to be present within the tissue to be a major participant in the destructive process 2. Some bacterial products may directly injure the hose cells and tissues 3. Others may interact with a variety of cells and activate the humeral and cellular immune reactions that secondarily affect the integrity of the periodontium Direct effect of plaque * P. gingivalis * Produces collagenase, the enzyme that degrades collagen * LPS or endotoxins ( which is a component of a gram (-) bacterial outer membrane) nduces inflammatory reactions and stimulates osteoclasts Indirect effects of plaque * Toxins from p. gingivalis and other gram (-) organisms stimulate the immune response, releasing prostaglandin E2, and interleukin 1B from macrophages and fibroblasts, which can induce bone resorption Gingivitis associated plaque * Increase thickness and mass of plaque * Increase in gram negative motile rods and spirochetes which are usually aerobic (require o2) * Fuso-bacterium nucleatum * Various species of prevotella and treponema * Campylobater rectus Periodontitis associated plaque * Prophyromonas gingivalis * Prevotella intermedia * Bacteroides forsythus * Treponema denticola * Peptostreptococcus micros Plaque biofilm summary Plaque is a biofilm meaning that it is an accumulation of microbes on the surface of teeth or other solid surfaces, not readily removed by rinsing * Plaque biofilm provides some protection for its resident microorganisms, increasing their survival * Therefore essential to physically remove plaque biofilms DAILY to maintain gingival and periodontal health- keeps plaque immature * Bacteria that colonize in the first few hours do not possess pathogenicity as the bacteria that dominate plaque after 34 hours. (plaque virulence increase with age) The role of calculus and other extrinsic factors in periodontal disease (chapter 5) Calculus * Calculus (tartar) is mineralized bacterial plaque, a hard tenacious mass that’s forms on natural teeth, dentures, and other dental appliances generally by the deposit of calcium and phosphate salts * 90% of treatment time on calculus removal and 5 % on plaque control * Not all plaque calcifies.Generally it takes 24 hours to 2 weeks to begin mineralization * Plaque can be mineralized in 2 days and up to 90% in 2 weeks * Formation rates influenced by diet and composition of microbial flora * Calculus can reduce drainage from a pocket by helping to trap bacteria and debris * Healing is prevented and advancement of the disease is encouraged Role of calculus in periodontal disease- pathogenicity * Originally the focus was on calculus as a mechanical irritant * Now the focus is on calculus as a rough surface for plaque growth and retention, and a reservoir for toxic microbial and tissue breakdown products because of its permeable surface * Spicules: small pieces and usually subgingival * Granular: similar to spicules but are a lot smaller * Veneer: common in lower anteriors and the buccal of the upper molars. It is important to air dry before checking if all is removedComparison of clinical characteristics of calculus: supragingival vs. subgingival Characteristic| Supragingival| Subgingival| Also known as:| * Supramarginal calculus or salivary calculus | * Submarginal calculus or serumal calculus| Source of minerals| * Saliva| * Crevicular fluid| Formation starts| * Along inner surface of supragingival plaque| * In attached subgingival plaque| Attached to/by| * Acquired pellicle directly to tooth surface| * Penetration into cementum Intercrystalline bonding, mechanically locking into surface irregularities (caused by loss of Sharpey’s fibers)| Composition| * Inorganic Material(70-90%) :1. Calcium pho sphate(75. 9%)2. Calcium carbonate(3. %) * Traces of magnesium, sodium, potassium, fluoride, zinc, strontium| * Similar to supra but increase in calcium, magnesium and fluoride (higher % in crevicular fluid) * Sodium content increases with pocket depth| Factors that influence formation| * Elevated salivary pH * Concentration of calcium in saliva * Concentration of salivary bacterial protein and lipid * Low individual inhibitory factors| * Higher total salivary lipid levels * Some medications(beta blockers, diuretics, thyroid supplements reduce the formation of supra | Commonly found (individual teeth)| * Coronal to margin of gingiva * Can be fine line near gingival margin * Cover large portion of clinical crown | * Apical to gingival margin * Can extend to bottom of the pocket and follows contour of soft tissue attachment. * As tissue recedes, subgingival calculus can become supra| Common Distribution Patterns| * Lingual surface of mandibular anteriors (Wharton’s Duct) * Faci al surface of max. molars (Stenson’s Duct) * Does not necessarily mean there are SUB deposits.Generally symmetrical except when: * Teeth are malpositioned * Functional irregularities * Oral hygiene inconsistent| * Heaviest in interpoximal areas * Lightest on facial surfaces * Occurs with or without SUPRA deposits| Shape| * Determined by tooth anatomy, contour of gingival tissue, pressure from lips, tongue and cheeks * Generally bulky gross deposits may form ‘calculus bridge’ between teeth or cover gingival margin or extend to incisal/occlusal edges| * Generally flattened to conform with pressure from pocket wall: * Ledge or ring like * Thin, smooth (veneers) * Spiny, spur-like * Granular (grainy) * Spicules (irregular amounts)| Consistency/Texture| * Moderately hard * Porous (may come off in pieces that easily break off from adjoining calculus) * Newer deposits are softer| * Harder and more dense than supra * Brittle/flint like * May feel a ‘snap’ as calculus is dislodged * Newest deposits (bottom of pocket) are less hard| Size and Quantity| * Depends on: * Efficacy of personal oral care * Diet * Function/use * Tobacco use| * Related to same as supra plus: * Pocket depth * duration| Supragingival calculus * Porous and rough * Provides lattice on which plaque can grow * Brings the bacteria close to the tissue * Interferes with oral self-cleaning mechanism * Makes plaque removal more difficult * Found on the clinical crowns of any tooth above the margin of the gingiva * Readily visible * Tightly adherent to the teeth * Yellowish-white in color, darkens with age * It is an organic matrix of plaque, microorganisms, glucans, lycol-proteins and lipids * Calcium is deposited in layers * 70-90% is inorganic mineral content Subgingival calculus * Associated with the progression of periodontal disease * Periodontal pockets almost always contain subgingival calculus * Provides a reservoir for bacteria and endotoxins that are related to th e disease process * Can cause greater disease progression than plaque alone * Located below the gingival margin * Attached to cementum or dentin * Tenacious and black in color * Also dark green due to organic matrix products of the subgingival plaque * Color also comes from blood products * Commonly deposited in rings or ledges on root surfaces The mineral content is derived from crevicular fluid rather than from saliva as supra * Similar inorganic mineral content as supra * Can be found anywhere subgingivally * Attaches by means of attached pellicle or mechanical locking into undercuts and irregularities in tooth surfaces * Therefore more difficult to remove * Improper removal of calculus will leave a smooth outer collar called burnished calculus Calculus removal * Calculus is more readily removed from some tooth surfaces than others * Ease of removal related to mode of attachment of the calculus to tooth surface * Can be attached to acquired pellicle, mechanical locking into under cuts or minute irregularities in tooth surface or direct contact between intercellular matric and tooth surfaceConditions that affect periodontal health 1. Malocclusion * Is not a cause of periodontal disease * Poorly aligned teeth will make it harder for daily plaque control, but malocclusion is not an imitator of pathology 2. Missing teeth * Teeth harder to clean as they can tip in if one is missing 3. Bulky restorations * Poorly contoured restorations may cause plaque traps, increase gingival inflammation, may complicate plaque control and this does contribute to periodontal disease 4. Partial dentures * They should be cleaned daily * Calculus can stick on plastic teeth and stain on dentures * Poor fitting dentures can also irritate the gingiva Stress to remove dentures at night. Soak in water 5. Mouth breathing * This can lead to localized gingival inflammation * Usually on maxillary anterior facials * It is associated with an increase in plaque and gingivitis 6. Food impaction * A common local factor that contributes to the initiation and progression of periodontal disease * Food is an excellent breeding ground for bacteria * Forceful wedging of food may also tear epithelial attachment 7. Orthodontic appliances * Fixed appliances have increased plaque retention and are difficult for self-care * Minimal increase in periodontics but increase in gingivitis Tobacco use on periodontal disease It is a risk factor for periodontal disease (can help cause it) * Smoking will constrict white blood cell supply and retard PMN’s (type of leukocyte). PMN’s have reduced ability to phagocytosis * It has been determined that smokers are 2. 5 times more likely to have periodontal disease * The vascular reaction to inflammation is reduced in smokers THEREFORE Gums look normal and pink and there less bleeding and less response to fighting disease * Smokeless tobacco is associated with a specific type of gingivitis called gingivitis toxica it is associated with t he destruction of gingiva and bone underling the area where the smokeless tobacco rests in the mouth Systemic factors in periodontal disease (chapter 16) Systemic factors * Systemic: pertaining to or affecting the whole body Systemic factors may complicate or intensify the periodontal disease * Systemic problems in some patients may: * Increase their susceptibility to infection * Interfere with wound healing * Require modification of standard approaches to treatment * Complicate factors associated with patient cooperation * More significant responses to bacterial plaque and other local predisposing factors Blood disorders (Dyscrasias) * A blood dyscrasia is any disorder that affects cellular elements of the blood (red or white blood cells) * Most common are anemia (need to know tablet or capsule form of iron taken), leukemia, abnormal bleeding * Most have an oral manifestation * In addition to changes to tissue there is: * Increased bleeding Lowered resistance to infection due to th e impaired function of defensive white blood cells-polymorphonuclear neutrophilic leukocytes (PMNs or neutrophils) Aplastic Anemia * Bone marrow has very reduced ability to produce most of the components of blood * May be due to exposure to toxic chemicals or certain drugs * May have no known etiology, ie. Idiopathic aplastic anemia * Patients have: * Rapidly progressing periodontitis * Reduction in neutrophils Agranulocytosis * A rare disease involving destruction of bone marrow * Caused by antipsychotic drugs or an autoimmune diseases such as Lupus (corticosteriods) * Sharp drop in WBC’s; bacterial invasion is rapid * Patients have: * Ulcerations in mouth or pharynx Gingival bleeding * Increase in salivation * An odor in the mouth Cyclic Neutropenia * Unknown etiology * Periodic reduction in neutrophils * Patients have: * Flare-ups of periodontal disease during depletion of neutrophils Leukemia * Cell malignancies of bone marrow with a decrease in WBC and platelets * Etiolo gy is unknown, although linked to certain viruses and ionizing radiation exposure * Abnormal WBC proliferate and suppress the normal WBC function (fighting infection) * Reduction in blood platelets means clotting ability is reduced * Clients with chronic leukemia have: * Increase susceptibility to infections * Decrease healing ability Spontaneous gingival bleeding * Acute forms have sudden onset and lead to death if not treated in a few months * Oral manifestations include painful ulcerations, spontaneous gingival bleeding, dry mouth, and secondary infections Endocrine dysfunctions * Periodontal disease is associated with endocrine changes or endogenous sex hormone changes * Puberty associated gingivitis: dramatic increase in hormone levels causes gingival inflammation * Menstrual cycle associated gingivitis: significant observable changes especially at ovulation * Menopause: tissue can be fragile. May have osteoporosis with loss of alveolar bone Diabetes Mellitus Usually hyperglyce mic due to defect in insulin (hormone) secretions or insulin action * Either a relative or absolute lack of insulin or inadequate function of insulin * Type I (juvenile diabetes): absolute insulin deficiency * Type II (adult diabetes): most common * Insulin secretion may be lower or higher than normal * Cannot use insulin effectively * Oral findings: * Increased gingival inflammation * Periodontitis is more frequent and often more sever * Increase in tooth mobility * Decrease in saliva flow * Fruity (acetone) breath due to glucose in sulcular fluid * Delayed healing and an increased chance for oral candidiasis (thrush) Pregnancy Increase in gingival inflammation * Tissues are red, swollen * Can lead to periodontitis with loss of alveolar bone * Inflammation due to plaque * Due to increase in estrogen and progesterone * These can cause dilation of gingival capillaries and thus increase permeability and increase in gingival crevicular fluid. This allows for more bacteria to enter and form plaque Nutritional deficiencies * Healthy tissues depend on adequate supply of nutritive material * Hard or fibrous foods provide stimulation necessary for the maintenance of the PDL and alveolar bone and also stimulate the gingival tissues Vitamins| Function| Oral manifestations (deficiencies)|Vitamin A| Growth and bone development| XerostomiaHyperkeratosis of gingiva| Vitamin K| Synthesis of blood clotting factors| Prolonged bleeding| Vitamin D| Promotes absorption of calcium and phosphorus| Hypo-calcification of enamel, bone, dentin, and cementum| Vitamin B| Helps with growth and tissue regeneration and maintains integrity of the oral mucosa| Poor wound healing, gingival inflammation, angular chelosis| Vitamin C| Collagen formation, promotes healing| Blue to red gingiva, bleeding, loss of PDL support, poor wound healing| Infectious diseases * Acquired immune deficiency (AIDS) * Caused by HHHIV (human immunodeficiency virus) * Transmitted by: needle sharing, sexual activities , infected mothers to their newborns, transfer of blood, possibly saliva * HIV infects and eventually kills a wide range of cells but particularly ‘CD4-positive helper T cells’ * Helper T cells are thymus derived lymphocytes that promote certain immunologic reactions * The depletion of these helper T cells can result in severe immune-suppression that makes the person susceptible to any life threatening fungal, bacterial, and viral infections * Oral manifestations: * Hairy leukoplakia: usually on lateral border of tongue * Those with AIDS usually have rapidly progressive periodontitis Cardiovascular disease 1. Hypertension * Blood pressure exceeds 160/95 mmHg (systolic/diastolic) * Normal is 120/80 mmHg * Avoid elective treatment if uncontrolled * Typical medications are diuretics and vasodilators * Drugs often cause xerostomia 2. Cardiac arrhythmias * Irregular heartbeat * Often due to stress 3. Anticoagulant therapy * Blood thinners to reduce the risk of blood clots th at can block circulation to vital organs * Consult with doctor prior to seeing Instrumentation can cause prolonged bleeding * Usual medications are: a) Warfarin (Coumadin) (INR levels) b) Heparin c) Aspirin Psychological stress * Emotional stress is associated with an increased risk of developing periodontitis * Stress may induce secretion of Norepinephrine which may make the periodontal tissues more susceptible to damage from plaque Neurological disorders * Patients with nervous and neuromuscular diseases present with 3 basic problems: 1. Physical inability to perform adequate oral hygiene procedures due to a decrease in motor skills 2. May have a mental or physical inability to cooperate with the clinician 3.May have changes in oral tissues that increase the risk from dental disease * Ex. phenytoin-influenced gingival enlargement: gingival enlargement with administration of anticonvulsive drugs that are used to control seizures. Mechanism is not completely understood Oral Cancer * Most frequent type is squamous cell carcinoma, develops from epithelial cells * Strongly linked to tobacco and pipe smoking * Chronic use of snuff (smokeless tobacco) * Be suspicious of long standing un-healing sores (anything longer than 2-3 weeks) * Red or white lesions on the lips or in the mouth What you can do * A thorough head and neck examination should be a routine part of each patient’s dental visit.Clinicians should be particularly vigilant in checking those who use tobacco or excessive amounts of alcohol * EXAMINE your patients using the head and neck examination described here * TAKE A HISTORY of their alcohol and tobacco use * INFORM your patients of the association between tobacco use, alcohol use, and oral cancer * FOLLOW-UP to make sure a definitive diagnosis is obtained on any possible signs/symptoms of oral cancer The exam * This exam is abstracted from the standardized oral examination method recommended by the World Health Organization. The method is cons istent with those followed by the Centers for Disease Control and Prevention and the National Institutes of Health.It requires adequate lighting, a dental mouth mirror, two 2Ãâ€"2 gauze, and gloves; it should take no longer than 5 minutes Oral cancer screening Incidence and survival * Oral or pharyngeal cancer will be diagnosed in an estimated 30,000 Americans this year, and will cause approximately 8,000 deaths. On average, only half of those with the diseases will survive more than five years The importance of early detection * Early detection saves lives; deaths from oral cancer could be dramatically reduced. The five-year survival rate for those with localized disease at diagnosis is 76% compared with only 19% for those whose cancer has spread to other parts of the body.Early detection of oral cancer is often possible. Tissue changes in the mouth that might signal the beginnings of cancer often can be seen and felt easily Warning signs 1. Lesions that might signal oral cancer * Two lesions that could be precursors to cancer: a) Leukoplakia (white lesions) b) Erythroplakia (red lesions) * Although less common than leukoplakia, erythroplakia and lesions with erythroplakic components have a much greater potential for becoming cancerous * Any white or red lesion that does not resolve itself in two weeks should be reevaluated and considered for biopsy to obtain a definitive diagnosis 2. Other possible signs/symptoms of oral cancer A lump or thickening in the oral soft tissues * Soreness or a feeling that something is caught in the throat * Difficulty chewing or swallowing * Ear pain * Difficulty moving the jaw or tongue * Hoarseness * Numbness of the tongue or other areas of the mouth * Swelling of the jaw that causes dentures to fit poorly or become uncomfortable * If the above problems persist for more than two weeks, a thorough clinical examination and laboratory tests, as necessary, should be performed to obtain a definitive diagnosis * If a diagnosis cann ot be obtained, referral to the appropriate specialist is indicated Risk factors 1. Tobacco /alcohol use * Increases the risk of oral cancer Using both tobacco and alcohol poses a much greater risk than either substance alone 2. Sunlight * Exposure to sunlight is a risk factor for lip cancer 3. Age * Oral cancer is typically a disease of older people usually because of their longer exposure to risk factors * Incidence of oral cancer rises steadily with age, reaching a peak in persons aged 65-74 * For African americans incidence peaks about 10 years earlier 4. Gender * Oral cancer strikes twice as often as it does women Oral changes due to drugs 1. Xerostomia: dry, smooth, shiny mucosa * Diuretics (Dyazide) * Histamines (Benadryl) * Antidepressants (Tofranil) * Antihypertensive (Seroasil) 2.Glossitis/Stomatitis: lesions o the tongue; small multiple ulcers * Anticoagulants (Warfarin) 3. Lichenoid eruptions: white striations; red patched of ulcers * CNS drugs (Aldomet) * Diuretics (Las ix) 4. Oral candidiasis/thrush: multiple with patches * Antibiotics (Vibramycin) 5. Hairy tongue: elongations of filiform papillae * Antibiotics (Tetracycline) Dental hygienist’s role * Consult with other health care providers for clients with systemic factors * Hygienists may be in a position to recognize changes at an early stage * Cautions: 1. Heart attack: need to wait at least 6 months before treating 2. Pregnancy: must finish 1st trimester 3.Cancer: deep scaling could be open channel for infection to reach bone so treatment contraindicated during chemo and radiation 4. Medical histories * Antibiotics: a) What? b) How long? c) How much? * Cancer: a) How long ago? b) Advised against cleaning or pre-meds? * Kidney disease: a) On dialysis? b) How long has treatment been going on? c) Pre-med? * Blood thinners: a) Advised against cleanings? b) What are they on? c) Dose? d) How long on meds? e) Date of last work up? The diseases of the gingiva (chapter 6) Gingivitis * Inflamma tion of the gingival tissue with no apical migration of the junctional epithelium beyond the cementoenamel junction (CEJ) * Manifests as: Color change (red/pink-red) * Edema (swelling of tissues) * Exudates (pus) * Tendency to bleed readily * Major indicators of gingivitis are: * Bleeding in response to gentle probing * Clear gingival fluid flow, or exudates, which appears to increase with the severity of the gingivitis * Gingivitis appears directly related to the amount of plaque on the tooth surface and the amount of time that the plaque is allowed to remain undisturbed- the plaque is considered nonspecific because it is not associated with any specific type of microorganisms Three stages of gingivitis 1. Stage I gingivitis: (initial or sub-clinical) * No clinical signs yet Occurs in the first few days of contact between microbial plaque and gingival tissues * Is an acute inflammatory response characterized by dilation of the blood vessels * PMN (neutrophils) are the principal def ense in acute inflammation- they phagocytoze (engulf) bacteria and their products * Small amounts of plasma leak into surrounding tissues causing edema * Exudate from early gingival inflammation is composed mostly of serum and it is referred to as ‘gingival fluid flow’- the fluid is clear, not yellow like pus, because few cells are present at this point * Lymphocytes will also appear at this stage (almost all are T-lymphocytes) * Collagen degradation will start to occur (collagen will start to break down) 2. Stage II gingivitis (early stage) * These lesions begin to form 4-7 days after plaque has accumulated in the gingival sulcus * Increase in T-lymphocytes- they are localized in the connective tissue under the epithelium of the gingival sulcus * Exudates increases and may appear white or yellow Clinically tissues will appear slightly red and swollen * Collagen fibers in connective tissue is destroyed by the inflammation and is replaced by blood plasma and inflammatory cells * Collagen fibers that attach the underlying connective tissue to the junctional epithelium are also destroyed * Gingival stippling if present, will begin to disappear causing the gingiva to appear shiny * The junctional epithelium will slightly start to lengthen against the root surface * Bleeding will occur upon probing * This stage may continue for 21 days or longer * It is the earliest clinical evidence of gingivitis 3. Stage III (established stage) * Occurs between 15-21 days * T and B lymphocytes are found in equal amounts indicating that tissue destruction by the inflammatory reaction is taking place * More collagen destruction during this stage * Junctional epithelium also continues lengthening Clinical probing depths will increase for 2 reasons: a) Probe can penetrate deeper due to collagen destruction b) Edema causes swelling of tissue and therefore may present as a deepening of the pocket * The increase of blood vessels and inflammatory cells in that area will caus e visible plus formation * Capillary proliferation also causes the gingiva to appear red * Tissues may appear cyanotic (blue) in extreme cases of congested blood cells within the gingiva * The presence of many O2 depleted RBC’s give the bluish color * This stage can persist for many months or years Summary of stages Stage| Clinical signs| Pathogenic events|Stage I (Initial) | * None| * Blood vessels * Polymorphonuclear (PMN’s) leukocytes migrate into CT * Plasma leaks into CT * Gingival fluid exits pockets * T-lymphocytes predominate| Stage II (Early)| * Gingiva may redden * Stippling disappears * Exudates may appear * Bleeding usually occurs on probing| * T-lymphocytes increase * Cells congregate under sulcular epithelium * Gingival fluid increases * Collagen is destroyed * Lengthened JE is disrupted * Fibroblasts destroyed| Stage III (Established)| * Gingiva is redden * Gingiva may appear blue-red * Probing depths increase * Pus forms * Tissue swells| * Capillaries p roliferate * T and B lymphocytes occur in equal numbers * Extensive collagen destruction * JE thickens and rete pegs extend into the CT * Plasma cells infiltrate * Edema increases| Microbiology review * The mature plaque found in long-standing gingivitis has a large % of gram-bacteria (this change from gram (+) plaque associated with health, to predominantly gram (-) plaque, or pathogenic plaque is a characteristic of gingivitis) Types of gingivitis 1. Plaque associated gingivitis * Most common form of gingivitis in general population Directly related to presence of bacterial plaque on tooth surface * Clinically, gingivitis causes a redden gingival margin, with pocket formation as a result of gingival swelling and edema, hypertrophy, and deepened penetration of periodontal probes on clinical evaluation * Surface of the gingiva may appear glazed or smooth, and stippling when present in health, usually disappears; microscopically there is an increase in capillaries along the gingival margin, and the epithelium lining in the sulcus is ulcerated when periodontal probe is placed in the crevice 2. Necrotizing ulcerative gingivitis * A disease that occurs occasionally in young adults Is a periodontal disease that can occur with NO BONE LOSS and a bacterial component * Related to excess stress-common outbreaks at universities and colleges * Very painful * AKA ‘trench mouth’ widespread among soldiers in WWI (stress or poor oral hygiene) * Sudden onset of burning mouth and inability to eat * Disease most commonly begins in the interdental papillae after a few days, the tips of the papillae appear punched out and covered by a white necrotic pseudomembrane * Attached gingival tissues usually appear inflamed * Often a distinctive odor termed ‘fetor oris’ that is unique to the disease * There is a presence of two microorganisms a) Fusiform bacillus b) Spirochetes * May have a fever Antibiotics (penicillin and metronidazole) are useful in treatment, but only if the patient has systemic symptoms of fever and severe malaise * Treatment is to completely debride the tissues of plaque and to begin a home regiment of plaque control * Careful debridement with curettes or ultrasonic scaler can be performed over a few appointments; after appointment can rinse with a dilute solution of hydrogen peroxide and warm water * Untreated, this disease may lead to bone loss and become Necrotizing Ulcerative Periodontitis (NUP) or periodontitis 3. Endocrine-influenced gingival disease * Gingivitis is often influenced by steroid-type hormones produced by the endocrine glands. These include: a) Puberty b) Pregnancy: several changes in the gingiva have been associated 1. As hormone levels increase during 2nd trimester, gingival inflammation may * Increase, even with good plaque control The gingiva may be come dark red or hyperplastic and may bleed excessively * Changes may occur as the pregnancy progresses but most improves with good home care and r emoval of irritants- some not till after the baby is born 2. Some may also get a pregnancy tumor-tissue is highly inflamed, bleeds easily, and may cause teeth to become mobile * When female hormone levels are increased, there is an increase in some subgingival bacteria, such as bacteroids species, and gingival inflammation may be greater * Estrogen may also regulate cellular proliferation, keratinization, and vascular proliferation, and vascular fragility in the gingival tissues * The extent of hormone related changes is related to the level of plaque control- poor plaque control aggravates the condition 4. Drug-induced gingival enlargement Various medications can cause changes in gingival tissue * Anti-seizure meds most commonly associated with gingival overgrowth * Gingival tissue may become fibrotic and enlarged (enlargement may be caused by changes in the epithelial cells and the fibroblasts that create a more dense CT) * Overgrowth begins with interdental papillae which enlarge until they coalesce involving all of the attached gingiva * An increase in bacterial plaque causes an increase in gingival overgrowth in patients taking these medications-excellent plaque control is needed here * Patients may have heavy calculus and increased levels of inflammation because of plaque retention * Treatment requires good oral home care, regular debridement, root planning, and often surgical reduction of the enlargements * Some cardiac meds also cause overgrowth-include nifidine and verapamil used to control BP * Cylcosporine (immunosuppressant in transplant patients) also causes gingival overgrowth; also used to treat MS; can cause excessive accumulation of CT in many other tissues of the body Plaque induced gingivitis can be modified by: crowded teeth, restorations, orthodontic appliances, etc Gingival disease can be modified by malnutrition: vitamins A, B1, B2, B6, and C The Diseases of the supporting tissues of the periodontium (chapter 7) Periodontal disease * Bro ad term referring to any disease of the tissues surrounding teeth * 2 basic classifications: 1. Gingivitis 2. Periodontitis Periodontitis: an inflammatory disease of the periodontium characterized by the loss of connective tissue attachment, destruction of bone, and possible tooth mobility * Periodontal pockets: a clinical manifestation of tissue destruction associated with bone loss (apical migration of sulcus) Periodontitis: pathogenesis of periodontal pockets 1. Bacterial challenge from plaque biofilm * In the early stages of periodontitis, the bacterial flora of the gingival pocket is similar to that of gingivitis * As the disease becomes more sever, the flora become more complex 2. Connective tissue loss * Associated with enzymes secreted by healthy and inflammatory cells (collagenase degradation) * Phagocytosis of collagen by fibroblasts 3. Epithelial cells proliferate and migrate apically 4. Junctional epithelium detaches from root surfaces * As it becomes engorges with infla mmatory cells 5.Gingiva swells and moves coronally from increased amount of cellular and serum elements 6. Epithelial lining of pocket loses integrity * Leukocytes and products of inflammatory response escape into pocket space and in opposite direction the tissue is permeable to bacterial products * This process results in a periodontal pocket the patient cannot clean adequately. This the disease cycles as follows: * Biofilm > gingival inflammation > pocket formation >biofilm formation * Exposed cementum absorbs bacterial products and becomes soft and necrotic * Repair is minimal unless necrotic tissue is removed by root planning Periodontitis: microbiology The continued presence of pathogenic plaque bacteria causing the inflammatory process to extend into the PDL, cementum, and alveolar bone leading to the loss of attachment of the gingiva to the tooth and the loss of supporting bone * The predominant organisms are gram – anaerobic rods * P. gingivalis seems to be the most i mportant periodontal pathogen based on its numeric presence (highest in numbers) Periodontitis: spread * Two mechanisms have been proposed for the initiation of the spread of infection 1. The bacteria and their products may break down the wall between the junctional and sulcular epithelium and cause detachment of the JE 2.The bacteria products may interfere with the normal growth and maintenance of the junctional and sulcular epithelium permitting it to break down * In either case, as inflammation progresses the sulcular epithelium increases in thickness and begins to infiltrate into the underlying connective tissue * Pockets deepen because of the breakdown of collagen fibers by enzymes such as collagenase, which is released by some of the plaque bacteria and the hosts inflammatory response * Because bone is an active tissue with continuous resorption and formation it is not possible to determine histologically exactly when bone loss has occurred as a result of periodontitis * When bone resorption exceeds apposition, a net decrease in the amount of bone occurs Periodontal bone loss The loss of crestal alveolar bone through the inflammatory process * Osteoclast bone resorption is driven by plaque and most derived mediators such as bacterial enzymes, prostaglandins, interleukins, and tumor necrosis factor * When disease established, plasma cells and lymphocytes present * Plasma cells important in antigen-antibody reactions which activates events attracting additional inflammatory cells * These cells cause additional destruction of collagen fibers * Bacteria stimulate lymphocytes which release lymphokines * Lymphokines have many effects on inflammatory system including production of chemical factors that activate osteoclasts * Osteoclasts increase osseous resorption Types of bone loss 1. Horizontal: Occurs when entire width of interdental bone is resorbed evenly 2.Vertical: Defect produced when interdental bone adjacent to root surface is more rapidly resorbed, l eaving angular uneven morphology Two types of periodontal pockets * Describes relationship of pocket to crestal bone 1. Suprabony: base of pocket occurs above the crest of the alveolar bone 2. Infrabony: pocket base is apical to crest of alveolar bone Clinical attachment loss * Total attachment loss from CEJ * Combines recession and probing depth (pocket depth) (only exists when recession is present) * Provides more complete assessment of loss of support than probing alone * Why? Crest of alveolar bone is not at CEJ but 1-2 mm apical to it * Page 131 figure 7-2 Furcation * When attachment lose occurs vertically and horizontally between toots of multi-rooted teeth Etiology As in gingivitis, plaque biofilm is the principle cause of all forms of periodontitis * Therefore, treatment directed at its elimination or reduction * The composition of the flora differ significantly from patient to patient and from pocket to pocket, as does patients susceptibility to it * This variability makes causes of periodontitis less obvious than plaque biofilm + gingivitis relationship * All conditions that retain biofilms or prevent its removal play significant roles as they do in gingivitis * In addition, deeper periodontal pockets house greater amounts of subgingival plaque that is impossible for the patient to remove * Most patients with periodontitis have high proportions of anaerobic gram –ve bacteria Classification of periodontal disease * American academy of periodontology * Periodontitis can be: * Localized (? 30% of involved sites) * Generalized (> 30% of involved sites) The defining element for classifying periodontal disease is probing depth, the level of attachment loss from the CEJ indicates bone loss * Page 130 box 7-2 Chronic periodontitis * Most common form of periodontal disease * Bacterially induced inflammation of the periodontium * True periodontal pockets result from apical migration of JE * A degree of false pocketing resulting from gingival edema or fi brosis is commonly present * Characterized by bone resorption that progresses slowly and predominantly in a horizontal direction * May have pre-clinical onset in adolescence and if not halted by therapy it appears to progress continually for life * Usually not clinically significant until 35 years of age may occur at any age * More common in males than females Severity of this disease is directly related to the accumulation of plaque and calculus on the surface of the teeth * Preventable! (not associated with abnormalities in host defense) * Rate of periodontal destruction varies depending on disease activity and patient’s resistance * Can be localized or generalized * Progresses slowly until teeth are lost by exfoliation or extraction * Appears to occur in episodic bursts (can be quiet and then rapidly comes on) * Progresses in the presence of dental plaque * Disease activity halts or stops when the host resistance controls the disease process through therapy or natural defe nses * Classified as slight, moderate, or severe Aggressive periodontitis Applied to those periodontal diseases that progress rapidly with massive bone loss * Attachment loss > 1mm/year is considered to be an aggressive type * Can be localized or generalized * Often associated with young people * Microbiology similar to chronic periodontitis Types of aggressive periodontitis * Early onset periodontitis (page 137-140) 1. Prepubertal periodontitis * Rare; may affect 1o or 2o with bone severe gingival inflammation, rapid bone loss, early tooth loss 2. Juvenile periodontitis * Localized juvenile periodontitis (usually 2o molars and incisors, minimal plaque and calculus, AA) * Generalized juvenile periodontitis (rarer, heavy calculus and plaque, p. gingivalis +E corrodens with AA) * Rapidly progressive periodontitis (page 140-142) * Refractory periodontitis (page 142) Unresponsive to thorough and varied periodontal treatments) Class VI: periodontitis as a manifestation of systemic diseas e 1. Associated with hematologic disorders 2. Associated with genetic disorders 3. Not otherwise specified Class IV: periodontitis as manifestation of systemic disease * Lesions associated with HIV: * Oral candidiasis * Karposi sarcoma: type of oral cancer usually seen on the palate * A malignant neoplasm associated with HIV infection and manifesting as brown or purplish tumors on the gingiva near the teeth or on the skin * Xerostomia * Unilateral/bilateral swelling of the salivary glands * Gingivitis * Spontaneous bleedingClass V: necrotizing periodontal disease 1. NUG: necrotizing ulcerative gingivitis 2. NUP: necrotizing ulcerative periodontitis * Necrotic gingival tissue-pseudo membrane * Pain * Fetid breath odor * Punched out papillae * Gingival bleeding * Progression of NUG * Bone loss AND connective tissue attachment loss Class IV: abscess of periodontium * Acute localized purulent infection * Usually untreated choric periodontitis * Pockets’ pathogenic bacteria become s occluded (cannot escape) * Associated with rapid bone loss * Requires immediate attention * Untreated- seeks drainage route and becomes chronic * Episodes of localized swelling * Periocoronitis is associated with the 8’s Treatment involves debridement and systemic antibiotics Class VII: periodontitis associated with endodontics * Periodontal pocket can progress to join an endodontic lesion * Treatment: endodontic therapy must be completed before scaling Class VIII: developmental or acquired deformities and conditions The role of abnormal occlusion and jaw dysfunction in periodontal treatment (chapter 10) Normal * Occlusal function- the dynamic state during talking, chewing, swallowing * Orthofunction: the state if morphofunctional harmony in which the forces developed during function are within adaptive range; means health and comfort with no pathological change Abnormal Dysfunction is a state of morphofunctional disharmony in which forces developed during mastication cause pathogenic/pathologic changes in tissue Role of abnormal occlusion and jaw dysfunction * These changes can cause bone loss * Poor occlusion alone does not cause or create periodontitis, it only exacerbates it * Antiaxial forces directed along tooth and periodontium can cause resorption or a hypertrophic response * Some areas will break down, others show no injury Factors * Certain factors affect the response of teeth and periodontal structures to normal and abnormal functions: * Size/shape of roots * Quality/quantity of alveolar bone * Presence of plaque * Missing teeth * Oral habits (parafunctional activity ie. grinding and clenching) Parafunctional activity 1. Bruxism Grinding or gnashing of teeth when not chewing or swallowing , usually during sleep * May lead to acute pulpitis, wear faucets, occlusal trauma, and muscle fatigue (summed up in periodontal injury, pain and jaw discomfort) 2. Clenching * Clamping and forcing the teeth together without grinding 3. Crepitation (crepit is) * A grinding noise in the TMJ from damage to the disc and articulating joint surfaces Traumatic occlusion * An occlusion that has caused injury to the teeth, muscles or TMJ * Primary traumatic occlusion is made when heavy occlusal forces exceed the adaptive range causing injury to tissues and bone * Secondary traumatic occlusion is made when normal forces exceed capability of a periodontium already affected by periodontal disease (ie. denture wear or lack) Assessing TMJ/occlusal dysfunction 1. Muscle palpation Normal muscles are equal in length and they should contract and relax without discomfort or pain * Myalgia is a pain in the muscle 2. Mandibular movement * Normal opening/closing of the jaw should be smooth and symmetrical * On average a person should be able to open about 40 mm * Page 222 and 223 3. Assessing occlusion * There should be a firm well disturbed pattern of occlusal contacts * Observe the patient opening and closing * You should note on closing any deviation t o the left or right * The posterior teeth should have even contact and maximum inter-cuspation * Anterior teeth should have light to no contact 4. Radiographic evaluation These changes from excessive forces can be observed in periapical films * Widening of PDL (caused by resorption of bony support) * Increased density of surrounding bone (hypertrophic response) * Increased cementum at apices (hypertrophic response) 5. Subjective questionnaire * Screens for patient reported signs and symptoms * Several questions assessing pain, noises, comfort level, headaches, injury, arthritis, previous treatment * Ex. questions page 221 Prevention is key * Attention to form and function of aspects of head and neck: * Form: morphology of teeth, bones, and TMJ * Function: morphology including neuromuscular system * Masticatory system is complex but adaptive to function When adaptive capacity exceeded, dysfunction ranges from discomfort to debilitation Temporal Mandibular Disorder (TMD) * Group of mu sculoskeletal conditions that produce pain or dysfuction in the masticatory system * When it involves muscles and not joint, it is referred to as extracapsular * When it involves the TMJ, it is referred to as intracapsular Etiology * Multifactorial therefore difficult to diagnose and treat * Stress * History of other diseases: arthritis and psychological problems * Car accident * Sports injury Microtrauma * Number of minor habits or events that cause damage to masticatory structures: * Bruxism * Postural habits * Oral habits (pen, pin, nail holding, nail biting, etc. Symptoms of temporal mandibular disorder (TMD) * Pain and tenderness in the muscles of mastication * Pain and tenderness in the TMJ * Painful clicking of the joint during function * Limitation of mandibular motion * You may also see muscle swelling and patient may complain of ringing in the ears * Arthralgia: pain in a joint structure Consideration for treatment * Short appointments * Aids during treatment- bite blocks to help keep mouth open * Home care suggestions- small tooth brush heads * Post treatment care- no gum chewing, possible medication, soft diet, warm towel * Frequent recalls Clinical Assessment (chapter 8) Clinical assessment of periodontal disease Assessment: represents the 1st phase of the dental hygiene process, provides the foundation for the subsequent diagnosis, planning, implementation, and evaluation of dental and dental hygiene care * Data collection: a systemic process of collecting information from multiple sources to help evaluate the health status of the patient. An example of data collection is the medical history * Documentation: this is the information gathered during the assessment and is a reference tool, an historical record; also has a medical and legal function * Examination: includes extraoral and intraoral, oral hygiene, periodontal and dentition assessments * Evaluation: At this point, the patient’s current progress (or lack thereof), is compared with baseline data and the stated goal.The evaluation is used to determine if the patient should be re-treated, referred, or placed on a maintenance program * Interpretation: being able to decipher and understand your findings clinically or radiographically Examination of gingival tissues: clinical markers * Periodontal screening and recording system (PSR) * Was introduced in 1993 * Is a periodontal disease detection system * To be used in the screening process * A specifically designed probe is used * Bleeding, overhangs, defective margins, supra/subgingival calculus are assessed while pocket depth is measured * A PSR code is given to each sextant * The code that best describes the most periodontally involved tooth in a sextant is assigned to that sextant PSR scale Code| Description| | * Colored area of the probe remains completely visible * No calculus or defective margins are detected * Gingival tissues are healthy, with no bleeding on probing| 1| * Colored area of the probe remains c ompletely visible in the deepest probing depth in the sextant * No calculus or defective margins are detected * There is bleeding on probing| 2| * Colored area of the probe remains completely visible in the deepest probing depth in the sextant * Supra or sub gingival calculus is detected or defective margins are detected| 3| * Colored area of the probe remains partly visible in the deeper probing depth in the sextant| 4| * Color