Legal Issues Affecting the Healthcare Work place Research Paper

Legal Issues Affecting the Healthcare Work place - Research Paper Example Bullying can include a series of incidents when overt or covert aggression can be inflicted on a person through spreading of rumors, withholding data, blocking promotion, or inflicting psychological abuse through exclusion (Leonard, Norman, and Spring, 2009). Horizontal violence is also a form of bullying, but it involves non-physical acts of aggression between employees of similar hierarchical positions. It includes: criticizing, insulting, undermining, and bickering (Leonard, Norman, and Spring, 2009). Mobbing involves negative actions of a group directed towards one employee. Parties involved may be those of higher positions abusing those in power positions. Workplace abuse may either be physical through shoving, pushing, and be kicking, or it may also be verbal through berating or threatening; it may be active or passive, and it may also be directly or indirectly carried out. In healthcare, studies and reviews indicate that these workers are about 16 times more likely to suffer workplace violence as compared to other employees. Moreover, nurses who are often at the frontline of health services are subjected to abuse from family members of patients. These nurses are unavoidably exposed to these dangers because they are exposed to patients who have issues related to substance abuse, domestic violence, HIV/AIDS, mental health problems, and other social issues. In effect, the patient’s health issues and unfavorable conditions when they face nurses create dangerous scenarios for nurses.

Periodontal Diseases In Children Health And Social Care Essay

Periodontal Diseases In Children Health And Social Care Essay Periodontics is a vast subject by itself and a pediatric dentist is called upon to use the knowledge of the same while examining and planning the treatment of children and young adults. Contrasting forms of periodontal disease affect children and adolescents with varying prevalence, severity, and extent, leading to a diverse prognosis in these age groups. For an early diagnosis and treatment of periodontal conditions in young patients, it is essential to be able to identify and classify the disease correctly at the earliest applying the basic principles along with understanding of etiology and risk factors. A pediatric dentist is in a unique position to identify and distinguish between a seemingly innocuous condition that may be a normal physiological aberration or an early sign of severe destruc ­tive periodontal disease. Although severe destruc ­tive periodontal conditions are uncommon in children, however it is essential that children receive a periodontal screening as part of their regular dental examination. Early diagnosis ensures a high likelihood of a successful therapeutic outcome primarily by reduction of etiologic factors, remedial therapy and development of an effective maintenance protocol. This prevents the recurrence and progression of disease and reduces the incidence of tooth loss. Key Words: adolescents, aggressive, chronic, gingivitis periodontitis. Clinical Relevance: Incorporation of periodontal screening in regular dental examination by pediatric dentist can help in early diagnosis and treatment of periodontal diseases. This would prevent further progression of disease and reduce the frequency of tooth loss. Objective: The reader should understand the importance of periodontal screening, early diagnosis, proper treatment planning and effective maintenance plan to prevent the progression and recurrence of periodontal disease in children and adolescents. Different forms of periodontal disease affect children and adolescents. The diseases affecting the periodontium can be limited to the gingival tissues or can be associated with destruction of the periodontal ligament and alveolar bone. There have been various attempts to classify periodontal diseases. Various classifications have been developed over a period of time.1-4 Based on the World Workshop in Clinical Periodontics in 1989,3 the American Academy of Periodontology proposed a classification of periodontitis as a) adult periodontitis b) early-onset periodontitis c) Periodontitis associated with systemic disease d) necrotizing ulcerative periodontitis and e) refractory periodontitis. Early-onset periodontitis was further classified into a) pre-pubertal periodontitis (localized and generalized) b) juvenile periodontitis c) rapidly progressive periodontitis.(Table 1) Problems associated with the 1989 classification led to 1999 international workshop on the classification of periodontal diseases.4 A new classification system was proposed in 1999 and is presently the most accepted classification system of periodontal diseases. The periodontal diseases are classified as: 1) gingival diseases (plaque induced and non plaque induced) 2) chronic periodontitis (localized and generalized) 3) aggressive periodontitis (localized and generalized 4) periodontitis as a manifestation of systemic disease 5) necrotizing periodontal disease 6) abscesses of periodontium 7) periodontitis associated with endodontic lesions and 8) developmental and acquired deformities and conditions.(Table 1) In the new classification4 adult periodontitis was changed to chronic periodontitis and juvenile periodontitis to aggressive periodontitis. These changes were made to eliminate the age-dependent criteria. Chronic periodontitis was considered less age-dependent description than adult periodontitis. The term early-onset periodontitis was discarded as this form of disease can occur in children, adolescents and adults. Localized aggressive periodontitis replaced the older expression localized juvenile periodontitis or localized early-onset periodontitis. Generalized aggressive periodontitis replaced generalized juvenile periodontitis or generalized early-onset periodontitis.(Table 2) Table 1 1989 Classification Of Periodontal Diseases 1999 Classification Of Periodontal Diseases Gingival diseases (Plaque induced and Non- Plaque Induced) Adult periodontitis Chronic periodontitis (Localized and Generalized) Early-onset periodontitis Aggressive periodontitis (Localized and Generalized). Periodontitis associated with systemic disease Periodontitis as a manifestation of systemic disease Necrotizing ulcerative periodontitis Necrotizing periodontal disease Refractory periodontitis Abscesses of periodontium Periodontitis associated with endodontic lesions Developmental and acquired deformities and conditions The categories of refractory periodontitis and rapidly progressive periodontitis were eliminated because of their heterogeneity. Prepubertal periodontitis was also eliminated as it was not perceived to be a single entity. Many severe periodontitis cases in children are caused due to presence of a systemic disease/s.5,6 (Table 2). Various studies show that gingivitis is prevalent in children and adolescents.7-11 Studies have indicated that attachment loss and supporting bone loss is infrequent in the young but that the incidence increases in adolescents aged 12 to 17 when compared to children aged 5 to 11.11-13 A study conducted on schoolchildren demonstrated that the prevalence and extent of gingivitis increased with age.14 Gingivitis starts in the deciduous dentition and reaching a peak at puberty. Gingivitis reduced during adolescence and followed by a gradual rise throughout adult life.15 The increase in gingivitis levels may be ascribed to the increase in sites at risk, plaque accumulation and inflammatory changes related with tooth eruption and the influence of hormonal factors in puberty. The decline in gingivitis in adolescence may be due to improved social awareness and enhanced oral hygiene.16 Table 2 Changes introduced in 1999 classification in comparison to 1989 Classification Of Periodontal Diseases A category of Gingival diseases (Plaque induced and Non- Plaque Induced) was introduced. Gingival diseases were not represented in 1989 classification. The term Adult periodontitis changed to Chronic periodontitis to eliminate the age-dependent criteria. The term Early-onset periodontitis was replaced by Aggressive Periodontitis to eliminate the age-dependent criteria. Localized juvenile periodontitis or localized early-onset periodontitis was replaced by Localized aggressive periodontitis. Generalized juvenile periodontitis or generalized early-onset periodontitis was replaced by Generalized aggressive periodontitis. Refractory periodontitis and rapidly progressive periodontitis eliminated because of their heterogeneity Prepubertal periodontitis was also eliminated as severe periodontitis cases in children are caused due to presence of a systemic disease/s. Prevalence of periodontitis in the deciduous dentition is difficult to estimate because of scarcity of data. Exfoliation and eruption can lead to undependable information. A low prevalence of marginal bone loss in the deciduous dentition is found in children of European origin in comparison to Asian children.17,18 The prevalence of early onset periodontitis in blacks was 2.1% 19- 2.6%.20 The prevalence rate for whites was 0.17%.20 In a survey in the United States, no significant difference was found in prevalence rates between males and females.20 Black males and white females were approximately three times more likely to have localized early-onset periodontitis than black females and white males respectively.20 Periodontitis in the deciduous dentition is generally clinically insignificant, severe generalized periodontitis may be found in young children with rare systemic diseases, such as Papillon-Lefevre syndrome, cyclic neutropenia, agranulocytosis, Downs syndrome, hypophosphatasia and leukocyte adhesion deficiency.21 Periodontal diseases that can affect young individuals include: 1) dental plaque-induced gingival diseases; 2) chronic periodontitis; 3) aggressive periodontitis; 4) periodontitis as a manifestation of systemic diseases; and 5) necrotizing periodontal diseases.22 However few other diseases like primary herpetic gingivostomatitis may also affect children.(Table 3) Table 3 Periodontal diseases affecting children and adolescents Dental plaque-induced gingival diseases Chronic periodontitis Aggressive periodontitis Periodontitis as a manifestation of systemic diseases Necrotizing periodontal diseases Dental plaque-induced gingival diseases: Definition: Plaque-induced gingivitis is defined as inflammation of the gingiva in the absence of clinical attachment loss.23 Gingivitis associated with dental plaque only: Chronic marginal gingivitis is the most prevalent type of gingival change in childhood. Dental plaque causes inflammation within the gingival tissues which manifests as clinical signs of gingivitis. The gingival diseases associated with plaque, endogenous hormonal fluctuations, drugs, systemic diseases, and malnutrition have numerous universal characteristics. The universal features of these gingival diseases include clinical signs of inflammation, signs and symptoms that are restricted to the gingiva, reversibility of the diseases by removing the etiology, the presence of bacterial plaque to initiate and intensify the severity of the lesion, and a potential role as a precursor to attachment loss.24 (Table 4). Table 4 Universal features of gingival diseases Clinical signs of inflammation Signs and symptoms that are restricted to the gingiva, Reversibility of the diseases by removing the etiology. Presence of bacterial plaque to initiate and intensify the severity of the lesion. A potential role as a precursor to attachment loss The features of plaque-induced gingivitis24 are 1) plaque present at gingival margin; 2) disease begins at the gingival margin; 3) change in gingival color;25,26 4) change in gingival contour;25,26 5) sulcular temperature change;27 6) increased gingival exudate;28 7) bleeding upon probing;25 8) absence of attachment loss; 9) absence of bone loss; 10) histological changes including an inflammatory lesion; 11) reversible with plaque removal. Subgingival levels of Actinomyces sp., Capnocytophaga sp., Leptotrichia sp., and Selenomonas sp. have been found to be increased in experimental gingivitis in children when compared to gingivitis in adults.29 Gingival Diseases Modified by Systemic Factors Associated with the Endocrine System: Hormonal changes affect the periodontal diseases, although bacterial plaque is essential to initiate gingival disease. Puberty-Associated Gingivitis: The rise in steroid hormone levels during puberty in both sexes has a transitory effect on gingivitis.30 There is an increase in gingival inflammation in circumpubertal age individuals of both sexes without a simultaneous increase in plaque levels.31-33 The predilection to develop candid signs of gingival inflammation in the presence of relatively small amounts of plaque during the circumpubertal period differentiates the disease. The incidence and severity of gingivitis in adolescents are also influenced by dental caries, mouth breathing, crowding of the teeth, and tooth eruption.34 Diabetes Mellitus-Associated Gingivitis: Diabetes mellitus-associated gingivitis is found in children with poorly controlled Type 1 diabetes mellitus (insulin-dependent diabetes mellitus or juvenile onset).35,36 The features of gingivitis associated with diabetes mellitus are similar to plaque-induced gingivitis. The level of diabetic management is an significant characteristic than plaque control in the severity of the gingival inflammation.35,36 Gingivitis is frequently associated with tooth eruption. Tooth eruption by itself does not cause gingivitis. The inflammation results from plaque accumulation around erupting teeth. Partially exfoliated, loose deciduous teeth often cause gingivitis due to plaque accumulation. The incidence and severity of gingivitis is more around malpositioned teeth because of their increased tendency to accumulate plaque.37 Periodontitis: Periodontitis irrespective of the specific classification show irreversible loss of connective tissue attachment and apical migration of the junctional epithelium and true pocket formation. The correct diagnosis of the different types of periodontitis is important as the management of periodontitis depends on the correct diagnosis. Incipient and incidental attachment loss A precursor to periodontitis: The terms incipient attachment loss38,39 and incidental attachment loss38,39 have been used to describe loss of support in adolescents. A loss of attachment >1 mm and early alveolar bone loss are prevalent and can affect a sizable proportion of adolescents.40-41 The term incipient is used to describe the initial stage of adult type periodontitis (chronic periodontitis) and a working definition is the presence of loss of attachment >2 mm that is not related to gingival recession.39 The term incidental attachment loss was used by Là ¶e Brown in relation to early-onset (aggressive) periodontitis in adolescents.20 It was suggested that it may correspond to an initial phase of an early-onset juvenile periodontitis or even be incidental to other factors. There is prevalence of attachment loss in adolescents that does not fit the categorization of localized early-onset periodontitis and/or generalized early onset periodontitis.38,42 The category of incidental attachment loss includes individuals who do not fit the criteria for diagnosis of either localized early-onset periodontitis or generalized early-onset periodontitis, but show à ¢Ã¢â‚¬ °Ã‚ ¥4 mm of attachment loss on one or more teeth.39 An epidemiological survey of early-onset periodontitis in 14 to 17 years old adolescents used attachment loss of à ¢Ã¢â‚¬ °Ã‚ ¥3 mm as the cut-off for diagnosis and found that 71% of the incidental early-onset periodontitis group had one site affected and 97% had three or less affected sites.42 The definition of incidental attachment loss can be used to classify individuals with few sites affected by abnormal attachment loss, not associated with local causes such as proximal caries or overhanging restorations. Chronic periodontitis: Definition: Chronic periodontitis is defined as inflammation of the gingiva extending into the adjacent attachment apparatus. The disease is characterized by loss of clinical attachment due to destruction of the periodontal ligament and loss of the adjacent supporting bone.43 Clinical Features:44(Table 5) 1. Chronic periodontitis is the most common form of periodontal disease in adults but can be found in children and adolescents affecting both the primary and secondary dentitions. 2. The amount of periodontal destruction is proportionate to local factors. 3. The composition of microbial plaque is complex and varies to a great extent within and between patients and subgingival calculus is a frequent finding. 4. Chronic periodontitis can be classified on the basis of extent of disease as localized when fewer than 30% of sites are affected, and generalized when this level is exceeded. 5. Chronic periodontitis can also be classified on the basis of the severity of the periodontal destruction. Disease is mild (1 to 2 mm clinical attachment loss), moderate (3 to 4 mm clinical attachment loss), or severe (à ¢Ã¢â‚¬ °Ã‚ ¥5 mm clinical attachment loss) 6. Although chronic periodontitis is initiated by microbial plaque, factors such as systemic risk factors including smoking, stress, diabetes, HIV and host factors influence the pathogenesis and progression of the disease. 7. Progression can only be confirmed by repeated clinical examinations and is considered likely to occur in diseased sites that are left untreated. It usually has slow to moderate rates of progression, but may have periods of rapid progression. Table 5 Clinical Features of Chronic periodontitis Most common form of periodontal disease in adults but children and adolescents also affected. The amount of periodontal destruction is proportionate to local factors. The composition of microbial plaque is complex and variable. Slow to moderate rates of progression with periods of rapid progression. Initiated by plaque but modified by systemic factors such as smoking, stress, diabetes, HIV and host factors. Extent of disease: Localized : 30% of sites involved. Severity of disease: Mild: 1-2mm of clinical attachment loss; Moderate: 3-4 mm of clinical attachment loss; Severe: à ¢Ã¢â‚¬ °Ã‚ ¥5mm of clinical attachment loss. Aggressive periodontitis: Definition: Aggressive periodontitis encompasses distinct types of periodontitis that affect people who, in most cases, otherwise appear healthy. It tends to have a familial aggregation and there is a rapid rate of disease progression. Aggressive periodontitis occurs in localized and generalized forms.45 Aggressive periodontitis can be classified as localized aggressive periodontitis and generalized aggressive periodontitis. Clinical Features:46 (Table 6) Primary features: Non-contributory medical history Rapid attachment loss and bone destruction Familial aggregation of disease Secondary features that are generally present but may not be present in all cases: 1) Amount of microbial deposits inconsistent with the severity of periodontal destruction. 2) Elevated proportions of Actinobacillus actinomycetemcomitans. 3) Phagocytic abnormalities 4) Hyper-responsive macrophage phenotype, including elevated production of PGE2 and interleukin-1ÃŽÂ ² in response to bacterial endotoxins. 5) Progression of attachment loss and bone loss may be self-arresting. The diagnosis may be made on historical, radiographic and clinical data. In addition to primary and secondary features common to all aggressive periodontitis patients, following features can be identified: Localized aggressive periodontitis: 1) Circumpubertal onset; 2) Localized first molar/incisor show interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors; 3) Robust serum antibody response. Generalized aggressive periodontitis: 1) Usually affecting persons under 30 years of age but patients may be older; 2) Generalized interproximal attachment loss affecting at least three permanent teeth, other than first molars and incisors; 3) Pronounced episodic nature of destruction of attachment and alveolar bone. 4) Poor serum antibody response. Chronic and aggressive periodontitis have numerous common clinical features, but the common features are not necessarily alike in both forms of the disease. It is well recognized that both chronic and aggressive periodontitis are complex infections that occur in susceptible hosts and are caused by biofilms.47-49 In addition, host immune response to the biofilms is largely responsible for periodontal destruction.50,51 Successful management of both forms of periodontitis includes reduction of bacterial load.52 The untreated disease invariably leads to loss of tooth. Table 6 Clinical Features of Aggressive periodontitis Primary features: Non-contributory medical history. Rapid attachment loss and bone destruction Familial aggregation of disease. Secondary features: generally present but not universal: Amount of microbial deposits inconsistent with the severity of periodontal destruction. Elevated proportions of Actinobacillus actinomycetemcomitans. Phagocytic abnormalities Hyper-responsive macrophage phenotype, including elevated production of PGE2 and interleukin-1ÃŽÂ ². Progression of attachment loss and bone loss may be self-arresting. Localized aggressive periodontitis: Circumpubertal onset Localized first molar/incisor involvement with interproximal attachment loss on at least two permanent teeth, one of which is a first molar, and involving no more than two teeth other than first molars and incisors. Robust serum antibody response. Generalized aggressive periodontitis: Usually affecting persons under 30 years of age but patients may be older; Generalized interproximal attachment loss affecting at least three permanent teeth, other than first molars and incisors; Pronounced episodic nature of destruction of attachment and alveolar bone. Poor serum antibody response. Similarities and differences in clinical features of chronic and aggressive periodontitis: One of the shared clinical characteristics of chronic and aggressive periodontitis is that affected individuals have no known medical or general health conditions that might contribute to development of their periodontitis. If an individual has a systemic disease that modifies the initiation and clinical course of periodontal infections, the resulting periodontitis should be classified as periodontitis as a manifestation of systemic disease.4 Chronic and aggressive forms of periodontitis have a number of significant clinical differences including: (i) age of onset; (ii) rates of progression; (iii) patterns of destruction; (iv) clinical signs of inflammation and (v) amount of plaque and calculus. The clinical differences are the primary basis for classifying individuals into one of the categories of periodontitis. A diagnosis is a summary statement of the clinicians best estimate regarding the disease or condition detected in a given patient. It is derived from a thorough analysis of all information collected during a review of relevant data from medical à ¢Ã‚ Ã¢â‚¬Å¾ dental histories, the results of diagnostic tests, and findings from a careful clinical examination.53,54 A diagnosis should be a short and concise statement that gives an idea of disease present in a specific patient. It provides a foundation about appropriate treatment approaches. The diagnosis may not precisely be according to the classification system. The exact definition of case is not a main issue in the management of specific patients in clinical practice, as the diagnosis is tailor-made for the individual.55 The clinical distinction between chronic and aggressive periodontitis may be difficult sometimes. This distinction becomes insignificant from a treatment viewpoint as anti-infective therapies are successful for bot h forms of the disease.55 Periodontitis as a manifestation of systemic diseases: Systemic diseases that predispose patients to highly destructive disease of the primary teeth, the diagnosis is periodontitis as a manifestation of systemic disease. This group is classified as:56(Table 7) Associated with hematological disorders: 1) Acquired neutropenia; 2) Leukemias; 3) Others. Associated with genetic disorders: 1) Familial and cyclic neutropenia; 2) Downs syndrome; 3) Leukocyte adherence deficiency syndrome; 4) Papillon-Lefà ¨vre syndrome; 5) Chediak-Higashi syndrome; 6) Histocytosis syndromes; 7) Glycogen storage disease; 8) Infantile genetic agranulocytosis; 9) Cohen syndrome; 10) Ehlers-Danlos syndrome (Types IV and VIII); 11) hypophosphatasia. Not Otherwise specified. Not otherwise specified includes diseases like osteoporosis and estrogen deficiency which have shown to affect periodontium but data regarding their effect requires confirmation. It was emphasized in the consensus report that other systemic conditions may be added after the evidence is available. Defects in neutrophil and immune cell function associated with these diseases may play an important role in increased susceptibility to periodontitis and other infections. Periodontitis as a manifestation of systemic disease in children is a rare disease that frequently begins between the time of eruption of the primary teeth up to the age of 5.57,58 In the localized form, affected sites exhibit rapid bone loss and minimal gingival inflammation.57 Quantitative (agranulocytosis or neutropenia) or qualitative (chemotactic or phagocytic) leukocytic deficiencies show evidence of severe annihilation of the periodontal tissues. Quantitative deficiencies are generally accompanied by destruction of the periodontium of all teeth, whereas qualitative defects are often associated with localized destruction affecting only the periodontium of certain teeth.59 Neutropenia. Patients present with a diverse periodontal manifestations. In the malignant form there is ulceration and necrosis of the marginal gingiva. Bleeding from gums is generally present and attached gingiva may get involved.60 In cyclic, chronic, and familial benign neutropenia the lesions show deep periodontal pockets and extensive, generalized bone loss involving the permanent dentition.61-63 Bone resorption may be seen in the deciduous dentition.64,65 Leukemia. Periodontal lesions have been frequently observed in patients with leukemia, particularly those with an acute form. Generalized gingival enlargement was apparent in 36% of the individuals with acute and in 10% of those with chronic forms.66 Gingival swelling due to infiltration by leukemic cells is a feature of acute monocytic leukemic.67 Gingival bleeding is also a common sign of the disease in both acute and chronic leukemia and may relate to the associated thrombocytopenia.68 Downs Syndrome. Patients with Down syndrome show a generalized early periodontitis, which commences in the deciduous dentition69,70 and continues into the adult dentition. The prevalence and severity of periodontal disease in individuals with Down syndrome is exceedingly high in comparison to their siblings71 or other mentally subnormal persons.70 Several studies have reported increased prevalence and severity of periodontal disease in children of older age groups.69,70 The periodontal destruction is most commonly seen around the incisor and molar teeth.69 The short roots of the mandibular incisors72 and the bone loss in the mandibular anterior region, can lead to the premature loss of these teeth.70 Leukocyte Adhesion Deficiency Syndrome. Defects in numbers of cell-cell adhesion receptors on the neutrophil surface may lead to increased inclination to periodontitis and other infectious diseases in conditions such as leukocyte adhesion deficiency syndrome.73 Young patients with leukocyte adhesion deficiency syndrome present with severe inflammatory periodontal disease.74-76 Leukocyte adhesion deficiency syndrome is a rare autosomal recessive disease. The disease is generally fatal and children with deficiencies in expression of the leukocyte function associated family of adhesins suffer from severe periodontal infections.73 Papillon-Lefà ¨vre Syndrome. Papillon-Lefà ¨vre syndrome is a disease with autosomal recessive inheritance.77 The disease shows signs of diffuse palmar-plantar keratosis with a severe generalized periodontitis, usually seen before puberty with early loss of deciduous and permanent teeth.78-80 A frequency of 1 in 4 million in the general population has been reported.80 25% have been reported to have an increased susceptibility to infection, and 33% have a history of consanguinity.79 Teeth are normally lost in the order of eruption.79 Haim Munk syndrome is also characterized by presence of palmoplantar hyperkeratosis and severe early-onset periodontitis. Genetic studies of the diseases exhibiting palmoplantar keratosis and early-onset periodontitis suggested that the gene defect in Haim Munk syndrome is not genetically linked to the more common forms of palmoplantar keratosis.81 It has been reported that there is a high degree of consanguinity in these families and that they are most likely part of the similar syndrome.82 Chediak-Higashi Syndrome. Chediak-Higashi syndrome is as an autosomal recessive disease associated with severe periodontitis.83,84 The people suffering from this disease are extremely susceptible to bacterial infections Neutrophil chemotaxis and bactericidal functions are abnormal in these patients. Generalized, severe gingivitis, extensive loss of alveolar bone, and premature loss of teeth are features commonly seen.85 Histiocytosis Syndromes. This group of diseases includes may affect infants, children, and adults. The periodontal lesions may clinically resemble necrotizing ulcerative periodontitis lesions. The lesions are punched-out necrotic ulcers with considerable granulation tissue, tissue necrosis, and marked bone loss. Biopsy of the granulation tissue can help in diagnosing the condition.86 Skeletal surveys and chest radiographs will assist in determining the extent of the disease. Glycogen storage disease. This is an autosomal recessive condition associated with defective carbohydrate metabolism. Clinical features include reduced neutrophil numbers, impaired neutrophil function and periodontal disease.87,88 Infantile genetic agranulocytosis. This disease presents with severe neutropenia and has been linked with periodontitis similar to the early-onset form. This is a rare autosomal recessive disorder.89,90 Cohens syndrome. This is also an autosomal recessive condition is characterized frequent and extensive alveolar bone loss.88 The patients also suffer from non-progressive mental and motor retardation, obesity, dysmorphia, and neutropenia.91 Ehlers-Danlos Syndrome. The Ehlers-Danlos syndrome is autosomal dominant disorder. Ehlers-Danlos syndrome is classified into 10 types and is characterized by defective collagen synthesis. Types IV and VIII have an increased susceptibility to periodontitis.92 Type VIII is linked with fragile oral mucosa and blood vessels. It is also associated with severe generalized periodontitis with manifestation of generalized early-onset periodontitis.93 Ehlers-Danlos syndrome type VIII has clinical similarity to the early-onset form, causing premature loss of permanent teeth.94 Hypophosphatasia. Patients present with decreased serum alkaline phosphatase levels. There is severe loss of alveolar bone and premature loss of the deciduous teeth.95-97 Premature loss of deciduous dentition primarily involves anterior region.97 Table 7 Periodontitis as a manifestation of systemic diseases Associated with hematological disorders: Acquired neutropenia; Leukemias; Others. Associated with genetic disorders: Familial and cyclic neutropenia; Downs syndrome; Leukocyte adherence deficiency syndrome; Papillon-Lefà ¨vre syndrome; Chediak-Higashi syndrome; Histocytosis syndromes; Glycogen storage disease; Infantile genetic agranulocytosis; Cohen syndrome; Ehlers-Danlos syndrome (Types IV and VIII); Hypophosphatasia. Not Otherwise specified Necrotizing periodontal diseases: Necrotizing periodontal disease

Physician-Assisted Suicide :: Euthanasia Death Suicide Essays

Introduction The history of physician-assisted suicide began to emerge since the ancient time. Historians and ancient philosophers especially had been debating over this issue. Thus, this issue is no longer new to us. However, it seems little vague because it has not yet been fully told. The historical story consists of patterns of thought, advocacy, and interpretation on whether to legalize assisted death. "Only until June, 1999, the United States Supreme Court issued decisions in two cases that claimed constitutional protection for physician-assisted suicide, Washington v. Glucksberg and Vacoo v. Quill, by a single 9-0 vote covering the case (Bartin, Rhodes, Silver, 1). They also say that this decision mark the beginning of long period debate, which will not be fully resolved (1). Hence, the debate began by professionals from different aspects, especially the physicians themselves. "I will never give a deadly drug to anybody if asked for it, nor will I make a suggestion to this effect". A frequent quoted portion of the Hippocratic Oath, written in Greece sometimes during the fifth to forth centuries B.C.E, represented an effort by an apparently small group of physicians to build public respectability by distancing themselves from other physicians who commit assisted suicide. It has had considerable influence in the history of Western medical society and now, once again, physician-assisted suicide has become a major ethical issue in medicine, as well as an issue that involves law and public interests. Of the various issues at the medicine issue, perhaps none has drawn as much attention as assisted suicide. This topic is being discussed with great frequency in newspaper, journals and books about whether it is really necessary and ethical to physicians to participate in this life-ending act. Proponents or advocates of physician-assisted suicide argue that each per son has freedom over their own life. Persons whose quality of life is nonexistent and who are having a terminal illness should have the right to decide to seek assistance. In contrast, opponents say that physician-assisted suicide is not an acceptable practice for the physicians legally as well as morally. This issue has become a central concern to the medical profession, legislators, philosophers, social psychologists, as well as the public. Interests in this controversial matter continue to grow increasingly whether it should be legalized. Perhaps everyone would have one's own thought and opinion. Nevertheless, assisted death is never a proper expression of compassion. It shows no care for the patients.

The Lorax 2

The Lorax Sequel By Georgia and Maddie â€Å"So†¦Catch! † calls the once-ler He lets something fall It’s a truffula seed It’s the last one of all You’re in charge of the last of the truffula seeds And truffula trees are what everyone needs Plant a new truffula, treat it with care Give it clean water and feed it fresh air Grow a forest protect it from axes that hack Then the lorax And all of his friends May come back. † So off ted went with the seed in his hand An idea in his head, and no greed in his planHe left for a place where the sky is blue With a small patch of sunlight That leaves the green grass new The clouds that filled the sky were a crisp white A place where the Swomee-Swans could take flight And the humming fish hummed in the rippulous pond While the Brown Bar- ba- loots played And sung in the shade â€Å"Excuse me! Excuse me! ‘Ted cried out ‘I need your help without a single doubt, To plant this Truffula seed to help i t grow We can work together its essential you knowWe could live in peace and learn to keep a balance Between the Truffula trees but also the Thneeds! I am a man of my word and a man of my deeds So let me help you and speak for the trees! ’ Slowly but surely the brown Bar-ba-loots peeked Out at this Ted that had made a loud squeak The humming fish glanced as the Swomee- Swans shrieked; ‘We’ll help you dear Ted plant your little Truffula seed! ’ As the Truffula tree slowly grew, More and more animals returned tooTo help little Ted and his crew Mature a forest creating a new world for me and you So let the word know, call them in We’ll live all together as kin In little huts up in those truffula tufts Where thneeds are still made And no trees will be slayed By taking those tufts a little And using nothing but whittle Leaving the tufts to restore In their glory and awe To create a balance that no one can flaw Up in the clouds The lorax did grin The plac e we created that is our greatest win

I Never Expected This Essay

Hey guys, I’m writing my English exam soon, and would really appreciate it if you can give me some suggestions one how to improve this piece. The word limit is 400~450, so I’m a little over the limit here. Topic is: This is the story of a young man/woman who was able to escape from a difficult past to make a success of his/her life. My essay: â€Å"This is the story of a young woman who was able to escape from a difficult past to make a success of†¦Ã¢â‚¬  I tuned off the school principal’s voice at this point, ignoring his excited gestures and flying spittle. I was eight then. The man came out of nowhere, and I remember pain, horror, screaming, torn clothes, more screaming†¦It was only afterwards, in the hospital, that I understood what had happened to me. Twenty years ago the society wasn’t exactly sympathetic towards rape victims; it still isn’t today. Principal Clarke’s voice pulled me back to reality. I stood up to the pitiful round of applause, and walked up the stage. As I looked down, half the students were dozing off; and most of the other half had a snicker on their face. I putted on a smile, and began to tell my story in a grave voice: how I struggled to live with my past; how my family gave me hope and support; how, after years of hard work, I finally became a bestselling author. It is a boring old story, nothing unheard of before. And if this speech managed to inspire even one of these students, it would be nothing short of a miracle. Of course, there are things that a high school guest speaker just cannot include in her speech. For example, the way my mother indulged in various substances after my â€Å"incident†, and my father and I never sent her to the rehabilitation centre for the fear of even more publicity. Or better, how I found my puppy strangled and hung from a tree one day, the words â€Å"WHORE† in red paint glistening right behind him. And the fact that my ex-boyfriend had left with all my money last year, leaving me too heartbroken to write is definitely unmentionable. If it was not for this, I would not have been stuck at this little school, allowing people to dig up my past for a minuscule payment in return. There are some things that a person simply cannot look past. I sat back down, and endured another hour of the old principal’s speech. Apparently, according to Principal Clarke, if I can live with been raped then the students can surely get over their teenage issues and focus on learning instead. His words are not what finally pushed me over the edge, though. It was his the way he looked at me – as if I am some pathetic, filthy stray dog. I caught his eyes when he turned towards me again, and smiled until he hurriedly looked away. The next morning I rose early, and in the aroma of fresh coffee listened to the radio news reporting the shocking, gruesome death of a certain high school principal. I hummed to myself, and started typing my new story.

ESL Lesson for Creating a New Product

ESL Lesson for Creating a New Product Nowadays, its common to talk about products, their functionality and marketing. In this lesson, students come up with a product idea, mock-up a design for the product and present a marketing strategy. Each student owns a step of the process in the final presentation to the class. Combine this lesson with a lesson on pitching a product and students can practice the essential elements of finding investors.   Aim: Learning vocabulary related to product development, developing team player skills Activity: Develop, design and market a new product Level: Intermediate to advanced level learners Lesson Outline Bring one of your favorite innovative products into class. Ask questions using the vocabulary terms provided in the product vocabulary reference. Give examples for your questions such as: What functionality does this phone have? - You can surf the internet, send email, and download apps. to help students with understanding.Once youve reviewed vocabulary as a class, ask students to provide their own examples of innovative products.  Provide the vocabulary reference and ask students to write five sentence describing a product they like.Have students divide into small groups - three to six students is best.  Ask each group to come up with a new product. They can either invent a new product, or create a variation on a product they know.  Have students answer the worksheet questions about their new product.With the worksheet answered, students should move on to developing a plan for building, designing and marketing their product. Students who feel more comfortable with drawing can design, and business orientated students can take on marketing.   Help students by checking grammar descriptions, asking probing questions about the functionality, logistics of production and marketing, etc.  Students complete the project by giving a presentation to the class. The inventor should provide a product overview, the designer provide a sketch of the product, and the marketer an advertising strategy.  Vote on the best product as a class.   Vocabulary Reference Use these words to discuss, develop and design a new product. functionality (noun) - Functionality describes the purpose of the product. In other words, what does the product do?innovative (adjective) - Products that are innovative are new in some way.aesthetic (noun) - The aesthetics of a product refer to the values (artistic as well as functional)intuitive (adjective) - An intuitive product is self-explanatory. Its easy to know how to use it without having to read a manual.thorough (adjective) - A thorough product is a product that is excellent in every way and well designed.branding (noun) - The branding of a product refers to how a product will be marketed to the public.packaging (noun) - The packaging refers to the container in which the product is sold to the public.marketing (noun) - Marketing refers to how a product will be presented to the public.logo (noun) - The symbol used to identify a product or company.feature (noun) - A feature is a benefit or use of a product.warranty (noun) - The warranty is a guarantee that the product will w ork for a certain period of time. If not, the customer will receive a refund or replacement.component (noun) - A component can be thought of as a part of a product.accessory (noun) - An accessory is something extra that can be bought in order to add functinality to a product.materials (noun) - The materials refer to what a product is made of such as metal, wood, plastic, etc.   Computer Related Products specifications (noun) - The specifications of a product refers to size, construction and materials used.   dimensions (noun) - The size of a product.weight (noun) -  How much something weighs.width (noun) - How wide something is.depth (noun) -  How deep a product is.length (noun) - How long something is.height (noun) - How tall a product is. When developing computer-related products the following specifications are important: display (noun) - The screen used.type (noun) - The type of technology used in a display.size (noun) - How big the display is.resolution (noun) -  How many pixels the display shows. platform (noun) - The type of software / hardware a product uses.OS (noun) - The operating system such as Android or Windows.chipset (noun) - The type of computer chip used.CPU (noun) - Central processing unit - The brain of the product.GPU (noun) - Graphic processing unit - The brain used to display videos, pictures, etc.   memory (noun) - How many gigabytes the product can store.   camera (noun) - The type of camera used to make videos and take photos.   comms (noun) - The different types of communications protocols used such as Bluetooth or WiFi. New Product Questions Answer these questions to help you develop your product.   What functionality does your product provide? Who will use your product? Why will they use it? What problems can your product solve? What advantages does your product present? Why is your product superior to other products? What are the dimensions of your product? How much will your product cost?

5 Cases of Unnecessary Hyphenation

5 Cases of Unnecessary Hyphenation 5 Cases of Unnecessary Hyphenation 5 Cases of Unnecessary Hyphenation By Mark Nichol In each of the following sentences, one or more hyphens are extraneous. A discussion and revision follows each example. 1. Data is accurate and often delivered in real-time. â€Å"Real time† is a compound noun, and such nouns are almost invariably open or closed; hyphenated exceptions such as mind-set are rare. If a compound noun does not appear in the dictionary in closed form (or hyphenated), treat it as an open compound: â€Å"Data is accurate and often delivered in real time.† (However, do hyphenate such a compound that functions as a phrasal adjective before a noun, as in â€Å"This tool provides valuable real-time insight into the process.† Exceptions include standing open compound nouns that are listed in the dictionary, such as â€Å"income tax†: â€Å"This rule does not apply to income tax returns.†) 2. As companies become increasingly informa ­tion-driven, information technology plays a pivotal role in this transformation. When a phrasal adjective follows the noun it modifies, do not hyphenate it: â€Å"As companies become increasingly informa ­tion driven, information technology plays a pivotal role in this transformation.† (However, as alluded to in the previous discussion, hyphenate a phrasal adjective when it precedes a noun, as in â€Å"information-driven companies.†) 3. Companies need to get up-to-speed quickly on their regulatory requirements. The words in â€Å"up to speed† do not collectively modify anything, so hyphens are not required: â€Å"Companies need to get up to speed quickly on their regulatory requirements.† 4. Protocols with minimal-to-no tolerance for mistakes should clearly articulate what constitutes a mistake, and how to avoid making it. This sentence includes an unnecessarily hyphenated phrase that is incorrect for the same reason that the one in the previous example is. However, because a noun follows the phrase â€Å"minimal to no,† the phrase may be misidentified as a phrasal adjective. But minimal and no are distinct adjectives that do not combine with to to create a single modifier: â€Å"Protocols with minimal to no tolerance for mistakes should clearly articulate what constitutes a mistake, and how to avoid making it.† 5. Many residents were stunned by the apparently racially-inspired crime. Adverbial phrases in which the adverb ends in -ly, not to be confused with phrasal adjectives, are not hyphenated: â€Å"Many residents were stunned by the apparently racially inspired crime.† Want to improve your English in five minutes a day? Get a subscription and start receiving our writing tips and exercises daily! Keep learning! Browse the Punctuation category, check our popular posts, or choose a related post below:50 Idioms About Legs, Feet, and ToesDawned vs. DonnedA "Diploma" is not a "Degree"