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D gastritis diet pills purchase misoprostol 200mcg with mastercard, Gingival tissue coronal to the cover screws is excised using the gingivectomy technique chronic gastritis leads to cheap misoprostol 100 mcg without a prescription. Visual inspection ensures intimate contact between the abutments and the implants gastritis milk buy 100 mcg misoprostol with mastercard. Figure7611 A gastritis eating too much cheap misoprostol 100 mcg mastercard, Partial-thickness flap is apically sutured to the periosteum, and excess connective tissue coronal to the cover screw is excised by gingivectomy. After the flap is repositioned and secured with periosteal sutures, the excess tissue coronal to the cover screw is excised, usually with a surgical blade (Figure 76-11, B). However, if removal of this tissue would jeopardize the amount of remaining keratinized tissue around the lingual aspect of the implant(s), a similar partial-thickness flap can be elevated and repositioned on the lingual side as well. When the excess tissue over the cover screw is removed or displaced, the outline of the cover screw is visible. A sharp blade is used to eliminate all tissues coronal to the cover screw (Figure 76-10, D). The cover screw is then removed, the head of the implant is thoroughly cleaned of any soft or hard tissue overgrowth, and the healing abutments or standard abutments are placed on the implant (Figure 76-10,E and F). However, if it is not possible to visualize clearly the intimate connection between the implant and the abutment, an intraoral periapical x-ray film should be taken to confirm complete seating. PostoperativeCare Once the implant is exposed, it is important to remind the patient of the need for good oral hygiene around the implant. A chlorhexidine rinse can be used to enhance oral hygiene for the initial 2 weeks while the tissues are healing. Figure 76-10,G and H, shows the postoperative results in a clinical case after 2 to 3 weeks and 4 months, respectively. Again, the implants are left unloaded and undisturbed for a period similar to that for the implants placed in the two-stage approach (2-4 months in mandible, 4-6 months in maxilla). In the two-stage surgical approach, the implant is placed flush with the bone crest, and the soft tissue covering is purposely kept thick to minimize the risk of premature exposure of the cover screws. In the one-stage surgical approach, the implant or the healing abutment protrudes about 2 to 3 mm from the bone crest, and the flaps are adapted around the implant/abutment. In posterior areas of the mouth, the flap is thinned and sometimes sutured apically to periosteum to increase the zone of keratinized attached gingiva around the implant. FlapDesign,Incisions,andElevation the flap design for the one-stage surgical approach is always a crestal incision bisecting the existing keratinized tissue. Facial and lingual flaps in posterior areas should be carefully thinned before total reflection to minimize the soft tissue thickness. The soft tissue is not thinned in anterior or other esthetic areas of the mouth to prevent the metal collar from showing. ImplantSitePreparation the implant site preparation for the one-stage approach is identical in principle to the two-stage implant surgical approach. The primary difference is that the implant or the healing abutment extension of the implant is placed in such way that the head of the implant protrudes about 2 to 3 mm from the bone crest. FlapClosureandSuturing the keratinized edges of the flap are sutured with single interrupted sutures around the implant. When keratinized tissue is abundant, scalloping around the implant(s) provides better flap adaptation. PostoperativeCare the postoperative care for one-stage surgical approach is similar to that for the two-stage surgical approach except that the cover screw or healing abutment is exposed to the oral cavity. Prosthetic appliances should not be used if direct chewing forces can be transmitted to the implant, particularly in the early healing period (first 4-8 weeks). Soft lining of denture is mandatory when a one stage, nonsubmerged surgical approach to implant placement is used. Fundamental protocols must be followed for implant placement (stage one) and implant exposure surgery (stage two). Adell R, Eriksson B, Lekholm U, et al: A long-term follow-up study of osseointegrated implants in the treatment of totally edentulous jaws, Int J Oral Maxillofac Implants 5:347, 1990. Klokkevold P, Nishimura T, Adachi M, et al: Osseo-integration enhanced by chemical etching of the titanium surface, Clin Oral Implant Res 8:442, 1997. Schroeder A, van der Zypen E, Stich H, et al: the reactions of bone, connective tissue, and epithelium to endosteal implants with titanium-sprayed surfaces, J Maxillofac Surg 9:15, 1981. Watanabe F, Tawada Y, Komatsu S, et al: Heat distribution in bone during preparation of implant sites: heat analysis by real-time thermography, Int J Oral Maxillofac Implants 7:213, 1992.

When cattle are beginning to experience panting scores of 2 or greater xenadrine gastritis misoprostol 200 mcg overnight delivery, some means of cooling may be needed gastritis diet ïùùïäó purchase 100mcg misoprostol mastercard. Cattle learn to take evasive action to alleviate heat stress chronic gastritis with intestinal metaplasia buy generic misoprostol 100mcg line, and competition for cooler areas in a pen or around the water trough increases gastritis diet ùâòùëäôûûòøëø buy generic misoprostol 100 mcg online, even during cooler days when heat alleviation methods. When this occurs, evidence of crowding is observed, which exacerbates heat stress problems. Wetting the ground or floor of holding facilities can be an effective method of cooling cattle managed in outdoor units without shade and where surface vegetation is sparse or nonexistent (Mader, 2003, 2014; Mader and Davis, 2004). Direct wetting of cattle during extreme heat is also an effective practice and is often used as an emergency measure. In these cases, care must be taken to allow cattle to acclimate because applying significant amounts of cold water to hot cattle can cause additional stress. Additionally, actively cooling cattle after maximum ambient temperature occurs is more effective at reducing heat load compared with active cooling during peak ambient temperature (Lees et al. Benefits of sprinkling are enhanced if sprinkling is started in the morning before cattle experience high heat loads (Davis et al. The size of the area to be sprinkled would be similar to the shade area recommendations. As a routine protective practice, wetting can be efficiently accomplished by using a timer to provide 5 to 10 min of spray during each 20- to 30-min period. Fogger nozzles are less effective than sprinkler nozzles because of the barrier formed by the fine droplets (mist). These droplets adhere to the outer hair coat of the animal, causing the heat for evaporation to come from the air rather than from the body. Additionally, Mader (2014) presented potential negative effects of sprinkling in some circumstance, including acclimation of cattle to sprinkler systems and elevated pen humidity in environments with poor air flow or when too large of an area is sprinkled. Shade for cattle can mitigate hyperthermia for animals that are not conditioned to a sudden heat wave with high solar radiant loads, such as experienced in the central and southern regions of the United States. In addition, use of shade may be costly and logistically prohibitive because of snow load requirements (unless shade is taken down after the summer), potential mud problems under shade (low evaporation rates), and the low percentage of time that cattle may actually benefit from using the shade. Although recouping benefits from shade structures through improved performance can be challenging, putting shade structures in sick pens or in pens with cattle prone to heat stress will be helpful. Shade structures should allow air movement but must be able to withstand strong winds, especially in certain regions. Designing shade structures requires careful consideration of location, orientation, and height, as well as repair and maintenance to prevent injury and regular cleaning under the shade to minimize increased pen floor humidity (Eirich et al. While providing shade alone will likely not completely eliminate the effects of high heat loads, the goal of providing shade is to reduce heat stress and prevent hyperthermia. Cattle subject to environments that could precipitate hyperthermia need to be observed for signs of heat stress, and management action should be taken as needed. Such structures are ventilated by natural airflow, and the resultant winter temperatures are typically warmer than outdoor conditions as a result of body heat and wind protection. Totally enclosed housing requires ventilation to maintain the air temperature at acceptable levels and to minimize the accumulation of water vapor, noxious gases, other odorous compounds, and dust in the air. Type of pen surface affects dustiness during hot dry weather and mud or manure build-up during wet periods. Soil-surfaced pens should be regularly cleaned of animal waste and maintained to minimize accumulation of water. In areas subject to excessive mud, a hard surface apron in front of the feed bunks and around water troughs and shelters should be considered in soilsurfaced pens. When slope and drying conditions are inadequate, mounds should also be provided in soilsurfaced pens for cattle to lie on during wet and muddy soil conditions (Table 6-1). Properly designed pens with adequate slope are extremely important for minimizing mud and related health and behavior problems. In areas where slope or drying conditions are limited, adding mounds is very useful for keeping cattle clean and dry. Under hot-humid conditions, mounds aid in preventing animal crowding and improve exposure to airflow for the animals that use them.

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Reed Pat Roach Roy Silverman Etta Smith Helen Sutton Natasha Tonres xxiii Final Supplemental Environmental Impact Statement for the Nuclear Facility Portion of the Chemistry and Metallurgy Research Building Replacement Project at Los Alamos National Laboratory, Los Alamos, New Mexico Campaign Z. Acevedo Judith Ackerman Inger Acking Dolores Adams Gordon Adams Julie Adams Steve Adams Elizabeth Adan Patrick Adcock M. Austin Czerny Auyang Donna Avent John Avery Sara Avery Ron Avila Benjamin Axt John Ayala Fatima Aydin Sue Azizi Sherry Azzara Barbara Babin Christa Babst Christina Babst Daniel Bachmann Ii Karen Hedwig Backman Margot Backus Jessie Bacon Joanne Baek Adam Baer Bernice Baeumler Janet Bagby Elaine Baglemann L. Bagley Rosette Bagley Helen Bailey Marcia Bailey Sharon Bailey William Bailey Jeffrey Bains Arlene Baker Ed Baker Kofi Baker Lang Baker Lee Baker Vickey Baker Gerritt and Elizabeth BakerSmith Sara Bakker Jack Balch Martha Baldoni Kimberely Baldridge Carol Baldwin Deanna Ball J. Bertelmann Ray Berthiaume Gerald Bertholl George Berton Latamore Lucille Bertuccio Linda Bescript Ruth Bescript Bill and Bobbie Best Isabel Best Jerry Best Tammy Betancourt Nina Beucler Emma Beverage Ken Biasco Sasan Bidari Annie Bien Amy Biggs Barbara Bills Raymond Bilodeau Sheryl Biondi Cathie Bird Patricia Birnie Rev. Bonvouloir Jennifer Books Richard Booth Sara Booth Kim Borba Margie Borchers Bryan Borger Dean Borgeson Sharon Bort Michelle Bosch Vic Bostock Jonathen Boston Carol Bosworth William Boteler Cheryl Botinelly Mary Botti Michelle Bourg Paula Bourgeois Jessie Bourke P. Boustany Susan Bouthot John Bowen Sandra Bowen Motz Bettina Bowers Schwan Louise J. Margery Bowser Richard Bowser Polly Boyajian Bruni Boyden Christopher Boyle Lorraine Brabham Wilma Bradbeer Rhonda Bradley Sabine Bradley Joan Bradow Beverly Bradshaw Lee Brady Sandra Brady Don Brake Chad Bramble Shaun Brammer George Y. Bramwell Anita Brandariz Julia Brandner Kate Brandt Vicky Brandt Kevin Branstetter Beth Brant Gretchen Bratvold Beth Braun Joseph Braus Larry Braverman Angie Bray Dolores Bray Roberty Brazy Linda Brebner Vernon Brechin Bonnie Breckenridge Ann Breeden Dana Brekke Denise Brennan John Brennan Noah and Natasha Brennder Heidi Bresilge Esther Brewer Laurel Brewer Molly Brewer Steve Breyman Christine Bridenbaker Janet Brigantino Sara Brigham Lesley Brill Willaim Brisolara Bill Britton Jerry Broadbent David Broadwater Nancy Brodersen Charlotte Brody Loretta Brogran Alan Bromborsky John Bromer Julia Broome Margaret Broughton Marilyn Broughton Michael Broughton Patricia Brower Alice Brown Bonnie Jean Brown Carlene Brown Carol Brown Deb Brown George C. Brownrigg Sarah Brownrigg Donna Brumlow Christopher Brunje David Brunner Robert Bruno Rose Bruno Emlyn Bruns Pat Brunson Walter Bruun Philip Bryer Ivy Buchanan Nancy Buckholt John Bucki Trent Buckman Shannon Buddes Olivia Buehl Joseph Buhowsky N. Catherine Buntin Mary Bunting John Buonaiuto Al Buono Melinda Burgess Bonnie Margay Burke Colleen Burke Paul Burke Paul Burks Deborah Burnett James Burnham Audrey Burns xxv Final Supplemental Environmental Impact Statement for the Nuclear Facility Portion of the Chemistry and Metallurgy Research Building Replacement Project at Los Alamos National Laboratory, Los Alamos, New Mexico Bruce Burns Darlyne Burns Judy Burris Steven Burrows Kirsten Burt Frances Burton Vic Burton Serena Buschi Victoria Bush Martha W. Edith Cacciatore Coral Cadman Terry Cadwallader Daniel Cadzow David Cain Renato Calabrese Kathleen Caldwell Pam Calhoun Thomas Cali Mary Anne Callaghan Timothy Callahan Mary Camele Denise Cameron Gloria Cameron Patrick Cameron David Camp Rob Camp Vincent Campanaro Francesco Campanoni Alexandra Campbell Benita Campbell Dudley and Candance Campbell Grant Campbell Karen Campbell Kent Campbell Norma Campbell Steven Campbell Tony Camuti Will Candler Annabel Caner Alex Cannara John Cannatella Ernest Canning Jay Caplan Anthony Capobianco P. Caporrino Hector Capote Jeanette Capotorto Dan Cappelllo Barbara Capron Bret Carbone Rodolfo Cardona Paul Cardwell Bill Carey Doris Carey Edward Carey Naomi Carey Juanita Carl Stephen Carl Ian Carlon Paul Carlsen Bob Carlsten Patricia Carlton Victor Carmichael Gaile Carr Robert Carr Sarah Carr Patricia Carrier Berry Carroll Mark Carroll Maureen Carroll Rhonda Carsten Roberto Carteno Natalie Carter Tim Casebolt David Casey Leslie Cassidy Robert Cassinelli Rae Castina Christina Castle Ray Corinne Cather James Catton Kelley Caudell Lenny Cavallaro Connie Cavara Michael Cecil Alice Diane Celebre James Celico Robert Cerello Louie Cervantes John Cevasco Kathy Chad Suzanne Chaffee Silvia Chai Matt Chalfa Angela Chamberlain Clinton Chamberlain Connie Chambers Craig Chambers Gloria Chambers Kathy Chan Nathaniel Chan Christopher Chan Wayne Chanault Norman Chance Tracey Chance Carolyn Chandler Leonard B. Collins Raymond Collins Virginia Collins Rosemary Colson Lisa Nelson Colton Lynne Colvig-Cameron Connie Colvin Steven Combes Betty Combs Janice Combs Sandy Commons Lucia Comnes Richard Comtois Jo Conaty Lumarion Conklin Catherine Connell Charles Connors David Conroy Patti Constantino-Martin Anita Cook Elizabeth Cook Jane Cook Patricia Cook Rick Cook Terry Cook Tina Cook Kelli Cool Don Cooney Mitzi Coons Betty Cooper Ruth Cooper Sandra Cope Anneke Corbett Sister Kathleen Corbett Tom Cordaro Carmen Cordero William Corey Joseph Corio Leela Corman Jared Cornelia Marie Corr Catherine Corwin Angelica Cory Jean Cossey Sonya Costanza James Costello Mike and Heather Costello Nancy Costello Daniel Cottle Brad Cotton David Cotton Elizabeth Cotton xxvi List of Commentors Ricardo Cottrell Jack Couch Chuck Countryman Ron Courson Vera Cousins Russell Covington Carla Cowgill Michael Cowsert Bruce Cox Catherine Cox Joe Cox Laurrie Cozz Phillip J. Dauby Randall Daugherty Diane Dauten Susan Davenport Maggie Davidson Stephen Davie Merrilly Davies Thomas Davies Adrianne Davis Anthony Davis Byron Davis Darlene Davis Dassano Davis Frances Davis George Davis Lee Davis Linda Davis Phillip Davis Shirley Davis William Davis Karen Davis-Aragon Carla Davis-Castro Althea Day Michael Dayton Ruthanne Dayton Renee de Alba Bro. Aleman de Gallardo Jane De Hawkhurst Barry De Jasu Carol De Marinis Elisse De Sio Vincent De Stefano Bonita De Trinis Mercedita de Valle Arienne De Vassasi Jeff Deal June Dean Sue Dean Dorothy Dean Angelina DeAntonis Elisa DeBoer Denise DeGarmo Carolyn Deibel Rachel Deierling Joan Delauro Lori Delbello Barb DeLeone Arthur Delgadillo Paul Delisle Jennifer Delker Jeanne Deller Pete Delorenzo Dave Delson Ben Demar Jackie Demarais Libby Demartelly Mary Jo DeMyer Teresa DeNardo Amy Denio James Denison Phillip Dennany Alison Denning Gudrun Dennis Bob Densmore Karen Deora Joan Depew Tiffaney Derreumaux Thierry Deshayes Kevin DeSilva Lillian Deslandes Marshall E. Dewing Jill Dexter Paul Diamond Brad Diaz Francisco Diaz Liliana Diaz Sara Diaz Carol Dibbern Regina Dickerson Laura Dickey Robert Dickinson Patricia Dicoste Margaret Diegelman Jennifer Diehl-Berman B. Thomas Diener Maria DiFiore Jo DiLallo Christi Dillon Lilian Dillon Richard Dimatteo Michael Dimen Carmen Dinescu Patricia Dion Deborah Dipierro B. Doyle Richard Doyle Sky Dredge John Dreiling Lyn Dremalas Linda Drescher Alicia Dressman Beth Drewelow Todd Dripps Paul Drowns Phyllis Drummond Chris Drumright Andrew Drury Rob Dryden Julie Du Bois Chief Dubie Thea DuBow Tim Duda Robert Duffy Pat Dugan Kathy Duke Robin Dulling Lloyd Dumas Maryse Dumas xxvii Final Supplemental Environmental Impact Statement for the Nuclear Facility Portion of the Chemistry and Metallurgy Research Building Replacement Project at Los Alamos National Laboratory, Los Alamos, New Mexico Pat Duncan Dave Dunkak John Dunn Krista Dunn Mary Dunn Clover Durfee Ganesh Durgadas Samuel Durkin Vanessa Duve Bob Dyck Doug Dyer Paul and Carol Dyer Tracey Dyer Darlene Dynega Denise Janssen Eager Susan Earle Vickie Early Rick Easton Linda Eaton Roger Eaton Wendy Ebersberger Gerhard Eckardt Nancy Eckel Sasha Eckert Stacy Eddings Muriel Edgerton Brian Edmison Jane Edsall Beverly Edwards Elliott Egan Emily Eggan Bruce Eggum Jeffrey Eiche William Eichinger Nancy Eichler Henry Eisenhauer Kimberly Eisentrager Charlotte Eisner Elizabeth Eisner Steve Eklund Carol Elder Randall Ellenburg Gunhild Ellerbe Nancy Ellingham Michelle Elliot Charles Elliott Eli Elliott John Elliott Julie Heath Elliott Chris Ellis Robert Ellis Maura Ellyn Angela Elmendorf David Elmendorf Celeste Elmore Carol Elrod Valerie Elster Ernest Ely Ronnie Endre John Engel Lori English Judith Enich Elizabeth Enright Dianne Ensign Beth Enson Nicole Eppstein Jamie Erfurdt Carole Erickson Frank Erickson Lisa Erickson Mary Christine Erickson Stephanie Erickson Judy Ericson Peter Eriksson Barbara Erlichson Kristin Erman Judith Ernst Grace Ertel Heather Ervin Donald Erway Victor Escobar Dan Esposito Danny Esposito John Essman Douglas Estes Chris Evans Dinda Evans Jason Evans Jonathan Evans Michael Evans Monica Evans Randy Eveleigh Suanne Ewing Megan Faber John Fabris Janet Fagan Judy Fairless James Fairley Daniel Faisal Bonnie Faith-Smith Florence Falk R. Faris Luke Farrell Nancy Lee Farrell Stephen Fass Darlene Fast Wendy Fast Thomas Fasy Rachel Fatoorachi Naomi Fatouros Don and Joyce Faulk Mariah Faulkner Vernon Faulkner Vanessa Favero Bob Fay Lori Fay Angela Fazzari Peggie Feddersen Raleigh Dennis Feichtinger Emily Feingold Elayne Feinsod Joe Feinstein John Felden Ovina Feldman Ruth Feldman Nancy Feraldi Beverly Ferguson Shirley Ferguson Linda Ferland John Fernandez Ed Ferrara Antonio Ferreira Rebecca Ferrell Sharon Fetter Alica Fichandler Pari Fields Nancy Fifer Donald Figge Yvonne Fileccia Laura Fillmore Robert Fingerman Tom Finholt Amanda Finlayson Joel Finley Mary Lou Finley Jeannie Finley-Kochanowski Paulette Finnegan Marion Fiore Sara Fisch Bernice Fischer Elaine Fischer Jason Fish Claudia Fisher Rich Fisher Ted Fishman William Fisk Marylee Fithian Calvin Fitzgerald Gerry Fitzgerald Stan Fitzgerald Steven Fitzgerald Mitra Fiuzat Tania Flancher Linda Flannery Robert Flavell Constance Fleming Doug Fleming Sarah Fletcher Susan Fletcher John Flitcraft Rick Flory F. Frotscher Christina Frugoli Beryl Fry Lisa Frye Steve Fuchs Jen Fullem Michelle Fuller Pamela Funkhouser Sherrill Futrell Wendy Futrick Joe Futterer Greg Gable Robert Gabriel Roland Gabriel Dennis Gadowski xxviii List of Commentors Marnie Gaede Mary Gail Decker Mark Galbraith Allison Gale Irene Gale Richard Gale Daniel Galindo Gary Gall Justin Galle Rita Gallin Christopher Galton Fairlee Gamble Margerite Gamboa Jeff Gammill Michele Gannon Toni Ganshert Kelly Garbato Julian Garberson Kathe Garbrick Sonya M. Garbutt Christine Garcia Kevin Garcia Lauren Garcia Olaya Garcia William Gardiner Brandi Gardner David Gardner Rebecca Gardner Gregory Garduno Rachel Garibay-Wynnberry Amber Garlan Toni Garmon M. Glick Janice Gloe Adams Glory Kris Glover Michelle Gobely Alicia Godbee Joan Godoy Frank/Joan Goebels Cathy Goff Sandy Gold James Goldberg Leslie Goldberg Michael Goldberg Joseph Goldman Steven Goldman William Goldman Andres Goldschmidt Marlene Goldsmith Sonia Goldstein Frances Golf Joseph Golinveaux Michael Gomel Gus Gomez Carlos Gonsalves Clarrisa Gonzales Veronica Gonzalez William Gonzalez Fran Good Medicine Wolf Klabunde Nicole Gooden Ben Goodin Diana Goodman Edward Goral Aaron Gorden Abe Gordon Ben Gordon Susan Gordon Carole Gorecki Eugene Gorrin Gordon Gosse Barbara Gotti Linda Gottschalk Pat Gottschalk Mark Gotvald Rebecca Gough Sean Gough Charity Gourley Norman Gourley Pat and Gary Gover Jennifer Goyette Anthony Gradert Jess Graffell Amanda Graham Charlie Graham George Graham Karen Graham Dabra Grant Dori Grasso Marya Grathwohl Tracy Grauel Dick Gray Erica Gray Heather Gray Roxy Gray Sandra Gray Slyvia Ruth Gray William Gray Marilou Greboval Jeanne Green JoAnn Green Sandra Green Stacy Green Michael Green Lenore Greenberg Dan Greenburg Dan Greenburg Amy Greene Barbara Greene Jerry Greenstein Ken Greenwald Cathy Greer Helen Greer Cara Gregoire Rosemary Gremillion Elaine Gremminger Kathleen Greshman Georgia Griffin John Griffin L. Hamilton James Hamilton Michelle Hamilton Sarah Hamilton Penny Hammack Barb Hammerlind Lisa Hammermeister Hank Hammett Marcella Hammond Stephanie Hammond Todd Hammond Richard Han Lillian Hanahan Karen Hancock xxix Final Supplemental Environmental Impact Statement for the Nuclear Facility Portion of the Chemistry and Metallurgy Research Building Replacement Project at Los Alamos National Laboratory, Los Alamos, New Mexico Janet Handford Tara Hands Steven Handwerker Stephen Hanft Denise Hanley Sue Hanlin Helen Hanna Roger Hannah Arbie Hansen Christine Hansen Art Hanson Donna Hanson Jim Hanson Kristi Hanson Mardi Hanson Natalie Hanson Phil Hanson Robert Hanson Michael Hante Tamara Harder Sondra Hardgrave Nicole Hardin Rinat Harel Missy Hargraves Betts Harley Linda Harlow Jack Harmell Angela Harmon J.

Perhaps the strong opinions on both sides should be the most valid indication that there is a time and a place for each gastritis en ingles purchase misoprostol 100 mcg on-line. Neither method can be advocated exclusively gastritis onions cheap misoprostol 100 mcg with visa, because a careful analysis of effective scaling and root-planing technique reveals that gastritis diet foods purchase misoprostol 200 mcg with mastercard, indeed gastritis vs pud 100mcg misoprostol with amex, both types of stroke activation are necessary for complete instrumentation. The wrist and forearm motion, pivoting in an arc on the finger rest, produces a more powerful stroke and is therefore preferred for scaling. Finger flexing is indicated for precise control over stroke length in areas such as line angles and when horizontal strokes are used on the lingual or facial aspects of narrow-rooted teeth. In the push stroke, the instrument engages the lateral or coronal border of the calculus, and the fingers provide a thrust motion that dislodges the deposit. Because the push stroke may force calculus into the supporting tissues, its use, especially in an apical direction, is not recommended. The root-planing stroke is a moderate to light pull stroke that is used for final smoothing and planing of the root surface. Although hoes, files, and ultrasonic instruments have been used for root planing, curettes are widely acknowledged to be the most effective and versatile instruments for this procedure. With a moderately firm grasp, the curette is kept adapted to the tooth with even, lateral pressure. As the surface becomes smoother and resistance diminishes, lateral pressure is progressively reduced. InstrumentsforScalingandRootPlaning UniversalCurettes the working ends of the universal curette are designed in pairs so that all surfaces of the teeth can be treated with one double-ended instrument or a matched pair of single-ended instruments (see Figure 51-16). In any given quadrant, when approaching the tooth from the facial aspect, one end of the universal curette adapts to the mesial surfaces, and the other end adapts to the distal surfaces. When approaching from the lingual aspect in the same quadrant, the double-ended universal curette must be turned end for end because the blades are mirror images. This means that the end that adapts to the mesial surfaces on the facial aspect also adapts to the distal surfaces on the lingual aspect, and vice versa. Both ends of the universal curette are used for instrumentation of the anterior teeth. On posterior teeth, however, because of the limited access to distal surfaces, a single working end can be used to treat both mesial and distal surfaces by using both its cutting edges. To do this, the instrument is first adapted to the mesial surface with the handle nearly parallel to the mesial surface. Because the face of the universal curette blade is honed at 90 degrees to the lower shank, if the lower shank is positioned so that it is absolutely parallel to the surface being instrumented, the tooth-blade angulation is 90 degrees. To close this angle and thus obtain proper working angulation, the lower shank must be tilted slightly toward the tooth. The distal surface of the same posterior tooth can be instrumented with the opposite cutting edge of the same blade. This cutting edge can be adapted at proper working angulation by positioning the handle so that it is perpendicular to the distal surface (Figure 51-73). Cross-sectional representations of the same universal curette blade as its cutting edges (a and b) are adapted to the mesial and distal surfaces of a posterior tooth. When adapting the universal curette blade, as much of the cutting edge as possible should be in contact with the tooth surface, except on narrow convex surfaces such as line angles. Although the entire cutting edge should contact the tooth, pressure should be concentrated on the lower third of the blade during scaling strokes. During root-planing strokes, however, lateral pressure should be distributed evenly along the cutting edge. The primary advantage of these curettes is that they are designed to be used universally on all tooth surfaces, in all regions of the mouth. However, universal curettes have limited adaptability for the treatment of deep pockets in which apical migration of the attachment has exposed furcations, root convexities, and developmental depressions. For this reason, many clinicians prefer the Gracey curettes and the new modifications of Gracey curettes, which are area specific and specially designed for subgingival scaling and root planing in periodontal patients. GraceyCurettes As discussed earlier, Gracey curettes are a set of area-specific instruments that were designed by Dr. Four design features make the Gracey curettes unique: (1) they are area specific, (2) only one cutting edge on each blade is used, (3) the blade is curved in two planes, and (4) the blade is "offset" (see Table 51-1. The facial and lingual surfaces of posterior teeth are instrumented with Gracey curettes #7-8 and 9-10.

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