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This article about special care dentistry in the middle years considers people
who have Downs syndrome and cerebral palsy and those who have cardiac
and respiratory disease. The increased life expectancy of people with Downs
syndrome, currently 50-60 years, is reflected in the chanin population profile
and needs of these individuals. The preventive and dental treatment of most
people with Downs syndrome and cerebral palsy can be met in eneral dental
practice. !owever, those people with profound disability, anxiety or learnin
disability may re"uire either a shared approach to care or referral for specialist
care. #ardiac and respiratory disease occur commonly in the eneral
population both in middle and older ae roups and the dental team will meet
increasin numbers of people with these conditions. The procedures and drus
used in dentistry can aravate heart disease and it is important that the
dental team are aware of the common cardiac condi tions and their
manaement, as well as how to best manae the oral care of this roup. $lso,
they have a role to play in the provision of oral health advice, smo%in
cessation and dietary advice. This is particularly important as poor oral hyiene
has been lin%ed to respiratory pathoen colonisation and dental pla"ue may
act as a reservoir for aspiration pneumonia in susceptible individuals.
&
'enior Dental (fficer in 'pecial
#are Dentistry, Dorset !ealthcare
)!' *oundation Trsut, Dental
Department, #anford !ealth
#entre, +oole, Dorset, ,!&- .D/0
12
#hairperson of the 'pecialist
$dvisory 3roup in 'pecial #are
Dentistry4'enior 5ecturer and
#onsultant in 'pecial #are
Dentistry, Department of 'edation
and 'pecial #are Dentistry, 6ins
#ollee 5ondon Dental 7nstitute,
*loor 16, 3uys Tower, 5ondon,
'8& .9T0
:
5ecturer and #onsultant
for ;edically #ompromised
+atients, Division (ne4'pecial
#are Dentistry, Dublin Dental
'chool and !ospital, 5incoln
+lace, Dublin 1, 7reland
2#orrespondence to< Dr =anice
*is%e
8mail<
=anice.*is%e>stt.nhs.u%
DOI: 10.1038/sj.bdj.2008.850
?
British Denta !"#rna
2008$ 205: 35%&3'1
This second article on
seamless care for people in
their middle years
considers two conditions
which have traditionally
been considered with
childhood and young adult
conditions, and two
conditions that have
traditionally been
associated with older
people. The first two
cerebral palsy and Downs
syndrome are included in
this article to reflect the
increasing life expectancy
of people with these condi
tions and the subsequent
change in their population
profile and needs. The
latter two conditions
cardiac and respiratory
disease now occur
commonly in middle age as
well as in older age and the
den tal team will see
increasing numbers of
people with these
conditions.
1. CEREBRA(
PA()*
Cerebral palsy C!" is an
umbrella term
encompassing a group of
non#progres sive
neurological and physical
disabilities caused by
damage or a lesion to a
childs brain early in the
course of development,
either in utero, during
birth or in the fi rst few
months of infancy.
$
The
damage to the brain is
caused mainly by hypoxia,
trauma and infection but
genetic and
biochemic
al factors
have also
been sug
gested.
$
!re#natal
ris% factors
include
pre
eclampsia,
irradiation,
a maternal
age of less
than &' or
over (),
and
infections
such as
cytomegal
ovirus,
rubella and
syphilis.
!eri#natal
ris% factors
include
trauma,
breach
birth or
prolonged
delivery.
$,&
Damage
may also
be caused
post#
natally
following
infections
such as
encephali
tis and
meningitis
during
infancy.
*ther
ris%
factors
include
cerebral
ischaemi
a,
haemorrh
age and
hypoxia
secondar
y to
trauma,
respirator
y
distress,
hypother
mia or
hypoglyc
aemia.
$,&
Cerebr
al palsy
is the
most
common
congenit
al cause
of
physical
impair
ment,
$
with an
incidenc
e of
approxi
mately
&#&.) per
$,'''
live
births in
develope
d
countries.
&
!rimarily
it is a
disorder
of
voluntary
moment,
which
results in
a wide
spectrum
of disabil
ity
ranging
from
virtually
unnoticea
ble
physical
impairme
nt. +t may
affect only
one limb
monople
gia", both
lower
limbs
paraplegi
a", one
upper and
one lower
limb on
the same
side
hemipleg
ia" or all
four limbs
equally
quadriple
gia".
$
There are
four main
types of
C! Table
$", the
fea
tur
es
of
wh
ich
are
go
ver
ne
d
by
the
are
a
of
bra
in
da
ma
ge.
&,(
Di
a+
n
"s
is
Di
ag
nos
is
is
usu
all
y
ma
de
fro
m
cli
nic
al
sig
ns,
suc
h
as
we
a%
nes
s
in
on
e
or
mo
re
lim
bs,
abnorma
l gait
with one
foot or
leg
dragging
,
excessiv
e
drooling
or
difficul
ties in
swallowi
ng and
poor
control
over
hand and
arm
moveme
nt. *ther
impair
ments
which
may
accompa
ny C!
include
visual,
hearing
and
speech
impairm
ents,
epilepsy,
drooling
and
learning
disabil
ity.
,
-ess
than
)'. of
individu
als with
C! have
a
learning
disabilit
y and
indeed
many
people
are
highly
intellige
nt and
well
educated
, though
severely
impaired
speech
du
e
to
dys
pra
xia
or
dys
ph
asi
a
an
d
sen
sor
y
im
pai
rm
ent
s
can
mi
sle
ad
so
me
un
wa
ry
obs
erv
ers
.
$
/lt
ho
ug
h
C!
is a
no
n#
pro
gre
ssi
ve
dis
ord
er,
oth
er
se
c
on
dar
y
co
mp
lic
ati
ons
ma
y
occ
ur
and can
include
respirato
ry
complica
tions,
sec
ondary
digestive
system
problem
s reflux
and
constipat
ion",
bladder
infection
s and
%idney
infection
s, s%in
problem
s on
pres
,CP-
sur
e
are
as
an
d
per
i#
ora
lly
fro
m
dro
oli
ng,
an
d
mu
scu
lo#
s%e
let
al
pro
ble
ms
suc
h
as
art
hrit
is,
dis
loc
ati
ons
an
d
def
or
mit
ies.
)
Tr
ea
t
.
en
t
0
hil
e
the
re
is
no
cur
e,
the
rap
y
c
a
n
h
el
p
c
h
il
d
r
e
n,
a
d
u
lt
s
a
n
d
t
h
ei
r
f
a
m
il
ie
s
m
a
n

a
g
e
t
h
e
p
r
o
b
le
m
s
t
h
at
c
e
r
e
b
r
al
p
al
s
y
pre
sen
ts.
12
ob
ath
the
rap
y
is
ver
y
po
pu
lar
an
d is
a
tra
ns#
dis
cip
lin
ary
ap
pro
ach
usi
ng
spe
cia
lise
d
ha
ndl
ing
an
d
pos
tur
e
tec
hni
qu
es
to
enc
our
age
mo
re
co
ntr
oll
ed
pat
ter
ns
of
mo
ve
me
nt.
Co
mb
ine
d
wit
h
ph
ysi
oth
era
py,
occ
up
ati
on
al
the
rap
y
an
d
spe
ech
an
d
lan
gu
age
the
rap
y it
can
cha
ng
e
the
cli
nic
al
pre
sen
tati
on
of
C!.
)
3
p
li
n
ts
,
o
rt
h
o
p
a
e
d
ic
s
u
r
g
e
r
y
a
n
d
m
e
d
ic
a

ti
o
n
s
s
u
c
h
a
s
m
u
s
cl
e
r
el
a
x
a
n
ts
a
r
e
u
s
e
d
t
o
r
el
ie
v
e
mu
scl
e
stif
fne
ss
an
d
to
red
uce
pai
n
an
d
co
nto
rtio
ns.
$
2et
we
en
&)#
('
.
of
pe
opl
e
wit
h
C!
ha
ve
epi
lep
sy
an
d
ta%
e
rel
ate
d
dru
g
the
rap
y.
$
Di
eta
ry
ad
vic
e is
req
uir
ed
wh
ere
nut
riti
on
or
sw
all
ow
ing
is
co
mp
ro
m
is
e
d.
,
-
if
e
ex
pec
tan
cy
in
C!
has
inc
rea
sed
sig
nifi
can
tly
in
the
last
dec
#
ade
s,
ho
we
ver
res
pir
ato
ry
inf
ect
ion
s
are
co
m
mo
n
an
d
asp
irat
ion
pn
eu
mo
nia
is a
ma
4or
cau
se
of
dea
th.
$
0
hee
lch
air
des
ign
an
d
ass
isti
ve
de
vic
es
c
a
n
h
el
p
t
o
p
r
o
v
i
d
e
a
d
e
g
r
e
e
o
f
i
n
d
e
p
e
n
d
e
n
c
e

5
i
g
s
$
a
n
d
&
".
O
r
a

a
n
d
d
e
n
t
a

/
e
a
t#
re
s
!e
opl
e
wit
h
C!
wil
l
enc
ou
nte
r
the
sa
me
ora
l
an
d
de
nta
l
dis
eas
e
as
the
res
t of
the
po
pul
ati
on,
ho
we
ver
the
re
are
ad
diti
on
al
fac
tor
s
suc
h
as
acc
ess
to
de
nta
l
car
e
an
d
sup
por
t in
car
ryi
ng
out
dai
ly
liv
ing
act
ivit
ies,
wh
ich
can
res
ult
in
hig
her
lev
els
of
unt
rea
ted
dis
eas
e
an
d
too
th
los
s.
,
3c
op
e,
the
nat
ion
al
vol
unt
ary
an
d
pol
itic
al
bo
dy
for
C!,
wo
r%s
act
ive
ly
on
ca
mp
aig
n
s
t
o
1
g
et
e
q
u
al

a
n
d
m
a
%
e
1r
i
g
h
ts
a
r
e
al
it
y
.
/
t
t
h
e
ti
m
e
o
f
w
ri
ti
n
g
it
w
a
s
r
u
n
n
i
n
g
a
n
o
n
li
n
e
c
am
pai
gn
see
%
ing
out
1di
sab
lis
m,
wh
ich
it
des
cri
bes
as
1di
scr
imi
nat
ory
,
op
pre
ssi
ve
or
ab
usi
ve
be
ha
vio
ur
ari
sin
g
fro
m
the
bel
ief
tha
t
dis
abl
ed
per
son
s
are
inf
eri
or
to
oth
ers
.
&
+t
wil
l
onl
y
be
a
ma
tter
of
tim
e
bef
ore
the
ir
act
ive
an
d
on
goi
ng
res
ear
ch
hig
h
lig
hts
the
ine
qu
alit
y
in
ora
l
hea
lth
an
d
act
s
acc
ord
ing
ly.
T
her
e
are
ma
ny
pot
ent
ial
cau
ses
of
inc
rea
sed
ris
%
of
de
nta
l
d
is
e
a
s
e
i
n
C
!.
T
h
e
y
i
n
cl
u
d
e6
D
e
v
e
l
o
p
m
e
n
t
a
l
a
b
n
o
r
m
a
li
ti
e
s

t
h
e
m
a
x
il
la
r
y
a
r
c
h
is
fr
e
q
u
e
ntl
y
tap
ere
d
or
ov
oid
an
d
the
up
per
inc
iso
rs
ma
y
be
lab
iall
y
inc
lin
ed,
ma
%in
g
ora
l
hy
gie
ne
dif
fic
ult.
$
Th
e
inc
ide
nce
of
ma
loc
cl
u
sio
n is
hig
h
an
d
del
aye
d
eru
pti
on,
po
or
oro
mu
scu
lar
co#
ord
ina
tio
n,
lac
%
of
ad
e
qu
ate
lip
sea
l
an
d
ora
l
ha
bit
s
of
ton
gu
e
thr
ust
co
ntri
but
e
to
thi
s.
$,
(,,
U
nc
ont
rol
led
mo
ve
me
nt

cha
rac
teri
s
tic
sy
mp
to
ms
of
the
mo
ve
me
nt
dis
ord
er
ma
y
be
o
b
s
e
r
v
e
d
i
n
t
h
e
o
r
o
f
a
ci
al
a
n
d
c
e
r
v
ic
al
m
u
s
cl
e
s,
7
i
n
cl
u
d
i
n
g
s
p
a
st
ic
it
y
o
f
t
h
e
te
m
p
o
r
o
m
a
n
d
i
bul
ar
4oi
nt
T
89
"
mu
scu
lat
ure
.
(
5a
cia
l
gri
ma
cin
g,
dy
s
ph
agi
a
an
d
sw
all
ow
ing
dif
fic
ulti
es
are
co
m
mo
n
(
an
d
4a
w
dis
loc
ati
on
du
e
to
spo
nta
ne
ous
sub
lux
ati
on
ma
y
occ
ur.
$
,,
B
ru
xis
m
an
d
too
th
we
ar

the
se
are
co
m
mo
n
in
C!,
esp
eci
all
y
in
tho
se
ind
i
vid
ual
s
wit
h
ath
eto
id
C!.
(
-o
ss
of
too
th
tiss
ue
ma
y
be
exa
cer
bat
ed
by
ero
sio
n
du
e
to
gas
tro
#
oes
op
ha
gea
l
refl
u
x,
w
h
ic
h
is
al
s
o
c
o
m
m
o
n.
$,
,
P
e
ri
o
d
o
n
t
a
l
d
is
e
a
s
e

is
r
e
p
o
rt
e
d
i
n
a
h
i
g
h
p
r
o
p
o
rt
i
o
n
o
f
p
e
o
ple
wit
h
C!
wh
ich
aff
ect
s
the
ir
up
per
lim
bs
an
d
ma
nu
al
de
xte
rity
.
!re
#
dis
pos
ing
fac
tor
s
to
per
i#
od
ont
al
dis
eas
e
in
thi
s
gro
up
inc
lud
e
mo
uth
bre
ath
ing
,
gin
giv
al
hy
per
pla
sia
sec
on
dar
y
to
the
use
of
p
h
e
n
y
t
o
i
n
f
o
r
t
h
e
tr
e
at
m
e
n
t
o
f
e
p
il
e
p
s
y
:
a
n
d
i
n
c
r
e
a
s
e
d
f
o
o
d
r
et
e
n
ti
o
n
w
h
ic
h
is
e
x
a
c
e
r
bat
ed
by
dif
fic
ulti
es
in
ora
l
sel
f#
car
e
an
d
pla
qu
e
re
mo
val
.
(,,
Th
e
inc
rea
sin
g
use
of
1pe
g
pe
rcu
tan
eo
us
en
dos
co
pic
gas
tro
no
my
"
fee
din
g
has
hel
pe
d
im
pro
ve
the
nut
ri
tio
nal
stat
us
of
pat
ien
ts
wit
h
sw
all
ow
ing
dif
fic
ulti
es,
but
the
nee
d
for
reg
ula
r
an
d
me
tic
ulo
us
ora
l
hy
gie
ne
has
not
bee
n
ad
dre
sse
d
,
eve
n
tho
ug
h
Di
c%s
et
al.
;
ha
ve
sho
wn
tha
t
cal
cul
us
for
ma
tio
n
is
sig
nif
i
can
tl
y
m
o
r
e
r
a
p
i
d
i
n
t
u
b
e
#
f
e
d
p
at
ie
n
ts
.
;
T
h
is
is
i
m
p
o
rt
a
n
t
a
s
p
o
o
r
o
r
al
h
e
al
t
h
i
n
p
at
ie
n
ts
w
it
h
d
y
s
ph
agi
a
has
fre
qu
ent
ly
bee
n
ass
oci
ate
d
wit
h
the
de
vel
op
me
nt
of
asp
irat
ion
pn
eu
mo
nia
.
<
Th
ere
is
go
od
evi
de
nce
tha
t
im
pro
ve
d
ora
l
hy
gie
ne
an
d
fre
qu
ent
pro
fes
sio
nal
ora
l
hea
lth
car
e
red
uce
s
the
occ
urr
enc
e
or
pro
gre
ssi
on
of
res
pir
ato
ry
dis
eas
es.
$
'
C
ari
es

the
ris
%
of
car
ies
is
inc
rea
sed
by
a
nu
mb
er
of
fac
tor
s
rel
ate
d
to
C!
an
d
its
tre
at
me
nt,
for
exa
mp
le
red
uce
d
che
wi
n
g
a
n
d
s
w
al
l
o
w
i
n
g
a
b
il
it
y,
t
h
e
te
n
d
e
n
c
y
f
o
r
f
o
o
d
t
o
b
e
r
et
ai
n
e
d
i
n
t
h
e
m
o
u
t
h,
,
m
al
o
c
cl
u
si
o
n
an
d
me
cha
nic
al
an
d
ph
ysi
cal
dif
fic
ulti
es
in
re
mo
vin
g
pla
qu
e.
+n
the
abs
enc
e
of
eff
ect
ive
ora
l
hy
gie
ne
pro
ced
ure
s,
ind
ivi
du
als
wit
h
fee
din
g
dif
fic
ulti
es
wh
o
use
die
tar
y
su
p
ple
me
nts
an
d
lax
ati
ves
wit
h a
hig
h
sug
ar
co
nte
nt
can
de
vel
op
ext
ens
ive
lev
els
of
car
ies
rap
idl
y.
,
F
ra
ctu
red
tee
th

the
inc
rea
sed
li%
e
lih
oo
d
of
fall
s
(
an
d
sei
=ur
es
$
am
on
gst
pe
opl
e
wit
h
C!
me
ans
t
h
at
fr
a
ct
u
r
e
d
te
et
h
a
r
e
m
o
r
e
li
%
el
y
t
h
a
n
i
n
t
h
e
g
e
n
e
r
al
p
o
p
u
la
ti
o
n.
X
e
r
o
st
o
m
i
a

d
r
y
m
o
u
t
h
s
eco
nd
ary
to
the
use
of
me
dic
ati
on
to
co
ntr
ol
se
i
=ur
es
is
un
do
ubt
edl
y a
cau
sati
ve
fac
tor
of
ora
l
dis
eas
e.
:
>o
we
ver
,
stu
die
s
ha
ve
sho
wn
tha
t
eve
n
wh
en
not
ta%
ing
suc
h
me
dic
ati
on,
pe
opl
e
wit
h
C!
ha
ve
a
lo
we
r
tha
n
nor
ma
l
sali
var
y
flo
w
rat
e,
lo
we
r
p>
an
d
red
uce
d
buf
feri
ng
cap
aci
ty,
fur
the
r
inc
rea
sin
g
the
ir
ris
%
of
ora
l
dis
eas
e.
$$
?x
ace
rba
ted
by
mo
uth
bre
ath
ing
,
cru
st
ing
m
u
c
o
u
s
d
e
p
o
si
ts
a
r
e
c
o
m
m
o
n
l
y
s
e
e
n
o
n
t
h
e
p
al
at
e
a
n
d
s
o
ft
ti
s
s
u
e
s.
,
D
r
o
o
li
n
g

p
r
o
b
le
m
d
r
ool
ing
aff
ect
s
up
to
);
.
of
chi
ldr
en
wit
h
cer
ebr
al
pal
sy
$
&,$(
an
d
alt
ho
ug
h
the
inc
ide
nce
is
lo
we
r in
ad
ult
s,
for
ma
ny
ind
ivi
du
als
it
is
sev
ere
en
ou
gh
to
int
erf
ere
wit
h
dai
ly
soc
ial
an
d
pra
cti
cal
fun
cti
ons
.
$(,$
,
+t
is
not
cau
sed
by
hy
per
#
sali
vat
ion
,
b
u
t
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d
u
e
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o
i
m
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ai
r
e
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al
l
o
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a
n
d
p
o
o
r
c
o
n

tr
o
l
o
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t
h
e
o
r
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ci
al
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u
s
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la
t
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r
e
$
),
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a
n
d
c
a
n
be
exa
cer
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ed
by
ma
loc
clu
sio
n,
pos
tur
al
pro
ble
ms,
de
nta
l
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ies
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d
an
ina
bili
ty
to
rec
og
nis
e
sali
var
y
spi
ll.
$
:
L
ip
tra
um
a
is a
co
ndi
tio
n
ass
oci
ate
d
wit
h
ind
ivi
du
als
wh
o
ha
ve
a
pro
fou
nd
ne
uro
dis
abi
lity
$;,$
<
an
d
has
bee
n
rep
ort
ed
in
pe
opl
e
wit
h
cer
ebr
al
pal
sy.
&
',&$
Th
e
bit
e
refl
ex
occ
urs
pat
hol
ogi
cal
ly
in
thi
s
gro
up
an
d
is
oft
en
a
res
ult
of
fac
ial
hy
per
sen
siti
vit
y,
an
xie
t
y
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n
d
p
o
o
r
h
e
a
d
p
o
si
ti
o
n.
$<
,&
&
S
e
a
m
l
e
s
s
c
a
r
e
T
h
e
m
a
n
a
g
e
m
e
n
t
o
f
o
r
al
h
e
al
t
h
n
e
e
d
s
t
o
be
em
be
dd
ed
int
o
the
ge
ner
al
car
e
pla
n
of
eve
ry
ind
ivi
du
al
wit
h
C!.
0
hil
e at
tim
es
the
de
nta
l
tea
m
ma
y
be
on
the
per
iph
ery
of
the
mu
ltid
isci
pli
nar
y
tea
m,
at
oth
ers
the
y
are
int
egr
al
an
d
can
pla
y a
sig
nifi
can
t
rol
e
in
im
pro
vin
g
the
qu
al
ity
of
life
for
pe
opl
e
wit
h
C!.
3o
me
of
the
wa
ys
the
y
co
ntri
but
e
to
thi
s
inc
lud
e6
T
h
e
m
a
i
n
t
e
n
a
n
c
e

o
f
i
n
d
e
p
e
n
d
e
n
c
e
.
+f
a
n
i
n
d
i
v
i
d
u
al
r
el
ie
s
o
n
m
o
u
t
h
#
h
el
d
de
vic
es
to
car
ry
out
cer
tai
n
act
ivit
ies
or
to
ass
ist
co
m
mu
nic
ati
on,
ma
int
ain
ing
go
od
ora
l
hea
lth
is
crit
ica
l to
ret
ain
ing
ind
epe
nd
enc
e
5i
g.
(".
The management of xerostomia and erosion.
may be prevented by the use aqueous lubricating gel both peri# and intraorally. Deposits may be removed by gentle brushing with a soft toothbrush or swab dipped in mucolytic solvent, for example 2isolvon & ml@mg bromhexin".
sitivity may be addressed with topical fluoride application as outlined in arti
Management of bruxism.
reduction of clench ing, reduction of any associated pain and prevention of further tooth damage. Traditional treatment options includ
trigger factors such as caries and sharp teeth, pain, poor posture and stress" are reduced.
airway protection. Aather than using alginate, 8ilwood
the mouth before final set to avoid loc%ing into undercuts and interdental spaces" and props to aid opening
techniques,
,
cryotherapy
&)
and the use of medications such as gabap
Management of drooling.
e
dos
age
and
the
lon
g#
ter
m
co
mp
lica
tio
ns
are
stil
l
un
%n
ow
n.
$)
,$7,&
;
3ur
ger
y,
alt
ho
ug
h
no
n#
rev
ersi
ble,
has
a
hig
h
suc
ces
s
rat
e
$),
$7
wit
h
pre
fer
enc
e
giv
en
to
mo
re
con
ser
va
tiv
e
pro
ced
ure
s, such
as sub#
mandibu
lar duct
relocatio
n.
$),$7
Treat
ment of
drooling
,
whether
phar
malogic
al or
surgical,
results
in
reduced
salivary
flow and
the
patient
will
always
be more
suscepti
ble to
dental
car ies.
$7
Aegular
dental
examina
tion and
extra
preventi
ve
measure
s, as
detailed
in article
, of this
series,
are
therefor
e
mandato
ry for
patients
undergoi
ng this
type of
therapy.
&
,
Mana
gement
of lip
trauma.
Bari ous
oral
applianc
es have
been
used in
an effort
to
pre
ven
t
tra
um
a
and
pr
o
mo
te
hea
lin
g
of
lesi
ons
.
$;,&
',&$,
&<,('
Th
e
dra
stic
sol
uti
ons
of
ext
rac
tin
g
teet
h
and
ort
ho
gna
thi
c
sur
ger
y
to
cre
ate
an
ant
eri
or
ope
n
bit
e
hav
e
bee
n
use
d
in
isol
ate
d
cases.
($
The
removal
of teeth
do
es
not
usu
all
y
sol
ve
the
pro
ble
m
as
tra
um
a is
rel
oca
ted
to
a
dif
fer
ent
site
on
ce
the
lip
sup
por
t is
red
uce
d
foll
ow
ing
ext
rac
tio
ns.
$<
/
de
nti
st#
led
mu
ltid
isc
i
pli
nar
y
te
a
m
a
c
%
n
o
w
le
d
g
e
d
t
h
at
c
u
rr
e
n
t
cl
i
n
ic
al
m
a
n
a
g
e
m
e
n
t
o
p
ti
o
n
s
a
r
e
li
m
it
e
d,
o
ft
e
n
ine
ffe
cti
ve,
an
d
req
uir
e
fur
the
r
de
vel
op
me
nt.
&
&
Cu
me
rou
s
fac
tor
s
aff
ect
the
ch
oic
e
of
tre
at
me
nt,
wit
h
pat
ien
t
co#
op
era
tio
n,
acc
ess
to
the
ora
l
cav
ity
an
d
wis
hes
of
the
ind
ivi
du
al
an
d
fa
mil
y
bei
ng
the
mo
st
lim
itin
g
fac
tor
s.
&&
3
yst
em
ic
des
ens
itis
ati
on
thr
ou
gh
tou
ch,
usi
ng
tec
hni
que
s
co
m
mo
n
am
on
gst
spe
ech
and
lan
gua
ge
the
rap
ists
,
has
bee
n
s
h
o
w
n
to
b
e
u
s
ef
ul
in
th
e
p
re
v
e
nt
io
n
o
f
bi
te
s
a
n
d
to
fa
ci
li
ta
te
i
m
p
re
ss
io
n
#
ta
%i
n
g
f
o
r
fa
b

ri
c
at
io
n
o
f
h
ar
d
a
cr
ylic
bite
gua
rds,
lip
bu
mp
ers
or
soft
vac
uu
m
mo
uld
s.
&&
*p
en
ing
of
the
mo
uth
ma
y
req
uir
e
assi
sta
nce
or
use
of
one
of
the
aid
s or
pro
ps
out
line
d
in
arti
cle
$
of
this
seri
es.
(
&
3i
mil
arly
,
the
use
of
bot
uli
nu
m
tox
in
&7
and
mu
scl
e
rel
axa
nts
suc
h
as
mi
da=
ola
m
hav
e
bee
n
use
d
to
this
end
wh
ere
the
re
is
spa
stic
ity
and
hy
per
ton
ia
of
the
T
89
mu
scl
es.
&
&
Th
e
gre
ate
st
cha
lle
nge
is
wh
ere
no
ne
of
the
se
tre
at
me
nt
o
pt
io
n
s
p
r
o
vi
d
e
a
s
ol
ut
io
n.
+
n
th
e
s
e
c
a
s
e
s
u
s
e
o
f
a
nt
i
m
ic
r
o
bi
al
g
el
a
n
d@
o
r
a
q
u
e
o
u
s
lu
b
ri
c
at
in
g
a
g
e
nts,
per
i#
and
intr
aor
ally
,
pro
vid
e
so
me
reli
ef
and
aid
pre
ven
tio
n
of
inf
ecti
on.
&&
!re
dis
pos
ing
fact
ors
suc
h
as
pos
tur
e
and
pos
itio
nin
g,
pati
ent
co
mf
ort,
illn
ess
or
pre
sen
ce
of
pai
n,
sho
uld
be
mi
ni
mi
sed
wh
ere
pos
sib
le
an
d
2o
bat
h
tec
hni
qu
es
ha
ve
bee
n
sho
wn
to
be
eff
ect
ive
.
$<,&
&
D
en
tal
tr
ea
tm
en
t
Th
e
pro
vis
ion
of
de
nta
l
tre
at
me
nt
can
pre
sen
t
its
ow
n
s
et
o
f
c
h
al
le
n
g
e
s.
>
o
w

e
v
er
,
w
it
h
%
n
o
w
le
d
g
e
a
n
d
u
n
d
e
rs
ta
n
d
i
n
g
o
f
C
!,
a
n
e
m
p
at
h
ic
a
p
p
r
o
a
ch
an
d
car
efu
l
pla
nni
ng,
the
y
can
ma
inl
y
be
ov
erc
om
e.
Th
ey
inc
lud
e6
C
on
se
nt

thi
s
sho
uld
be
ass
ess
ed
on
an
ind
ivi
du
al
bas
is
an
d it
is
ess
ent
ial
tha
t
ass
um
pti
ons
ab
out
cap
aci
ty
are
not
ma
de
on
the
bas
is
of
ap
pea
ran
ce
or
spe
ech
,
wh
ich
can
be
mi
sle
adi
ng.
$
/rt
icl
e (
in
thi
s
ser
ies
pro
vid
es
fur
the
r
inf
or
ma
tio
n
on
thi
s
top
ic.
(
(
A
cc
ess

so
me
ind
ivi
du
als
wit
h
C!
are
wh
eel
c
h
ai
r
u
s
e
rs
a
n
d
m
a
y
r
e
q
u
ir
e
a
s
si
s
t
a
n
c
e
o
r
tr
a
n
sf
e
r
ai
d
s,
s
u
c
h
a
s
a
h
o
is
t

5
i
g.
,
"
t
o
a
c
c
e
s
s
the
pra
cti
ce
or
the
de
n
tal
cha
ir.
Thi
s
has
bee
n
co
ver
ed
in
det
ail
in
arti
cle
$
of
thi
s
ser
ies.
(&
P
rev
ent
ive
de
nti
str

co
uns
elli
ng
ab
out
die
t,
ora
l
hy
gie
ne
an
d
the
use
of
flu
ori
des
is
im
por
tan
t
for
thi
s
gro
up
of
pe
opl
e.
$
3ui
tab
le
too
thb
rus
h
ada
pta
tio
ns
as
out
lin
ed
in
arti
cle
,
of
the
ser
ies
"
ma
y
be
cru
cia
l to
ach
iev
e
opt
im
al
sel
f#
car
e
an
d
liai
son
wit
h
car
ers
wil
l
be
req
uir
ed
wh
e
r
e
t
h
e
y
a
r
e
r
e
s
p
o
n
si
b
le
f
o
r
p
r
o
v
i
d
i
n
g
o
r
al
c
a
r
e.
&,
T
h
e
u
s
e
o
f
s
p
r
a
y
s
a
n
d
g
el
s
i
n
p
la
c
e
of
mo
uth
#
rin
ses
is
mo
re
ap
pro
pri
ate
for
ind
ivi
du
als
wh
o
ha
ve
dys
ph
agi
a
an
d
po
or
oro
mu
scu
lar
co#
ord
ina
tio
n.
(,
C
om
mu
nic
ati
on

ma
y
be
co
mp
ro
mi
sed
by
spe
ech
im
pai
rm
ent
an
d
sen
sor
y
def
i
cits
an
d
req
uir
e
the
use
of
co
m
m
u
n
ic
at
i
o
n
st
r
at
e
g
ie
s
s
u
c
h
a
s
t
h
e
u
s
e
o
f
h
e
a
ri
n
g
l
o
o
p
s,
c
o
m
p
u
te
r
a
s
si
st
e
d
te
c
h
n
o
l
o
g
y
a
n
d
/
/C
aid
s
5i
g.
)".
(
,(&,(
)
/rt
icl
e &
in
thi
s
ser
ies
co
nsi
der
s
co
m
mu
nic
ati
on
in
det
ail.
()
!
pe
rat
ive
pr
oc
ed
ure
s
req
uir
e
car
e
ful
co
nsi
der
ati
on
of
ph
ysi
cal
pos
tur
e
an
d
pos
itio
nin
g
of
the
sub
4ec
t,
thr
ou
gh
ap
pro
pri
ate
sup
por
t
wit
h
cus
hio
ns,
etc
,
dur
ing
tre
at
me
nt.
&
&
To
get
her
wit
h
use
of
hig
h
vol
um
e
suc
tio
n
an
d@o
r
the
use
of
rub
ber
da
m,
it
wil
l
aid
pre
ve
nti
on
of
ch
o%i
ng
or
si
le
n
t
a
s
p
ir
at
i
o
n
d
u
ri
n
g
tr
e
a
t
m
e
n
t
d
u
e
t
o
s
w
al
l
o
w
i
n
g
d
if
fi
c
u
lt
ie
s
a
n
d
p
o
o
r
p
r
o
te
ct
i
v
e
ai
r
w
ay
refl
exe
s.
,
3u
d
de
n
mo
ve
me
nts
ma
y
req
uir
e
the
use
of
ph
ysi
cal
int
erv
ent
ion
,
wit
h
the
pat
ien
ts
co
nse
nt,
suc
h
as
the
ge
ntl
e
res
trai
nin
g
of
a
lim
b
(7
5i
g.
7",
or
the
use
of
a
mo
uth
pro
p
or
fin
ger
gu
ard
to
pre
ve
nt
sud
de
n
clo
sin
g
du
e
to
mu
scl
e
spa
sm
or
the
bit
e
refl
ex.
$
Ae
sto
rati
on
of
fra
ctu
red
ant
eri
or
tee
th
is
im
por
tan
t to
pre
ve
nt
dis
co
mf
ort
an
d,
mo
re
so,
to
r
e
st
o
r
e
s
el
f#
e
st
e
e
m
a
n
d
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o
ci
al
a
c
c
e
p
ta
b
il
it
y.
5
o
r
t
h
e
la
tt
e
r
t
w
o
r
e
a
s
o
n
s,
it
c
a
n
b
e
ar
g
u
ed
tha
t
aes
the
t
ics
is
of
gre
ate
r
im
por
tan
ce
to
the
per
son
wit
h
dis
abi
lity
tha
n it
is
for
the
ind
ivi
d
ual
wit
h
no
dis
abi
lity
,
(:
an
d a
full
ran
ge
of
res
tor
ati
ve
tre
at
me
nt
sho
uld
be
ma
de
available to them. There are no contra
Anxiet and movement management
anxiety may worsen the usual athetoid movements or spasticity, and anxiolyt
drugs.
(:
/rticle ) of this series provides further information.
8anley demon strated that the use of conscious sedation provides a valuable solution to providing a good standard of care in patients with C!. +t enables repeated treatment ses
options.
(:
>e advocates the technique of titration of intravenous mida=olam against patient response, with the suggested use of '.&) ml of ,' mg@ml intra#nasal mida=olam initially if required to overcome difficul
disorder, patient co#operation, and@or compromised cognition. 5or people with profound disabilities or movement disor
can limit treatment provision if they are lengthy procedures or require repeat appointments.
increased ris% of hypothermia.
The preventive and dental needs of most people with cerebral palsy can be met in general dental practice. >owever, some people, mainly those with profound neuro#disability, anxiety or learning dis
referral for specialist care.
2. DO012) )*1DRO3E
Downs syndrome D3" is a genetic con
&$"
tha
t
res
ult
s
in
a
cha
rac
teri
stic
ap
pea
ran
ce,
lea
rni
ng
dis
abi
lity
w
hic
h
ran
ges
fro
m
mil
d
to
sev
ere
"
an
d a
var
i
ety
of
ph
ysi
cal
an
d
me
dic
al
fea
tur
es.
(
<
Th
e
cha
rac
teri
stic
ap
pea
r
a
n
c
e
i
n
D
3
is
t
h
at
o
f
s
h
o
rt
st
at
u
r
e,
r
el
at
i
v
el
y
s
h
o
rt
a
r
m
s
a
n
d
le
g
s,
b
r
o
a
d
h
a
n
d
s
a
n
d
s
h
o
rt
fi
ng
ers,
flat
ten
ed
fac
e
an
d
occ
ipu
t,
sla
nti
ng
eye
s
wit
h
pro
mi
ne
nt
epi
ca
n
thi
c
fol
ds
an
d
un
der
de
vel
op
me
nt
of
the
mi
ddl
e
thir
d
of
fac
e
res
ulti
ng
in
rel
ati
ve
pro
gn
ath
is
m
5i
g.
;".
*
ral
an
d
de
nta
l
cha
rac
teri
stic
s
inc
lud
e
del
aye
d
de
vel
op
me
nt
an
d
eru
pti
on
of
bot
h
de
ntit
ion
s,
hy
po
do
nti
a,
mi
cro
do
n
tia,
sho
rt
roo
ts,
hy
po
cal
cifi
cat
ion
an
d
hy
po
pla
stic
def
ect
s,
occ
lus
al
p
r
o
b
le
m
s,
a
n
d
a
h
i
g
h
i
n
ci
d
e
n
c
e
o
f
s
e
v
e
r
e
e
a
rl
y
o
n
s
et
p
e
ri
o
d
o
n
ta
l
d
is
e
a
s
e

5
i
g.
<
".
,'
!
h
y
s
ic
al
a
nd
me
dic
al
fea
tur
es
inc
lud
e
car
dia
c
an
om
ali
es
,'
.",
,$
vis
ual
im
pai
rm
ent
)'
.",
,&
hea
rin
g
im
pai
rm
ent
mi
ld
to
mo
der
ate
in
)'
.",
,(
atl
ant
oa
xia
l
ins
ta
bili
ty
or
sub
lux
ati
on
&'
.",
,,
co
mp
ro
mi
sed
im
mu
ne
sys
te
m,
,
$
hy
pot
hyr
oid
is
m
$)
."
,
,)
inc
rea
sed
ris
%
of
epi
lep
sy
&#
$'
.
de
pe
ndi
ng
on
age
",
,7
inc
rea
sed
ris
%
of
dia
bet
es
Ty
pe
$
&
."
,:
a
nd
ear
lier
ons
et
of
/l
=he
im
er
s
dis
eas
e.
,;
/ll
of
t
h
e
s
e
c
o
n
d
it
i
o
n
s
n
e
e
d
t
o
b
e
c
o
n
si
d
e
r
e
d
w
h
e
n
p
r
o
v
i
d
i
n
g
d
e
n
ta
l
tr
e
at
m
e
n
t.
,<
(
i
4
i
n
+

"
n
+e
r
Th
ere
are
cur
ren
tly
mo
re
tha
n
&7,
''
'
pe
opl
e
wit
h
D3
in
the
D
E
an
d
an
inc
i
de
nce
of
$
in
$,'
''
birt
hs,
bot
h
ma
le
an
d
fe
ma
le.
,
7
Th
e
life
ex
pec
tan
cy
of
pe
opl
e
wit
h
D3
has
im
pro
ve
d
dra
ma
tic
all
y
fro
m
an
ave
rag
e
of
nin
e
yea
rs
in
$<
''
to
an
ave
rag
e
of
)'#
7'
yea
rs
cur
ren
tly.
/s
the
pre
val
enc
e
of
D3
is
set
to
ris
e,
age
ing
in
D3
is
onl
y
be
gin
nin
g
to
be
res
ear
che
d
a
n
d
a
d
d
r
e
s
s
e
d.
)'
/
lt
h
o
u
g
h
m
a
n
y
p
e
o
p
le
w
it
h
D
3
a
r
e
a
b
le
t
o
li
v
e
h
e
al
t
h
y
a
d
u
lt
li
v
e
s
w
it
h
o
u
t
co
nce
rns
rel
ate
d
to
ser
i
ous
illn
ess
or
ad
diti
on
al
dis
abi
lity
, it
is
rep
ort
ed
tha
t
the
hea
lth
nee
ds
of
old
er
pe
opl
e
wit
h
D3
are
not
yet
bei
ng
me
t
an
d
so
me
pe
opl
e
wit
h
D3
are
dyi
ng
fro
m
ma
na
gea
ble
an
d
tre
ata
ble
co
ndi
tio
ns.
)$
/
lth
ou
gh
life
ex
pec
tan
cy
has
inc
rea
sed
, it
is
stil
l
lo
we
r
tha
n
for
the
ge
ner
al
po
pul
ati
on.
!o
ssi
ble
ex
pla
na
tio
ns
are
tha
t
pe
opl
e
wit
h
D3
1ag
e
pr
e
m
at
u
r
el
y
a
n
d
t
h
u
s
li
f
e
e
x
p
e
ct
a
n
c
y
is
r
e
d
u
c
e
d
F
a
n
d
t
h
at
D
3
is
a
s
s
o
ci
at
e
d
w
it
h
a
n
i
n
c
r
e
a
s
e
d
ris
%
of
illn
ess
an
d
mo
rtal
ity.
Th
e
for
me
r
ex
pla
nat
ion
is
ge
ner
all
y
fav
our
ed,
an
d it
is
tho
ug
ht
tha
t
the
ag
e
ing
pro
ces
s
sta
rts
soo
ner
or
is
spe
ede
d
up.
3u
btl
e
me
mo
ry
los
ses
,
ph
ysi
cal
tire
dn
ess
an
d
ge
ner
al
frai
lt
y,
a
s
w
el
l
a
s
s
p
e
ci
fi
c
il
l
n
e
s
s
e
s,
m
a
y
b
e
p
r
e
s
e
n
t
w
h
e
n
a
p
e
rs
o
n
w
it
h
D
3
is
i
n
h
is
@
h
e
r
t
h
ir
ti
e
s
rat
her
tha
n
his
@he
r
six
ties
.
>o
we
ver
,
/l
=he
im
er
s
dis
eas
e
/
D"
is
the
onl
y
co
ndi
tio
n
ass
oc
i
ate
d
wit
h
dec
rea
sed
life
ex
pec
tan
cy
tha
t
occ
urs
ear
lier
in
D3
.
)$
+t
inc
rea
ses
fro
m
ab
out
the
age
of
(',
an
d
by
the
ir
fi
ftie
s
aro
un
d
)'
.
of
pe
opl
e
wit
h
D3
sho
w
sig
ns
of
/
D.
+t
inc
rea
ses
wit
h
age
at
a
si
mil
ar
rat
e
as
in
the
ge
ner
al
po
pul
ati
on,
but
('
or
,'
yea
rs
soo
ner
.
+ts
ons
et
c
a
n
b
e
d
if
fi
c
u
lt
t
o
d
et
e
ct
a
s
i
n
p
e
o
p
le
w
it
h
D
3
it
m
a
y
af
f
e
ct
p
e
rs
o
n
al
it
y
o
r
b
e
h
a
v

i
o
u
r
b
e
f
o
r
e
the
cla
ssi
cal
ear
ly
fea
tur
es
of
me
mo
ry
los
s
bec
om
e
ap
par
ent
.
,;
De
me
n
tia
wil
l
be
ex
pla
ine
d
in
mo
re
det
ail
in
the
ne
xt
arti
cle
in
thi
s
ser
ies.
Di
ag
nos
is
is
bas
ed
on
the
exc
lus
ion
of
oth
er
co
n
diti
ons
tha
t
mi
ght
pre
sen
t
wit
h
si
mil
ar
sy
mp
to
ms
Ta
ble
&".
!
eo
ple
wit
h
D3
ex
per
ien
ce
the
sa
me
co
ndi
tio
ns
as
the
ge
ner
al
po
pul
ati
on
as
the
y
age
but
ex
per
ien
ce
the
m
at
an
ea
r
li
e
r
a
g
e.
>
o
w
e
v
er
,
t
h
e
y
m
a
y
b
e
m
is
i
n
te
r
p
r
et
e
d
a
n
d
w
h
e
r
e,
f
o
r
e
x
a
m
p
le
,
h
e
a
ri
n
g
o
r
v
is
u
al
i
m
pai
rm
ent
s
lea
d
to
a
dec
lin
e
in
co
m
mu
nic
ati
on
or
livi
ng
s%i
lls,
the
y
can
be
mi
sdi
ag
nos
ed
as
de
pre
ssi
on.
,;
De
pre
ssi
on
itse
lf
is
on
e
of
the
mo
st
fr
e
qu
ent
ly
dia
gn
ose
d
psy
chi
atri
c
dis
ord
ers
in
the
D3
po
pul
ati
on,
but
is
pro
ba
bly
un
der
#
rep
ort
ed
as
pe
opl
e
wit
h
D3
ma
y
fin
d it
dif
fic
ult
to
ex
pre
ss
ho
w
the
y
are
fee
lin
g,
co
mp
lic
ati
ng
its
dia
gn
osi
s.
Or
a
he
at
h
De
spi
te
a
n
a
g
ei
n
g
D
3
p
o
p
u
la
ti
o
n,
m
o
st
o
f
t
h
e
li
te
r
at
u
r
e
a
b
o
u
t
o
r
al
h
e
al
t
h
a
n
d
D
3
r
el
at
e
s
t
o
c
h
il
d
r
e
n
a
nd
ad
ole
sce
nts.
)&
))
Th
ese
stu
die
s
ge
ner
all
y
ind
ica
te a
lo
we
r
car
ies
rat
e
tha
n
in
the
chi
ld
po
pu
lati
on
as
a
wh
ole
.
>o
we
ver
,
Da
vil
a
et
al.
fou
nd
)(
.
of
the
ir
stu
dy
po
pul
ati
on
ha
d
car
ies
)7
an
d a
stu
dy
of
&'#
,'
yea
r
old
ad
ult
s
wit
h
lea
rni
ng
dis
abi
lity
livi
ng
in
an
ins
titu
tio
n
fou
nd
a
sig
nifi
can
tly
lo
we
r
D
8
5T
in
pe
opl
e
wit
h
D3
co
mp
are
d
wit
h
tho
se
wit
h
cer
ebr
al
p
al
s
y
o
r
i
d
i
o
p
at
h
ic
d
e
v
el
o
p
m
e
n
ta
l
d
el
a
y.
):
/
>
o
n
g
E
o
n
g
s
u
r
v
e
y
l
o
o
%
i
n
g
at
t
h
e
o
r
al
h
e
al
t
h
st
atu
s
of
7)
co
m
mu
nit
y
dw
elli
ng
ad
ult
s
wit
h
D3
age
d
bet
we
en
$:
an
d
,&
yea
rs
fou
nd
a
lo
we
r
car
ies
rat
e
in
the
D3
gro
up
tha
n
the
ma
tch
ed
co
ntr
ol
gro
up.
Th
e
ad
ult
s
wit
h
D3
ha
d
sig
nifi
can
tly
fe
we
r
fill
ed
tee
th,
fe
we
r
dec
aye
d
tee
th,
mo
re
pe
g#
sha
pe
d
ma
x
il
la
r
y
la
te
r
al
i
n
ci
s
o
rs
,
a
n
d
m
o
r
e
r
et
ai
n
e
d
d
e
ci
d
u
o
u
s
te
et
h.
);
T
h
e
l
o
w
c
a
ri
e
s
p
r
e
v
al
e
n
c
e
i
n
c
h
ildr
en
wit
h
D3
has
bee
n
lin
%e
d
to
im
mu
ne
pr
o
tec
tio
n
fro
m
ele
vat
ed
sali
var
y
"tr
ep
toc
oc
cu
s
mu
tan
s
+g
/
co
nce
ntr
ati
ons
.
)<
>o
we
ver
, a
stu
dy
am
on
g
(<
pe
opl
e
wit
h
D3
age
d
fro
m
$$
to
7<
yea
rs
de
mo
n
str
ate
d a
lo
we
r
rat
e
of
sali
var
y
sec
reti
on
in
pe
opl
e
wit
h
D3
tha
n
in
a
no
n#
D3
co
n
trol
gro
up.
+t
wa
s
attr
ibu
ted
to
dec
rea
sed
sti
mu
lat
ed
par
oti
d
sali
var
y
flo
w
an
d,
al
t
h
o
u
g
h
n
o
t
st
at
is
ti
c
al
l
y
si
g
n
if
ic
a
n
t,
d
e
c
r
e
a
s
e
d
w
it
h
i
n
c
r
e
a
si
n
g
a
g
e.
T
h
u
s
it
is
p
o
s
si
b
le
t
h
at
car
ies
ma
y
bec
om
e
mo
re
of
a
pro
ble
m
as
pe
opl
e
wit
h
D3
age
,
alt
ho
ug
h
as
yet
the
re
is
no
evi
de
nce
to
sup
por
t
thi
s
hy
pot
hes
is.
T
he
sev
erit
y,
pre
val
enc
e
an
d
ext
ent
of
per
iod
ont
al
dis
eas
e
are
all
sig
nifi
can
tly
gre
ate
r in
the
D3
po
pul
ati
on
tha
n
in
the
ge
ner
al
po
pul
ati
on.
7'
!re
val
enc
e
has
bee
n
rep
ort
ed
fro
m
);#
<7
.
for
pe
opl
e
wit
h
D3
un
der
the
age
of
()
yea
rs,
7
'
wit
h
lo
we
r
i
n
ci
s
o
rs
a
n
d
u
p
p
e
r
fi
rs
t
m
o
la
rs
m
o
st
c
o
m
m
o
n
l
y
af
f
e
ct
e
d.
7$
T
h
is
si
t
u
a

ti
o
n
is
n
o
t
at
tr
i
b
u
te
d
s
o
le
l
y
to
po
or
ora
l
hy
gie
ne
an
d
the
re
has
bee
n a
foc
us
on
an
alt
ere
d
im
mu
ne
res
po
nse
du
e
to
the
un
der
lyi
ng
ge
net
ic
dis
ord
er
of
D3
.
7'
5in
din
gs
reg
ard
ing
the
ma
na
ge
me
nt
of
per
iod
ont
al
dis
eas
e
in
pe
opl
e
wit
h
D3
are
mi
xe
d.
Gig
mo
nd
et
al.
7
$
rep
ort
ed
tha
t a
pre
ve
nti
ve
pro
gra
m
me
ha
d
no
eff
ect
on
red
uci
ng
the
pro
g
r
e
s
si
o
n
o
f
ei
t
h
e
r
g
e
n
e
r
al
is
e
d
o
r
l
o
c
al
is
e
d
p
e
ri
o
d
o
n
ta
l
d
ise
ase
,
ind
ica
tin
g
tha
t
im
pai
red
ora
l
hy
gie
ne
pla
ys
a
rel
ati
vel
y
mi
nor
rol
e
in
its
pat
ho
ge
nes
is.
Thi
s is
at
od
ds
wit
h
the findings of Galdivar#Chiapa
$, people with D3 aged $, to (' years.
young adults with D3 aged $) to &7 years.
monthly recalls in &$ adults with D3 aged &' to (' years.
review.
);,7(,7,
The short roots of teeth in D3 com
limited information relating to tooth wear is in the child population only and the fi ndings are mixed. 2ell
ero sion, while more recently, bruxism has been reported as no more common in children with D3 than in those without it.
Seamless care
The ma4ority of dental treatment for most people with D3 should be possi
as acclimatisation and 1tell#show#do. The degree to which this is successful in people with a learning disability may depend on the sever
3. CARDIO5A)C6(AR DI)EA)E
Cardiovascular disease CBD" is the most common cause of adult death in the developed world. Dental procedures and drugs used in dentistry can aggravate heart disease and it is important that the dental team are aware of the common cardiac
conditions and their manage
periodontitis places certain patients at increased ris% of developing CBD.
a- 789ertensi"n
>ypertension is a persistently raised blood pressure H$,'@<' mm >g. Cinety percent of cases are 1essential, with no obvious cause, although smo%ing, diet and lifestyle are recognised causes. !harmacological intervention should be offered to
patients with persistently high blood pressure of over $7'@$'' mm >g, with the aim of maintaining it at or below $,'@<' mm >g to reduce the ris% of cardiovascular disease and death.
diuretics, beta bloc%ers, calcium channel bloc%ers, /C? inhibitors, sympatholytics and vasodi
and dental hospitals, respectively, reported to ta%e anti#hypertensive drugs.
The Cational +nstitute for >ealth and Clinical ?xcellence C+C?" recommends patient#centred care for management of hypertension, ta%ing account of individ
T
a
b

e

3

T
h
e

r
i
s
:

/
a
;
t
"
r
s

/
"
r

;
a
r
d
i
"
4
a
s
;
#

a
r

d
i
s
e
a
s
e
evi
den
ce#
bas
ed
info
rma
tion
to
allo
w
patients
to reach
informe
d
decision
s about
their
care.
b-
A
n
+i
na
/n
gin
a is
sev
ere
,
cru
shi
ng
che
st
pai
n.
3ta
ble
an
gin
a is
typ
ica
lly
pre
cip
itat
ed
by
eff
ort
an
d
reli
eve
d
by
res
t
wit
hin
ten
mi
nut
es.
Th
e
usu
al
cau
se
is
c
o
r
o
n
a
r
y
at
h
e
r
o
s
cl
e
r
o
si
s
r
e
s
u
lt
i
n
g
i
n
i
n
s
u
ff
ic
ie
n
t
b
l
o
o
d
fl
o
w
t
o
a
n
d
o
x
y
ge
nat
ion
of
the
hea
rt
mu
scl
e.
:;
Th
e
pai
n
typ
ica
lly
occ
urs
be
hin
d
the
ste
rnu
m,
rad
iati
ng
to
the
left
up
per
ar
m
an
d
occ
asi
on
all
y
to
the
left
ma
ndi
ble
,
an
d
rar
ely
to
the
tee
th,
ton
gu
e
or
pal
ate
.
Dn
sta
ble
an
gin
a is
tha
t
occ
ur
rin
g
at
res
t,
on
mi
ni
ma
l
exe
rtio
n
or
wit
h
rap
idl
y
inc
rea
sin
g
sev
erit
y.
2o
th
for
ms
are
reli
eve
d
by
sub
lin
gu
al
gly
cer
yl
tri
n
itra
te

I
T
C
"
s
p
r
a
y
o
r
ta
b
le
ts
.
D
n
st
a
b
le
a
n
g
i
n
a
c
a
rr
ie
s
a
si
g
n
if
ic
a
n
t
ri
s
%
o
f
m
y
o

c
a
r
d
ia
l
i
n
f
a
r
ct
an
d
ele
cti
ve
de
nta
l
tre
at
me
nt
sho
uld
not
be
car
rie
d
out
.
3ur
gic
al
tre
at
me
nt
usi
ng
eit
her
ste
nts
or
cor
o
nar
y
art
ery
by
pas
s
gra
fts
has
a
go
od
sur
viv
al
rat
e.
;-
3
8"
;a
rd
ia
in/
ar
;ti
"
n
3ig
ns
an
d
sy
mp
to
ms
of
my
oca
rdi
al
in
f
arc
tio
n
8
+"
are
si
mil
ar
to
an
gin
a
but
are
mo
re
sev
ere
, of
lon
ger
dur
ati
on
an
d
are
not
reli
eve
d
by
IT
C.
Th
e
de
nta
l
tea
m
sho
uld
be
aw
are
t
h
at
s
o
m
e
m
y
o
c
a
r
d
ia
l
i
n
f
a
r
ct
i
o
n
s
a
r
e
1s
il
e
n
t
a
n
d
o
c
c
u
r
w
it
h

o
u
t
a
n
y
r
e
c
o
g
n
is
e
d
s
y
m
pto
ms
or
sig
ns
at
the
tim
e.
S
ea
ml
es
s
ca
re
5or
pat
ien
ts
wit
h
hy
per
ten
sio
n,
pre
ve
n
tiv
e
ad
vic
e
an
d
inf
or
ma
tio
n
on
acc
ess
to
ora
l
hea
lth
car
e
sho
uld
be
ins
titu
ted
at
dia
gn
osi
s
to
av
oid
the
nee
d
for
de
nta
l
car
e
lat
er
on.
+f
fea
sib
le,
de
nta
l
tre
at
me
nt
is
bes
t
car
rie
d
out
usi
ng
loc
al
ana
lge
sia,
wit
h
or
wit
ho
ut
co
nsc
iou
s
sed
ati
on.
/n
xio
lyti
c
age
nts
an
d
u
s
e
o
f
s
e
d
at
i
o
n
a
r
e
v
al
u
a
b
le
t
o
o
ls
f
o
r
r
e
d
u
ci
n
g
t
h
e
ef
f
e
ct
s
o
f
st
r
e
s
s
w
h
il
e
m
ai
n
ta
i
n
i
n
g
o
xy
ge
nat
ion
an
d
ob
via
tin
g
the
nee
d
for
ge
ner
al
ana
est
hes
ia.
3id
e#
eff
ect
s
of
bet
a
blo
c%e
rs
can
inc
lud
e
xer
ost
om
ia
an
d
ap
pro
pri
ate
ma
na
ge
me
nt
of
dry
mo
uth
nee
ds
to
be
ins
tig
ate
d.
&,
/ls
o,
cal
ciu
m
cha
nn
el
blo
c%e
rs,
par
tic
ula
rly
nif
edi
pin
e,
ha
ve
bee
n
ass
oci
ate
d
wit
h
gin
giv
al
ov
erg
ro
wt
h
wh
ich
is
bes
t
ma
n
age
d
thr
ou
gh
go
od
ora
l
hy
gie
ne
but
ma
y
req
uir
e
sur
ger
y.
:7
,:<
2
o
t
h
b
et
a
b
l
o
c
%
e
rs
a
n
d
n
o
n
#
p
o
ta
s
si
u
m
s
p
a
ri
n
g
d
i
u
r
et
ic
s
c
a
n
e
x
a
c
e
r
b
at
e
t
h
e
ef
f
e
ct
s
o
f
e
pin
ep
hri
ne
in
de
nta
l
loc
al
ana
est
het
ic
age
nts
an
d it
is
rec
o
m
me
nd
ed
tha
t
pat
ien
ts
wit
h
mil
d
to
mo
d
era
te
CB
D
rec
eiv
e
the
sm
all
est
am
ou
nt
of
loc
al
ana
est
het
ic
nee
de
d
to
pro
vid
e
eff
ect
ive
ana
lge
sia,
usi
ng
an
asp
irat
ion
tec
hni
qu
e
to
pre
ve
nt
intr
ava
scu
lar
in4
ec
tio
n.
;'
8a
ny
pat
ien
ts
wit
h
CB
D
ma
y
be
ta%
ing
ant
ico
ag
ula
nts
suc
h
as
asp
irin
or
wa
rfa
rin
an
d
the
ma
na
ge
me
nt
of
t
h
e
s
e
i
n
d
i
v
i
d
u
al
s
is
d
e
s
c
ri
b
e
d
i
n
a
rt
ic
le
)
o
f
t
h
is
s
e
ri
e
s.
(;
?
ff
e
ct
i
v
e
a
n
al
g
e
si
a,
s
h
o
rt
a
p
p
o
int
me
nts
an
d
ava
ila
bili
ty
of
bot
h
ox
yg
en
an
d
IT
C
are
all
im
por
tan
t in
tre
at
me
nt
reg
im
ens
.
!ro
ph
yla
cti
c
IT
C
pri
or
to
de
nta
l
tre
at
me
nt
has
bee
n
sho
wn
to
be
eff
ect
ive
in
the
pre
ve
nti
on
of
bot
h
hy
per
ten
sio
n
an
d
a
n
g
i
n
a
d
u
ri
n
g
tr
e
at
m
e
n
t.
;$
I
T
C
s
h
o
u
l
d
al
s
o
b
e
e
a
si
l
y
t
o
h
a
n
d
t
h
r
o
u
g
h
o
u
t
d
e
n
ta
l
tr
e
at
m
e
n
t
an
d
sho
uld
reli
eve
che
st
pai
n
in
an
gin
a
wit
hin
fiv
e
mi
nut
es.
!ro
lon
ge
d
use
of
IT
C
tab
lets
has
bee
n
fou
nd
to
cau
se
car
ies
loc
alis
ed
to
the
are
a
wh
ere
the
tab
let
is
ret
ain
ed
5i
g.
$'"
.
;&
Thi
s
can
be
av
oid
ed
by
usi
ng
a
IT
C
spr
ay.
+
t is
co
m
mo
nly
rec
om
me
nd
ed
tha
t
pat
ien
ts
do
not
rec
eiv
e
de
nta
l
car
e
for
at
lea
st
six
mo
nth
s
aft
er
ex
per
ien
cin
g
an
8+
.
;(,;
,
>o
we
ver
,
8e
ech
an
sug
ges
ts
t
h
at
i
d
e
al
ly
,
el
e
ct
i
v
e
tr
e
at
m
e
n
t
s
h
o
u
l
d
b
e
p
o
st
p
o
n
e
d
f
o
r
a
y
e
a
r
a
s
t
h
e
r
e
is
a
h
i
g
h
c
h
a
n
c
e
of
a
fur
the
r
inf
arc
t
dur
ing
thi
s
per
iod
.
:;
Dn
til
thi
s
tim
e,
acu
te
de
nta
l
nee
ds
sho
uld
be
ma
na
ge
d
in
co
nsu
lta
tio
n
wit
h
the
pat
ien
ts
ph
ysi
cia
n.
/ll
pat
ien
ts
wit
h
CB
D
sho
uld
be
ma
na
ge
d
usi
ng
a
str
ess
#
red
uct
ion
pro
toc
ol
tha
t
inc
lud
es
sho
rt
ap
poi
nt
me
nts
,
pre
fer
abl
y
in
the
mo
rni
ng
wh
en
pat
ien
ts
are
we
ll
res
ted
F
use
of
eff
ect
ive
loc
al
ana
est
het
ic
to
mi
ni
mi
se
dis
co
mf
o
rt
F
u
s
e
o
f
c
o
n
s
ci
o
u
s
s
e
d
at
i
o
n
t
o
r
e
d
u
c
e
st
r
e
s
sF
a
n
d
p
r
o
v
is
i
o
n
o
f
e
x
c
el
le
n
t
p
o
st
#
o
p
e
r
at
ive
ana
lge
sia.
d
-

C
"
n
+
e
n
i
t
a


;
a
r
d
i
a
;

;
"
n
d
i
t
i
"
n
s

a
n
d

a
;
<
#
i
r
e
d

;
a
r
d
i
a
;

d
i
s
e
a
s
e
+nf
ect
ive
en
do
car
diti
s
+?
",
alt
ho
ug
h
un
co
m
mo
n,
ma
y
aff
ect
da
ma
ge
d
hea
rt
val
ves
,
pro
sth
eti
c
hea
rt
v
al
v
e
s,
a
c
o
a
r
ta
te
d
a
o
rt
a,
p
at
e
n
t
d
u
ct
u
s
a
rt
ei
o
s
u
s
o
r
v
e
n
tr
ic
u
la
r
s
e
p
ta
l
def
ect.
/s
"tr
ept
o
co
cc
us
vir
ida
ns
is
the
mo
st
co
m
mo
nly
iso
lat
ed
bac
teri
a
in
+?,
:;
unt
il
rec
ent
ly
pro
ph
yla
cti
c
use
of
ant
ibi
oti
cs
wa
s
recommended for dental treatment in patients with acquired valvular heart disease with stenosis or regurgitation, valve replacement, structural congenital heart disease, previous +? and cardiac myopathy. /lthough these groups are still considered
to be at ris% of developing endocarditis, after reviewing the litera
who have received antibiotic cover for dental treatment for many years will require careful counsel
Seamless care
C+C? recognises the pivotal role that both the individual and the dental profes
maintain good oral health in the primary dental care setting. The responsibility of the dental team is to educate the patient about, and to alert them to, the signs of infective endocarditis Table ," and when to see% expert adviceF and to instil in them
the importance of good oral hygiene and regular reviews and dental treatment as appropriate.
e- Inherited and a;<#ired beedin+ dis"rders
This sub4ect has been dealt with in article ) of this series and the reader is referred to it for information.
Iiven the high mortality rate of CBD and the relatively minor morbidity of periodontal therapy, maintenance of periodontal health should be among the routine recommendations for prevention of heart disease.
=. RE)PIRATOR* DI)EA)E
This section covers only the respiratory diseases most li%ely to be encountered in dental practice, namely chronic obstruc
a- Chr"ni; "bstr#;ti4e 9#."nar8 disease ,COPD-
Chronic obstructive pulmonary disease C*!D" is the name for a collection of
There is no single diagnostic test for C*!D and diagnosis relies on clini
disease is tailored to the severity of the symptoms and the cor
can improve short ness of breath but limits activities and may mean they are confined to home. The impact of C*!D on the quality of life of individuals and carers can be consid
Seamless care
!atients with C*!D should have access to the wide range of s%ills available from a multidisciplinary team 8DT". !rofes
assist with managing daily living activities and, for people with end stage disease, the palliative care team. The
die
tici
an
ma
y
als
o
be
inv
olv
ed,
as
ab
out
on
e
thir
d
of
pe
opl
e
wit
h
C*
!D
ha
ve
sig
#
nifi
can
t
ma
lnu
trit
ion
rel
ate
d
to
di
mi
n
ish
ed
ap
pet
ite
an
d
the
inc
rea
sed
ene
rgy
ex
pe
ndi
t
u
r
e
r
e
q
u
ir
e
d
f
o
r
b
r
e
at
h
i
n
g.
T
h
e
d
e
n
ta
l
p
r
o
f
e
s
si
o
n
al
c
a
n
b
e
a
v
al
u

a
b
le
m
e
m
b
e
r
o
f
t
h
e
8
DT
as
the
re
are
a
nu
mb
er
of
ora
l
hea
lth
ris
%
fac
tor
s.
Th
e
fre
qu
enc
y
an
d
sev
erit
y
of
per
iod
on
tal
dis
eas
e is
inc
rea
sed
in
pe
opl
e
wit
h
C*
!D
.
<(
Th
e
ora
l
hea
lth
ris
%
can
be
exa
c
erb
ate
d if
the
ind
ivi
du
al
is a
sm
o%
er,
or
if
the
y
are
on
ox
yg
en
the
rap
y,
wh
ich
is
ass
oci
ate
d
wit
h
xer
ost
om
ia.
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di
tio
nal
ly,
pat
ien
ts
ma
y
be
ad
vis
ed
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eat
sm
all,
nut
rie
nt
an
d
cal
ori
e#
ri
c
h
m
e
al
s
fr
e
q
u
e
n
tl
y.
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h
e
d
e
n
ta
l
te
a
m
h
a
v
e
a
r
o
le
t
o
p
la
y
i
n
t
h
e
p
r
o
v
is
i
o
n
o
f
o
r
al
h
e
al
t
h
a
d
vic
e,
sm
o%i
ng
ces
sati
on
an
d
die
tar
y
ad
vic
e.
Thi
s is
par
tic
ula
rly
im
por
tan
t,
as
po
or
ora
l
hy
gie
ne
has
bee
n
lin
%e
d
to
res
pir
ato
ry
pat
ho
ge
n
col
oni
sati
on
an
d
de
nta
l
pla
qu
e
ma
y
act
as
a
res
erv
oir
for
acq
uir
ed
pn
eu
mo
nia
in
old
er
pe
o
ple
,
par
tic
ula
rly
res
ide
nts
of
lon
g#
ter
m
car
e
fac
iliti
es.
<
,
8
ost
pe
opl
e
wit
h
C*
!D
can
rec
eiv
e
de
nta
l
tre
at
me
nt
saf
ely,
wit
h
onl
y
m
i
n
o
r
a
d
4
u
st
m
e
n
ts
t
o
p
r
o
c
e
d
u
r
e
s,
i
n
g
e
n
e
r
al
d
e
n
ta
l
p
r
a
ct
ic
e.
5
o
r
c
o
m
f
o
rt
o
f
b
r
e
at
h

i
ng,
the
y
ma
y
nee
d
to
ha
ve
the
ir
de
nta
l
tre
at
me
nt
in
an
upr
igh
t or
se
mi#
rec
lin
ed
pos
itio
n.
!e
opl
e
on
ox
yg
en
the
rap
y
wil
l
nee
d
am
bul
anc
e
tra
nsp
ort
for
de
nta
l
ap
poi
nt
me
nts
an
d
an
ade
qu
ate
sup
ply
of
ox
yg
en
dur
ing
the
vis
it,
or
pro
vis
ion
of
do
mi
cili
ary
ora
l
hea
lth
car
e.
!at
ien
ts
wit
h
sev
ere
C*
!D
are
at
par
tic
ula
r
ris
%
wh
en
giv
en
intr
ave
no
us
sed
ati
ves
,
op
i
ate
s
or
g
e
n
e
r
al
a
n
a
e
st
h
et
ic
s
d
u
e
t
o
r
e
s
p
ir
at
o
r
y
d
e
p
r
e
s
si
o
n,
a
n
d
w
h
e
r
e
p
o
s
si
b
le
s
h
o
u
l
d
b
e
tr
e
at
e
d
wit
h
loc
al
ana
lge
sia.
;;
Th
e
res
pir
ato
ry
cen
tre
of
a
1bl
ue
blo
ate
r
is
rel
ati
vel
y
ins
ens
itiv
e
to
car
bo
n
dio
x
ide
an
d
the
ind
ivi
du
al
reli
es
on
hy
po
xic
dri
ve
to
ma
int
ain
res
pir
ato
ry
eff
ort.
!r
o
vid
ing
sup
ple
me
nta
l
ox
yg
en
for
mo
re
tha
n
bri
ef
per
iod
s
can
be
da
ng
ero
us
to
suc
h
pat
ien
ts
as
wit
ho
ut
the
hy
po
xic
dri
ve
the
y
ma
y
hy
po
ve
ntil
ate
or
sto
p
bre
ath
ing
alt
og
eth
er.
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)
b
-
A
s
t
h
.
a
/
st
h
m
a
is
c
o
m
m
o
n.
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is
e
st
i
m
at
e
d
t
h
at
).
&
m
il
li
o
n
p
e
o
p
le
a
r
e
af
f
e
ct
e
d
i
n
t
h
e
D
E
,
w
ith
at
lea
st
on
e
aff
ect
ed
per
son
in
eve
ry
fi
ve
ho
use
hol
ds.
<7
+n
&'
'),
$,(
$;
D
E
dea
ths
we
re
attr
ibu
tab
le
to
ast
hm
a.
+t
is
des
cri
be
d
as
a
ge
ner
alis
ed
air
wa
y
obs
tru
cti
on
wh
ich
, in
the
ear
ly
sta
ges
, is
par
ox
ys
ma
l
an
d
rev
ers
ibl
e.
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e
obs
tru
c
tio
n
is
du
e
t
o
b
r
o
n
c
h
ia
l
m
u
s
cl
e
c
o
n
tr
a
c

ti
o
n,
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u
c
o
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al
s
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el
li
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g
a
n
d
i
n
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r
e
a
s
e
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m
u
c
o
u
s
p
r
o
d
u
ct
i
o
n
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nd
lea
ds
to
co
ug
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ing
,
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ee=
ing
,
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d@o
r
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rtn
ess
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bre
ath
.
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Co
m
mo
n
trig
ger
s
inc
lud
e
ho
use
dus
t
mit
es,
ani
ma
l
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pol
len
,
tob
acc
o
sm
o%
e,
col
d
air,
che
st
inf
ect
ion
s
an
d
str
ess
,
an
d
ad
ult
ast
hm
a
can
de
vel
op
aft
er
a
vir
al
inf
ect
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.
Th
ere
is
no
cur
e
for
ast
hm
a
an
d
tre
at
me
nt
an
d
ma
na
ge
me
nt
inc
lud
e
the
use
of
pre
ve
nte
r
an
d
reli
eve
r
inh
ale
rs.
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thi
s
p
r
o
v
e
s
i
n
s
u
f
fi
ci
e
n
t,
i
n
h
al
e
d
st
e
r
o
i
d
s
a
r
e
u
s
e
d
a
n
d
i
n
s
e
v
e
r
e
c
a
s
e
s
s
y
st
e
m
ic
st
e
r
o
i
d
s
ma
y
be
pre
scr
ibe
d.
S
ea
ml
es
s
ca
re
/n
ti#
ast
hm
ati
c
me
dic
ati
on,
suc
h
as
sal
but
am
ol
inh
ale
r or
tab
lets
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d
be
c
la
me
tha
son
e
inh
ale
r,
can
lea
d
to
bot
h
inc
rea
sed
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nta
l
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ies
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d
per
iod
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al
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er
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co
ntr
ol
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y
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si
ble
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cer
bat
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de
nta
l
dis
eas
e,
pe
o
ple
wit
h
ast
hm
a
sho
uld
be
ad
vis
ed
by
the
ir
do
cto
r,
ph
ar
ma
cist
or
de
nti
st
tha
t
the
y
nee
d
t
o
a
d
o
p
t
m
o
r
e
p
r
e
c
a
u
ti
o
n
a
r
y
o
r
al
h
y
g
ie
n
e
p
r
a
ct
ic
e
s
a
n
d
h
a
v
e
r
e
g
u

la
r
d
e
n
ta
l
r
e
v
ie
w
s.
<:
3al
but
am
ol
is a
J&
adr
ene
rgi
c
ag
oni
st
an
d
can
pro
du
ce
dry
mo
uth
,
tast
e
alt
era
tio
n
an
d
dis
co
l
our
ati
on
of
tee
th.
!e
opl
e
usi
ng
cor
ti
cos
ter
oid
inh
ale
rs
are
als
o
pre
dis
pos
ed
to
de
vel
opi
ng
can
did
osi
s.
<;
,<<
To
hel
p
pre
ve
nt
the
se
sid
e#
eff
ect
s,
pe
opl
e
are
ad
vis
ed
to
rin
se
an
d
gar
gle
wit
h
wa
ter
an
d
bru
sh
the
ir
tee
th
aft
er
usi
ng
the
ir
pre
ve
nte
r
inh
ale
r.
<7
2
efo
re
de
nta
l
tre
at
m
e
n
t,
a
n
a
st
h
m
a
h
is
t
o
r
y
t
h
at
i
n
cl
u
d
e
s
ef
fi
c
a
c
y
o
f
m
e
d
ic
a

ti
o
n,
u
s
e
o
f
st
e
r
o
i
d
s
a
n
d
a
n
y
e
p
is
od
es
of
hos
pit
alis
ati
on
sho
uld
be
asc
ert
ain
ed.
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+f
ste
roi
ds
ha
ve
bee
n
ta%
en
lon
g#
ter
m,
co
nsi
der
ati
on
sho
uld
be
giv
en
to
the
nee
d
for
inc
rea
sin
g
the
dos
e
pri
or
to
inv
asi
ve
de
nta
l
tre
at
me
nt.
Th
e
sev
erit
y
of
an
ind
ivi
du
als
ast
hm
a
wil
l
var
y,
so
it
is
pru
de
nt
to
pla
n
de
nta
l
car
e
aro
un
d
per
iod
s
wh
en
the
co
ndi
tio
n
is
les
s
sev
ere
.
/s
ex
pos
ure
to
all
erg
ens
an
d@o
r
str
ess
can
i
n
d
u
c
e
a
n
a
st
h
m
a
at
ta
c
%,
it
is
a
d
v
is
a
b
le
f
o
r
t
h
e
i
n
d
i
v
i
d
u
al
t
o
u
s
e
t
h
ei
r
i
n
h
al
e
r
p
ri
o
r
t
o
tr
e
at
me
nt
an
d
to
ha
ve
it
ava
ila
ble
thr
ou
gh
out
the
ap
poi
nt
me
nt.
/d
diti
on
all
y,
eff
ort
s
sho
uld
be
ma
de
to
all
ay
an
xie
ty
as
far
as
is
pos
sib
le.
!re
f
era
bly
,
tre
at
me
nt
sho
uld
be
car
rie
d
out
wit
h
loc
al
ana
lge
sia.
<)
+f
co
nsc
iou
s
sed
a
tio
n
is
req
uir
ed,
rel
at
i
v
e
a
n
al
g
e
si
a
is
t
h
e
te
c
h
n
i
q
u
e
o
f
c
h
o
ic
e
a
s
i
n
t
h
e
e
v
e
n
t
o
f
a
n
a
st
h
m
a
at
ta
c
%,
it
c
a
n
b
e
m
o
r
e
r
api
dly
co
ntr
oll
ed
tha
n
intr
ave
no
us
sed
ati
on.
<)
/s
piri
n is
not
rec
om
me
nd
ed
for
ana
l
ges
ia
as
ma
ny
pe
opl
e
wit
h
ast
hm
a
are
all
erg
ic
to
it.
<
)
/ls
o,
use
of
no
n#
ste
ro
i
dal
ant
i#
infl
am
ma
tor
y
dru
gs
C
3/
+D
s"
ma
y
pre
cip
itat
e
an
ast
hm
a
att
ac%
an
d it
is
saf
er
to
rec
om
me
nd
the
use
of
par
ace
ta
mo
l.
+
f
an
ast
hm
a
att
ac%
occ
urs
on
the
de
nta
l
pre
mi
ses
,
the
ind
ivi
du
al
sho
uld
use
the
ir
r
el
ie
v
e
r
i
n
h
al
e
r
i
m
m
e
d
ia
te
ly
,
si
t
b
u
t
n
o
t
li
e
d
o
w
n,
a
n
d
l
o
o
s
e
n
a
n
y
ti
g
h
t
cl
o
t
h
i
n
g.
+f
t
h
e
r
e
is
no
im
me
dia
te
im
pro
ve
me
nt,
the
y
sho
uld
co
nti
nu
e
to
use
the
ir
reli
eve
r
inh
ale
r at
the
rat
e
of
on
e
puf
f
eve
ry
mi
nut
e
for
fi
ve
mi
nut
es
or
unt
il
sy
mp
to
ms
im
pro
ve.
+f
sy
m
p
to
ms
do
not
im
pro
ve
in
fi
ve
mi
nut
es
the
em
erg
enc
y
ser
vic
es
sho
uld
be
cal
led
an
d
the
reli
eve
r
inh
ale
r
use
co
nti
nu
ed
eve
ry
mi
nut
e
unt
il
hel
p
arri
ves
.
<7
/
lth
ou
gh
a
lar
ge
pro
por
tio
n
of
pe
o
ple
w
it
h
r
e
s
p
ir
at
o
r
y
d
is
e
a
s
e
a
r
e
a
b
le
t
o
r
e
c
ei
v
e
r
o
u
ti
n
e
d
e
n
ta
l
tr
e
at
m
e
n
t
i
n
g
e
n
e
r
al
d
e
n
ta
l
p
rac
tic
e,
tho
se
wit
h
si
g
nifi
can
t
res
pir
ato
ry
pro
ble
ms
are
bes
t
tre
ate
d
in
a
hos
pit
al
sett
ing
.
#he
illu
stra
tive
mat
eri
al
use
d in
Fig
ure
s $%
&% '
and
( is
cre
dite
d to
ww
w.)
ohn
Bir
dsa
ll.c
o.u
*.
#he
aut
hor
s
wo
uld
li*e
to
tha
n*
the
Do
wn+
s
"n
dro
me
Ass
oci
atio
n
,or
pro
vidi
ng
the
m
wit
h
t
h
e
il
l
u
st
r
a
tive
mat
eri
al
use
d in
Fig
ure
-.