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Whereas who returned from Iraq reported risky private payers (including private insurers and alcohol use but only 0 order 800 mg viagra vigour visa diabetes and erectile dysfunction causes. Uniform Mental Health Services requires access to opioid maintenance therapy generic 800mg viagra vigour erectile dysfunction lotion, fewer Public payers picked up the tab for 79. C) Current national data on regional differences in The concentration of spending for addiction the proportion of individuals in need of † treatment in public programs suggests that addiction treatment are not available. However, insurance across the board does not adequately other research indicates that the disparity cover costs of intervention and treatment, with between the number of people who need costly health and social consequences falling to addiction treatment and the number who receive ‡ government programs. National data indicate it varies substantially among states and regions 45 that those with private insurance are three to six of the country, with southern and southwestern times less likely than those with public insurance states having the largest estimated treatment § 52 to receive specialty addiction treatment. It is not possible to understood, possible explanations include determine from these data why treatment access variations among states in funding of treatment differed based on insurance type since the study services, including differences in coverage of the could not take into account important factors such as costs of these services in state managed care 48 individual characteristics and circumstances that may systems. One study found that only 21 percent relate both to type of insurance and likelihood of of the variation among states in the percent who treatment access (e. Therefore, the estimates reported in the federal, state and local categories are exclusive of the estimates of public funds spent through Medicare and Medicaid programs. E Expenditures by Providers and Components of Public Addiction Types of Services Treatment Spending (Total $22. I tried the emergency room; many times to get help for my addiction but due to the lack of insurance and money, was 56 denied. H Admissions to Publicly-Funded Addiction * While some addiction treatment programs may Treatment by Primary Substance address nicotine, they do not report these services in and Multiple Substances their treatment admission data. The number of patients in these facilities whose treatment is not admissions to addiction treatment; therefore, data publicly funded is unknown. K Of all the admissions to publicly-funded Sources of Referral to Publicly-Funded addiction treatment in 2009, 44. The fact Community sources of referral also include government agencies that provide aid in the areas of that the largest proportion of referrals to poverty relief, unemployment, shelter or social addiction treatment comes from the criminal welfare and referrals from defense attorneys. Referrals to treatment programs from health care § Addiction service providers are those programs, providers include those from physicians (including clinics or health care providers whose principal psychiatrists) or other licensed health professionals, objective is treating patients with addiction, or where or from a general hospital, psychiatric hospital, a program’s services are related to substance use mental health program or nursing home. The continuous treatment episode from the initiation of a data reported here do not include referrals to new treatment episode, some transfers may be detoxification programs. L) Available data on treatment venues to which referrals are made distinguish between intensive and non-intensive services provided in non- Figure 7. L Admissions to Different Types of residential settings and between short- and Treatment Service Venues longer-term services provided in residential 70 P settings: E 63. Intensive services are those T Non- Intensive Non- Short-Term Longer-Term that last at least two or more hours per day Intensive/Non- Residential Residential Residential for three or more days per week. The highest completion rates Non- Residential Residential were from venues to which there were the least Residential referrals: Total 63. M Percent of Treatment Admissions and Completions by Different Types of Treatment Service Venues, 2008 P Admissions 73. The general completion rate among all discharges (regardless of whether they were linked to admission data) was 42. The treatment completion rate for Variations in Treatment Completion by admissions involving multiple substances was 79 Source of Referral 38. Admissions to addiction treatment for which the Variations in Treatment Completion by Key source of referral was an employer were the Patient Characteristics most likely to complete treatment (57. No significant and individual sources--including concerned age-related differences in treatment completion family members, friends and the self-referred-- 80 were found. Concern about potential loss of complete treatment than were whites or blacks a job or criminal sanctions might help account (46. However, what is commonly viewed as denial might also be characterized as Existing data do not provide an explanation for a misunderstanding of the disease. As is the these differences and no data are available on case for seeking treatment for other health treatment needs and outcomes by funding source conditions such as diabetes, hypertension or 89 and type of service provided. Possible heart disease, most cases of denial that serve as contributing factors, however, might include that barriers to treatment access actually involve privately-funded admissions are likelier to cases in which a person with symptoms of involve less severe cases of addiction, those with addiction does not recognize that he or she has a 90 private resources may have greater access to treatable disease, underestimates the severity 91 effective support services or quality care, or of the disease or does not believe that the 92 those with private insurance may be less likely symptoms can be allayed through treatment. Continuing to misuse substances despite the associated harms is a In addition to the limited private sector coverage 94 defining symptom of the disease of addiction of addiction treatment and the lack of treatment and in many cases results from the changes that referrals from the health care system, many addictive substances produce in the structure and other barriers stand in the way of individuals function of the areas of the brain that control accessing and completing addiction treatment. Other not get the help they need is that they refuse to factors having to do with treatment quality are admit to having a problem or that they do not discussed in Chapter X. Another study found that all addictive substances including nicotine into between eight and 16 percent of people who had standard treatment protocols. Negative Public Attitudes and Behaviors Toward People with Addiction The most frequently-mentioned barrier to accessing treatment for addiction involving Related to widespread misunderstanding of the alcohol and drugs other than nicotine is not disease of addiction is the stigma attached to it-- ‡ 99 being ready to stop using these substances. A the well documented, strong disapproval of or study of current smokers in Wisconsin found discrimination against those with the disease-- that the main barriers to quitting that participants and the fear of repercussions which prevent reported were not being ready to stop smoking 103 people with addiction from getting help. Another way of people looking for needed addiction national survey found that two-thirds (67 102 treatment. Stigma was defined for respondents as “something § Met clinical diagnostic criteria for addiction that detracts from the character or reputation of a involving alcohol or drugs other than nicotine. The analyses conducted for the study, Defined in this study as including services delivered which controlled for other factors that predict in an inpatient ward, outpatient clinic, rehabilitation employment outcomes, suggest that employer program, halfway house, emergency room or crisis discrimination may be an important contributing center or by a private physician, psychiatrist, psychologist, social worker or other professional; factor to job instability in this population. The alcohol or other drug detoxification; and self- authors speculate that while the Americans with help/mutual support programs (e. N discrimination against addicted Participants Reporting They Would Be Less Likely* individuals are all too common. Privacy Concerns Discrimination against those with addiction is manifested on the governmental and institutional Because of negative public attitudes toward levels as well. Insurance companies generally addiction and the consequent potential for provide less coverage for addiction treatment stigma and discrimination, prospective patients 119 services than for other medical services. This populations where patients may fear a lack of perception was true across income levels: 67 anonymity due to relatively smaller and more percent of adults with annual incomes under 125 close-knit communities. Twenty-nine million insured people are --Johnny Allem † 131 Founder and President underinsured perhaps prompting them to postpone needed treatment. Those with public insurance focus more on accessibility A 2009 national survey found that nearly half issues (waiting times, eligibility) as barriers to (49 percent) of U. This disparity may be due to the not be able to afford treatment for addiction fact that some private insurance companies do ‡ involving alcohol or other drugs if they or not cover addiction treatment and some employers do not extend their benefit plans to 140 * include addiction treatment coverage. One study treatment providers in New York State found found that people randomly assigned to receive that a significant proportion of the respondents free methadone maintenance therapy stayed in said that a lack of conveniently located treatment their treatment programs longer than those programs “somewhat” (62. A significant barrier to obtaining addiction Some individuals who need addiction treatment treatment is the lack of knowledge about where face eligibility criteria for program entry that are to go for help and the limited ability of too stringent--including a patient’s ability to pay physicians, parents and other family members, and a required agreement to comply with all teachers, coaches, employers, clergy and law rules and treatment protocols regardless of 150 enforcement to identify the signs of addiction in individual goals. In contrast, the main others and know how to help patients access criterion for treatment access in mainstream 144 medicine is the principle of medical necessity, effective treatment. This barrier can undermine an they need to treat their disease are those who 154 individual’s fragile resolve to enter treatment.

By 1 month after the frst dose buy viagra vigour 800 mg with visa impotence 23 year old, 94%–100% of mentally infected animals cheap 800 mg viagra vigour overnight delivery erectile dysfunction medicine names, but transmission by saliva has not adults have protective antibody levels; 100% of adults develop been demonstrated. In randomized con- In the United States, almost half of all persons with hepatitis trolled trials, the equivalent of 1 dose of hepatitis A vaccine A report having no risk factor for the disease. Among adults administered before exposure has been 94%–100% efective in with identifed risk factors, most cases occur among interna- preventing clinical hepatitis A (2). Kinetic models of antibody tional travelers, household or sexual contacts, nonhousehold decline indicate that protective levels of antibody persist for contacts (e. A combined hepatitis A and hepatitis B vaccine has been developed and licensed for use as a 3-dose series in adults aged Diagnosis ≥18 years (Table 3). Patients with acute hepatitis A usually require only support- Prevaccination Serologic Testing for Susceptibility ive care, with no restrictions in diet or activity. Hospitalization might be necessary for patients who become dehydrated Approximately one third of the U. Te potential cost-savings of testing should Hepatitis B be weighed against the cost and the likelihood that testing will Hepatitis B is caused by infection with the hepatitis B virus interfere with initiating vaccination. This vaccine is recommended for persons aged ≥18 years who are at increased risk for both hepatitis B and hepatitis A virus infections. Periodic testing to determine antibody health-care provider should consider the need to achieve levels after routine vaccination in immunocompetent persons completion of the vaccine series. Approved adolescent and is not necessary, and booster doses of vaccine are not currently adult schedules for both monovalent hepatitis B vaccine (i. Pain at the injection site and low-grade fever are A 4-dose schedule of Engerix-B at 0, 1, 2, and 12 months is reported by a minority of recipients. When scheduled to receive the second dose, ado- vaccine administered, approximately one vaccinee will experi- lescents aged >15 years should be switched to a 3-dose series, ence this type of reaction. No deaths have been reported in with doses two and three consisting of the pediatric formula- these patients (3,4,447). For adolescents and adults, the needle length Pre-exposure Vaccination should be 1–2 inches, depending on the recipient’s weight (1 inch for females weighing <70 kg, 1. If the vaccine series is interrupted after the adults, acknowledgement of a specifc risk factor is not a frst or second dose of vaccine, the missed dose should be requirement for vaccination. Te series does not need to Hepatitis B vaccine should be routinely ofered to all unvac- be restarted after a missed dose. Other approximately 30%–55% acquire a protective antibody settings where all unvaccinated adults should be assumed to be at risk for hepatitis B and should receive hepatitis B vaccination Vol. Exposed persons who are known to have recommended for persons whose subsequent clinical manage- responded to vaccination are considered protected; therefore, ment depends on knowledge of their immune status (e. Persons who have health-care workers or public safety workers at high risk for written documentation of a complete hepatitis B vaccine series continued percutaneous or mucosal exposure to blood or body who did not receive postvaccination testing should receive a fuids). Studies are limited on the maximum interval after exposure during which postexposure prophylaxis is efective, but the interval is unlikely to exceed 7 days for percutaneous exposures and 14 days for sexual exposures. Pregnancy • Household, sexual, and needle-sharing contacts of chron- ically infected persons should be identifed. However, other tissue, or semen; and infected persons serve as a source of transmission to others and – refrain from sharing household articles (e. Tey should discuss the low but present risk identifying them and then providing medical management for transmission with their partner and discuss the need for and antiviral therapy, if appropriate. Liver function tests should be serially • if possible, use sterile water to prepare drugs; otherwise, monitored, and those persons with new and unexplained use clean water from a reliable source (e. Sexually transmitted gastrointestinal syndromes include Prompt identifcation of acute infection is important, because proctitis, proctocolitis, and enteritis. Evaluation for these syn- outcomes are improved when treatment is initiated earlier in dromes should include appropriate diagnostic procedures (e. Proctitis occurs predominantly among persons who participate Patients should be advised that approximately six of every 100 in receptive anal intercourse. Pathogenic organisms include Campylobacter and also is greater (2–3 times) if the woman is coinfected with sp. Reinfection might be difcult to intestinal illness can be caused by other infections that usually distinguish from treatment failure. Multiple Management of Sex Partners stool examinations might be necessary to detect Giardia, and Partners of persons with sexually transmitted enteric infec- special stool preparations are required to diagnose cryptospo- tions should be evaluated for any diseases diagnosed in the ridiosis and microsporidiosis. When laboratory diagnostic capabilities are available, treatment decisions should be based on the specifc diagnosis. Ectoparasitic Infections Diagnostic and treatment recommendations for all enteric Pediculosis Pubis infections are beyond the scope of these guidelines. Pediculosis pubis Acute proctitis of recent onset among persons who have is usually transmitted by sexual contact. Malathion can be used when treat- should be managed in the same manner as those with genital ment failure is believed to have resulted from drug resistance. If painful perianal ulcers Te odor and long duration of application for malathion make are present or mucosal ulcers are detected on anoscopy, pre- it a less attractive alternative than the recommended pedicul- sumptive therapy should include a regimen for genital herpes cides. Patients who do the patient cannot tolerate other therapies or if other therapies not respond to one of the recommended regimens should be have failed. Lindane should not be used immediately after a bath Management of Sex Partners or shower, and it should not be used by persons who have Sex partners that have had sexual contact with the patient extensive dermatitis, women who are pregnant or lactating, or within the previous month should be treated. Lindane resistance has been reported in abstain from sexual contact with their sex partner(s) until some areas of the world, including parts of the United States patients and partners have been treated and reevaluated to rule (474). Special Considerations Permethrin is efective and safe and less expensive than Pregnancy ivermectin (471, 474). One study demonstrated increased mortality among elderly, debilitated persons who received Pregnant and lactating women should be treated with ivermectin, but this observation has not been confrmed in either permethrin or pyrethrins with piperonyl butoxide; subsequent studies (475). However, pruritus might transplant recipients, mentally retarded or physically inca- occur within 24 hours after a subsequent reinfestation. Substantial risk for treatment failure might exist with especially if treatment with topical scabicides fails. Ivermectin should be Infants, Young Children, and Pregnant or combined with the application of either 5% topical benzyl Lactating Women benzoate or 5% topical permethrin (full body application to Infants, young children, and pregnant or lactating women be repeated daily for 7 days then 2 times weekly until release should not be treated with lindane; however, they can be treated from care or cure). Ivermectin is not recommended for pregnant risks for neurotoxicity associated with both heavy applications or lactating patients, and the safety of ivermectin in children and denuded skin. Treatment failure can be caused by resistance crusted scabies, for which ivermectin has been reported to to medication, although faulty application of topical scabicides be efective in noncontrolled studies involving only a limited also can contribute to persistence — patients with crusted number of participants. Even when treatment is successful and reinfection is avoided, symptoms can persist or worsen as a Adults and Adolescents result of allergic dermatitis. Treatment with an alternative regimen is recom- specimens for forensic purposes, and management of potential mended for persons who do not respond to the recommended pregnancy or physical and psychological trauma are beyond treatment. Management of Sex Partners and Examinations of survivors of sexual assault should be Household Contacts conducted by an experienced clinician in a way that minimizes further trauma to the survivor. Evidentiary privilege an epidemic can only be achieved by treatment of the entire against revealing any aspect of the examination or treatment population at risk. If treatment was provided, testing should prophylactic antimicrobial treatment, compliance with follow be conducted only if the survivor reports having symptoms. As a result, routine preventive women are of particular concern because of the possibility of therapy after a sexual assault should be encouraged.

Because the cervix remains in uterus and its blood supply followed by place purchase 800mg viagra vigour amex erectile dysfunction medicine reviews, there is less chance of removal of the uterus viagra vigour 800mg mastercard erectile dysfunction treatment youtube. The most difficult long-term vaginal support part (and the part which leads to the problems since the supporting most complications) is removal of the structures (cardinal and lowest portion of the uterus and cervix. In an emergency setting, it is very The disadvantages to the supracervical acceptable to avoid those problems by hysterectomy are several, but relate more performing a "supracervical to the elective or semi-elective hysterectomy. If malignancy narrows, (above the level of the bladder is present in the uterus, an incomplete and ureters), a scalpel cuts across the procedure has been performed. Further, lower uterine segment, resulting in the if infection is present, some infected removal of the upper portion of the tissue may be left behind. The raw, cut edge of the cervix disadvantages seem persuasive, and the and lower uterine segment is sutured for advantages in speed, safety and hemostasis. This part of the uterus can, if 9 Surgical Emergencies in Obstetrics & Gynecology simplicity suggest supracervical These patients have moderate to heavy hysterectomy is preferable when needed. Prophylactic antibiotics cervix, you may grasp is gently with covering gram negative and anaerobic sponge forceps and ease it the rest of the bacteria is an excellent idea in the way out of the cervix. If pregnancy tissue is passed, If fever is present, broad-spectrum it is reclassified as either an incomplete antibiotics are wise, particularly if D&C or complete abortion. Rh negative women means the cervix has begun to dilate and should ideally receive Rhogam (Rh bleeding is so heavy that spontaneous immune globulin) within 3 days of a abortion must occur. Bedrest will usually slow the bleeding temporarily, but will not change the final Complete Abortion outcome of the pregnancy. A complete abortion is the passage of all Incomplete Abortion pregnancy tissue from inside the uterus. Typically, these patients complain of When some pregnancy tissue has been vaginal bleeding and cramping which passed, but more remains inside the leads to passage of tissue. The responsible bacteria are usually a mixed group of Bedrest for a day or two may be all that strep, coliforms and anaerobic is necessary to treat a complete abortion. Save in formalin any tissue which the Remember, though, that she has the patient has passed for pathology potential for becoming extremely ill very examination. If you can grab a portion of the placenta (assuming a part of it is or extruded through the cervix), you sometimes can tease the rest of the Cefoxitin 2. They typically involve a labor-type Third Trimester Delivery experience for the patient, with delivery Complications of a non-viable fetus. Cesarean Section After delivery of the fetus, be prepared to wait as long as several hours for the In the face of intractable hemorrhage in placenta (afterbirth) to separate and be an undelivered patient or totally delivered. While waiting, clamp and cut obstructed labor, emergency cesarean the umbilical cord and remove the fetus section will probably be life-saving. Manual Removal of the Placenta If the placenta remains inside longer than 6 hours, D&C is indicated to After delivery of the infant, the placenta remove it. Insert your hand through the Alternative diagnoses which can cause vagina into the uterus and grasp the similar symptoms include a corpus placenta. With This is generally caused by the uterus a threatened abortion, the pain is central failing to contract. After manually or suprapubic and the uterus itself may exploring the uterus to make sure no be tender. If she should suddenly rupture and go into Post Partum Hysterectomy shock, you can respond more quickly. Typically, this is a The vibration during a helicopter ride or supracervical hysterectomy (subtotal the jostling over rough roads in an hysterectomy) even in experienced ambulance or truck may provoke the hands because of the difficulty in easily actual rupture. A woman with an unruptured ectopic pregnancy may have the typical Ruptured Ectopic Pregnancy unilateral pain, vaginal bleeding, and adnexal mass described in textbooks. Women with a ruptured ectopic Alternatively, she may have minimal pregnancy will nearly always have pain, symptoms. If surgery is not an ultrasound scan to confirm the available option, stabilization and placement of the pregnancy. If abdominal surgery is not an available option, the outlook for a patient with a Ovarian Cyst ruptured ectopic pregnancy is not totally bleak. Aggressive fluid and blood These cysts are common and generally replacement, oxygen and complete cause no trouble. Each time a woman bedrest will result in about a 50/50 ovulates, she forms a small ovarian cyst chance of survival. If the pulse is >100 or urine Occasionally, ovarian cysts may cause a output <30, she needs more fluid. If she becomes short of breath Delaying menstruation and the lung sounds become Rupturing "crackly," slow down the fluids Twisting as she probably is becoming fluid Causing pain overloaded. If she becomes short of breath 95% of ovarian cysts disappear and the lungs sound dry, increase spontaneously, usually after the next the fluids and give blood as she menstrual flow. Those that remain and is probably anemic and in need those causing problems are often of more oxygen carrying removed surgically. If the This problem is often indistinguishable cyst is small, its rupture usually occurs clinically from a pelvic abscess or unnoticed. If large, or if there is appendicitis, although an ultrasound associated bleeding from the torn edges scan can be helpful. The pain is Treatment is surgery to remove the initially one-sided and then spreads to necrotic adnexa. Unruptured Ovarian Cyst Other surgical conditions which may While most of these cysts are without resemble a twisted ovarian cyst (such as symptoms, they can cause pain, bowel obstruction, appendicitis, ectopic particularly with strenuous physical pregnancy) may not have a good activity or intercourse. The cyst and ovary (and often a Gradual onset of mild bilateral pelvic portion of the fallopian tube) die and pain with purulent vaginal discharge is necrose. Since surgery may be required, Treatment consists of: transfer to a definitive surgical facility should be considered. In addition, they have palpable pelvic masses from dilated, abscessed Pregnancy-related problems fallopian tubes. With the antibiotics, the makes caring for these patients very patient will either improve and stabilize, simple. This surgery may be difficult because the Mechanical Causes of Abnormal considerable inflammation will obscure Bleeding anatomic landmarks and the edematous tissues will be friable and difficult to Uterine fibroids or endometrial polyps manipulate. In such a setting, are examples of mechanical problems supracervical hysterectomy may be a inside the uterus which may cause wise course even considering the leaving abnormal bleeding. Overview Hormonal Causes of Abnormal Bleeding Occasionally, abnormal bleeding will be due to a laceration of the vagina, a 17 Surgical Emergencies in Obstetrics & Gynecology Hormonal causes include anovulation With bedrest and hormonal treatment, leading to an unstable uterine lining, bleeding should be substantially breakthrough bleeding associated with improved within 24 hours. It should birth control pills, and spotting at continue to improve with additional days midcycle associated with ovulation. If hormonal control is not solution to all of these problems is to succeeding, then a D&C will be take control of the patient hormonally necessary. After a month Malignancy as a Cause of Abnormal or two, her bleeding should be well Bleeding under control. Abnormal bleeding can be a symptom of If the bleeding is heavy or her blood malignancy, from the vagina, cervix or count low, then it is best to have her lie uterus. Cancer of the cervix is several days to three a day, then two a more common but a normal Pap smear day, and then one a day.

People who consume high-starch/low- between 45 and 81% in areas with around 1 mg fluoride/L sugars diets generally have low caries experience whereas 1 water cheap viagra vigour line erectile dysfunction treatment natural food. Enamel fluorosis as well as skeletal fluorosis are people who consume low-starch/high-sugars diets have 75 found in large areas of India cheap viagra vigour 800mg kidney transplant and erectile dysfunction treatment, Thailand, in the Rift Valley of high levels of caries. In the Turku study intake of starch Starches and dental caries was not limited and all groups ate unlimited starch yet low Starch constitutes a heterogeneous food group and it caries occurred in the xylitol (sugar free) group. All these factors should be considered diet and dental caries in 11–12-year-old English children, when assessing the potential and relative cariogenicity of Rugg-Gunn et al. Some argue that cooked and processed starches starch and caries increment when controlling for sugars enter into the caries process because starches are broken intake. Children with high-starch and low-sugars intakes down by salivary amylase releasing glucose, maltose and had significantly fewer caries develop than children with 95 maltotriose and that these are metabolised by oral bacteria low starch/high sugars intake. The not good at discriminating the acidogenic potential intake of starch increased during this period in Norway 125 and Japan yet the occurrence of caries was reduced. Populations that habitually consume a remove plaque from all areas of the mouth and then high-starch/low-sugars diet have also been reported to 68,75,134,135 measure pH (harvesting method) are more discriminating have low levels of dental caries. For example and have shown that starch-containing foods are less the Chinese and Vietnamese, Ethiopians and South Diet, nutrition and prevention of dental diseases 215 American Indians have eaten cooked starches in the form in fruits. These studies have also used an indwelling of rice, wheat and maize but have a low sugars intake and plaque pH electrode that tends to give a hypersensitive 136 low caries levels. Animal studies have shown that, when fruit is well as comparing sugar availability and level of caries, consumed in high frequencies (e. However, when the have shown that, as habitually consumed, fruit is of low 79 data were reanalysed by Rugg-Gunn to control for sugar cariogenicity. For example, a number of cross-sectional availability the relationship between wheat availability studies have compared dental caries experience to levels 144 and dental caries disappeared. In 147 stimulate increased secretion of saliva, increasing its a study of longitudinal design, Clancy et al. Unrefined plant foods also contain negative association between caries increment over 1 year phosphates and there is some evidence that they convey a and the consumption of apples and fruit juice. The only 79 Rugg-Gunn extensively reviewed the evidence on the epidemiological study in which an association between relationship between starches and dental caries and fruit consumption and dental caries was reported was that 148 concluded that: of Grobler and Blignaut who compared the dental caries experience of workers on apple and grape farms. Finely ground and heat-treated starch can induce dental whereas the workers on the grape farms consumed on caries but the amount of caries is less than that caused average three bunches of grapes per day. Many highly Dried fruit may potentially be more cariogenic since the processed starchy foods are also relatively high in fats and drying process breaks down the cellular structure of the or free sugars and salt (e. He also concluded Fruit and dental caries that, on present evidence, increasing consumption of fresh In experimental conditions in which fruit is a major dietary fruit in order to replace ‘non-milk extrinsic sugars’ (free constituent, fruits may participate in the caries process; sugars) in the diet is likely to decrease the level of dental 79 however, as consumed as part of the mixed human diet caries in a population. A number of Novel carbohydrates and dental caries risk plaque pH studies have found fruit to be acidogenic Glucose polymers (glucose syrups and maltodextrins) 139,140 (though less so than sucrose) although the extent of comprise a mixture of short chain saccharides and alpha- 141 this varies according to texture and sugars content. When isolated from foods, suggest that maltodextrins and glucose syrups are phytate is an effective anti-caries factor but as an intrinsic 149–151 79 cariogenic. Plaque pH fibrous foods protect the teeth is because they mechani- studies and experiments in vitro suggest that isomaltoo- cally stimulate salivary flow. Other foods that are good ligosaccharides and glucooligosaccharides may be less gustatory and/or mechanical stimulants to salivary flow 152–154 acidogenic compared with sucrose. Plaque pH studies have shown that consuming cheese following a sugary snack virtually abolishes the usual fall Classification of sugars and carbohydrates for 157 in pH that is associated with sugars consumption. The calcium concentration of manufacturer, cook or consumer) but also includes sugars dental plaque strongly influences the balance between de- present in fruit juices, honey and syrups. In an epidemiological and general health purposes it is important to distinguish study, cheese intake was higher in children who remained between sugars naturally present in fruits, vegetables, caries-free over a 2-year period than in those who grains and milk as the evidence shows that these foods are 95 developed caries. The consumption of 158 leagues , in a controlled clinical trial in children, these foods is also desirable, whereas the consumption of demonstrated that eating a 5 g piece of hard cheese foods rich in free sugars is not. If the intake of free sugars daily, following breakfast, for a period of 2 years, resulted were limited and the intake of fruit, vegetables, whole- in the development of significantly less caries. Several studies have shown that the fall in plaque Is there an inverse relationship between the intake 159,160 pH following cows’ milk consumption is negligible. There is some evidence from animal studies that the It is important to consider the effect that changing one addition of cows’ milk to a cariogenic diet reduced the aspect of the diet has on other components of the diet. A few that have monitored dietary changes and the influence that specific case studies have linked prolonged ad libitum and changing one constituent has on other nutrients do not nocturnal breastfeeding to early childhood caries. Breast- support the hypothesis for an inverse relationship feeding has the advantage that it does not necessitate the between the intake of free sugars and fat. There is a use of a feeder bottle, which has been associated with growing body of evidence from such longitudinal research early childhood caries. A breastfed infant will also receive that shows that changes in intake of fat and sugar are not 168 milk of a controlled composition to which additional free inversely related. There are no benefits to dental sectional study, found that fat intake by adolescents health of feeding using a formula feed. Animal studies have looked at the effect of dietary intervention study to increase fibre intake, Cole- acidic food and drink consumption on demineralisation of 170 143 Hamilton et al. Miller inverse relationship between intake of free sugars and fat made the important observation that fruit juices were 3–10 and furthermore overall dietary goals that promote times more destructive than whole fruit in rats. However, increased intake of wholegrain staple foods, fruits and due to differences in drinking technique and salivary flow vegetables and a reduced consumption of free sugars are and composition, there are difficulties in extrapolating the unlikely to lead to an increased consumption in fat. Many of the reports on diet and erosion have been Diet and dental erosion single case reports and have shown that extensive erosion 179 The evidence for an aetiological role of diet in the has been associated with sucking lemon wedges , development of dental erosion comes from clinical trials, drinking cola continuously or holding cola in the 180,181 human observational studies, experimental clinical mouth , addition of baby fruit juices to comforters 182 studies, animal studies, case reports and experiments in or reservoir feeders , or mega doses of chewable 171 183 vitro. However, in general such studies have 172 shown that beverages with a high titratable acidity or a pH Stabholz et al. Fruit juices have also been 184 10–18 months and found that the teeth showed slight shown to be more erosive than pulped fruits. However, Meurman 21 association between dental erosion and the consumption and Cate argue that present data does not allow the of a number of acidic foods and drinks including frequent ranking of different acids. Levels observed in industri- beverages and foods is a more important determinant of alised countries are thought to be due to increased erosion than total amount consumed and also that erosion consumption of acidic beverages (i. Fruit juices are more erosive than whole fruits and tends to occur in individuals with good oral hygiene. Other risk factors reduce the prevalence of erosion the frequency of acidic included eating disorders (largely due to effect of intrinsic beverages needs to be reduced and/or the resistance to acids on vomiting), gastro-oesophageal reflux and a low erosion needs to be increased. The age-related increase was more comprehensive population-based studies on the greatest in the highest bands of soft drink consumption. The longitudinal patterns of the dental proportion who had erosion increased from 28 to 52% erosion in populations needs to be monitored and related between ages 7–10 and 11–14, whereas in the lowest to changes in dietary factors (e. Summary of the strengths and weaknesses of the Experimental clinical studies have shown that con- evidence sumption of, or rinsing with, acidic beverages significantly lowers the pH of the oral fluids and this is most marked The strength of the evidence linking dietary sugars to 141 with grapefruit juice. Enamel slab experiments have dental caries risk is in the multiplicity of the studies rather shown that enamel is softened within 1 hr of exposure to than the power of any individual study. Today it would not Strong evidence of the relationship between sugar be possible to repeat these intervention studies due to availability and dental caries levels comes from the 53 more stringent ethical codes.