– I will send through a vast array of different references – feel free to use these as you may find appropriate, or source others if you can. Be mindful that reference sources (other than those sent) should be no older than the last 10 years, and preferably use only published journal articles.

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– I will send through a vast array of different references – feel free to use these as you may find appropriate, or source others if you can. Be mindful that reference sources (other than those sent) should be no older than the last 10 years, and preferably use only published journal articles.

– Please ensure this order is completed by a native English speaker.
– I am more than happy to answer any questions – just sent them through via message.
– Also please don’t feel you have to reach 2200 words. The word limit for this task is 2000 so anywhere between 2000-2200 is fine.
____________________________________

Students will undertake an essay addressing the following topic:

‘Perhaps, we should no longer question whether ‘bad supervision’ occurs; instead, we need to focus on how to detect, solve, and prevent what appears to be a major problem in the field …[Inadequate] supervision may be less likely to occur if supervisors are mandated to receive training in supervision that includes supervision of supervision … many supervisees may have unknowingly received inadequate and/or harmful supervision. If supervisees are more aware of their basic rights in supervision (e.g., the supervisor’s responsibilities), they may be more cognizant of and able to identify when harmful or inadequate supervision is taking place’ (Ellis, Berger, Hanus, et al., 2014)
.
Critically evaluate the role of clinical supervision as a strategy designed to support safe and effective mental health care.

Your evaluation is to include an outline of arrangements for
clinical supervision in your workplace and the role that you could play in further developing these arrangements.

Ref.
Ellis, M., Berger, L., Hanus, A., Ayala, E., Swords, B., & Siembor, M. (2014). Inadequate and harmful clinical supervision: testing a revised framework and assessing occurrence. The Counselling Psychologist, 42 (4), 434-472.
_______________________________

In regards to arrangements for clinical supervision in my workplace and the role that I could play in further developing these arrangements, the process of clinical supervision within my workplace is quite ad-hoc. Clinical supervision is something that is undertaken well in other disciplines (e.g. psychology, social work etc), however it is not generally seen as valuable for nurses.
Whilst clinical supervision is supported, it is not encouraged.
It is certainly not encouraged among new graduate nurses or other junior stuff – and they are the ones that need it the most!
In terms of how I

A 25-year-old G1 P1 patient arrives with her husband for her office visit.

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A 25-year-old G1 P1 patient arrives with her husband for her office visit.

A 25-year-old G1 P1 patient arrives with her husband for her office visit. She states she delivered her daughter 3 months ago and since then she, the patient, cries all day, cannot sleep, and has no energy. Her husband has taken over most of the care of the baby, but must return to work. She stopped nursing. Her physical exam is negative.

1. Prioritize what additional questions you must
ask this patient?
2. What is your differential diagnosis?
3. Will you obtain laboratory screening, yes/no
and explain rational.
4. What treatment will you prescribe?
5. What referrals/consults will you schedule?
6. What education will you provide?

Please use references that are US Based and can be found on line, peer reviewed, and evidenced based

How does CMS’s involvement impact the reimbursement model for Healing Hands Hospital and other health care organizations?

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How does CMS’s involvement impact the reimbursement model for Healing Hands Hospital and other health care organizations?

Paper , Order, or Assignment Requirements

For this assignment, write a 2-3 page report that you will deliver to Mr. Magone on how the new Centers for Medicare and Medicaid Services (CMS) initiatives and regulations will impact the organization’s revenue structure. In your presentation, address the following questions:
• Why did CMS become more involved in the reimbursement component of health care? How does CMS’s involvement impact the reimbursement model for Healing Hands Hospital and other health care organizations? If CMS reimbursement regulations for Medicare and Medicaid change, does it follow that other insurance providers change their policies on reimbursement?
• What tools can be implemented to ensure organizations such as Healing Hands Hospital and physician practices are meeting the policies and procedures set forth by CMS?
• Identify 3 tools from the CMS Web site that are helpful in meeting the requirements for Medicare reimbursement set forth by CMS.

Journal Entry: Advocacy Internationally

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ORDER NOW FOR AN ORIGINAL PLAGIARISM-FREE PAPER: Journal Entry: Advocacy Internationally

Journal Entry: Advocacy Internationally

Throughout the world, members of the LGBTQ community continue to struggle for their rights. In some countries, they have made some progress. In 2016, 20 countries legally recognized marriage for same-sex couples (Human Rights Campaign, 2016). However, in other countries, the LGBTQ community faces much greater obstacles, and the consequences of fighting for basic rights are grave for both LGBTQ individuals and allies. Being gay is a crime punishable by death in 10 countries and is illegal in a total of 73 countries (Human Rights Campaign, 2016). Because of the violence and social exclusion experienced globally, LGBTQ individuals may seek refugee status because of their sexual orientation or gender identity/expression (UN High Commissioner for Refugees [UNHCR], 2016).

Human Rights Campaign. (2016). International. Retrieved from http://www.hrc.org/explore/topic/international

UN High Commissioner for Refugees. (2015). Protecting persons with diverse sexual orientations and gender identities: A global report on UNHCR’s efforts to protect Lesbian, Gay, Bisexual, Transgender, and Intersex asylum-seekers and refugees. Retrieved from http://www.refworld.org/docid/566140454.html

Read the United Nations Address on Global LGBT Rights by Hilary Clinton.

a 2 page detailed explanation of your reaction to this essay. Then, explain why, in the context of practicing social work in North America, it is important for us to acknowledge and address sexual orientation and gender diversity of marginalized populations across the world. Explain the role of social workers on an international level in relation to the rights of the LGBTQ community. Identify specific skills and actions you would employ as an advocate.

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NursingPapers

What are the main determinants in health disparities and how can these be modified to improve health status and create health equity in society?

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What are the main determinants in health disparities and how can these be modified to improve health status and create health equity in society?

Define moral hazard and give an original example. Do you agree with this concept of moral hazard, explain your answer?

What are the main determinants in health disparities and how can these be modified to improve health status and create health equity in society? In addition to what is in the text, elaborate on these determinants and solutions based on observations that you have made in your own life.

Pros and Cons of Liver Transplant

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Pros and Cons of Liver Transplant

Pros and Cons of Liver Transplant

Liver transplantation involves surgical procedures to substitute a failed liver in a recipient, with a healthy one from a donor. Organ transplant has been one of the medical advances in the recent past. However, itraisesseveral ethical issues regarding the donor and recipient. Vital organ failure and decreasing organ pool has been related to the long waiting periods and mortalities. Methods of allocation of these organs have also raised a concern since they are cited as being unjust. Besides, minors have been involved in organ donations, which question their eligibility.Organtrafficking for financial gains has been on the rise and is achieved by exploiting poor individuals.This however, could be minimized by use of living donors and Split Liver Transplantation (SLT). Besides, animal organs and xenotransplantation could help to solve organ shortages. Organ donations are also associated with several risks both for the donor and recipient. Consent from donors is also crucialto allow for organ procurement (Cupples & Ohler, 2003). To be precise, ethical issues regarding liver transplants revolves around their procurement as well as distribution.

The benefits of liver transplants are enormous since they allow patients with liver disease to live happily. However, if the disease results from Alcohol-induced Liver Disease (ALD),their eligibility is often controversial. Additionally, for this type of transplants, it is often cited that since the disease is self-inflicted, the ALD patients should not be eligible to the alreadyscarceorgans. These patientsare also said to undergo recidivism and therefore, the disease could recur and therefore no need for liver transplant. Organ complications also arise since there is no agreement with medical therapy.On the other hand, ALD patients should be treated equally with other patients who need organ transplants. Liver dysfunction that cannot be reversed is managed by having a transplant. However, the condition could be contraindicated due to cancerous cells surrounding the organ, alcoholism, septic infections, advanced age and heart disease, since they do not allow for transplantation. The economic expenses, which come with the procedure, may overburden a patient. These are incurred during liver dialysis, immunosuppressive management, blood transfusion, medical evaluation of donors, andprocedures to manage graft rejection. This paper aims at evaluating the pros and cons of liver transplants, to givedetailed information on ethical and medical issues related to liver transplants (Everson &Trotter, 2009).

Pros of Liver Transplant

The main advantage of liver transplant is its potential to safeguard life. Individuals donate organs to safe other helpless persons especially for living donors. Liver transplant is the greatest alternative for a patientwith a terminal liver disease. Living donors have aided in managing liver organs shortages and comes with more benefits as compared to diseased donors hence, increased liver organ pool. This is particularly possible since livingdonorsdecline the waiting mortalities particularly for hepatocellular carcinoma (HCC) patients. Living donors allows room for preoperative interventions, which includes dietary treatment(Kaido & Uemoto, 2010).They allow timely transplantation procedures and this decline progression of the disease and reduce mortality. The damage caused to the liver is less in living donors since the surgical procedures are elective and happen simultaneously. The donors of the liver have to be in good health, which guarantee good organs unlike cadaveric organs, which undergo pathophysiologic effect as a result of brain death(Carr, 2009). Since preoperative interventions are possible for living donors, treatment and medical stabilization of patients is possible prior to the surgery. Besides, living organs are not subject to excessive cold-ischemia, which often takes one hour unlike for deceased organs, which take six to ten hours in more than fifty percent of patients. This may increase complications as well as graft dysfunction (Killenberg et al., 2006).The patient must also be in a better health state, in order to undergo successful surgery and recover with no postoperative complications. The prognosis of liver transplants is promising and survival rates are high(Carr, 2009).

Some of the important questions to ask the opponentsinclude; what are the reasons for liver transplantation? Life threatening health problems such as hepatitis and cirrhosis identified a doctor could require a patient to undergo liver transplantation.What are the sources of liver transplants? Cadaver donors and living donors supply the liver organ pool.What are the survival rates of patients following liver transplants? The survival rate is high and ranges close to eighty percent.Why are liver transplants a good target for organ traffickers? Illegal organs fetch good money due to their shortage. It is part of illegal organ trade where doctors are involved. Is it possible to prevent organ trafficking? Indeed. This can be curbed by implementing policies to prevent illegal organ trafficking. Heavy penalties should be imposed on the individuals involved. Healthcare systems should be monitored to avoid corruption and trading of organs. What are the procedures of allocating liver transplants? In the developing world, procedures to allocate organs have been corrupted to comprise distributive injustice. The poor are exploited and are denied equal rights to the organs. Would you choose to secure a liver transplant or face death as a result of liver dysfunction?I would rather secure the livertransplant since my health would be promoted. Besides, the patients’ survival rates are high and it is only a matter of choice on whether to live or die by either opting for the organs transplant or not. Does clinical transplantation always arouse ethical issues? Yes. However, when it comes to matters of life or death, ethical issues are often sidelined. What are ways to manage ethical issues surrounding liver transplants? It is essential for donors to give consent to procure the organs. Besides, the procurement from deceased donors should be done following the brain death or legal death. Strict measures should also be drafted by involved bodies in order to curb organ trafficking. Liver transplantation is a matter of life and death and ruling it out on ethical basis is vague. To what extent do you agree with the statement? I agree. This is because life is much more worth than the ethical issues involved. Safeguarding that life should therefore, be a priority whatsoever. Does genetic engineering offer any solution to liver transplants? Yes. Gene therapy is essential to increase the organ pool by having safe transplants which have been under extended cold ischemia. Is liver always procured during total brain death from a deceased donor?This should always be the case but it has been controversial since there lacks an agreement to when the legal deathoccur.Some physicians could also procure organs contrary to the set standard. Do liver transplants promote health and societal wellbeing? Yes. Patients with terminal liver diseases can be restored back to life through substituting the diseased organ with a healthy one. What are some of human rights related to liver transplant? Right to good health should be safeguarded irrespective of the socioeconomic status of the patients. Merit should be used in the healthcare system to distribute equally the organs. What do you consider as legal death? This is brain death which cannot be reversedsince the cerebral neurons become dysfunctional due to lack of oxygen. It is the legalindicator where transplant organs could be procured. Do you think organs should be harvested from living of deceased donors? Living donors are better since they could have preoperative preparations to ensure the organ is in good condition unlike deceased donors.

Cons of liver Transplant

Thecrucial issue on liver transplant is their dysfunction or complications which may arise.Living donors increases donor risks thus the mortality rate is close to 0.1-0.3% (Kaido & Uemoto, 2010). Donor mortality and morbidity results are controversial due to inadequate comprehensive database.Therefore, the donors lack the actual information of the risks involved in the procedure in order to give an informed consent. The survival rates of grafts in living donors is less than that of diseased donors and may result to more biliary complications in patients. Hence,successivepreoperative interventions are necessary to manage biliary complications. Living donors allow elective procedures to minimize complications when waiting unlike cadaveric organs. Shortage of organs cannot meet the needs of many patients who need them, many of whom die waiting for cadaveric organs. In addition, the right hepatic lobe graft could not offer appropriatehepatic function in patents with “severely decompensated liver disease” (Killenberg et al., 2006 p. 198). Several requirements such as donor-recipient blood type compatibility are a perquisite before the liver transplant is conducted to minimize the probability of organ rejection. However, consent from the donor is always crucial for the organs to be procured.

Some of the questions to ask the supporters of liver transplants include; what are the reasons for liver transplantation?Life threatening health problems such as hepatitis and cirrhosis identified a doctor could require a patient to undergo liver transplantation.What is the period taken to get a new functional liver? It depends on the availability of donor organs, waiting period and the condition of the liver.The tests might take a few days or even weeks. What is the procedure for replacing a diseased liver with a healthy one? After live therapy, an orthotopic transplantation is conducted which involves hepatectomyto remove the liver, anhepatic phase where liver is absent and post-implantation phase following the transplant. An incision is put over upper abdomen by separating ligaments that attach to the liver and the liver is removed and replaced with a healthy one.How does organ rejection occur and how can it be prevented? It occurs due to incompatibility of blood types which cause agglutination. Histocompatibility is also another cause due to mismatched HLA. HLA typing and Immunosuppressive treatment is awarded to manage rejection.Are there alternatives to liver transplants? Gene therapy, hepatocyte transplantation, xenotransplantation and bioartificial liver are some of the alternatives.In case of ALD, what is the recidivism rate for patients who have had prior liver transplant? It is usually high and patients have been noted to return to alcoholism barely ayear after surgery which cause histological liver problems like fibrosis When can a patient resume to normal activities such as work? Can work facilitate postoperative complications? Yes. Heavy manual job could lead to complications. Patients are advised to stick to clean, simple and better working environments. Is vocational rehabilitation necessary for transplant recipients? Yes. It is essential to access, train and help the postoperative patients to go back to work.Whatare the risks of undergoing a liver transplant and should they be paid for? Risks involve graft rejection, anesthesia, and surgical risks such as bleeding, infection and recurrent liver disease. What are their success rates? Prognosis on Liver transplants is very promising and success rate is high. Is a patient eligible for a second transplant?Yes. Every patient has a right to good health no matter the number of organs he or he has acquired. Are liver transplants worth the financial costs incurred? Yes. In order to promote health liver transplants are worth in clinical practice to safeguard life. How can procurement of liver transplants be efficient? The organ is harvested from deceased donors after brain death or from living donors following their consent. Is there an assurance that the new liver will work and how do I prevent it from being damaged? If there are no postoperative complications, the new organ is highly functional. It should be safeguarded by taking a lot of pure water and supplements such as milk thistle which is an essential antioxidant.

Conclusive Argument

Organ transplant has been one of the medical advances in the recent past. However, it raises several ethical issues regarding the donor and recipient since the process is both challenging and complicated. The past decades have been marked by advancement in surgical procedures, which have facilitated the results of patients who have undergone liver transplantation. The liver ranks second of all transplant organs following the kidney. This is as a result of increasing liver diseases such as hepatitis and liver cirrhosis, which calls for liver transplantation. The process is often challenging and triggers several ethical issues. All the same, radiological procedures such asmagnetic resonance as well as computed tomography (CT) have enabled patient in need of liver transplantation to be evaluated precisely,prior and after the procedure. Thishas gone a long way in the reduction of complications. Therefore, theprognosis of liver transplants has been successful. This depicts the successnature of the procedures, which makes it safe for human in order to safeguard their lives.The transplants have however, been invaded by traffickers who seek their personal wealth through exploiting others. This is part of the global transplantation tourism, which has to be prevented by establishing the necessary measures.

To become medically eligible for a liver transplant the patient has to be surgically suitablefor the process and give consent for the same.Consent from a donor is also important and if he or she is not in a position to do so, the family members could give their consent to allow for the procurement of the organ following their legal death. Patients withmanyhealth issues could cause jeopardy of the procedure. The increased organ shortages have called for living donors and procedures such as Split Liver Transplantation (SLT)(a surgical procedure,which forms two allografts from a single cadaver or donor organ). The procedure is however, technical and requires specialized physicians. These methods are aimed to increase donor pooland have caused a high morbidity andunsuccessful procedures (Chakravarty& Jan, 2010).Liver transplants helps to promote health and the overall welfare of the society. As a result, liver transplantations have more benefits as compared to the disadvantages and therefore, should be conducted under strict medical practice

References

Carr, B. I. (2009). Hepatocellular Carcinoma: Diagnosis and Treatment. New York: Springer.

Chakravarty, D., & Jan, W. C. (2011). Liver Transplantation. New Delhi: JP Medical Ltd.

Cupples, S. A., & Ohler, L. (2003).Transplantation Nursing Secrets. Philadelphia, Pennsylvania: Elsevier Health Sciences.

Everson, G. T., &Trotter, J. F. (2009). Liver Transplantation: Challenging Controversies and Topics. Totowa, NJ: Springer.

Kaido, T., & Uemoto, S. (2010). Does living donation have advantages over deceased donation in liver transplantation?Journal of Gastroenterology and Hepatology Foundation and Blackwell Publishing Asia Pty Ltd, 25(10):1598-603. doi: 10.1111/j.1440-1746.2010.06418.x. Retrieved on July, 6, 2011 from https://www.ncbi.nlm.nih.gov/pubmed/20880167

Killenberg, P. G., Clavien, P., &Smith, A. (2006). Medical Care of the Liver Transplant Patient: Total Pre-, Intra- And Post-Operative Management. Malden, Massachusetts: Wiley-Blackwell

Framework of Vulnerability Assessment in cybersecurity operations Implication of vulnerable assessment in physical security operations Vulnerable assessment is explosive- volatile and unpredictable co

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Framework of Vulnerability Assessment in cybersecurity operations

Implication of vulnerable assessment in physical security operations

Vulnerable assessment is explosive, volatile and unpredictable component in physical security operation:

  1. Provide detail narrative of VA explosive, volatile and unpredictable activities on organization asset?
  2. Provide detail narrative of VA explosive, volatile and unpredictable activities on rural community?

Do public funded health care programs overrule cultural differences for the sake of the providing a standard level of care?

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Do public funded health care programs overrule cultural differences for the sake of the providing a standard level of care?

How do cultural differences and language barriers like the ones demonstrated with the Lee family have an impact on health care compliance?
What is the difference between civil right and civil liberties?
How have the courts ruled on them throughout history?
Does the Terry Stop violate a person’s rights? Explain.
Do we have any inherent (Constitutional) privacy rights that would protect us from these type of issues?

Nursing as a discipline is considered to be both an art and a science.

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Nursing as a discipline is considered to be both an art and a science.

Nursing as a discipline is considered to be both an art and a science. Esthetic and empiric patterns of knowing are complex and divergent. Can the advanced practice nurse perform simultaneously from both perspectives? Why or why not? Would this be a desirable situation?

Nursing as a discipline is considered to be both an art and a science. Esthetic and empiric patterns of knowing are complex and divergent. Can the advanced practice nurse perform simultaneously from both perspectives? Why or why not? Would this be a desirable situation?

Nursing as a discipline is considered to be both an art and a science. Esthetic and empiric patterns of knowing are complex and divergent. Can the advanced practice nurse perform simultaneously from both perspectives? Why or why not? Would this be a desirable situation?

Nursing as a discipline is considered to be both an art and a science. Esthetic and empiric patterns of knowing are complex and divergent. Can the advanced practice nurse perform simultaneously from both perspectives? Why or why not? Would this be a desirable situation?

Nursing as a discipline is considered to be both an art and a science. Esthet Nursing as a discipline is considered to be both an art and a science. Esthetic and empiric patterns of knowing are complex and divergent. Can the advanced practice nurse perform simultaneously from both perspectives? Why or why not? Would this be a desirable situation? ic and empiric patterns of knowing are complex and divergent. Can the advanced practice nurse perform simultaneously from both perspectives? Why or why not? Would this be a desirable situation?

Clinical case scenario assignment

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The impact of oral conditions on an individuals’ quality of life can be profound, more so when they are increased risk patients such as the elderly or those with Down syndrome. These individuals experience the same dental problems as the general population; however, poor oral health may add an additional burden, whereas good oral health has benefits in that it can improve general health, social acceptability, self-esteem and quality of life (Fiske, Griffiths, Jamieson, & Manger, 2000).

When formulating an oral health care plan for higher risk patients, it is valuable to have a general knowledge of how to treat such cases. This assessment will explore two clinical case scenarios and the process through which each treatment plan is developed. Furthermore, the importance of providing a patient with quality care, rather than merely treatment, will be explored.

CASE 1

Appointment 1:

Complete Initial Assessment

Take medical history

According to Duggal, Hosy, and Welbury (2005, p.42), taking a comprehensive case history is an “essential prelude to clinical examination, diagnosis, and treatment planning”, and also plays a role in establishing a relationship with the patient.

In this case the patient is a thirteen year old female with Down syndrome, a genetic disorder that ranges in severity with unique characteristics that can influence dental care (Pilcher, 1998). It is associated with physical and medical conditions such as cardiac defects, compromised immune system, and upper respiratory infections (MacDonald & Avery, 2000).

Dental consideration

The history reveals that the patient received surgery for a cardiac abnormality at birth, and does not require antibiotic cover for dental treatment. The National Heart Foundation of New Zealand (2009) state that antibacterial cover is given as a prophylactic measure to prevent endocarditis; a serious and potentially fatal infection that affects the endocardium when bacteria is transported through the blood stream from the mouth because of dental work. Although prophylaxis is not necessary, consultation with the patient’s physician is crucial to determine any underlying medical conditions that concern her dental treatment.

According to Pilcher (1998) the eruption of teeth in persons with Down syndrome is usually delayed, may occur in an unusual order and there is an extremely high rate of missing teeth in both the primary and permanent dentitions. Therefore, it is important to maintain the primary dentition for as long as possible. Additionally, The National Institute of Dental and Craniofacial Research (NIDCR) (2010) state that patients with Down syndrome can experience rapid destructive periodontal disease thought to be a result of their lowered host immune response. Other related factors include abnormal tooth morphology with an increased likelihood of smaller or conical roots, bruxism, malocclusion, and poor oral hygiene (Boyd, Quick, & Murray, 2004).

Therefore, good homecare is vital to manage periodontal disease and carious lesions. The mental capability of people with Down syndrome can vary widely (NIDCR, 2010), which is why as a health professional it is important to perceive how much information the patient is able to comprehend. Education should be given to the family and caregiver to ensure optimal homecare is provided.

Plaque index

Taking a plaque score is a quick and useful way for a dental provider to assess oral hygiene by estimating the tooth surface covered with debris and/or calculus (Wilkins, 2009). The patient has plaque deposits along the gingival margins of many tooth surfaces and calculus deposits on the lingual surfaces of the lower anterior teeth indicating poor oral hygiene.

Periodontal probing

It is described that the patient has red and inflamed gingival tissues with the worst area associated with the upper anterior teeth. This is likely to be a result of mouth breathing which is common in patients with Down syndrome due to a small nasal airway and incompetent lips (Pilcher, 1998). Periodontal charting will determine whether the condition is gingivitis which is reversible or periodontitis. If there are periodontal pocket depths greater than 3mm, bone loss and root surface involvement, a more extensive treatment will be required (Wilkins, 2009).

Record examination and dental charting

– Upper permanent lateral incisors appear to be absent

– Upper deciduous canines show no mobility & permanent canines not visible

– Mesial marginal ridge of 75 broken down as a result of dental caries and is symptomless

– Fistula buccal to 74

– Permanent incisors and first molars show signs of mild to moderate hypoplasia

Radiographs

Bitewing radiographs should be taken to check for bone levels, calculus, overhangs of restorations, and carious lesions in the posterior teeth. An orthopantomogram (OPG) will determine the presence and position of permanent teeth and assess growth and development as well as other pathology (Cameron & Widmer, 2003). Additionally, a periapical radiograph will be necessary for pre-operative assessment of tooth 74 and 75 to determine the origin of the fistula.

Diagnosis

– Abscessed tooth (74 or 75 depending on radiographs)

– 75 has dental caries with pulpal involvement

– Periodontal disease (depending on pocket depth)

Differential diagnosis: – Severe plaque-induced gingivitis or

– Chronic periodontitis

– Mild to moderate molar incisor hypomineralisation hypoplasia

Oral health education and instruction

The patient has poor plaque control and therefore should be taught brushing and flossing techniques using the tell/show/do method so the dental provider can see how well the patient and parent or caregiver understand what is being instructed. She should be advised to brush at least twice a day and floss daily, as well as brush the tongue and gingiva.

The use of an electric toothbrush and floss holders should be recommended as those with Down syndrome often have limited manual dexterity (Sacks & Buckley, 2003). Additionally, a high concentration of fluoride such as Neutrofluor 5000 Plus toothpaste is recommended for daily use by patients with high risk of dental caries which Wilkins states will promote remineralisation and help strengthen the teeth (2009).

Dietary advice

Diet should be discussed with a focus on finding if the patient has a lot of sugar in her diet and educating her on the effects of cariogenic foods, perhaps using Stephan’s curve to explain depending on her level of understanding. The patient should be encouraged to eat cheese, unsweetened yogurt, milk and other dairy products as they contain calcium, phosphorous and magnesium which helps protect dental health (The Dairy Council Digest, 2000). Moreover, sugary and acidic drinks should be minimised as they can cause enamel erosion. It is vital the parent or caregiver receive this information as they may have a significant influence over her diet and pamphlets taken home to serve as a reference or reminder.

Formulate a treatment plan

Cameron and Widmer (2003, p. 6) state that treatment should be performed in the following order: (1) Emergency care and relief of pain, (2) preventive care, (3) surgical treatment, (4) restorative treatment, (5) orthodontic treatment, (6) extensive restorative or further surgical management, and (7) recall and review.

Once this has been completed it should be discussed with both the patient and her parents or caregiver and informed consent must be given.

Appointment 2:

The amalgam restoration in the 74 is described as appearing sound but there is a fistula present buccal to the tooth. A fistula is a channel allowing excess exudate to drain from an abscess (Ibsen & Phelan, 2004). Although this can be painless, it is considered an emergency and should be dealt with before any dental treatment.

It is likely that the fistula is related to the 75 which is broken down due to dental caries. When the marginal ridge of a primary molar is broken down due to dental caries, the pulp is consistently exposed (Cameron & Widmer, 2003). Although the 75 is described as symptomless, this may be because the drained exudate is relieving pressure from inside the tooth meaning it is less likely to be painful. If the PA radiograph confirms that the carious lesion on tooth 75 has pulpal involvement, it will be treated with either pulpectomy or extraction.

Pulpectomy: If tooth 35 is not present, the 75 should be preserved and a referral to a dentist to perform root canal therapy will be given. It is advised that a stainless steel crown be placed as according to Cameron and Widmer (2003) this is the strongest possible final restoration following pulpectomy and will be necessary to preserve the 75 for as long as possible.

Extraction: If 35 is present, the 75 should be extracted. However if 35 is not ready to erupt, a space maintainer is recommended to preserve the gap after extraction of 75 to prevent the adjacent teeth drifting into its space. This will enable the 35 to erupt in the proper position and prevent malocclusion in the future and will require a referral to an orthodontist.

The amalgam restoration on tooth 74 appears sound and depending on radiograph results, if there is no abscess on tooth 74 and 34 is present, no treatment is needed on this tooth. If there is abscess on 74, the same treatment for abscessed 75 is indicated.

Appointment 3:

Reassess oral hygiene: Reinforce good behaviour and make necessary recommendations for continual improvement.

Scale and polish: The aim of this is to remove as much bacteria from the oral cavity as possible and have a healthy mouth to perform restorative work in. According to Stefanac and Nesbit (2001), when planning treatment, it is sensible to put the least invasive treatments first when possible so that the patient can familiarise themselves with the dental setting and feel comfortable. (Pilcher, 1998) states that having a patient with Down syndrome that is relaxed and at ease can assists with cooperation in the chair and useful for future appointments.

Hypoplasia: The permanent incisors and first molars are described as having mild to moderate hypoplasia. Enamel hypoplasia is a deficiency in quantity of enamel that results in a defect of contour in the surface (Cameron & Widmer, 2003). This defect can cause tooth sensitivity, may be unsightly and more susceptible to dental caries. A compromised immune system is a characteristic of most individuals with Down syndrome which contributes to a higher rate of infections (Pilcher, 1998) and it is possible that the hypoplasia is related to the patient’s condition. Because of the teeth involved, this is likely to be Molar Incisor Hypomineralisation (MIH) which is defined as a hypomineralisation of systemic origin of one to four permanent first molars frequently associated with affected incisors (Weerheijm, 2003).

It is important that MIH be treated as soon as identified to minimise the heightened risk of dental caries and prevent the patient from experiencing tooth sensitivity. Treatment options depend on the severity of the hypoplasia and the symptoms associated with it (University of Iowa, n.d.). It should be noted that the worst area of inflamed gingival tissue is associated with the upper anterior teeth which could be a result of the patient avoiding these as they are sensitive or painful to brush. It may be useful to ask the patient about this so that education can be given on the importance of brushing all areas and the problem can be addressed.

In this case scenario, the most effective treatment would be the application of a fluoride varnish to the hypoplastic areas followed by resin-based sealants. Alternatively, if ideal moisture control cannot be achieved, glass ionomer sealant can be used. According to Subramaniam, Konde, and Mandanna (2008), the retention of resin sealant is seen to be superior of that of the glass ionomer which should be treated as temporary only. Cameron and Widmer (2003) explain that localised defects may be restored with composite resin and pitting defects may require stain removal with either rotary instruments or some sort of bleaching system. Furthermore, if there is sensitivity, the use of tooth mousse products should be advised to assist with remineralisation and desensitisation of the teeth (Walsh, 2007).

Appointment 4:

Remove IRM: Although the temporary restoration on tooth 65 is sound, it should be replaced with a permanent filling as Mount and Hume state that zinc oxide eugenol hydrolyses in time and should not be used for over six months (1998). Additionally, composite should not be used because the release of eugenol will inhibit the polymerisation of the composite resin (Mount & Hume, 1998). Therefore, an amalgam restoration should be placed on tooth 65 if the radiograph shows tooth 25 is present. If the permanent successor is not present, the temporary restoration should be replaced with a permanent restoration like a stainless steel crown and may require pulpotomy depending on how far the carious lesion has progressed in the tooth.

Recall:

A three month recall should be arranged as the patient is high risk for caries and periodontal disease. It is essential that optimal oral hygiene is maintained and well monitored by the dental practitioner.

CASE 2

The human needs of each older adult must be assessed individually and not based on preconceived stereotypes as the healthcare needs of elderly persons can vary from health to severe illness (Darby & Walsh, 2010). According to Fiske et al. (2000) there is a general trend for a reduction in edentulism and an increase in the retention of natural teeth. This attitude leads to more people wanting to understand how to best maintain good oral hygiene and it is the role of the dental provider to assist these individuals with appropriate educational instructions.

In this clinical case scenario the patient is an 81 year old man who comes to the clinic for dental hygiene care.

Appointment 1:

Complete Initial Assessment

Take medical history

The patient shows early signs of Parkinson’s disease; a progressive neurodegenerative disorder of neurons that produce dopamine (Little, Falace, Miller, & Rhodus, 2008). Loss of these neurons results in characteristic motor disturbances including a resting tremor, muscular rigidity, bradykinesia and postural instability. It is common for those with Parkinson’s disease to also experience xerostomia as a result of polypharmacy and is significant as this increases the risk of periodontal disease and coronal and root surface caries (Wilkins, 2009).

It is described that the patient has mild congestive heart failure which The American Heart Association (2011) state is the inability of the heart to supply sufficient blood flow to meet the needs of the body and can be a result of myocardial infarction and other forms of ischemic heart disease, hypertension, valvular heart disease, and cardiomyopathy. As the heart failure is mild, he will not require antibiotic prophylaxis for dental treatment however it is wise to confirm this with his physician.

The patient is taking nitroglycerin tablets under the tongue to relieve chest pain several times a week. It is taken sublingually for immediate relief of chest pain by reducing the oxygen need of the heart and may cause dizziness, light-headedness and fainting and may cause xerostomia (Medline Plus, 2011).

The patient has stiffness in the fingers of his dominant right hand due to arthritis; an inflammatory or degenerative process which involves the joints (Arthritis Foundation, 2011). Patients with arthritis may experience pain, swelling, limitation of motion and deformity of the joints and may find it difficult to keep an open mouth for long dental procedures.

Oral hygiene assessment

The patient has poor oral hygiene. It is likely that due to his arthritis which affects the fingers in his right hand, he is not adequately brushing quadrants 2 and 3. It should be noted that there are signs of abrasion lesions on the buccal surfaces of quadrants 1 and 4. Abrasion is the mechanical wearing away of tooth substance by forces other than mastication (Wilkins, 2009, p.272) and this is likely to be a result of the patient vigorously brushing horizontally. Furthermore, he has heavy plaque deposits on the lower lingual and all interproximal which indicate interproximal plaque removal methods must be instructed.

Periodontal probing

All periodontal pockets measure 1-3 mm except for 26 mesial with a probing depth of 4mm indicating generally good periodontal health.

Record exam and dental charting

– 27 moderately filled teeth present with tooth 25 lost due to a fractured root

– Gingival recession is present with 1-2 mm areas of root surfaces exposed on most teeth. A couple of theses surfaces present with light brown marks that are soft to touch

– Tooth 26 shows sign of periodontal bone loss palatally as well as tipping and drifting forward into the space left by 25

– Heavy plaque deposits on the buccal surfaces of quadrant 2 and quadrant 3 as well as lower lingual and all interproximal surfaces

– Very light plaque deposits on the buccal surfaces of quadrant 1 and quadrant 4

– Some surfaces with light plaque show signs of abrasion

Radiographs

To complete the initial assessment, bitewing radiographs and an OPG should be taken. This can give the dental provider information on alveolar bone levels, plaque retention factors, interproximal and secondary caries, furcation defects, subgingival calculus and additional pathology (Tugnail, Clerehugh, & Hirschmann, 1999). A periapical radiograph of tooth 26 is taken to examine bone loss and to check for subgingival calculus and root surface caries.

Risk assessment

The patient is at high risk of developing dental caries and moderate risk for periodontal disease due to his medical history. His lack of manual dexterity associated with Parkinson’s disease and arthritis, makes adequate plaque removal difficult to achieve. Moreover, due to medications, he is more likely to have xerostomia which will increase his risk of periodontal disease and dental caries, especially root surface caries (Wilkins, 1999).

Diagnosis

– Moderate plaque-induced gingivitis

– Localised moderate chronic periodontitis on tooth 26 due to tilting

– Generalised gingival recession

– Toothbrush abrasion

– Areas of root surface caries

Oral health education and oral hygiene instruction

Perhaps the most important treatment a dental provider can give is that of oral health education, information, promotion and counselling. This enables the patient to maintain good oral hygiene themselves and prevent further disease processes. In this clinical case scenario it is vital to advise the patient on homecare which will address his risks of dental caries and periodontal disease.

According to Darby & Walsh (2010) caries control and prevention activities must address three interrelated factors: (1) removal of bacterial plaque and biofilm, (2) reduction of refined carbohydrates and snacking in the diet, and (3) use of topical fluoride.

The patient’s oral hygiene activities are compromised due to the arthritis in his right hand and in the future will be further affected by his developing Parkinson’s disease. His poor oral hygiene should be addressed firstly by recommending the use of adaptive devices. Using a powered toothbrush and modifications of handle size, width, and grip, will provide assistance for the patient with thorough plaque removal. It should also be suggested that the patient use floss holders to ensure the effective removal of interproximal plaque or alternatively, interproximal brushes can be recommended if the patient is able to use them effectively.

Poor dietary practices involving the over consumption of soft, retentive refined carbohydrates and frequent snacking patterns are common among older adults (Darby & Walsh, 2010). The dental provider has an obligation to educate the patient on optimum food choices and nutritional patterns to promote oral health. It could also be beneficial to speak with any caregivers regarding the patient’s diet and make suggestions to prevent further carious lesions. Replacing sweet snacks with cheese and crackers or substituting sugar-free hard candy for mints are examples of two specific dietary interventions that may be more easily and realistically implemented for older adults.

Furthermore, the frequent use of topical fluoride products for home use should be encouraged. A high fluoride toothpaste (5,000 ppm) will help to strengthen enamel and aid in the prevention of dental caries and will cause little change in the routine of the patient.

For management of xerostomia, the patient is advised to take frequent sips of water and avoid the consumption of alcoholic drinks which will further dry out the oral mucosa. Sugar-free chewing gums will help stimulate the saliva but if the patient experiences difficulty in chewing because of arthritis, this may not be advisable. Additionally, tooth mousse should be recommended to provide lubrication and assist in preventing root surface caries (Walsh, 2007).

If the patient is unable to provide adequate home care, alternative solutions should be provided, such as the introduction of the Collis curve toothbrush, assisted brushing, or chlorhexidine rinses (Little et al., 2008) These aids facilitate self-care and hence self-determination for the patient. The patient may suffer from mild dementia and due to his age may have difficulty remembering everything discussed at the initial appointment therefore all instruction should be written down and passed to him or a caregiver.

Formulate a treatment plan

Appointments should be kept short and scheduled in the morning or early afternoon when patient is less tired or whenever suits his needs best. Once a care plan has been completed it should be discussed with the patient and informed consent must be given.

Appointment 2:

– Re-assess oral hygiene

– Quadrant scaling is recommended in case a full debridement cannot be completed in one appointment

– Reinforce good oral hygiene

Appointment 3:

– Re-assess oral hygiene

– Complete scaling and full mouth polish

– Reinforce good oral hygiene

A referral letter to the patient’s dentist is to be written and given to him regarding the restorative work required on the root caries present in his mouth. The importance of treatment should be explained to the patient and if necessary his caregivers should also be advised of the work required. As a preventive method, fluoride varnish should be applied to the other receded areas to help remineralise the enamel and reduce any sensitivity the patient may be experiencing (Wilkins, 2009).

Recall:

Upon completion of treatment for this patient, a three month recall should be arranged as his medical history indicates he may require regular maintenance in the future. This is also a good chance to evaluate the outcome and effectiveness of the previous treatment.

According to Stefanac and Nesbit (2001) an oral health care plan is about balancing the ideal with the practical, and emphasis should be placed on the patient and their needs which ought to drive the treatment planning process. There has been a shift in treatment given by dental providers, where the focus is now on not only restoring the problem in the clinic, but educating the patient on how they can best achieve optimal oral health themselves.

This assessment has investigated two different clinical case scenarios and discussed oral health care plans for each. In addition, it has examined the importance of treating each patient as an individual with specific needs and the significance of providing them with methods or self-care.