Paresthesia Case Study: Diagnosis and Management

Paresthesia Case Study: Diagnosis and Management ABSTRACT Parasthesia is defined as a sensory disturbance with clinical manifestations such as burning, prickling, tingling, numbness, itching or any deviation from normal sensation1. Paresthesia of the inferior alveolar nerve can occur during various dental Procedures like local anesthetic injections, third molar surgery, orthognathic surgery, Ablative surgery, Implants, and endodontics. This case report highlights a commonly occurring and often reported problem of Paresthesia involving the Mental Nerve during endodontic treatment. Most of the previous case reports have used radiographs for the diagnosis and management of these cases. Since the radiographic image is a 2 dimensional image it has its limitation while a 3 dimensional imaging modality like a cone beam computed tomography (CBCT) provides the clinician with additional information which can be critical in the management of cases. The exact 3 dimensional location of the mental foramen in relation to the apex of the concerned tooth ca n be confirmed using CBCT scans, helping make more informed diagnosis and treatment plans. This case was successfully managed using CBCT images for guidance during the root canal treatment. INTRODUCTION Parasthesia is defined as a sensory disturbance with clinical manifestations such as burning, prickling, tingling, numbness, itching or any deviation from normal sensation1. Paresthesia of the Inferior Alveolar Nerve and its branches can occur during various dental Procedures like Local Anesthetic Injections, Third Molar Surgery, Orthognathic Surgery, Ablative Surgery, Implants, and Endodontics2, 3. Damage to vital structures in the head and neck area during dental treatment is always a vexing prospect for the clinician. During Endodontic Treatment precautions have to be taken against this, as there is a possibility of injury to a vital structure with the instruments or chemicals being used and also a chance of depositing infected material with their byproducts from the tooth into these areas causing a subsequent immunological response from the body. Today we are able to use 3 Dimensional imaging to locate and respond to such situations much more precisely than ever before4,5.This case highlights a commonly occurring and often reported problem of Paresthesia involving the Mental Nerve during endodontic treatment6.7 which was managed using a CBCT to offer the patient a predictable treatment. Most of the previous case reports have used OPG’S and Intra oral periapical radiographs for the diagnosis and management of these cases. Since these are 2 dimensional imaging technique s they have their limitations. Cone Beam Computed Tomography (CBCT) is 3 dimensional imaging modality which provides the clinician with additional information which can prove to be critical in the management of such cases. CASE REPORT A 32 Year old female patient was referred to the Department of Conservative Dentistry with the chief complaint of a dislodged temporary restoration in a tooth undergoing endodontic treatment at a private dental clinic. Patient gave a history of Root canal treatment having been started 2 weeks back. Clinical Examination revealed an exposed access opening and extreme tenderness to percussion. Radiographic evaluation confirmed the history presented by the patient (Fig 1). A differential diagnosis of Periapical granuloma/ Periapical Abscess was recorded and the patient was advised to complete the Root canal treatment. In the first appointment the access opening was refined under local anaesthesia and the pulp tissue remnants were extirpated using a barbed broach followed by temporistion.The patient was recalled after 4 days for Root canal instrumentation. In the second appointment local anaesthesia was administered and working length determination was done using an apex locator (Propex 2,Dentsply) followed by confirmation with a radiograph (Fig 1). The working length was kept at 0.5mm short of the radiographic length of the tooth and the root canal instrumentation was carried out. Saline and Sodium Hypochlorite were used to copiously irrigate the root canal space and instrumentation was carried out with the Protaper Rotary system. The root canal was dried and the tooth was temporized for obturation in the following visit. On the next visit 7 days later the patient complained of Parasthesia of the lower lip from the date of the previous visit. On examination there was Parasthesia of the left half o f the lower lip and its distribution was consistent with the supply of the mental nerve (Fig 2). A close examination of the IOPA revealed the presence of the mental foramen directly below the apex of the treated premolar indicating possible deleterious effects of the previous procedure causing and periapical inflammation and subsequent damage to the mental nerve. A CBCT was taken to confirm the exact location of the mental foramen. The CBCT images confirmed the extreme close nature of the mental foramen to the apex of the treated premolar (Fig 3, 4). The distance between the apex of the premolar to the mental foramen was measured to be 0.4mm by using the CBCT software. Taking this into account the working length was reset at 1.5 mm short of the radiographic apex. The tooth was then instrumented to the new working length and the canals were irrigated with saline and sodium hypochlorite followed by drying using paper points. The patient was advised that the Parasthesia will gradually disappear and that the lip will regain normal sensation and was scheduled weekly recall appointments. The Parasthesia was still present at the one week recall appointment until the 6th week after which gradual normalization was observed. At end of two months the Parasthesia had completely disappeared and normal sensation had returned. Endodontic treatment was resumed keeping the new working length. The instrumentation was completed and the tooth was obturated using F3 (Protaper Dentsply) size gutta percha for apical fill and Obtura 2 with System B for back fill using continuous wave of condensation techniqueA one week follow up was done to confirm the absence of any recurrence of the Parasthesia following the obturation. Finally the tooth was restored with a No.1 size fiber post (Angelus Brazil) and crown was placed (Fig 5). DISCUSSION Dental radiographic evaluation is a fundamental tool for endodontic diagnosis. Conventional Intraoral Periapical radiographs are routinely employed during endodontic diagnosis to examine the tooth, identify the pathology and plan the treatment. However, a conventional radiograph is a two dimensional image of a three dimensional object and consequently has limitations. Numerous prior studies have demonstrated the effective use of CBCT in the assessment of complex endodontic cases .In cases where location of a vital structure such as the mental foramen or the Mandibular canal are concerned the 3 Dimensional imaging capabilities of a CBCT are invaluable. With CBCT and its advanced 3 D reconstruction software, it is possible precisely orient the teeth under treatment with the adjacent anatomic structures across a multitude of planes to get measurable values of distance, which help with the consequent predictable treatment plan. In situations of close proximity of a nerve to a tooth which is being endodontically treated various possibilities of damage to the nerve exist. Mechanical compression of the nerve, Damage to the nerve due to over instrumentation, Extrusion of necrotic debris and toxic metabolites from the root canal space, overfill or the passage of various endodontic materials (root canal irrigants, sealers, and paraformaldehyde containing pastes) into the vicinity of the nerve or its branches. In the present case the most probable cause of the Parasthesia could have been an acute exacerbation of the Periapical infection due to Extrusion of the necrotic debris from the root canal space into the mental foramen space and/or inadvertent direct mechanical compression of the nerve because of over instrumentation of the tooth during working length determination Direct peripheral nerve injury has been previously classified into three basic types: Neurapraxia, Axonotmesis and Neurotmesis 8. Neurapraxia occurs due to a slight compression of the nerve trunk resulting in a temporary conduction block. Neurapraxia of the inferior alveolar nerve or mental nerve will usually manifest as a Paresthesia or Dysaesthesia of the lip and chin region 9. Axonotmesis refers to the actual degeneration of the afferent fibers as a result of internal/external irritation resulting in anesthesia 10. Neurotmesis is the complete severing of the nerve trunk, resulting in permanent Paresthesia which can only be corrected by microsurgery and has a more guarded prognosis (8-10). The most likely form of injury in the present case seems to be Neurapraxia due to either periapical infection or direct injury by over-instrumentation/inadvertent passage of the root canal irrigant or both. The tooth responded well to conservative treatment, and upon completion of the debridement and disinfection of the root canal, the symptoms of periapical infection subsided and Paresthesia started to diminish. CONCLUSIONS The lower mandibular premolars very frequently are in close approximation to the Mental foramen and the Mandibular canal. The pre-operative radiograph does provide us with a 2 dimensional image but better more accurate location can be obtained using the CBCT whenever possible. Finally the best method to prevent any damage to the Mental Nerve is to locate it.

Eymp 5

2. 1 Explain the ways in which adults can effectively support and extend the speech, language and communication development of children during the early years. Adults can effectively support the speech, language and communication development of the child by the parent talking fluently and clearly so the child can hear the patterns of the language they are learning. The adult can also help the child’s understanding of communication by miming the actions they are saying, this help the child put together the actions and words to understand what he adult is saying.An adult can extend the child’s development by introducing new words, and getting the child to use more intellectual words such as ‘dog’ instead of ‘doggy’. Babies communicate by crying for their needs such as for a nappy change or a bottle. Adults can support the child’s development by talking to babies in short phases and high pitched voices and emphasis on key words, this is cal led parentese.Another way that adults communicate with children is by eye contact, if the child has sigh issues then the babies response would be by listening intently and becoming still, as for a baby that is well sighted would ‘dance’ and smile. Adults can extend the child’s communication development by repeating a word to the baby to get them used to the word, and then showing the child the meaning, by also miming and using body language. 2. Explain the relevant positive effects of adult support for the children and their causes. The positive effects of adult support for the children involve improvements in speech, language and communication skills, social interaction, behaviour and emotional development / self confidence. Praising and encouragement are very important when supporting the child’s speech, language and communication development as they need a lot of praising or rewards when the child is speaking correctly.By the adults giving the child rew ards and praising them supports the child as they know they are doing good, and will continue to excel and improve their development, as well as the child gains self – confidence and self – esteem when they are being praised which allows the child to experience new things and experiences, this would help the child’s communication as they would have the confidence to speak up and ask questions. There are a few methods that are used to praise children, one is verbal, such as praising the child by giving them positive comments about what they are doing and how they do things like ‘Brilliant Tony!You played really well’ As this has two positive comments would make the child feel good, and would then go and play well again and this would improve their social interaction as well as their motional development. Another positive method that the adult could use is symbols, such as smiley faces and well done stickers when the child has done something well such as reading, this would have a positive effect on the child development as they feel confident as they can read well or playing well, which could lead to the child trying to learn and do more things as they feel good about themselves.

Marketing †ethics Essay

Marketing ethics is an area that deals with the moral principles behind marketing. Ethics in marketing applies to different spheres such as in advertising, promotion, pricing. However, for purposes of this essay, the ethics of advertisements will be dealt with especially in relation to children. (Mohandeep, 2001)) Many marketers and analysts have agreed that children are marketer’s best friend. This is backed up by evidence from watch groups such as Media Channel. In the year 2007, they highlighted the fact that in the United States, close to two billion dollars was spent on advertisements to children. It was also revealed that children greatly affect the commodities their parents buy. Estimates done in this field show that projects tailored for children in the year 2006 totaled fifty two billion dollars. (McGee and Heubusch, 1997) Regardless of all this potential returns that children can give manufacturers and their marketers, there are key ethical issues that arise in the discussion. For example, do children have the capability of understanding some of the intricate marketing tactics? Do children possess the final buying power? Do marketers need to get permission from their parents? And do children understand the negative effects of some of the products advertised to them? These key questions will be analyzed in relation to business pressures then recommendations will be made. Key ethical issues in marketing to children Some companies have become notorious for the utilization of psychologists in their advertising and marketing campaigns. Normally what such companies do is that when trying to create marketing strategy, they will involve psychologist to tell them about tactics that they can use to influence children. Since psychologists understand the way child’s mind works, they can help marketers create campaigns that will be directly aimed at them and those ones that can easily influence their choices. This trend has becoming so alarming that the American Psychological Association has raised an alarm about it. They have set up a committee to estimate the effect that the involvement of psychologists in the marketing process of children’s products has on them. The group has asserted that no psychological principles should be used when marketing to children. They are also recommending that there should be some sort of strategy to protect the young ones from exploitation though the use of psychological ploys. (Beder, 1998) The basic framework which steers marketing ethics revolves around three main issues. These are: values, stakeholders, processes. Marketing ethics that are done on a value inclined framework are those one that involve the analysis of the kind of value that the marketing idea creates. So advertisements may instill in their target audiences positive or negative attributes. This all depends on their implementation. For example, an advertising targeting a child may become a problem if it violates the right to privacy, transparency, honesty or autonomy. By using psychologists in the process of creating advertisements for children, marketers are imposing upon children’s right to autonomy and transparency. They try studying children’s behavioral trends and then use this to exploit those children. This is quite unethical. The process oriented framework in marketing ethics is founded on the basis of analysing marketing ethics through the categories that marketers use. For example research, promotion and placement must be done in an ethical manner. This is something that marketers have chosen to ignore because their research is not done in an ethical manner. Their research involves using psychological experts who may use their knowledge to take advantage of children who belong to vulnerable groups (Lizabeth, 2001) Targeting children alone Marketers who create marketing campaigns that are just directed towards children only are engaging in unethical marketing practices. This is because children are naive. They are at a stage of development called proximal development. At this stage, children simply take up elements of what they perceive in the world around them and then use it in various aspects of their lives. There is a certain level of trust that children have over and above than one of adults. They lack the ability to weigh arguments in a sober and even sometimes a cynical way. Consequently, this makes them very vulnerable to exploitation. (Murphy et al, 2004) Examples of advertisements that are directed towards children alone are those ones that have cartoon characters and are seen as specifically meant for children. At that point, children will feel like they are the only ones with the ability of purchasing the item yet it is their parents who have to foot the bill. Unethical advertisements are those ones that do not involve getting consent from parents. Most of the time such advertisements are usually aired in the afternoon during kid’s programming sessions. They usually create desires in children to have those advertisements at all costs. When advertising is done without parental consent; that is when children are watching shows on their own then it became unethical. Children are too young to realize the manipulations that are going on through television or media advertisements. They also do not realize the financial pressures that come with the purchase of items. It would therefore be unethical for marketers to leave parents out of their marketing strategies. Normally, ethical advertisements are those ones that require children to get their parents involved in the marketing place. This can be achieved by stating it directly in the advertisement. It can also be achieved by limiting some children’s products in parental magazines or targeting families in general instead of just children. (Waymack, 2000) Advertisements targeting children alone have shown their effects in a number of ways. In the year 2007, it was found that about fifty eight percent of all the items purchased by children (through their allowances) are sweets and toys were the next highest items to be purchased by children. This took up a whooping thirty percent. Toys and candy are all items that are advertised directly children hence the staggering statistics. (Davidson, 2002) Advertising to children alone brings out very fundamental ethical issue. It highlights the power analysis issue in marketing. Any form of marketing that claims to be ethical must adhere to the power balance principle. The scales must not be tipped towards the consumer neither should they favor the marketer either. When marketers target vulnerable markets, they tend to make the situation favor them. This is what is called caveat emptor in marketing. It is an unfair scenario and is also exploitative in nature. (McGee and Heubusch, 1997) Types of products, manner of advertisements and other qualities can indicate whether or not an advertisement is targeting children. It should be noted that there are certain elements that if conducted by marketers may be deemed unethical for example, when an advertisement is made in such a manner as to imply that it is meant for children. Some elements to watch out for are: music, images, voices, color. These are all elements that are meant to draw on children’s attention. Besides this, there may be certain activities expected to captivate children such a drawing, then those advertisements may be meant for them. Besides that, some advertisements may have characters that are designed for that demographic group. Sometimes some advertisements may be placed in publications that are usually read by children alone. They may also be placed in areas that have children. (Murphy et al, 2004) All these features can be deemed unethical if they will be seen or heard by children exclusively, For example, if the advertisement is placed in a publication that is read by children alone then this is unethical because there is not parental consent there or if it is broadcast at times when children could be watching without parental consent. (Lizabeth, 2001) Sometimes the kind of content in the advertisements matters too. Advertisements that are created in such ways as to make children feel less about themselves if they lack that product may be deemed unethical. Also advertisements that will promote harmful products to children are also unethical. For example, there were certain toys from China that had an excess of chemical elements and exposed certain risks to children who were playing with them. If advertisements possess those characteristics, then they may be considered unethical. Responsible marketing The issue of marketing itself has two main components. The first group is made up of the abolitionists and the second are the libertarians. The abolitionists believe that all advertising to children is wrong and that it should be completely eliminated. But this is something that is unrealistic and cannot be feasible in today’s fast paced and commercial world. The other extreme is held by the liberalists who believe that advertisements to children should be left as they are. They insist that society shapes advertisements and that advertisements do not change moral values. But this is denying the obvious. The fact that children in the UK and even in other parts of the world spend the largest portion of their leisure time watching television implies that they will pick up some of the habits depicted on their screens. (Waymack, 2000) In light of the above facts, it is important to come up with a compromise on the issue through taking up responsible marketing. Children can still be considered as a target audience for marketing of retail products, however, this should be conducted in such a responsible and socially sustainable manner. There are three main alternatives available for marketers targeting children and these are: viewing children as docile consumers, viewing children as non-consumers, viewing children as informed consumers. Choosing the non-consumer part would not be very market friendly because as it has been seen from earlier parts of the essay; children have substantial levels of buyer power. It is would therefore be uneconomical not to tap this very valuable market resource. On the other hand, viewing children as docile consumers causes a lot of ethical controversies that have been raised earlier. Consequently, the most sustainable form of marketing should be viewing children as informed consumers. Marketers need to advertise and market their products in such a way that there will still be room for them in the future. This will be effectively achieved by informing children about marketing ideas. This will enlighten them and give them a very valuable asset; choice. (McGee and Heubusch, 1997) Informing children about the intricacies of marketing at an early age will go a long way in ensuring that children can understand the fundamentals of the commercial world. It will mean that children’s naivety will not be taken advantage of and that they will have the power to decide for themselves whether or not products are good for them. The ethical issues that have been brought forward stem from the fact that children are too young to understand the main reasons behind marketing displays. Informing them about this will drastically reduce those ethical concerns and will at the same time still allow marketers to go about marketing their products. (Beder, 1998) It should be noted that some countries like Sweden have argued that children can understand the effects of commercial marketing after reaching the age of twelve; some have suggested four and others ten. They claim that at that point, be it 4, 10, or 12, children can understand the commercial world and the exploitation tendencies that their worlds present them. Consequently, human rights groups claim that marketers should not target children that fall below that group. But that debate can be eliminated if children below those established ages are made aware of the commercial world. Regulations This is something that is already in place, but still needs more emphasis. Advertisements should not be aired during children’s programming as they are likely to be unsupervised at that point. Governments should institute statutory regulations on television advertisements. Advertisements should also be edited such that they do not seem to appeal to the child directly. They should be made in such a way that they will involve the parent or family. (Mohandeep, 2001)) Conclusion Advertisements to children have sparked off lot of controversy resulting in various reactions in various countries. However, experts agree that unethical marketing occurs when advertisements are directly aimed at children without getting consent from parents. Organisations can go about this issue through regulating their content, changing their times and embarking on a consumer education to make their young audiences aware. (Waymack, 2000) Reference: Beder, S. (1998): Marketing to Children, University of Wollongong Journal Lizabeth E. (2001): Marketing With A Conscience: Sales and Ethics; Journal for the US Dept. of State Mohandeep S. (2001): Ethics in Marketing; Encyclopedia of Business and Finance Davidson, D. (2002): The Moral Dimension of Marketing; South-Western Educational Journal Murphy, P. et al (2004): Ethical Marketing; Prentice Hall Waymack, M. (2000): The ethics of selectively marketing the Health Maintenance Organization, Journal of Theoretical Medicine and Bioethics, Issue 8, Volume 11, Pages 301-309 McGee, T. and Heubusch, K. (1997): Getting Inside Kids’ Heads; American Demographics, Vol. 19, No. 1.

Essay on The Women - 770 Words

The womens suffrage party fought for years on the right to vote. They werent going to stop until they got their right. For instance, Alice Paul organized a parade through Washington D.C. on inauguration day, which supported womens suffrage and also picketed the White House for 18 months. Paul was put in jail for that and started a hunger strike. Susan B Anthony and Elizabeth Cady Shanton supported the womens suffrage for fifty years later. Neither of them lived to see the 19th amendment ratified on August 26, 1920. The amendment was ratified under Wodrow Wilson as the President of the United States. Now with the 19th amendment, women have the right to own property, be employed, get an education, get a divorce, and get custody of†¦show more content†¦In 1916, Jeannette Rakin of Montana became the first woman to be taken into the United States House Of Representatives. There were seventy-five women who had major roles in womens suffrage. They were ver important and did a lot o f hard work for the womens suffrage. Some of them were: Susan Brownell Anthony arrested for trying to vote Elizabeth Cady Shanton wrote the Declaration of Sentiments Alice Stone Blackwell was the recording secretary Harriot Stanton Blatch founder of the Womens Political Union Amelia Bloomer publisher defending women and how they dressed in New York. Lucy Burns helped organized the Congressional Union Carrie Lane Chapman Catt became president in 1915 Lucretia Coffin Mott started the first womens rights convention with Stanton and her sister Martha Wright in New York Anna Howard Shaw was President from 1904 to 1915 Charlotte Perkins Gilman wrote a book about women independence. Alice Paul picketed the White House for womens suffrage 240 WOMENS SUFFRAGE By definition, womens suffrage is the right for women to vote. Womens suffrage started back as far as the 1600s. I am going to talk about the 1800s. 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