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She has been doing well since discharge from the hospital after birth with excellent growth and development buy malegra dxt. Her parents report that she has not been eating well for the past 2 days and that her diapers are not as wet as usual for her 130mg malegra dxt for sale. She has had some diarrhea as well and they are concerned because she is not at all “herself cheap 130 mg malegra dxt otc. Her blood pressure is normal and her pulses are strong order generic malegra dxt, yet on auscultation the usually very loud murmur is no longer appreciated. Discussion: This patient is having a hypercyanotic spell (tet spell) likely brought on by dehy- dration from gastrointestinal illness. Because there is little pulmonary blood flow, the loud murmur which is due to pulmonary stenosis is no longer audible. The child must be referred immediately to a tertiary care center for management of a hypercyanotic spell using the emergency medical transport system. In the meantime, turn out the lights in the exam room (calming effect) and ask the mother 176 D. Torchen to hold the baby while bringing her knees to her chest to increase the systemic resistance by kinking the femoral blood vessels. Once a hypercyanotic spell has occurred, it is generally accepted that the best course of action is to undergo complete surgical repair to avoid occurrence of future similar spells. Because the word “predominantly” is somewhat vague, it is generally accepted that if >50% of a great artery is supplied by the right ventricle, it is to be considered to have arisen from that ventricle. Clinical Manifestations How a patient does prior to any repair or palliation varies based in large part on the underlying anatomy and generally falls into one of three categories: 1. Numbers represent volume of blood flow in liters per minute per square meter (l/min/m2). The former will cause congestive heart failure and the latter will cause poor cardiac output. A patient with this type of pathophysiology will not have congestive heart failure and the cardiac output will be adequate. However, the limited volume of pulmonary blood flow will result in significant cyanosis. There is a tolerable increase in pulmonary blood flow and adequate cardiac output 180 D. If left untreated, they exhibit extreme failure to thrive and eventually succumb due to complications such as respiratory infections. On examination, these patients are quite cyanotic and sickly appearing with the degree of cyanosis worsening in proportion to the amount of pulmonary stenosis. The lung beds are no longer reactive to changes in circulation or oxygen level thus rendering them ineffective. Once having reached this point, heart-lung transplantation may be considered; or palliative measures can be implemented to improve the quality of life. Mild or no pulmonary stenosis will cause increased pulmonary blood flow resulting in prominent pulmo- nary vasculature and cardiomegaly. The great arteries are well visualized in these views and one can make the determination of whether or not there is >50% “commitment” of the aorta to the right ventricle. In addition, pulsed and continuous wave Doppler allow interrogation of the pulmonary valve and right ventricular outflow tract so as to assess any pulmonary stenosis that may be present. Cardiac Catheterization Cardiac catheterization is generally not indicated for diagnosis, although in com- plicated cases it can certainly aid in delineating the anatomy. Treatment As with most congenital heart defects, the goal is to undergo a complete repair resulting in a physiologically normal heart. Depending on what was done to the pulmonary outflow tract, further operations may be necessary. Case Scenarios Case 1 A newborn male is noted to have a loud murmur while in the nursery. His heart rate is 155 beats/min and his blood pressure measures 86/54 in all four extremities. His chest X-ray is generally unremarkable with normal cardiac silhouette and lung markings. Case 2 A newborn is discharged home after an unremarkable stay in the newborn nursery. His parents relate that he starts out well with a bottle but then “loses steam” and often falls asleep before finishing. On physical examination you note that while initially thought to be comfortable, he is in fact quite tachypneic with a respiratory rate >60 breaths/min. His blood pressures are normal in all extremities and he is somewhat tachycardic at 155 beats/min. His liver is palpable 3 cm below the right costal margin and his pulses are strong throughout. Chest X-ray demonstrates a large cardiac silhouette with a significant amount of pulmonary overcirculation. Busse Management These patients are often started on anitcongestive medications such as digoxin and lasix, if failure to thrive persists despite aggressive medical therapy, they will need to be referred for complete repair. Definition Transposition of the great arteries is a cyanotic congenital heart diseases where the great arteries (pulmonary artery and aorta) are connected to the wrong ventricle. This leads to an abnormal circulatory pattern where poorly oxygenated blood from the systemic veins is ejected back to the body and well oxygenated pulmonary venous blood is ejected back to the lungs. Patients typically have on or 2 levels of blood mixing (atrial septal defect and patent ductus arteriosus) allowing some improvement in systemic oxygenation. Patients with this lesion and a ventricular septal defect pres- ent with less cyanosis as it provides an additional level of blood mixing. That is, the infe- rior and superior vena cavae return deoxygenated blood to the right atrium. Deoxygenated blood then passes through the tricuspid valve and enters the right ven- tricle. Oxygenated blood returns to the left atrium via the pulmonary arteries and then passes through the mitral valve and enters the left ventricle. In the remainder of cases, associated anomalies are present, most commonly ventricular septal defect which is present in 30–40% of cases. In this case, two wrongs actually do make a right with deoxygen- ated blood draining from the right atrium to the left ventricle to the pulmonary artery and oxygenated blood draining from the left atrium to the right ventricle to the aorta. Unfortunately, the fact that the right ventricle becomes the pumping chamber to the body (systemic circulation) rather than to the lungs can eventually lead to heart failure. The great vessels are switched; the aorta emerges from the right ventricle while the pulmonary artery emerges from the left ventricle. The parallel course of great vessels gives the narrow mediastinal appearance on chest X-ray Pathophysiology In the normal heart, the pulmonary and systemic circulations are in series with one another. Deoxygenated blood from the body returns to the right side of the heart and then travels via the pulmonary artery to the lungs where it becomes oxygenated. Oxygenated blood returns to the left side of the heart via the pulmonary veins and is pumped out of the aorta where is it delivered to the body, becomes deoxy- genated once more, and returns to the right side of the heart. The deoxygenated blood that enters the right side of the heart is pumped into the aorta which is abnormally connected to the right ventricle, and therefore deoxygenated blood returns to the body without the benefit of improving its oxygen- ation. In the parallel circulation, oxygenated blood returning to the left heart goes back to the lungs through the abnormally connected pulmonary artery, therefore, depriving the body from receiving oxygenated blood. Mixing of oxygenated and deoxygenated blood at one or more of three levels is required for survival. Severe hypoxemia and subsequent anaerobic metabolism result in lactic acid production and metabolic acidosis, eventually leading to cardiogenic shock. Clinical Manifestations Transposition of the great arteries, as with most congenital heart defects, is well tolerated during fetal life. Depending on the degree of mixing of oxygen- ated and deoxygenated blood at the atrial, ventricular, and arterial levels, patients can become severely cyanotic within the first hours or days of life. Closure of the ductus arteriosus, one of the potential levels of mixing of deoxygenated and oxygenated blood, leads to cyanosis and acidosis.

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In an era when an increasingly multiply risk of infection discount malegra dxt 130mg mastercard, and that anyone—even large number of young people regard oral sex as someone using condoms—can become infected casual sexual activity order malegra dxt master card, doctors see more cases of through sexual activity with an infected person cheap 130 mg malegra dxt with visa. Today cheap malegra dxt 130 mg line, oral gonorrhea and oral should arm himself or herself with information on herpes are increasingly prevalent. The public health motto “One shot, one cases of chlamydia and gonorrhea in the 579 volun- syringe” is clearly not being taken seriously by teers aged 18 to 35 that the researchers called into illicit drug users. The study’s lead author, Charles Turner, than half of all new infections, according to recommended routine annual or biannual monitor- research reported in the year 2000. Dennis Fortenberry of the University of Indiana experiences fever, sore throat, headache, and joint Medical School suggested routine school-based pain. After symptoms dis- course, raises the controversial issues of cost, politics, appear, there may be no symptoms for years, but and confidentiality. Nevertheless, he says, “The time when these recur, the sinister infection can affect has come. When symptoms do appear in get sexually transmitted diseases by being infected females, usually they are vaginal discharge (white, via sex with someone who has an infection. Those who participate in anal sex can have ally active may have a sexually transmitted disease. Oral sex with a gonorrhea- Fear should not prevent someone from seeing a infected individual can result in sore throat. In most cases, a physician can the genitals, with small blisters that form and then diagnose this kind of disease via a physical exam, burst open. The who believes he or she or a partner may have a dis- first herpes outbreak can also be accompanied by ease should have an assessment because most sex- swollen glands, fever, and aching. Herpes sufferers ually transmitted diseases lead to other, bigger can have outbreaks the rest of their lives; in many problems when they are untreated. Hepatitis B sufferers have muscle aches, loss of appetite, fever, fatigue, headache, and dizziness. The Majors With progression of this disease, a person may Chlamydia stealthily erodes one’s health because have loose stools, yellow eyes and skin, dark the sufferer may have no symptoms at all, particu- urine, and tenderness in the liver area (just below larly in the case of women. Some ital area or on the cervix; these warts are painless women have dull pain in the pelvic area, and oth- but can proliferate wildly. The physical, psychological, and societal collateral Other legal and social issues that cause difficulties for damage due to sexually transmitted diseases is those with sexually transmitted diseases, especially immense. Thus, these individu- Considering the physical and emotional devasta- als may fail to seek treatment until the illnesses tion of such diseases, it is impossible to overesti- have advanced to the point that the diseases are mate their impact on individuals, couples, and already beginning to ravage their bodies. For example, undiagnosed human papil- underscores the importance of disseminating infor- lomavirus may, in some individuals, lead to cervi- mation in new and better ways. In some people, hepatitis B leads even in the early stages, when symptoms are mild to liver failure or liver cancer, and thus death. Gon- or even nonexistent but the individual knows he or orrhea can lead to pelvic inflammatory disease. It is hoped that a good fund of information will Furthermore, people with sexually transmitted spur people to ask a doctor’s advice if there is cause diseases are often ostracized because of prejudice or for concern. In 1999 and 2001 publications, he reiterated Experts predict that these four will cause the that “we know what works. In fact, this route of transmission is Also, an unclassified version of a national intel- viewed as such a threat that researchers at the U. Also, a large number of tuberculosis- the spread takes drug-resistant and/or more vir- infected illegal immigrants new to the United ulent forms. Introduction xvii Looking at the world picture, it is believed that Finally, the third scenario is the one viewed the most vulnerable region is sub-Saharan Africa, most likely to occur. At highest risk are those soldiers in likely” was one of steady progress—one that the developing countries. In devel- gation,” adding that “immoral persons must not oping countries, these diseases are unreported or under any circumstances be allowed to live in the underreported for several reasons: the stigma, the same house with those who lead moral lives. Doctors can use a prophylactic strategy of nosis and reporting are blurred because morbidity educating the public with regard to “risks of vene- and mortality rates can be multicausal. The figure was 155 per for treating venereal diseases; suppressing all 100,000 men and 184 per 100,000 women. Fur- advertisements of preventives, and so forth, that thermore, London doctors conjecture that these encourage vice by promising impunity; making reported infections are only about 10 percent of all transmission of syphilis an offense that would cases. From 1999 to 2000 in the United Kingdom, merit a jail sentence (adding that this probably the incidence of chlamydia rose by 17 percent, and could not be enforced but that its presence on the the number of cases doubled from 1994 to 2000. With a higher inci- enforcement of existing laws is the best prophylaxis for venereal disease. The To see how matters have changed in regard to sex- buds of an education program were launched; as is ually transmitted diseases, consider the contents of clear from current statistics, it apparently failed the article “Prophylaxis of Venereal Disease,” miserably—or fell on deaf ears. This was suspected but never before con- sexually transmitted diseases, it is not easy to stay firmed. It has tremendous repercussions for those on top of the many new developments that who are sexually active in that persons engaging researchers unveil on a regular basis. None of the participants chose the first information for those in developing countries option. Most of the young women had no symp- where women lack the power to control how toms, whereas results showed that 28. This was the first such case in decades, may have greater potential for disease protec- since the inception of stringent blood screening tion than was previously believed. The saliva, semen, vaginal fluid, and blood of people xx The Encyclopedia of Sexually Transmitted Diseases newly infected by the virus, and these levels a traditional exam. The participants were 228 were higher than or as high as levels in those teenage women. These are findings that suggest many basic misconceptions about the kinds of using combination antiretroviral therapy as an behavior that prevent infection. About 20 per- semen and vaginal fluid with the goal of lower- cent believed use of birth control pills protected ing the number of people contracting the virus. A simple pro- nal samples they obtained during a two-year cedure (much like a Pap smear) can result in study revealed a high percentage of undiagnosed detection of cancerous lesions among high-risk sexually transmitted diseases. Nearly 13 per- head and neck cancers—but it is also associated cent of women who had never previously had a with improved survival rates (more so than such gynecological exam had a positive test finding cancers stemming from other causes). The three-year- (termed intermittent viremia) may not be as omi- old boy had an opportunistic infection seen nous as was once believed. This was announced in February the egg from which the child developed, proba- 2003. Some even experience dramatic Another important figure is the dramatic dips in their counts. The also cause other illnesses such as conjunctivitis most widely known form of needleless acupres- (eye infection). Forty-nine types that cause sure is shiatsu, in which practitioners use finger human illness have been found. Certain types pressure on certain body points to stimulate chi have been shown to cause malignancy in (vital energy). Viewed by ease, adherence has been cited as an important the traditional medical establishment as alternative determinant of degree and duration of virologic medicine, acupuncture has many advocates who suppression. An acupuncturist seeks there is a strong association between poor adher- to correct deficiencies of chi, or life energy, and ence and failed virologic suppression. To this end, nee- predictor of failure to achieve viral suppression dles are used to direct chi to specific areas in the below the level of detection. In essence, what mented that 90 to 95 percent of doses must be this boils down to is that the needling serves to taken for optimal suppression; lesser degrees of activate deep sensory nerves, thus causing the compliance are more often associated with viro- brain to release endorphins, which are generally logic failure. Reasons cited were forgetting, being busy or depressed, disliking adverse side effects, or being acute respiratory distress syndrome The sudden ill. It seems log- 4 advocacy ical that the instability of homelessness would facilitated and promoted by having an assertive automatically lead to a lack of adherence, but that patient advocate. Predictors of poor adherence affirmations Declarations of specific emotional- include lack of rapport between clinician and health platforms, the repetition of which is meant patient, drug/alcohol use, mental illness, lack of to soothe tension and heighten resolve.

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God gave to the children of Israel a revelation of Himself at the waters of Meribah best purchase for malegra dxt. If they would only hearken to His voice and serve Him malegra dxt 130mg with mastercard, no disease would have the ability to afflict their bodies discount malegra dxt 130mg free shipping. All they had was a relationship with Jehovah best 130 mg malegra dxt, yet this was enough to immunize them, and make them ‘disease-free. By reason of the fall, man had come under the influence of disease and all that was evil. But God told them if only they would give ear to Him, and walk right; He would not allow any of these diseases to afflict them. In this case man was under the influence of sickness, but God revealed Himself Introduction and said, “I am the Lord that healeth thee. Exodus 23:25, “And ye shall serve the Lord your God, and he shall bless thy bread, and thy water; and I will take sickness away from the midst of thee. To prove to them that not only could He heal, but that He was also willing to fulfill His promises, He healed them several times by His Word and, there was not one weak person among them. Psalm 105:37, “He brought them forth also with silver and gold: and there was not one feeble person among their tribes. The Lord shall smite thee with madness, and blindness, and astonishment of heart:” The Amplified Version puts it this way; “The Lord will smite you with the boils of Egypt and the tumors, the scurvy and the itch, from which you can- not be healed. The Lord will smite you with madness and blindness and dismay of (mind and) heart. But He also promised that these boils, tumors and scurvy wouldn’t come upon them if they would only obey and serve Him. They had the condition of obe- dience to fulfill before they could enjoy God’s prom- ises. If God wanted the people of the Old Testament well and ‘disease-free,’ how much more those of us that were bought with the precious blood of His Son Jesus Christ? So many people have asked these questions about God, and a lot of Christians believe that God punishes and corrects with sickness. The most important thing to understand is this - God wants you well and in good health, and He isn’t the originator of sickness. James 1:17, “Every good gift and every perfect gift is from above, and cometh down from the Father of lights, with whom is no variableness, neither shadow of turning. Sickness has ruined many families, it drained their entire livelihood until they became poor, just like the woman with the issue of blood (Matthew 9:20). The Psalmist said, “Pre- cious in the sight of the Lord is the death of his saints” (Psalm 116:15). Sickness - A Legacy of the Fall After God created man in the Garden of Eden, He gave him dominion over all the works of His hand. God told Adam he could have anything in the garden for food except for the tree in the midst of the garden. Genesis 2:16-17, “And the Lord God com- manded the man, saying, Of every tree of the garden thou mayest freely eat: But of the tree of the knowl- edge of good and evil, thou shalt not eat of it: for in the day that thou eatest thereof thou shalt surely die. This scripture there- fore referred not only to physical death but also spiri- tual death, which is separation from God; being cut off from fellowship with God. Thus the day Adam disobeyed God’s instruction and ate from the tree, he died spiritually, and only then could he die physi- cally. Man is a spirit, he possesses a soul with which he regulates his life, actions, thoughts, reasonings and emotions, and he lives in a body (1 Corinthians 5:23). Through disobedience, sin gained dominion over man’s spirit, and through sin fear also got a hold of him. He now became afraid of the creatures over which he had pre- viously exercised dominion. He was cut off from fellowship with God be- cause he now had the nature of the devil, and a new master. But after the fall of man, when the devil stole man’s dominion, he infused them with death - which is his life. The Reign of Death Man died spiritually and right from then on death reigned over him. Romans 5:12, 14, 17, 21, “ Wherefore, as by one man sin entered into the world, and death by sin; and so death passed upon all men, for that all have sinned:... That as sin hath reigned unto death, even so might grace reign through righteousness unto eternal life by Jesus Christ our Lord. Adam to Jesus, sin gained the mastery over man’s spirit, and sickness came in, leading to physical death. Thus the reign of sin and sickness began in man’s spirit and ended up in his body, such that the human body could now experience death. But happy are you if you’re born again, be- cause death no longer reigns over you! Romans 5:16-21, “And not as it was by one that sinned, so is the gift: for the judgment was by one to condemnation, but the free gift is of many offences unto justification. But where sin abounded, grace did much more abound: That as sin hath reigned unto death, even so might grace reign through righteous- ness unto eternal life by Jesus Christ our Lord. The reign of sin and sickness over us has ended, and so has the dominion of disease. This is why any of the diseases that afflicted the Egyptians, or any other disease that afflicts man should not af- flict us. For us, the Cross holds so much meaning, though to the rest of the world, it was a place of shame. The Brazen Serpent John 3:14-15, “And as Moses lifted up the ser- pent in the wilderness, even so must the Son of man be lifted up: That whosoever believeth in him should not perish, but have eternal life. Why would He liken Himself to the brazen serpent that God instructed Moses to make? Numbers 21:5-9, “And the people spake against God, and against Moses, Wherefore have ye brought us up out of Egypt to die in the wilderness? And the Lord sent fiery ser- pents among the people, and they bit the people; and much people of Israel died. Therefore the people came to Moses, and said, We have sinned, for we have spo- ken against the Lord, and against thee; pray unto the Lord, that he take away the serpents from us. And the Lord said unto Moses, Make thee a fiery serpent, and set it upon a pole: and it shall come to pass, that every one that is bitten, when he looketh upon it, shall live. And Moses made a serpent of brass, and put it upon a pole, and it came to pass, that if a serpent had bitten any man, when he beheld the serpent of brass, he lived. When they cried to Moses in repen- tance and he in turn prayed to God on their behalf, God instructed him to make a fiery serpent of brass and set it upon a pole so all whoever was bitten by the serpents had to do was look upon the brazen ser- pent and live. Thus God telling Moses to make a brazen serpent indicated that the serpent had been judged for the sins of the children of Israel. And all they needed to do was accept this substitution by The Mystery of The Cross looking at the serpent; then they would live and not die. This brazen serpent was indeed a type of Christ, foreshadowing His death on the Cross. Thus when Jesus said to Nicodemus in John 3:14-15, “And as Moses lifted up the serpent in the wilderness, even so must the Son of man be lifted up: That whosoever believeth in him should not perish, but have eternal life” He meant He was to be judged for us. Our sins were to be placed on Him, so just like the children of Israel, we would not perish but obtain the life of God and live. And Aaron shall come into the tabernacle of the con- gregation, and shall put off the linen garments, which he put on when he went into the holy place, and shall leave them there:” Once every year, specifically on the tenth of the seventh month, God instructed the high priest to make atonement for the sins of the children of Israel (Leviticus 16:29-31). He was to select two goats; one to be the sin offering and the second the scapegoat. After killing the sin offering and offering its blood within the veil, He was to take the scapegoat and con- fess on its head all the iniquities of the children of Israel, and for the rest of the year till the following year, their sins would be covered, and they wouldn’t be judged for them. Next, the scapegoat would be led by the hand of a fit man into the wilderness, into a land not in- The Mystery of The Cross habited; bearing upon its head the sins of the people. This Scapegoat was actually a type of Christ, who offered Himself as a sacrifice for us. But in His case, He did not die for the children of Israel but for all people everywhere. When you consider the betrayal, arrest and condemnation of Jesus to death you will understand better why both Jews and Gentiles can hold claim to Him as their sacrifice for sins. In Matthew 20:18,19 Jesus said to His disciples on their way to Jerusalem, “Behold, we go up to Jerusalem; and the Son of man shall be betrayed unto the chief priests and unto the scribes, and they shall condemn him to death, And shall deliver him to the Gentiles to mock, and to scourge, and to crucify him: and the third day he shall rise again. John 11:49-52, “And one of them, named Caiaphas, being the high priest that same year, said unto them, Ye know nothing at all, Nor consider that it is expedient for us, that one man should die for the people, and that the whole nation perish not.

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First purchase malegra dxt pills in toronto, a fall in the prevalence of dental caries in developed countries buy malegra dxt 130 mg with visa, and second an increase in the prevalence of the disease in some developing countries that have increased their consumption of sugars and have not yet been introduced to the presence 105 of adequate amounts of fluoride discount malegra dxt 130 mg fast delivery. Despite the marked overall decline in dental caries over the past 30 years discount malegra dxt 130mg with amex, the prevalence of dental caries remains unacceptably high in many developed countries. Moreover, there is some indication that the favourable trends in levels of dental caries in permanent teeth have come to a halt (8). Many developing countries have low decayed, missing, filled primary teeth (dmft) values but a high prevalence of dental caries in the primary dentition. Data on 5-year-old children in Europe suggest that the trend towards reduced prevalence of dental decay has halted (9--11). In most developing countries, the level of caries in adults of this age group is lower, for example, 2. Few data are available on the prevalence and severity of root caries in older adults, but with the increasingly ageing population and greater retention of teeth, the problem of root caries is likely to become a significant public health concern in the future. The number of edentulous persons has declined over the past 20--30 years in several industrialized countries (3). Despite overall gains however, there is still a large proportion of older adults who are edentulous or partially dentate and as the population continues to age tooth loss will affect a growing number of persons worldwide. Table 13 summarizes the available information on the prevalence of edentulousness in old-age populations throughout the world. Dental erosion is a relatively new dental problem in many countries throughout the world, and is related to diet. There is anecdotal evidence that prevalence is increasing in industrialized countries, but there are no data over time to indicate patterns of this disease. There are insufficient data available to comment on worldwide trends; in some populations, however, it is thought that approximately 50% of children are affected (20). Deficiencies of vitamins D and A and protein-- energy malnutrition have been associated with enamel hypoplasia and salivary gland atrophy (which reduces the mouth’s ability to buffer plaque acids), which render the teeth more susceptible to decay. In developing countries, in the absence of dietary sugars, undernutrition is not associated with dental caries. Undernutrition coupled with a high intake of sugars may exacerbate the risk of caries. There is some evidence to suggest that periodontal disease progresses more rapidly in undernourished populations (22); the important role of nutrition in maintaining an adequate host immune response may explain this observation. Apart from severe vitamin C deficiency, which may result in scurvy-related periodontitis, there is little evidence at present for an association between diet and periodontal disease. Current research is investigating the potential role of the antioxidant nutrients in period- ontal disease. Poor oral hygiene is the most important risk factor in the development of periodontal disease (21). Dental caries occur because of demineralization of enamel and dentine by organic acids formed by bacteria in dental plaque through the anaerobic metabolism of sugars derived from the diet (24). Organic acids increase the solubility of calcium hydroxyapatite in the dental hard tissues and demineralization occurs. Saliva is super-saturated with calcium and phosphate at pH 7 which promotes remineralization. If the oral pH remains high enough for sufficient time then complete remineralization of 108 enamel may occur. If the acid challenge is too great, however, demineralization dominates and the enamel becomes more porous until finally a carious lesion forms (25). The development of caries requires the presence of sugars and bacteria, but is influenced by the susceptibility of the tooth, the bacterial profile, and the quantity and quality of the saliva. Dietary sugars and dental caries There is a wealth of evidence from many different types of investigation, including human studies, animal experiments and experimental studies in vivo and in vitro to show the role of dietary sugars in the etiology of dental caries (21). Collectively, data from these studies provide an overall picture of the cariogenic potential of carbohydrates. Sugars are undoubtedly the most important dietary factor in the development of dental caries. Here, the term ‘‘sugars’’ refers to all monosaccharides and disaccharides, while the term ‘‘sugar’’ refers only to sucrose. The term ‘‘free sugars’’ refers to all monosaccharides and disaccharides added to foods by the manufacturer, cook or consumer, plus sugars naturally present in honey, fruit juices and syrups. The term ‘‘fermentable carbohydrate’’ refers to free sugars, glucose polymers, oligosaccharides and highly refined starches; it excludes non-starch polysaccharides and raw starches. Worldwide epidemiological studies have compared sugar consumption and levels of dental caries at the between-country level. A later analysis by Woodward & Walker (28) did not find a similar association for developed countries. Populations that had experienced a reduced sugar availability during the Second World War showed a reduction in dental caries which subsequently increased again when the restriction was lifted (30--32). Although the data pre-date the widespread use of fluoride dentifrice, Weaver (33) observed a reduction in dental caries between 1943 and 1949 in areas of northern England with both high and low concentrations of fluoride in drinking-water. As economic levels in such societies rise, the amount of sugar and other fermentable carbohydrates in the diet increases and this is often associated with a marked increase in dental caries. There is evidence to show that many groups of people with high exposure to sugars have levels of caries higher than the population average. Examples include children with chronic diseases requiring long-term sugar-containing medicines (40), and confectionery workers (41--44). Likewise, experience of dental caries has seldom been reported in groups of people who have a habitually low intake of sugars, for example, children of dentists (45, 46) and children in institutions where strict dietary regimens are inflicted (47, 48). A weakness of population studies of this type is that changes in intake of sugars often occur concurrently with changes in the intake of refined starches, making it impossible to attribute changes in dental caries solely to changes in the intake of sugars. Human intervention studies are rare, and those that have been reported are now decades old and were conducted in the pre-fluoride era before the strong link between sugars intake and dental caries levels was established. It would not be possible to repeat such studies today because of ethical constraints. The Vipeholm study, conducted in an adult mental institution in Sweden between 1945 and 1953 (50), investigated the effects of consuming sugary foods of varying stickiness and at different times throughout the day on the development of caries. It was found that sugar, even when consumed in large amounts, had little effect on caries increment if it was ingested up to a maximum of four times a day at mealtimes only. Increased frequency of consumption of sugar between meals was, however, associated with a marked increase in dental caries. It was also found that the increase in dental caries activity disappears on withdrawal of sugar-rich foods. Despite the complicated nature of the study the conclusions are valid, although they apply to the pre-fluoride era. The Turku study was a controlled dietary intervention study carried out on adults in Finland in the 1970s which showed that almost total substitution of sucrose in the diet with xylitol (a non-cariogenic sweetener) resulted in an 85% reduction in dental caries over a 2-year period (51). Nine out of 21 studies that compared amount of sugars consumed with caries increment found significant associations, while the other 12 did not. Moreover, 23 out of 37 studies that investigated the association between frequency of sugars consumption and caries levels found significant relationships, while 14 failed to find any such associations. A cross-sectional study in the United States of 2514 people aged 9-- 29 years conducted between 1968 and 1970 found that the dental caries experience of adolescents eating the highest amounts of sugars (upper 15% of the sample) was twice that of those eating the lowest amounts (lower 15% of the sample) (52). When the effects of oral hygiene and fluoride were kept constant, the children with a low intake of sugars between meals had up to 86% less caries than those with high intakes of sugars. Other studies have found fluoride exposure and oral hygiene to be more strongly associated with caries than sugars consumption (54, 55). A recent study in the United Kingdom of a representative sample of children aged 4--18 years showed no significant relationship between caries experience and level of intake of free sugars; in the age group 15--18 years, however, the upper band of free sugars consumers were more likely to have decay than the lower band (70% compared with 52%) (20). Many other cross-sectional studies have shown a relationship between sugars consumption and levels of caries in the primary and/or permanent dentitions in countries or areas throughout the world, including China (56), Denmark (57), Madagascar (58, 59), Saudi Arabia (60), Sweden (61, 62), Thailand (63) and the United Kingdom (64). When investigating the association between diet and the development of dental caries it is more appropriate to use a longitudinal study design in which sugars consumption habits over time are related to changes in dental caries experience. Such studies have shown a significant relationship between caries development and sugars intake (65--67). In a comprehensive study of over 400 children in England aged 11---12 years, a small but significant relationship was found between intake of total sugars and caries increment over 2 years (r = + 0.

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