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T. Sebastian, M.B. B.A.O., M.B.B.Ch., Ph.D.

Vice Chair, University of Arizona College of Medicine – Tucson

Blood vessels that normally occupy a position closer to the bone showed a displacement toward the cemental surface. Primate Model Zander and Muhlemann (1956) used 9 monkeys and placed a hollow screw-type device that applied a horizontal force on teeth. All animals subjected to trauma showed necrosis and hyalinization of the periodontal ligament, osteoclastic activity in pressure zones, and new bone formation in tension areas. The findings indicated that furcations were the areas most susceptible to occlusal trauma, while only slight Section 6. When an excessive force was applied to 1 tooth in a splint, the periodontal tissues of all splinted teeth suffered comparable injury. Glickman and Smulow (1962) created excessive occlusal forces upon the periodontal tissues of 6 adult monkeys by constructing gold crowns in abnormal occlusal relationships. The authors reported that excessive occlusal forces alter the pathway of gingival inflammation into the underlying periodontal tissues and affect the pattern of bone destruction. Excessive occlusal pressure was more significant than tension in determining the pathway of gingival inflammation. Injury to the periodontium induced by artificial alterations in the occlusion is reversible. Glickman and Smulow (1968) also analyzed the effect of chronic trauma in monkeys by combining a high gold crown to cause hyperocclusion with an orthodontic appliance and a spring to bring the tooth back to its original position when the teeth were apart. The authors mention that chronic trauma from occlusions occurs in 3 stages: injury, repair, and adaptive alterations. This study failed to show a change in the pathway of inflammation under the influence of trauma from occlusion. Kenney (1971) placed gold inlays which were "high" in centric and protrusive in upper incisors of 4 Rhesus monkeys. The animals had moderate gingivitis and were scaled 2 weeks prior to crown cementation. Histologic evidence of tramatic occlusion or orthodontic movement was seen in all animals; the inlays did not produce any change in the intensity or distribution of the inflammatory cells. Pihlstrom and Ramfjord (1972) compared the periodontal status of non-functional teeth to functional teeth clinically, radiographically, and histologically in Rhesus monkeys. Marginal periodontitis was initiated using silk ligatures to enhance plaque retention. Primarily horizontal, non-excessive jiggling forces were applied by placing orthodontic ligatures in alternating interproximal sites on a daily basis. The following questions were addressed in these studies: Does occlusal trauma cause periodontal disease Is bone loss reversible when trauma is removed in a normal periodontium (adaptive changes) versus an inflamed reduced periodontium Is bone loss reversible when inflammation is removed and trauma remains in an inflamed reduced periodontium Poison (1974) produced a single episode of trauma subjacent to an established periodontitis. There was no difference in loss of connective tissue attachment and loss of alveolar bone between experimental and control teeth. There was no difference in three of four pairs of surfaces examined, indicating that it was unlikely jiggling trauma had accelerated the loss of connective tissue attachment. There was some loss in alveolar crest height and considerable reduction in volume (40%) of interproximal bone. When jiggling trauma was removed from teeth with an inflamed but reduced periodontium, there was no decrease in tooth hypermobility and no bone regeneration, suggesting that bone regeneration may be inhibited in the presence of inflammation. No alteration in connective tissue attachment levels occurred but new bone formation did occur without an increase in alveolar bone height. When marginal inflammation is resolved where tooth mobility is due only to marginal periodontitis (no superimposed trauma), tooth mobility is significantly reduced (Poison et al. Poison and Zander (1983) investigated the effect of trauma on surgically-created intrabony defects versus similar non-traumatized defects.

Githens and Abramsohn (2010) found that only 25% of adults 50 and over who were single or had a new sexual partner used a condom the last time they had sex. These results indicated that educating all individuals, not just adolescents, on healthy sexual behavior is important. Remarriage and Cohabitation: Older adults who remarry often find that their remarriages are more stable than those of younger adults. Kemp and Kemp (2002) suggest that greater emotional maturity may lead to more realistic expectations regarding marital relationships, leading to greater stability in remarriages in later life. Older adults are also more likely to be seeking companionship in their romantic relationships. Carr (2004a) found that older adults who have considerable emotional support from their friends were less likely to seek romantic relationships. In addition, older adults who have divorced often desire the companionship of intimate relationships without marriage. As a result, cohabitation is increasing among older adults, and like remarriage, cohabitation in later adulthood is often associated with more positive consequences than it is in younger age groups (King & Scott, 2005). No longer being interested in raising children, and perhaps wishing to protect family wealth, older adults may see cohabitation as a good alternative to marriage. In contrast, 80% older adults reported that they did not wish to cohabitate or marry. By 2025 that number is expected to rise to more than 7 million (National Gay and Lesbian Task Force, 2006). Despite the increase in numbers, older lesbian and gay adults are one of the least researched demographic groups, and the research there is portrays a population faced with discrimination. According to the Centers for Disease Control and Prevention (2011), compared to heterosexuals, lesbian and gay adults experience both physical and mental health differences. More than 40% of lesbian and gay adults ages 50 and over suffer from at least one chronic illness or disability and compared to heterosexuals they are more likely to smoke and binge drink (Hillman & Hinrichsen, 2014). When compared to heterosexuals, lesbian and gay elders have less support from others as they are twice as likely to live alone and four times less likely to have adult children (Hillman & Hinrichsen, 2014). Lesbian and gay older adults who belong to ethnic and cultural minorities, conservative religions, and rural communities may face additional stressors. Ageism, heterocentrism, sexism, and racism can combine cumulatively and impact the older adult beyond the negative impact of each individual form of discrimination (Hillman & Hinrichsen, 2014). David and Knight (2008) found that older gay black men reported higher rates of racism than younger gay black men and higher levels of perceived ageism than older gay white men. Although lesbian and gay older adults face many challenges, more than 80% indicate that they engage in some form of wellness or spiritual activity (Fredrickson-Goldsen et al. They also gather social support from friends and "family members by choice" rather than legal or biological relatives (Hillman & Hinrichsen, 2014). An important consideration when reviewing the development of gay and lesbian older adults is the cohort in which they grew up (Hillman & Hinrichsen, 2014). The oldest lesbian and gay adults came of age in the 1950s when there were 421 Figure 9. The baby boomers, who grew up in the 1960s and 1970s, began to see states repeal laws that criminalized homosexual behavior. Future lesbian and gay elders will have different experiences due to the legal right for same-sex marriage and greater societal acceptance. Consequently, just like all those in late adulthood, understanding that gay and lesbian elders are a heterogeneous population is important when understanding their overall development. This may be because younger older adults more often live with adult children or a spouse, two groups with the most likely abusers. Cognitive impairment, including confusion and communication deficits, is the greatest risk factor for elder abuse, while a decline in overall health resulting in greater dependency on others is another. Having a disability also places an elder at a higher risk for abuse (Youdin, 2016). Definitions of elder abuse typically recognize five types of abuse as shown in Table 9. Psychological and emotional abuse is considered the most common form, even though it is underreported and may go unrecognized by the elder. Continual emotional mistreatment is very damaging as it becomes internalized and results in late-life emotional problems and impairment.

While surgical silk and nylon (ethilon) are generally considered to be non-absorbable suture materials, they, in fact, undergo very slow absorption. In response to local information, silk is completely absorbed in 1 to 2 years while nylon (amide polymer) is absorbed via slow hydrolysis. These include cotton, steel, polyester (mersilene, dacron), ethibond, propylene (prolene, surgilene), polyethylene and polybutester (elastic). These materials are primarily used in conjunction with general and vascular surgery (Meyer and Antonini, 1989A and 1989B). Nine 4-0 suture materials were placed in the buccal mucosa and tongues of adult mongrel dogs which were sacrificed in groups of 2 at 1, 2, 3, 4, 6, 8, and 10 days post-placement. Block sections were processed for light microscopy and tissue reactions graded as mild, moderate, or severe. Plain gut created a mildto-moderate reaction (suture was not present at 8 or 10 days) and braided materials (polyester, dermal, cotton, and silk) resulted in similar reactions (29% to 65% judged severe at 8 to 10 days). The author suggests that the more severe tissue reaction to the braided (multifilament) materials is due to a "wicking" action that may transmit bacteria and fluids to the depths of the wound. The inflammatory infiltrate increased from day 1 through day 7 for both materials with the infiltrate close to the sutures appearing to be comparable, while the infiltrate some distance from the lumen was more intense with silk. The material should also be absorbable, non-allergenic, nonelectrolytic, non-carcinogenic, and withstand sterilization. Levin (1980) described the relative strengths and weaknesses of available suture materials as follows: Braided Sutures. These (cotton, linen, polyester, and silk) are more pliable and flexible than monofilaments and have better knot security. Disadvantages include the tendency to collect bacteria, a "sawing" effect when pulled through tissue and fragmenting within the tissue (especially silk). This results histologically in a greater inflammatory reaction, though severe reactions are rarely seen within the first 10 days. These sutures (steel, nylon, polypropylene) are generally stronger, more durable, and create less tissue reaction. Unfortunately, they are also more difficult to handle and have inferior knot-holding properties. These materials are plain and chromic gut, plain and chromic collagen, polyglycolic acid, and polyglactin. Plain gut suture is probably the best choice when difficult or inconvenient removal is anticipated. It is more difficult to tie than silk, has inferior knot-holding properties, and forms a hard knot which may irritate tissues. Chromic gut suture has chromic salts deposited on the outer surface or within the entire strand, providing greater resistance to absorption. Basic shapes include straight, three-eighths circle, half circle, and five-eighths circle. The immediate needle return from the tissue when using a curved needle is an advantage, and the half circle is easier to use in confined locations. Needle points may be tapered or cutting, the latter being more useful for thick resistant tissues. Conventional cutting needles are triangular in crosssection with a cutting edge on the inside of the curve. The reverse cutting needle has the third cutting edge on the outside of the needle curvature, minimizing tissue laceration. Sutures may be threaded through the needle or attached in the non-cutting end (swagged). Swagged needles are more expensive, but less time-consuming, and cause less tissue damage on penetration. The most popular needle is the three-eighths circle with a reverse cutting point (Meyer and Antonini, 1989). The butyl and isobutyl forms of cyanoacrylate are the most acceptable in the oral cavity; the methyl form (super glue) is toxic to tissues. Cyanoacrylates are capable of cementing living wet tissues and are exfoliated in 4 to 7 days.

The infant becomes more and more actively engaged in the outside world and takes delight in being able to make things happen. Repeated motion brings particular interest as, for example, the infant is able to bang two lids together from the cupboard when seated on the kitchen floor. The infant combines these basic reflexes and simple behaviors and uses planning and coordination to achieve a specific goal. Perhaps because of continued maturation of the prefrontal cortex, the infant become capable of having a thought and carrying out a planned, goal-directed activity. For example, an infant sees a toy car under the kitchen table and then crawls, reaches, and grabs the toy. The infant is coordinating both internal and external activities to achieve a planned goal. The toddler is considered a "little scientist" and begins exploring the world in a trial-and-error manner, using both motor skills and planning abilities. The sensorimotor period ends with the appearance of symbolic or representational thought. Additionally, the child is able to solve problems using mental strategies, to remember something heard days before and repeat it, and to engage in pretend play. This initial movement from a "hands-on" approach to knowing about the world to the more mental world of substage six marks the transition to preoperational thought. Object permanence is the understanding that even if something is out of sight, it still exists (Bogartz, Shinskey, & Schilling, 2000). According to Piaget, young infants do not remember an object after it has been removed from sight. Infants who had already developed object permanence would reach for the hidden toy, indicating that they knew it still existed, whereas infants who had not developed object permanence would appear confused. Piaget emphasizes this construct because it was an objective way for children to demonstrate that they can mentally represent their world. Once toddlers have mastered Source object permanence, they enjoy games like hide and seek, and they realize that when someone leaves the room they will come back. Toddlers also point to pictures in books and look in appropriate places when you ask them to find objects. Babies may demonstrate this by crying and turning away from a stranger, by clinging to a caregiver, or by attempting to reach their arms toward familiar faces, such as parents. Stranger anxiety results when a child is unable to assimilate the stranger into an existing schema; therefore, she cannot predict what her experience with that stranger will be like, which results in a fear response. Researchers have found that even very young children understand objects and how they work long before they have experience with those objects (Baillargeon, 1987; Baillargeon, Li, Gertner, & Wu, 2011). For example, Piaget believed that infants did not fully master object permanence until substage 5 of the sensorimotor period (Thomas, 1979). However, infants seem to be able to recognize that objects have permanence at much younger ages. Diamond (1985) found that infants show earlier knowledge if the waiting period is shorter. At age 6 months, they retrieved the hidden object if their wait for retrieving the object is no longer than 2 seconds, and at 7 months if the wait is no longer than 4 seconds. Others have found that children as young as 3 months old have demonstrated knowledge of the properties of objects that they had only viewed and did not have prior experience with. In one study, 3-month-old infants were shown a truck rolling down a track and behind a screen. The box, which appeared solid but was actually hollow, was placed next to the track. The infants spent significantly more time looking at this impossible event (Figure 3. Baillargeon (1987) concluded that they knew solid objects cannot pass through each other. Infant Memory Memory requires a certain degree of brain maturation, so it should not be surprising that infant memory is rather fleeting and fragile.