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Randomization was determined by selecting the restorative system (via a coin toss), then using the selected system on the tooth with the lowest number. Clinical procedures All cavities were prepared under local anesthesia and rubber dam isolation (Hygienic Dental Dam, Coltene/Whaledent, Inc. In cases with deeper areas, a calcium hydroxide lining (Kerr Life, Kerr Dental) was used. Before the start of treatment, patients were informed of the research methodology, risks, and benefits, as well as their right to withdraw from the research at any time. A sectional metal matrix, fixed with an elastic ring (Garrison Dental), was installed to restore the proximal contact and marginal ridge. Increments of resin composite (maximum thickness of 2 mm) were placed and photocured. Occlusal anatomy was developed using hand instruments before the composite was cured at the occlusal surface. After polymerization, the margins were inspected carefully for overhangs, which were removed with a No. The teeth in Figure 2, after placement of dimethacrylate-based resin composite on tooth No. Modified United States Public Health Systems criteria for the clinical evaluation of silorane- and dimethacrylatebased resin composites used in this study. When disagreement occurred during the evaluation process, the evaluators had to reach a consensus before the patient could be dismissed. The same procedures performed at the baseline were performed again 1 year post-treatment. Marginal discoloration/marginal adaptation Marginal discoloration was detected in some restorations from both groups. Surface texture In terms of surface texture, there was no significant difference between the 2 restorative systems (P > 0. Anatomic form All restorations at the 1-year recall were continuous with existing anatomic form. Color match In terms of the color match between the restoration and the tooth, 84. Clinical success rate At the 1-year recall, all composite restorations showed acceptable clinical performance. The McNemar statistical test was used to draw a comparison between baseline and 1 year for each resin composite system and no significant differences were found. The null hypothesis that there would be no difference in the clinical performance between the 2 resin composite systems was confirmed. Both composite materials presented satisfactory results with no significant difference between them. Discussion To increase the validity of this clinical trial and allow for future comparisons with similar studies, care was taken to reduce bias. A randomized allocation and fully blinded investigation was employed using 2 calibrated evaluators, with 1 experienced dentist placing all of the restorations. A paired allocation design was employed and a maximum of 2 pairs of restorations was allowed per patient to reduce the effects of clustering. The sample size was comparable to previous studies in which 1 operator performed all of the restorative treatments, rather than using a multicenter approach. The 1-year recall was used as an initial evaluation of the marginal adaptation, since polymerization shrinkage develops at an early stage during restoration placement. Comparing the baseline data with those obtained at the 1-year evaluation revealed an increase in Bravo ratings for marginal discoloration, the most common problem reported in clinical trials involving resin composite restorations. Filtek Silorane was designed for posterior restorations; it requires its own dedicated adhesive system, to which hydrophobic bifunctional monomers are added to match the hydrophobic silorane resin. Although exceptional esthetic results are not considered essential for posterior restorations, both composites showed acceptable results.

Multimodal analgesia is the administration of two or more analgesic drugs with different mechanisms of action. These drug combinations should present substantial synergism which allows the use of lower doses of each class of analgesics with minimal adverse effects. Pain assessment Pain assessment in dogs and cats represent a challenge for the veterinarian since specific instruments/tools for the evaluation of pain in patients with oral disease have not been published. An instrument is currently under investigation and it is generally accepted that these animals have pain in the majority of cases especially those where a chronic infection or trauma exists. Dental disease has been associated with pain in cats in a recent study (Palmeira et al 2017). Box 2 - For example, it is not uncommon to observe increased body weight and activity, and better sleeping patterns/quality of life after treatment of oral disease. Some animals become friendlier after the procedure than before indicating a potential emotional and affective component of pain and inflammation. Analgesic management reduces pain and suffering and has a welfare benefit (see section of welfare). In general, pain associated with oral disease may create specific and/or nonspecific clinical signs which will improve after oral treatment. Signs of dental pain include ptyalism, halitosis, decreased appetite, rubbing or pawing the face, changes in demeanor and reluctance to play with toys. Pain recognition and assessment can be performed using the Glasgow pain scoring tools for dogs (Reid j et al 2007) and cats (Reid et al 2017). These instruments have not been specifically validated for patients with oral disease but they provide an idea of the "overall" picture and can be used for any medical/surgical condition. Perioperative pain control Opioids are the first line of treatment in acute pain management and they have been reviewed in detail elsewhere. Different opioids have variable effects based on their receptor affinity, efficacy, potency and individual responses. This discussion is beyond the scope of the guidelines, however most full opioid agonists. This is of interest in dental patients, however there might be liability issues of prescribing these medications to be administered by owners. Most oral and maxillofacial disorders and therapies involve inflammation and tissue damage/trauma. This may be particularly important after significant oral surgery, such as full-mouth extractions due to feline chronic gingivostomatitis. Analgesic infusions are important especially when oral administration of analgesics is not an option due to severe trauma or trismus (masticatory muscle myositis), among others. Local anesthetic techniques of the oral cavity Local anesthetic drugs produce a reversible block of sodium and potassium channels and transmission of nociceptive input. These blocks require minimal training and can be used for a variety of dental procedures including extractions or surgery of the oral cavity such as maxillectomy, mandibulectomy, among others. Some considerations are presented below: Unfortunately, local anesthetic techniques are not widely employed in veterinary medicine due to the lack of familiarity with use. These drugs are readily available and should be incorporated in the anesthetic management of patients with oral and maxillofacial disorders. It is important to note that techniques used in dogs cannot be directly extrapolated to cats due to anatomical differences between species. Materials: Loco-regional anesthetic techniques of the oral cavity require simple and low-cost materials such as disposable 1 mL syringes, 25-mm to 30-mm 27-G or 25-G needles. Larger needles should be avoided as they may cause nerve and vascular damage while smaller needles may produce excessive pressure at injection and result in local tissue damage.

Sigma receptor stimulation results in cardiac and respiratory stimulation, anxiety and hallucinations. Doses of 3 to 4 mg/kg of butorphanol given to budgerigars had no statistically significant effect on heart rate or respiratory rate;3 however, some treated birds lost motor control. Return to normal motor coordination occurred within two to four hours post-administration. Buprenorphine hydrochloridev is another opioid with agonist/antagonist activity that appears to be effective in controlling pain in avian patients. Regurgitation or vomiting occurred within two to five miniutes after administration in five of six patients. Aspirin has been recommended at a dose of one 5 gr tablet dissolved in 250 ml drinking water. These nonsteroidal agents have the potential to cause serious gastrointestinal side effects and may prolong clotting time. They should be used with caution until their benefits and limitations are better understood. A light- and electron-microscope study, with emphasis on the macrophage, epithelioid cell, and multinucleate giant cell reaction. Harrison S oft tissue surgical techniques that can be performed in birds have increased substantially over the last decade because of the widespread use of isoflurane anesthesia, the introduction of microsurgical techniques to the avian practice, improvement in microsurgical instrumentation, improvements in bipolar radiosurgical instrumentation and the growing expertise of avian surgeons. Board certified surgeons are becoming attracted to the field for the purpose of developing and refining avian procedures. Procedures that were once considered impossible are now performed on a routine basis. The most substantial limitation to soft tissue surgery of the abdomen is the small size (<100 grams) of many avian patients. Some of these problems can be overcome with the use of magnification, but others are a result of having limited surgical access to an area, and are difficult to overcome. Surgery of the thoracic area, even in large companion birds, presents a similar problem, in that the organs of interest are covered by the sternum and heavy musculature. The avian surgeon should practice surgical techniques on cadavers prior to performing the procedures on clinical patients. The delicate avian tissues tear in the presence of slight autolysis; therefore, the use of fresh specimens will give the surgeon an appreciation of avian tissue characteristics and allow the surgeon to explore the capabilities of surgical instrumentation. When necropsies are necessary, the clinician should approach this procedure from the perspective of a surgeon rather than of a pathologist, by dissecting and reviewing anatomy from a regional approach rather than by performing the necropsy strictly from the traditional ventrodorsal approach. Birds have relatively thin, dry epidermis, and the dermis is attached to the underlying muscle fascia with little subcutaneous tissue. Compared to mammals, the skin is only loosely attached to underlying structures, except in the distal extremities where it is firmly adherent to underlying bone. Passerine Leg Scales Passerine leg scale syndrome is characterized by the development of abnormally large scales of the legs and feet, possibly as a result of mite infection or malnutrition (see Chapter 43). They also predispose the bird to bacterial pododermatitis (usually Staphylococcus spp). If present, the shiny, convex carapace of the female Knemidocoptes mite can usually be visualized, with the aid of the operating microscope, inside the burrows they create. In most instances, lesions resolve after treatment with ivermectin or correction of nutritional deficiencies. In severe cases, it may be necessary to surgically debride the proliferative scales to prevent vascular compromise. Toe Necrosis (Constricted Toe Syndrome) Avascular necrosis of digits may occur secondary to circumferential constriction caused by fibers, scabs or necrotic tissue (see Color 24). These constrictions cause edema and if untreated, sloughing of the digit distal to the constriction.

Reported inaccuracies of gas dilution and plethysmographic techniques reduce our confidence in many previous observations regarding hyperinflation. Decreases in tissue elasticity are a primary determinant of the observed decreases in lung recoil in emphysema. Though decreases in surface forces resultant from increase in the sizes of airspaces may play a role in reducing lung recoil 62, animal data on experimentally induced hyperinflation from pneumonectomy refute this role. This mechanism for beneficial elevations in lung volume is lost during endotracheal intubation and must be replaced with positive end-expiratory pressure. Post-inspiratory activity of the inspiratory muscles has been demonstrated which in adults asthmatics as well as healthy newborn infants causes retardation of expiration and increased end-expiratory lung volume. Reflex increases in diaphragmatic tone at the end of expiration may also play a role. In part because of the obvious difficulties in measuring absolute lung volumes during exercise, alterations in lung volumes and volume-adjusted tidal breathing flows during exercise have in the past been neglected, especially in children. Radiographic techniques are potentially the most appropriate option for assessing changes in absolute lung volumes during exercise but present their own technical challenges and have rarely been used. Increases in respiratory drive from stimulation of J receptors may also play a less direct role. Such decreases make infants precariously susceptible to rapid decreases in O2 saturation during apnea. Measures of dynamic hyperinflation have been shown to be better predictors of the risk of complications from mechanical ventilation than measures of tidal volume or peak airway pressures. Such decreases are readily reversible and different from the more serious decreases in lung volumes after 5 or more days of 100% O2 breathing attributed to lung injury. The following are the recommendations and rationales which evolved from review of these issues. Although one can also derive measurements of gas mixing 98 from this procedure, these aspects of lung function will not be covered in this document. Inaccuracy of static volume measurements should be less than 3% over the entire range; minimal resolution should be equal to or less than 25 mL. The gas volume in the spirometry apparatus with the bell at zero volume including the circuit tubing to the mouthpiece valve should preferably not exceed 4. The recommended equipment specifications and procedures will establish an advantageous starting He concentration near full scale deflection of the meter. The mouth pressure needed to initiate a change in spirometer volume should be < 0. The mixing fan should mix the gas throughout the circuit within 8 s after the end of exhalation into the circuit. Typically, breathing circuit flows of about 50 L/min are utilized to ensure adequate mixing of He concentration measurements which are reported every 15 s. If pneumotachometers or other flow devices are used instead of volume displacement spirometers, and if they are not isolated from variations in gas properties. Because thermal conductivity He analyzers are sensitive to temperature changes, it should be assured that the temperature of the gases entering the He analyzer is the same as during calibration. Some of the problems associated with various types of He analyzers can be avoided by the use of a respiratory mass spectrometer, often employing other inert gases such as argon. Since changes in the flow of gas through the analyzer or in the pressure of gas in the analyzer circuit will affect response time or accuracy, variations in flow and pressure should be minimized. The breathing valve and mouthpiece should have a combined deadspace of less than 100 mL and should be easy to disassemble for sterilization. The size of this deadspace should be available from the manufacturer or measured by water displacement. Errors in O2 supply can be prevented by continuously measuring the O2 concentration. In some systems, this can be accomplished by injecting about 3 L of air into the system, closing the breathing valve, then pressurizing the breathing circuit to about 0.

It is important to stay away from strenuous physical activities for at least three months to allow for proper healing of the neck musculature. Your neurosurgeon may consider using a long-acting local anesthetic into the muscles and the nerves in the neck to delay the onset of pain. Pain control is also In children, scoliosis can be a presenting symptom in at least 15-20% of patients. Many times the recurrence may be due to scar tissue formation, or late development of instability or changes that can occur as a result of the opening of the envelope (dura) of the brain. It is important to recognize that even though the patient may get relief of symptoms, the syrinx cavity may not deflate. There is downward location of the cerebellar tonsils (open arrow) below the rim of the foramen magnum (small black arrow). Often, the spinal cord is actually stuck to the lining of Figure 2 the spinal sac (meninges). If the spinal cord is adherent, or stuck, either toward the back of the sac (dorsal) or the front of the sac (ventral) or to the side (lateral) or in any combination, it is termed a tethered (stuck or adherent) spinal cord. In either case, these syrinx or myelomalacic changes may be associated with various signs and symptoms of neurological dysfunction. These signs and symptoms can appear individually or in any combination and may be unilateral (on one side of the body), bilateral (on both sides of the body), may alternate from side to side or be positionally related. By positioning the patient up on one side or the other for several weeks after surgery (only while in bed), we have achieved a better overall outcome and less recurrent tethering. In rare cases in which untethering fails as the first line of therapy, shunts can still be safely performed with diversion of the spinal fluid from within the spinal cord to another cavity or compartment in the body (chest or abdominal cavity) as described earlier. The shunt can be placed either with open surgical exposure into the abdomen or chest, or through a cannula (large needle) as Figure 4 Spinal cord syrinx (confluent) C6 and myelomalacia (microcystic) C7. Often in cases of diffuse arachnoiditis (scarring) or multiple failed operations, shunting is necessary. In some patients this technique is modified by placing a short piece of the silastic catheter (shunt) into the cyst and bringing it out just a fraction of an inch and placing it into the spinal fluid (subarachnoid) space. This is sometimes called a stent rather than a shunt, but in reality, it is shunting the spinal fluid from the syrinx cavity into the spinal fluid space surrounding the cord rather than into the abdomen or chest. There are risks that can occur with any general anesthetic, that range all the way from death to other anesthetic complications. The neurological complications of spinal cord surgery could include paralysis or weakness, loss of sensation, bowel, bladder or sexual dysfunction, as well as infection, hemorrhage, etc. Unfortunately, recurrence is not a rare situation even in the experience of the most skilled surgeons, and even when patients follow the medical advice for postoperative activity. If tethering or cyst formation recurs, treatment may require revision or repeat surgery. The majority of patients can expect to stop the progression of their symptoms with surgery. However, often there is a reversal of some, and less commonly of all of the preoperative signs and symptoms. As mentioned previously, some patients may be unchanged or may even worsen with surgery. For example, almost every patient who has a shunt placed in the spinal cord experiences some increased numbness, often patchy and reversible, although it may be permanent. This occurs from just making a tiny incision with the aid of a microscope into the spinal cord to place the shunt tube (often less than 1/10 of an inch in diameter). However, when one realizes that the spinal cord is like an electrical cable with millions of wires or fibers going through it, it becomes understandable how even the smallest incision can cause temporary or permanent damage. For these reasons, shunts are usually placed in the back of the spinal cord where one is less likely to lose motor strength or pain and temperature sensation. The loss of crude touch-type sensation or position sense are more likely to be experienced. Depending on which surgeon you talk to or which article you read, failure of these operations may result in patients requiring re-operation or losing function permanently. It is imperative that every patient feels comfortable with their surgeon and his/her credentials and experience in this area so that the surgical procedure becomes a team effort. The patients and their families or significant others should have full knowledge and understanding of all the pros and cons, alternatives and risks.