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Smoking in some cases of chronic diseases may be permitted generic cialis soft 20 mg visa erectile dysfunction melanoma, when the patient had been accustomed to an uninterrupted use of it purchase 20 mg cialis soft mastercard erectile dysfunction at the age of 21, and if he does not expectorate; but smoking should always be limited order cialis soft with a visa erectile dysfunction age at onset, and more so if the mental activity, sleep, digestion or the evacuations are defective. If evacuations regularly only take place after smoking, the use of this palliative must be all the more circumscribed, and the same result must be obtained in a lasting manner through the appropriate antipsoric remedies. More objectionable yet, however, is the using of snuff, which is wont to be abused as a palliative against rheum and obstruction of the nose and insidious inflammation of the eyes, and which being a palliative, is a great hindrance in the cure of chronic diseases; it can, therefore, not be allowed with such patients, but must be diminished every day and at last stopped. An especial reason for this is also that in snuff the medicinal liquors (sauces) with which almost all snuff is medicated touches with its substance the nerves of the inner nose and injures just as if a foreign medicine were taken, which is less the case with the burning smoking tobacco in which the strength is disintegrated by the heat. I now pass to the other hindrances to the cure of chronic diseases which must be avoided as far as possible. All those events in human life which can bring the psora latent and slumbering within, which has hitherto manifested itself only by some of the signs mentioned above, wherein the patient varies from a state of health, so as to break out into open chronic diseases, these same events if they occur to a person already a chronic patient may not only augment his disease and increase the difficulty of curing it, but, if they break in on him violently, may make his disease incurable, if the untoward circumstances are not suddenly changed for the better. Excessive hardships, laboring in swamps, great bodily injuries and wounds, excess of cold or heat, and even the unsatisfied hunger of poverty and its unwholesome foods, etc. A psora slumbering within, which still allows the favorite of a prince to live with the appearance of almost blooming health unfolds quickly into a chronic ailment of the body, or distracts his mental organs into insanity, when by a change of fortune he is hurled from his brilliant pinnacle and is exposed to contempt and poverty. The sudden death of a son causes the tender mother, already in ill health an incurable suppuration of the lungs or a cancer of the breast. A young, affectionate maiden, already hysterical, is thrown into melancholy by a disappointment in love. How difficult it is, and how seldom will the best antipsoric treatment do anything to relieve such unfortunates! By far the most frequent excitement of the slumbering psora into chronic disease, and the most frequent aggravation of chronic ailments already existing, are caused by grief and vexation. Uninterrupted grief and vexation very soon increase even the smallest traces of a slumbering psora into more severe symptoms, and they then develop these into an outbreak of all imaginable chronic sufferings more certainly and more frequently than all other injurious influences operating on the human organism in an average human life; while these two agencies just as surely and frequently, augment ailments already existing. As the good physician will be pleased when he can enliven and keep from ennui the mind of a patient, in order to advance a cure which is not encumbered with such obstructions, he will in such a case feel more than ever the duty incumbent upon him to do all within the power of his influence on the patient and on his relatives and surroundings, in order to relieve him of grief and vexation. The continuation of the fairest edifice is foolish, when the foundation is being daily undermined, even if but gradually, by the play of the waves. Almost as near, and often nearer yet, to insurability are the chronic diseases, especially with great and rich men, who for some years, besides the use of mineral baths, have passed through the hands of various, often of many, allopathic physicians, who have tried on them one after another all the fashionable modes of cure, the remedies which are so boastingly lauded in England, France and Italy, - all strongly acting mixtures. By so many unsuitable medicines, which are injurious by their violence and their frequent repetition in large doses, the psora which always lies within, even if not combined with syphilis, becomes every year more incurable, as do also the chronic ailments springing from it; and after the continuation of such irrational medical assaults on the organism for several years it becomes almost quite incurable. It cannot well be decided, since these things take place in the dark, whether these heroic unhomoeopathic doses have added, as may be suspected, new ailments to the original disease, which ailments through the largeness of the doses and their frequent repetition have now become lasting and as it were chronic, or whether through abuse there has resulted a crippling of the different faculties of the organism, i. In short, this many-sided disharmony and perversion of parts and of forces most indispensable to life present a chaos of ailments which the homoeopathic physician should not lightly declare curable. If in such cases the sad consequences of these indirect assaults of the old methods of cure were dynamic disturbances only, they would surely either disappear of themselves when the treatment is discontinued, or they ought at least to be extinguished again effectively through homoeopathic medicines. Very likely by these indirect, continuous and repeated assaults on the sensitive, irritable fiber by such injudicious medicinal disease-potencies, which are given in large doses frequently repeated, the vital force is obliged to meet this attack and to endeavor either to dynamically change these tender internal organs which are assaulted so mercilessly, or to reconstruct them materially so as to make them unassailable to such violent attacks, and thus to protect and shield the organism from general destruction. So also in a long continued allopathic treatment, which has no true healing power with respect to the disease, no direct pathic (homoeopathic) relation to the parts and processes concerned in the chronic disease, but internally assaults other delicate parts and organs of the body, in such cases the vital force, in order to protect the whole from destruction, dynamically and organically transmutes these fine organs; i. On the one side the most tender fiber is abnormally thickened or hardened, and the more vigorous fibers consumed or annihilated - thus there arise artificially, adventitious organisms, malformations and degenerations, which at postmortem examinations are cunningly ascribed to the malignancy of the original disease. Only where there are still sufficient vital powers in a body not too much bowed down by age (but where under an allopathic regime do we not find the powers wasted? Such a transformation is, however, only possible to a still energetic vital force, which has been in great part set free from its psora. Only however, under favorable external circumstances, and after the lapse of a considerable time and usually in only an imperfect manner, does the vital force succeed in this almost creative endeavor. Experience proves daily that the more zealously the allopath puts into practice in chronic disease his perverse destructive art (often with great care, industry and persistence), the more he ruins his patients in health and life. He can therefore promise an improvement only after a long period of time, but never a full restoration, even if the vital powers are not (as is so frequently the case) altogether wasted; for where this is the case, he would feel compelled to desist from treatment even at the first glance. First the many chronic medicinal diseases which pass over the fluctuating state of health must gradually be removed (perhaps during a several monthsÕ stay in the country almost without medicine); or they must depart as of themselves through the activity of the vital force, when the antipsoric treatment has to some degree begun, with an improved manner of living and a regulated diet. For who could find remedies for all these ailments artificially produced by a confused mass of strong unsuitable medicines? The vital force must first absorb and reform what it has compulsorily deformed, before the true healer will in time see again before him a partially cleared malady similar to the original one, and which he will then be able to combat. A similar great hindrance to a cure of far-advanced chronic diseases is often found in the debility and weakness into which youths fall who are spoiled by rich parents, being carried away by their superabundance and wantonness, and seduced by wicked companions through destructive passions and excesses, through revellings, abuse of the sexual instinct, gambling, etc. Without the least regard for life and for conscience, bodies originally robust are debilitated by such vices into mere semblances of humanity, and are besides ruined by perverse treatment of their venereal diseases, so that the psora, which frequently lurks within, grows up into the most pitiable chronic diseases, which, even if the morality of the patient should have improved, on account of the depressing remorse, and the little remnant of their wasted vital powers, accept antipsoric relief only with the greatest difficulty. Such cases should be undertaken by homoeopathic physicians as curable only with the greatest caution and reserve. But where the above-mentioned often almost insurmountable obstacles to the cure of these innumerable chronic diseases are not present,* there is nevertheless found at times, especially with the lower classes of patients, a peculiar obstruction to the cure, which lies in the source of the malady itself, where the psora, after repeated infections and a repeated external repression of the resulting eruption, had developed gradually from its internal state into one or more severe chronic ailments. A cure will, indeed, also be certainly effected here, if the above-mentioned obstacles do not prevent, by a judicious use of the antipsoric remedies, but only with much patience and considerable time, and only with patients who observe the directions and who are not too aged nor too much debilitated. In such cases a more intelligent physician, recognizing the circumstances and the natural impulse implanted by the Creator, will give his permission and thus not infrequently render curable a multitude of hysterical and hypochondriac states, yea, often even melancholy and insanity. For experience informs us that in a case of itch arising from a new infection, even when, after several preceding infections and repressions of the eruption, the psora has made considerable progress in the production of chronic diseases of many kinds, the itch which has last arisen, if it has only still kept its full primitive eruption unhindered on the skin, may be cured almost as easily as if it were the first and the only one, i. I have little further to say to the physician already skilled in the homoeopathic art as to how he is to operate in the cure of chronic diseases, except to direct him to the antipsoric remedies appended to this work; for he will know how to use these remedies for this noble end successfully. First of all, the great truth is established that all chronic ailments, all great, and the greatest, long continuing diseases (excepting the few venereal ones) spring from psora alone and only find their thorough cure in the cure of the psora; they are, consequently, to be healed mostly only by antipsoric remedies, i. The homoeopathic physician, therefore, in curing a chronic (non- venereal) disease, and in all and in every symptom, ailment and disorder arising in this disease, no matter what seductive name these may have in common life or in pathology, will usually and especially look to the use of an antipsoric medicine selected according to strictly homoeopathic rules, in order to surely attain his end. The new infection, while the chancre remains undisturbed, may be cured, together with the venereal disease sprung from the former infection, just as easily by a single dose of the best mercurial preparation, as if the first chancre were still present, - provided that no complication with either of the other two chronic miasmata, especially the psoric, has taken place; for in such a case, as has been mentioned above, the psora must first be removed. For if the symptoms occurring during the action of the remedy have also occurred, if not in the last few weeks, at least now and then some weeks before, or some months before in a similar manner, then such occurrences are merely a homoeopathic excitation, through the medicine, of some symptom not quite unusual to this disease, of something which had perhaps been more frequently troublesome before, and they are a sign that this medicine acts deeply into the very essence of this disease, and that consequently it will be more effective in the future. The medicine, therefore, should be allowed to continue and exhaust its action undisturbed, without giving the least medicinal substance between its doses. But if the symptoms are different and had never before occurred, or never in this way, and, therefore, are peculiar to this medicine and not to be expected in the process of the disease, but trifling, the action of the medicine ought not for the present to be interrupted. Such symptoms frequently pass off without interrupting the helpful activity of the remedy; but if they are of a burdensome intensity, they are not to be endured; in such a case they are a sign that the antipsoric medicine was not selected in the correct homoeopathic manner. Its action must then be checked by an antidote, or when no antidote to it is known, another antipsoric medicine more accurately answering its symptoms must be given in its place; in this these false symptoms may continue a few more days, or they may return, but they will soon come to a final end and be replaced by a better help. Least of all, need we to be concerned when the usual customary symptoms are aggravated and show most prominently on the first days, and again on some of the following days, but gradually less and less.

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They are also common in industrial workers buy cheapest cialis soft erectile dysfunction causes uk, schoolchildren order cheap cialis soft line erectile dysfunction statistics singapore, athletes and military personnel who share shower or bathing facilities generic 20mg cialis soft visa erectile dysfunction following radical prostatectomy. Period of communicability—As long as lesions are present and viable spores persist on contaminated materials. Educate the public to maintain strict personal hygiene; take special care in drying between toes after bathing; regularly use a dusting powder or cream containing an effective antifungal on the feet and partic- ularly between the toes. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics in some countries; no individual case report, Class 4 (see Reporting). Oral terbinafine, or itraconazole may be indicated in severe, extensive or protracted disease; griseofulvin, although less active, is an alternative. Epidemic measures: Thoroughly clean and wash floors of showers and similar sources of infection; disinfect with a fungi- cidal agent such as cresol. Identification—A chronic fungal disease involving one or more nails of the hands or feet. The nail gradually becomes detached from the nail bed, thickens, and becomes discolored and brittle, an accumulation of soft keratinous material forms beneath the nail or the nail becomes chalky and disintegrates. Diagnosis is made by microscopic examination of potassium hydroxide preparations of the nail and of detritus beneath the nail for hyaline fungal elements. Mode of transmission—Presumably through extension from skin infections acquired by direct contact with skin or nail lesions of infected people, or from indirect contact (contaminated floors and shower stalls) with a low rate of transmission, even to close family associates. Preventive measures: Cleanliness and use of a fungicidal agent such as cresol for disinfecting floors in common use; frequent hosing and rapid draining of shower rooms. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Official report not ordinarily justifiable, Class 5 (see Reporting). Epidemic measures, Disaster implications and International measures: Not applicable. It is a symptom of infection by many different bacterial, viral and parasitic enteric agents. The specific diarrheal diseases—cholera, shigellosis, salmonellosis, Escherichia coli infections, yersiniosis, giardiasis, Campylobacter enteritis, cryptosporidiosis and viral gastroenteropa- thy—are each described in detail under individual listings elsewhere in this book. Diarrhea can also occur in association with other infectious diseases such as malaria and measles, as well as chemical agents. Change in the enteric flora induced by antibiotics may produce acute diarrhea by overgrowth and toxin production by Clostridium difficile. Approximately 70%–80% of the vast number of sporadic diarrheal episodes in people visiting treatment facilities in less industrialized countries could be diagnosed etiologically if the complete battery of newer laboratory tests were available and utilized. From a practical clinical standpoint, diarrheal illnesses can be divided into 3 clinical presentations: 1) Acute watery diarrhea (including cholera), lasting several hours or days; the main danger is dehydration; weight loss occurs if feeding is not continued. The details pertaining to the individual diseases are presented in separate chapters. Each has a different pathogenesis, possesses distinct virulence properties, and comprises a separate set of O:H serotypes. Transmission is usually through contaminated food, water or hands; an outbreak in 2003 in Ohio was attributed to respiratory transmission via contaminated sawdust. The diarrhea may range from mild and nonbloody to stools that are virtually all blood. Lack of fever in most patients can help to differentiate this infection from that due to other enteric pathogens. The other most common serogroups in the United States are O26, O111, O103, O45, and O121. Occurrence—These infections are an important problem in North America, Europe, Japan, the southern cone of South America and southern Africa. Mode of transmission—Mainly through ingestion of food contam- inated with ruminant feces. Direct person-to-person transmission occurs in families, child care centers and custodial institutions. Waterborne transmission occurs both from contaminated drinking water and from recreational waters. Period of communicability—The duration of excretion of the pathogen is typically 1 week or less in adults but 3 weeks in one-third of children. Little is known about differences in susceptibility and immunity, but infections occur in persons of all ages. Preventive measures: The potential severity of this disease and the importance of infection in vulnerable groups such as chil- dren and the elderly calls for early involvement of local health authorities to identify the source and apply appropriate preven- tive measures. Measures likely to reduce the incidence of illness include the following: 1) Manage slaughterhouse operations to minimize contamina- tion of meat by animal intestinal contents. Decrease the contamination with animal feces of foods consumed with no or minimal cooking 4) Wash fruits and vegetables carefully, particularly if eaten raw. Reliance on cooking until all pink color is gone is not as reliable as using a meat thermometer. Because of the small infective dose, infected patients should not be employed to handle food or provide child or patient care until 2 successive negative fecal samples or rectal swabs are obtained (collected 24 hours apart and not sooner than 48 hours after the last dose of antimicrobials). In communities with a adequate sewage disposal system, feces can be discharged directly into sewers without prelim- inary disinfection. All contacts should be educated about thorough handwashing after defecation and before handling food or caring for children or patients. Culture of suspected foods has rarely been productive in sporadic cases except when a specific ground beef item is strongly suspected. Epidemic measures: 1) Report at once to the local health authority any group of acute bloody diarrhea cases or cases of hemolytic uraemic syndrome or thrombotic thrombocytopenic purpura, even in the absence of specific identification of the causal agent. Disaster implications: A potential problem where personal hygiene and environmental sanitation are deficient (see Typhoid fever, 9D). Identification—A major cause of travellers’ diarrhea in people from industrialized countries who visit developing countries, this disease is also an important cause of dehydrating diarrhea in infants and children in the latter countries. Enterotoxigenic strains may behave like Vibrio cholerae in producing a profuse watery diarrhea without blood or mucus. Abdom- inal cramping, vomiting, acidosis, prostration and dehydration can occur; low grade fever may or may not be present; symptoms usually last less than 5 days. The most common O serogroups include O6, O8, O15, O20, O25, O27, O63, O78, O80, O114, O115, O128ac, O148, O153, O159 and O167. Infection occurs among travellers from industrialized countries that visit developing countries. Transmission via contaminated weaning foods may be particularly important in infection of infants. Direct contact transmission through fecally contaminated hands is believed to be rare. Preventive measures: 1) For general measures for prevention of fecal-oral spread of infection, see Typhoid fever, 9A. A much preferable approach is to initiate very early treatment, beginning with the onset of diarrhea, e. Control of patient, contacts and the immediate environment: 1) Report to local health authority: Obligatory report of epidem- ics; no individual case report, Class 4 (see Reporting). In communities with adequate sewage disposal system, feces can be discharged directly into sewers without preliminary disinfection.

Also best cialis soft 20 mg impotence exercise, caregivers should not let their own tions that sometimes result in distancing buy cialis soft once a day health erectile dysfunction causes. However trusted 20 mg cialis soft erectile dysfunction causes medscape, feelings prevent them from providing the help these patients still need empathy and warmth, and needed. The person experi- pubic lice 181 encing chronic anxiety may have difficulty in con- pubic lice from infested bedding and clothing. Most centrating, feel exhausted and agitated, and have people discover they have pubic lice when the trouble sleeping. For this reason, the panic and anxiety aggressively, and there are a person with pubic lice should try to avoid touching number of medications that work well. Pubic lice are the size of a pinhead and look brownish red because puberty The period during one’s life when sex they contain blood. In girls the menstrual period begins and breasts and pubic hair develop; in boys scrotal, Treatment testicular, and penis growth begins; pubic hair Most people use over-the-counter lotions and grows; and secondary sex characteristics, including shampoos to kill pubic lice. After vide prescriptions such as permethrin (Elimite) or puberty, the reproductive organs become functional; lindane (Kwell) lotion. Permethrin is more com- this means a girl can become pregnant, and a boy monly used. A second treatment is done seven to who has reached puberty is capable of impregnating 10 days after the first in order to kill newly hatched her with his sperm. Pubic lice die within 24 hours of being sepa- body stimulate the testes (in males) and ovaries (in rated from the human body. Because the eggs may females), touching off an increase in sex hormones live up to six days, it is important to apply the sec- that brings about the physical changes of puberty. The age at which an individual reaches puberty can Pregnant women definitely should not use a range from nine to 15. If the lotion or cream is being used on a child, it is important to follow a pubic lice Extremely tiny insects that infest the doctor’s instructions for its use. Apply the lotion as pubic hair and survive by feeding on human directed in order to eradicate all eggs. Cause For treating eyelashes, a person should thickly Pubic lice (pediculosis pubis) is caused by blood- apply a prescription petrolatum twice a day for sucking lice (Phthirus pubis) that feed off human seven to 10 days. They infest pubic, perianal, or thigh hair Sex partners, family, and anyone else who has and occasionally axillary (armpit) hair or even eye- close contact with a person who has pubic lice lashes. Clothing and bedding must be although, in rare cases, people have contracted washed in very hot water and dried at a high setting. Q quality health care Most people agree, in rela- into play in the realm of artificial insemination, for tion to sexually transmitted diseases, quality med- example. Germany is a not likely to impose their sexual morals or stan- country that has no regulation requiring a three- dards by giving patients unsolicited advice, they are month quarantine of sperm before its use. The individual who is living with a mechanism of transmission must drive disease- particular sexually transmitted disease is obviously containment strategy. In some cases, though, it becomes clear contagious disease would be isolated from those that this person needs assistance, and at such times, who do not. Certainly, it can be over- is determined, of course, by the illness under con- whelming to discover that one has a disease that sideration. Rather than using quarantine, it is more may result in unexpected medical care expenses, likely that measures recommended to prevent dis- partner notification, and social ostracism. Thus, the ease spread would be along the lines of rapid vac- goal for caregivers is to help each patient attain the cination or treatment, use of disposable masks, highest level of quality of life that is possible when short-term voluntary restrictions on public meet- living with a sexually transmitted disease. Downloaded on Febru- ually transmitted diseases, the quarantine comes ary 12, 2001. This can mean rectal pain and discharge Discomfort that occurs that a person is at risk of contracting the disease a in the rectum (the terminal part of the intestine second, third, or fourth time. In other words, hav- ending at the anus) or fluid release (discharge) ing the disease once does not prevent reinfection. Chancres (of syphilis) are typically painless anonymous testing site and be tested anony- unless they become infected by bacteria. Chancroid mously (the identifying information is not linked can cause painful anal (and genital) ulcers. According Other states tried to do case surveillance without to Centers for Disease Control and Prevention esti- name identifiers by using codes designated for mates, in 1996, about two-thirds of all infected nonsurveillance purposes. Several subsequent studies could anonymous sites, and those who use home collec- not find a code system that worked as well as tion kits, but the popularity of anonymous testing name-based methods. Some contend that view of the fact that some sexually transmitted treatment failure is probably caused by the preex- diseases are developing resistance to currently istence of resistant mutants, but it may also be used drugs. A retro- treatment and represented 10 cities in North virus uses the enzyme reverse transcriptase to syn- America (1995–2000). Insisting on one’s “right to has contact with blood, feces, or other bodily flu- know” is understandable, considering the enor- ids; and maintaining good overall health. Decades ago, genital sexual contact is viewed as somewhat less the California Supreme Court found in Tarasoff v. This has led to the context that may act as a trigger for risk behavior changing of some U. Most doms, early sexual activity, excessive use of alco- agree, however, that the strongest claim to a right hol and substances that impair judgment, sex to know is that of people who are conducting ongo- with partners who have multiple partners, and ing sexual or needle-sharing relationships. The act supported development of systems of risk control In relation to sexually transmitted care that respond to local needs and resources. He died at age 19 on April 8, active people can control their risk of infection to 1990, a few months before Congress passed the some degree by avoiding the main modes of trans- act. As part of the federal budget, it is administered by the Health Resources risky behavior According to a report on trends and Services Administration (part of the U. Deep kissing is considered a moderate-risk soon as possible to achieve better and longer-last- activity. Forms of low-risk sex include self-mastur- ing results, it is important to spread information bation, mutual masturbation, and dry kissing. Safe that makes people more likely to seek testing and sex became a household term after the first few treatment early. It also can be transmitted by contact with skin or infested sheets, towels, or even furniture. During this time, the person may pass • Setting up projects that promote knowledge of the disease unknowingly to a sex partner or some- serostatus and prevention and care for those liv- one with whom he or she has close contact. Small red bumps or lines involvement (Partnership Council and Leader- appear on parts of the body where the female sca- ship Action Alliances). To recommends that specific content of prevention make a diagnosis, a physician can take a scraping programs be determined by local communities so of the irritated area and examine it under a micro- that they will be in line with parental and com- scope to look for the presence of a mite. Treatment screening Testing that can be done to evaluate Ectoparasiticide cream (Permethrin) or scabicide for the presence of sexually transmitted diseases lindane lotion can be used to treat scabies. Var- partners and family members of the affected indi- ious types of tests are used to determine whether vidual should be treated, too. The lotion is applied an individual has contracted a sexually transmit- at bedtime to all skin below the neck and then ted disease. Permethrin can are numerous forms of medical screenings, be repeated in seven days if necessary.

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The authors of this review reported: “In vitro discount cialis soft 20 mg overnight delivery impotence massage, the cleaning effcacy of air-powder abrasive treatment on titanium strips purchase discount cialis soft line erectile dysfunction future treatment, discs or implants is high” proven 20mg cialis soft erectile dysfunction ka ilaj. Promising results for the air 7 abrasive were also reported in a review evaluating the decontamination of infected implants by mechanical, chemical and physical methods (Meyle 2012). This review included in vitro, animal and human studies, and the authors concluded: “For decontamination of infected 8 implant surfaces air-abrasive treatment seems to work”. In clinical situations, several factors, such as the soft and hard tissues surrounding the 9 implant, the implant/abutment design or the design of the restoration may render the ac- cessibility of the titanium surfaces more diffcult and may limit the cleaning effcacy of an instrument. The accessibility of an air abrasive device with glycine powder to clean minimal- ly rough implant surfaces was assessed in models imitating peri-implantitis with different defect morphologies. The authors concluded: “ Although a complete cleaning of the implant surfaces was not possible in any of the defect models, it was possible to clean the biggest part of the surface up to more than 95% in easy accessible defects. In broad defects of 60° and 90° defect angulations, it was even possible to get access to more than 75% of the lower faces of the implant threads”. Narrow defects (< 30o) and the area under the threads were diffcult to reach (Sarhmann et al. In a subsequent study using the same model, the air-abrasive device was compared with other modalities as a stainless-steal curette and an ul- trasonic device with metal tip. In wide defects, the differences between the in- struments were more pronounced (Sahrmann et al. The two-abovementioned studies simulated condition similar to an open-fap debridement. Recently, the same research group 2 published another study using a bone defect-model that includes a custom-made mucosa mask in order to simulate the conditions of nonsurgical implant surface debridement, which 3 made the access to the implant even more diffcult. The air abrasive with a glycine powder and a subgingival nozzle provided superior cleaning results compared to a metal curette or an ultrasonic device with a metal tip. Again the differences between the instruments were 4 more pronounced in the wider defects irrespective of the operator’s experience (Ronay et al. Air pressure seems to be the most important parameter that infuences the cleaning 5 effciency of the air abrasive device. It has been shown that in order to get the best results when used subgingivally the device should be used with high pressure, deep insertion of 6 the nozzle and enough water fow. The cleaning effect of the device reaches deeper than the nozzle physically reaches and the movement of the nozzle improves the cleaning effciency, irrespective of the direction of the movement (Tastepe et al. The plaque extracts had a greater effect in decreasing the growth rate of fbroblasts than that of epithelial cells. The elemental composition of unused commercially pure titanium foils was 9% titanium (Ti), 48% carbon (C), 40% oxygen (O) and traces of 10% nitrogen (N) and chlorine, whereas intraorally contaminated foils exhibited 70% C, 20% O, 10% N and only traces of titanium (<1%). Next to bacterial contamination, treatment modalities used to decontaminate the titanium surface can also affect its surface topography and chemical composition. The surface composition of failed and retrieved ma- chined titanium implants after various cleaning procedures has been evaluated in a study. Although some of the tested methods resulted in a macroscopically clean surface, all of them failed to re-establish the original surface elemental composition (Mouhyi et al. In ad- dition, residues of the instruments may deposit themselves to the treated surfaces, which in turn might disturb cell attachment (Schwarz et al. Residues of various curettes and 226 Summary, Discussion… inserts for ultrasonic devices, as well as powder remnants after the use of air abrasive de- 1 vices, have been found on the titanium surfaces after instrumentation (Schwarz et al. It is obvious that an instrument would be of no value if it renders the surface non-biocompatible, i. Subse- 3 quently a third systematic review was conducted in chapter 4 and concluded that all instru- ments reduce the biocompatibility of the surface irrespective of the presence or absence of 4 plaque. The 7 air abrasive device showed slightly better results that the other modalities. This modality induced titanium alloy purity and hydrophily without altering osteoblast proliferation and 8 production of cytokines potentials (Toma et al. Similarly, an earlier animal study employing the ligature-induced peri-implantitis defect model demonstrated the cre- ation of a smooth surface, which supported a close adhesion of the sub-epithelial connective tissue (Schwarz et al. Taking together the results of the systematic reviews in chapters 2, 3, 4 it seems, based on the currently available in vitro data, that air-abrasive devices represent the most promis- ing tool in the treatment of peri-implant infections. They are effective in bioflm removal, without causing major changes on the surface topography or having detrimental effect on the biocompatibility of a titanium surface. These results are corroborated to a certain extent by fndings from animal studies. Mechanical cleaning with an air abrasive device appeared to provide adequate decontamination to allow for some new bone formation in direct contact with the implant surface (Roos-Jansåker et al. The available data suggest that air polishing used as an adjunctive mea- sure or as monotherapy can result in signifcant clinical improvements in terms of bleed- 3 ing scores, following a single or repeated nonsurgical treatment of peri-implant mucositis and/or peri-implantitis. At mucositis sites, glycine air polishing seems to be as effective as conventional mechanical debridement with non-metal instruments with or without local 4 antiseptics. For the non-surgical treatment of peri-implantitis, glycine powder air polishing was associated with a signifcant improvement in bleeding scores over the control mea- 5 sures investigated (Schwarz et al. A retrospective study evaluating the effect of an air abrasive device during surgical treatment of peri-implantitis compared with plastic curettes 6 and cotton pellets impregnated with saline reported that, although both groups revealed a signifcant improvement in clinical parameters, the air abrasive group yielded better results regarding bleeding scores and probing depths at 12 months (Toma et al. It has been shown that tricalcium phosphate, when used as an additive to powders, may increase the cleaning effciency of the air abrasive (Tastepe et al. However, all powders that were tested affected the biocompatibility and the extent to which this was infuenced depended on the powder used. This fnding has been attributed to the hard- ness and bigger particle size of sodium bicarbonate, which has also been observed to induce surface changes. It was speculated that a certain amount of surface ablation might improve the biocompatibility of moderate rough surfaces (Schwarz et al. In the study in 2 chapter 5, the aim was therefore to assess the possible effect of fve commercially available air-abrasive powders, on the viability and cell density of three types of cells: epithelial cells, gingival fbroblasts and periodontal ligament fbroblasts. This study showed that powders 3 might indeed have different effects on various cells. It has been speculated that tricalcium phosphate residues on 4 the implant surface could improve biocompatibility and support wound healing (Tastepe et al. Chemotherapeutica 6 Surface decontamination Chemotherapeutic agents, alone or in combination with mechanical instruments, have also 7 been used for cleaning implant surfaces. Chapter 6 reviewed the literature for evidence re- garding the ability of different chemotherapeutic agents to decontaminate titanium sur- faces. Yet, it seems 8 that citric acid has the highest potential to remove bacteria and bacterial products from titanium surfaces. It should however be kept in mind that chemical agents are less capable in 9 removing bioflm than mechanical instruments. In an earlier study different results with respect to the killing potential of citric acid were reported.