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Section shows—typical osteitis fibrosa with increased vascularity and a few giant cells buy 5mg warfarin visa. Diagnosis—smooth order 2mg warfarin, solid purchase warfarin 5mg otc, hard and ill- defined inflammation or other physical signs makes the diagnosis obvious. Adenoma Histologically they contain cavities lined with cuboid or cylindrical epithelium and filled with mucoid material. Olfactory Neuroblastoma This is a neuroectodermal tumour and may arise from the cribriform plate of the olfactory area. It occurs most frequently in the frontal sinus followed by ethmoids and maxillary sinus. Symptoms are produced by pressure on the nerves or extension of the tumour into surrounding tissues. Fibrous Dysplasia It is a condition in which normal bone is replaced by collagen, fibroblasts and varying amounts of osteoid tissue. It presents as involvement a bony hard, diffuse and painless swelling usually at puberty. These are rare tumours arising from the The growth ceases at 20 to 25 years of age. Two clinical types are generally recognised, Most patients are over the age of 50 years. Radiology most common symptoms are nasal obstruc- shows ground glass appearance of the bone tion and epistaxis with a blackish mass inside depending upon the relative amount of the nose. Treatment is Tumours of the Nose and Paranasal Sinuses 231 surgical removal of the abnormal bone. Carcinoma of Paranasal Sinuses Though the paranasal sinuses are lined by ciliated columnar epithelium, yet the most common malignant neoplasm of the paranasal sinuses is squamous cell carcinoma. Classification Two vertical lines are drawn through the There has been no agreement on classifying medial canthi, which separate the ethmoid tumours at these sites because of late diagnosis and nasal fossa from the maxillary sinus, the of the disease in these inaccessible deep nasal septum separates the ethmoid and nasal recesses of the nasal cavities. Infrastructure sites (inferior region) Ohngren’s classification An imaginary line is a. Tumours simultaneously involving the through the pupils downwards, thus dividing hard palate and antrum or hard palate the maxilla into four quadrants, namely and floor of nose anterosuperior, anteroinferior, postero- d. Respiratory portion of the nasal fossa nosis as such tumours are difficult to resect c. Lateral nasal wall (including inferior two horizontal lines, one through the floor of turbinate). Lederman’s classification is based on the T4 Massive tumour with invasion of the above mentioned regions and sites. Ethmoid tumours: T2 Tumour having limited spread to the T Tumour confined to ethmoid with or1 same region or two adjacent horizon- without bone erosion. Tumour involving three regions or T3 Tumour extends into anterior orbit compartments with or without and/or maxillary antrum orbital involvement. The N and M categories are the same as N1 Single clinically positive homolateral elsewhere. Lederman’s classification did not find wide N2 Single clinically positive homolateral acceptance. Maxillary sinus tumours: N3 Massive homolateral nodes, one more Primary tumour (T) than 6 cm in diameter, bilateral nodes Tx Minimum requirements to assess the or contralateral nodes. MxMinimum requirements to assess the T1 Tumour confined to antral mucosa of distant metastasis cannot be met. Tumours of the Nose and Paranasal Sinuses 233 Clinical Features Posteriorly the spread occurs to the pterygopalatine fossa and infratemporal fossa Malignancy of the paranasal sinuses usually resulting in trismus because of involvement presents in the late stages. Nasal obstruction and blood-stained dis- Inferiorly the growth involves the oral charge or frank epistaxis may be the present- cavity and palate. Dental pain is common and many times Lymphatic spread Lymphatics of the nose and such patients land in dental clinics for extrac- paranasal sinuses drain first to retropharyn- tions, without any relief. Palatal swelling and geal nodes, wherefrom these drain into the loosening of teeth may occur. The retro- orbital pain and epiphora may be complained pharyngeal nodes are not palpable clinically. Detailed examination of the nose and naso- Visible facial swelling, a bleeding friable mass pharynx should be supplemented by radio- in the nose, fulness of the gingivobuccal logy and proof puncture. Radiological examinations: Plain views of the tosis and facial neuralgia should raise suspi- paranasal sinuses like occipitomental view, cion of malignancy in the nose and paranasal occipitofrontal view, oblique view of the sinuses. An unresolving acute or chronic ethmoid and base of the skull are of limited sinusitis may occur as a result of an under- value in diagnosis showing any bony lying malignant process. Medially, the growth initially pushing to depict swellings arising from deeper soft out the lateral wall of nose, may present in tissues of the face, intracranial compart- the nose, wherefrom it may involve the ment and the orbit. Biopsy: Tissue is taken for histopathological The growth may spread to the cranial examination if growth is seen in the nose cavity from the nose and nasopharynx. Total maxillectomy is done for an operable and biopsy may be undertaken by the tumour involving the maxilla. The bony attach- ments of the maxilla are broken and Because of late diagnosis and involvement of maxilla removed. For small limited adjacent structures, treatment of cancer of the tumours, partial maxillectomy may suffice. Extended maxillectomy: Maxillectomy may Surgery or radiotherapy alone have not be done along with orbital exentration, shown good results. Combined therapy excision of the skin, face or the soft tissues (surgery and radiotherapy) is the treatment in the infratemporal fossa if the growth of choice at present. Lateral rhinotomy: This operation is done for over 5 to 6 weeks, followed by surgical tumours limited to the nasal cavity and excision. An incision from the medial surgically followed by postoperative radio- canthus follows the side of the nose into therapy. The periosteum is Surgical procedures The type of surgery elevated lateral bony wall of the nose performed depends upon the extent of invol- broken and eradication of disease is done vement of the sinus and adjacent structures. Neck dissection: When metastasis is sus- pected in neck nodes, maxillectomy may be done along with block dissection of the neck nodes on that side. Distant metastasis, inoperable metastatic nodes, involvement of the base of skull or nasopharynx are contraindications to surgical treatment. Chemotherapy Systemic anticancer drugs or intra-arterial chemotherapy through the external carotid artery may be given as adjuvant therapy and have only a palliative Fig. Primary malignant tumours of the frontal sinus and ethmoids are rare and when present are also treated by the combined regime. Miscellaneous: Such as sinus headache, In tension headache prompt and convincing cold-induced headache, glaucoma asso- reassurance is vital. Post-traumatic headache following anxiolytics have a limited role, and all drugs severe head injury. Cervicogenic headache: Due to cervical periods under supervision, to prevent spondylosis and causing pain on one or habituation and drug-induced headache. Toxic headache: After exposure to Migraine is due to a vasomotor disturbance polluted environment, allergens, volatile of arteries of the head. The history taking session presenting in this form, but it should be Headache 237 remembered that it is the most common cause its low oral bioavailability, high incidence of of facial pain and is unlikely to have this clas- headache recurrence and contraindication in sical presentation. Hence, eyes and cheek, nasal obstruction and the new 5th receptor agonists such as rhinorrhoea are common accompaniments of zelmitriptan, rizatriptan and nartriptan have pure migraine, and should not lure the become increasingly popular due to their otolaryngologist into thinking that nasal or better safety profiles. Management of migraine is divided into Prophylaxis abortive or symptomatic treatment for If the attacks occur more than twice each immediate relief of symptoms and prephy- month, prophylactic agents such as calcium lactic therapy for prevention of attacks. Analgesics (paracetamol, naproxen or aspirin) should be taken immediately when the attack Cluster Headache begins and then repeated every 4 to 6 hours as necessary. Absorption is improved by Treatment is with ergotamine, or sumatriptan ingestion of antiemetics such as domperidone, given in anticipation of attacks or with 10 to 20 mg. In recent years serotonin (5th) methysergide or verapamil for the duration receptor agonists have been introduced for the of cluster. Oxygen, given at reversing the dilation of cranial vessels seen a rate of 6 to 8 litres/minute, often affords during migraine. Where dental teeth, periosteum, blood vessels and the disease is not obvious, but this story is present, articular fat pads within the temporomandi- percussion of the teeth is a useful clinical bular joints.

Citric acid showed no statistically signifcant differences in effectiveness as compared 6 with water or saline cheap 1mg warfarin free shipping. A possible explanation for this result is the small sample sizes used in both studies (three surfaces per treatment) discount 5mg warfarin free shipping, which could be responsible for the lack of power 7 and thus the lack of signifcant results buy warfarin 5mg online. In that study, almost total bone fll was observed in all groups, and bone-to-implant contact ranged from 39% to 46%. They allowed some threads to protrude in the oral cavity to permit plaque accumulation and the development of peri-implant dis- ease. The contaminated parts of each implant were treated using three different techniques: (1) swabbing with citric acid for 30 s, (2) cleansing with a toothbrush and saline for 1 min and (3) swabbing with 10% hydrogen peroxide for 1 min. Next, the treated implants and one pris- tine implant (control) were installed to the full implant length on the contralateral sides of the mandibles. The amount of osseointegration did not vary signifcantly, either between the different treatment modalities or in comparison with the new, sterile implant. These studies demonstrated that the method of decontamination used for the titanium surface might not …contaminated titanium surfaces: a systematic review 155 1 be a determining factor if the recipient site is healthy. Nevertheless, the implants used had a smooth or a minimally rough surface that facilitated the decontamination process (Denni- son et al. Furthermore, in clinical reality, peri-implant tissues are likely to be infamed, 2 which can impair healing. H2O2 has been used in clinical protocols for the treatment of infected implant surfaces 3 (Mombelli & Lang 1998). First, although the binding of endotoxin to the root surface appears to be weak (Nakib et al. Further, endotoxin is a char- 7 acteristic component of the cell wall of gram-negative bacteria and it plays a signifcant role in the binding process of these bacteria and in initiation of the host response. Bacterial endotoxin 9 has been shown to inhibit fbroblastic growth and attachment to root surfaces (Layman & Diedrich 1987). In our opinion, it is more clinically relevant to grow bioflms on titanium surfaces to test various chemical treatments. Furthermore, this approach can pro- vide information regarding both the killing and removal abilities of these agents. The only study to investigate the killing capacities of antimicrobials was that reported by Chin et al. This method is clearly not quantitative and thus does not allow us to draw any 4 defnitive conclusions. The real incidence of peri-implantitis is probably underestimated (Esposito et al. Thus, the need for effcient treatment and further maintenance of successfully treated implants will increase in the near future. This fnding does not mean that 7 all current treatments are ineffective (Esposito et al. In our opinion, a systematic approach to the treatment of contaminated implant surfaces should be initiated. The available treatment 8 modalities should be categorized and evaluated separately in a controlled manner. Review- ing the literature for this type of studies on chemical decontamination of titanium surfaces 9 was rather disappointing. Considering the number of studies that have been published on the technical aspects and aesthetic outcomes of implant surgery, it is striking that so little controlled research has been undertaken to determine how the titanium implants should be maintained in order to reduce the chances of biological complications (perimucositis and peri-implantitis) and further how to treat the titanium surfaces in the event of such compli- cations. Finally, the greatest challenge will be to determine the treatment protocol that best balances decontamination (Persson et al. To date, the killing effect of citric acid has not been investigated on titanium surfaces. Additionally, the assessment of surface decontamination should involve quantifcation of the residual bioflm. The results obtained using rough titanium surfaces are more clini- cally relevant and increase the applicability of the fndings. Finally, in vivo studies should be 7 performed to test the in vitro fndings and to establish an evidence-based protocol for the treatment of peri-implant diseases. Confict of interest and source of funding statement: The authors declare that they have no confict of interest. Ntrouka contributed to the conception, design, acquisition, analysis, interpretation of data, drafted the manuscript. Slot contributed to the design, analysis, interpretation of data, critically revised the man- uscript for important intellectual content. Louropoulou contributed to the conception, design, analysis, interpretation of data, criti- cally revised the manuscript for important intellectual content. Journal and chemical properties of different surfaces of Periodontology 65: 942–948. The International Re-osseointegration on rough implant surfaces Journal of Oral & Maxillofacial Implants 16: 5 previously coated with bacterial bioflm: an 783–792. Clinical Oral Implants for replacing missing teeth: treatment of Research 2: 81–90. Prevalence of subjects with progressive bone loss Claffey N, Clarke E, Polyzois I, Renvert S. Lindhe J, Meyle J, Group D of European Workshop (2005) Treatment of peri-implantitis by the Vector on Periodontology. Clinical Oral Implants Research 16: 288– consensus report of the sixth European 3 293. The International Journal of Oral & Maxillofacial Clinical Oral Implants Research 9: 185–194. Clinical Oral carbon dioxide laser and hydrogen peroxide: an in Implants Research 14: 373–380. Applied and of periodontally healthy and diseased human Environmental Microbiology 63: 3352–3358. The Journal of Prosthetic supported rehabilitations in the edentulous Dentistry 77: 76–82. Journal of Biomedical 4 Infectious risks for oral implants: a review of the Materials Research 56: 417–426. The International Journal of Oral (2006) Nine to fourteen-year follow up of implant & Maxillofacial Implants 13: 845–850. World Congress on Alternatives and Animal Use in (1997) Controlled local delivery of tetracycline the Life Sciences, August 21–26, Berlin, Germany. Oral surgery, Oral Medicine, Oral Pathology, Oral Radiology, and Endodontics 103: 34–37. Overview of the studies that were excluded after complete reading and the reason for exclusion 2 Reason for rejection Author(s) (year) Combination of mechanical and chemical treatment Schwarz et al. Methodological quality scores of the selected studies 1 Author: Zablotsky Dennison Mouhyi Chin 2 Quality criteria: et al. Point estimates presented for primary + – – + outcome measurements Measures of variability presented for the – – – + primary outcome Statistical analysis* + + – + Author’s estimated risk of bias High High High High *Items used to estimate potential risk of bias. Reduction of endotoxin level relative to baseline values on machined and plasma- 1 sprayed titanium surfaces, and level of signifcance for the treatments compared with water (adapted from Dennison et al. Mean percentage of viable organisms remaining on machined titanium surfaces 8 after treatment, and level of signifcance compared with untreated controls (adapted from Chin et al. Consequently, regular and effective plaque removal constitutes an important 2 issue in the prevention of such responses. Several studies have shown that consistent profes- sional maintenance and the standard of the patients’ home care are key factors for long term stability of dental implants and the prevention of biological complications (Bauman et al. In a longitudinal multicenter study, failing implants were associated with higher plaque 4 bioflm levels than successful implants (van Steenberghe et al. More bone loss was observed around implants supporting fxed bridges in edentulous patients with poor oral hygiene than in those with better oral hygiene (Lindquist et al. In the consensus meeting of the Sixth Eu- 7 ropean Workshop on Periodontology regarding peri-implant diseases it was concluded that insuffcient oral hygiene is an important risk factor for developing peri-implant infections (Heitz-Mayfeld, 2008). The me- 9 chanical plaque control may involve the use of manual or power toothbrushes as well as proximal cleaning dental devices (Eskow & Smith 1999). The purpose of this study was to re- view and evaluate the literature, in a systematic way, with respect to various self-performed mechanical, oral hygiene modalities around implant-supported dental restorations in rela- tion to peri-implant soft tissue health. The 5 search strategy was customized according to the requirements of each database (for details on the search terms used see Box 1). The titles and abstracts were frst screened in- 7 dependently by two reviewers (D.

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If a patient becomes symptom- with the passage of a fertilized egg down into the free discount warfarin 5mg otc, she should nevertheless complete the uterus cheap warfarin 2 mg online, causing the egg to implant in the fallopian course of the medication to cure the infection discount warfarin 2mg line. A severe vomiting) and need intravenous administration of cough and congestion, caused by pneumonia, drugs in a hospital setting. Complica- risks to the baby’s health are great, it is not uncom- periodontal disease 171 mon for doctors to recommend routine testing of • Correctly and consistently use male latex con- pregnant women for chlamydia. Do not have sex, and go to see a doctor encompasses bone, periodontal membrane, and immediately. Caused by the action of plaque on the teeth rash, discharge with odor, sore(s), burning with adjacent to these tissues, periodontal disease in its urination, or bleeding between menstrual cycles. People 172 peripheral neuropathy with poor oral hygiene often have periodontal dis- ally start in the feet or hands, then move toward ease, but it is also a major problem for those who the body’s center. Defi- cient nerve stimulation to a muscle group trans- peripheral neuropathy A complication associ- lates to weakness or reduced control of movement. The central nervous system uses the Numerous treatment modalities may be consid- peripheral nervous system to work in concert ered for their appropriateness, from nutritional with the rest of the body. Peripheral neuropathy of neuropathy, a person may need to use over-the- may indicate damage to a single nerve, a nerve counter analgesics or prescription pain medica- group, or many nerves. It appeared diphtheria, leprosy, rheumatoid arthritis, amyloido- that the patch did improve the subjects’ ability to sis, lupus, sarcoidosis, dietary deficiencies, Charcot- work, sleep, and walk because the peripheral neu- Marie-Tooth disease, Friedreich’s ataxia, diabetes, ropathy was less of a factor. Also associated with neu- mal enlargement of the lymph nodes, which creates ropathy are exposure to toxins, use of certain drugs, a chronic problem that lasts for more than a month prolonged exposure to cold, and decreased oxygen in at least two separate areas (not including the and blood flow. Pneumocystis carinii pneumonia 173 pet ownership In people who are ill, a practice time and again. Some people argue against the use that is believed to be a significant stress reducer. Furthermore, a sex partner who is actually a person worth having phallus Another name for the penis. No one should fall for the “If pharyngeal gonorrhea Gonorrhea infection that you loved me, you’d do it for me” logic. Being has infected the throat, usually as a result of oral swept away in the “magic of the moment” is con- sex with a gonorrhea-infected partner. A family physician, urologist, gynecolo- prepare and plan sexual activity that is fulfilling gist, or internal medicine doctor can take a matter- and relatively safe. Cause “ping-pong” infection Transmission of a sexu- This is a form of pneumonia that is caused by infec- ally transmitted disease back and forth between tion with Pneumocystis carinii. The infection also occurs planned sex Preparing oneself to have sex, in in other people with compromised immune sys- order to enjoy a feeling of being in charge of one’s tems and in premature or ill infants. Most people who 174 pneumonia are infected with this fungus do not get pneumo- problem known as thrush). According to a study reported in The caused by various pathogens, but most com- New England Journal of Medicine, researchers think monly by bacteria. Symptoms are cough, fever, that combination antiretroviral therapy induces a shortness of breath, and chest pain. The most clinically significant restoration of immunity common form of pneumonia is bronchopneumo- against P. But researchers warn that nia, thus named because it starts around the patients who have already been exposed to the bronchi and bronchioles. Pus can fill the air sacs and thus regular blood tests to check the strength of his or exclude air. Other conditions for which a doctor Mycoplasma pneumoniae, and Chlamydia pneumoniae. In 1999, The River by the fact that viruses that infect one species usually Edward Hooper supported this idea. In recent years, there has been a switch ture—then chemicals are used to weaken it, and from Dr. Albert Sabin’s oral polio vaccine to use of it is frozen and diluted so that it can be used as a the inactivated polio vaccine. The history of polio vaccines dates back carefully monitored and tested by the Centers for to the 1950s, when they were developed and Disease Control and Prevention, the U. Jonas Salk introduced the first one that Drug Administration, the National Institutes of was widely used as a polio vaccine as a shot in Health, and other federal agencies. Hilary Koprowski introduced an oral polio labs and animals and three phases of testing in vaccine that people swallowed. All tissues and cells that dures, early vaccines were used on monkeys, are used to grow and produce any vaccine must be chimpanzees, guinea pigs, mice, and rabbits. Basically, the two kinds of durable plays a role in causing cancer, including in those power of attorney are one for health care deci- who got virus-contaminated polio vaccines (in the sions and one for financial decisions. Also, the legal document can give or deny this agent the right to admit the ill person to power of attorney A legal arrangement that a psychiatric facility, the right to authorize psychi- gives an assigned individual the right to sign atric medications and treatments, and the right to checks, give medical consent, and conduct other decide about nursing home placement. Special business for a person with a terminal illness such as instructions can also be included in the document. A durable power of attorney can be Those who do assign someone durable power of exercised in the event that the ill person becomes attorney for health care may want to update it mentally incapacitated or unconscious. In most occasionally because laws regarding durable power states, this power can be assigned to anyone older of attorney are subject to frequent change. The basic plan is that this person will then have the right to sign on the person’s behalf if that becomes necessary. The goal is to pre- pregnancy The period during which a woman vent legal, financial, and medical matters from carries a developing fetus. The doctor who is supervising wants it to go into effect or when the ill person the pregnancy should be informed of all perti- becomes incompetent. Two physicians’ agreement is the pregnant woman may not have tested posi- required to declare incompetence in a patient. The most important prevention message is this: avoiding sexual contact with other people is the only surefire way to prevent getting a sexually prevention messages Public service announce- transmitted disease. The goal is to convey to sexually active people that they need to • Have a mutually monogamous sexual relation- make certain behavior changes if they are cur- ship with an uninfected partner. Risk of acquiring ners should make sure that a new condom is used for sexually transmitted diseases also increases with each separate act of intercourse. Department of Health • Avoid douching, which removes some of the and Human Services of the Centers for Disease Con- vagina’s normal bacteria, thus heightening the trol and Prevention. Ideally, those who are drug risk of sexually associated problems such as bac- users will seek help in a drug-treatment program. Lymphoma is a cancer of the vaccination is a good idea for anyone being evalu- lymphatic system. For example, genital the first federal privacy standards to protect patients’ herpes outbreaks are often preceded by prodromal medical records and other health information took symptoms. The regulation profiles of behavior Epidemiological researchers covers health plans, health care clearinghouses, and often study various groups of people to determine health care providers who electronically conduct what sorts of lifestyles appear to contribute to the such transactions as enrollment, billing, and eligibil- spread of certain diseases. Certain small health plans have an transmitted diseases, profiles of behavior can spot- extra year to comply, but most health insurers, light groups whose needs should be addressed pharmacies, doctors, and other health care providers insofar as disseminating information on transmis- had to meet the April 14, 2003, deadline. Criminal prostatitis An inflammation of the prostate penalities apply for actions such as knowingly gland. Penalties range up to $50,000 and Causes one year in prison for certain offenses; up to By far, the most common type of prostatitis is non- $100,000 and up to five years in prison for bacterial. The others—chronic and acute bacterial offenses committed under false pretenses; and up prostatitis—stem from bacteria. Inflammation of to $250,000 and up to 10 years in prison for the prostate gland as a result of infection is com- offenses committed with intent to sell, transfer, or mon in men 50 and younger. A man who has nonbacterial prostatitis has pain (perineal, suprapubic, or low back) and urinary proctitis An inflammation of the rectum that is symptoms (frequent irritation, difficulty in urinat- characterized by diarrhea, bleeding, and unproduc- ing). Chronic prostatitis often causes recurrent uri- tive straining to have a bowel movement. This nary tract infections, low back pain, urination occurs in ulcerative colitis and sometimes in Crohn’s problems, pain after ejaculation, penile pain, disease and can also result from other conditions. Researchers in a review experiences fever and chills with urinary tract reported in August 2001 that routinely giving infection (or obstruction) symptoms, such as fre- antibiotics or alpha-blockers to men with chronic quent urination or difficulty urinating. However, some who has acute prostatitis may experience low back evidence supports using the two-glass test, and pain, perineal pain, joint pain, and malaise and will some small studies have shown that symptoms and probably feel very ill. Testing Also, some abacterial prostatitis patients find relief Diagnosis of prostatitis is a matter of excluding pos- from pelvic pain via antioxidants (tomato extract, sibilities because prostate cancer, benign prostatic selenium, lycopene). In the largest prostate cancer enlargement, and prostatitis can coexist and symp- prevention study to date, the National Cancer Insti- toms may overlap.

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A water softener system can be added to the system water supply to reduce the amount of calcium buy warfarin 2mg on line, thus increasing the service life of the membrane 1 mg warfarin. The power controller provided with each cell includes a 600 watt dimmer switch to manually adjust the input voltage to the battery charger cheap 1mg warfarin. Adjustment of the dimmer switch will increase or decrease the voltage output of your battery charger to the desired amperage setting. Salt Addition For every 50 lb bag of water softener salt, approximately 30 lbs of chlorine is made. The amount of salt that can be added to the cell depends on the shape of the salt pellets; however, a typical amount of salt added in each cycle is roughly 12 lbs. Twelve pounds of salt in the anode compartment will generate 7 lbs of chlorine considering that not all the salt is used in each cycle. For example: A 150 gpm municipal well operating a total of 6 hours per day (54,000 gpd) using a 1. Salt replenishment in the anode compartment requires the drainage of the brine, flushing the anode compartment with water, and addition of new salt and water to the cell. Adding of salt to the cell without flushing and cleaning is not recommended for several reasons. First, the anode compartment contains residual chlorine gas that will be displaced when salt is added. Second, the brine contains concentrated mineral impurities that will foul the membrane at a more rapid rate if it is not removed. The sodium hydroxide will neutralize the residual chlorine in the brine and make a salt saturated hypochlorite solution. Waterborne Diseases ©6/1/2018 515 (866) 557-1746 Waterborne Diseases ©6/1/2018 516 (866) 557-1746 Sodium Hydroxide Dilution Safety: Please note that sodium hydroxide is corrosive and irritating to the skin. If sodium hydroxide touches the skin, wash with water immediately to prevent chemical burn. Wear protective clothing such as rubber gloves and goggles when handling sodium hydroxide. For every 50 lb bag of water softener salt, approximately 36 gallons of 18 percent sodium hydroxide solution is made. The actual amount of sodium hydroxide produced is dependent upon the level and frequency of dilution. Assuming a 7 lb chlorine cycle per cell, the amount of sodium hydroxide produced from the cell is approximately 8. Using the same 18-day operational cycle as discussed above, approximately one-half gallon of sodium hydroxide solution is produced every day of operation. Dilution of sodium hydroxide in the cathode compartment requires the removal of approximately one-half gallon of sodium hydroxide and the addition of dilution water to 4- inches from the top of the cathode compartment (Note: more sodium hydroxide is produced than water added for dilution). It is desirable to use softened water for the dilution to reduce the mineral fouling of the membrane. Maintenance of the sodium hydroxide solution within the optimum range (10-18 percent) provides extended life of the membrane. Daily testing of the sodium hydroxide solution with a typical battery hydrometer will verify the need to dilute the sodium hydroxide. The following table illustrates the specific gravity and concentration of sodium hydroxide at a temperature of 60 degrees F (15. Waterborne Diseases ©6/1/2018 517 (866) 557-1746  Add dilution water (preferably softened water) to a level of 4-inches from the top of the cathode compartment. System Maintenance The chlorine generator has no moving parts and requires minimal maintenance. The salt and water added to the chlorine generator contain calcium and other minerals that accumulate on the surface of the membrane. These mineral deposits increase the electrical resistance across the membrane eventually reducing the amperage to the cell, thus reducing the chlorine production. Using the same 18-day operational cycle as discussed above, you may achieve two to four months of cell operation before needing to clean the cell membrane (depends on the dilution water quality) Operating the cell at 1 lb/day for 24 hours/day may require membrane cleaning every month (again, depending on the dilution water quality). Cleaning the Membrane Involves the Following:  Turn off the power supply to the cell. The membrane removed from the cell is then cleaned in a weak hydrochloric acid solution (muriatic or pool acid) to dissolve the mineral deposits. After cleaning, observe the condition of the membrane and discard if pin-holes are observed in the membrane. Replacement Items Items that wear and need eventual replacement include the vacuum tubing, rubber gasket/o-ring, membrane, and the anode. The anode has an expected life of five years based on a chlorine rate of 1 lb/day under moderate usage. The membrane has an anticipated life of one year depending on the frequency and dilution of the sodium hydroxide (see above). The rubber gasket in the cathode compartment may also need to be replaced every few years as needed. The vacuum tubing should be checked annually and replace when cracks are observed. Take precaution when applying chlorine in the sewer line near a wastewater treatment plant to control hydrogen sulfide production and anaerobic bacteria. Waterborne Diseases ©6/1/2018 519 (866) 557-1746 Waterborne Diseases ©6/1/2018 520 (866) 557-1746 Understanding Disinfection Wastewater Disinfection There are a number of chemicals and processes that will disinfect wastewater, but none are universally applicable. These applications rely on the formation of a biomat at the gravel-soil interface where "biodegradation and filtration combine to limit the travel of pathogens. Water Disinfection Disinfection is usually the final stage in the water treatment process in order to limit the effects of organic material, suspended solids and other contaminants. There are numerous alternative disinfection processes that have been less widely used in small and very small water treatment systems, including chlorine dioxide, potassium permanganate, chloramines and peroxone (ozone/hydrogen peroxide). Surface waters have been the focal point of water disinfection regulations since their inception, as groundwaters (like wells) have been historically considered to be free of microbiological contamination. Amendments to the Safe Drinking Water Act in 1996 mandate the development of regulations to require disinfection of groundwater "as necessary. While these proposed regulations have not yet been finalized, they will likely include; testing by each state, identification of contaminated water supplies, corrective action requiring disinfection and compliance monitoring. Waterborne Diseases ©6/1/2018 521 (866) 557-1746 Chlorates are powerful oxidizers and should be kept away from organics or easily oxidized materials. Mixtures of chlorate salts with virtually any combustible material (sugar, sawdust, charcoal, organic solvents, metals, etc. Chlorates were once widely used in pyrotechnics for this reason, though their use has fallen due to their instability. The salts of hydrochloric acid contain chloride ions and can also be called chlorides. The chloride ion, and its salts such as sodium chloride, are very soluble in water. It is an essential electrolyte located in all body fluids responsible for maintaining acid/base balance, transmitting nerve impulses and regulating fluid in and out of cells. The word chloride can also form part of the name of chemical compounds in which one or more chlorine atoms are covalently bonded. Other salts such as calcium chloride, magnesium chloride, potassium chloride have varied uses ranging from medical treatments to cement formation. An example is table salt, which is sodium chloride with the chemical formula NaCl. Examples of inorganic covalently bonded chlorides that are used as reactants are:  Phosphorus trichloride, phosphorus pentachloride, and thionyl chloride, all three of which reactive chlorinating reagents that have been used in a laboratory. Calcium chloride is a salt2 that is marketed in pellet form for removing dampness from rooms. Calcium chloride is also used for maintaining unpaved roads and for sanite fortifying roadbases for new construction. In addition, Calcium chloride is widely used as a deicer since it is effective in lowering the melting point when applied to ice. In the petroleum industry, the chlorides are a closely monitored constituent of the mud system. An increase of the chlorides in the mud system may be an indication of drilling into a high-pressure saltwater formation.

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