DH 2017

  1. Characteristics of tar.
    particulate matter generated from burning tobacco which appears as a sticky brown substance.
  2. Describe the characteristics of Nicotine.
    found in tobacco leaves, addictive, processed in the liver (80%) excreted in the kidneys.
  3. Characteristics of Carbon Monoxide
    competes with oxygen. Reduces O2 carrying ability. Crosses the placenta and reduces O2 to the fetus. increases the risk of cardiovacular disease.
  4. List carcinogenic compounds in tobacco
    • Nitrosamines-organic, cancer causeing.
    • Aromatic Hydrocarbon- benzoapyrene. Found in the smoke.
    • Polonium 210-natural. radioactive in leaves. 
    • Formaldehydes
    • Other inorganic: Arsenic, beryllium, cadmium, lead and nickel
    • Other Organic: benezene, Vinyl Chloride.
  5. Absorption of Smoking.
    Tar & carcinogenic compounds affect the oral and resp. tissue prior to absorption, once nicotine is in the lungs it passes quickly to circulatory system.
  6. Distribution of smoking:
    once absorbed, nicotine, tar and carcinogens are processed in the liver, sent to brain, and excreted in the kidney. Once nicotine is in the liver, converts to cotinin. Once in the brain, triggers release of dopamine, noreip, endorphins, and serotonin.
  7. Absorption of spit tobacco
    directly thru mucosa. 2-3 X more absorb. into circulatory than cigarettes.  Secondary absorption is in the intestinal tract if swallowed.
  8. Distribution of spit tobacco
    circulatory to brain, liver, kidneys. High levels of free nicotine, (ionized) results in greater addiction.
  9. Systemic effects of tobacco use:
    • Cardio: Increase of athero, CAD, peri arterial disease, hypertension and stroke. 
    • Resp: COPD, emphysema, chronic bronchitis, lung cancer.
    • GI: ulcers and cancers
    • Pregnancy:miscarriage, pre-term, SIDS
    • Other: osteoporosis, ulcers, impotence, other cancers. stomach esoph pancrease
  10. Oral effects of tobacco use:
    • tooth staining
    • perio_ (50% of perio pts) 2-6X more likely 
    • oral cancers
    • Lung cancer
    • stomatitis
    • Increased CAL 
    • neg. effect on bone metabolism 
    • delayed healing
    • resistant to DH therapy

    xerostomia, hairy tongue, halitosis, impaired taste, attrition and recession
  11. Tolerance
    A physiologic adaptation- neuroadaptation,  to a substance/chemical. Over time more tobacco is needed for the desired response.
  12. Dependence
    Physical need. withdrawals.
  13. 5 A's approach to tobacco cessation:
    • ASK
    • ADVISE
    • ASSESS
    • ASSIST
  14. 5 Symptoms of Nicotine withdrawal
    irritability, anxiety, depression, restlessness, increased appetite, intestinal distress, loss of concentration, and or loss of sleep.
  15. NRT
    • Nicotine Replacement therrapy
    • 1.) the Patch
    • 2.) Transmucosal (gum, lozenges, inhaler, spray)
    • 3.) NonNicotine prescr. drugs: Bupropion HCL, Varenicline.
    • Contains 1/3 to 1/2 nicotine as cigs.
    • No Cancer causing ingredients found in tobacco products. 
    • Not to be used for more than 6 months. Can become addicting.
  16. How many smoker have a smoking related disease?
  17. 16 mil. have smoking related disease
  18. How many adults in the US smoke?
    40 million
  19. How many in US use smokeless tobacco?
    12 million
  20. Reduction in life expectancy due to smoking?
    10 years.
  21. percentage of lung cancer is 2nd hand smoke?
  22. % of oral cancers assoc. with smokeless tobacco
  23. Betel quid
    • areca nut and betel leaf. 
    • add tobacco and it is Gutka.
    • Sucked or chewed. Highly addictive. mild stimulant with relaxation effects.
  24. Gutka oral effects
    • stain
    • erythroplakia, leukoplakia, oral cancers, lip and tongue, oropharyns, and esopoageal.
  25. Cig. alternatives:
    • Marijuana
    • Hookah
    • Beedies and cloves
    • E-cigs
  26. Marijuana forms of use
    dried plant, resin, oil, powder, tinctures.
  27. Marijuana Ingredients
    • THC 
    • Cannabidiol- sedative
    • Terpenes- antiInflam. anagesic, (distint aroma)
  28. Marijuana routes of entry:
    • smoking
    • water pipe
    • vaporizers
    • oral
    • sublingual
    • rectal
    • transdermal
  29. Therapeutic use of marijuana
    • Cancer
    • Neoropathy
    • chronic pain
    • pain assoc. with chemo
    • osteoarthritis
    • PTSD
    • Alzheimers
    • (migraines, IBS, Fibromyalgia, arthritis, epilepsy, leukemia, tourettes)
  30. Physiological effects of marijuana
    • rapid heart rate
    • increased BP
    • Increase breathing
    • Increased appetite
    • xerostomia
  31. psychological effects of marijuana
    • hallucinogenic (reality distortions)
    • mood alteration
    • impaired memory
    • impaired concentration
    • Reduced psychomotor coordination
  32. Effects of cannabis on the body
    • Eyes: reddening, decreased intraoccular pressure
    • Mouth: xerostomia
    • Skin: sensation of heat or cold
    • Heart: increased HR
    • Muscles: relaxed
  33. Oral effects of marijuana
    • stain
    • xero
    • malodor
    • increase caries risk
    • chronic irritation of tissues
    • increased risk of perio
    • Delayed wound healing
  34. Hookah
    Device used to smoke flavored tobacco, (shisha) ( hubble-bubble, Goza, ghalyn or Nargile)
  35. History of Hookah
    • India
    • originally for opium or hashish (17th cent)
    • 1990 rapid pop. in US
  36. Hookah parts
    • HEAD: tobacco bowl. 
    • WATER BOWL: vase. water filled
    • HOSE & MOUTH piece: draws the smoke from the bowl for inhalation.
  37. Hookah health risks:
    • same as cigarettes
    • along with communicative risks from sharing the mouthpiece: TB, Hep, HSV, Mono)
    • Low birthweight babies
    • similar second hand smoke effects.
  38. Beedies
    • (bedis) Unfiltered cigs. leaves from the temburni plant.
    • Flavored
    • 3X nicotine as cigs
    • 5X the tar
    • increased risk of oral, lung, liver, and stomach cancer.
  39. Cloves
    • aka: kreteks
    • filtered or unfiltered
    • 2/3 tobacco and 1/3 cloves
    • Indonesia
    • may have clove oil
    • 2-3X the tar and nicotine of cigarettes
    • Increased risk of lung and respiratory condtitions
  40. E-cigarettes
    • battery powered device attached to a vaporizer, and then to a cartridge of synthetic nicotine dissolved in propylene glycol. up to 20 mg of nicotine
    • Device heats up and then vaporizes
    • User puffs on the mouth piece and inhales the voporized nicotine.
  41. Risks of E-cigs
    • Carcinogenic potential from Diethylene Gylcol and nitrosamines found in the cartridges. 
    • Can be used for cessation.
    • Second hand arosol: propylene glycol, a volitile organic compound. 
    • No relation to carbon dioxide or tar.
  42. Presription drugs use for tobacco cessation
    • Bupropion HCL
    • Valernicline
  43. Nicotine patch
    • OTC
    • transdermal
    • self adhesive
    • chg every 18-24 hours.
  44. nicotine gum
    • nicorette)
    • Polacrilex
    • sweetened with xylitol, mint, or orange flavor.
    • chew then park
    • oral mucosa
    • lasts 30 min
    • otc
  45. nicotine lozenge
    • (committ, nicorette)
    • polacrilex 2mg or 4 mg
    • Sweetened with manitol or aspartame
    • 30 min to dissolve
    • oral mucosa
    • OTC
    •  "candy"
  46. Varenicline ( chantex)
    • reduces cravings
    • nicotine receptor agonist
    • use for 12 weeks. If successful use for 12 more. 
    • prevents release of dopamine.
    • Can be used with nicotine replacement therapies.
    • Rx only
  47. Anorexia
    • Serious, chronic, life threatening eating disorder defined by a refusal to maintian minimal body weight within 15% of an individuals normal weight. 
    • SUBtypes:
  48. Subtypes of Anorexia
    Restricting: excessive exercise, dieting, starvation to control wieght.

    Binge-purging: vomit, diuretics, laxitives, diet pills, and enemas
  49. Signs of a person with anorexia
    • Intense fear of gaining weight
    • distorted body image
    • obsessive/excessive exercise
    • low self worth
    • introverted shy
    • high achiever
    • withdrawn
    • avoids public eating
    • avoids specific foods
    • lethargic
  50. Bulimia Nervosa
    A serious eating disorder marked by a destructive pattern of binge-eating and recurrent inappropriate behavior to control one's weight. Can occur with other psych. disorders. Depression, OCD, Substance dependence (80-90%), exhibit vomiting behaviors.
  51. Subtypes of Bulimia
    Purging: vomit, laxitive, diuretics, diet pills, enemas

    Non-purging: diet and exercise
  52. Health effects of Bulimia Nervosa
    • Dry lips
    • puffy cheeks (swollen parotid)
    • chronic sore throat
    • irritated palate
    • esophageal tears and GI problems
    • laxitive dependent
    • cardiac problems
    • arrhythmias
    • depression and calluses on the semicircles of the dom. hand.
  53. Signs of Bulimia
    • Freq. bathroom use
    • self induced vomiting
    • laxative abuse
    • diuretics
    • enemas.
    • Non purging: fasting, execes. exercise
    • inconspicuous eating
    • ritual eating
    • excessive use of breathfresheners
    • Normal body wieght, low self esteem, depression, mood swings, extroverted
  54. EDO-NOS
    Eating Disorder Not Otherwise Specified
  55. List EDO-NOS
    Binge eating disorder: compulsive eating. A chronic eating disorder characterized by obsessive, uncontrolled, compulsive eating beyond feeling full. No purging. Obese and have difficulty losing weight. Any eating disorder not defined as anorexia or bulimia.
  56. Comorbid
    eating disorder coupled with one or more psychiatric disorders, increasing morbidity.
  57. Oral manifestations of Anorexia & bulimia
    • enamel erosion (permylolysis) 
    • thinning and chipped enamel
    • dentinal sensitivity
    • increase in caries, iron & B complex def., xero,sore throat, swollen parotid, gingival disease.
  58. Intervention strategies used by dental clinicians (eating disorders)
    • Approach the pt.
    • Notify parents/guardian
    • Refer to counselor etc
    • Dev. a dental tx plan.
  59. Describe dental tx plan for pt with eating disorders
    • soft tissue can be fragile-provide pain control
    • give OHI
    • recommend neutral sodium fluoride application in office
    • encourage sodium bicarbonate rinses if xero
    • discourage pt from brushing immed. after purging.
  60. How many Americans have an eating disorder?
    approx. 10 million
  61. What are the 3 Causes of eating disorders?
    • Biological influence
    • Psychological/emotional health
    • Cultural and societal
  62. Biological factors of eating disord. include
    • possible genetic link
    • serotonin (5-HT) may influence
    • possible hormonal influences
  63. Eating disorders are intertwined with what other mental health conditions?
    • Depression, anxiety, drug/substance abuse
    • OCD, self-harming behaviors.
  64. What are the 6 risk factors to eating disorders?
    • Gender
    • Age
    • Family 
    • Excessive/frequent dieting
    • Life changes/Transitions
    • Sports, work and artistic activities
  65. What is % of people with eating disorders are male?
  66. At what age does an eating disorder develop?
    • May dev. pre-adolescent thru older adults.
    • most commonly teens and early 20s
  67. Does genetics play a role in eating disorders?
    • Yes
    • Signif. more likely to occur in people who have parents or a sibling who have had a eating disorder.
    • Family attitude toward physical appearance and dieting.
  68. Eating disorders are common among?
    ballerinas, gymnasts, runners, and wrestlers
  69. Effects of anorexia on the brain/nerves
    fearful of weight gain, sad, moody, fainting, change in brain chemistry, depression
  70. effects of anorexia on hair/nails
    thin and brittle
  71. anorexia effects on heart
    low BP, low HR, fluttering, heart failure
  72. anorexia effects on blood
    anemia & other blood problems
  73. anorexia effects on Muscles, joints and bones
    weak muscles, swollen joints, bone loss, easily fracture, osteoporosis
  74. Anorexia effects on kidneys
    kidney stones, kidney failure,
  75. Anorexia effects on body fluid
    low K, Na, magnesium
  76. anorexia effects on GI
    Constipation, bloating
  77. Anorexia effects on hormones
    difficult to concieve, low birthweight, c-section, increase rate of miscarriage and increase in post partum depression.
  78. Anorexia on skin
    Bruise easy, dry skin, fuzz like hair all over the body,yellow skin
  79. Which teeth are most effected by purging?
    maxillary anteriors

    (L, O, I ) due to low gastric pH (vomiting)
  80. 5 steps to nutritional couseling
    • Assessment
    • identification
    • Setting of goals
    • Implementation
    • evaluation
  81. List the objectives involved in assessment of Nutritional status
    • Med Hx
    • Dental Hx
    • Social Hx
  82. 6 factors in a Social Hx
    • economic resources
    • Ethnic/religious considerations
    • Eating alone/dining out
    • Motivational level
    • Education level
    • Physical/mental challenges
  83. During the assessment of a pt. what clinical observations should be looked for?
    • Inflamed gingiva 
    • Cheilosis
    • Glossitis
    • Ulcerations
  84. What components make up a dietary hx?
    • 24 hour recall. 
    • Food questionnaire
    • Food diary
  85. Objectives in the identification of dietary status
    • Evaluate balance of diet
    • Determine cariogenic potential
    • Determine inadequacies
  86. Name the 4 objectives in planning and setting goals
    • Prevention and mgmt of perio. disease
    • prevention and control of caries
    • incorporation of client goals 
    • consider medical, dental and social needs
  87. Steps of plan implementation
    • Plan a menu
    • provide firm, nutritional knowledge
    • focus on established guidelines
    • set realistic goals-behavior changes
  88. Evaluation process
    • have the goals been met/achieved?
    • can they be maintained?
    • What modification are needed?
    • What are the barriers?
  89. 3 functions of a carbohydrate
    • Main source of fuel for the body
    • provides heat and energy
    • ground substance for the foundation of collagen; excess is stored as fat
  90. What are the functions of fat?
    • concentrated source of energy
    • protects vital organs and nerves
  91. Saturated fats
    • Solid at room temp.
    • Can be hydrogenated: solidifying a liquid
  92. polyunsaturated fats
    liquid at room temp and always derived from vegetable sources
  93. Function of Protein
    • Maintain and repair body tissue
    • Makes hemoglobin (carries O2)
    • Forms antibodies in the bloodstream
    • produces enzymes and hormones
  94. List the 9 water soluble vitamins
    • C
    • B1 (Thiamin)
    • B2 (Riboflavin)
    • B3 (Niacin)
    • B6 ( Pyridoxine)
    • Folate
    • Panothenic Acid
    • B12
    • Biotin
  95. List the fat soluble vitamins
  96. define Nutrients
    biochemical substance that can only be only be supplied from an outside source (food)

    • water
    • carbs
    • fats
    • proteins
    • vitamins
    • minerals
  97. Function of a nutrient
    Provide energy, build and maintain tissue, regulate
  98. Sugar alcohols (polyols)
    • sorbitol (most common)
    • mannitol (mannos/legumes)
    • xylitol
    • Do not cause sudden change in glucose levels
    • Non-cariogenic
    • Slowly absorbed and metabolized
    • possible laxative effect
  99. Sucrose-
    • glucose + fructose
    • Glucose + galactose
    • gluctose + gluctose
  100. Sucrose is
    • table sugar
    • from sugar beets and sugar cane
    • found in some fruits and veg
    • tree sugars
  101. lactose is
    milk sugar
  102. Maltose is
    malt sugar
  103. starches:
    • amylose, amylopectin
    • grains, cereals, legumes, potatoes, unripe fruit
  104. dietary fiber
    • cellulose (hemicellulose)
    • promotes GI function
    • gums, pectin
  105. Minerals
    • Inorganic elements found in the body that maintain functions. 
    • 4% of body weight
    • Calcium, Phosphorus, sodium, potassium, magnesium, chlorine, sulfur.
  106. Micronutrients
    Iron, iodine, copper, zinc, manganese, selenium, chromium
  107. Calcium
    • Most abund. mineral in body.
    • Formation of thrombin
    • aids in synthes. of neurotransmitters
    • muscle and nerve activity
    • bone health
    • Vit C and D enhance absorption
    • (milk, spinach, broccoli, soy)
  108. Phosphorus
    • 2nd most abund.
    • 85% in teeth and bone
    • metabolism (dna-rna)
    • muscle contraction and nerve activity
    • (meat and dairy)
  109. Iodine
    • supports physical and mental function
    • req for form. of thyroxine
    • (seafood, iodized salt)
  110. Magnesium
    • Bone cell func. 
    • nerve transmission
    • Muscle contraction
    • energy metabolism
    • (whole grains, nuts, beans, green leafy)
  111. Fluoride
    • supports integrity of bone health
    • (seafood, brewed tea)
  112. Sodium
    • water balance
    • reg. acids/bases
    • Muscle contraction
    • Nutrient absorp.
    • (animal sources, some veg, processed, canned, and processed food.)
  113. Potassium
    • Protein and glycogen synthesis
    • pH balance
    • Nerve transmission
    • muscle contraction (heart)
    • (meat, dairy, grain fruit, and veg)
  114. Iron
    • component of hemoglobin
    • cofactor for many enzymes
    • immune function and production of antibodies
    • synthesis of collagen
    • removal of lipids from blood
    • (meat, esp beef, yolks, dark green veg, enriched foods)
  115. chlorine
    maintain electrolyte balance and osmotic equilibrium

    (salt Nacl)
  116. Zinc
    • DNA/RNA and protein synthesis
    •  (lamb, crustaceans, eggs, peanuts)
  117. Vit C
    • Absorbic acid
    • collagen form
    • hormone synthesis
    • wound healing
    • resist. to infection
    • enhances iron absorption
    • (citrus, bell peppers, strawberry and kiwi)
  118. B1
    • Thiamin
    • Metabol. of carbs, proteins, and fats
    • normal brain func, nerves, muscles, heart
    • reg. appetite
    • DNA RNA formation
    • (whole grains, cereals, pasta)
  119. B2
    • (riboflavin)
    • cellular growth
    • metab. of carbs, proteins, and fats 
    • healthy eyes and mucous membrane
    • aids in syn. of niacin (B3)
    • (milk, dairy, meat, poultry and fish)
  120. B3
    • Niacin
    • all cell func.
    • release of energy from carbs, protein, fat
    • co-enzyme of ATP
    • (meats, cereals, nuts, seeds, legumes)
  121. B6
    • Pyridoxine
    • coenzyme in protein synthesis
    • energy from glycogen
    • nervous system function
    • (meat poultry fish)
  122. Folate
    • Folic acid, folacin
    • maturation of RBC
    • func. with B12 and C
    • DNA/RNA synthesis
    •  (liver, green leafy, fort. foods)
  123. Pantothentic acid
    • syn of vit D
    • aid in release of energy from carb, fat, protein
    • (animal products and whole grains)
  124. B12
    • cobalamin
    • form of mature RBC
    • DNA/RNA synth.
    •  (meat and animal products)
  125. Biotin
    DNA/RNA synth. 

    (egg yolk and liver)
  126. Vit A
    • Retinol
    • bone and tooth dev
    • healthy skin and mucous membranes
    • immune system func.
    • vision in dim light
    • (dairy, eggs,meat(liver) fortified food)
  127. Vit D
    • Calceferol
    • Absorption of calcium and phosphorus
    • mineralization of bone
    • (sunlight, seafood)
  128. Vit E
    • Tocopherol
    • most important fat sol, anti-ox
    • protects RBCs
    • (whole grains, nuts, seeds, green leafies)
  129. Vit K
    • Formation of prothrombin 
    • activiates proteins for bone form. 
    • (green leafies, meat, dairy)
  130. water
    • most abund, component of body
    • primary component of blood and lymph
    • medium for secretions and excretions
    • acts as a solvent
    • maintains fluid stability
    • enables chemical reactions
    • aids in cell lubrication
    • transport for nutrients
    • regulate body temp.
  131. 3 types of power driven scaling devices
    • Magnetostrictive
    • Peizoelectric
    • Sonic
  132. Magnetostrictive
    • high freq.electrical energy converted to rapid vibration. tip=elliptical pattern
    • ultrasonic technology
    • 25 or 30K units
  133. Peizoelectric
    • energy is created by ceramic crystal or quartz transducers in the handpiece.
    • tip=linear
    • less heat, less water than Magento
    • No magnetic field created
  134. Sonic scaler
    • lower freq than magneto. pressure sensitve
    • energy levels range form 2000-6300 cps. 
    • tip=elliptical 
    • little heat is gen.
  135. cavitation
    vibration energy of water resulting in the lyses of the bacterial cell wall. ( minute bubbles implode)
  136. magnetostrictive
    ultrasonic action created by high freq electrical current converted to ellipitical movemt of the tip
  137. amplitude
    amt of power in the tip related to the length of the tip movement.  longer the stroke, the more energy and greater ability to remove more tenacious deposits
  138. Frequency
    number of cycles of tip movement or vibration in one second.
  139. autotuning units
    magneto units that have a pre-set freq. have adj water and power controls. The freq automatically adjusts with adaptation of the tip and as conditions change during instrumentation
  140. manual tuning instruments
    magneto units that have adj freq. in addition to adj water and power controls.
  141. name the specific parts of the ultrasonic insert tip and power levels of each
    • The tip=Most power 2-4mm
    • Face (concave) of tip= next highest power
    • Back of tip (convex)
    • Lateral sides of tip (least powerful)
  142. Acoustic turbulance
    • the cooling effect and hydrodynamic movmt of water around the elliptical tip that moves subgingival debris and disrupts bacteria. 
    • AKA microstreaming
  143. list the contraindication for Ultrasonic scaling
    • pt with pacemakers
    • pt with communicable/ infect. diseases that are tramissable through aerosols
    • pt with COPD, asthma, CF
    • Pt with strong gag reflex/diff swallowing
    • implants
  144. parts of an insert system
    insert tip, grip, O ring, stack
  145. care and maintenance of inserts
    • Do not submerge in glutaraldehyde or spray with birex.
    • Rinse and place in indiv. pkg
    • Do not run thru ultrasonic
    • Ck periodically for wear
    • Replace )-ring if water leaks from handpiece or feels loose.
    • Bag so that the tip can be viewed. Tip down. 
    • Autoclave paper side down. 
    • Check "born on" date
    • replace if stack is bent or splayed
    • use an efficience indicator template to check the wear in the tip length.
  146. techniques to avoid senstivity
    • decrease power-length of stroke
    • decrease freq. 
    • increase water flow
    • avoid sensitive teeth
    • keep the tip moving at all times and maintain constant water  flow.
  147. controlling water
    • seat the client as upright as possible
    • provide adequate suction
    • avoid continuous use.
  148. Asepsis and infection control
    • PPE, face shield, mask, gloves, gown
    • Client: protective lenses and cloth towel/prerinse 
    • Ultrasonic unit: drape with plastic
    • Ultrasonic handpiece: sterilize . Bleed 1 minute
    • Water evac. - use high volume if working with an assistant. 
    • water spray: water flow should be on low
  149. Adv. of ultrasonic scalers
    • water lavage
    • lyses bacterial cell wall
    • removes plaque
    • gram - most suseptible
    • less tissue trauma
    • increased pt comfort
    • decreased operator fatigue
    • MAY req less tx time
    • Better access to deep pockets
    • no sharpening, less lateral pressure, less tissue distention
  150. lavage
    • water flushes debris
    • removes endotoxins
    • removes plaque
    • can add a antimicrobial
  151. Disadv of ultrasonics
    • decrease tactile sense
    • req water evac
    • produces aerosol
    • potential for damaging restoratives
    • visibility is increased by clearing blood
  152. Do you need to get informed consent before using the ultrasonic?
  153. name the 2 water sources for the ultrasonic
    internal or external
  154. Gross debridment
    use to remove mod to heavy calculus ABOVE the gingival margin and in shallow pockets.
  155. Assorted speciality tips
    • chisel
    • beaver tail
    • furcation tips ( .8mm ball on the end)
    • diamond coated
  156. Slimline inserts
    access tight contacts and increase client comfort when light dep are subgingival.
  157. Straight
    • use for healthy maintenance 
    • 4mm or less pockets
  158. paired inserts
    • Right or left curved. 
    • perio case type III IV
  159. Basic principles of ultrasonic use
    • the thinner the tip the lower the power setting
    • the lighter the dep. the lower the power setting
    • Low power should always be used wht the patient in NOT anesthetized for debridement. 

    • Do not use on HIGH power
    • finish with hand scaling
Card Set
DH 2017