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Dengue control techniques such as fogging are not very effective in Malaysia because home owners do not allow the fogging distributors into their homes cheap 10 mg vaseretic overnight delivery. Secondly discount vaseretic 10 mg, people are wary of inspectors who conduct mosquito checks as they are perceived to discount vaseretic 10mg without a prescription be there only to purchase vaseretic 10 mg with visa collect fines rather than prevent dengue. Thus, home owners are reluctant to let fogging distributors and inspectors into their homes. As a result, inspection methods are poorly implemented and lack regulatory oversight. Another reason for fogging’s ineffectiveness is that it targets only adult mosquitoes. Source reduction is very important as trans-ovarial transmission of dengue virus can occur. One measure that has been discussed in Malaysia to improve the efficiency of fogging is to engage private companies in this work. However, this measure has not been implemented due to concerns around cost cutting. Private companies may choose to dilute the composition of the chemicals required for fogging. However, this can have dangerous consequences as mosquitoes may develop a resistance to fogging due to the weakness of the 39 chemicals. However, considering Malaysia’s booming population and rapid globalisation these numbers and the health system’s surge capacity need to 41 be improved. In Kuala Lumpur, local authorities noted that contractors with weak credentials didn’t collect rubbish frequently and drains were left clogged (The Sun Daily, March 18, 2015). In Penang, the auditor general noted that the amount of solid waste at landfill sites exceeded the limit, rubbish bins were too small for household waste, 39 Interview with professor, Kuala Lumpur, 11 February 2015 40 Interview with lecturer, Kuala Lumpur,12 February 2015 41 Interview with professor, Kuala Lumpur, 11 February 2015 26 Singapore, May 2015 and there were unnecessary delays in responding to complaints (The Malay Mail, April 8, 2014). Table 9: National Strategic Plan for Dengue, number of cases from 2009-2013 National Strategic Plan for Dengue Target Number of cases per year 2009-2013 Implemented in April, 2009 2009 41,486 Following aspects included under the 2010 46,171 plan: -Surveillance System 2011 19,884 Integrated Vector Management To reduce the number of cases by half 2012 21,900 Dengue Case Management over a period of five years Communication and Social Mobilisation 2013 43,346 Dengue Outbreak Response Dengue Research 2014 108,698 Dengue Strategic Plan for Klang Valley Notes on sources: Number of cases per year from 2009-2012: Dr Rose Nani Mudin, ‘Dengue update from Malaysia’ (presentation at the early adopter countries for dengue vaccine meeting, Bangkok, 24 October 2013); Number of cases per year for 2013 and 2014: ‘Situasi semasa demam denggi di Malaysia’, accessed 9 March 2015, idengue. Environmental: rural-to-urban migration and natural habitat erosion In Selangor and Kuala Lumpur an increase in the number of migrants has led to further overcrowding of urban spaces. As a result of greater urbanisation there has been an erosion of natural habitats and more co-habitation between mosquito vectors and humans highlighting the dominance of non-sustainable land 42 use strategies. For example, Subang Jaya is an area with 80% urban development and 20% vegetation with a significant number of investment properties. It has become a dengue hotspot in Selangor, and is the most affected in Petaling district. In response, biological control such as toxo mosquitoes which can eat the larvae of Aedes aegypti mosquitoes, have been tried in the region. However, toxo mosquitoes need areas with greater vegetation and so have only been effective in 20 percent of Subang Jaya. As a result, these factors have seen the 44 geographical distribution of dengue in this area widen over the past five years. Legal: Limited scope of regulatory framework At present, the greatest challenge to accurate and reliable data collection on dengue is that the private sector reporting system isn’t robust enough as it lacks investigative tools and mechanisms. At the individual level, maintenance of personal, home and immediate vicinity sanitation and hygiene is of utmost importance. At the community level, it is important to 42 Interview with lecturer, Kuala Lumpur, 12 February 2015 43 Interview with lecturer, Kuala Lumpur, 12 February 2015 44 Interview with lecturer, Kuala Lumpur, 12 February 2015 27 Singapore, May 2015 come together to ensure general neighbourhood cleanliness. The local authorities ensure rubbish collection on a timely and frequent basis, and that drains are not clogged. This is a part of the integrated vector management programme, outlined in the National Strategic Plan for dengue. However, other agencies have a role to play to ensure general cleanliness and to eliminate vector breeding sites in areas that are under their purview. Opportunities Political: Positive incentives and multi-sectoral public health interventions At the political level, there is an opportunity to further deepen multi-sectoral partnerships. This can be done by analysing and learning from successful case studies of partnerships already in place in Malaysia. There are opportunities to improve public communication and to increase effectiveness of established programmes. University students, guided by iM4U, visited 14 dengue hotspot communities in Malaysia such as Lembah Pantai to investigate the challenges there. For example, they have conducted research about housing design and structure that might encourage mosquito breeding in different areas. These companies often sponsor events with mosquito repellents, ointments and hydrating drinks to raise awareness of dengue at subsidised rates or 45 free of charge in exchange for positive publicity and product placement. In Costa Rica, the health ministry partnered with Geotecnologias to develop a mobile app. Users log on while at a suspected site and upload photographs and their details to be updated. This can improve the use of pesticides to target aedes mosquito breeding grounds (Griliopoulos, 2014) and contribute to Malaysia’s dengue control and prevention strategy. Mosquito breeding occurred as there weren’t enough rubbish bins, rubbish collection was infrequent and the drains were clogged with waste such as Styrofoam cups. The village residents were not aware about the connection between their sanitary habits and dengue.

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Relaxing music at mealtime in nursing homes: Effects on agitated patients with dementia generic vaseretic 10 mg amex. Evidence based practice recommendations for working with individuals with dementia – Retrieval training cheap 10mg vaseretic with visa, Journal of Medical Speech – Language Pathology vaseretic 10mg online, 13(4) cheap 10 mg vaseretic, xxvii-xxxiv. A multifactorial intervention program reduces the duration of delirium, length of hospitalization, and mortality in delirious patients. Evidence-based practice recommendations for working with individuals with dementia: Montessori-based interventions. Weight increase in patients with dementia, and alteration in meal routines and meal environment after integrity promoting care. Assessing patients complaining of memory impairment, Geriatrics & Aging, 11(3), 168 -178. Evidence and consensus-based German guidelines for the management of analgesia, sedation and delirium in intensive care – short version. Montreal, Canada: Department of Clinical Epidemiology and Community Studies, St, Mary’s Hospital Center. Multicomponent intervention strategies for managing delirium in hospitalized older people: Systematic review. Does serotonin augmentation have any effect on cognition and activities of daily living in Alzheimer’s dementia Identication of common mental disorders and management of depression in primary care: An evidence-based best practice guideline. Facilitating resident information seeking regarding meals in a special care unit: An environmental design inter-vention. Factors inuencing best practice guideline implementation: Lessons learned from administrators, nursing staff and project leads. The prevention, diagnosis and management of delirium in older people: Concise guidelines. Communication strategies to promote spiritual well-being among people with dementia. Efcacy of an evidence-based cognitive stimulation therapy programme for people with dementia: Randomised controlled trial. A randomised controlled trial testing the impact of exercise on cognitive symptoms and disability of residents with dementia. Contemporary Nurse: A Journal for the Australian Nursing Profession, 21(1), 32-40. Structured reminiscence: An intervention to decrease depression and increase self transcendence in older women. Exercise plus behavioral management in patients with Alzheimer disease: A randomized controlled trial. The effect of staff training on the use of restraint in dementia: A single-blind randomised controlled trial. The effects of the implementation of snoezelen on the quality of working life in psycho-geriatric care. Pain in elderly people with severe dementia: A systematic review of behavioural pain assessment tools. However, we acknowledge that in a number of areas, particularly those dealing with service configuration, the evidence base is incomplete. The Faculty and Society are addressing this ‘evidence gap’ as a joint initiative by developing a portfolio of evidence-based guidelines. Chapter Two describes in detail the structure of the service, including physical facilities and staffing. Chapter Three details the process of the service and focuses on the patient’s pathway. Chapter Four describes the activity of the Critical Care service, including aspects of disease management and prevention as well as specialised critical care. Chapter Five contains other additional key components of the service, ranging from operational delivery networks to resilience planning. Finally, Chapter Six is a duplication of Core Standards 2013 in which the same numbering system used in the original document is retained to help avoid confusion. For units where Recommendations are not currently met there should be a clear strategy to meet these as soon as possible. Relevant Standards can be quoted by authors only if they are already included in the Core Standards 2013 document. With regard to the clinical Recommendations and Standards, the material presented does not in any sense obviate the need for experienced clinical judgement exercised by individual practitioners acting in the best interest of their patients. Moreover, the guidance should not in any way inhibit the freedom of clinical staff to determine the most appropriate treatment for any patient they are asked to manage in a particular place at a particular time. When such constraints exist, it is important that these units work closely with commissioners and their local Adult Critical Care Operational Delivery Networks to agree an appropriate action plan. The terms ‘Critical Care’, ‘Intensive Care’ and ‘High Dependency Care’ are all used interchangeably throughout this document where ‘Intensive Care’ is synonymous with ‘Level 3 Critical Care’ and ‘High Dependency Care’ is synonymous with ‘Level 2 Critical Care’. The report Comprehensive Critical Care recommended that a classification be employed that focused on the level of dependency that individual patients need, regardless of location. This level includes all complex patients requiring support for multi-organ failure. Whilst the system of classification described is not universally employed nor nationally validated, it is 2,3 referred to by national authorities as a useful means of defining the varying needs of the critically ill. These classifications of levels of care therefore underpin all the recommendations made in this Guideline. A supplementary classification has been proposed to identify those patients requiring specialist investigation and treatment such as is usually provided at tertiary referral hospitals.

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The National Palliative Care Program also provides important resources to discount 10mg vaseretic overnight delivery discuss end of life 272 matters with Aboriginal and Torres Strait Islander people buy vaseretic 10mg on-line. They raise the notion of ‘cultural safety’ as an important aspect of discussing medical treatment with Aboriginal and Torres Strait Islander people discount vaseretic 10mg fast delivery. Cultural safety is practice which respects generic vaseretic 10 mg with mastercard, supports and empowers the cultural identity and wellbeing of an individual, and empowers them to express identity and have their cultural needs met. Cultural safety recognises that every person brings a set of values and beliefs to all interactions with other people and all that they do. Each clinician will bring values and perspectives from their own culture to the situation. Sometimes these can be obvious; sometimes they are so subtle the clinician may not even be aware there can be an impact on the patient. A guideline prepared by Queensland Health provides awareness about broader issues around 273 patient care for Aboriginal and Torres Strait Islander people. There is continuing growth in cultural diversity across Queensland, including a notable growth in South East Queensland. Queensland is an increasingly multicultural society being home to people who speak more than 220 languages, hold more than 100 religious beliefs and come from 274 more than 220 countries. The Queensland Government Statistician’s Office also produces 275 regular overseas migration figures for Queensland. End-of-life care: Guidelines for decision-making about withholding and withdrawing January 2018 122 life-sustaining measures from adult patients Culture, for the purpose of this guideline, may be defined as: ‘a complex, learned, shared system of human behaviour, rituals and symbolism’. Despite the difference between cultures, there are usually common interests that may serve as starting points for discussion. In most cultural groups, the family has traditionally been the main source of security, assisted by adherence to their religious or spiritual beliefs. Migration from the country of birth cuts off many support systems and reduces the recognition and celebration of symbolic events. This can increase the sense of alienation and helplessness at times where difficult decisions are required. Once living in Australia, people who are displaced from their birth country tend to live in the same vicinity to retain their traditional community support. It is to this community support that people often turn to if they are faced with difficult end 277 of life decision-making. Generally, many cultural groups approach religion and spirituality very seriously. There are a number of religions that cross language and cultural boundaries, so it is important when working with a person facing a life-threatening illness and their family to not assume anything, and to understand where religion fits within the spectrum. There are many for whom religion in the context of their life in Australia does not have as significant a role as it may have in their homeland. However, when faced with a life-threatening illness and the possible or subsequent death of a family member or friend, religious practices, rituals and beliefs may resume their importance. The sometimes startling differences in approaches to death and dying for the various multicultural groups means that clinicians treating patients who identify with another culture must be mindful about how the subject can be approached with the family. It is important for health professionals and others to acquire some knowledge about these issues to ensure a sensitive approach when working with people facing terminal illness, their family and friends. Cultural factors shape patients’ preferences around decision-making, receiving bad news and end of life care. The developed world’s emphasis on patient autonomy, informed consent and truth telling is often at odds with the beliefs and values of some cultural groups, who may place greater value on family involvement in decision making as opposed to individual autonomy. For example, in some cultures, discussing death is actively discouraged as it is viewed as an indication of disrespect, likely to extinguish hope, invite death, and/or cause distress, depression 278 and anxiety. The notion of ‘cultural safety’ is often referred to in recent literature about health care for people from other cultures. Cultural safety acknowledges that the culture of the provider can adversely impact on the recipient if there is a power imbalance. People from all cultural backgrounds may feel disempowered for many reasons, including: lack of medical knowledge lack of understanding of the illness and/or treatment/support care strategies not being involved in care planing unfamiliarity with the care environment (for example, a hospital/hospice) perceived social inequality differences in lifestyle lack of literacy/numeracy skills (for example, understanding medicine dosage) previous negative experiences with health care, and having heard negative stories from relatives about their experiences with health care. Source: Clark & Phillips (2010) End-of-life care: Guidelines for decision-making about withholding and withdrawing January 2018 123 life-sustaining measures from adult patients 5. People who are transgender, gender diverse or intersex may describe themselves as heterosexual and therefore not a minority sexual group. Some people with Intersex variations may self-identify as male or female, as intersex or as non-binary. However, according to some researchers, there is little understanding in Australia of the special issues faced by gay, lesbian, bisexual and transgender people in end-of-life care and advance 279 care planning. As in the wider population, however, significant barriers to advance care planning exist. Anticipating discrimination: People access palliative care services late or not at all, either because they anticipate stigma or discrimination or they think the service is not for them 2. Assumptions about identity and family structure: Health and social care staff often make assumptions about people’s sexuality or gender identity that have an impact on their experience of palliative and end of life care. Evidence suggests that some clinicians do discriminate on the basis of sexual orientation. Unsupported grief and bereavement: Partners feel isolated or unsupported during bereavement because of their sexuality. Informal care, particularly from a partner, plays a vital role in ensuring someone gets access to palliative care. However, further research is needed on how being single influences access to health and social care services at the end of life, and on how adaptable hospice and 282 palliative care services are to alternative family structures. End-of-life care: Guidelines for decision-making about withholding and withdrawing January 2018 124 life-sustaining measures from adult patients 5. Although research shows around seventy per cent of Australians support organ and tissue donation, only thirty per cent 283 have registered to become donors.

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The role of postopera tive changes in disc height in explaining postoperative pain and disability is unpredictable and indefinite (Gillet 2003) purchase 10mg vaseretic with mastercard. Study Subjects order vaseretic 10mg,D iag nosis Interventions M ainoutcom e M ainR esults andLeng thof F ollow -up M oller& H ed n= 111F = 54 buy vaseretic 10 mg visa,M = 57 G 1:Posterolateralfusionw ithorw ithoutinstru D isability D isabilityandpainde lund2000 10 mg vaseretic fast delivery,E k G 1:n= 77,G 2:n= 34, m entation Pain creasedsig nificantlym orein m an,M oller& m eanag e39y G 2:E x erciseprog ram (streng thandposturaltrain fusiong roup at2years H edlund2005 Isthm icspondylolisthe ing w ithem phasisonabdom inalandbackm uscles) 2,9(rang e5 N osig nificantdifferences sis 3sessionperw eekforthefirst6m onthsand2ses 13),and10 betw eeng roupsinlong -term sionperw eekbetw een6and12m onths (rang e10-17)y follow -up. Supervisedtreatm entfor1w eek,then2 w eeksathom eand2w eeksundersupervision Brox etal. Attempts to achieve these aims are made via improving both functional capacity of the lumbo-pelvic complex and health related fitness. Consequently, a patient with impaired physical ability cannot be physically active enough to maintain or improve muscular and cardiovascular capacity. For this reason, many patients are afraid to be active, fearing that they will jeopardize the fusion pro cess. Currently, infor mation on what post-operative therapeutic exercise should include is minimal. Thus, several structural and functional changes may have taken place in their trunk muscles and spinal control that will not spontaneously normalize after surgery, alt hough the intensity of pain will probably decreases. Secondly, fusion itself changes the normal biomechanics of the lumbar spine, and causes muscle injury and atrophy which especially affect adjacent segment function. Thirdly, healing of soft tissue and bone, limit loading of the spine during the early recover. It takes several months before bony fusion achieves adequate strength (Kalfas 2001, Pilitsis, Lucas & Rengachary 2002). Strain on the fused and adjacent seg ment and risk of breakage of the instrumentation or pulling out of the pedicle screws should also be minimized during rehabilitation (Christensen 2004). It is challenging to find exercises for a rehabilitation program that are simultaneous ly safe, functional to maximize transfer of the training effect to daily activities, and fulfil the demands of training intensity. Trunk stability can be seen as the product of central nervous system func tion and the muscular capacity of the lumbo-pelvic complex. Trunk strength and endurance are critical for performance because all movements either origi nate in or are coupled through the trunk (Kibler, Press & Sciascia 2006, Okada, Huxel & Nesser 2011). Deficiencies in central nervous system function or mus cle capacity decrease the ability to prevent trunk torque, which results in un controllable motion and injury (Zazulak, Cholewicki & Reeves 2008). Maintaining the neutral position of the lumbar spine during loading in creases the shear and compression tolerance of the spine and probably im proves the safety of the exercises (McGill, Hughson & Parks 2000, Gunning, Callaghan & McGill 2001). The term functional neutral spine control exercise is a descriptive term for exercises which aim to improve both the capacity of con trol of the neutral spine position and position sense awareness (Akuthota & Nadler 2004). During neutral spine control exercise, a destabilizing force acts on the trunk via loading of the extremities, and therefore proper recruitment of the trunk muscles is required to stabilize the lumbar spine and pelvis (McGill et al. Trunk muscle strength and endurance are important both for functional capacity and for optimal function of the lumbo-pelvic complex (Wagner et al. Neutral spine control exercises have been reported to decrease pain in patients with chronic low-back pain (Suni et al. In this classification, neutral spine control exercises are in the category of non core exercises. If performed in the standing position, both free weight and non core exercises can be seen as functional exercises, since activation of the trunk muscles during those exercises mimic specific trunk muscle function patterns needed in performing occupational and functional daily tasks (Borghuis, Hof & Lemmink 2008). Thus, the transfer effect of functional training for real life de mands may be better than. With the selection of correct and appropriate ex ercise, it is possible to focus changes on the desired muscles and functions. In order to achieve a training effect, exercises intensity should be challenging enough. Exercises that elicit larger activity represent greater challenges to the neuromuscular sys tem. Direct comparison of results between different studies is difficult due to different loading protocols, measurement approaches, and equipment. Study Subjects E x ercise,resistance,andstudied M ainR esults m uscles,and/orspinallevelof m easurem ent Arokoskietal. N = 24healthy Bilateralisom etricshoulderex Shoulderex tensionactivateR A andO E A atlevelw hichw as>50% of 2001 subjects,F = 14, tensionandflex ionandunilateral M V C inw om en M = 10 horiz ontaladduction. Activityof long issim usandm ultifidusw as 50% of M V C during ag erang e21 M anualresistance. E S activityw as jects, sition hig herduring unilateralthanbilateralpressinstanding position. Cognitive-behavioral elements related to fear of movement or injury were also an essential part of the program. However, the best practice in postoperative rehabilitation remains unclear (Rushton et al. Abbott,Tyni n= 107 G 1:H om etraining prog ram (Back,ab D isability Scoresfordisability,self Lenne& H ed G 1:n= 54,F = 31,M = 18, dom inal,andleg m uscleendurancetrain Backpain efficacy,outcom eex pec lund2010 ag e50y ing,stretchesandcardiovasculartraining H R Q L tancyandfearof m ove G 2:n= 53,F = 35,M = 23, G 2:3outpatientsessionsfocusing on O utcom eex pectancy m entim provedsig nifi ag e51y m odifying m aladaptivepaincog nitions, Self-efficacy cantlym oreinG 2thanin behaviours,andm otorcontrolof trans F earof m ove G 1atallfollow -up points. The main focus was to test the feasibility of neutral spine control exercises for rehabilita tion purposes. To determine pain, disability, trunk muscle strength, and functional mobility pre and postoperatively in patients undergoing lumbar spine fusion and to analyze associations between changes in trunk muscle strength and disability (Study I). In the study I, 114 patients (64% females and 36% males), who had undergone non-urgent lumbar spine fusion, owing to degenerative olisthesis, spondyloly sis, lumbar spinal stenosis, or degenerative disc disease, in Tampere University Hospital and Central Finland Central Hospital participated in the study.

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In most instances cheap vaseretic 10 mg online, it is necessary to vaseretic 10 mg overnight delivery make minor adjustments to vaseretic 10mg without a prescription provide a more comfortable fit buy generic vaseretic 10 mg. In order for you to wear your dentures successfully, most patients will require adjustments of their attitude and habits. If you are unable to reach your dentist during holidays, weekends, or after hours, remove the dentures to prevent further trauma to the tissues. Dropping the denture on a hard surface can result in breakage of the pink flange and/or the teeth. Soak your dentures at night in a denture cleaner or a solution of water, mouthwash. Annual examinations of the supporting tissue for abnormalities and to assess the function and fit of the denture are important for your dental health. Partial denture: A prosthesis that replaces one or more, but not all of the natural teeth and supporting structures. Interim denture (provisional; temporary): A denture used for a short interval of time to provide: a. Stability: Resistance to movement in a horizontal direction (anterior-posteriorly or medio-laterally 6. Retainer: A component of a partial denture that provides both retention and support for the partial denture B. Implant supported prosthesis – most costly, closest replacement to natural dentition, less costly over long term 4. Complete denture (if few teeth left, with poor prognosis); if replacement of missing teeth is very complex or costly D. Crown or Fixed partial denture’s for removable partial denture abutments (if necessary) 9. Final Framework Impression (must include hamular notches/retromolar pads for distal extension removable partial dentures 10. Major Connector: the unit of a removable partial denture that connects the parts of one side of the dental arch to those of the other side. The principle functions of minor connectors are to provide unification and rigidity to the denture. Direct Retainer: A unit of a partial denture that provides retention against dislodging forces. Denture Base: the unit of a partial denture that covers the residual ridges and supports the denture teeth. Classification the Need for Classification There may be over 65,000 possible combinations of teeth and edentulous spaces. Since there are several methods of classifying partial dentures, the use of non-standard classifications could lead to confusion. Kennedy Classification In 1923, Kennedy devised a system that became popular due to its simplicity and ease of application. A tremendous number of possible combinations can be reduced to four simple groups. Rule 2: If the 3rd molar is missing and not to be replaced, it is not considered in the classification. Rule 3: If the 3rd molar is present and to be used as an abutment, it is considered in the classification. Rule 4: If the second molar is missing and not be replaced, it is not considered in the classification. Rule 6: Edentulous areas other than those determining classification are called modification spaces. Anatomy Tour 6 Anatomy Tour for Complete and Partial Dentures Identify the following structures, and answer the corresponding questions regarding anatomy that is important in the fabrication of complete and partial dentures. The tour does not provide a comprehensive overview of all critical anatomy, but a sample of structures that are easily visible in the dentate mouth and on casts. Vermilion Border When a denture provides insufficient lip support (teeth set too far palatally), the vermilion border becomes narrow, or disappears, adversely affecting appearance. Philtrum If denture teeth are set too far facially, the maxillary lip is stretched so that the depression of the philtrum is lost. Nasolabial Angle the angle measured between the columella of the nose and the philtrum of the lip. Tissue of the Upper Lip Gather the loose tissue of the upper lip between your thumb and index finger, so you have some idea of the tension of the tissue or support of the lip on a dentate individual. Masseter Muscle Have a partner clench while you palpate this muscle externally and internally! Maxillary Tuberosities these will be more easily observed in edentulous patients (identify, then see casts) What influence will these structures have on dentures: a) if they are oversized Incisive Papilla Important landmark for setting of teeth (midline of papilla to labial of incisor! What is the mediolateral relation of the incisive papilla to the midline of the maxillary teeth ! Denture border must terminate on “soft displaceable tissue”, to provide comfort and retention. In some patients the notch is posterior to where the depression in the soft tissue appears. Posterior Border of the Hard Palate What significance is this border for maxillary complete and partial dentures Vibrating Line Critical posterior border of complete dentures and some partial dentures. If the denture terminates posterior to this, movements of the soft palate cause it to dislodge and drop.