Evidence For Prescribing Fluoride Varnishes Health And Social Care Essay

Dental cavities is one of the most common disease processes across all populations throughout the universe and a cardinal factor in dental hurting and tooth loss. Caries is a procedure that can happen on any tooth surface in the oral cavity where alveolar consonant plaque is able to develop over clip. Bing a biofilm, plaque contains many different microorganisms that work together and are continually active. Some of these bacteriums are able to ferment soluble saccharides to bring forth acids, ensuing in a bead in sourness below pH 5 and hence doing demineralization of the enamel surface. Acid is neutralized by spit and the demineralization procedure halted, as the pH rises, mineral may be regained and remineralisation can happen. If the cumulative consequence of these procedures is a net loss in mineral, a carious lesion will be observed. The carious procedure is hence natural and can non be prevented nevertheless with suited intercession, the patterned advance into a seeable lesion can be avoided1. The bar of cavities is considered more cost-efficient than intervention and is hence considered a priority2. Fluoride varnishes since the 1960 ‘s have been clinically utilized for this reason17,18. Application of concentrated fluoride varnishes to tooth surfaces consequences in the formation of Ca fluoride. As the sourness of the environment additions, a greater sum of enamel disintegration occurs and hence an copiousness of ionic Ca allows for a considerable sum of Ca fluoride formation. Significant precipitation of spherical globules of Ca fluoride in dental plaque and unaccessible countries is of great benefit leting for important remineralisation due to the high concentration of free ionic Ca available3. Fluoride besides has a direct consequence on bacterial metamorphosis ( see appendix 4, table 1 for details16 ) .MethodOf the three surveies reviewed, one was carried out in Sweden4, one in Florida5 and one in San Francisco6. In these trials,1375 participants were studied ru ning from ?1.8 to 16 old ages old and followed for periods between 9 months and 3 old ages. Each survey had a specific purposes, one focused on a school based fluoride varnish programme and the patterned advance and incidence of approximal cavities from high, medium and low socio-economic backgrounds4. Another concerned the efficaciousness of fluoride varnish in add-on to reding in the bar of early childhood caries6, whilst the concluding survey evaluated the consequence of fluoride varnish on enamel cavities patterned advance in the primary dentition5. The chief features of each survey and their consequences are displayed in Appendices 14, 25 and 36. Randomization was used to delegate participants into each of the groups in all tests and one study6 outlined the allotment technique used. Two surveies were individual blind4,5 where the tooth doctor was incognizant of the group allotments and one was conducted as a dual blind trial6. All surveies used Duraphat ( 5 % Sodium Fluoride 22,600 F-ppm ) with two studies5,6 using varnish to all tooth surfaces and the 3rd study4 using varnish merely to approximal surfaces from the distal surface of the eyetooths to the mesial surface of the 2nd grinders. Two surveies stated the sum of fluoride varnish to be used ; 0.1ml per arch6 and ?0.3ml in total4. Examination techniques differed amongst the three selected surveies. One conducted a ocular scrutiny three times6, another conducted four overall bitewing radiogram at baseline and after the trial4. The 3rd conducted both radiographic bitewings and a ocular scrutiny besides at baseline and following the test, explicitly discoursing the method6. All experiments experienced a loss of participants to some grade. Weintraub et al.6 concluded 67 % of participants enrolled at baseline saw the survey through, the test conducted by Autio-Gold et al.5 retained 81 % of initial participants. In the concluding experiment by Sk & A ; ouml ; ld et al.4, 89 % of topics completed the test. Ultimately, all surveies agreed fluoride varnish is of significance in forestalling caries4,5,6 and may be effectual in change by reversaling cavity and crevice enamel lesions5. Findingss were assessed in footings of statistical significance and all three4,5,6 gave P values. Differences in measuring lesions clinically can be seen. Sk & A ; ouml ; l et al.4 used a self-devised numbered marking system to find cavities incidence and patterned advance of carious lesions. Weintraub et al.6 used the NIDCR diagnostic standards for dental caries7 for the appraisal of cavitated, decayed and filled surfaces on primary dentitions and auxiliary criteria8 to name pre-cavitated lesions. Finally Autio-gold et al.5 utilised a marking system9 which differentiates between active and inactive enamel carious lesions.DiscussionAlthough all surveies statistically support the usage of fluoride varnish in the bar of cavities, the methodological analysis of each demand to be considered before any decisions c an be drawn. Double blind randomized control tests are considered the ‘gold criterion ‘ in footings of survey design10 and minimise prejudice. In all of these tests, the tooth doctors were incognizant of patient allocated groups nevertheless in two4,5, the participants were cognizant. This could hold led to bias in those surveies as cognizing they were portion of a test with regular follow up periods, patients may hold been more self-aware with respect to their unwritten wellness and hence take more preventive steps compared to groups with fewer visits. Overall this consequence may give the feeling that a more frequent application of varnish reduces cavities incidence. Sample size demands to be taken into history as a larger cohort will give a more accurate representation of the population, doing Sk & A ; ouml ; l et al.4 the most representative of the three tests. Gender was reasonably every bit distributed in both varnish and hazard groups. This is of significance as it has been shown that females are by and large more compliant than males11 and therefore are more likely to brush on a regular basis, maintaining to the survey design. Bias in this illustration is hence reduced as females are every bit distributed across all groups. Weintraub6 and Autio-Gold5 did non advert gender distribution and hence lend themselves to this prejudice. When sing the clip period in which tests are conducted, a greater clip graduated table allows for a more comprehensive result. Potential side effects of fluoride varnish are more likely to go evident and its anti cavities consequence can be reviewed for any possible alterations as there may be a critical period for which it has consequence. Again, Sk & A ; ouml ; l et al.4 conducted the longest test at 3 old ages and hence in footings of clip period, have the most accurate consequences for effects of fluoride and its side effects, of which they found none. Weintraub et al.6 besides used a sensible clip period and would demo any side-effects or critical periods for fluoride applications, merely one kid in the group having fluoride four times a twelvemonth developed an ulcer on their cheek which had resolved at the following followup. There is no grounds to back up unwritten ulcerations as a consequence of fluoride varnish application. The test conducted Autio-Gold5 was over a shorter period and hence compared to Weintraub6 and Sk & A ; ouml ; l4, can non be as conclusive in critical periods of application and side effects. Follow up periods are of relevancy as changing frequences of application can be assessed for effectivity. Sk & A ; ouml ; l et al.4 utilised the greatest figure of groups with the most differing frequences to set up the most effectual intervals. The method in which fluoride varnish was applied varied and one specific survey, Autio-Gold5, failed to stipulate whether application on all tooth surfaces at the 2nd follow up occurred, as at the baseline. Besides the sum of fluoride varnish applied is non stated as in the two other studies4,6. Therefore the survey can potentially be classified as inconsistent and cogency of the consequences questionable. Application of the varnish was conducted in similar ways across all three tests nevertheless Weintraub et al.6 used ?66 % of the fluoride varnish than Sk & A ; ouml ; l et al.4 and it must be considered that a higher dose of fluoride may hold a greater preventive consequence. The locations in which the surveies took topographic point differ. Sk & A ; ouml ; l et al.4 conducted their probe in Sweden where H2O is fluoridated. Socio-economic position is associated with unwritten health12 and in this survey, the low hazard group had a high socio-economic position. The extra factor nevertheless, is that the location of this group is besides in an country of H2O fluoridization ten times higher than that of the medium or low hazard groups. It has been shown that fluoridization reduces cavities incidence13 intending these participants technically received an increased dose and therefore may hold influenced the consequences to demo a decreased effectivity of fluoride varnish. In the other two studies5,6 this variable was controlled and Weintraub et al.6 ensured participants resided in the country for at least 2 old ages. Age of participants is of importance as striplings in the Sk & A ; ouml ; l et al.4 survey are responsible for their ain unwritten hygiene and it has been shown that 25 % of 14-year-olds do non on a regular basis brush their teeth14,15. Consequences can hence be influenced in this test. If ?25 % participants did non brush on a regular basis, theoretically it would do increased cavities incidence in these people compared to the other 75 % of the cohort and finally give the feeling fluoride varnish has a lesser consequence than in world. Autio-Gold5 and Weintraub6 used primary5 and pre-school6 kids where parents and defenders are more likely to conform to the survey design and better the cogency of the consequences. Consequences were based on the findings of the testers therefore their determinations are important. Autio-Gold5 and Weintraub6 both calibrated testers nevertheless Sk & A ; ouml ; l et al.4 did non advert any dependability apart from re-examining radiogram after 2 months, the consequences of which, are non published. There is hence a possibility of inaccuracy in cavities diagnosing at each follow up, which would give either a greater or lesser perceived fluoride consequence depending on tester tolerance. Caries diagnosing methods vary, ideally a radiographic and ocular scrutiny should be conducted as white topographic point lesions and early cavities can non be seen radiographically, the attack taken by Autio-Gold et al.5. Weintraub et al.6 used merely ocular scrutinies and hence, although improbable, potentially leting for non-cavitated lesions to be missed. Sk & A ; ouml ; l et al.4 took merely radiographs nevertheless this was appropriate as approximal cavities can be merely be s een in this manner. Deviations in protocol can be seen in two surveies. In Sk & A ; ouml ; l et Al. ‘s4 test, all groups received an extra application of fluoride every one-year visit including the control group. Realistically the control group hence received intercession and perchance affected the consequences. Weintraub et al.6 experienced a more terrible divergence. For 10 months, participants received a placebo varnish alternatively of the active merchandise and merely one kid received all four planned applications. Besides 21 applications could non be confirmed as active and were assumed placebo. This may hold given the feeling of a greater good consequence of fluoride varnish if the placebo was active. Any long term positive or negative effects can therefore non be concluded with every bit much assurance as the other two trials4,5 as there was a interruption in the application of active merchandise. A Cochrane systematic review19 determined that on norm, fluoride varnish reduced cavities in the deciduous teething by 33 % and by 46 % in the lasting teething.DecisionIn decision, holding considered the grounds base for the usage of fluoride varnish and evaluated the advantages and disadvantages of all mentioned surveies and their restrictions, fluoride varnish is an effectual method in commanding cavities incidence and patterned advance.RecommendationsFluoride varnish should be indicated in all kids and striplings. Adults with a high cavities hazard should besides be considered, such as those with particular demands, dry mouth or active carious lesions. Children and striplings should have application biannually and grownups with carious lesions or particular demands should hold varnish applied between two and four times yearly. No common or serious inauspicious effects have been reported in any surveies. As a safeguard fluoride varnish is contraindicated in terrible asthmatics, ulc erative gingivitis and stomatitis. Besides allergy to seal components is an obvious contraindication.MentionsKidd EAM. Introduction. In: Kidd EAM editor. Necessities of Dental Caries. 3rd erectile dysfunction. New York: Oxford University Press Inc. ; 2005. p. 2-19. Burt BA. Prevention policies in the visible radiation of the changed distribution of dental cavities. Acta Odontologica Scandinavia 1998 ; 56:179-86. Fejerskov O, Kidd EAM. Chemical interactions between the tooth and unwritten fluids. In: 10 Cate JM, Larsen MJ, Pearce EIF, Ferjerskov O, editors. Dental cavities: the disease and its clinical direction. Oxford: Blackwell Munksgaard ; 2003. p. 49-69. Sk & A ; ouml ; ld UM, Petersson LG, Lith A, Birkhed D. Effect of school-based fluoride varnish programmes on approximal cavities in striplings from different cavities risk countries. Caries Res. 2005 ; 39:273-9. Autio-Gold JT, Courts F. Assessing the consequence of fluoride varnish on early enamel carious lesions in the primary teething. JADA. 2001 Sept ; 132:1247-1253. Weintraub JA, Ramos-Gomez F, Shain JS, Hoover CI, Featherstone JDB, Gansky SA. Fluoride varnish efficaciousness in forestalling early childhood cavities. J Dent Res. 2006 Feb ; 85 ( 2 ) :172-6. USDHHS, PHS, NIH, NIDR. Oral wellness studies of the National Institute of Dental Research: diagnostic standards and processs. NIH Publication No 91-2870. Bethesda, MD: US Department of Health and Human Services, NIH: 1991. Drury TF, Horowitz AM, Ismail AI, Maertens MP, Rozier RG, Selwitz RH. Diagnosing and describing early childhood cavities for research intents. J Public Health Dent 1999 ; 59:192-7. Nyvad B, Fejerskov O. Assessing the phase of cavities lesion activity on the footing of clinical and microbiological scrutiny. Community Dent Oral Epidemiol 1997 ; 25:69-75. Concato J, N Shah, RI Horwitz. Randomized, controlled tests, experimental surveies, and the hierarchy of research designs. N Engl J Med. 2000 ; 342:1887-92. Kuczynski L, Kochanska G, Radke-Yarrow M, Girnius-Brown O. A developmental reading of immature kids ‘s disobedience. Developmental Psychology. 1987 ; 23,799. Bolin AK, Bolin A, Jansson L, Calltorp J. Children ‘s dental wellness in Europe. Sociodemographic factors associated with dental cavities in groups of 5 and 12-year-old kids from eight EU-countries. Swed Dent J 1997 ; 21:25-40. Brunelle JA, Carlos JP. Recent trends in dental cavities in U.S. kids and the consequence of H2O fluoridization. J Dent Res.1990 Feb ; 69 ( Particular Issue ) :723-7 Klock B, Emilson CG, Lind SO, Gustavsdotter M, Olhede-Westerlund AM. Prediction of cavities activity in kids with today ‘s low cavities incidence. Community Dental Oral Epidemiol. 1989 ; 17:285-8. Koivusilta L, Honkala S, Honkala E, Rimpel & A ; auml ; A. Toothbrushing as portion of the striplings lifestyle predicts education degree. J Dent Res. 2003 ; 82:361-6. Marsh PD. Effect of fluorides on bacterial metamorphosis. In: Bowen WH, editor. Relative efficaciousness of Na fluoride and Na monofluorophosphatae as anti-caries agents in detrifices. London: Royal Society of Medicine Press Limited ; 1995. Bawden JW. Fluoride varnish: a utile new tool for public wellness dental medicine. J Public Health Dent. 1998 ; 58:266-9. Beltran-Aguilar ED, Goldstein JW, Lockwood SA. Fluoride varnishes: a reappraisal of their clinical usage, cariostatic mechanism, efficaciousness and safety. J Am Dent Assoc. 2000 ; 131:589-96. Marinho VCC, Higgins JPT, Logan S, Sheiham A. Fluoride varnishes for forestalling dental cavities in kids and striplings. Cochrane Database Syst Rev. 2002 ; 3: CD002279.Appendix 1Sk & A ; ouml ; ld 20054: Methods Randomised control test, individual blind to dentist. 11 % bead out after 3 old ages. Reasons for bead out include traveling off from country and non go toing all Sessionss. Overall 96 losingss. Participants 758 participants analysed at 3 old ages ( concluding scrutiny ) Average age at get downing: 13 old ages Exposure to other fluoride: H2O, toothpaste, varnish at annually check-up Year survey began: 1998 Location: Sverige Interventions Fluoride varnish Duraphat ( 22,600 ppm F- ) ( 3 groups ) vs. control group: Group 1: F- varnish 2x yearly at 6 month intervals Group 2: F- varnish 3x yearly within one hebdomad Group 3: F- varnish 8x yearly with 1 month intervals Control group: No intercession Teeth cleaned with toothbrush without toothpaste and interproximally cleaned utilizing dental floss Applied ?0.3ml with syringe on all approximal surfaces from distal of eyetooth to mesial of 2nd grinder. Results Prevented fraction in per centum in the different cavities risk countries and all countries together ( Table 3 ) 4 Areas Group 1 Group 2 Group 3 All countries 57 % 47 % 76 % Low hazard 20 % 68 % 50 % Medium hazard 66 % 31 % 83 % High hazard 69 % 54 % 82 % Notes Participants randomised ( n=854 ) All groups including control exposed to fluoride at one-year cheque up Figures and tabular arraies demoing consequences from Sk & A ; ouml ; ld et al.4Appendix 2Autio-Gold 20015: Methods Randomised control test, individual blind to dentist. 19 % bead out rate after 9 months. Due to backdown of school programme, traveling from country, refusal to go on and six topics necessitating renewing intervention instantly after survey began. Overall 35 losingss. Participants 148 participants analysed at 9 months ( concluding scrutiny ) Average age at get downing: 3 to 5 old ages Exposure to other fluoride: H2O Year survey began: Not stated Location: Florida, USA Interventions Fluoride varnish Duraphat ( 22,600 ppm F- ) Varnish group: 2x over 9 months, one time at baseline and one time after 4 months Control group: No intercession In dental clinic, dried dentition with tight air and applied varnish with little coppice to all tooth surfaces. In school dentitions dried with unfertile cotton sponges and varnish applied to all tooth surfaces with coppice. Result Change in carious activity between varnish and control group Group No alteration ( i.e. still active ) Inactive lesions ( i.e. no longer active ) Varnish 8.2 % 81.2 % Control 36.9 % 37.8 % Notes Participants randomised ( n=183 ) Does non province whether or non varnish was applied to all surfaces during the 2nd visit in varnish group. Besides how much varnish applied in both visits. Figures and tabular arraies demoing consequences from Autio-Gold et al.5:Appendix 3Weintraub 20066: Methods Randomised controlled dual blind test. 33 % bead out rate after 2 old ages. 51 discontinued from survey due to cavities. Participants 202 participants analysed at 2 old ages ( concluding scrutiny ) Average age at get downing: 1.8 old ages Exposure to other fluoride: H2O Year survey began: 2002 Location: San Francisco, USA Interventions Fluoride varnish Duraphat ( 22,600 ppm F- ) Group 1: F- varnish 4x over 2 old ages ( baseline, 6, 12 and 18 months ) Group 2: F- varnish 2x over 2 old ages ( baseline and 12 months ) Control group: Parental guidance All groups received parental guidance. 0.1ml applied per arch. Dried with gauze and varnish brushed onto all surfaces of all dentitions. For control group, teeth dried and gauze folded dry surface brushed onto dentitions and therefore health professionals unaware of groups. Results Cavities activity across the three groups: No cavities Cavities Group 1 67 3 Group 2 59 10 Control 48 15 Notes Participants randomised utilizing computing machine generated random assignment ( n=384 ) . 75 % kids intended to have two applications merely received one ; 15 % received two. 49 % kids intended to have four applications merely received two. One kid received four applications. For five hebdomads, 21 varnish applications could non be confirmed as active – assumed placebo. Figures and tabular arraies demoing consequences from Weintraub et al.6:

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Directing Hamlet Essay If I were to have the pleasure of directing Hamlet I would first think about how and where the scene would be set. I would have the scene set in the suburbs of Italy where the gangsters are, because the portrayal of gangster Italy, on television (which the audience may be familiar with) is like the situation in Hamlet. Where revenge must be taken by the son, also upholding the family honour and such family situations. Also the portrayal of Italians is that they are very religious and that they tend to be Catholics, so the religious aspect of this scene (trying to pray and having the need to be forgiven by god) would fit in with my version and Shakespeares. I would have this scene set in a Roman Catholic Church to support the fact that Claudius wishes to pray here and that he is Catholic. I would like the church to echo the voices to show that Claudius heart must be empty for him to have committed this evil crime, so all he hears is the voices of his head, telling him what he thinks is the right thing to do, for example to pray for forgiveness. However his heart would be telling him to give up the things that he killed for, which Claudius himself mentions, since I am still possessd of those effects for which I did the murder. I would like the lighting to be an orangey afternoon colour, like when the sun sets. I imagine churches to be empty around early sunset time and if Claudius really felt guilty he would not want people o see that he is unable to pray I would not have any sound effects as the church would echo and I would like the audience to focus on what the actors were saying. Also silence between lines tends to create a sense of atmosphere. It would make the audience feel tense as though something was about to happen. I would like Claudius to look into the mirror when he is talking to himself throughout most of the scene. Except when it is inappropriate, for instance when he goes to pray. I would like the audience to feel more relaxed by this, as Claudius does not seem to be very emotionally at thins. I would like the audience to feel quite angry with Claudius. I would like them to feel this as they can see that he is not mentally disturbed by the goings on. However when Hamlet goes to talk to himself I would like to have him talking to the audience to show that although Hamlet said in an earlier scene that he would pretend to go mad, How strange or odd someer I bear myself-As perchance hereafter shall think meet to put an antic disposition on all the frustration about getting revenge and his fathers murder may have actually driven him mad. I feel that having Hamlet talk to the audience shows this, as the other members of the play do not seem to be able to see the audience (King Claudius talking to himself in the mirror). I would like the audience to be shocked, by this and feel on edge as this scene is all about whether Hamlet will kill the king or not which is very tense. Since Claudius is a King in Shakespeares Hamlet I would like him to play someone of high importance, so I would have him being played as a gangster leader. The outfit I would like him to wear would be a grey Armani suit, a waistcoat, blue collared shirt, and patent leather shoes. I would like him to have square framed glasses and for him to wear lots of gold jewellery, but especially a gold signant ring to symbolise that he is the leader of a gang, which has resemblance to the fact that he is a king (monarchs wear a ring to show that they are married to their country). I would like Hamlet to be wearing rather informal clothes to show that he may have gone slightly mad. I would have him wearing a plain black shirt, which would be reasonably tight. I would then have him wearing a black Hawaiian shirt with a thatched pattern on it. I would also like him to be wearing dark blue jeans. The dark clothes would be symbolising that Hamlet is still in mourning for his fathers death. I would like Hamlet to be wearing a silver Saint Christopher around his neck, to show that Hamlet may need guidance for the revenge of his fathers death. I would like to keep the language the same as I feel that if the text were to be converted into modern language the impact of the rhythm and words would be lost. Such as when Claudius says, It hath the primal eldest curse upont, means Its like when the first murder happened in the bible. These words do not have nearly as much effect as the original line. The original line provides some atmosphere. The word curse suggests evil, as witches were thought in Shakespeares time to send curses. Also as people were more religious in Shakespeares time the fact that Claudius has committed the worst sin n the bible they may have been horrified by Claudius crime. This wouldnt have as much effect on a modern day audience however I feel that the words too tend to portray that Claudius shows disgust towards himself. Some of the words in this scene are quite difficult to interpret so I would have to make some sort of gesture in order to make it more obvious what the two actors mean. I think that obvious hand or body gestures would make it more obvious. For example when Hamlet says, Up, sword, and know thou a more horrid hent I think that Hamlet should, lift his sword and then approach Claudius. This would make the true meaning of the sentence clearer. A few lines in this scene make it so enjoyable to watch, but it all depends on the actors interpretation and delivery of the line. When Claudius says, O, my offence is rank This line needs to be emphasised as it shows that Claudius may be feeling regret for what he did. So he could show this by shouting the line, which displays the anger that he may be feeling with himself. Also a brothers murder must be emphasised as this is the reason to Claudius guilt, and why he is so angry with himself. He could portray this to the audience by saying it slowly, and going into an audible whisper as if someone may hear. Claudius should also emphasise when he says, Forgive me my foul murder! as this shows that maybe he does truly repent and feel guilt. He could shout this line to the ceiling as if he were talking to god. When Claudius talks of the things he does not wish to give up, My crown, mine own ambition, and my queen. The should be said in a low husky tone, to show that Claudius although in this scene he may seem to be wanting forgiveness, he does not truly want it as he would give up these items that he killed his brother for. When Claudius is describing how in the criminal world he can buy himself out of trouble, In the corrupted currents of this world. This line and the following three lines should also be delivered in the same low husky tone to show that Claudius is still evil as to mix himself with criminals, who were also known as sinners in Shakespeares time. Also when Claudius talks to his knees, telling them to, Bow stubborn knees he should speak softly as though here were speaking to a child. This would emphasise the line and show that Claudius is encouraging himself to pray; just a children are encouraged when spoken to in a soft voice. The line he says, All may be well should also be softly as he trying to convince himself that everything will be all right. It is the final two lines that should be emphasised the most as this show the true irony of the whole scene. Hamlet decides not to kill Claudius, as he believes that Claudius is praying and would go straight to heaven. Here when Claudius says, My words fly up, my thoughts remain below. Words without thought never to heaven go. We learn that he was unable to pray anyway so Hamlet could have killed Claudius, only Hamlet did not know this. His line could be emphasised with pauses in between up and my, and in-between thought and never. When Hamlet says And now Ill do it. I think here the actor should raise his sword above his head and increase the volume of his voice to a shout. Hamlet should then approach Claudius and let out a war like cry to emphasise this line. This I feel is effective as it emphasises this line and the silence that would follow would also emphasise the next line, and so a goes to heaven. I think that those two lines are very important as they show that Hamlet is about to kill Claudius until he decides that hell wait. I also think that when Hamlet is talking about the death of his father, A took my father grossly, he should speak through his teeth, in a low tone. I feel that Hamlet would be feeling very angry, as he cannot yet revenge his fathers death. So I feel that that talking through his teeth would portray that anger to the audience. This also emphasises the line as the audience would listen to what he was saying as him talking through his teeth would be obvious to them. Hamlet, however should speak with joy when he talks about what kind if thing Claudius will be doing when Hamlet could kill him, When he is drunk asleep, or in rage; Or in th incestuous pleasure of his bed; At game, a-swearing, or about some act. I feel that Hamlet would be imagining Claudius being killed and going straight to hell, which would make him very happy. I then think that when Hamlet delivers this last line, this physic but prolongs thy sickly days. It must be emphasised as Hamlet would be feeling quite sad and angry that he has Claudius in very vulnerable position yet he feels that he cannot kill him, as that would not give him true revenge. I feel that sadness and anger can be portrayed by Hamlet having a pause between physic and but. Also the actor should speak in a low tone to get the audience attention as this line displays the irony as Claudius is unable to pray. This scene is only effective because the audience knows what happened in the previous scene. They know that Claudius has portrayed his true guilt to Hamlet, confirming Hamlets beliefs that Claudius killed his father. The way in which he did show his guilt, (When the players put on a play with a murder committed the same way that he killed his brother) would be more effective in Shakespeares time as then all people who committed murder were believed to go mad, and be affected by the site of their crime. When Claudius views his crime he horrified by himself and feels the need to be forgiven which explains his sudden desperate need to pray. I feel that this scene gives Hamlet its edge of tenseness. The rest of the play is an unwinding tale leaving the audience wondering right until the last scene, will Hamlet kill Claudius?