Use of a subcutaneous tunnel following replantation of an amputated penis.

We describe a new technique for immobilization and protection of the penis following microsurgical replantation, using a subcutaneous tunnel created in the suprapubic area. This tunnel protects the phallus from reinjury while maintaining an anatomic position and a normothermic environment in the immediate postoperative period.

Use of dental care by HIV-infected medical patients.

Although increasing attention has been paid to the use of dental care by HIV patients, the existing studies do not use probability samples, and no accurate population estimates of use can be made from this work. The intent of the present study was to establish accurate population estimates of the use of dental services by patients under medical care. The study, part of the HIV Cost and Services Utilization Study (HCSUS), created a representative national probability sample, the first of its kind, of HIV-infected adults in medical care. Both bivariate and logistic regressions were conducted, with use of dental care in the preceding 6 months as the dependent variable and demographic, social, behavioral, and disease characteristics as independent variables. Forty-two percent of the sample had seen a dental health professional in the preceding 6 months. The bivariate logits for use of dental care show that African-Americans, those whose exposure to HIV was caused by hemophilia or blood transfusions, persons with less education, and those who were employed were less likely to use dental care (p < 0.05). Sixty-five percent of those with a usual source of care had used dental care in the preceding 6 months. Use was greatest among those obtaining dental care from an AIDS clinic (74%) and lowest among those without a usual source of dental care (12%). We conclude that, in spite of the high rate of oral disease in persons with HIV, many do not use dental care regularly, and that use varies by patient characteristics and availability of a regular source of dental care.

A Markovian model for evaluating dental care programs.

A Markov model is suggested as a means of evaluating dental care programs. Four mutually exclusive states of dental care are defined as Markovian states. These are episodic, initial, maintenance and nonuse. Records for all patients entering a university teaching clinic (n = 578) over a 12-month period were examined and classified in one of the states of care at entry into the clinic and at 1-year intervals from the date of entry for 3 years. An analysis of the findings indicated that the Markov model did fit reasonably well and provided a good approximation of the empirical data.

Self-reported oral dryness and HIV disease in a national sample of patients receiving medical care.

OBJECTIVES: We sought to analyze the relationship between self-reported oral dryness and the demographic, enabling, behavioral, clinical, and treatment characteristics among human immunodeficiency virus (HIV)-positive patients in medical care. STUDY DESIGN: The study group consisted of the HIV Cost and Services Utilization Study cohort, a nationally representative probability sample of HIV-infected adults receiving medical care in the contiguous United States. RESULTS: It was estimated that 29% of adults (64,947 individuals) with HIV infection receiving medical care in the United States have a complaint of dry mouth. A multivariate logistic analysis was carried out to explore the association between several covariates and dry mouth. It was shown that compared with whites, individuals of Hispanic ethnic origin were 61% more likely to report dry mouth (OR, 1.61; 95% CI, 1.04-2.50; P =.04). Those who were unemployed were 55% more likely to report the symptom of dry mouth than were subjects who were employed (OR, 1.55; 95% CI, 1.22-1.98; P =.001). In comparison with nonsmokers, current smokers were 36% more likely to report dry mouth (OR, 1.36; 95% CI, 1.04-1.79;P =.03). The use of antidepressant drugs and antituberculosis/anti-Mycobacterium avium (anti-TB/anti-MAC) medications had the strongest association with dry mouth complaint. Those taking antidepressants were 55% more likely to report dry mouth (OR, 1.55; 95% CI, 1.23-1.97; P =.0001); compared with nonusers, patients receiving anti-TB/MAC drugs were 46% more likely to report dry mouth (OR, 1.46; 95% CI, 1.03-2.06; P =.04]. In comparison with those with undetectable viral load, individuals with a viral load of more than 100,000/mm(3) were 151% more likely to report dry mouth (OR, 2.51; 95% CI,1.58-3.96; P =.0001). CONCLUSIONS: Our findings suggest that optimizing viral suppression, smoking cessation, and tailoring antidepressant and anti-TB/MAC medications may be promising interventions to decrease dry-mouth symptoms among HIV-infected individuals.

Consistency across panels of ratings of appropriateness of dental care treatment procedures.

OBJECTIVE: To report on a study investigating the consistency across different consensus panels of ratings of appropriateness for dental procedures. RESEARCH DESIGN: The study conducted four consensus panels to determine, under various conditions, the appropriateness of five options for patients: no treatment; filling; crown; root canal with a filling or crown; extraction. The patients were categorised according to age; regular versus irregular use of dental care; degree of caries; degree of pain; degree of periodontal disease. PARTICIPANTS: The panellists were dentists enrolled in a continuing education programme on assessing the quality of dental care. The panellists were all individuals employed by various dental plans to evaluate the quality of care plans operating in California. RESULTS: The results indicate that the method does distinguish the dimensions of appropriateness used by the panellists in making their decisions, and that it is possible to substantially increase consensus among a diverse group of dentists and across separate panels on some procedures. However, it also showed that the process is sensitive to varying panels and that different variables had different outcomes in the ratings from the various panels. CONCLUSION: The consensus panel method holds some promise for determining the appropriateness of dental care. However the results of this study question whether it results in consistent ratings across different panels.

Utilization of emergency dental services by rural, nonreservation Indians.

The Shasta-Trinity-Siskiyou Indian dental clinic, which serves rural, nonreservation Indians in California, implemented a health education program designed to convert patients from an emergency to a routine care basis. A study was conducted, therefore, of the utilization patterns of 109 emergency patients treated at a clinic from September, 1971, through November, 1972, in order to provide information to improve this educational program. The results of the study showed that 58.7 percent of the emergency patients returned for routine care. Analyses of those patients who returned and those who did not return for care were made with regard to age, sex, time since last dental visit, and type of emergency treatment received. There were significant differences between the two groups of emergency patients with regard to age and type of treatment received. Those most likely to return for routine care were the patients 15 years or younger, and those who had received operative care. The emergency patients in the 16-25 age group, and those who received periodontal care were the least likely to return. No significant differences were found with regard to sex, or time since last dental visit. The emergency patients and patients whose initial visit to the clinic was for routine care were compared. A significant difference was found with regard to age. The patients 15 years or younger had the lowest percentage of initial visits for emergency care, and the 16-25 year age group had the highest. No significant differences were found with regard to sex, or time since last dental visit. This study may well be the first to examine the utilization of dental services by rural, non reservation Indians. The findings presented can serve as a basis for future investigation to improve the provision of dental services to this patient population.

Aspects of quality of dental hygiene care in supervised and unsupervised practices.

OBJECTIVE: The purpose of this study was to assess aspects of the quality of care provided by dental hygienists in a California demonstration project in which hygienists treated patients independent of dentists' supervision. METHODS: The structure and process of care were evaluated in nine independent practices using site visits and reviews of 25 records at each practice. The findings were compared to evaluations of six general dentist practices reviewed for a government agency and insurance company during the same time period. Patient satisfaction was assessed by a questionnaire. RESULTS: The structural aspects of the unsupervised hygienist practices were generally acceptable and surpassed the dentist practices in most areas, including infection control. For process, the hygienist practices had high percentages of acceptable care and were significantly better than the dentist practices in several areas, including follow-up to medical findings, updating the medical history at recall, and documenting the evaluation of the periodontal status and soft tissues. Ninety-eight percent of patients expressed satisfaction with their care in hygienist practices. CONCLUSION: Under the circumstances of the demonstration project and the methods used to assess the quality of care, the study showed that independent dental hygienist practice did not increase the risk to the health and safety of the public.

Characteristics of patients seeking care from independent dental hygienist practices.

OBJECTIVES: This study determined demographic characteristics, satisfaction with care, and likelihood of follow-up dentist visits for patients seen in office-based, independent, dental hygienist practices. METHODS: New patients were surveyed after their initial visits to independent hygienist practices to assess their demographic characteristics and satisfaction with care at both the beginning of practice operations and 18 months after the start of these practices. Follow-up surveys were sent to patients 12 and 24 months after their initial visits to the independently practicing dental hygienists to determine if patients had visited a dentist. RESULTS: Most respondents were white, female, had attended some college, and reported high family incomes. Ninety-eight percent of respondents were satisfied with their dental hygiene care. Follow-up questionnaires revealed that over 80 percent of respondents visited the dentist within 12 months of receiving dental hygiene care in independent settings. This level of follow-up care with dentists was found both for respondents who reported having a regular dentist at their initial visits with the hygienists and for those who reported not having a regular dentist. CONCLUSIONS: Independent practice by dental hygienists provided access to dental hygiene care and encouraged visits to the dentist.

Dental health: what is being taught to college students.

An analysis of the dental health material in all college-level, health education textbooks published between 1966 and 1973 showed a deficiency in the amount, the thoroughness, and the quality of the dental health information given. Realibility of information from one source to another is low, and some information is inaccurate. On the basis of information in these textbooks, serious questions are raised concerning the adequacy of dental health education in college-level health education courses. The dentist is advised to review and to examine the dental health information that is being taught in these courses.

Assessing quality in dentistry: dental boards, peer review vary on disciplinary actions.

Reported inconsistencies in entry level exams and variations in available disciplinary mechanisms suggest the need for modifications to improve these processes. A quality assurance system combining education with some sanctions is likely to engender dentist support and improve quality of care.

Clinical board examinations: variation found in pass rates.

This study found significant variation in pass rates within and among state and regional dental board clinical examinations during 1979-1988. This suggests that factors other than the abilities of the candidates influence exam outcomes. As long as individual states can argue that there is currently no definitive system to assure the quality of dental care, states may remain reluctant to relax their restrictions on dentists' freedom of movement.

Managed care and dentistry: promises and problems.

At its inception in the mid-1950s, managed care held a number of promises for dental care providers and dental patients. Sometime during the development of managed care, however, many programs lost sight of the importance of provider equity. Using data from current programs, the authors contrast the original promises with the realities of managed care in dentistry.

Educational value of a university-sponsored community dental clinic: a three year student evaluation.

The overall assessment of the clinic experience by the students was positive. Response to the open-ended questions showed that a number of students took pride in the Venice clinic and that they gained a great deal of personal and professional satisfaction from being able to provide service to people in a low-income and minority community. Almost 90% stated that their understanding of health problems of the poor was improved; 75% felt that their ability to relate to patients from different backgrounds was broadened; and 45% expressed more willingness to practice in a low-income area. This community setting also enlarged the scope of the students' clinical experience. Over 50% saw pathological conditions that they had not viewed previously. In addition, over 90% of the students did at least 50% more work, and over half of these performed twice as much treatment.

Doctor-patient relationships in global society. Informed consent in dentistry.

The concept for initiation of treatment only after the explicit consent of the patient, based on preliminary information, is the most important element determining the relationship between patient and doctor nowadays. The application of this concept in dentistry and its inclusion in the professional documents regulating these relationships needs more comprehensive and modern conditions-relevant analysis of ethical, legal and professional aspects of the problem. The purpose of the study was to define the modern view of informed consent and its application in dentistry in different social environment. The general and specific features of the evolution of the problem and the social practice in Bulgaria, The European Community and Northern America are discussed in the context of the global tendency for free movement of patients and mutual recognition of professional qualification. The results suggest that despite the different degree of social and economical development in different countries the interest in the problem grows significantly and harmonization of legislation for health protection is based on the new social decree in the construction of doctor-patient relationships. It is expected that the comparative studies in this field will promote the improvement of dentists' training and improvement of scientific and expert exchange in solving problems of patents' rights and professional ethics.

Practice characteristics of dental hygienists operating independently of dentist supervision.

PURPOSE: This paper presents business characteristics of ten experimental independent dental hygiene practices operating in California between 1987 and 1990. Sixteen dental hygienists participated in the experiment, the Health Manpower Pilot Project 139 (HMPP 139). HMPP 139 dental hygienists wanted to work independently in traditional office-based settings, institutional settings, and other arrangements. They worked in group and solo practices, on a full- or part-time basis. METHODS: Data were collected from the HMPP 139 practices on services provided, patient visits, fees charged, referrals to dentists, acceptance of Medicaid patients, and services to organizational clients. Data collection methods varied, depending on the question addressed. Surveys of dentists' offices provided data on fees and Medicaid policies for comparison with the independent dental hygiene practices. RESULTS: All experimental practices attracted new patients for each quarter in operation. These practices mostly provided prophylaxis treatments; however, a wide variety of services was provided. Fees charged in HMPP 139 office-based practices were less than comparable fees charged in dentists' offices. At least one-third of patients in the HMPP 139 office-based settings received a referral to or an opinion about a dentist from the dental hygienist. HMPP 139 practices were more available to Medicaid patients than were California dentists offices. Each experimental independent practice provided care to at least one client in a nontraditional setting. CONCLUSIONS: The HMPP 139 practices consistently attracted new patients. This suggests independent practice for dental hygienists may be a viable and flexible alternative if the practices can stabilize total patients at a sufficiently high level. An independent practice alternative might increase access to care, contain fees, and direct the flow of patients to dentists. Further study is needed to test these findings.

A new paradigm for increasing access to dental care: the Oregon Health Plan.

The Oregon Health Plan, one of the most controversial health care proposals to emerge in recent years, was implemented on February 1, 1994. The plan's intent was to control cost and increase access to health care for Oregon's low-income and Medicaid population. A key feature was limiting covered services to a state-approved list created by an open public process. Services were ranked from most important to least important, with covered services to be determined by available funding. For the first time, the listing included a merged set of medical and dental services, with many dental services ranked higher than medical services. Oregon's Medicaid program, which previously did not cover any adult dental care, now has one of the most generous set of Medicaid dental benefits in the United States. From the perspective of increasing access to dental care, this article suggests that the dental profession should re-examine its current policy supporting the separation of medical and dental benefit packages.

Dental licensure in the European Economic Community: implications for the United States.

The formation of the European Economic Community is resulting in historic changes. By the end of 1992, the European Community is expected to be operating as a single market of more than 320 million consumers, the largest in the world. The fundamental assumption underlying the creation of the European Community is that the best method to increase the general prosperity is a free market. The free market included services as well as goods and required the elimination of restrictions on the movement of people, goods and services among the 12 nations. In dentistry, this has already meant the elimination of licensure restriction for dentists in good standing who are citizens of the EEC and trained in approved educational programs within the EEC, but commercial barriers still remain to be eliminated by the end of 1992. The events occurring in Europe indicate that the outcome of the controversy regarding movement of dentists among states in the United States will be determined by larger societal considerations outside of the profession. The free market principle which underlies the changes in Europe is the fundamental economic philosophy in the United States. To the extent that limitation on the movement of health professionals is seen to contribute to higher costs for health care services in the United States, there may be increased efforts to license by credentials. Similarly, factors such as the need of families for greater freedom of movement between states and court challenges based on constitutionally protected rights may determine the outcome of licensure of dentists rather than issues which are of concern within the professional dental community.