Validity and reliability of the COVID-19 Anxiety Syndrome Scale in Canadian dentists.

BACKGROUND: The COVID-19 pandemic has resulted in a high level of mental health problems for the population worldwide including healthcare workers. Several studies have assessed these using measurements for anxiety for general populations. The COVID-19 Anxiety Syndrome Scale (C-19ASS) is a self-report measure developed to assess maladaptive forms of coping with COVID-19 (avoidance, threat monitoring and worry) among a general adult population in the United States. We used it in a prospective cohort study of COVID-19 incidence rates in practising Canadian dentists. We therefore need to ensure that it is valid for dentists in French and English languages. This study aimed to evaluate the validity of the C-19ASS in that population. METHODS: Cross-sectional data from the January 2021 monthly follow-up in our prospective cohort study were used. Exploratory factor analysis (EFA) and confirmatory factor analysis (CFA) were performed. RESULTS: The results of EFA revealed a 2-factor structure solution that explained 47% of the total variance. The CFA showed a good model fit on the data in both English and French languages. The Cronbach's alpha indicated acceptable levels of reliability. Furthermore, the C-19ASS showed excellent divergent validity from the Generalized Anxiety Disorder-7 (GAD-7) scale. CONCLUSIONS: The C-19ASS is valid and reliable instrument to measure COVID-19-related anxiety in English and French among Canadian dentists. PRACTICAL IMPLICATIONS: This validated measure will contribute to understanding of the mental health impact of the pandemic on dentists in Canada and enable the dental regulatory authorities and organizations to intervene to help dentists.

Indicators of integrating oral health care within universal health coverage and general health care in low-, middle-, and high-income countries: a scoping review.

BACKGROUND: The World Health Organization (WHO) has recently devoted special attention to oral health and oral health care recommending the latter becoming part of universal health coverage (UHC) so as to reduce oral health inequalities across the globe. In this context, as countries consider acting on this recommendation, it is essential to develop a monitoring framework to measure the progress of integrating oral health/health care into UHC. This study aimed to identify existing measures in the literature that could be used to indicate oral health/health care integration within UHC across a range of low-, middle- and high-income countries. METHODS: A scoping review was conducted by searching MEDLINE via Ovid, CINAHL, and Ovid Global Health databases. There were no quality or publication date restrictions in the search strategy. An initial search by an academic librarian was followed by the independent reviewing of all identified articles by two authors for inclusion or exclusion based on the relevance of the work in the articles to the review topic. The included articles were all published in English. Articles concerning which the reviewers disagreed on inclusion or exclusion were reviewed by a third author, and subsequent discussion resulted in agreement on which articles were to be included and excluded. The included articles were reviewed to identify relevant indicators and the results were descriptively mapped using a simple frequency count of the indicators. RESULTS: The 83 included articles included work from a wide range of 32 countries and were published between 1995 and 2021. The review identified 54 indicators divided into 15 categories. The most frequently reported indicators were in the following categories: dental service utilization, oral health status, cost/service/population coverage, finances, health facility access, and workforce and human resources. This study was limited by the databases searched and the use of English-language publications only. CONCLUSIONS: This scoping review identified 54 indicators in a wide range of 15 categories of indicators that have the potential to be used to evaluate the integration of oral health/health care into UHC across a wide range of countries.

Canadian dental hygienists' experiences and perceptions of regulatory guidelines during the COVID-19 pandemic: a qualitative descriptive analysis.

BACKGROUND: In Spring of 2020, due to the COVID-19 pandemic, Canadian provincial dental hygiene regulatory bodies implemented new practice guidelines. Reports of stress, anxiety and conflict experienced by dental hygienists have been linked to miscommunication between oral health regulators at this time. Limited data exists on the perceptions and experiences of dental hygienists navigating new guidelines for dental hygiene care during the pandemic. Therefore, the objective of our study was to explore via descriptive thematic analysis how dental hygienists experienced and perceived: i) dental hygiene practice during the COVID-19 pandemic, and ii) their regulatory body's COVID-19 guidelines. METHODS: Participants were identified through provincial dental hygiene licensing bodies. Online bi-monthly questionnaires were administered to participants (n = 876) from December 2021 to January 2022. Two open-ended questions were asked in the questionnaire. A qualitative descriptive thematic analysis was applied to these two questions. RESULTS: Major themes at baseline relayed challenges related to workplace compliance, patient treatment and communication of practice protocols. Across responses, hygienists confirmed conflicting messaging from regulators and guideline interpretations as stressors impacting their professional practice and satisfaction within the profession. Participant responses at endpoint cited increased satisfaction with regulatory guidelines as the pandemic evolved, yet inconsistencies in regulators' messaging was noted as a prevailing issue. CONCLUSION: Inconsistent guideline messaging reflects an increased need for collaboration amongst oral health care regulators to streamline protocols for practice and reduce interprofessional conflict in pandemic circumstances. A national unified approach is warranted in establishing guidelines for dental hygiene practice in Canada.

Dentists' Experiences and Dental Care in the COVID-19 Pandemic: Insights from Nova Scotia, Canada.

BACKGROUND: This study aimed to describe dental care provision and the perceptions of dentists in Nova Scotia, Canada, during 1 week of the COVID-19 pandemic, shortly after the closing down of non-emergency, in-person care. METHODS: A survey was distributed to all 542 registered dentists in Nova Scotia, asking about dental care provision during 19-25 April 2020. Most answers were categorical, and descriptive analyses of these were performed. Data from the 1 open-ended question were analyzed using an inductive approach to identify themes. RESULTS: The response rate was 43% (n = 235). Most dentists (181) provided care but only 13 provided in-person care. From the open-ended question, 4 concerns emerged: communication from the regulatory authority; respondents' health and that of their staff; the health of and access to care for patients; and the future of their business. CONCLUSION: Most respondents remained engaged in non-in-person dental care using various modes. They expressed concerns about their health and that of their staff and patients as well as about the future of their practice. PRACTICAL IMPLICATIONS: Dentists and dental regulatory authorities should engage in discussions to promote the health of dental staff and patients and quality of care during the chronic phase of the pandemic.

Oral diseases: a global public health challenge.

Oral diseases are among the most prevalent diseases globally and have serious health and economic burdens, greatly reducing quality of life for those affected. The most prevalent and consequential oral diseases globally are dental caries (tooth decay), periodontal disease, tooth loss, and cancers of the lips and oral cavity. In this first of two papers in a Series on oral health, we describe the scope of the global oral disease epidemic, its origins in terms of social and commercial determinants, and its costs in terms of population wellbeing and societal impact. Although oral diseases are largely preventable, they persist with high prevalence, reflecting widespread social and economic inequalities and inadequate funding for prevention and treatment, particularly in low-income and middle-income countries (LMICs). As with most non-communicable diseases (NCDs), oral conditions are chronic and strongly socially patterned. Children living in poverty, socially marginalised groups, and older people are the most affected by oral diseases, and have poor access to dental care. In many LMICs, oral diseases remain largely untreated because the treatment costs exceed available resources. The personal consequences of chronic untreated oral diseases are often severe and can include unremitting pain, sepsis, reduced quality of life, lost school days, disruption to family life, and decreased work productivity. The costs of treating oral diseases impose large economic burdens to families and health-care systems. Oral diseases are undoubtedly a global public health problem, with particular concern over their rising prevalence in many LMICs linked to wider social, economic, and commercial changes. By describing the extent and consequences of oral diseases, their social and commercial determinants, and their ongoing neglect in global health policy, we aim to highlight the urgent need to address oral diseases among other NCDs as a global health priority.

Ending the neglect of global oral health: time for radical action.

Oral diseases are a major global public health problem affecting over 3·5 billion people. However, dentistry has so far been unable to tackle this problem. A fundamentally different approach is now needed. In this second of two papers in a Series on oral health, we present a critique of dentistry, highlighting its key limitations and the urgent need for system reform. In high-income countries, the current treatment-dominated, increasingly high-technology, interventionist, and specialised approach is not tackling the underlying causes of disease and is not addressing inequalities in oral health. In low-income and middle-income countries (LMICs), the limitations of so-called westernised dentistry are at their most acute; dentistry is often unavailable, unaffordable, and inappropriate for the majority of these populations, but particularly the rural poor. Rather than being isolated and separated from the mainstream health-care system, dentistry needs to be more integrated, in particular with primary care services. The global drive for universal health coverage provides an ideal opportunity for this integration. Dental care systems should focus more on promoting and maintaining oral health and achieving greater oral health equity. Sugar, alcohol, and tobacco consumption, and their underlying social and commercial determinants, are common risk factors shared with a range of other non-communicable diseases (NCDs). Coherent and comprehensive regulation and legislation are needed to tackle these shared risk factors. In this Series paper, we focus on the need to reduce sugar consumption and describe how this can be achieved through the adoption of a range of upstream policies designed to combat the corporate strategies used by the global sugar industry to promote sugar consumption and profits. At present, the sugar industry is influencing dental research, oral health policy, and professional organisations through its well developed corporate strategies. The development of clearer and more transparent conflict of interest policies and procedures to limit and clarify the influence of the sugar industry on research, policy, and practice is needed. Combating the commercial determinants of oral diseases and other NCDs should be a major policy priority.

Information service in head and neck cancer care-a qualitative study.

AIM: We aimed to understand how information was delivered to head and neck (H&N) cancer patients and describe the perceptions of the H&N patients concerning information delivery. METHODOLOGY: This qualitative investigation was a part of our larger quantitative study that was conducted with H&N cancer patients at two academic hospitals in Montreal. After obtaining the ethical approval, a purposeful sample of participants was recruited from the main study until the content of the information gathered reached saturation. Data were collected by observing the information delivery and interviewing the study participants and Nurse Pivots. All observations and interviews were audiotaped. Data were transcribed verbatim; transcripts were developed, audited, and subjected to a thematic analysis. RESULTS: Eleven H&N patients participated in the study. We found that the doctors were the main source of information at both hospitals; one hospital delivered information systematically to every patient using a multimedia-based information disseminating tool while the second hospital delivered information verbally in an ad hoc manner. Those who received information using the multimedia tool understood what was said to them and were better prepared for the next step, while those who received information verbally did not retain much, were confused, and expressed dissatisfaction. CONCLUSIONS: Although the doctors were the main source of information, patients experience difficulties in understanding what was said to them. Comprehensive information together with audiovisuals, when provided to H&N cancer patients based on their needs, seems to improve their understanding of their cancer and prepare them for their treatment.

Fruit and vegetable intake among Emirati adolescents: a mixed methods study.

BACKGROUND: Interventions to promote healthy eating in adolescents are needed in the United Arab Emirates. To design effective interventions, adolescent eating behaviours need to be understood. AIMS: This study aimed to describe eating behaviours of adolescents in Dubai and the factors associated with fruit and vegetable intake. METHODS: This was a sequential explanatory study using a mixed methods approach. Ten of the 34 Arabic high schools in Dubai were randomly selected and students in grades 10-12 were included. Data were collected on self-reported fruit and vegetables intake, eating behaviours, food availability and sociodemographic variables. In the qualitative phase, 14 students were interviewed about their eating behaviour. RESULTS: A total of 620 students were included: 57% were boys and most reported medium/high family affluence. Only 28% of the participants met the recommended daily fruit and vegetable intake, with significantly more males than females meeting it (P < 0.01). Lunch was the most frequently eaten meal, breakfast was frequently skipped, and there were high levels of fast food and soft drink consumption. Adequate fruit and vegetable intake was positively associated with increased lunch frequency, being male, parental support for healthy eating, and positive perception of family meals. CONCLUSIONS: There are significant differences in eating habits between Emirati male and female adolescents. Lunch, as the main family meal, faces threats because of modern working hours. The gender-specific social context may require targeted interventions to achieve optimal outcomes in each group.

Aetiological heterogeneity of head and neck squamous cell carcinomas: the role of human papillomavirus infections, smoking and alcohol.

Tobacco and alcohol consumption are the main risk factors for head and neck squamous cell carcinoma (HNSCC). In addition, human papillomavirus (HPV) infection plays a causal role in oropharyngeal cancer (OPC), a subset of HNSCC. We assessed the independent effects of tobacco, alcohol and HPV infection on OPC risk in the head and neck cancer (HeNCe) Life study, a hospital-based case-control study of HNSCC with frequency-matched controls by age and sex from four Montreal hospitals. Interviewers collected information on socio-demographic and behavioural factors. We tested exfoliated oral cells for HPV DNA by polymerase chain reaction (PCR). We included only OPC cases (n = 188) and controls (n = 427) without missing values for HPV, smoking or alcohol. We examined associations by estimating odds ratios (ORs) and corresponding 95% confidence intervals (CI) using unconditional logistic regression. Smoking (OR = 1.90, 95% CI: 1.04-3.45) and alcohol (OR = 2.74, 95% CI: 1.45-5.15) were associated with an increased risk of OPC independent of HPV status. Positivity for HPV 16 among heavy smokers and heavy alcohol users was associated with a 30.4-fold (95% CI: 8.94-103.26) and 18.6-fold (95% CI: 5.75-60.13) elevation in risk of OPC relative to participants who were HPV negative, respectively. Moreover, the combined effect of heavy smoking and alcohol comsumption with HPV 16 infection substantially increased OPC risk (OR = 48.76, 95% CI: 15.83-150.17) and (OR = 50.60, 95% CI: 15.96-160.40), respectively. Our results support the independent roles of smoking, alcohol and HPV infection in OPC risk and a possible combined effect. Efforts should be made to tackle these major risk factors simultaneously.

Uptake Kinetics and Trophic Transfer of Tungsten from Cabbage to a Herbivorous Animal Model.

This investigation builds on previous studies on military-relevant tungsten (W) to more thoroughly explore environmental pathways and bioaccumulation kinetics during direct soil exposure versus trophic transfer and elucidate its relative accumulation and speciation in different snail organs. The modeled steady-state concentration and bioaccumulation factor (BAF) of W from soil into cabbage were 302 mg/kg and 0.55, respectively. Steady-state concentrations (34 mg/kg) and BAF values (0.05) obtained for the snail directly exposed to contaminated soil were lower than trophic transfer by consumption of W-contaminated cabbage (tissue concentration of 86 mg/kg; BAF of 0.36). Thus, consumption of contaminated food is the most important pathway for W mobility in this food chain. The highest concentrations of W compartmentalization were in the snail's hepatopancreas based on wet chemistry and synchrotron-based investigations. Chemical speciation via inductively couple plasma mass spectrometry showed a higher degree of polytungstate partitioning in the hepatopancreas relative to the rest of the body. Based on synchrotron analysis, W was incorporated into the shell matrix during exposure, particularly during the regeneration of damaged shell. This offers the potential for application of the shell as a longer-term biomonitoring and forensics tool for historic exposure.

Periodontal diseases and risk of oral cancer in Southern India: Results from the HeNCe Life study.

Some studies suggest that periodontal diseases increase the risk of oral cancer, but contradictory results also exist. Inadequate control of confounders, including life course exposures, may have influenced prior findings. We estimate the extent to which high levels of periodontal diseases, measured by gingival inflammation and recession, are associated with oral cancer risk using a comprehensive subset of potential confounders and applying a stringent adjustment approach. In a hospital-based case-control study, incident oral cancer cases (N = 350) were recruited from two major referral hospitals in Kerala, South India, from 2008 to 2012. Controls (N = 371), frequency-matched by age and sex, were recruited from clinics at the same hospitals. Structured interviews collected information on several domains of exposure via a detailed life course questionnaire. Periodontal diseases, as measured by gingival inflammation and gingival recession, were evaluated visually by qualified dentists following a detailed protocol. The relationship between periodontal diseases and oral cancer risk was assessed by unconditional logistic regression using a stringent empirical selection of potential confounders corresponding to a 1% change-in-estimates. Generalized gingival recession was significantly associated with oral cancer risk (Odds Ratio = 1.83, 95% Confidence Interval: 1.10-3.04). No significant association was observed between gingival inflammation and oral cancer. Our findings support the hypothesis that high levels of periodontal diseases increase the risk of oral cancer.

No role for human papillomavirus infection in oral cancers in a region in southern India.

Oral cancer is a major public health issue in India with ∼ 77,000 new cases and 52,000 deaths yearly. Paan chewing, tobacco and alcohol use are strong risk factors for this cancer in India. Human papillomaviruses (HPVs) are also related to a subset of head and neck cancers (HNCs). We examined the association between oral HPV and oral cancer in a sample of Indian subjects participating in a hospital-based case-control study. We recruited incident oral cancer cases (N = 350) and controls frequency-matched by age and sex (N = 371) from two main referral hospitals in Kerala, South India. Sociodemographic and behavioral data were collected by interviews. Epithelial cells were sampled using Oral CDx® brushes from the oral cancer site and the normal mucosa. Detection and genotyping of 36 HPV genotypes were done using a polymerase chain reaction protocol. Data collection procedures were performed by qualified dentists via a detailed protocol with strict quality control, including independent HPV testing in India and Canada. HPV DNA was detected in none of the cases or controls. Associations between oral cancer and risk factors usually associated with HPV infection, such as oral sex and number of lifetime sexual partners, were examined by logistic regression and were not associated with oral cancer. Lack of a role for HPV infection in this study may reflect cultural or religious characteristics specific to this region in India that are not conducive to oral HPV transmission. A nationwide representative prevalence study is needed to investigate HPV prevalence variability among Indian regions.

Mapping Activity Patterns to Quantify Risk of Violent Assault in Urban Environments.

BACKGROUND: We collected detailed activity paths of urban youth to investigate the dynamic interplay between their lived experiences, time spent in different environments, and risk of violent assault. METHODS: We mapped activity paths of 10- to 24-year-olds, including 143 assault patients shot with a firearm, 206 assault patients injured with other types of weapons, and 283 community controls, creating a step-by-step mapped record of how, when, where, and with whom they spent time over a full day from waking up until going to bed or being assaulted. Case-control analyses compared cases with time-matched controls to identify risk factors for assault. Case-crossover analyses compared cases at the time of assault with themselves earlier in the day to investigate whether exposure increases acted to the trigger assault. RESULTS: Gunshot assault risks included being alone (odds ratio [OR] = 1.6, 95% confidence interval [CI] = 1.3, 1.9) and were lower in areas with high neighbor connectedness (OR = 0.7, 95% CI = 0.6, 0.8). Acquiring a gun (OR = 1.4, 95% CI = 1.1, 1.6) and entering areas with more vacancy, violence, and vandalism (OR = 1.7, 95% CI = 1.1, 2.7) appeared to trigger the risk of getting shot shortly thereafter. Nongunshot assault risks included being in areas with recreation centers (OR = 1.2, 95% CI = 1.1, 1.4). Entering an area with higher truancy (OR = 1.6, 95% CI = 1.1, 2.5) and more vacancy, violence, and vandalism appeared to trigger the risk of nongunshot assault. Risks varied by age group. CONCLUSIONS: We achieved a large-scale study of the activities of many boys, adolescents, and young men that systematically documented their experiences and empirically quantified risks for violence. Working at a temporal and spatial scale that is relevant to the dynamics of this phenomenon gave novel insights into triggers for violent assault.

Specific and number of comorbidities are associated with increased levels of temporomandibular pain intensity and duration.

BACKGROUND: Temporomandibular pain disorder (TMD) is a common pain condition in the face. People with TMD report multiple pain comorbidities. The presence of fibromyalgia and migraine in people with TMD is associated with an increase in TMD pain intensity and duration. However, data on the relationship between increasing number of pain comorbidities and TMD pain are rare. The aims of this study were: firstly to evaluate the extent to which increasing number of comorbidities is associated with increasing TMD pain intensity and duration; and secondly to evaluate the extent to which the presence of specific comorbidities is associated with increasing TMD pain intensity and duration. METHODS: The sample included 180 people seeking TMD treatment at Boston and Montreal clinics. TMD was diagnosed using the Research Diagnostic Criteria for TMD. A Numerical Pain Rating Scale assessed TMD pain intensity and participants provided their TMD pain duration in a study questionnaire. The comorbidities of migraine, chronic fatigue syndrome, irritable bowel syndrome, interstitial cystitis and restless leg syndrome were diagnosed by 5 validated diagnostic questionnaires. The associations were analyzed by linear regression, controlling for confounders. RESULTS: There was a positive association between the number of comorbidities present and TMD pain intensity (p < 0.01) and between the number of comorbidities present and TMD pain duration (p < 0.01). Also, the presence of migraine was positively associated with TMD pain intensity (p < 0.01) and the presence of chronic fatigue syndrome was positively associated with TMD pain intensity (p < 0.05) and with TMD pain duration (p < 0.01). When TMD patients were separated into groups, these associations did not change for the myofascial pain group, whereas in the non-myofascial pain group, the relationship between number of comorbidities and TMD pain duration was the only one still present. CONCLUSION: This study shows that the number of comorbidities is positively associated with TMD pain duration and intensity. The presence of specific conditions, such as migraine and chronic fatigue syndrome, is associated with an increase in TMD intensity and duration.

D-dimer levels remain elevated in acute aortic dissection after 24 h.

BACKGROUND: D-dimer levels are elevated in patients with acute aortic dissection (AAD). Although D-dimer levels have been used to rule out AAD within 24 h of symptom onset, it is unknown whether they may be used reliably after 24 h but within the acute period. Here, we tested the hypothesis that D-dimer levels remain elevated in AAD patients for at least 10 d after dissection onset. MATERIALS AND METHODS: D-dimer levels were measured in preoperative heparinized plasma samples from 100 patients with confirmed AAD for up to 10 d after onset of dissection. When possible, serial samples were obtained for ≥2 d. D-dimer levels were measured in fibrinogen equivalent units using a BCS XP automated coagulation analyzer, which is approved for citrated samples. Therefore, we first validated our samples by comparing D-dimer levels in heparinized and citrated plasma samples from 29 individuals, including patients with and without aortic disease and healthy donors. RESULTS: The correlation between heparinized and citrated plasma samples was 0.991 (P ≤ 0.001). At a threshold of 1.6 µg/mL, the overall sensitivity of the D-dimer assay in AAD patients up to 10 d after onset of dissection was 95.3%. CONCLUSIONS: D-dimer levels remained elevated in AAD patients over a 10-d period after dissection onset and may be helpful in ruling out AAD in patients who seek treatment after the first 24 h but within the acute period. Heparinized plasma samples may be substituted for citrated samples when evaluating D-dimer levels using the BCS XP coagulation analyzer.

Providing care to people on social assistance: how dentists in Montreal, Canada, respond to organisational, biomedical, and financial challenges.

BACKGROUND: Dentists report facing difficulties and experiencing frustrations with people on social assistance, one of the social groups with the most dental needs. Scientists ignore how they deal with these difficulties and whether they are able to overcome them. Our objective was to understand how dentists deal with critical issues encountered with people on social assistance. METHODS: We conducted in-depth, semi-structured interviews with 33 dentists practicing in Montreal, Canada. The interview guides included questions on dentists' experiences with people on social assistance and potential strategies developed for this group of people. Analyses consisted of interview debriefing, transcript coding, and data interpretation. RESULTS: Dentists described strategies to resolve three critical issues: missed appointments (organisational issue); difficulty in performing non-covered treatments (biomedical issue); and low government fees (financial issue). With respect to missed appointments, dentists developed strategies to maximise attendance, such as motivating their patients, and to minimise the impact of non-attendance, like booking two people at the same time. With respect to biomedical and financial issues, dentists did not find any satisfactory solutions and considered that it was the government's duty to resolve them. Overall, dentists seem reluctant to exclude people on social assistance but develop solutions that may discriminate against them. CONCLUSIONS: The efforts and failures experienced by dentists with people on social assistance should encourage us to rethink how dental services are provided and financed.

Living with cleft lip and palate: the treatment journey.

OBJECTIVE: To better understand how individuals with cleft lip and palate (CLP) perceive and experience their treatment process and how these perceptions and experiences change over the life course. DESIGN: Qualitative in-depth semistructured interviews with 11 adults with nonsyndromal complete CLP. PARTICIPANTS/SETTING: Individuals from three Canadian cities were recruited by convenience and theoretical sampling through AboutFace International. The number of participants was determined by the principle of theoretical saturation. RESULTS: The experience of individuals with CLP through the treatment process changes over the life course. In childhood and early adolescence, most individuals experience stigma, negative self-perception, and as a result were more prone to perceiving the treatment process not only as unbearably burdensome but also as fueling their feeling of "defectiveness." In adulthood, participants' self-perception improved, partly because of definitive surgical correction, leading them to realize treatment benefits and reappraise the treatment process as satisfactory rather than burdensome. Subsequently, some individuals pursued further surgeries hoping for additional psychological gains, in lieu of psychosocial interventions addressing the underpinnings of residual feelings of "defectiveness." This led to dissatisfaction and frustration when the procedures did not lead to the hoped-for psychological gains. CONCLUSIONS: The results emphasize the importance of self-perception in determining how participants perceive several important aspects of the treatment experience throughout the life course. Further studies should focus on how to incorporate self-perception as an important variable and outcome in the treatment process.

When one spouse has an affair, who is more likely to leave?

OBJECTIVE: We examine whether having an affair around the time a marriage broke up is associated with being the person who wanted the divorce more or the person who was left. We also examine predictors of having an affair around the end of the marriage. METHODS: We use the National Survey of Families and Households, using each ex-spouse's reports of which spouse wanted the divorce more and whether either was having an affair around the end of the marriage. We combine latent class models with logistic regression, treating either spouse's report as a fallible indicator of the reality of whether each had an affair and who wanted the divorce more. RESULTS: We find that a spouse having an affair is more likely to be the one who wanted the divorce more. We find little gender difference in who has affairs preceding divorce. CONCLUSIONS: Results suggest that it is more common to leave because one is having an affair, or to have an affair because one has decided to leave, than it is to discover one's spouse having an affair and initiate a divorce.

Teledentistry for improving access to, and quality of oral health care: A protocol for an overview of systematic reviews and meta-analyses.

Digital technologies are becoming essential to address and optimize the suboptimal performance of healthcare systems. Teledentistry involves the use of information and communication technology to improve access to oral health care and the quality of oral health care delivery. Several systematic reviews (SRs) have been conducted to synthesize evidence on the effectiveness of teledentistry but with conflicting results. The aim of this review is to comprehensively summarize available SRs and provide evidence on the impact of teledentistry on access to oral care, patients' and oral healthcare providers' outcomes, quality of oral health care and costs. This protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO CRD42022373964). Six electronic databases including MEDLINE (Ovid), Embase (Embase.com), CINAHL (EBSCO), Web of Science, Cochrane Library and Epistemonikos will be searched for SRs of quantitative, qualitative, and mixed reviews evaluating teledentistry modalities involving both patients and/or oral health care providers (OHCPs). We will include studies published in English or French. The outcomes will include patients' outcomes (e.g., access to oral health care, patient-reported outcomes, and patient-reported experiences); patient indicators (e.g., clinical outcomes, adherence to treatment, adverse outcomes and costs); and OHCP indicators (e.g., diagnostic accuracy, barriers and enablers costs and equity). Two independent reviewers will perform data screening, data extraction and will assess the quality of included studies using AMSTAR 2 and ROBIS tools. Data will be synthesized narratively and presented by tables and graphs. We will report any overlap of primary studies in the SRs. A statement on the strength of evidence for each outcome will be provided if possible. This review will inform decision-makers, patients, OHCPs, and researchers on the potential effectiveness, benefits, and challenges of teledentistry and support them in making recommendations for its use. Results will be disseminated through peer-reviewed publications, presentations at conferences, and on social media.