Correction: 'They eat it like sweets': A mixed methods study of antibiotic perceptions and their use among patients, prescribers and pharmacists in a district hospital in Kabul, Afghanistan.

[This corrects the article DOI: 10.1371/journal.pone.0260096.].

How is the implementation of empirical research results documented in conflict-affected settings? Findings from a scoping review of peer-reviewed literature.

Implementation science scholars argue that knowing 'what works' in public health is insufficient to change practices, without understanding 'how', 'where' and 'why' something works. In the peer reviewed literature on conflict-affected settings, challenges to produce research, make decisions informed by evidence, or deliver services are documented, but what about the understanding of 'how', 'where' and 'why' changes occur? We explored these questions through a scoping review of peer-reviewed literature based on core dimensions of the Extended Normalization Process Theory. We selected papers that provided data on how something might work (who is involved and how?), where (in what organizational arrangements or contexts?) and why (what was done?). We searched the Global Health, Medline, Embase databases. We screened 2054 abstracts and 128 full texts. We included 22 papers (of which 15 related to mental health interventions) and analysed them thematically. We had the results revised critically by co-authors experienced in operational research in conflict-affected settings. Using an implementation science lens, we found that: (a) implementing actors are often engaged after research is produced to discuss feasibility; (b) new interventions or delivery modalities need to be flexible; (c) disruptions affect how research findings can lead to sustained practices; (d) strong leadership and stable resources are crucial for frontline actors; (e) creating a safe learning space to discuss challenges is difficult; (f) feasibility in such settings needs to be balanced. Lastly, communities and frontline actors need to be engaged as early as possible in the research process. We used our findings to adapt the Extended Normalization Process Theory for operational research in settings affected by conflicts. Other theories used by researchers to document the implementation processes need to be studied further.

'They eat it like sweets': A mixed methods study of antibiotic perceptions and their use among patients, prescribers and pharmacists in a district hospital in Kabul, Afghanistan.

BACKGROUND: Antibiotic resistance is a growing public health threat. In Afghanistan, high levels of indiscriminate antibiotic use exist, and healthcare programmes are not informed by understanding of local attitudes towards rational antibiotic use. Médecins Sans Frontières is an international non-governmental organization providing healthcare services to the Ahmad Shah Baba (ASB) District Hospital in Kabul, Afghanistan, since 2009. This mixed-methods study aimed to explore the perceptions and attitudes toward antibiotics among patients, prescribers, and pharmacists in the ASB District hospital outpatient department. METHODS AND FINDINGS: Knowledge of antibiotics including their purpose and function, how and why they are used, and drivers for choice of antibiotic was examined at patient, prescriber, and provider-level. The first phase of the study, an exploratory qualitative component using an interpretative approach, was used to inform the second phase, a structured survey. Thirty-six interviews were conducted with 39 participants (21 patients or caretakers and 18 hospital health workers). Three hundred and fifty-one (351) patients and caretakers completed the second phase, the structured survey. This study found that poor knowledge of antibiotics and antibiotic resistance is a driving factor for inappropriate use of antibiotics. Participant perceptions of living in a polluted environment drove the high demand and perceived 'need' for antibiotics: patients, doctors and pharmacists alike consider dirty and dusty living conditions as causes of 'disease' in the body, requiring antibiotics to 'clean' and 'strengthen' it. CONCLUSIONS: Findings highlight the need for strategies to improve awareness and knowledge of the general public, improve practice of doctors and pharmacists, regulate antibiotic dispensing in private pharmacies, and implement antibiotic stewardship in hospitals.

'She is like my mother': Community-based care of drug-resistant tuberculosis in rural Eswatini.

Patients with drug-resistant tuberculosis (DR-TB) have received community-based care in Eswatini since 2009. Trained and compensated community treatment supporters (CTSs) provide directly observed therapy (DOT), injectables and psychological support. We examined the acceptability of this model of care among DR-TB patients, including the perspective of family members of DR-TB patients and their CTSs in relation to the patient's experience of care and quality of life. This qualitative research was conducted in rural Eswatini in February 2018. DR-TB patients, CTSs and family members participated in in-depth interviews, paired interviews, focus group discussions and PhotoVoice. Data were thematically analysed and coded, and themes were extracted. Methodological triangulation enhanced the interpretation. All patients and CTSs and most family members considered community-based DR-TB care to be supportive. Positive aspects were emotional support, trust and dedicated individual care, including enabling practical, financial and social factors. Concerns were related to social and economic problems within the family and fears about infection risks for the family and the CTSs. Community-based DR-TB care was acceptable to patients, family members and CTSs. To reduce family members' fears of TB infection, information and sensitisation within the family and constant follow-up appear crucial.

"Better dead than being mocked": an anthropological study on perceptions and attitudes towards unwanted pregnancy and abortion in the Democratic Republic of Congo.

Unwanted pregnancy and unsafe abortion contribute significantly to the burden of maternal suffering, ill health and death in the Democratic Republic of Congo (DRC). This qualitative study examines the vulnerabilities of women and girls regarding unwanted pregnancy and abortion, to better understand their health-seeking behaviour and to identify barriers that hinder them from accessing care. Data were collected in three different areas in eastern DRC, using in-depth individual interviews, group interviews and focus group discussions. Respondents were purposively sampled. All interviews were audio recorded and transcribed verbatim. Transcriptions were screened for relevant information, manually coded and analysed using qualitative content analysis. Perceptions and attitudes towards unwanted pregnancy and abortion varied across the three study areas. In North Kivu, interviews predominantly reflected the view that abortions are morally reprehensible, which contrasts the widespread practice of abortion. In Ituri many perceive abortions as an appropriate solution for reducing maternal mortality. Legal constraints were cited as a barrier for health professionals to providing adequate medical care. In South Kivu, the general view was one of opposition to abortion, with some tolerance towards breastfeeding women. The main reasons women have abortions are related to stigma and shame, socio-demographics and finances, transactional sex and rape. Contrary to the prevailing critical narrative on abortion, this study highlights a significant need for safe abortion care services. The proverb "Better dead than being mocked" shows that women and girls prefer to risk dying through unsafe abortion, rather than staying pregnant and facing stigma for an unwanted pregnancy.

"They have been neglected for a long time": a qualitative study on the role and recognition of rural health motivators in the Shiselweni region, Eswatini.

BACKGROUND: Community health workers (CHWs) are increasingly engaged to address human resource shortages and fill primary healthcare gaps. In Eswatini, a cadre of CHWs called Rural Health Motivators (RHM) was introduced in 1976 to respond to key public health challenges. However, the emergence of health needs, particularly HIV/TB, has been met with inadequate programme amendments, and the role of RHMs has become marginalised following the addition of other CHWs supported by non-governmental organisations. This study was implemented to understand the role of RHMs in decentralised HIV/TB activities. In this paper, we explore the findings in relation to the recognition of RHMs and the programme. METHODS: This exploratory qualitative study utilised individual in-depth interviews, group and focus group discussions, participatory methods (utilising a game format) and observations. Participants were purposively selected and comprised RHM programme implementers, community stakeholders and local and non-governmental personnel. Data collection took place between August and September 2019. Interviews were conducted in English or siSwati and transcribed. SiSwati interviews were translated directly into English. All interviews were audio-recorded, manually coded and thematically analysed. Data was validated through methodical triangulation. RESULTS: Suboptimal organisational structure and support, primarily insufficient training and supervision for activities were factors identified through interviews and observation activities. Significant confusion of the RHM role was observed, with community expectations beyond formally endorsed tasks. Community participants expressed dissatisfaction with receiving health information only, preferring physical assistance in the form of goods. Additionally, gender emerged as a significant influencing factor on the acceptability of health messages and the engagement of RHMs with community members. Expectations and structurally limiting factors shape the extent to which RHMs are recognised as integral to the health system, at all social and organisational levels. CONCLUSIONS: Findings highlight the lack of recognition of RHMs and the programme at both community and national levels. This, along with historical neglect, has hindered the capacity of RHMs to successfully contribute to positive health outcomes for rural communities. Renewed attention and support mechanisms for this cadre are needed. Clarification of the RHM role in line with current health challenges and clearer role parameters is essential.

Patient and nurse perspectives of a nurse-led community-based model of HIV care delivery in Malawi: a qualitative study.

BACKGROUND: Differentiated models of care (DMOC) are used to make antiretroviral therapy (ART) accessible to people living with HIV (PLHIV). In Malawi, Lighthouse Trust has piloted various DMOCs aimed at providing quality care while reducing personal and logistical barriers when accessing clinic-based healthcare. One of the approaches was community-based provision of ART by nurses to stable patients. METHODS: To explore how the nurse-led community ART programme (NCAP) is perceived, we interviewed eighteen purposively selected patients receiving ART through NCAP and the four nurses providing the community-based health care. Information obtained from them was complemented with observations by the study team. Interviews were recorded and transcribed. Data was analysed using manual coding and thematic analysis. RESULTS: Through the NCAP, patients were able to save money on transportation and the time it took them to travel to a health facility. Caseloads and waiting times were also reduced, which made patients more comfortable and gave nurses the time to conduct thorough consultations. Closer relationships were built between patients and care providers, creating a space for more open conversations (although this required care providers to set clear boundaries and stick to schedule). Patients' nutritional needs and concerns related to stigma remain a concern, while operational issues affect the quality of the services provided in the community. Considerations for community-led healthcare programmes include the provision of transportation for care providers; the physical structure of community sites (in regard to private spaces); the timely consolidation of data collected in the field to a central database; and the need for care providers to cover multiple facility-based staff roles. CONCLUSIONS: The patients interviewed in this study preferred the NCAP approach to the facility-based model of care because it saved them money on transport, reduced waiting-times, and allowed for a more thorough consultation, while continuing to provide quality HIV care. However, when considering a community-level DMOC approach, certain factors - including staff transportation and workload - must be taken into consideration and purposefully planned.

"I feel like I am less than other people": Health-related vulnerabilities of male migrants travelling alone on their journey to Europe.

During 2015 and 2016, an unprecedented flow of approximately 800,000 migrants coming from Turkey towards Western Europe crossed the Balkans. Male migrants are perceived as being less vulnerable compared to other migrants and they are not given priority in service and support provision. This qualitative study examines the self-perceived vulnerabilities of male migrants travelling alone along the Balkan route to Europe. Twenty-four individual in-depth interviews, two group interviews and participant observation were conducted with male migrants in Belgrade, Serbia in 2017. Data was coded manually, and analysed thematically. Male migrants traveling alone face the cumulative vulnerability of various traumatic events and migration-related contextual circumstances. Three main themes emerged: the ongoing desperate journey, the better treatment of 'traditionally' well recognised vulnerable sub-groups and the impact of the continuous stress on mental health. Deterrence measures imposed for border control purposes in the form of push-backs, expulsions, detention and degrading, inhumane treatment amplify the psychological distress of male migrants. Feelings of hopelessness, desperation, lack of self-value and self-esteem were reported. 'Traditionally vulnerable' populations were said to have had better treatment throughout the journey from smugglers, border state authorities, governmental officials, civil society and international organizations. The devastating experiences of male migrants, as well as the better treatment offered to other groups of migrants like women and children, results in a perceived neglect of the needs of men in humanitarian response, rendering them vulnerable and exposing them to further health and protection risks. In a context where needs are unmet and people's dignity and health are at risk, specific strategies should be developed to include men in the assistance and protection offered, particularly in relation to exposure to violence.

Human papillomavirus prevalence in a Mid-European oral squamous cell cancer population: A cohort study.

OBJECTIVES: Human papillomavirus infection has been investigated intensively regarding oropharyngeal carcinoma. However, there is still lack of knowledge about the impact of oral HPV infections concerning oral squamous cell carcinoma. This study investigates the prevalence of oral HPV infection in such patients, identifying possible differences between HPV+ and HPV- patients. SUBJECTS AND METHODS: One hundred and six consequent patients were investigated. After completion of a study questionnaire regarding risk factors, a brush smear sample was taken in each subject to identify the individual oral HPV status (overall/low risk/high risk). RESULTS: About 35.8% of the patients were tested positive for HPV in the oral cavity (14% low risk, 28.3% high risk). Patients with oral HPV infection and high-risk HPV infection were significantly younger (p < 0.001) and had a higher alcohol consumption (p = 0.0075 resp. p = 0.0022). A high number of different sexual partners were significantly correlated with any type of HPV infection. At last, patients with high-risk oral HPV infection had experienced more tooth extractions during their lifetime. CONCLUSION: Oral HPV infections may influence the course of disease of oral squamous cell carcinoma as HPV+ patients are about 10 years younger. It seems that high alcohol consumption facilitates high-risk HPV infection. It may be presumed that both alcohol consumption and high-risk oral HPV infection act synergistically, explaining earlier cancer onset.

"My Favourite Day Is Sunday": Community Perceptions of (Drug-Resistant) Tuberculosis and Ambulatory Tuberculosis Care in Kara Suu District, Osh Province, Kyrgyzstan.

OBJECTIVES: Kyrgyzstan is one of the 27 high multidrug-resistant tuberculosis (MDR-TB) burden countries listed by the WHO. In 2012, Médecins Sans Frontières (MSF) started a drug-resistant tuberculosis (DR-TB) project in Kara Suu District. A qualitative study was undertaken to understand the perception of TB and DR-TB in order to improve the effectiveness and acceptance of the MSF intervention and to support advocacy strategies for an ambulatory model of care. METHODS: This paper reports findings from 63 interviews with patients, caregivers, health care providers and members of communities. Data was analysed using a qualitative content analysis. Validation was ensured by triangulation and a 'thick' description of the research context, and by presenting deviant cases. RESULTS: Findings show that the general population interprets TB as the 'lungs having a cold' or as a 'family disease' rather than as an infectious illness. From their perspective, individuals facing poor living conditions are more likely to get TB than wealthier people. Vulnerable groups such as drug and alcohol users, homeless persons, ethnic minorities and young women face barriers in accessing health care. As also reported in other publications, TB is highly stigmatised and possible side effects of the long treatment course are seen as unbearable; therefore, people only turn to public health care quite late. Most patients prefer ambulatory treatment because of the much needed emotional support from their social environment, which positively impacts treatment concordance. Health care providers favour inpatient treatment only for a better monitoring of side effects. Health staff increasingly acknowledges the central role they play in supporting DR-TB patients, and the importance of assuming a more empathic attitude. CONCLUSIONS: Health promotion activities should aim at improving knowledge on TB and DR-TB, reducing stigma, and fostering the inclusion of vulnerable populations. Health seeking delays and adherence problems will be countered by further implementation of shortened treatment regimens. An ambulatory model of care is proposed when convenient for the patient; hospitalisation is favoured only when seen as more appropriate for the respective individual.

Surgical treatment of mandibular condyle fractures using the retromandibular anterior transparotid approach and a triangular-positioned double miniplate osteosynthesis technique: A clinical and radiological evaluation of 124 fractures.

OBJECTIVE: Different modalities have been described regarding the treatment of mandibular condyle fractures. The most advantageous and safest one is still a topic of discussion. The present analysis describes the combination of a retromandibular, transparotideal approach combined to a triangular-positioned double-miniplate osteosynthesis, with a special regard for the patients' long term outcomes. MATERIAL AND METHODS: Clinical data of 102 patients with 124 condyle fractures treated with the mentioned surgical procedure were evaluated. Functional parameters such as the maximal interincisal distance, deviations/deflections, facial nerve function, occlusion as well as complications regarding the parotid gland, osteosynthesis, and esthetics were evaluated 1 week, 2 weeks, 3 months, and 6 months postoperatively. RESULTS: The mean maximal interincisal distance ranged from 38 mm after 1 week to 45 mm after 6 months. Deviations/deflections were seen in 22.5% of the cases 1 week postoperatively and decreased to 2% at 6 months postoperatively. A temporary facial palsy was diagnosed in 3.9% during the first follow-up, whereas no impairment was recorded after 3 or 6 months. At the same time, no patient had occlusional disturbances or complications regarding the parotid gland or the osteosynthesis 6 months postoperatively. CONCLUSIONS: Direct fracture visualization and a stable three-dimensional fracture stabilization are the main advantages of the presented combination of a surgical approach and osteosynthesis technique. Additionally, the absence of long-term complications confirms the safety of the procedure. Therefore, it may be considered as a successful treatment option for mandibular condyle fractures.

Health-seeking behaviour and community perceptions of childhood undernutrition and a community management of acute malnutrition (CMAM) programme in rural Bihar, India: a qualitative study.

OBJECTIVE: Since 2009, Médecins Sans Frontières has implemented a community management of acute malnutrition (CMAM) programme in rural Biraul block, Bihar State, India that has admitted over 10 000 severely malnourished children but has struggled with poor coverage and default rates. With the aim of improving programme outcomes we undertook a qualitative study to understand community perceptions of childhood undernutrition, the CMAM programme and how these affected health-seeking behaviour. DESIGN: Semi-structured and narrative interviews were undertaken with families of severely malnourished children, non-undernourished children and traditional and allopathic health-care workers. Analysis of transcripts was by qualitative content analysis. SETTING: Biraul, Bihar State, India, 2010. SUBJECTS: One hundred and fifty people were interviewed in individual or group discussions during fifty-eight interviews. RESULTS: Undernutrition was not viewed as a disease; instead, local disease concepts were identified that described the clinical spectrum of undernutrition. These concepts informed perception, so caregivers were unlikely to consult health workers if children were 'only skinny'. Hindu and Muslim priests and other traditional health practitioners were more regularly consulted and perceived as easier to access than allopathic health facilities. Senior family members and village elders had significant influence on the health-seeking behaviour of parents of severely malnourished children. CONCLUSIONS: The results reaffirm how health education and CMAM programmes should encompass local disease concepts, beliefs and motivations to improve awareness that undernutrition is a disease and one that can be treated. CMAM is well accepted by the community; however, programmes must do better to engage communities, including traditional healers, to enable development of a holistic approach within existing social structures.

Comparison of the prevalence of human papilloma virus infection in histopathologically confirmed premalignant oral lesions and healthy oral mucosa by brush smear detection.

OBJECTIVE: The role of human papilloma virus (HPV) infections in oral carcinogenesis is an important topic of research in maxillofacial oncology. Nevertheless, the association between such infections in the oral cavity and the development of oral precancerous lesions remains unclear. The aim of this study was to evaluate the association between oral HPV infections and oral leukoplakia or erythroplakia. STUDY DESIGN: The case control study included 118 patients with manifest oral leukoplakia or erythroplakia, who underwent surgical biopsy, including a histopathologic grading of the lesion, and 100 control patients without any oral lesions. HPV detection was achieved with a noninvasive brush smear method (Digene Cervical Sampler, Hybrid Capture II-Test). Logistic regression analysis was performed to assess the associations. RESULTS: A significant association was found between high-risk oral HPV infection and the presence of oral premalignant lesions (P = .001). Among all other evaluated parameters, only smoking showed a significant association with the presence of oral lesions. CONCLUSIONS: Oral HPV infections may play a role in the pathogenesis of premalignant oral lesions.

A 7-year prospective radiographic evaluation of marginal bone level around two different implant systems: a randomized clinical trial.

OBJECTIVE: The aim of this study was to evaluate the change in marginal bone level radiographically around two different implant systems after 7 years of use. MATERIAL AND METHODS: Twenty fully edentulous patients were included in the study and randomly assigned to two treatment groups of machined surface implants (Brånemark, n = 40) and rough-surface implants (Xive, n = 40). The implants were early loaded with individual bar-retained overdentures. All patients were treated by the same surgeon and the same prosthodontist. Clinical and radiographic examinations were conducted at the time of implant loading (baseline) and annually for up to 7 years of use. Measurements to the nearest 0.1 mm were taken at the mesial and distal site, and the average values were calculated for each implant. A three-level mixed-effect analysis of covariance (ANOVA) was used to test the significance of the mean marginal bone change in the two implant groups. RESULTS: The study population consisted of 15 women (75%) and five men (25%) with an average age of 61.6 years. A total of 79 of 80 implants integrated successfully. n = 1 Brånemark implant failed after 3 weeks. There was a significant difference (P < 0.001) between the two implant systems at the baseline measurements (0.14 mm Brånemark vs. 0.39 mm Xive) and a highly significant difference for the annual bone loss (0.07 mm [Brånemark] vs. 0.18 mm [Xive], P < 0.001). CONCLUSION: Both the implant systems are clinically satisfying. Nevertheless, the Brånemark group showed a better radiological performance than the Xive group.

Management of frontal sinus fractures--treatment decision based on metric dislocation extent.

The treatment of frontal sinus fractures is still a matter of research in neurosurgical and craniofacial surgery. The present study aimed to determine new criteria regarding surgical or observational treatment, especially concerning the fracture dislocation. Clinical information on 164 consecutive patients with fractures of the frontal sinus, treated at the Department of Craniomaxillofacial Surgery of the Medical University of Innsbruck from 2006 to 2010, have been evaluated. 23 female (14%) and 141 male (86%) patients suffered mainly from traffic (31.7%) and sports accidents (28.0%), followed by work accidents (20.1%), violence (3.7%) and accidents at home (3.1%). 51.8% presented an isolated fracture of the anterior wall, 47.6% both anterior and posterior wall fracture, 0.6% an isolated posterior wall fracture. Injury of the nasofrontal duct was found in 29.2%, CSF liquorrhoea in 15.9%. In total, 44.5% of the patients underwent surgical therapy, 55.5% were treated conservatively by observation. Treatment decision depended significantly on concomitant injuries of the nasofrontal duct and the presence of rhinoliquorrhoea as well as on the fracture dislocation. A new classification of frontal sinus fractures depending on their maximum dislocation is proposed. In addition, a treatment algorithm considering displacement, liquorrhoea and injury of the nasofrontal duct is presented.

Life-threatening complications of deep neck space infections.

Odontogenic infections represented a challenge for every craniomaxillofacial surgeon in the pre-antibiotic era, not least due to the frequent association with septic complications and lethal consequences. Nowadays, the incidences of serious infection-related complications are less frequent thanks to the medical progress. Nevertheless, the development of severe infections is still hard to foresee. The following analysis provides an overview of four patients with severe, life-threatening odontogenic deep neck space infections treated at the University Clinic for Oral and Maxillofacial Surgery in Innsbruck and describes the etiology, therapy, and outcome for each patient while analyzing differences between the single cases. Crucial aspects in origin, progression, and treatment of DNIs are highlighted, comparing the results with the international literature.

Dental zirconia implants up to three years in function: a retrospective clinical study and evaluation of prosthetic restorations and failures.

PURPOSE: The clinical evaluation of one-piece zirconia dental implants with different diameters to determine survival rate and type of implant failure. MATERIALS AND METHODS: Information concerning implant surgery (number, diameter, length, and position of inserted implants; patient age, sex, risk factors, and bone quality) was extracted from the clinical records. All treated patients were then recalled for a follow-up examination to check the current clinical parameters concerning soft tissue, implants, and prosthetic reconstructions. RESULTS: A total of 79 patients received 170 implants (diameter-reduced 3.25 mm: n = 59; diameter 4.0 mm: n = 82; diameter 5.0 mm: n = 29). The clinical examination showed no signs of gingival inflammation. Prosthetic information was available for 119 implants restored with single crowns (87 implants), fixed partial dentures (25 implants), and removable hybrid dentures (7 implants). Overall, 30 implants were lost due to lack of osseointegration (n = 17) or fracture (n = 13). The diameter-reduced implants showed the lowest survival rate (59.5%) compared to the implants with a diameter of 4.0 mm (90.6%) and 5.0 mm (73.9%). The survival rate for diameters of 3.25 mm was significantly lower than that for diameters of 4.0 mm. The estimated cumulative survival rate up to 3 years demonstrated a survival probability of 82.4% for all types of implant diameters and failure. CONCLUSIONS: Based on these results, diameter-reduced zirconia dental implants cannot be recommended for clinical use. The overall survival rate of 82.4% is not acceptable in comparison to the well-established survival rate of titanium implants.

Impact of a prior medical degree on students' dental school performance in Innsbruck, Austria.

The purpose of this study was to identify the performance differences between two groups of Austrian dental students (one with a prior medical degree and one without a medical degree) during their dental school training and final dental licensure examination. A specific aim was to determine if having a medical degree is a predictive factor for dental students' scores on the Austrian Dental Admission Test (Austrian DAT), performance in the dental clinic, and scores on final exam. The study consisted of a retrospective analysis of 122 students (thirty-nine with a medical degree and eighty-three without a medical degree) who were enrolled in the Dental Clinic at Innsbruck Medical University, Innsbruck, Austria, between 2001 and 2006. Three performance categories were considered: Austrian DAT results, clinical performance after the first clinical year in dental school, and performance on the final dental licensure examination. Information on students' age, gender, and previous medical degree was collected from official records. Analyses with student's t-test and Pearson's chi-square test revealed that the students with a medical degree had significantly higher Austrian DAT total test scores, grade point averages after the first clinical year, and scores on the final exam. Additionally, those students had significantly better performance on the final exam in prosthodontics and oral and maxillofacial surgery. The linear regression analysis showed that a medical degree had an independent effect on average scores on the final exam, age, and Austrian DAT test scores, while gender showed no statistically significant effect. Overall, the study found that dental students with a prior medical degree had significantly higher Austrian DAT total test scores and performed significantly better in the first clinical year and on the final exam than those without a prior medical degree.

Clinical performance of porcelain laminate veneers for up to 20 years.

PURPOSE: The aim of this clinical retrospective study was to evaluate the clinical quality, success rate, and estimated survival rate of anterior veneers made of silicate glass-ceramic in a long-term analysis of up to 20 years. MATERIALS AND METHODS: Anterior teeth in the maxillae and mandibles of 84 patients (38 men, 46 women) were restored with 318 porcelain veneer restorations between 1987 and 2009 at the Medical University Innsbruck, Innsbruck, Austria. Clinical examination was performed during patients' regularly scheduled maintenance appointments. Esthetic match, porcelain surface, marginal discoloration, and integrity were evaluated following modified California Dental Association/Ryge criteria. Veneer failures and reasons for failure were recorded. The study population included 42 (50.0%) patients diagnosed with bruxism and 23 (27.38%) smokers. The success rate was determined using Kaplan-Meier survival analysis. RESULTS: The mean observation time was 118 ± 63 months. Twenty-nine failures (absolute: 82.76%, relative: 17.24%) were recorded. The main reason for failure was fracture of the ceramic (44.83%). The estimated survival rate was 94.4% after 5 years, 93.5% at 10 years, and 82.93% at 20 years. Nonvital teeth showed a significantly higher failure risk (P = .0012). There was a 7.7-times greater risk of failure associated with existing parafunction (bruxism, P = .0004). Marginal discoloration was significantly greater in smokers (P ⋜ .01). CONCLUSION: Porcelain laminate veneers offer a predictable and successful restoration with an estimated survival probability of 93.5% over 10 years. Significantly increased failure rates were associated with bruxism and nonvital teeth, and marginal discoloration was worse in patients who smoked.