C-terminal deletion of NOTCH1 intracellular domain (N1ICD) increases its stability but does not amplify and recapitulate N1ICD-dependent signalling.

Since the generation of a mouse strain conditionally expressing the active intracellular domain of Notch1 (N1ICD), many laboratories have exploited this model (RosaN1-ICD) to assess the impact of constitutive Notch1 signalling activation in normal and pathological processes. It should be underscored that Cre-recombination leads to the expression of a C-terminally truncated form of N1ICD (N1ICDdC) in the RosaN1-ICD mutant mice. Given that no studies were undertaken to delineate whether deletion of this region leaves intact N1ICD function, stable cell lines with single targeted integration of inducible N1ICD and N1ICDdC were generated. We found that C-terminal deletion of N1ICD stabilized the protein but did not promote the activity of Notch responsive promoters. Furthermore, despite higher expression levels, N1ICDdC failed to phenocopy N1ICD in the promotion of anchorage-independent growth. Our results thus suggest that the C-terminal region of N1ICD plays a role in shaping the Notch response. Therefore, it should be taken into consideration that N1ICD is truncated when interpreting phenotypes of RosaN1-ICD mutant mice.

Factors associated with bat mortality at wind energy facilities in the United States.

Hundreds of thousands of bats are killed annually by colliding with wind turbines in the U.S., yet little is known about factors causing variation in mortality across wind energy facilities. We conducted a quantitative synthesis of bat collision mortality with wind turbines by reviewing 218 North American studies representing 100 wind energy facilities. This data set, the largest compiled for bats to date, provides further support that collision mortality is greatest for migratory tree-roosting species (Hoary Bat [Lasiurus cinereus], Eastern Red Bat [Lasiurus borealis], Silver-haired Bat [Lasionycteris noctivagans]) and from July to October. Based on 40 U.S. studies meeting inclusion criteria and analyzed under a common statistical framework to account for methodological variation, we found support for an inverse relationship between bat mortality and percent grassland cover surrounding wind energy facilities. At a national scale, grassland cover may best reflect openness of the landscape, a factor generally associated with reduced bat activity and abundance that may also reduce turbine collisions. Further representative sampling of wind energy facilities is required to validate this broad pattern. Ecologically informed decisions regarding placement of wind energy facilities involves multiple considerations, including not only factors associated with bat mortality, but also factors associated with bird collision mortality, indirect habitat-related impacts to all species, and overall ecosystem impacts.

Risks Associated With Lentiviral Vector Exposures and Prevention Strategies.

Lentiviral vectors (LVVs) are powerful genetic tools that are being used with greater frequency in biomedical laboratories and clinical trials. Adverse events reported from initial clinical studies provide a basis for risk assessment of occupational exposures, yet many questions remain about the potential harm that LVVs may cause. We review those risks and provide a framework for principal investigators, Institutional Biosafety Committees, and occupational health professionals to assess and communicate the risks of exposure to staff. We also provide recommendations to federal research and regulatory agencies for tracking LVV exposures to evaluate long-term outcomes. U.S. Food and Drug Administration approved antiviral drugs for HIV have theoretical benefits in LVV exposures, although evidence to support their use is currently limited. If treatment is appropriate, we recommend a 7-day treatment with an integrase inhibitor with or without a reverse transcriptase inhibitor within 72 hours of exposure.

Improving Interdisciplinary Provider Communication Through a Unified Paging System.

OBJECTIVES: Interdisciplinary communication at a Veterans Affairs (VA) academic teaching hospital is largely dependent on alphanumeric paging, which has limitations as a result of one-way communication and lack of reliable physician identification. Adverse patient outcomes related to difficulty contacting the correct consulting provider in a timely manner have been reported. METHODS: House officers were surveyed on the level of satisfaction with the current VA communication system and the rate of perceived adverse patient outcomes caused by potential delays within this system. Respondents were then asked to identify the ideal paging system. These results were used to develop and deploy a new Web site. A postimplementation survey was repeated 1 year later. This study was conducted as a quality improvement project. RESULTS: House officer satisfaction with the preintervention system was 3%. The majority used more than four modalities to identify consultants, with 59% stating that word of mouth was a typical source. The preferred mode of paging was the university hospital paging system, a Web-based program that is used at the partnering academic institution. Following integration of VA consulting services within the university hospital paging system, the level of satisfaction improved to 87%. Significant decreases were seen in perceived adverse patient outcomes (from 16% to 2%), delays in patient care (from 90% to 16%), and extended hospitalizations (from 46% to 4%). CONCLUSIONS: Our study demonstrates significant improvement in physician satisfaction with a newly implemented paging system that was associated with a decreased perceived number of adverse patient events and delays in care.

A prospective evaluation of standard versus battery-powered sequential compression devices in postsurgical patients.

BACKGROUND: Sequential compression devices (SCDs) reduce deep venous thrombosis in postsurgical patients, but the use is hindered by poor compliance. METHODS: General and orthopedic surgery patients (n = 67) were randomized to standard- or battery-powered SCDs. Compliance was documented hourly. Nurses and patients were issued a survey to assess barriers to compliance and device satisfaction. RESULTS: Compliance with standard SCDs was 47% compared with 85% with battery-powered SCDs (P < .001). The most common barriers identified by nurses and patients were ambulation and transfers, which were mitigated with the battery-powered device. A majority (79%) of those issued a battery-powered device reported no major problems compared with only 14% of patients issued a standard device (P < .005). CONCLUSIONS: The dual venous thromboembolism prevention strategies of early mobilization and SCD utilization can be met with the appropriate equipment.

Developing and integrating a practice model for health finance reform into wound healing programs: an examination of the triple aim approach.

Throughout the United States, government and private payers are exploring new payment models such as accountable care organizations and shared savings agreements. These models are widely based on the construct of the Triple Aim, a set of three principles for health services reform: improving population-based outcomes, improving patient care experiences, and reducing costs through better delivery systems. Wound programs may adapt to the new health financing environment by incorporating initiatives known to promote the Triple Aim, such as diabetes amputation reduction and pressure ulcer prevention programs, and by rethinking how health services can best be delivered to meet these new criteria. The existing literature supports that programmatic approaches can improve care, quality, and cost, especially in the field of diabetic foot ulcers. Wound healing programs have opportunities to develop new business plan models that provide quality, cost-efficient care to their patient population and to be leaders in the development of new types of partnerships with payers and health delivery organizations.

Dissemination of therapist-assisted internet cognitive behaviour therapy: development and open pilot study of a workshop.

There is considerable research suggesting that therapist-assisted Internet cognitive behaviour therapy (ICBT) is efficacious in the treatment of depression and anxiety. Given this research, there is a growing interest in training students in therapist-assisted ICBT in order to assist with the dissemination of this emerging modality into routine clinical practice. In this study, we developed, delivered, and evaluated a therapist-assisted ICBT workshop for clinical psychology graduate students (n=20). The workshop provided both research evidence and practical information related to the delivery of therapist-assisted ICBT. The workshop also incorporated an experiential component with students working on and discussing responses to client e-mails. Before and after the workshop, we measured knowledge of therapist-assisted ICBT research and professional practice issues, as well as attitudes towards and confidence in delivering therapist-assisted ICBT. Statistically significant changes were observed in all areas. Eighty-five per cent of students are now offering therapist-assisted ICBT under supervision. We conclude by discussing future research directions related to disseminating therapist-assisted ICBT.

Simulation-based mock codes significantly correlate with improved pediatric patient cardiopulmonary arrest survival rates.

OBJECTIVE: To evaluate the viability and effectiveness of a simulation-based pediatric mock code program on patient outcomes, as well as residents' confidence in performing resuscitations. A resident's leadership ability is integral to accurate and efficient clinical response in the successful management of cardiopulmonary arrest (CPA). Direct experience is a contributing factor to a resident's code team leadership ability; however, opportunities to gain experience are limited by relative infrequency of pediatric arrests and code occurrences when residents are on service. DESIGN: Longitudinal, mixed-methods research design. SETTING: Children's hospital at an tertiary care academic medical center. PATIENTS: Pediatric. INTERVENTIONS: Clinicians responsible for pediatric resuscitations responded to mock codes randomly called at increasing rates over a 48-month period, just as they would an actual CPA event. Events were recorded and used for immediate debriefing facilitated by clinical faculty to provide residents feedback about their performance. MEASUREMENTS: Self-assessment data were collected from all team members. Hospital records for pediatric CPA survival rates were examined for the study duration. RESULTS: Survival rates increased to approximately 50% (p = .000), correlating with the increased number of mock codes (r = .87). These results are significantly above the average national pediatric CPA survival rates and held steady for 3 consecutive years, demonstrating the stability of the program's outcomes. CONCLUSIONS: This study suggests that a simulation-based mock code program may significantly benefit pediatric patient CPA outcomes-applied clinical outcomes-not simply learner perceived value, increased confidence, or simulation-based outcomes. The use of mock codes as an integral part of residency programs could provide residents with the resuscitation training they require to become proficient in their practice. Future programs that incorporate transport scenarios, ambulatory care, and other outpatient settings could further benefit pediatric patients in prehospital contexts.

Medicaid reimbursement of hearing services for infants and young children.

As newborn hearing-screening programs have expanded, more and more infants and young children need hearing services. Medicaid is one of the primary sources of funding for such services and, by law, must establish payment rates that are sufficient to enlist enough providers to provide services. In this study we compared 2005 Medicaid reimbursement rates for hearing services for infants and young children in 15 states with the payment rates for the same services by Medicare and commercially available health insurance. On average, Medicaid rates for the same services were only 67 as high as Medicare and only 38 as high as commercial fees. Furthermore, most Medicaid rates declined from 2000 to 2005, and many states did not have billing codes for a significant number of the hearing services needed by infants and young children. These factors likely contribute to infants and young children with hearing loss not being able to get the hearing services they need to benefit from early identification of hearing loss. These data also raise questions about the extent to which states are meeting the federal requirement that Medicaid payments be sufficient to enlist enough providers so that care and services are adequately available to the general population in the geographic area.

PA-driven VTE risk assessment improves compliance with recommended prophylaxis.

OBJECTIVE: Venous thromboembolism (VTE) is a major cause of morbidity and mortality in hospitalized patients, particularly surgical patients. We hypothesize that PAs are well-positioned to assist health systems with implementation of efforts to reduce the rates of this in-hospital complication and increase adherence to published standards for VTE prophylaxis. METHODS: We conducted a retrospective cohort study of general surgical patients who underwent an operation at the University of Michigan between July 2005 and June 2007. The PAs in the Department of Surgery implemented a VTE assessment and prophylaxis intervention in June 2006. Preintervention VTE risk scores were calculated using patient demographic information, operating room data, and diagnosis codes from the International Statistical Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). Those calculated scores were then tested on patients who had a VTE risk score documented by PAs. Postintervention VTE was determined using ICD-9-CM diagnosis codes for deep vein thrombosis (DVT) or pulmonary embolism (PE) and identified as "acquired in hospital" or readmitted with a principal diagnosis of DVT or PE within 30 days following surgery. We then compared the frequency with which patients in the preintervention and postintervention periods received recommended VTE prophylaxis. RESULTS: Overall, 2,046 patients underwent surgery during the study period. There were 1,079 patients in the preintervention group and 967 patients in the postintervention group, with no systematic differences in the case mix between the two groups. For all patients with a risk score of 3 or higher (indicating high and highest risk combined), orders for appropriate prophylaxis improved from an average of 23.1% in the preintervention group to an average of 63.7% in the postintervention group. Similarly, for all patients with a risk score of 5 or higher (indicating highest risk), orders for appropriate prophylaxis improved from an average of 29.4% in the preintervention group to an average of 69.5% in the postintervention group. CONCLUSIONS: Through a PA-driven VTE risk assessment process, we dramatically increased the number of patients within our health system who were prescribed appropriate orders for VTE prophylaxis according to published guidelines and according to individual patient risk.

Do the AHRQ patient safety indicators flag conditions that are present at the time of hospital admission?

OBJECTIVE: The Agency for Healthcare Research and Quality (AHRQ) developed 20 patient safety indicators (PSIs) to identify potentially preventable complications of acute inpatient care based on administrative data. The objective of this patient safety performance study was to assess the impact of cases flagged by each PSI for diagnoses that were actually present on admission on unadjusted PSI rates. METHODS: The latest AHRQ PSI software, which allows users to produce 14 of the 20 PSIs for adult inpatients both without and with a "present on admission" (PoA) variable, was applied to administrative data for adult patients discharged from the University of Michigan Health System (UMHS) in 2006. The impact of the PoA values on unadjusted PSI rates was evaluated. Because of concerns about the accuracy of PoA values, results were compared with those of a prior analysis at UMHS that was similar but based on a review of medical records. FINDINGS: Thirteen PSIs had at least 1 case in the numerator. Rates for all but 1 of the 13 were lower using the PoA values and the reduction was statistically significant for 5 PSIs: decubitus ulcer (P < 0.001), foreign body left in (P = 0.033), selected infections due to medical care (P < 0.001), postoperative physiologic and metabolic derangement (P = 0.039), and postoperative pulmonary embolism or deep vein thrombosis (P < 0.001). Results were consistent with those of the analysis of medical records. CONCLUSIONS: Unadjusted PSI rates at UMHS are substantially overstated, because the PSIs do not differentiate preexisting conditions from complications and therefore include false positive cases. Because of these findings and the lack of a broader study of the validity of the indicators, PSIs should not be used to profile hospital performance.

Plaque removal efficacy of a novel manual toothbrush with MicroPulse bristles and an advanced split-head design.

OBJECTIVE: To assess the plaque removing efficacy and safety of a novel manual toothbrush (Oral-B Pulsar-PUL) compared to leading manual and battery toothbrushes. METHODOLOGY: Three clinical studies were conducted, each having a randomized, examiner-blind, crossover design. Study 1 compared PUL to a newly marketed manual toothbrush, Colgate 360 degrees (COL), Study 2 compared PUL to the Oral-B Advantage Plus (AP) and Oral-B CrossAction (CA) manual toothbrushes, and Study 3 compared PUL to two battery toothbrushes, Oral-B CrossAction Power (CAP) and Crest SpinBrush Pro (SBP). Before each brushing visit, subjects refrained from all oral hygiene procedures for 23-25 hours, received an oral tissue examination, and pre-brushing plaque was scored based on the Rustogi et. al, odified Navy Plaque Index. After subjects brushed with the assigned toothbrush in their usual manner for one minute, oral tissues were then re-examined and post-brushing plaque scores recorded. Subjects with pre-brushing whole mouth mean plaque scores > or = 0.6 continued in the study after the first visit. Following a brief washout period between additional visits, the above procedures were repeated in the remaining treatment periods. The examiners who made all clinical measurements were blinded to the treatment sequence. RESULTS: All toothbrushes significantly (p = 0.0001) reduced plaque levels from all areas after a single brushing. Study 1 showed a significant difference for PUL in all areas, whole mouth, margin, and approximal (p < 0.05) compared to COL. In Study 2, PUL removed significantly more whole mouth (p < 0.01) and approximal plaque (p < 0.005) than AP as scored by two examiners, but did not show a significant advantage versus CA. In Study 3, PUL removed significantly more plaque than CAP and SBP for whole mouth (both p = 0.0001), marginal (both p = 0.0001), and approximal (p < 0.005, p = 0.0001, respectively) areas. All toothbrushes were found to be safe with no evidence of hard or soft tissue trauma. CONCLUSION: The new Oral-B Pulsar toothbrush removed significantly more plaque than Colgate 360 and Oral-B Advantage Plus. Additionally, Pulsar removed significantly more plaque than two battery brushes, Oral-B CrossAction Power and Crest SpinBrush Pro.

Patient safety rounds: description of an inexpensive but important strategy to improve the safety culture.

Patient safety rounds (PSRs) were established at the University of Michigan Medical Center to improve patient safety by opening a new line of communication between the chief of staff and frontline caregivers. Patient safety rounds are biweekly, hour long meetings between the chief of staff and care givers on individual patient care units. In the past 4 years (2002 to 2006), 70 PSRs have been conducted, and more than 900 area staff members have participated. Staff attendance averages 8 to 10 unit or area staff members per session. Patient safety rounds have proven to be a concrete, inexpensive mechanism to enhance patient safety. Benefits have been documented in the improvement in the safety culture and development and implementation of preventive strategies to solve patient safety issues. Key components in the success of PSRs are active medical staff leadership and the engagement of physicians and senior management in the process improvements the PSRs have directed.

Nursing lessons from the MHA keystone ICU project: developing and implementing an innovative approach to patient safety.

Given the pivotal role of nurses in providing and supervising patient care, it is essential that nursing professionals are engaged fully in making care safer. Nursing involvement was instrumental in the Michigan Health and Hospital Association Keystone ICU Project, which resulted in rapid reduction in catheter-related blood stream infection rates and ventilator-associated pneumonia rates. Nurses of every credential and every nursing position participated in this broad scale improvement effort. This article describes the MHA Keystone ICU Project, including challenges implicit in changing nursing practice and team behavior in the ICU. The improvement strategies implemented by Keystone ICU teams, and lessons learned by nurses engaged in the work, are likely to have application in other clinical settings.

Correlations between two plaque indices in assessment of toothbrush effectiveness.

BACKGROUND: The Rustogi et al. Modified Navy (RMNPI) and Turesky et al Modification of the Quigley Hein (TQHPI) plaque indices are commonly used to measure plaque removal. This study evaluated the possible correlations of both indices using data relative to a single use assessment of plaque removal using commercially available toothbrushes. METHODS: Single use crossover study designs have been previously reported. Disclosed plaque was scored pre- and post-brushing using both the RMNPI and the TQHPI. Sixty subjects, with an initial mean RMNPI score of 0.6 or greater, were enrolled and completed the study. No minimum score was required for TQHPI. After the initial scoring, the order for each index was randomized so that each subject was scored with either RMNPI followed by TQHPI or vice versa. Two manual toothbrushes [Oral-B CrossAction (CA) and Colgate Navigator (NA)] and one battery-powered brush (Crest SpinBrush Pro) (SBP) were evaluated in the trial. One examiner performed all clinical measurements. Pearson correlations were performed on whole mouth, buccal, and lingual plaque scores for the CA toothbrush. RESULTS: Strong positive correlations were found between the two plaque indices for pre- and post-brushing scores for the whole mouth and on lingual and buccal surfaces, where Pearson correlation coefficients ranged between 0.963 and 0.995. There was no correlation between the pre-brushing plaque score and the amount of plaque removed by brushing indicating that higher plaque levels before brushing do not necessarily predict that greater amounts of plaque will be removed during toothbrushing. Each toothbrush was found to be safe and significantly reduced plaque levels after a single brushing (t-test, p=0.0001). Significantly greater plaque reductions were found with the CA than the NA and SBP toothbrushes at whole mouth, lingual, and approximal surfaces for both indices (analysis of variance (ANOVA), p < or = 0.0002 for all comparisons). CONCLUSIONS: Strong positive correlations were found between two plaque indices (the RMNPI and TQHPI) for pre- and post-brushing scores at whole mouth, lingual, and buccal surfaces as assessed using data from a single use assessment of plaque removal. Efficacy data from this study demonstrated the CA toothbrush provided superior cleaning when compared to the NA manual toothbrush and SBP battery toothbrush. CLINICAL IMPLICATIONS: Two commonly used indices for assessing plaque removal in clinical studies are RMNPI and TQHPI. However, each index differs in the way plaque is scored. This study used both indices to assess comparative toothbrush efficacy and showed a strong correlation between indices for both pre- and post- brushing plaque scores. The result suggests that both indices demonstrate sufficient sensitivity to differentiate toothbrush efficacy.

A 30-day clinical comparison of a novel interdental cleaning device and dental floss in the reduction of plaque and gingivitis.

OBJECTIVE: To compare the safety and efficacy of a novel battery-operated interdental cleaning device (Oral-B Hummingbird) [ID], fitted with either a flossette or pick attachment, versus hand-held dental floss in the reduction of plaque and gingivitis when combined with manual tooth brushing over a 30-day period. METHODOLOGY: This randomized, examiner blind, parallel group study assessed three treatment groups: ID/flossette (ID/F), ID/pick (ID/P), and unwaxed manual dental floss. All groups used the same soft manual toothbrush and toothpaste. The 84 subjects were stratified to treatment groups based on initial whole mouth mean plaque scores, gingivitis scores, and gender. Subjects were instructed to brush twice daily and use their assigned interdental method once daily in the evening before brushing. Gingivitis, gingival bleeding, and plaque were evaluated at baseline and Day 30. RESULTS: A total of 78 subjects completed all aspects of the study and were included in the analyses. There was no significant difference between treatment groups in baseline plaque, gingivitis, and bleeding scores. After 30 days, statistically significant reductions from baseline gingivitis and bleeding scores were found for all groups (p < 0.0001), but there were no significant statistical differences among groups. Whole mouth and approximal plaque scores were significantly reduced from baseline in the manual floss and ID/F groups after 30 days of product use, with no significant difference between groups. Plaque reduction for both the manual floss and ID/F groups was significantly greater than the ID/P group. All interdental cleaning methods were safe as used in the study, with no evidence of oral hard or soft tissue trauma. CONCLUSION: The Oral-B Hummingbird was safe and effective in reducing approximal plaque and gingival inflammation, and provides a useful alternative device for interdental cleaning.

Plaque removal efficacy of a novel tooth wipe.

OBJECTIVE: This study was designed to evaluate the safety and plaque removal efficacy of a tooth wipe (Oral-B Brush-Ups) using a manual toothbrush as a control. METHODOLOGY: Twenty-five healthy subjects from a general population were enrolled in this randomized, single-use, crossover study. After 23-25 hours of no oral hygiene, oral hard and soft tissues were examined, and disclosed plaque was scored using the Turesky, et al. modification of the Quigley Hein Plaque Index. Subjects used their randomly assigned product for a timed period of one minute without instruction, after which hard and soft tissues and plaque scores were reassessed. Subjects returned to the clinic after a one-week washout period, and the clinical procedures were repeated before and after use of the alternate product. All clinical measurements were made by one examiner who was masked to treatment sequence. RESULTS: Both the tooth wipe and toothbrush were found to be safe, and significantly reduced plaque levels from whole mouth, facial, and lingual surfaces (p < 0.0001). The toothbrush removed significantly greater plaque than the tooth wipe (p < 0.0001) on whole mouth surfaces (49% vs. 29%), facial surfaces (71% vs. 44%), and lingual surfaces (25% vs. 13%). CONCLUSION: The tooth wipe provides an effective method of plaque removal when tooth brushing is not practical.

A reminder reduces urinary catheterization in hospitalized patients.

BACKGROUND: Indwelling urinary catheters are placed in up to 25% of hospitalized patients and are a leading cause of hospital-acquired infection. Duration of catheterization is the dominant risk factor for hospital-acquired urinary tract infection. Physicians are often unaware that their patients have a urinary catheter, and these "forgotten" catheters are frequently unnecessary. METHODS: A controlled trial, using a pretest-posttest design, was conducted on four hospital wards at an academic medical center. A simple written reminder was designed to aid the hospitalized patient's team in remembering that the patient had a urinary catheter. Two of the four wards were assigned to the intervention group, and two served as controls. A research nurse monitored the urethral catheter status of each patient daily. RESULTS: A total of 5,678 subjects were evaluated. After adjusting for age, sex, and length of stay, the average proportion of time patients were catheterized increased by 15.1% in the control group but decreased by 7.6% in the intervention group in the intention-to-treat analysis (p = .007). There was no significant difference in urethral recatheterizations between intervention and control groups. The hospital cost savings provided by the intervention offset the necessary costs of this nurse-based intervention. CONCLUSIORN: In the approximately 90% of U.S. hospitals currently without computerized order-entry systems, a written reminder should be considered as one method for improving the safety of hospitalized patients.

Plaque removal efficacy and safety of the next generation of manual toothbrush with angled bristle technology: results from three comparative clinical studies.

PURPOSE: To investigate the safety and efficacy of a novel angled-bristled toothbrush in comparison with three established brushes. METHODS: The Oral-B CrossAction Vitalizer toothbrush was compared with two manual toothbrushes, the Oral-B CrossAction and Oral-B Advantage, and the battery-operated Crest SpinBrush Pro brush in three independent single-use, examiner-blind, crossover studies. In each study, over 50 healthy subjects from a normal population brushed with their randomly assigned toothbrush for 1 minute without instruction. Subjects returned after a 1-week washout period and brushed with the alternate toothbrush. At each visit, oral hard and soft tissues and plaque were examined before and after brushing. Plaque was evaluated using the Rustogi Modified Navy Plaque Index. RESULTS: Each tested toothbrush significantly (P=0.0001) reduced plaque levels after a single brushing. However, in all three studies, the CrossAction Vitalizer was significantly (P=0.0001) more effective than the comparator brushes in plaque removal from the whole mouth, the gingival margin and approximal surfaces. All toothbrushes were found to be safe with no evidence of oral hard or soft tissue trauma.