Legal and Ethical Issues in Treating Adolescent Patients.

Adolescent patients may present with unique and challenging ethical dilemmas and legal considerations during dental treatment. From the moment the patient registers with the practice, the issues of medical history, informed consent, treatment decisions, and role of the patient and parent affect the dynamic of the doctor-patient relationship. Providers are challenged with balancing the physical, psychological, and social changes occurring in these patients and the changing relationships between the patients and their parents/guardians. State laws, practice standards, and consumerism in dental practice all affect the relationship between the practice, the adolescent, and the parent/guardian.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia

Abstract Background and objectives: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. Methods: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients’ internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5 min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4) min. Results: There was a significant decrease between T0 and T1 in heart rate (80.5 ± 11.6 vs. 75.9 ± 14.4 beats/min), MAP (105.8 ± 21.9 vs. 78.9 ± 18.4 mmHg) and PSI (88.5 ± 8.3 vs. 30.3 ± 9.7) (all p < 0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. Conclusion: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20 min.

Resumo Justificativa e objetivos: Demonstrar as possíveis alterações hemodinâmicas e do fluxo sanguíneo cerebral (FSC) em pacientes que foram posicionados de supinação para cadeira de praia (CP) e detectar se a mudança de posição causa alguma alteração na atividade cortical como mensurado pelo monitor de EEG com quatro canais. Métodos: Foram incluídos 35 pacientes. Antes da indução, os valores da PAM e do IEP foram registrados (T0). Após a intubação, ultrassonografias com Doppler da carótida interna e artérias vertebrais dos pacientes foram avaliadas para adquirir os valores do FSC a partir da fórmula. Em supinação, os valores da PAM, IEP e FSC foram registrados (T1) e o paciente foi posicionado em CP. Após cinco minutos, todas as mensurações foram repetidas (T2). As mensurações do IEP e PAM foram repetidas após 20 (T3) e 40 minutos (T4). Resultados: Houve uma diminuição significativa entre T0 e T1 na FC (80,5 ± 11,6 vs. 75,9 ± 14,4 bpm), PAM (105,8 ± 21,9 vs. 78,9 ± 18,4 mmHg) e IEP (88,5 ± 8,3 vs. 30,3 ± 9,7) (p < 0,05 para todos). A PAM diminuiu significativamente após a mudança de posição e permaneceu diminuída em relação a T1. A análise global dos valores do IEP (T1-T4) não mostrou mudança significativa, mas a comparação de apenas T1 e T2 resultou em redução estatisticamente significativa do IEP. Houve redução significativa do FSC após o posicionado em CP. Conclusão: O posicionado em CP foi associado à diminuição do FSC e dos valores do IEP. O IEP foi afetado pela mudança gravitacional do FSC; no entanto, ambos os fatores não estavam diretamente correlacionados. Além disso, a diminuição do valor do IEP foi transitória e voltou aos valores normais dentro de 20 minutos.

Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

[Patient state index and cerebral blood flow changes during shoulder arthroscopy in beach chair position]. / Patient State Index e alterações do fluxo sanguíneo cerebral durante artroscopia do ombro em posição de cadeira de praia.

BACKGROUND AND OBJECTIVES: The aim of the study were to demonstrate the possible hemodynamic changes and cerebral blood flow alterations in patients who were positioned from supine to beach chair position; and to detect if the position change causes any cortical activity alteration as measured by the 4-channeled electroencephalography monitor. METHODS: 35 patients were included. Before the induction, mean arterial pressure and patient state index values were recorded (T0). After the intubation, doppler-ultrasonography of the patients' internal carotid and vertebral arteries were evaluated to acquire cerebral blood flow values from the formula. In supine position, mean arterial pressure, patient state index and cerebral blood flow values were recorded (T1) and the patient was positioned to beach chair position. After 5min all measurements were repeated (T2). Measurements of patient state index and mean arterial pressure were repeated after 20 (T3), and 40 (T4)min. RESULTS: There was a significant decrease between T0 and T1 in heart rate (80.5±11.6 vs. 75.9±14.4beats/min), MAP (105.8±21.9 vs. 78.9±18.4mmHg) and PSI (88.5±8.3 vs. 30.3±9.7) (all p<0.05). Mean arterial pressure decreased significantly after position change, and remained decreased, compared to T1. The overall analysis of patient state index values (T1-T4) showed no significant change; however, comparing only T1 and T2 resulted in a statically significant decrease in patient state index. There was a significant decrease in cerebral blood flow after beach chair position. CONCLUSION: Beach chair position was associated with a decrease in cerebral blood flow and patient state index values. Patient state index was affected by the gravitational change of the cerebral blood flow; however, both factors were not directly correlated to each other. Moreover, the decrease in patient state index value was transient and returned to normal values within 20min.

Is a mid-level dental provider model acceptable to potential patients?

OBJECTIVE: This study aims to assess patient attitudes toward mid-level dental providers, known as dental therapists (DTs), by surveying those likely to be their patients. The recent adoption of accreditation standards by the Commission on Dental Accreditation has reignited a debate surrounding the state-by-state legalization of DTs in the United States; while the dental profession is divided on DTs, it is important to understand how potential patients may view the DT model. METHODS: A questionnaire that asks about oral health experience, and comfort with the model of a dually trained dental therapist-hygienist, based on a provided definition, was administered to 600 patients and their waiting room companions at a large urban university-based dental clinic. RESULTS: Forty percent of respondents indicated they would be comfortable being treated by a DT for all 7 of the procedures referenced, and over 75% were comfortable with each of 5 procedures. Having caps or crowns placed was the only treatment about which respondents were evenly divided. Factors associated with greater odds of comfort with various procedures include being uninsured and being under the age of 65. Uninsured patients were 1.5 to 2 times more likely than privately insured patients to accept a DT. CONCLUSIONS: The introduction of mid-level dental providers is a strategy that those lacking regular care appear on the whole to be comfortable with.

Complexities of Providing Dental Hygiene Services in Community Care Settings.

UNLABELLED: Direct access care provided by dental hygienists can reduce oral health disparities for the underserved, yet legal, regulatory, and ethical considerations create complexities and limits. BACKGROUND AND PURPOSE: Individual state dental practice acts regulate the scope of practice and level of supervision required when dental hygienists deliver care. Yet, inconsistent state practice act regulations contribute to ethical and legal limitations and dilemmas for practitioners. The dental hygienist is positioned to assume an increasingly larger role in the management of oral health disparities. However, there are several legal and ethical considerations that impact both dental hygienists and dentists providing care in complex community settings. This article informs dental hygienists and other related constituencies about conundrums that are encountered when providing care 'beyond the operatory.' METHODS: An evidence-based view of ways in which dental hygienists are reducing oral health disparities illustrates the complex issues involved in providing such care. Potential scenarios that can occur during care provision in underserved settings provide the basis for a discussion of legal and other associated issues impacting dental hygiene practice.

In contrast to leptin, serum concentrations of ghrelin are not related to premenstrual syndrome.

OBJECTIVE: Premenstrual syndrome (PMS) is a disorder related to mood and appetite changes during the premenstrual phase. Unfortunately, the understanding of the pathophysiology of PMS is quite poor. Though, ghrelin and leptin play important roles in the control of food intake. The aim of this study was to evaluate leptin and ghrelin serum concentrations in PMS patients. PATIENTS AND METHODS: Forty-five PMS patients diagnosed according to ICD-10 diagnostic criteria and 45 healthy women as a control group, were included in the study. These groups were matched for age, body mass index and duration of menstrual cycle. Symptoms of the patients were evaluated using "Menstrual Distress Questionnaires". Serum leptin and ghrelin serum concentrations were measured using ELISA in the postmenstrual phase (5-9 days) and 2-3 days before menstruation. Mann-Whitney U test, independent sample t-test and Wilcoxon test were used for statistical analyses. RESULTS: In the PMS group, there was no difference in the serum concentrations of ghrelin; however, leptin serum concentrations were 31.05 (± 14.16) and 16.42 (± 15.81) ng/ml during the premenstrual and postmenstrual periods, respectively (p < 0.05). Ghrelin serum concentrations in the premenstrual period were 6.9 (± 9.3) ng/ml in the PMS group and 8.8 (± 9.3) ng/ml in the control group, but this difference was not statistically significant (p = 0.79). CONCLUSIONS: Ghrelin serum concentrations were not associated with PMS, while leptin serum concentrations were found to be higher in the premenstrual period in PMS patients. Though, these two hormones work antagonistically to control the food intake and body weight, we suggest that this function is not relevant to PMS.

U.S. Dental school deans' attitudes about mid-level providers.

The introduction of mid-level providers to the U.S. dental workforce is currently a topic of heated debate. As little is known about the opinions of those who educate oral health professionals on the subject of such practitioners, a survey of U.S. dental school deans was undertaken to gauge their attitudes about alternative workforce models in the dental profession. The survey was sent to deans of the then-fifty-eight U.S. schools of dentistry; forty-four responded for a 76 percent response rate. Over three-fourths of the respondents agreed that the scope of practice for both dental hygienists and dental assistants should be expanded; significantly, over half agreed that the future of dentistry should include a dental therapist-type practitioner. Moreover, three-fourths agreed that such practitioners or expanded-duty hygienists would improve access to care for the underserved, and between half and two-thirds agreed that the quality of care delivered by these professionals would not be a problem. The attitudes of the deans about mid-level providers falls somewhere between that reported for U.S. dentists generally, who tend to be skeptical, and for dentists in other countries, who, once they have worked in a system with dental therapists, tend to be supportive.

Strategic management and organizational behavior in dental education: reflections on key issues in an environment of change.

With issues such as shrinking revenue, access to care, faculty workloads, and graying faculty, dental schools are faced with difficult challenges that fall to dental school deans to manage. Do dental school deans have the organizational skill sets and ethical frameworks necessary to address the challenges now facing dental schools? The purpose of this article is to pose questions and suggestions regarding some of the key issues in dental colleges today and to stimulate discussion in the dental community about needed changes in dental education.

The state of the art in evaluating the performance of assistant and associate deans as seen by deans and assistant and associate deans.

This study explores the little-understood process of evaluating the performance of assistant and associate deans at dental colleges in the United States and Canada. Specifically, this research aimed to identify the methods, processes, and outcomes related to the performance appraisals of assistant/associate deans. Both deans and assistant/associate deans were surveyed. Forty-four of sixty-six deans (66.7 percent) and 227 of 315 assistant/associate deans (72.1 percent) completed surveys with both close-ended and open-ended questions. In addition, ten individuals from each group were interviewed. Results indicate that 75-89 percent of assistant/associate deans are formally evaluated, although as many as 27 percent may lack formal job descriptions. Some recommended best practices for performance appraisal are being used in a majority of colleges. Examples of these best practices are having at least yearly appraisals, holding face-to-face meetings, and setting specific, personal performance objectives/benchmarks for assistant/associate deans. Still, there is much room to improve appraisals by incorporating other recommended practices. Relatively high levels of overall satisfaction were reported by both assistant/associate deans and deans for the process and outcomes of appraisals. Assistant/associate deans rated the value of appraisals to overall development lower than did deans. Qualitative data revealed definite opinions about what constitutes effective and ineffective appraisals, including the use of goal-setting, timeliness, and necessary commitment. Several critical issues related to the results are discussed: differences in perspectives on performance reviews, the importance of informal feedback and job descriptions, the influence of an assistant/associate deans' lack of tenure, and the length of service of deans. Lastly, recommendations for enhancing performance evaluations are offered.

Effect of pre-heating resin composite on restoration microleakage.

Improving the adaptation of resin composites during placement is necessary to increase durability and reduce microleakage. Flowable resin liners have been introduced to improve adaptation in composite restorations. In addition, a device that lowers the viscosity of regular dental composites has been introduced (Calset, AdDent Inc, Danbury, CT, USA). This device lowers the viscosity of composites by preheating them to 54.4 degrees C, which should lead to improved adaptation. This study compared microleakage in Class II composite restorations prepared using: 1) preheated resin composite, 2) unheated composite and 3) a flowable liner followed by unheated composite. Class II cavities were prepared on the mesial and distal surfaces of extracted third molars. Ten preparations were restored with resin composite (Esthet-X, Dentsply, York, PA, USA) for each of the following four techniques: Control (Esthet-X with Prime & Bond NT, Dentsply), Flowable (f) (as Control but used Esthet-X Flow liner), Preheated (p) (as Control but with preheating composite to 54.4 degrees C) and Delay (d) (as Preheated but followed by a 15-second delay before curing). The teeth were restored, finished, stored in distilled water for 24 hours, then thermocycled between water bath temperatures of 5 degrees C and 55 degrees C with a one-minute dwell time for 1000 cycles. Tooth apices were sealed with epoxy and varnish was applied to within 1 mm of the restoration margins. The teeth were placed in 0.5% basic fuschin dye for 24 hours, rinsed, then embedded in self-curing resin. The embedded teeth were sectioned mesiodistally with a slow-speed diamond saw, providing multiple sections per restoration. Microleakage was rated by two evaluators using a 0-4 ordinal scale at the occlusal and cervical margins of each restoration and light microscopy (40x). The data were analyzed with Kruskal-Wallis ANOVA and pairwise testing with the Sign test (alpha=0.05). No statistical differences were observed among materials at the occlusal margin. However, at the cervical margin, the preheated samples P showed statistically lower microleakage than the controls and all other treatments. The D samples showed higher microleakage than the P and F samples. Ranked sum scores for the cervical were D (4516), C (3974), F (2756) and P (1958). There was a statistically greater amount of leakage at the cervical margins compared to the occlusal p<0.05. Preheating the composite resulted in significantly less microleakage at the cervical margins compared to the flowable liner and control. Delaying light curing of the preheated composite for 15 seconds (D) was counterproductive and led to increased microleakage.

The state of the art in evaluating the performance of department chairs and division heads.

This study explores the little understood process of evaluating the performance of department chairs/division heads in dental schools. Specifically, this research aimed to elucidate the methods, processes, and outcomes related to the job performance of department chairs/division heads. Forty-three deans and 306 chairs completed surveys with both close-ended and open-ended questions. In addition, ten deans and ten chairs were interviewed. Results indicate that 80 to 90 percent of department chairs are formally evaluated, although as many as 50 percent may lack job descriptions. Recommended best practices for performance appraisal--such as having at least yearly appraisals, holding face-to-face meetings, and setting specific, personal performance objectives/benchmarks for chairs--are being used in most schools. Still, there is much room to improve appraisals by incorporating other recommended practices. Overall high levels of satisfaction were reported by both chairs and deans for the process and outcomes of appraisals. Qualitative data showed some convergence of opinions about appraisals with the notable exception of informal feedback. We explore some implications of these results, especially as they relate to improving performance appraisals.

Effects of X-ray radiation on lipid peroxidation and antioxidant systems in rabbits treated with antioxidant compounds.

The aim of this study was to investigate the effects of supplemental antioxidant vitamins and minerals on lipid peroxidation and on the antioxidant systems in rabbits exposed to X-rays. The rabbits were divided into two experimental groups and one control group, each group containing seven rabbits. The first group (VG) received daily oral doses of vitamin E (460 mg/kg live weight) and vitamin C (100 mg/kg live weight). The second group (MG) was fed a mineral-enriched diet that contained 60 mg manganese chloride, 40 mg zinc sulfate, and 5 mg copper sulfate per kilogram of feed. The third group served as controls and received only a standard diet. Blood samples were obtained before and after the supplementation with vitamins or minerals, as well as before and after irradiation with a total dose of 550-rad X-rays. The blood samples were analyzed for their content of malondialdehyde (MDA), plasma vitamins C and E, retinol, reduced glutathione (GSH), and glutathione peroxidase activity (GPx). After irradiation, the control group showed increased levels of MDA and activity of GPx (p<0.05), whereas the levels of GSH, vitamin C, and vitamin E were decreased. In the VG, the concentration of MDA was lower (p<0.05), and the concentration of GSH and vitamins C and E were higher (p<0.05) when compared to controls. In the MG, the concentrations of MDA, GSH, vitamin C, and retinol were not affected by the mineral administration and radiation. The level of vitamin E in the MG increased with mineral administration (p<0.05), but decreased after irradiation (p<0.05). For the control group, the level of GSH was higher than in the two experimental groups. After irradiation, the VG animals had vitamin E and C levels that were higher than in MG and control groups (p<0.05). The activity of GPx was not affected by vitamin or mineral supplementation or by irradiation. We conclude that the supplementation with antioxidant vitamins and minerals may serve to reinforce the antioxidant systems, thus having a protective effect against cell damage by X-rays.