Gerencia única: una ilusión sin evidencia / Single management: an illusion without evidence

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Gestión por procesos en atención primaria. Experiencia en Osakidetza/Servicio Vasco de Salud

Los servicios que se prestan en los centros de salud (CS) son el resultado de procesos que se desarrollan a través de los diferentes escenarios (área de atención al cliente, consulta médica, de enfermería...) de estas organizaciones. Por este motivo, cuando se analizan los resultados parciales se corre el riesgo de perder la perspectiva final del proceso. Por otra parte, aunque se trata de organizaciones que carecen del nivel de competitividad presente en otros entornos, las necesidades de sus clientes son cambiantes, tanto en los niveles de acogida como en el requerimiento de servicios. Esto obliga a una adaptación continua que requiere un alto nivel de optimización y de innovación en los procesos, que no puede basarse en la intuición, sino en la toma de decisiones a partir de una información más fiable, proveniente de un cuadro de mando del CS. De esta forma, los CS necesitan desarrollar sus servicios no sólo con una alta capacidad de adaptación, sino también con el nivel de eficiencia exigible a una organización pública de servicios sanitarios. Por tanto, requieren el desarrollo de un sistema de gestión que les permita avanzar en la organización. La gestión por procesos integra el conocimiento y la experiencia de cada una de las personas que forman parte de la organización, e implica hacer cotidiana la mejora continua de la misma. En este sentido, se trata de un cambio cultural de la gestión que favorece, además, la creatividad y la iniciativa de las personas (AU)

Experiencia de certificación con normas ISO 9000 en centros de atención primaria

Cuando se inició esta experiencia en Osakidetza-Servicio Vasco de Salud la certificación de servicios con las Normas ISO 9000 no era un área de trabajo muy conocida en nuestro medio. Sin embargo, se valoró como una herramienta interesante para mejorar la gestión de los procesos en los centros de atención primaria, ya identificada como área de mejora tras las autoevaluaciones con el modelo EFQM, realizadas en las comarcas sanitarias de atención primaria. La primera certificación se realizó con la Norma ISO 9002 en 3 centros de salud. Los 12 centros de salud posteriores se certificaron con la nueva Norma ISO 9001:2000 y con esta misma Norma se renovó la certificación anterior. En la actualidad 15 centros de salud más están en proceso de implantación. En el presente artículo exponemos las características del proceso desarrollado en la certificación, así como los aspectos positivos y dificultades identificadas (AU)

Copago y accesibilidad a los servicios sanitarios / Co-payment and access to health services

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Treatment of multiple adjacent gingival recessions with the tunnel subepithelial connective tissue graft: a clinical report.

This article describes a surgical periodontal plastic procedure for the coverage of multiple adjacent gingival recessions. This surgical technique is based on the construction of a tunnel under the gingival tissue by means of a sulcular incision beyond the mucogingival line without raising the papillae. A large connective tissue graft obtained from the palatal mucosa is introduced through this tunnel, covering the adjacent gingival recessions. A suturing technique to allow this graft to slip through the tunnel under the gingival tissues and to secure and stabilize the graft covering the recessions is described. Twelve-month postoperative results are presented from 21 teeth that were treated with this technique: 100% root coverage was achieved in 66.7% of the recessions treated, with a mean root surface coverage of 91.6%. This study suggests that the use of this surgical procedure allows the treatment of multiple adjacent recessions in a single procedure with adequate early healing and highly predictable root coverage results.

Generalizability of the added benefits of guided tissue regeneration in the treatment of deep intrabony defects. Evaluation in a multi-center randomized controlled clinical trial.

BACKGROUND: Several studies have shown that GTR therapy of intrabony defects results in significantly better outcomes than access flap alone. Most of the available data, however, have been produced in highly controlled research environments by a small group of investigators. Generalizability of results to different clinicians and different subject populations has not been evaluated so far. METHODS: This parallel group study involved 143 patients recruited in a practice-based research network of 11 offices in 7 countries. It was designed to evaluate: 1) the applicability of the documented added benefits of GTR in the treatment of intrabony defects to different populations, and 2) the generalizability of the expected results to different clinicians. GTR was compared to access flap alone. Defects, one in each patient, were accessed with a previously described papilla preservation flap in both the test and control group. In addition, GTR sites received application of a bioabsorbable poly-D,L-lactide-co-glycolide membrane. A stringent plaque control regimen was enforced in all patients during the 1-year observation period. Outcomes included gains in clinical attachment (CAL) and reductions in probing depth. RESULTS: Observed gains in CAL were 2.18 +/- 1.46 mm for access flap and 3.04 +/- 1.64 mm for the GTR-treated group. The treatment-associated difference was statistically significant (P = 0.03) after correcting for both center effect and defect anatomy. Among the various centers, a 1.73 mm difference in CAL gain was observed. This is a clinically relevant amount, which underlines the significance of center variability in the outcome of periodontal surgical procedures. A frequency distribution analysis of the obtained CAL gains indicated that GTR treatment of deep intrabony defects decreased, with respect to the access flap control, the probability of obtaining only a modest attachment gain at 1 year. Conversely, CAL gains of 4 mm or more were observed in more than 40% of GTR-treated defects and in less than 20% of the controls (P < 0.0001). CONCLUSIONS: These data indicate that GTR therapy of deep intrabony defects performed by different clinicians on various patient populations resulted in both greater amounts and improved predictability of CAL gains than access flap alone.

Profile surgical template: a systematic approach to precise implant placement. A technical note.

The precise placement of dental implants is essential to designing a prosthesis that fulfills the esthetic and functional requirements of the patient, and simultaneously allows clear phonetics and facilitates oral hygiene. To achieve this, an effective surgical template is essential: it must provide good orientation, be comfortable, have adequate intraoral fixation, allow freedom of choice to the surgeon, and be capable of use during image-diagnostic procedures. In accordance with this criteria, the profile surgical template, based on utilization of the buccal contour of missing teeth, has been designed.

Guided tissue regeneration in human Class II furcations and interproximal infrabony defects after using a bioabsorbable membrane barrier.

This study clinically evaluated a bioabsorbable barrier membrane designed for periodontal regeneration. Ten Class II furcations and 12 interproximal infrabony defects were treated by flap debridement and placement of a bioabsorbable barrier membrane using the principles of guided tissue regeneration. Treatment was evaluated in terms of changes in vertical probing depth, horizontal attachment level, clinical attachment level, and recession. Baseline data were collected on the day of surgery, and outcome measurements were performed at the 1-year appointment. The mean initial probing depth for Class II furcations was 6.5 mm. At 1 year, the mean probing depth was reduced to 2.9 mm, a 3.6 mm change. These differences were clinically and statistically significant (P < 0.01). There was a mean gain of 2.4 mm in clinical attachment level (P < 0.01) and a mean 3.4-mm change in horizontal attachment level (P < 0.01). Recession increased 1.2 mm. For interproximal infrabony defects, there was a mean probing depth reduction of 5.0 mm (P < 0.01), a mean gain of clinical attachment level of 3.8 mm (P < 0.02), and a mean increase of 1.2 mm in recession (P < 0.04). The results indicate that significant improvements occurred after treatment of Class II furcations and interproximal infrabony defects with the use of a bioabsorbable barrier membrane and guided tissue regeneration.

[Suggestions to improve dentist-endodontist collaboration]. / Sugerencias para la óptima colaboración odontólogo-endodoncista.

Referrals from the general dentist to the endodontist are in some occasions complicated with lack of proper communication among dentist-patient-specialist, resulting in the loss of confidence or even the patient. Suggestions to improve this communication are discussed, which will provide the patient a higher confidence in the indicated endodontic treatment and a better dental service. It will also enhance the prestige of the general dentists' and specialists' practice.

[Desmoplastic fibroma. Differential diagnosis of a periapical lesion from endodontic failure]. / Fibroma desmoplástico. Diagnóstico diferencial con lesión periapical por fracaso de una endodoncia.

Treatment of endodontically involved teeth requires accurate diagnosis of the clinical pulpal condition to determine the primary cause of pathosis. The case presented shows the differential diagnosis between a desmoplastic fibroma and a failure of a misdiagnosed endodontic treatment. The initial direction of treatment should had never been the endodontic therapy but local surgical curettage of the lesion.