The Toronto outcome measure for craniofacial prosthetics: reliability and validity of a condition-specific quality-of-life instrument.

PURPOSE: The purpose of this study was to refine the Toronto Outcome Measure for Craniofacial Prosthetics (TOMCP), present evidence for its reliability and validity, and use the instrument to explore differences in quality of life between prostheses made with chlorinated polyethylene (CPE) (experimental) and silicone (control). MATERIALS AND METHODS: As part of a multicenter prospective controlled randomized double-blind single-crossover clinical trial of the two materials, the TOMCP was administered at the start and end of two 4-month study arms, during which 42 patients wore prostheses made from one material then the other. Reliability was assessed at the crossover. To determine validity of the TOMCP, the Linear Analogue Self-Assessment (LASA-12) and the Short-Form 8 (SF-8) were also administered with the TOMCP. The TOMCP was reduced by removing items that were unreliable, had poorly distributed answers, showed increased internal consistency after their removal, or were too highly correlated with more than one other item. The tests of reliability and validity were then repeated. Finally, the reduced instrument was used to test for differences in quality of life between prostheses made of the two materials. RESULTS: The item reduction tactics pared the 52-item instrument down to 27 items. The correlations of both TOMCP versions with the LASA-12 and the SF-8 were found to be statistically significant, providing evidence of the validity of the TOMCP. The instrument revealed significantly better quality of life with silicone rather than CPE prostheses. CONCLUSIONS: Both versions of the TOMCP were found to be reliable and valid. The instrument was able to show differences in quality of life between two materials.

Validity and reliability problems with patient global as a component of the ACR/EULAR remission criteria as used in clinical practice.

OBJECTIVE: To investigate what factors influence patient global health assessment (PtGlobal), and how those factors and the reliability of PtGlobal affect the rate, reliability, and validity of recently published American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) rheumatoid arthritis (RA) remission criteria when used in clinical practice. METHODS: We examined consecutive patients with RA in clinical practice and identified 77 who met ACR/EULAR joint criteria for remission (≤ 1 swollen joint and ≤ 1 tender joint). We evaluated factors associated with a PtGlobal > 1, because a PtGlobal ≤ 1 defined ACR/EULAR remission in this group of patients who had already met ACR/EULAR joint criteria. RESULTS: Of the 77 patients examined, only 17 (22.1%) had PtGlobal ≤ 1 and thus fully satisfied ACR/EULAR criteria. A large proportion of patients not in remission by ACR/EULAR criteria had high PtGlobal related to noninflammatory issues, including low back pain, fatigue, and functional limitations, and a number of patients clustered in the range of PtGlobal > 1 and ≤ 2. However, the minimal detectable difference for PtGlobal was 2.3. In addition, compared with a PtGlobal severity score, a PtGlobal activity score was 3.3% less likely to be abnormal (> 1). CONCLUSION: Noninflammatory factors contribute to the level of PtGlobal and result in the exclusion of many patients who would otherwise be in "true" remission according to the ACR/EULAR definition. Reliability problems associated with PtGlobal can also result in misclassification, and may explain the observation of low longterm remission rates in RA. As currently constituted, the use of the ACR/EULAR remission criteria in clinical practice appears to be problematic.

Remission of rheumatoid arthritis in clinical practice: application of the American College of Rheumatology/European League Against Rheumatism 2011 remission criteria.

OBJECTIVE: To describe use of the American College of Rheumatology/European League Against Rheumatism (ACR/EULAR) rheumatoid arthritis (RA) remission criteria in clinical practice. METHODS: Remission was examined using data on 1,341 patients with RA (91% men) from the US Department of Veterans Affairs RA (VARA) registry (total of 9,700 visits) and 1,153 patients with RA (25.8% men) in a community rheumatology practice (Arthritis and Rheumatology Clinics of Kansas [ARCK]) (total of 6,362 visits). Cross-sectional and cumulative probabilities were studied, and agreement between the various remission criteria was assessed. Aspects of reliability of the criteria were determined using Boolean-based definitions, as well as the Clinical Disease Activity Index (CDAI) and Simplified Disease Activity Index (SDAI) scoring methods proposed by the ACR/EULAR joint committee. RESULTS: When the 3-variable ACR/EULAR definition of remission recommended for use in community practice (swollen and tender joint counts ≤1, and visual analog scale score for patient's global assessment of disease activity ≤1) was applied, cross-sectional remission was 7.5% (95% confidence interval [95% CI] 6.4, 8.7%) for ARCK and 8.9% (95% CI 7.9, 9.9%) for VARA, and cumulative remission (remission at any observation) was 18.0% (for ARCK) and 24.4% (for VARA), over a mean followup of ∼2.2 years. Addition of the erythrocyte sedimentation rate or C-reactive protein level to the criteria set reduced remission to 5.0-6.2%, and use of the CDAI/SDAI increased the proportions to 6.9-10.1%. Moreover, 1.8-4.6% of the patients met remission criteria at ≥2 visits. Agreement between criteria definitions was good, as assessed by kappa statistics and Jaccard coefficients. Among patients in remission, the probability of a remission lasting 2 years was 6.0-14.1%. Among all patients, the probability of a remission lasting 2 years was <3%. Remission status and examination results for each patient varied substantially among physicians, as determined by multilevel analyses. CONCLUSION: Cross-sectional remission occurred in 5.0-10.1% of the patients in these cohorts, with cumulative remission being 2-3 times greater; however, long-term remission was rare. Problems with reliability and agreement limit the usefulness of these criteria in the individual patient. However, the criteria can be an effective method for measuring clinical status and treatment effect in groups of patients in the community.

Clinical trial of chlorinated polyethylene for facial prosthetics.

PURPOSE: Extraoral maxillofacial prostheses have been fabricated with silicone elastomer for 50 years with few improvements. The objective of this controlled, randomized, prospective, double-blind, single-crossover, multicenter, phase III clinical trial was to determine the noninferiority of chlorinated polyethylene elastomer (CPE) to silicone elastomer for fabricating prostheses. MATERIALS AND METHODS: Forty-two patients were randomly assigned to wear a custom-made prosthesis fabricated from both materials for 4 months and asked to rate their satisfaction (0 = not satisfied, 10 = completely satisfied). Many other measures of prosthesis performance were investigated (see online appendices). RESULTS: Of the 28 patients who completed the study, 68% had used silicone prostheses previously. Overall, patients rated the silicone prosthesis higher than CPE (difference: 2.2, 95% confidence interval [CI]: 0.9 to 3.6, P = .017). Previous users had a stronger preference for silicone (difference: 3.3, 95% CI: 1.7 to 4.9, P = .001), while the 9 new users rated the two materials similarly (difference: 0.0, 95% CI: -2.1 to 2.1, P = 1.00). CONCLUSIONS: The noninferiority of CPE could not be established because of the early termination of the trial. Previous users of silicone prostheses preferred those made of silicone. However, new users expressed no preference between prostheses fabricated with the low-cost CPE or silicone. The authors have developed original clinical trial methodology for assessing extraoral maxillofacial prostheses.

Is fatigue an inflammatory variable in rheumatoid arthritis (RA)? Analyses of fatigue in RA, osteoarthritis, and fibromyalgia.

OBJECTIVE: To investigate whether fatigue is an inflammatory (rheumatoid arthritis; RA) variable, the contributions of RA variables to fatigue, and the levels of fatigue in RA compared with osteoarthritis (OA) and fibromyalgia (FM). METHODS: We studied 2096 RA patients, 1440 with OA, and 1073 with FM in a clinical setting, and 14,607 RA, 3173 OA, and 2487 patients with FM in survey research. We partitioned variables into inflammatory and noninflammatory factors and examined variable contribution to fatigue (0-10 visual analog scale). RESULTS: Factor analysis identified Disease Activity Score-28 (DAS28) and swollen (SJC) and tender joint count (TJC) as a physician-inflammation factor, and patient global assessment, pain, Health Assessment Questionnaire, and fatigue as patient components. Fatigue demonstrated weak correlations with erythrocyte sedimentation rate (ESR; r = 0.071) and SJC (r = 0.112), weak to fair correlations with TJC (r = 0.294), physician global assessment of RA activity (r = 0.384), and DAS28 (r = 0.399), but strong correlation with patient global assessment of severity (r = 0.567). In hierarchical regression analysis, patient global explained 43.1% of DAS28 fatigue variance; when SJC, TJC, and ESR were entered, the explained variance increased to 43.7%. In reverse order, SJC, TJC, and ESR explained 9.2% of the variance, but explained variance increased to 43.7% when patient global was added. The mean clinic fatigue scores were RA 4.9, OA 4.8, FM 7.6; mean survey scores were RA 4.5, OA 4.4, FM 6.3. Adjusted for age and sex, RA and OA fatigue scores were not significantly different. CONCLUSION: Inflammatory components of the DAS28 contribute minimally to fatigue. RA and OA fatigue levels do not differ. Fatigue is not an inflammatory variable and has no unique association with RA or RA therapy.

The problem of rheumatoid arthritis disease activity and remission in clinical practice.

OBJECTIVE: To investigate the results and feasibility of available scales to measure minimal disease activity (MDA) and remission in rheumatoid arthritis (RA) in the clinic. METHODS: We studied 849 consecutive patients with RA seen in a community rheumatology practice for routine RA care by 4 rheumatologists, beginning in March 2007 and ending in August 2007. Patients and physicians completed a simple form at each visit. We calculated the Disease Activity Score 28 (DAS28), Clinical Disease Activity Index (CDAI), physician assessment of global activity, and the Patient Activity Scale (PAS-II). From these we calculated remission and MDA prevalence in this community practice. RESULTS: The DAS28 could not be determined in more than 50% of patients because of referring physician and insurance company restrictions. Remission prevalences differed by assessment method: DAS28 28.5%, CDAI 6.5%-8.1%, physician global 12.5%, PAS 13.7%. MDA was 26.9% using the American College of Rheumatology core set variables, 34.7% using the DAS28, and 26.8% using the PAS-II. The kappa statistic was only fair (0.2 to 0.4) for most comparisons between assessment methods. No significant differences were noted for remission and MDA according to biologic therapy. CONCLUSION: The CDAI and/or physician global and PAS-II are simple acceptable ways to measure RA activity in the clinic, but results differ strikingly according to method. Further standardization appears to be required for full implementation of the CDAI. Caution is urged before using these methods for regulatory purposes.

The influence of early loading on bony crest height and stability: a pilot study.

PURPOSE: The aim of this prospective pilot study was to investigate differences in changes in implant stability and crestal bone height between loaded and unloaded dental implants at 4 months after placement. MATERIALS AND METHODS: In the test group, 20 implants were placed in the anterior region of the mandible in 10 patients. They were connected with a Dolder bar within 10 days and placed into function immediately. In the control group, 21 implants were placed in the anterior region of the mandible in a 2-stage procedure in 12 patients. The implants used were TiUnite, with a diameter of 3.75 mm and a minimum length of 10 mm. Resonance frequency analysis was used to measure differences in implant stability, with the implant stability quotient (ISQ) as the unit of measure. An instrument was developed to measure the bone level directly. On a customized abutment, a probe with a stopper measured the distance between the shoulder of the instrument and the bone. Measurements were made on all 4 sides of each implant. Intra- and interexaminer variability showed an agreement that was greater than 99% (kappa > 0.99) for both sets of measurements. RESULTS: In the early loading group, the mean change in ISQ was -0.08 +/- 0.77 and the mean bone loss from buccal, mesial, distal, and lingual sites was 0.69 +/- 0.15 mm. In the unloaded group, the mean change in ISQ was 1.33 +/- 1.65 and the mean bone loss from buccal, mesial, distal, and lingual sites was 0.53 +/- 0.18 mm. There was no statistically significant difference across the 2 treatment groups. The changes in bone height at buccal and lingual sites were not statistically different from the changes at mesial and distal sites. When gender was included as a factor, the changes in stability and bone loss were statistically smaller among female patients than among male patients. CONCLUSION: In this preliminary study, early loading did not show an influence on bony crest height and stability in TiUnite implants placed in the anterior mandible during the first 4 months of service.

Ten-year survival rate for cantilevered fixed partial dentures.

DATA SOURCES: PubMed (1966-April 2004) provided the primary data source along with the bibliographies from identified articles and reviews. A manual search of two relevant journals (Clinical Implant Dentistry and Related Research, Clinical Oral Implants Research, International Journal of Oral & Maxillofacial Implants, International Journal of Periodontics and Restorative Dentistry, International Journal of Prosthodontics, Journal of Clinical Periodontology, Journal of Periodontology and Journal of Prosthetic Dentistry published; published 2001-2003) provided a further source of data. STUDY SELECTION: Because there were no randomised controlled trials (RCT) that compared fixed partial dentures (FPD) with and without cantilever extensions, other studies were selected if they met the following criteria: were published in the English language; were prospective and retrospective cohort studies; had a mean follow-up of >5 years; included patients who were clinically examined at follow-up; and reported details on suprastructures and described at least one-third of reconstructions as FPD. DATA EXTRACTION AND SYNTHESIS: Two independent reviewers screened articles for inclusion. Disagreements were resolved by discussion and agreement determined by kappa. Two reviewers extracted data on the survival and success of the reconstructions and on biological and technical complications. Failure and complication rates were calculated by dividing the number of events by the total exposure time. RESULTS: Three prospective and 10 retrospective cohort studies incorporating 700 patients and 816 FPD were included. The mean number of cantilever extensions ranged from 1.1 to 6.0. Meta-analyses gave an estimated survival, after 10 years, of 81.8% [95% confidence interval (CI), 78.2-84.9] and a proportion success of 63% (95% CI, 54.7-70.2). Considering biological complications using Poisson model analyses, the estimated rate of FPD lost because of caries after 10 years was 3.1% (95%CI, 1.0-8.8) and that for loss of vitality was 32.6% (95% CI, 13.9-64.9). The rate of FPD lost because of periodontitis was 1% (95% CI, 0.3-3.0). Cumulative 10-year complication rates were: 2.9% (95% CI, 1.7-5.0) for fracture of abutment tooth; 2.4% (95% CI, 0.6-9.8) for rate of loss as a result of abutment fracture; 16.1% (95% CI, 8.8-28.4) for loss of retention; and 5.9% (95% CI, 3.3-10.4) for material complications. CONCLUSIONS: Success and survival rates for cantilever FPD are poorer than those for conventional FPD and this is accompanied by frequent biological and technical complications.

An alternative agriculture system is defined by a distinct expression profile of select gene transcripts and proteins.

Conventional agriculture has relied heavily on chemical inputs that have negatively impacted the environment and increased production costs. Transition to agricultural sustainability is a major challenge and requires that alternative agricultural practices are scientifically analyzed to provide a sufficiently informative knowledge base in favor of alternative farming practices. We show a molecular basis for delayed leaf senescence and tolerance to diseases in tomato plants cultivated in a legume (hairy vetch) mulch-based alternative agricultural system. In the hairy vetch-cultivated plants, expression of specific and select classes of genes is up-regulated compared to those grown on black polyethylene mulch. These include N-responsive genes such as NiR, GS1, rbcL, rbcS, and G6PD; chaperone genes such as hsp70 and BiP; defense genes such as chitinase and osmotin; a cytokinin-responsive gene CKR; and gibberellic acid 20 oxidase. We present a model of how their protein products likely complement one another in a field scenario to effect efficient utilization and mobilization of C and N, promote defense against disease, and enhance longevity.

Block of human NaV1.5 sodium channels by novel alpha-hydroxyphenylamide analogues of phenytoin.

Voltage-gated sodium (Na) channels are a critical component of electrically excitable cells. Phenytoin (diphenylhydantoin, DPH) is an established sodium channel blocker and is a useful anticonvulsant and class 1b antiarrhythmic, and has been effectively used in the treatment of neuropathic pain. In this study, we have synthesized novel alpha-hydroxyphenylamide analogues of diphenylhydantoin and examined their ability to inhibit human Na(V)1.5 sodium channels expressed in Chinese Hamster Ovary (CHO-K1) cells. Phenyl ring substitutions were examined including para-methyl, para-fluoro, para-chloro, ortho-chloro and meta-chloro. We have found that phenyl ring substitutions with electron withdrawing properties resulted in compounds with greater activity. In comparison to diphenylhydantoin, the novel chloro-substituted alpha-hydroxyphenylamide compounds produced as much as a 20-fold greater tonic and frequency-dependent blockade of Na(V)1.5 channels with an IC(50) value of 14.5 microM. In addition, the chloro-substitutions have position specific state dependent blocking properties. The ortho-, meta- and para-chloro substitutions have an 8-, 13- and 3-fold increased affinity for the inactivated state, respectively. Molecular modeling suggests that these differences in affinity are due to a direct interaction with the receptor. Comparing models of diphenylhydantoin to the novel alpha-hydroxyphenlyamide compound suggests that the increased activity may be due to an optimized phenyl ring position and increased molecular volume. This information may be useful in the development of more potent sodium channel blockers.

Voltage-gated sodium channel blockers as cytostatic inhibitors of the androgen-independent prostate cancer cell line PC-3.

The recent discovery of sodium (Na(+)) channel expression in human prostate cancer (PCa) cells led us to investigate the potential use of neuronal Na(+) channel blockers as inhibitors of PCa cells. Our initial studies discovered two classes of Na(+) channel blockers that were effective inhibitors of PCa cell proliferation. Both hydroxyamides (compounds 1 and 4) and a hydantoin (compound 5) were shown to inhibit the androgen-independent PCa cell line PC-3 in vitro. Electrophysiology showed that all compounds functionally block brain type II voltage-gated Na(+) channels (Nav1.2) expressed in Xenopus laevis oocytes. Long-term growth assays in androgen-independent PC-3 cells showed remarkable inhibition of cell growth, with cells growing to a maximum of 30% of controls with analogue 1. Further, our analogues demonstrated only marginal impact on cell viability over the same treatment interval.

Altered gene expression in three plant species in response to treatment with Nep1, a fungal protein that causes necrosis.

Nep1 is an extracellular fungal protein that causes necrosis when applied to many dicotyledonous plants, including invasive weed species. Using transmission electron microscopy, it was determined that application of Nep1 (1.0 micro g mL(-)(1), 0.1% [v/v] Silwet-L77) to Arabidopsis and two invasive weed species, spotted knapweed (Centaurea maculosa) and dandelion (Taraxacum officinale), caused a reduction in the thickness of the cuticle and a breakdown of chloroplasts 1 to 4 h after treatment. Membrane breakdown was most severe in cells closest to the surface of application. Differential display was used to isolate cDNA clones from the three species showing differential expression in response to Nep1 treatment. Differential gene expression was observed for a putative serpin (CmSER-1) and a calmodulin-like (CmCAL-1) protein from spotted knapweed, and a putative protein phosphatase 2C (ToPP2C-1) and cytochrome P-450 (ToCYP-1) protein from dandelion. In addition, differential expression was observed for genes coding for a putative protein kinase (AtPK-1), a homolog (AtWI-12) of wound-induced WI12, a homolog (AtLEA-1) of late embryogenesis abundant LEA-5, a WRKY-18 DNA-binding protein (AtWRKY-18), and a phospholipase D (AtPLD-1) from Arabidopsis. Genes showing elevated mRNA levels in Nep1-treated (5 micro g mL(-)(1), 0.1% [v/v] Silwet-L77) leaves 15 min after Nep1 treatment included CmSER-1 and CmCAL-1 for spotted knapweed, ToCYP-1 and CmCAL-1 for dandelion, and AtPK-1, AtWRKY-18, AtWI-12, and AtLEA-1 for Arabidopsis. Levels of mRNA for AtPLD-1 (Arabidopsis) and ToPP2C-1 (dandelion) decreased rapidly in Silwet-L77-treated plants between 15 min and 4 h of treatment, but were maintained or decreased more slowly over time in Nep1-treated (5 micro g mL(-)(1), 0.1% [v/v] Silwet-L77) leaves. In general, increases in mRNA band intensities were in the range of two to five times, with only ToCYP-1 in dandelion exceeding an increase of 10 times. The identified genes have been shown to be involved or are related to gene families that are involved in plant stress responses, including wounding, drought, senescence, and disease resistance.

Effect of mode of polymerization of bonding agent on shear bond strength of autocured resin composite luting cements.

PURPOSE: There have been anecdotal reports of low bond strength with autocured resin composite materials, particularly when light-cured bonding agents that combine primer and adhesive in a 1-bottle preparation are used. The objective of this study was to determine if the mode of polymerization of the bonding agent influences the strength of the attachment of autocured resin composite luting cements to dentin. METHODS: The shear bond strength of 2 resin luting cements, Calibra and RelyX ARC, polymerized by autocuring, in combination with 4 different bonding agents, Scotchbond Multipurpose Plus, Prime & Bond NT, IntegraBond and Single Bond, polymerized to bovine dentin by light-curing, autocuring or dual-curing, was determined. The pH of each bonding agent and its components was measured. Two-way analysis of variance was used to test the effect of cement and adhesive on shear bond strength. For each bonding agent, the adhesive variable combined the factors product brand and mode of polymerization. With significant interaction among the above variables, the least square means of the 16 combinations of resin cement and adhesive were compared. RESULTS: There was no consistent relationship between shear bond strength and mode of polymerization of the bonding agent. Significant differences in bond strength were specific to the proprietary brand of bonding agent. The pH of the bonding agent depends on the manufacturer's formulation, and low pH may contribute to low bond strength. CONCLUSIONS: The low in vitro bond strength occurring with some combinations of bonding agent and resin cement could be clinically significant.

An implant-retained auricular impression technique to minimize soft tissue distortion.

Achieving adaptation of an auricular prosthesis begins with an accurate impression. It is important to consider how the selection of the impression materials will affect the final outcome of the prosthesis. A procedure is presented to minimize the distortion of the soft tissues caused by the impression materials and procedure. The procedure consists of splinting the implant impression copings, then recording the soft tissue in silicone impression material, followed by the application of acrylic tray resin to provide rigidity.

Therapeutic approaches targeting prostate cancer progression using novel voltage-gated ion channel blockers.

The early detection and treatment of prostate cancer have increased survival and improved clinical outcomes. The nature of the disease and pathologic understaging result in a high proportion of patients developing locally recurrent disease or distant metastases. The development of prostate cancer the time from tumor initiation and progression to invasive carcinoma often begins in men in the fourth or fifth decades of life and extends across decades. This prolonged window highlights the tremendous clinical impact that early intervention with therapeutic agents that selectively target the invasive and metastatic potential of the prostate cancer cell could have on patient survival and quality of life. Our research is currently focused on the development and testing of novel voltage-gated ion channel blockers. The expression of voltage-gated sodium channels (VGSCs) was recently associated with the metastatic behavior of prostate cancer cells. In these studies, VGSC blockers altered prostate cancer cell morphology and arrested prostate cancer cell migration. Clinically, one of the most widely used sodium channel blockers is phenytoin. We have used rational drug design based on the phenytoin binding site in a VGSC to make novel sodium channel blockers with enhanced activity and minimal acute toxicity. Our initial studies in vitro demonstrate enhanced binding of the compounds to the sodium channel and increased inhibition of prostate cancer cell growth in culture and in soft agarose compared with phenytoin. These derivatives are currently being tested for their antitumor activity in human prostate cancer xenografts.

Formation of dimer-type ketals in the reaction of 2,4,6-trichlorophenol and 2,4,6-trichloro-m-cresol with calcium hypochlorite in methanol: conversion to quinones and other compounds.

2,4,6-Trichlorophenol (2) and 2,4,6-trichloro-m-cresol (5) react with calcium hypochlorite (Ca(OCl)(2)) in MeOH to give respectively dimer-type ketals 2-(2',4',6'-trichlorophenoxy)-4,4-dimethoxy-6-chlorocyclohexadien-2,5-one (6) and 2-(3'-methyl-2',4',6'-trichlorophenoxy)-4,4-dimethoxy-5-methyl-6-chlorocyclohexadien-2,5-one (7). Ketal 6, which was too unstable to be isolated, and 7 hydrolyzed in H(2)O/HCl to 2-(2',4',6'-trichlorophenoxy)-6-chloro-1,4-benzoquinone (8) and 2-(3'-methyl-2',4',6'-trichlorophenoxy)-5-methyl-6-chloro-1,4-benzoquinone (9), respectively. Ketal 6 and quinone 8 were also produced when 2 and Ca(OCl)(2) reacted in DMF, followed by addition of MeOH and H(2)O, respectively. The mechanisms of these reactions are examined. Conversion of the ketals and quinones to other products is described.

The question.

This exercise of isolating the strongest article from the found titles should take no more than 1 to 2 minutes. Thus, the whole process of searching for the best evidence should take no more than 5 minutes. In medical practices where evidence based practice is done routinely, this process can be completed in less than 1 minute. Obviously, the evaluation could not have been made as expeditiously without the benefit of the specific details articulated in the question. The question focused the search terms and expedited the identification of the strongest evidence that directly addressed the patient's problem from among the found titles. It provided the dentist with good (but not compelling) evidence to support an answer to the patient. It also provided the dentist with a new piece of information to use the next time the problem of reduced implant support comes up. The dentist has thus enjoyed the satisfaction of quickly identifying new knowledge and the confidence that comes with its use. In addition, the information has provided the dentist with a small but important block against the deterioration of clinical judgment skills.