Continuing benefits of the Montreal Protocol and protection of the stratospheric ozone layer for human health and the environment.

The protection of Earth's stratospheric ozone (O3) is an ongoing process under the auspices of the universally ratified Montreal Protocol and its Amendments and adjustments. A critical part of this process is the assessment of the environmental issues related to changes in O3. The United Nations Environment Programme's Environmental Effects Assessment Panel provides annual scientific evaluations of some of the key issues arising in the recent collective knowledge base. This current update includes a comprehensive assessment of the incidence rates of skin cancer, cataract and other skin and eye diseases observed worldwide; the effects of UV radiation on tropospheric oxidants, and air and water quality; trends in breakdown products of fluorinated chemicals and recent information of their toxicity; and recent technological innovations of building materials for greater resistance to UV radiation. These issues span a wide range of topics, including both harmful and beneficial effects of exposure to UV radiation, and complex interactions with climate change. While the Montreal Protocol has succeeded in preventing large reductions in stratospheric O3, future changes may occur due to a number of natural and anthropogenic factors. Thus, frequent assessments of potential environmental impacts are essential to ensure that policies remain based on the best available scientific knowledge.

The response of the ozone layer to quadrupled CO2 concentrations.

An accurate quantification of the stratospheric ozone feedback in climate change simulations requires knowledge of the ozone response to increased greenhouse gases. Here, we present an analysis of the ozone layer response to an abrupt quadrupling of CO2 concentrations in four chemistry-climate models. We show that increased CO2 levels lead to a decrease in ozone concentrations in the tropical lower stratosphere, and an increase over the high latitudes and throughout the upper stratosphere. This pattern is robust across all models examined here, although important inter-model differences in the magnitude of the response are found. As a result of the cancellation between upper and lower stratospheric ozone, the total column ozone response in the tropics is small, and appears to be model dependent. A substantial portion of the spread in the tropical column ozone is tied to inter-model spread in upwelling. The high latitude ozone response is strongly seasonally dependent, and shows increases peaking in late-winter and spring of each hemisphere, with prominent longitudinal asymmetries. The range of ozone responses to CO2 reported in this paper has the potential to induce significant radiative and dynamical effects on the simulated climate. Hence, these results highlight the need of using an ozone dataset consistent with CO2 forcing in models involved in climate sensitivity studies.

Counseling principles for more effective patient education.

Patients often fail to progress in preventive dentistry behavior. Greater success will be realized if the dentist uses a counseling approach based on basic theoretical principles of psychological counseling. Humanistic and behavioral counseling theories are adaptable to the dental environment. An approach modeled on the exploration, understanding, and action phases of counseling is practicable for the clinical dentist.

Microbial respiratory activity in the euphotic zone of the Mediterranean Sea.

Microplankton respiration in the euphotic zone in the Central Mediterranean Sea was calculated by ETS activity measurements. Distribution of ETSa in the studied area appeared homogeneous and comparable with previous data measured in the Mediterranean Sea. A typical ETSa value for euphotic Mediterranean waters of 0.14 meq O2 h-1 m-3 was calculated. The investigated area supports a metabolic CO2 production of 70 g C m-2 y-1. When compared with regional productivity, the respiration budget in the euphotic zone accounted for 22% of carbon fixed. ETSa appeared a useful assay for the study of evolutive history of the water masses in the Mediterranean Sea.

Dental treatment during pregnancy: a preventive approach.

Applying the basics of preventive dentistry at the primary level will broaden the scope of prenatal care. Dentists should encourage all patients of childbearing age to seek oral health counseling and examination as soon as they learn they are pregnant. Specific printed information on pre- and postnatal fluoride, plaque control, nutrition, and tooth development should be available for pregnant patients. Recall systems should allow for pregnant patients. Emergency problems should not be deferred for treatment in the second trimester but should be alleviated immediately. Indicated medications should not be withheld because of pregnancy but patients must be informed of benefits and risks. Consultation with the patient's physician is always appropriate.

Rapidly progressive periodontal disease associated with HIV infection: report of case.

A case of rapidly progressive periodontal disease associated with human immunodeficiency virus (HIV) infection is presented. Rapid horizontal bone loss, with only moderate inflammation, occurred during a 13-month period. Pocket depth was significantly less than anticipated, given the degree of bone loss. The patient had no signs or symptoms of acquired immune deficiency syndrome (AIDS). The cause, features, diagnosis, and management are discussed.

Addressing family violence among dental patients: assessment and intervention.

Health care professionals increasingly encounter family violence victims, but often do not recognize the signs of abuse. A mailed survey and personal interviews with dental health care workers reveal an uncertainty about intervening when abuse is suspected. The authors examine DHCWs exposure to family violence among their patients, educational history and thoughts about intervention.

Oral cancer detection. The importance of routine screening for prolongation of survival.

The incidence of oral cancer has increased in the past ten years. Early diagnosis and treatment are essential to long-term survival; however, patients at highest risk visit the dentist infrequently. The reddish, velvety or erythroplakial lesion at the base of the tongue or floor of the mouth is highly suspicious in any patient and requires further evaluation. High-risk patients with less suspicious appearing lesions must be reevaluated on close recall. Prognosis improves vastly when the lesion is detected and treated early. One study demonstrated a 64% five-year survival rate for patients with oral cancer that was diagnosed before regional lymph node involvement versus a 15% five-year survival for patients whose lesions were diagnosed after regional lymph node involvement. By including an oral cancer examination in routine physical examination of patients, the physician and public health nurse can increase the likelihood of early detection of oral cancer.

Sexual advances by patients in dental practice: implications for the dental and dental hygiene curricula.

The occurrence of patient initiated sexual advances toward dental health professionals has not previously been examined. Information from other health care specialties and reports from dental and dental hygiene students indicate that such advances do occur and that providers are rarely educated to deal effectively with them. Utilizing an anonymous survey of 300 Oregon dentists and 300 dental hygienists, this study sought to quantify the frequency of patient initiated sexual advances toward dental professionals and to survey practitioners as to their reactions to and methods of dealing with such advances. The information provided by the 483 (81 percent) respondents indicates that up to 44 percent of providers experience one or more patient verbal advances and up to 23 percent of providers experience one or more patient physical advances during a five year period. These advances are a significant source of concern for many dental professionals. Based upon this information, implications for the dental and dental hygiene curricula are considered.

Patient death and bereavement: what is the dentist's role?

The dentist's role following a patient's death has not been examined to date; neither has the attrition rate of a dental practice because of deaths of patients belonging to that practice. This topic was explored through a survey of 400 Oregon dentists. Seventy-two percent of dentists in active practice who participated in the survey had at least one patient death each year; the mean number of patient deaths per year was five. Following these deaths, most dentists reported providing some type of emotional support to the bereaved survivors. Dentists send sympathy cards 72% of the time and attend funerals 27% of the time; 55% of dentists regard the majority of their patient deaths as unexpected. These deaths are a source of emotional stress for dentists, as are subsequent discussions with survivors. Only 3% of the respondents reported having received formal education in death and bereavement, and 66% of dentists believe that some type of education in dying and bereavement should be included in dental school.

Treatment recommendations: "doctor knows best".

Patients often develop an abiding trust in their health care providers and may agree with any recommendations that a dentist offers. This level of trust is a compliment to the dentist and the profession. However, patients who request that a doctor perform the treatment that he or she feels is best and who prefer to avoid an informed consent process must be educated as to the role of informed consent and their part in the process. Even when a patient is adamant in refusing information about his or her condition or states a clear reason as to why he or she does not desire to know a diagnosis or treatment plan (for example, dental phobia or fear of cancer), the dentist has an ethical and legal obligation to work with an appropriate surrogate of the patient's choice and make reasonable attempts at including the patient in the discussion. These patients should be offered the option of discussing the diagnosis and treatment alternatives with a family member or friend present and may include such a surrogate in the informed consent process. When patients clearly lack capacity to consent, the process of informed consent will revert automatically to appropriate surrogates. Finally, patients from different cultures may bring a new set of considerations to the process of informed consent and may require that a modification of the Western tradition be considered, allowing a significant role for the family of the patient in making treatment decisions.

Ethical duties when patients make suspicious narcotic requests.

Practicing dentists are likely to be familiar with the prospect of patients who request controlled substances for doubtful indications. Torn between ethical obligations of beneficence and nonmaleficence, the dentist may be uncertain whether to prescribe a medication with the intention of alleviating pain or to refuse the prescription due to concerns related to chemical dependency, underlying emotional illness, or ulterior motives on the part of the patient. Pharmaceutical choices often do not provide a mechanism for sidestepping this dilemma as chemically dependent patients may be quite sophisticated in their knowledge of drugs and the ways in which to couch their requests. Dentists have an ethical obligation to move beyond simply refusing prescriptions for patients suspected to be chemically dependent; they should sensitively discuss the issue with these patients and be prepared to offer referral for intervention. However, dentists must always be open to the possibility that a particular patient's assertion of chronic physical pain may be of complex origin. When this is the case, appropriate treatment is essential and may involve referring the patient to others with specialized skills. Dentists should not withhold pain medication from patients with uncontrolled pain in the final stages of life.

The dentist's role in bereavement support.

An aging population that is retaining more dentition and an increasing number of persons affected by terminal illnesses have resulted in dentists encountering dying patients and patient deaths with increasing frequency. These events call upon dentists and their staffs to provide support for the terminally ill and for survivors of the deceased. Dentists are effective in providing bereavement support and survivors benefit greatly from it. However, this type of support is stressful for dentists and many report the need for more formal education in this area. The ethical basis for dealing effectively with a dying patient's need for open and honest discussion derives from the obligations of the doctor-patient relationship. These ethical requirements carry over to providing some level of bereavement support for the surviving loved ones of the deceased and address the professional duties of compassion and care. Sending a sympathy card with a personal note, attending the patient's funeral, or making a follow-up telephone call to the patient's survivors are all appropriate, beneficial, and appreciated.

Cosmetic treatment, autonomy, and risks: "if you don't do it, I'll go to a dentist who will".

Patient requests and treatment goals may exceed the limits of professional practice and may have an adverse effect on health. When doctors encounter these types of requests, they first must decide whether the patient has the capacity to consent to such care. In the case of child patients, no such capacity exists and surrogate consent to care must be, in the opinion of the doctor, in the child's best interests. Parents who request potentially harmful procedures for a child with no hope for any health care benefit should be refused politely. Adult patients who request harmful elective procedures for themselves also should be educated and helped to fully understand why the request represents substandard treatment. The long-term consequences of these requests must be detailed clearly for these patients. Elective cosmetic treatment that will lead to long-term adverse effects on function and health raises serious ethical concerns in which the principle of nonmaleficence likely will trump the patient's autonomy.

Virtue versus ethical obligations: working for system-wide change.

Clinical ethics issues most often focus on the individual encounter or relationship between a specific doctor and patient. This is an appropriate focus, since this dynamic defines the normal course of health care delivery and it is within this relationship that most ethical dilemmas arise. Once a provider has discharged his or her ethical duties to a particular patient, further efforts toward assisting that patient or toward social policy affecting health care in general are virtuous but are not ethical mandates. Issues of distributive justice in health care allocation and reimbursement are examples of policy issues that impact persons who may not be patients in one's practice but who may benefit from the actions of the dental profession. Many times, as in the case presented, the dentist's awareness of such issues of distributive injustice may arise from an individual patient encounter. In the process of attempting to secure justice for a particular patient, the dentist may become aware of the broader social context of the problem. This awareness calls upon dentists, just as it calls upon other health care providers, to become involved via their professional organization and to work for distributive justice. While individual values may mediate the duty to advocate for many social issues, professional values that are oriented toward improving the health and well-being of all in a society require organized health care professions to advance these causes.

Issues of justice in dentistry.

Perhaps the greatest appeal of holding individuals responsible for behavior-related health problems arises from the idea of just desserts. Some individuals believe that a person who engages in risky behaviors deserves to suffer and should not expect pity. Health care providers with such opinions are not permitted to discriminate against patients in high-risk behavior groups. Some conduct may seem offensive or unnecessary to health care providers; however, they must care compassionately for those whose problems arise from such behaviors. Beneficence requires that dentists use their skills to help those in need, and set aside notions of punishing patients.

The ethical foundations of a duty to treat HIV-positive patients.

Unfortunately, those who commit the most egregious acts of HIV-related discrimination may not be motivated to change either by fines and sanctions, or by educational programs. Perhaps the best solution to dealing with the small, but significant, number of health care providers who discriminate against HIV-positive patients is the action of the majority. Most dentists are ethical and concerned health care professionals, who willingly care for patients with a wide array of medical problems. This majority must continue to serve as an example to those who refuse to care for HIV-positive patients, and must make it clear that such actions are professionally intolerable.

Chemically dependent doctors.

Overcoming denial and admitting to having a chemical dependency problem is a hurdle that is extraordinarily difficult for anyone to handle without professional assistance. Addicted health care professionals often become even more deeply enmeshed in denial of their problem. They refuse help because they see themselves as educated beyond the level of those who are attempting to help them, and because they fear professional humiliation. Dental professionals who become aware of a colleague's chemical dependence, have an ethical duty to intervene in a constructive way. Reporting to a dental society wellness committee will accomplish this goal while protecting patients, the profession, the addicted provider, and the provider's family. Nonetheless, assisting chemically dependent colleagues to seek treatment can be an enormous burden. Thus, the dental hygienist in the case presented has few choices. She clearly has sufficient evidence of the dentist's chemical dependency problem and, ethically, she must act to prevent harm to patients. If a wellness program is available, it will help her. However, she should not expect gratitude from the dentist at the time of her intervention. Addicted persons rarely thank those who try to help them until much later and whistle-blowers are rarely appreciated. As is often the case, doing the right thing may be a challenge that risks losing a relationship or, as in the case presented, a job.

Self-effacement in dental practice.

Self-effacement is a difficult challenge for some providers. When their professional ehtics and personal morals conflict, health care providers may feel trapped in a dilemma that has no acceptable resolution. In some instances, legal requirements bolster the ethical requirement to be self-effacing. For example, according to the ADA Code, "dentists shall not refuse to accept patients...or deny dental service to patients because of the patient's race, creed, color, sex, or national." Discriminating against patients because of these attributes is unethical and violates civil rights. Providers are held to the highest standards of ethics and should tolerate differences in values. Patients who are morally reprehensible to dentists must be treated with the same degree of care and compassion as other patients receive.