- Email: [email protected]
Ethics and managed care
245
CURRENT LITERATURE This study is an investigation to see if administration of prophylactic antibiotics have an effect on postoperative wound infections. A total of 1.400 patients were classified into 4 groups based on type of procedure. The 1 groups included reconstructive procedures, cosmetic procedures, flap or grafting procedures, and patients whom received alloplastic implants. Preoperatively, half of each group was blindly and randomly given either a 2 g intravenous dose of ampicillin/sulbactam or a placebo saline solution. Wounds were monitored postoperatively for 2 weeks for signs and symptoms of infection. Infections were treated with surgical incision and drainage procedures and appropriate culture and sensitivity testing. No significant differences were observed between the antibiotic prophylaxis group and placebo group for any of the 4 categories of patients. Recommendations by the authors were that antibiotic prophylaxis is not necessary in plastic surgery.-J. BROKI.OFF Reprint requests to Dr Bar-an: Cuniz dere 06700 Ankara. Turks-y.
Sok, Bureau
Ethics and Managed 26:163. 1999
Perkel
Care.
Apt. 29P
Kavakli-
RL. Clin Plast Surg
A number of authors have attempted to describe a workable nomenclature for medical ethics. A variation on the basic theme of the Beauchamp and Childress formulation represents a useful scheme for practitioners to think about medical ethics: autonomy (including confidentially. truth telling, futility), beneficence, nonmaleficence. and justice. Beneficence is a principle that reflects on a trdditional physician attitude of being kind. Nonmalelicence means do no harm. The physician-institutional difference in values does not by itself describe a more ethical/less-ethical stipulation but does highlight distinct ethical underpinnings. The principle features of managed care are; organized delivery, team care, at-risk financing, dual agency of providers, risk pooling demographic determinants of care, payer demands, and a focus an outcomes and practice guidelines. Certain ethical principles seem to enjoy a propensity for coming into potential or actual conflict with managed care and these include the following: confidentiality, conflicts of interest, informed consent, double agentry, honesty. interference in the physician-patient relationship, and the relationship with other providers. Physicians must challenge, address, redefine, and reaffirm the potential and ethical pitfalls presented to them in all medical care delivery systems, but at the same time they must understand that it is not, ultimately, the system that is to blame, but is the failure of an individual responsibility that must be held accountable if individual physician’s ethics fail in the coming managed care era.-R.H. HACK Reprint requests to Dr Perkcl: Department Jefferson Medical College. Thomas Jefferson 1015 Walnut St. Philadelphia, PA 19107.
of Family Medicine, llnivcrsity. 401 Curtis,
Toward an Understanding of Implant Occlusion Strain Adaptive Bone Modeling and Remodeling. ford CM, Brand RA. J Prosthet Dent 81:5, 1999
and Stan-
Initial stability of dental implants is determined by surgical technique and the amount, quality, and distribution of bone within the proposed implant site, whereas, long-term implant interfaces can only be maintained through dynamic modeling and remodeling processes. The purpose of this article is to explore the current understanding of the role of
mechanical loading on trdbecular modeling and remodeling and the role occlusion may play in this process. The abiIi5 of bone to maintain the implant-bone interface is a labile process and sensitive to the effects of aging, hormones, vascularit). and various mechanical properties inherent in the rapid and high frequency loads that occurs during mastication. Bone is capable of selectively responding to ail these stimuli in a process referred to as “temporal processing.” Temporal processing implies a biologic response that is not only dependent on a signal but also the time frame over which it occurs. Conclusions drawn by the authors from this review and discussion were as follows: 1) the high success rates of dental implants suggest tissues are capable of a long-term adaptive response to implant loading: 2) implant surfaces are important but may not affect the long-term adaptive responses of bone; 3) the relationship between parameters of the mechanical environment and functional tissue adaptation is not well understood, yet, predictive theories, such as “temporal processing” of mechanical signals are useful as a means to evaluate combinations of the signal parameters that would be more predictive of tissue response(s) than any one parameter alone; and 4) influence of aging on the ability of osteoblastic cells to continue to respond to the mechanical environment may lead to a diminished capacity of tnbecular bone to maintain a long-term dental implant interface.-F.F. KATABI Reprint requests to Dr Stanford: N-i05 DOWS Institute for Dental Research. 522t2.
College
of DentistF.
University
Clinical Uses of Osteotomes. 25123. 1999
of Iowa.
Iowa
City.
L4
Hahn J. J Oral Implant01
This article describes a technique where the preparation for implant placement is achieved by using series of graded osteotomes instead of traditional drilling technique. There are 3 indications for using osteotomes: 1) Where the ridge is too narrow to adequately accommodate an implant, ostee tomes expand the ridge buccolingually. The reasons for expanding the ridge include, changing the emergence angulation, improving the chances of matching opposing landmarks, reducing maxillary undercuts, and expanding the buccal or labial bone for aesthetic reasons. 2) Where the bone at the implant site is soft and tnbecular, osteotomes compress the bone laterally and thus create a denser area for implant placement. 3) Osteotomes can be used to elevate the nasosinus cortical floor, typically by 1 to 3 mm. This elevation can enable placement of longer implant than would otherwise be usable. Osteotome technique does not generate heat which is a major detriment for osseointegration. Bone density should be assessed before surgery. Type III and IV bone (Branemark classification) are best suited for trdbecular compaction. The author recommends to keep the periosteom intact to maintain the blood supply to the buccal and lingual cortical plates. A minimum initial width of 3.0 mm is recommended. When the alveolar bone is soft or when the ridge has resorbed enough to compromise implant placement, the ability to preserve existing bone rather than drilled, improve its quality, and manipulate its shape becomes more desirable.-I. Slc\ha Reprint requests to Dr Hahn: Cosmetic and Implant Center of Cincinnati. 910 Barry Ln. Cincinnati, OH 45229.
Dentistry
CURRENT LITERATURE This study is an investigation to see if administration of prophylactic antibiotics have an effect on postoperative wound infections. A total of 1.400 patients were classified into 4 groups based on type of procedure. The 1 groups included reconstructive procedures, cosmetic procedures, flap or grafting procedures, and patients whom received alloplastic implants. Preoperatively, half of each group was blindly and randomly given either a 2 g intravenous dose of ampicillin/sulbactam or a placebo saline solution. Wounds were monitored postoperatively for 2 weeks for signs and symptoms of infection. Infections were treated with surgical incision and drainage procedures and appropriate culture and sensitivity testing. No significant differences were observed between the antibiotic prophylaxis group and placebo group for any of the 4 categories of patients. Recommendations by the authors were that antibiotic prophylaxis is not necessary in plastic surgery.-J. BROKI.OFF Reprint requests to Dr Bar-an: Cuniz dere 06700 Ankara. Turks-y.
Sok, Bureau
Ethics and Managed 26:163. 1999
Perkel
Care.
Apt. 29P
Kavakli-
RL. Clin Plast Surg
A number of authors have attempted to describe a workable nomenclature for medical ethics. A variation on the basic theme of the Beauchamp and Childress formulation represents a useful scheme for practitioners to think about medical ethics: autonomy (including confidentially. truth telling, futility), beneficence, nonmaleficence. and justice. Beneficence is a principle that reflects on a trdditional physician attitude of being kind. Nonmalelicence means do no harm. The physician-institutional difference in values does not by itself describe a more ethical/less-ethical stipulation but does highlight distinct ethical underpinnings. The principle features of managed care are; organized delivery, team care, at-risk financing, dual agency of providers, risk pooling demographic determinants of care, payer demands, and a focus an outcomes and practice guidelines. Certain ethical principles seem to enjoy a propensity for coming into potential or actual conflict with managed care and these include the following: confidentiality, conflicts of interest, informed consent, double agentry, honesty. interference in the physician-patient relationship, and the relationship with other providers. Physicians must challenge, address, redefine, and reaffirm the potential and ethical pitfalls presented to them in all medical care delivery systems, but at the same time they must understand that it is not, ultimately, the system that is to blame, but is the failure of an individual responsibility that must be held accountable if individual physician’s ethics fail in the coming managed care era.-R.H. HACK Reprint requests to Dr Perkcl: Department Jefferson Medical College. Thomas Jefferson 1015 Walnut St. Philadelphia, PA 19107.
of Family Medicine, llnivcrsity. 401 Curtis,
Toward an Understanding of Implant Occlusion Strain Adaptive Bone Modeling and Remodeling. ford CM, Brand RA. J Prosthet Dent 81:5, 1999
and Stan-
Initial stability of dental implants is determined by surgical technique and the amount, quality, and distribution of bone within the proposed implant site, whereas, long-term implant interfaces can only be maintained through dynamic modeling and remodeling processes. The purpose of this article is to explore the current understanding of the role of
mechanical loading on trdbecular modeling and remodeling and the role occlusion may play in this process. The abiIi5 of bone to maintain the implant-bone interface is a labile process and sensitive to the effects of aging, hormones, vascularit). and various mechanical properties inherent in the rapid and high frequency loads that occurs during mastication. Bone is capable of selectively responding to ail these stimuli in a process referred to as “temporal processing.” Temporal processing implies a biologic response that is not only dependent on a signal but also the time frame over which it occurs. Conclusions drawn by the authors from this review and discussion were as follows: 1) the high success rates of dental implants suggest tissues are capable of a long-term adaptive response to implant loading: 2) implant surfaces are important but may not affect the long-term adaptive responses of bone; 3) the relationship between parameters of the mechanical environment and functional tissue adaptation is not well understood, yet, predictive theories, such as “temporal processing” of mechanical signals are useful as a means to evaluate combinations of the signal parameters that would be more predictive of tissue response(s) than any one parameter alone; and 4) influence of aging on the ability of osteoblastic cells to continue to respond to the mechanical environment may lead to a diminished capacity of tnbecular bone to maintain a long-term dental implant interface.-F.F. KATABI Reprint requests to Dr Stanford: N-i05 DOWS Institute for Dental Research. 522t2.
College
of DentistF.
University
Clinical Uses of Osteotomes. 25123. 1999
of Iowa.
Iowa
City.
L4
Hahn J. J Oral Implant01
This article describes a technique where the preparation for implant placement is achieved by using series of graded osteotomes instead of traditional drilling technique. There are 3 indications for using osteotomes: 1) Where the ridge is too narrow to adequately accommodate an implant, ostee tomes expand the ridge buccolingually. The reasons for expanding the ridge include, changing the emergence angulation, improving the chances of matching opposing landmarks, reducing maxillary undercuts, and expanding the buccal or labial bone for aesthetic reasons. 2) Where the bone at the implant site is soft and tnbecular, osteotomes compress the bone laterally and thus create a denser area for implant placement. 3) Osteotomes can be used to elevate the nasosinus cortical floor, typically by 1 to 3 mm. This elevation can enable placement of longer implant than would otherwise be usable. Osteotome technique does not generate heat which is a major detriment for osseointegration. Bone density should be assessed before surgery. Type III and IV bone (Branemark classification) are best suited for trdbecular compaction. The author recommends to keep the periosteom intact to maintain the blood supply to the buccal and lingual cortical plates. A minimum initial width of 3.0 mm is recommended. When the alveolar bone is soft or when the ridge has resorbed enough to compromise implant placement, the ability to preserve existing bone rather than drilled, improve its quality, and manipulate its shape becomes more desirable.-I. Slc\ha Reprint requests to Dr Hahn: Cosmetic and Implant Center of Cincinnati. 910 Barry Ln. Cincinnati, OH 45229.
Dentistry