What is the future of palliative medicine in Germany?

Traditional medical treatment approaches for incurably and terminally ill persons are often felt by the patients and their families to be lacking, since distressing physical and spiritual symptoms of the disease cannot be adequately addressed. In many cases, care in the final stage of life represents a complex medical challenge whose objective is to maintain an individually sufficient quality of life for the patient. New strategies for therapy and care evolving out of the international hospice movement have entered medical training programs under the heading of palliative medicine. Although palliative medicine has only recently enjoyed increasing acceptance in professional as well as lay circles in Germany, it is widespread in many Anglo-Saxon countries, where it also is offered as an academic discipline in research and teaching. According to the most recent American legal interpretations, palliative treatment has been approved as a constitutional right for patients with severely debilitating symptoms. Against the background of sweeping social restructuring, demographic and tumor-epidemiological developments are exerting increasing pressure on our modern societies to improve treatment approaches for incurable patients. In the public itself a changed and more open treatment of the topics of death and dying is becoming apparent, resulting in a demand as well for medical treatment options. From all this, as well as the fact that Germany has been strongly hesitant to establish palliative medicine facilities, it is apparent that there is a clear need to catch up in the area of palliative medicine treatment, research and teaching. The current mood of fiscal restraint in health care may delay medical progress, but it will not be able to prevent it.     

Providing patient-friendly financial options

Having flexible payment options ensures that patients will have all of the motivation and information that they need to accept care in your office. An HCCC simply offers you the chance to make more expensive treatment available to those who need or want it. The small cost of using a HCCC program more than pays for itself--in fact, it costs less than one-third of what you would spend if you were to bill these patients instead. Having consistent financial policies and flexible payment options can dramatically increase your office's productivity and profitability, while expressing your commitment to customer service and high-quality dentistry.     

The development of hospital dentistry in America--the first one hundred years (1850-1950)

The development of hospital dentistry in America began in the middle of the nineteenth century with the pioneering endeavors of Dr. Simon Hullihen and Dr. James Garretson who is credited with the development of the specialty of oral surgery. While starting small, the prodigious work of these and other dentists laid the foundation on which modern hospital dentistry would be built. Throughout its establishment, however, hospital dentistry would have to fight for a place in the hospital, not only with the medical community but also from within the dental community. In time though, hospital dentistry would come to have the support of the American Dental Association and the respect of the medical community.     

Guidelines for the restoration of Class V lesions

Approximately 18 percent of all permanent teeth have Class V lesions. In addition, the prolonged retention of teeth in an increasingly older population is expected to increase the prevalence of Class V lesions. Much has been written about the merits of various techniques for restoring such lesions, but little information is available comparing and contrasting all the material and procedural options available to the general dentist. Etiologies, indications for treatment, and restorative materials are discussed to provide guidance in planning treatment. A diagnostic decision tree is proposed for this dynamic area of restorative dentistry.     

The evolution of clinical periodontal therapy

Periodontal diseases are considered as old as the history of mankind, Magical, religious and herbal treatments were demonstrated in almost all of the early writings. However, methodical, carefully reasoned therapeutic approaches did not exist until the middle-ages and modern treatment with a scientific base and sophisticated instrumentation did not develop until the 18th century. Prior to the 1950s, diseases were mostly treated by root debridement and the extraction of the affected teeth. Until the 1970s, it was primarily the symptoms of periodontal diseases that were treated. The goal was radical elimination of the periodontal pocket (resective therapy). The means were gingivectomy, flap procedures and osseous surgery. The disadvantages were the massive sacrifice of periodontal tissues, lack of regeneration and clinically elongated teeth. These disadvantages, along with the realization of the importance of aetiologic agents, raised questions about the necessity of total pocket elimination, and the control of subgingival infection by a thorough scaling and root planing (nonsurgical therapy), with and without antibiotics, became a commonly used treatment during the 1980s. Comparative longitudinal studies, surgical versus nonsurgical, demonstrated that both surgical and nonsurgical therapy result in limited regeneration and healing with a long junctional epithelium. The most important aspects of today's modern concept of periodontal therapy are causal, regenerative, and specific for disease type and severity. Although the regeneration of the periodontium can be accomplished with the biological principles of guided tissue regeneration and graft materials, compared to conventional methods, the restoration of a completely normal periodontal status has not yet been achieved. We are about to reach our ultimate goals and presently, the more promising research directions for a substantial regeneration seems to lie in biological mediators. Although the future of periodontal therapy is bright, it is still of critical importance to have a preventive strategy to keep individuals healthy beforehand.     

Voluntary wheel running: a review and novel interpretation

One of the most difficult tasks for the practicing urologist is to counsel the patient in a decision for the optimal treatment for his localized prostate cancer. After providing the patient with contemporary and unbiased information and data, it is important to find the preferred treatment based on his age, the medical realities and, last but not least, the patient's personal preference. Radical prostatectomy, radiotherapy and observation are standard treatment options. TRUS-guided brachytherapy and cryosurgery are considered investigational treatment options since follow-up is inadequate to provide sufficiently precise outcome estimates. The literature does not provide clear-cut evidence for the superiority of any one treatment. The patient most likely to benefit from radical prostatectomy would have a relatively long life expectancy, no significant surgical risk factors and a preference to undergo surgery. The major advantage of radical prostatectomy is its potential for total removal of the cancer and cure in properly selected patients. Potential harm includes urinary incontinence and impotence. The patient most likely to benefit from radiation therapy would have a relatively long life expectancy, no significant risk factors for radiation toxicity and a preference for radiotherapy. The advantages of radiotherapy are that it has a potential for cure and it is well tolerated in the majority of men when the modern techniques are used. Potential harm includes radiation cystitis, proctitis and impotence, persisting severe complications are only seen in 1% of patients. The patient most likely to benefit from surveillance are those with a shorter life expectancy and/or a low grade tumour. Benefits are lack of treatment related morbidity with only marginal compromise of disease-specific survival at 5-10 years follow-up.     

The use of air-plasma flows in military field surgery and disaster medicine

Plasma currents of high energy are considered to be very promising in the surgical treatment of modern pathology. The scientists of this country have constructed a portable field surgery apparatus in which a heated atmospheric air assumes a form of a high-temperature thin jet used like a surgeon's scalpel. Experiments and clinical tests proved the efficacy of this microplasmotron that can destroy and coagulate body tissue when treating it with plasma. This new method has, besides hemostatic action, some noticeable antimicrobic effect that leads to acceleration of tissue granulation and wound healing. In specialized and skilled medicare this progressive and priority method should be applied for initial surgical wound treatment, secondary hemorrhage arrests and surgical interventions when a high risk of infection spreading is involved.     

Surgery for urinary incontinence

Burch colposuspension remains the most effective surgical procedure for stress urinary incontinence with a continence rate, which shows better longevity than other methods of treatment. Sling procedures have a comparable continence rate to colposuspension and there appears to be little reduction in continence over time. It is expected that the tension-free vaginal tape will eventually supersede the open Burch colposuspension as the preferred method of primary incontinence surgery principally because it is a minimal-access procedure and medium-term data suggest similar effectiveness to colposuspension. Initial reports on the trans-obturator tape, which minimises bladder and vascular trauma, are encouraging but longer term results remain uncertain. Although the injectable agents have a lower success rate than other procedures, they may still have a role when other procedures have failed due to their low morbidity. Anterior colporrhaphy and needle suspension procedures should no longer be offered as treatments for stress urinary incontinence.The surgical options for detrusor activity should be considered when pharmacological options have been exhausted. Appropriate patient selection is crucial when choosing which surgical option would be most suitable, especially as many of these procedures carry with them a significant risk of morbidity. Some surgical options are becoming less invasive and modern developments, such as intravesical botulinum toxin injection may in future become a first line treatment option for detrusor overactivity.     

Practicing implant dentistry profitably

The success of dental implants has opened up countless treatment possibilities for restorative dentists to offer to their patients. Just as our clinical paradigms have had to change because of this new technology, so too must our paradigms concerning the way we communicate with our patients change if we are to get them to say "yes" to treatment that we know that they need. Success in clinical treatment using implants requires a systematic approach. A systematic approach to communicating with your patients will allow you to have the same high degree of success with treatment acceptance that is possible with dental implants. The key to the systems we have discussed is Relationship Centered Care. A relationship is fostered and enhanced through a Comprehensive Examination Process, a structured Consultation Process utilizing the influencing process and Financial Arrangements that allow the patient to receive what they want while the office maintains the profitability that it needs. A system for calculating rational fees can be utilized that allows the practice to have control over an area that traditionally was controlled by anecdotal factors. The Pride Institute has developed this material and is presenting it to the profession so that restorative dentists can truly practice implant dentistry profitably.     

Treating restorative dentistry to health

The concepts that underpin much of dental practice need refocusing so as to accommodate the many scientific advances that have been made in recent years in understanding oral disease processes and their management. "Treatment' should come to mean what it says, namely the curing of diseases- and much of this can only be accomplished by non-invasive means. Restorative procedures should be seen simply as prosthetic, making up for lost tissues. The sequence of events with respect to caries should usually be diagnosis followed by treatment, and then the option of restoration if appropriate. In order to achieve this state of affairs for the whole population, I believe it will be necessary to stream dental undergraduates so that, while a portion learn restorative techniques and become licensed to practise them, the remainder concentrate on the non-restorative aspects of dentistry, having a special emphasis on the prevention and non-invasive "treatment' of oral and dental diseases, including caries, on a community scale. This latter group of dentists would not be licensed to undertake restorative procedures.     

Review of Guide to Psychiatry.

Reviews the book, Guide to Psychiatry by Myre Sim. This textbook is in the older British tradition. There is no attempt to be encyclopedic, yet the references are representative of our present state of knowledge. The style is lucid and, while in no way can it be accused of being dogmatic, the options and problem areas are clearly reviewed so that confusion is not substituted for uncertainty. This textbook is a good reliable review of modern psychiatry presented in the traditional fashion but ideal for psychiatric residents and post-graduate students in the mental health field providing they use it only as the author intended, as a guide. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Modern dilemmas in the treatment of breast carcinoma

By means of a detailed analysis of literature data and our own results when available, the paper presents different therapeutic options in the treatment of breast cancer patients that are applied in our country today and the that might be applied in relation to modern knowledge and discoveries in experimental oncology, early detection and diagnostics of breast cancer. It is stressed that the use of this knowledge may result in slightly better rate of survival but the main emphasis is on the quality of life of treated patients and more rational delivery of available therapeutic options.     

The treatment of Parkinson's disease: current concepts and rationale

The recent advances in the treatment of Parkinson's disease have made for significant improvements in the quality of life and mortality rate of those who suffer from this neurodegenerative disease. At the same time, the number of options and the complexity of multi-drug regimens have posed a great challenge for the clinician caring for the patient with Parkinson's disease. Though there are still many questions to be answered in regard to the potential neuroprotective effects of several medications, a few general rational treatment plans can be outlined. In patients requiring treatment in the early stages of the disease, especially with a predominance of tremor, anticholinergics or amantadine should be considered initially. At this point, it would be reasonable to add selegiline for both therapeutic and possible neuroprotective effects. As a patient becomes more affected by the disease and additional therapy is necessary, starting either a dopamine agonist or levodopa would be a rational choice. Continuation of selegiline and, possibly, amantadine for neuroprotective reasons should be contemplated. Titration in levodopa therapy (with controlled-release or standard levodopa) to higher levels should prompt addition of a dopamine receptor agonist if one has not been started previously. Conversely, if a patient is receiving only a dopamine receptor agonist and is becoming progressively disabled, levodopa should be added to the regimen. Fluctuations in motor abilities may be improved further by the use of a COMT inhibitor. Patients with uncontrollable motor fluctuations should be considered for surgery. Undoubtedly, the coming years will bring more treatment options and more evidence on which sequences and combinations of therapies are the most beneficial. Differences in efficacy and adverse effects for each patient must be taken into consideration when outlining and carrying out a treatment plan. By using a rational approach to the treatment of Parkinson's disease, with the above guidelines in mind, the patient should be able to enjoy a good quality of life and level of function for many years.     

Glial tumor cell proliferation and immune response in the brain

Absence of the maxillary lateral incisor creates an aesthetic problem which can be managed in various ways. The condition requires careful treatment planning and a consideration of the options and outcomes following either space closure or prosthetic replacement. Recent developments in restorative dentistry have warranted a re-evaluation of the approach to this clinical situation. Factors relating both to the patient and to the teeth, including the presenting malocclusion and the effect on the occlusion, are considered. This review considers the possible options: no treatment; orthodontic space closure with canine modification; space maintenance and replacement of the missing tooth with denture, bridge (adhesive and conventional), or implant.     

Determinants of quality in operative dentistry

The definition of quality in operative dentistry has often, at least in part, been related to how well a cut preparation compares with an ideal preparation. The ideal preparation follows well-defined design principles. These design principles have their roots in empirical dentistry and scientific evaluations, the latter often being conducted in vitro. Because of the complexity of following these design principles practically, a large portion of dental education consists of perfecting cavity preparations. By focusing on how to cut these cavity preparations as closely as possible to the ideal preparation, dentists with high psycho-motor skills have been able to provide the public with restorative procedures of high standards over the years. However, because of the tendency of relating quality in operative dentistry to the ideal preparation, we found it justifiable to review the literature dealing with the cavity design principles of the Class II amalgam preparation. What triggered this review was a request from the International Dental Federation (FDI) to start a process leading to a scientifically based quality definition of dental restorations, a definition that determines how different factors, including cavity design principles, affect the longevity of both tooth and restoration. From our review, we conclude that patient response and restoration performance over time, rather than how closely a cavity preparation compares with the ideal preparation, will be of more significance in determining the longevity of a Class II amalgam restoration.     

Lipid peroxidation in patients with ischemic heart disease, hyperlipidemia and/or hypertension while polyunsaturated omega-3 fatty acids of plant and animal origin were in their diet

Missing anterior teeth are being replaced by implant-supported restorations quite frequently in modern dentistry. Providing the patient with a temporary prosthesis prior to or following implant fixture placement must satisfy established esthetic and functional criteria. When orthodontic treatment is included as part of the overall treatment effort, additional considerations include the retention and stabilization of newly established tooth positions. This article describes the fabrication, use and advantages of a provisional anterior prosthesis that replaces missing teeth prior to or following implant placement.     

Dental pain and suffering prior to the advent of modern dentistry

In Prehistoric and Mediaeval times few dentitions in this country remained intact much after the age of 40-45 years. The point is made that dental caries and periodontal disease played little part in this early disintegration and it is unlikely that the population of this time suffered severely with their teeth. A change in dietary habits in the late seventeenth and early eighteenth century measurably increased the lifespan of the dentition, but also radically altered the prevalence of caries. This change is likely to have been responsible for a vast increase in dentally-related pain and suffering which was only capable of being tackled as a social problem by the advent of modern dentistry.     

The need for empirical studies in school consultation.

Conceptual models are not, as is often thought, constructed from logical deductions derived from observed facts, but rather, are postulated. Statements describing models are assumed and predictions are derived from them (Walker, 1963). Conceptual models are not lacking in school consultation literature. Yet aspects of our conceptual models have not received adequate scientific investigation, and there are those researchers and practitioners who have voiced doubts concerning the knowledge base for consultation, as well as fundamental assumptions underlying it. It is our assumption that such doubts can be resolved only by the most rigorous application of scientific method. With this aim in mind, we have devoted this issue to empirical studies in consultation. The goal of this issue is to present scientific endeavors that look at evidence systematically, without concern for where the data lead. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Cosmetics and the esthetic patient and laboratory communication

With increasing consumer awareness of the innovative procedures available for cosmetic dentistry, this area of practice is growing rapidly and has become an excellent source for patient referrals. Unfortunately, it can also be a large source of stress for the practitioner. Esthetics has been described by The Pocket Oxford Dictionary as "the philosophy of beautiful"; its perception varies from individual to individual. In the field of dentistry, there are criteria which define one tooth as being more esthetic than another and one individual's smile as more pleasing than another. However, that which is esthetically pleasing to the clinician may not be esthetically pleasing to the patient.     

Comparative study on gingival retraction using mechanochemical procedure and pulsed Nd = YAG laser irradiation

The aim of the present study was to study the tissue reaction and gingival healing in pulsed laser gingival retraction in comparison with chemico-mechanical gingival retraction technique. This work was applied on six patients recommended for orthodontic extraction of first premolars upper and lower. The patients were divided into three groups (two patients each). -One group with laser tissue retraction. -Another group with ferric sulphate (13.3%). -Third group with aluminium chloride (25%). The present histologic findings revealed that with the application of pulsed Nd: YAG laser the gingival tissues showed faster healing with less hemorrhage and less inflammatory reaction in comparison with the other two groups. In conclusion it was evident that pulsed laser is a surgical device increasingly important to dentistry. The present study can support with the clinical application of laser in gingival retraction as a simple convenient, painless method.