Trends in the level of evidence and impact of clinical studies published in leading oral implantology journals: 2008-2018

Level of evidence and characteristics of clinical studies published in leading prosthodontics journals

STATEMENT OF PROBLEM

Data on the level of evidence and the characteristics of studies published in peer-reviewed prosthodontic journals are lacking.

PURPOSE

The purpose of this study was to investigate the characteristics and level of evidence (LOE) scores of studies published in 3 leading peer-reviewed prosthodontic journals.

MATERIAL AND METHODS

Clinical studies published in the Journal of Prosthetic Dentistry (JPD), the Journal of Prosthodontics (JP), and the International Journal of Prosthodontics (IJP) in 2013 and 2020 were included in the analysis. Abstracts, letters to the editor, book reviews, and animal and laboratory studies were excluded from the investigation. For each study, design, type and LOE scores (Levels 1 to 5), publication year, impact factor (IF) of the journals, geographic origins of the first and corresponding authors, and funding status were recorded. Level 1 and Level 2 were defined as high evidence (HE), and Level 3, Level 4, and Level 5 were defined as low evidence (LE). Descriptive statistics and logistic regression analysis were performed (α=.05).

RESULTS

Among the 439 studies included in the analysis, the proportion of HE and LE studies was 14.1% and 85.9%, respectively. According to univariate and multivariate analysis results, year of publication (P=.010 and P=.029), geographic origin of the corresponding author (P<.001), and funding status (P<.001 and P=.002) were significantly associated with the LOE of a study. However, the journal IF was not associated with LOE (P=.328).

CONCLUSIONS

Although the number of HE studies in 3 leading prosthodontic journals has increased over time, the total number was still limited compared with LE studies. A further improvement in the overall LOE of clinical studies in prosthodontics is needed.

Mapping the trends and impact of research collaboration between countries in oral implantology publications: A bibliometric analysis from 1999 to 2019

STATEMENT OF PROBLEM

Scientific collaboration provides a suitable strategy for enhancing the exchange of knowledge and technological development. However, the impact of collaboration in oral implantology research between countries and how it has been influenced by the income status of the country has not been previously evaluated.

PURPOSE

The purpose of this bibliometric analysis was to evaluate how collaboration between countries affected oral implant publications and whether patterns of collaboration differ depending on the country's income.

MATERIAL AND METHODS

Articles were retrieved from 7 well-established journals whose scope included oral implantology at 5 time points (1999, 2004, 2009, 2014, and 2019). Data were extracted, and descriptive, bivariate, and multivariate logistic regression analyses were performed (α=.05).

RESULTS

A total of 1944 articles were included; of which, 27.5% presented collaboration between countries. In 2009, 2014, and 2019, collaboration between countries was more likely to occur than at previous time points (P≤.005). Corresponding authors with a higher h-index (P<.05) and authors from Europe and North America (P<.001) were more likely to establish international connections. The possibility of collaboration between countries was higher for animal studies (P<.001) and for articles published by Clinical Oral Implants Research (P=.026). Collaborations between high-income and upper-middle- or lower-middle-income countries were more likely to happen in 2014 and 2019 (P<.05), as well as when the number of authors was higher (P=.015), compared with collaboration between high-income countries. With regard to the continent, European articles were less likely to have collaborations with upper-middle- or lower-middle-income countries (P<.001).

CONCLUSIONS

The findings revealed that some parameters related to the study, authors, countries, and journals were statistically associated with the presence of collaboration between countries. However, the bibliometric parameters showed different trends when countries of different incomes established collaboration.

25 years of Clinical Implant Dentistry and Related Research (CIDRR): A modern bibliometric and Altmetrics network analysis

INTRODUCTION

Since its establishment in 1999, the journal of Clinical Implant Dentistry and Related Research (CIDRR) has consistently disseminated notable clinical and translational research within the domain of oral implantology. As the journal approaches its milestone 25th anniversary, this study endeavors to systematically delineate the publication trends, level of evidence, and bibliometric indices characterizing the initial quarter-century of CIDRR's scholarly activity. Notably, the investigation adopts a contemporary methodology by incorporating Altmetric analysis, thereby enriching the evaluation with an assessment of the broader societal and online impact of the published research.

METHODS

A comprehensive search was performed in SCOPUS and PubMed to access the bibliographic data of all articles published in the journal from 1999 to 2024. Additionally, Altmetric database was used to obtain social media attention scores (AAS). Journal's overall performance via impact factor and quartile range was assessed. Most cited papers were identified and the most prolific authors, institutions and countries and the collaboration networks among those were assessed. The level of evidence of all articles was determined based on Oxford level of evidence scale. All articles were categorized based on their major topic in the field of implant dentistry.

RESULTS

Throughout its first 25 years of activity, CIDRR published 1912 articles with an annual growth rate of 2.67% and consistently being ranked at Q1 quartile in "Dentistry (miscellaneous)" and "Oral Surgery" journal categories. When clinical studies are considered, level I and II evidence constituted 22.82% and 11.82% of all articles, respectively. Sweden, the USA, and Italy as well as Göteborgs Universitet, Sahlgrenska Akademin. and Malmö Högskola were the most prolific countries and institutions respectively. "Implant system/design/characteristics," "Bone Augmentation," and "Implant Prosthesis" were the top most investigated topics.

CONCLUSIONS

The examination of the journal's initial 25 years highlighted that CIDRR has surpassed similar dental research journals in publishing a greater number of high-level evidence articles. It also showcased diverse country- and author-collaboration networks. However, the journal's social media presence is still evolving. This article, presenting a comprehensive overview of the journal's scientometric and bibliographic activities, serves as a valuable reference for researchers, clinicians, and stakeholders, offering insights into both traditional and contemporary perspectives.

Five decades of research on immediate implant therapy: A modern bibliometric network analysis via Altmetric and level of evidence mapping

AIM

To conduct a bibliometric network analysis to explore the research landscape of immediate implant placement (IIP) and provide insights into its trends and contributors.

MATERIALS AND METHODS

The Scopus database was utilized as the bibliographic source, and a search strategy was implemented to identify relevant research articles. Various bibliometric parameters were extracted, including publication year, journal, authors, citations, and funding. The analysis involved examining authorship patterns, international collaborations, level of evidence, Altmetric data, and funding analysis.

RESULTS

We identified a steady annual growth rate of 6.49% in IIP research. The top three countries contributing to research output were the USA, Italy, and China. Prolific authors were identified based on publication and citation metrics. International collaborations among different countries were observed. The level of evidence analysis revealed that over 30% of the articles fell into higher levels of evidence (levels 1 and 2). Altmetric data analysis indicated no significant correlations between citation counts and Altmetric Attention Score (AAS), and conversely a significant association with Mendeley readers count. Funding and open access did not significantly impact the bibliometric indices of the papers.

CONCLUSIONS

The focus of research on IIP has been evolving as indicated by an exponential growth rate in this study. Only approximately 16% of the articles fit into level 1 evidence, therefore, emphasizing on higher quality level research study shortage in this field. Modern indices can be used as new bibliometric indicators as they also cover social media and online attention scores.

Industry support for dental implant research: A metatrend study of industry partnership in the development of new technologies

STATEMENT OF PROBLEM

Industry needs scientific knowledge to develop new products and services, and their financial support to dental implant researchers translates into commercial products. Therefore, identifying the relevant factors for a successful industry partnership is important.

PURPOSE

The purpose of this study was to provide a 20-year bibliometric overview of industry-sponsored studies in implant dentistry to identify possible factors involved in industry partnership motivations.

MATERIAL AND METHODS

A hand search of 6 of the most established journals in the implant dentistry field was performed for articles published in 1999, 2004, 2009, 2014, and 2019. Information regarding the continent of origin of the corresponding author, interinstitute collaboration, type and topic of research, and the h-index of the corresponding author was recorded for each included article. Bivariate and multivariate logistic regression was used to determine statistical relationship between industry support and exploratory factors (α=.05).

RESULTS

A 6% increase in the chance of industry investment was observed over the years (odds ratio [OD]=1.06; P<.001). Studies from North America (OD=4.87; P<.001) and Europe (OD=3.13; P<.001) were more likely to receive industry funding. Data also revealed a direct relationship between the increasing number of institutions involved in the study and the probability of industry funding (OD=1.21; P<.001). Animal studies (OD=2.26; P<.001) about surgical procedures and prosthodontic topics (OD=1.40; P=.044) stood out for having greater industry support. Researchers with an h-index between 31 and 40 were more likely to receive industry financial support (OD=2.46; P=.001).

CONCLUSIONS

Industry support for dental implant research was closely aligned with the continent of origin, interinstitute collaboration, type and topic of research, and the h-index of the corresponding author.

Level of evidence analysis of the Saudi Dental Journal: A bibliometric analysis of publications from 2012 to 2021

Objectives

The Level of Evidence (LOE) ranking system is used to measure the methodological quality of research. This study aimed to analyze and evaluate the trends of LOEs in articles published in the Saudi Dental Journal (SDJ) between 2012 and 2021.

Methodology

The bibliometric details of all articles published from 2012 to 2021 were extracted from the SDJ website. All articles, expect editorials, were included in the analysis. The articles were divided based on LOEs, dental specialties, number of authors, and centers. The citation metrics were obtained from Google Scholar, and the statistical analysis was performed using JMP Pro 15.2.0 software.

Results

Five hundred twenty-two articles were selected for analysis. They had an average of 21.19 citations per article, and a growing trend in the number of articles was observed. Authors from 40 countries contributed to the articles, with the most contributions from the Kingdom of Saudi Arabia. Most articles (n = 269; 51.53%) were LOE IV and V, while a low proportion (5.56%) were LOE I articles. Aside from miscellaneous articles, periodontics composed most of the LOE I studies, followed by endodontics, and oral and maxillofacial Surgery (OMFS). Orthodontics had the highest number of LOE II studies, pediatric dentistry had the most LOE IV, and prosthodontics had the most LOE V studies. No significant correlations were found between LOE and the number of authors or centers. However, a significant correlation was found in the distribution of LOE contributed by academic institutes.

Conclusion

The study results highlight that most articles were LOE IV and V, whereas nominal LOE I articles were found. Furthermore, there is a need to encourage dental scientists to carry out high-quality evidence studies. Professional dental societies can play a pivotal role in this regard.

Characteristics, level of evidence, and impact of clinical studies on peri-implantitis: 2017 to 2021

BACKGROUND

The level of evidence (LOE) is an important tool in current evidence-based practice and clinical research. However, in clinical studies on peri-implantitis, the present status of the LOE and its association with research impact remains to be determined. The present study aimed to gather the characteristics and LOE of clinical studies on peri-implantitis conducted from 2017 to 2021 and assess the association of the LOE with social and scientific impact.

METHODS

The PubMed database was searched to retrieve clinical studies that evaluated peri-implantitis-related healthcare interventions and were published between 2017 and 2021. A 4-level modified Oxford 2011 LOE tool was used to determine the LOE of these studies. Citation count and Altmetric Attention Scores (AAS) were derived from the Web of Science and Altmetric Explorer, respectively. Multivariate generalized estimation equation (GEE) analysis was conducted to explore relationships between the LOE and citation count, and between the LOE and AAS; the publication year was considered the grouping factor for adjusting for potential clustering effects.

RESULTS

Two hundred and thirty-five studies were considered eligible. The percentages by level from Level-1 to Level-4 were 9.8%, 35.7%, 28.9%, and 25.5%. Multivariable GEE analyses revealed that studies with higher LOE ratings had significantly greater citation counts (p = 0.008). However, no significant association (p = 0.872) was observed between the LOE and AAS.

CONCLUSIONS

From 2017 to 2021, more than 40% of studies published on peri-implantitis each year had high-LOE ratings. High-LOE studies showed a tendency to have greater scientific impact.

Scientific production of an oral implantology journal: a 5-year bibliometric study

Oral implantology is a science in constant evolution, with a considerable number of articles being published every year in scientific journals. Publications can be analyzed through bibliometric analysis, thus observing the evolution and trends of the articles published in the journal. To evaluate, through bibliometric analysis, the scientific production of Clinical Implant Dentistry and Related Research (CIDRR) and its evolution and trends in the last 5 years (2016-2020).All articles published in CIDRR in the last 5 years were reviewed and classified according to the year of publication, volume, number, the number of authors, demographic data of the first and last author, the geographical scope of the article, the number of affiliations of the authors, research topic, type of study, and study design. The association between these variables and citation counts was also analyzed. 599 articles were analyzed. 77.4% were authored by 4-6 authors, obtaining 78.4% from 1 to 3 different affiliations. Male researchers predominated in both the first and last authorship. China showed the highest number of publications when comparing the origin of the authors' affiliations individually; however, most researchers (40.9%) were from the European Union (EU)-Western Europe area. The most studied topic was the implant/abutment design/treatment of the surface (19.1%). Clinical research articles accounted for 92.99% of the publications, of which cross-sectional observational studies prevailed (21.7%). The presence of articles from the United States of America-Canada and EU-Western Europe was positively correlated with the impact factor. This study revealed an increasing trend in Asian research production, particularly Chinese, whereas production of European origin showed a decrease. Clinical studies increased their relative weight to the detriment of translational ones. A growing tendency in the relative weights of female authors was appreciated. Journal citations were associated with certain study variables.

Surgical interventions for implant placement in the anterior maxilla: A systematic scoping review with evidence mapping

OBJECTIVES

Simplification and standardization of interventions are critical challenges to improving performance in implant dentistry. This study aimed to systematically identify and schematically present the evidence base of the implant dentistry surgical interventions for the anterior maxilla as a basis for further development and standardization.

METHODS

Electronic searches were conducted in PubMed, Embase and Cochrane CENTRAL. Primary clinical studies reporting surgical interventions in the anterior maxilla, with a sample size of at least ten patients, were included. Bibliometric information and study details were extracted. Descriptive analysis and a mind map approach were used to describe the documentation of different surgical interventions.

RESULTS

Two hundred and seventy-two studies reporting on 9001 patients were included. Within the past two decades, the number of literatures on implant placement in the anterior maxilla has increased dramatically (7 studies before 2005, 151 studies after 2016). Overall, the evidence map identified six primary operations and 33 variations. For hopeless tooth extraction, immediate implant placement was the most frequently reported (141 studies, 4670 patients); flapless implant placement with hard tissue augmentation and immediate provisionalization was the most commonly reported variation (33 studies, 987 patients). Type 3/4 implant placement (62 studies, 1902 patients) and implant site augmentation (33 studies, 788 patients) were frequently reported for missing teeth. Geographical differences were observed, with type 2 placement studies almost exclusively from Europe.

CONCLUSIONS

Research on immediate implant placement was the most reported surgical intervention in the anterior maxilla. Hard tissue augmentation was frequently reported simultaneously with or before implant placement. Immediate provisionalization was mainly used for type 1 implant placement. The finding that six primary operations with 33 variations have been reported indicates the need for additional research to simplify and consolidate the surgical approach.

THE USE OF DENTAL PATIENT-REPORTED OUTCOMES AMONG RANDOMIZED CONTROLLED TRIALS IN ORTHODONTICS: A METHODOLOGICAL STUDY

OBJECTIVE

To identify and summarize the use and characteristics of dental patient-reported outcomes (dPROs) and dental patient-reported outcome measures (dPROMs) within randomized controlled trials (RCTs) published in 5 leading orthodontic journals.

METHODS

A manual search was conducted to identify intervention (therapeutic or preventive) related RCTs published in selected journals between 2015 and 2021. Two authors extracted the characteristics of each included trial, as well as all outcomes and outcome measures used in these trials independently and in duplicate. Thereafter, the use of dPROs and dPROMs was identified and summarized. We classified all dPROs into 2 general types (oral health-related quality of life [OHRQoL] and others) and dPROMs into 3 categories (single-item questionnaires, generic multiple-item questionnaires, and specific multiple-item questionnaires). We also identified whether these dPROMs assessed 4 dimensions of OHRQoL (Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact).

RESULTS

From 4631 examined articles, a total of 315 RCTs were included, of which 76 (24.1%) used dPROs and dPROMs. Eight different dPROs (OHRQoL, patients' satisfaction with treatment, difficulty, compliance, preference, efficacy, duration, and unwanted events) and 34 different dPROMs (including 13 single-item questionnaires, 7 generic multiple-item questionnaires, and 14 specific multiple-item questionnaires) were identified in these trials. OHRQoL was the most commonly used dPRO (n = 71; 93.4%), followed by patients' satisfaction with treatment (n = 10; 13.2%), patient-reported difficulty (n = 5; 6.6%), and patient-reported compliance (n = 4, 5.3%). The 4 most frequently used dPROMs were pain measured with 10 mm Visual Analogue Scale (n = 20; 24.1%), pain measured with Numerical Rating Scale (n = 11; 13.3%), the Feldmann's Questionnaire (2007) (n = 6; 7.2%), and the Oral Health Impact Profile 14 (n = 5; 6.0%).

CONCLUSION

Only about one-fourth of RCTs published in leading orthodontic journals can reflect patients' perspectives. OHRQoL was the most commonly used dPRO in these trials. Substantial heterogeneity exists among dPROMs used for OHRQoL assessment. Efforts are needed from researchers, reviewers, editors and other stakeholders to promote the wide and standardized use of dPROs in orthodontic research.

The reporting and methodological quality of split-mouth trials in oral implantology: A methodological study

OBJECTIVES

The objective of this study is to assess the reporting and methodological quality of split-mouth trials (SMTs) in oral implantology published during the past 10 years, and to investigate whether there was any improvement over time.

MATERIALS AND METHODS

We searched PubMed for SMTs in oral implantology published during 2011-20. We used CONSORT 2010, its extension for within-person trial (WPT), and an SMT-specific methodological checklist to assess trial reporting quality (TRQ), WPT-specific reporting quality (WRQ), and SMT-specific methodological quality (SMQ), respectively. Binary scores were given to each item, and total scores of TRQ (range 0-32), WRQ (0-15), and SMQ (0-3) were calculated for each study. Multivariable regression analyses were performed to compare the quality of SMTs published before (2011-17) and after (2018-20) the release of CONSORT for WPT.

RESULTS

Seventy-nine SMTs were included. The mean TRQ, WRQ, and SMQ were 16.4, 6.7, and 1.3, respectively. Less than one-third (n = 25, 31.6%) reported the rationale for using split-mouth designs. Only 4 (5.1%) trials adequately conducted sample size calculation, and 40 (50.6%) used appropriate statistical methods that considered dependency and clustering of data. In multivariable analyses, compared with 2011-17, studies published in 2018-20 had significantly higher TRQ (p = .044), while WRQ and SMQ did not show improvement.

CONCLUSIONS

The reporting and methodological quality of SMTs in oral implantology need to be improved. Joint efforts are needed to improve the reporting and methodology of SMTs in this field.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Bone preservation or augmentation simultaneous with or prior to dental implant placement: A systematic review of outcomes and outcome measures used in clinical trials in the last 10 years

AIM

To evaluate outcome measures and methods of assessment in clinical studies on bone augmentation/preservation procedures for the placement of dental implants.

MATERIALS AND METHODS

A systematic search was performed on three databases from January 2011 to April 2021 to identify clinical studies reporting on any type of bone augmentation/preservation procedure. The outcomes that have been used to assess efficacy or performance in each study were registered and assigned to different domains (group of outcomes). The review followed the Preferred Reporting Items for Systematic Review and Meta-Analyses statement.

RESULTS

Seven-hundred and eighty-three publications were included. Only 81.8% of the papers had a clear definition of their primary outcome. The rate of complications (59.3%), implant survival (58.2%), 3D radiographic bone gain/change (30%), marginal bone level (MBL; 29%), and histological outcomes (25.5%) were the most frequently reported outcome domains. The most commonly used primary outcome was 3D radiographic bone gain/change (25.8%), followed by implant survival (13.0%). Patient-reported outcome measures (PROMs) were reported in 15.7% of studies. Differences in the reported outcomes were observed among different types of bone preservation/augmentation interventions (i.e., alveolar ridge preservation, immediate implants, horizontal and/or vertical ridge augmentation, and sinus floor augmentation).

CONCLUSION

Within the past decade, great heterogeneity was observed among the outcomes considered in studies evaluating bone preservation/augmentation procedures. Three-dimensional radiographic bone gain/change was the most routinely reported main outcome variable, while PROMs were rarely reported.

Association between industry support and the reporting of study outcomes in randomized clinical trials of dental implant research from the past 20 years

BACKGROUND

Industry support is a significant funding source in implant dentistry research, not only to provide regulatory processes, but also to validate and promote products through randomized clinical trials (RCTs). However, industry funding should not affect scientific outcomes.

PURPOSE

The aim of this study was to investigate whether there is an association between industry support for RCTs in implant dentistry and a greater chance of the reporting of positive outcomes, and whether there are other funding tendencies.

MATERIALS AND METHODS

Randomized clinical trials from five implant dentistry journals were reviewed. Data were extracted, and descriptive and inferential statistical analyses (α = 0.05), including bivariate and multivariable logistic regression, and Spearman's correlation were performed.

RESULTS

Two hundred eleven RCTs were included. Industry-funded and -unfunded studies presented similar outcomes, in terms of positive and negative results (p ≥ 0.05). North American and European countries received more industry funding, as did high-income countries, which showed well-established collaboration with each other. Clinical Oral Implants Research and Clinical Implant Dentistry and Related Research published 83.6% of industry-funded articles. Industry-funded studies from middle-income countries established more international collaborations with high-income countries than did unfunded studies. Citation numbers were similar for funded and unfunded studies. The chance of RCTs being industry-funded was higher for high-income (odds ratio [OR] = 3.00; 95% confidence interval [CI], 0.99-9.32; p = 0.05) and North American articles (OR = 3.40; 95% CI, 1.37-8.42; p = 0.008) than in lower-middle-income and other continents, respectively. Higher industry funding was associated with specific topics such as "surgical procedures," "prosthodontics topics," and "implant macrodesign" (OR = 4.7; 95% CI, 1.45-15.20; p = 0.010) and with the increase in numbers of institutions (OR = 1.52; 95% CI, 1.16-2.0; p = 0.002).

CONCLUSION

The available evidence suggests no association between industry funding and greater chances of the reporting of positive outcomes in implant dentistry RCTs. A strong association was identified in industry trends concerning geographic origins, higher numbers of institutions, and specific research topics.

Annual review of selected scientific literature: A report of the Committee on Scientific Investigation of the American Academy of Restorative Dentistry

The Scientific Investigation Committee of the American Academy of Restorative Dentistry offers this review of the 2020 professional literature in restorative dentistry to inform busy dentists regarding noteworthy scientific and clinical progress over the past year. Each member of the committee brings discipline-specific expertise to this work to cover this broad topic. Specific subject areas addressed include prosthodontics; periodontics, alveolar bone, and peri-implant tissues; implant dentistry; dental materials and therapeutics; occlusion and temporomandibular disorders (TMDs); sleep-related breathing disorders; oral medicine and oral and maxillofacial surgery; and dental caries and cariology. The authors focused their efforts on reporting information likely to influence day-to-day dental treatment decisions with a keen eye on future trends in the profession. With the tremendous volume of dentistry and related literature being published today, this review cannot possibly be comprehensive. The purpose is to update interested readers and provide important resource material for those interested in pursuing greater detail. It remains our intent to assist colleagues in navigating the extensive volume of important information being published annually. It is our hope that readers find this work useful in successfully managing the dental patients they encounter.