Dental Group Research Articles

Comparison of the reproducibility of results of a new peri-implantitis assessment system (implant success index) with the Misch classification.

ObjectivesThe present study was conducted to determine the reproducibility of peri-implant tissue assessment using the new implant success index (ISI) in comparison with the Misch classification.Materials and MethodsIn this descriptive study, 22 cases of peri-implant soft tissue with different conditions were selected, and color slides were prepared from them. The slides were shown to periodontists, maxillofacial surgeons, prosthodontists and general dentists, and these professionals were asked to score the images according to the Misch classification and ISI. The intra- and inter-observer reproducibility scores of the viewers were assessed and reported using kappa and weighted kappa (WK) tests.ResultsInter-observer reproducibility of the ISI technique between the prosthodontists-periodontists (WK=0.85), prosthodontists-maxillofacial surgeons (WK=0.86) and periodontists-maxillofacial surgeons (WK=0.9) was better than that between general dentists and other specialists. In the two groups of general dentists and maxillofacial surgeons, ISI was more reproducible than the Misch classification system (WK=0.99 versus WK non-calculable, WK=1 and WK=0.86). The intra-observer reproducibility of both methods was equally excellent among periodontists (WK=1). For prosthodontists, the WK was not calculable via any of the methods.ConclusionThe intra-observer reproducibility of both the ISI and Misch classification techniques depends on the specialty and expertise of the clinician. Although ISI has more classes, it also has higher reproducibility than simpler classifications due to its ability to provide more detail.

A Study of Patient Satisfaction with Maxillary Anterior Teeth Restorations and Desirable Esthetic Treatment Options

Method:650 patients participated in the study , divided into 4 age groups. A structured, interviewer- guided questionnaire was used to identify patient satisfaction with their general dental appearance, cosmetic elements and desired treatments .Their maxillary anterior teeth status was classified into 4 groups: (1) Composite filling group (CFG) (2) Porcelain jacket crown group (PJCG) (3) Fixed partial denture group (FPDG) (4) Removable partial denture group (RPDG). The participants judged appearance and tooth colour using 3-point scale: dissatisfied, moderately dissatisfied and satisfied. Their desired esthetic treatment options were assessed. Results: The overall rating of satisfaction was moderate; almost 39.5% patients were completely satisfied with their dental appearance and tooth colour. A significant difference was observed for both the dental appearance and the tooth colour between different maxillary anterior teeth status groups and between different age groups (p < 0.05) .The majority of individuals with CFG and FPDG were completely satisfied, while those with PJCG and RPDG were dissatisfied with their dental appearance and tooth colour (p < 0.05). 50.9% patients wished to have their teeth whitened. Conclusion: Aesthetic attitudes towards the maxillary anterior teeth appearance and colour differed both between different age groups and different maxillary anterior teeth status groups. Dissatisfaction with tooth color,protruding teeth and unesthetic fillings were common and females were more dissatisfied than males in appearance.Tooth whitening was the most desired treatment to improve the esthetics.

Factors Affecting Self-reported Implementation of Evidence-based Practice Among a Group of Dentists

ObjectiveThe study aimed at assessing the factors affecting the implementation of evidence-based practice (EBP) among a group of dentists in Saudi Arabia. MethodsA cross sectional study design was used where a link to an electronic questionnaire was posted on the websites of the Saudi Dental Society and a social networking site for dentists. The questionnaire was available for three months after which responses were downloaded and analyzed. Descriptive statistics were calculated for various variables and logistic regression analysis was used to identify factors with significant effect on the implementation of EBP. ResultsImplementation of EBP was reported by 69.3% of respondents. Most respondents reported knowing and using MEDLINE and being able to search for evidence. The most frequently reported barriers were lack of time and availability of evidence. Factors that significantly affected the implementation of EBP were 1) having some knowledge of terms related to EBP, 2) reporting lack of EBP skills as a barrier, and 3) reporting resistance to change as a barrier. ConclusionsBackground knowledge related to EBP and training in its skills are needed for the implementation of EBP whereas the presence of resistance to change does not necessarily prevent its implementation.

Reproducibility and Diagnostic Outcomes of Two Visual-Tactile Criteria Used by Dentists to Assess Caries Lesion Activity: A Cross-Over Study

The aim of this study was to evaluate the reproducibility and differences in diagnostic outcomes by practicing dental clinicians previously inexperienced in using the Nyvad criteria and the ICDAS II criteria with the Lesion Activity Assessment system (ICDAS II + LAA). Four volunteer dentists were randomly allocated to one of two groups. Both groups of dentists examined the same voluntary sample (n = 140) of caries active young adults using Nyvad and ICDAS II + LAA criteria in different sequences. The first group used the Nyvad criteria during period 1, followed by ICDAS II + LAA during period 2; the second group did the examinations in the opposite sequence. Before the period 1 and 2 examinations, dentists from both groups were trained with the Nyvad or ICDAS II + LAA criteria, depending on the group to which they were assigned. Intra-examiner agreement for lesion severity was high for both diagnostic instruments (weighted kappa 0.62-0.80). For lesion activity the intra-examiner unweighted kappa values ranged from 0.31 to 0.61 for ICDAS II + LAA and from 0.36 to 0.51 for Nyvad. The mean number of active non-cavitated caries lesions was significantly higher for ICDAS II + LAA (6.14 ± 5.4) than for Nyvad (3.90 ± 3.9) (p < 0.001). Active cavitated/dentinal caries lesions were significantly higher for ICDAS II + LAA (4.14 ± 4.1) than for Nyvad (2.13 ± 3.1) (p < 0.001). Both the Nyvad and ICDAS II + LAA diagnostic criteria showed high reproducibility for lesion severity assessment. The mean number of active caries lesions among high caries risk subjects was significantly higher using the ICDAS II + LAA criteria, which may subsequently lead to more caries treatment. Trial registration: ISRCTN65592532.

SAMS – A Systems Architecture for Developing Intelligent Health Information Systems

In this paper, SAMS, a novel health information system architecture for developing intelligent health information systems is proposed and also some strategies for developing such systems are discussed. The systems fulfilling this architecture will be able to store electronic health records of the patients using OWL ontologies, share patient records among different hospitals and provide physicians expertise to assist them in making decisions. The system is intelligent because it is rule-based, makes use of rule-based reasoning and has the ability to learn and evolve itself. The learning capability is provided by extracting rules from previously given decisions by the physicians and then adding the extracted rules to the system. The proposed system is novel and original in all of these aspects. As a case study, a system is implemented conforming to SAMS architecture for use by dentists in the dental domain. The use of the developed system is described with a scenario. For evaluation, the developed dental information system will be used and tried by a group of dentists. The development of this system proves the applicability of SAMS architecture. By getting decision support from a system derived from this architecture, the cognitive gap between experienced and inexperienced physicians can be compensated. Thus, patient satisfaction can be achieved, inexperienced physicians are supported in decision making and the personnel can improve their knowledge. A physician can diagnose a case, which he/she has never diagnosed before, using this system. With the help of this system, it will be possible to store general domain knowledge in this system and the personnel's need to medical guideline documents will be reduced.

Lip Asymmetry and Smile Aesthetics

Objective : To determine if lip asymmetry can affect lip aesthetics. Setting and Participants : A group of dentists (n = 40) and cleft patients (n = 40) were recruited from the dental hospital and cleft service. Interventions : Still photographic digital images of lips and teeth were manipulated to produce a computerized gradient of smile appearance with different degrees of upper-lip vertical asymmetry. These five photographs (with 0 mm representing "symmetry," and 1, 2, 2.5, and 3 mm, asymmetries) were assessed by participants using a 5-point Likert scale. Statistics : Descriptive statistics in addition to chi-square test were used to analyze the data. In order to satisfy the requirement of the chi-square test, the five smile ratings were reduced to three. Results : Lip asymmetry did affect relative smile aesthetics, as determined by dentists and cleft patients. Both the dentists and cleft patients rated the 0-mm photograph more attractive than the 2.5-mm and 3-mm smiles (P < .05). The 0-, 1-, and 2-mm smiles were indistinguishable for both dentists and cleft patients. Conclusion : Lip asymmetry affects smile aesthetics. However, cleft patients and dentists were tolerant of minor asymmetries. This suggests that small degrees of lip asymmetry do not affect relative smile aesthetics as much as large degrees of lip asymmetry (2.5 mm or more).

Attitudes and Behaviour regarding Deep Dentin Caries Removal: A Survey among German Dentists

Incomplete removal of deep caries has been shown to reduce the risks of pulp exposure and postoperative pulpal complications. It is therefore of interest whether dentists perform one- or two-step incomplete excavation, and which criteria and methods they use to assess and provide removal of deep caries. This study investigated the attitudes and behaviour of dentists in northern Germany using a new, validated questionnaire. The survey included 2,346 practitioners, 821 (35%) of whom responded. Demographic and sensitivity analysis did not indicate selection bias. 50% of dentists considered only complete excavation, even if pulp exposure was likely. If caries was to be removed incompletely, 77% considered two-step excavation. Hardness was the most important criterion to assess excavation. To treat an exposed pulp, 75% of dentists considered direct capping, 70% refused incomplete excavation fearing caries progression or pulp damage, and 59% reported to prefer more invasive treatment to facilitate restoration longevity. Over 50% recognised an influence of professional regulations on their treatment decisions. There was a moderate correlation between attitudes and behaviour of dentists, with dentists who suspected residual caries to be harmful rejecting incomplete excavation and vice versa. Cluster analysis identified two groups of dentists with opposite attitudes and behaviour, independently from dentist's age or gender. In conclusion, the majority of surveyed dentists was sceptical about leaving caries during excavation and does not practice incomplete caries removal. Therefore, benefits of partial excavation should be highlighted in under- and postgraduate education and regulatory incentives modified to promote minimally invasive techniques.

Regional density of private dentists: empirical evidence from Austria

We investigated the determinants of disparities in the regional density of private dentists in Austria. Specifically, we focused on the relationship between the density of private dentists and their public counterparts, thereby controlling for other possible covariates of dentist density. Dentist density was measured at the district level. We used panel data of dentist density from 121 Austrian districts over the years 2001-2008. We applied a Hausman-Taylor framework to cope with possible endogeneity and to control for cross-district effects in the dentist density. A significant negative relationship was found between the density of private and public dentists, indicating a substitution effect between the two dentist groups. A significant positive spatial relationship also existed for private and public dentists in the neighboring regions. Dental capacities in public and private hospitals and dental laboratories run by the public health insurance system did not have a significant effect on private dentist density. Although a strong negative relationship existed between private and public dentists within the districts, one should not draw the conclusion that private dentists in Austria are close substitutes for public dentists. Such a conclusion would require further empirical analysis on the utilization patterns of dental services and their relationships with financing mechanisms.

Patient safety incident prevention and management among Finnish dentists

Objective. Assessing current patient safety incident (PSI) prevention measures and risk management practices among Finnish dentists. Materials and methods. A total of 1041 dentists practicing in the private or public sectors in southern Finland completed an online questionnaire concerning PSI prevention, PSI-reporting systems, feedback and knowledge gained from device incidents and patient-generated safety information and the knowledge of national PS-guidance. The answers were handled anonymously. Statistical evaluations were performed using chi-square analysis. Results. Dentists suggested multiple methods for preventing PSIs related to dental diagnostics, various treatments, equipment and devices, medications, communication, infection control and general practice safety. Preventive methods reported most frequently included working with caution and forethought, keeping accurate patient records and the availability of correct patient information. A special PSI-reporting system was used by less than one third of respondents. Feedback received on PS-related data and the utilization of guidebooks varied significantly between the studied dentist groups. Conclusions. Several PSI prevention techniques are already used in Finland. However, wide variation exists in PSI prevention and risk management practices among Finnish dentists. Systematic implementation of available safety methods would probably prevent several PSIs. The results indicate that the more dentists know about PS risks, the easier it is for them to recognize situations possibly leading to patient harm. Anonymous PSI reports, patient complaints and claims data should, therefore, be actively used for mutual learning. Increased PS education in dentistry is also needed.

A Program to Recruit and Mentor Future Academic Dentists: Successes and Challenges

There is a continuing shortage of academic dentists due to myriad factors. However, each graduating class of dental students includes a select group who choose to explore academic positions. It is this group of potential academic dentists that a four-year R25 initiative, funded by the National Institute of Dental and Craniofacial Research, has targeted with the intent of increasing their numbers and mentoring them for success in a future faculty position. The aims of the program at the School of Dentistry, University of California, Los Angeles, are to target and recruit potential clinician-scientists and to design and implement an Academic Track (AT) that complements existing clinical and research training with the comprehensive skill set of pedagogical, organizational, and personal strategies necessary to be successful in an academic career. Recruitment to the AT targeted candidates from a variety of sources including those enrolled in the dual D.D.S./M.S. and D.D.S./Ph.D. programs, dental residents, Ph.D. candidates in other disciplines, and predental students. Through a variety of professional development activities in the AT, selected students receive teaching, leadership, and mentoring experiences. Outcomes and lessons learned related to specific activities and lessons learned are presented in this article, and a model that recognizes the diverse paths to an academic career in dentistry is recommended.

Clinical interpretation of a masticatory normative indicator analysis of masticatory function in subjects with different occlusal and prosthodontic status

ObjectivesTo analyse the masticatory function of subjects characterised by different occlusal and prosthodontic status. Using Optosil® as a test food, the masticatory normative indicator (MNIOPT) was used to differentiate between sufficient (‘normal’) and impaired masticatory function. MethodsOutcomes of occlusal force and masticatory tests were aggregated from three earlier studies dealing with four denture groups and three natural dentition groups. The four denture groups had a complete removable dental prosthesis in the upper jaw, and displayed one of the four following lower jaw prosthodontic rehabilitations: (i) complete removable dental prosthesis on a low mandible; (ii) complete removable dental prosthesis on a higher mandible; (iii) overdenture on natural roots; and (iv) overdenture on dental implants. The three natural dentition groups were: (i) shortened dental arch; (ii) complete dentition in older participants, and (iii) complete dentition in younger participants. All participants were women. They performed the same tests twice, and outcomes were averaged. ResultsA MNIOPT value of 3.68mm was determined from the participants with complete natural dentitions. Applying the MNIOPT to the participants in the denture groups pointed at a considerable chance for impaired masticatory function, except for participants in the overdenture –implants group. The four denture groups compensated for reduced masticatory efficiency by increased number of masticatory cycles and prolonged mastication time until ‘swallowing’. Nevertheless, they also ‘swallowed’ larger particles compared to the complete dentition group. Clinical significanceFor a given patient or for a group of subjects with specific dental conditions, MNI enables to discriminate between a sufficient (‘normal’) and an impaired masticatory function.

İmplant destekli overdenture ve klasik tam protezlerin hasta memnuniyeti açısından karşılaştırılması

Objectives: The aims of this study were toevaluate satisfaction of patients used implantretained overdentures and conventional completedentures, and to investigate the effect ofsociodemographic properties on satisfaction.Materials and Methods: Forty two patients, 27female and 15 male,used implant-retainedoverdentures and conventional complete dentureswere included in this study, who attended toUniversity of Yeditepe, Faculty of Dentistry in2011. A questionnaire was prepared and distrubutedto evaluate the patient satisfaction levels about theirdentures and sociodemographic properties such asage, gender, education, marital and income status.The answers were asked to give as not satisfied,satisfied, very satisfied. Chi-square test and Fisher’sExact Chi-square test were used to analyze thequantitative data. An alpha level of 0.05 was usedfor all statistical analyses.Results: The mean age of the 42 patients(64.3% female, 35.7% male) was 62.26. It wasobserved that patients with higher educational levelprefered implant-retained overdentures, comparedto conventional complete dentures.In theconventionalcomplete denture group, highernumbers of patients were very satisfied with thecleanabilitycompared to implant-retainedoverdenture group. (p=0.039). There was nostatistically significant differences betweenimplant-retained overdentures and conventionalcomplete denture groups with regard to satisfactionlevel of esthetic, chewing, speech, retention andcomfort.Conclusions:It can be concluded thatsociodemographic factors did not affect thesatisfaction of different denture types. The patientswith conventional complete dentures were moresatisfied with the cleanability, compared to implantretained overdentures.

All on Four® Fixed Implant Support Rehabilitation: A Masticatory Function Study

Fixed implant-supported prostheses according to All-on-Four® (Nobel Biocare, Goteborg, Sweden) principles have become an accepted treatment modality in totally edentulous patients, whereas the functional effect of this therapy is limited. The purpose of this study was to evaluate the muscular function of patients totally rehabilitated with All-on-Four. This study evaluated 63 patients. Twenty-one patients were successfully rehabilitated with maxillary and mandibular All-on-Four (no dropout implants, satisfactory aesthetic and function demands prosthesis), 21 patients were dentate, and 21 were rehabilitated with double complete dentures. Electromyography was carried out during clenching, nonhabitual and habitual chewing, and rest. All values were standardized as percentage of a maximum voluntary contraction. Data were analyzed by ANOVA to compare groups and paired t-test was used for comparison between sides within each group. All groups presented symmetric muscular activity. The All-on-Four and dentate groups had a similar muscles surface electromyography (sEMG) contraction pattern, that is, a higher sEMG activity of masseter than temporalis muscles, differing (p ≤ .05) from those of denture group. Not one statistical difference was found between All-on-Four and dentate groups. The muscular function similarity of All-on-Four and dentate patients shows that this treatment concept may be considered as a good option for oral rehabilitation in edentulous patients.

Prevalence and Contributing Factors of Musculoskeletal Pain among a Group of Dentists in Bengaluru

Prevalence and Contributing Factors of Musculoskeletal Pain among a Group of Dentists in Bengaluru

Antibiotic Prescribing Habits of Dental Surgeons in Hyderabad City, India, for Pulpal and Periapical Pathologies: A Survey

Aim. To determine the antibiotic prescribing habits for pulpal and periapical pathology among dentists in Hyderabad city, India. Methodology. A total of 246 questionnaires were distributed to all the dentists registered with the local dental branch. Demographic details and questions regarding type and dosage of antibiotics prescribed for allergic and nonallergic patients were recorded. Inferential statistics were performed, and P < 0.05 was considered statistically significant. Results. The response rate for the study was 87.8%. Around 148 (68.5%) of respondents regularly prescribed antibiotics for endodontic management. The first antibiotic of choice for patients with no history of medical allergies was a combination of amoxicillin and metronidazole, followed by amoxicillin alone (29.1%). The first antibiotic of choice in case of allergy to penicillin was erythromycin. Necrotic pulp with acute apical periodontitis with swelling and moderate/severe preoperative symptom was the condition most commonly identified for antibiotic therapy (92.1%). Conclusion. The present study reveals that the overall antibiotic prescribing practices among this group of dentists were quite high, and there is a need for more educational initiatives to rationalize the use of antibiotics in dentistry.

The Influence of Relining or Implant Retaining Existing Mandibular Dentures on Health-Related Quality of Life: A 2-Year Randomized Study of Dissatisfied Edentulous Patients

The purpose was to assess and compare self-reported oral health and oral and general health related quality of life (OHRQoL and HRQoL) in two groups of edentulous adults who reported dissatisfaction with their mandibular dentures, and who were treated with a conventional relining of this denture or by having it converted into an implant-retained one. Sixty subjects were randomly allocated into two equal groups, a relined conventional denture (RCD) group and an implant-retained overdenture (IOD) group. Data on demographics, oral health, OHRQoL, and HRQoL were recorded by means of a self-administered questionnaire at baseline, 3 months, and 2 years. Fifty-four subjects completed the protocol, 28 in the IOD-group and 26 in the RCD-group. The IOD group reported significant improvement in oral health and Oral Health Impact Profile (OHIP-20) sum score and all its domains after 3 months. The improvements remained stable at the 2-year control. The RCD group reported almost no significant improvements. Neither group reported improved HRQoL. The results of this study support the findings from other RCT studies that to implant-retain the mandibular denture significantly improves self-reported oral health and OHRQoL. This treatment modality should be a minimum standard of care in complete denture wearers dissatisfied with their mandibular denture.

Comparative Analysis of Colony Counts of Different Species of Oral Streptococci in Saliva of Dentulous, Edentulous and in those Wearing Partial and Complete Dentures

To study and compare the number of colony forming units of Streptococcus mutans, Streptococcus sanguis, Streptococcus salivarius, Streptococcus mitis and Streptococcus milleri in dentulous, edentulous and in those wearing partial and complete dentures by using semi-quantitative culture method of saliva samples with calibrated standard loop. Sterile specimen collection bottles, Mitis salivarius agar plates, Standard loop, Candle jar, Incubator, Colony counter. Study population consisted of 100 subjects with 25 in each group, with an age range of 40 to 80 years, who were attending the Department of Community Dentistry and Prosthodontics at MNR Dental College, Sangareddy, Hyderabad. Unstimulated saliva samples were collected from patients and inoculated on to Mitis salivarius agar plates using calibrated standard loop. The plates were then incubated anaerobically at 37°C for 24 hours and left at room temperature for further 24 hours. Using a colony counter, the number of colonies of each species was counted. Streptococcus mutans and Streptococcus mitis predominates in the dentulous group, Streptococcus sanguis in complete denture group, Streptococcus salivarius in edentulous group and Streptococcus milleri in removable partial denture group. The results of our study are in accordance with the previous studies, which have sought to differentiate different groups of mutans streptococci using a simple calibrated standard loop.

Evaluating the head posture of dentists with no neck pain

Dentistry is one of the professions that requires a high degree of concentration during the treatment of patients. There are many predisposing factors, affecting dentists when working on the patient's teeth, including neck flexion, arm abduction and inflexible postural positions, which may put them at the risk of developing musculoskeletal disorders related to the neck. Although dentists with long records of service show different levels of pain and discomfort in their necks, there is no evidence regarding whether younger dentists report neck pain before the onset of an abnormal condition in this region, including forward head posture (FHP). Discovering any alteration in the head posture of dentists might confirm one of the reasons for neck pain in this population. Forty one dentists with no neck pain and forty controls having jobs other than dentistry who had no risk factors related to head posture voluntarily participated in the present study. A standard method was used to measure the cervical curve in these two groups. There was no significant difference between the mean values of cervical curve in dentists and the control group (p > 0.05). There was also no significant difference between cervical curve values in dentists working for either 5-8 years or 8-12 years (p > 0.05). The only significant difference was observed in mean cervical curve values of men and women in the dentist group (p < 0.05). No alteration of cervical curve in the dentist group compared to controls might be due to absence of pain sensation in the dentists in the current study. In other words, this group might have not yet experienced sufficient change in head posture to experience significant pain in their neck region.

An analysis of the implant‐supported overdenture in the edentulous mandible

This investigation examined the cumulative survival rate of the implant-supported overdenture using two types of attachments in patients treated at Show Chwan Memorial Hospital Implant Center from 1992 to 2006. Fifty-one patients (30 men and 21 women) were treated with mandibular implant-supported overdentures. Attachment systems used were the Hader bar with bilateral, cast ERA attachments (Group A, 31 patients with 15 men and 16 women, 134 implants) and the Hader bar with bilateral, distal extension cantilevers (Group B, 20 patients with 15 men and 5 women, 85 implants). Two hundred and four implants remained at the end of the follow-up period. Among failed implants, 10 implants were in Group A (failure rate: 10/134 = 7·5%), whereas five implants were in Group B (failure rate: 5/85 = 5·9%). Sixty-six point seven per cent (10/15) of failed implants were placed in the distal anterior mandible, and 33·3% (5/15) were placed in the middle anterior mandible. Survival was also examined with respect to condition of the opposing arch. Patients wearing a maxillary removable partial denture had the highest implant failure rate (5/51 = 9·8%), whereas the failure rate of the maxillary complete denture group was only 5·7%. The most frequent need for maintenance was wear over patrix component of ERA or Hader clip (n = 56). Eight patients experienced connector fracture between ERA and Hader bar, and one experienced distal extension cantilever fracture. The implant-supported overdenture can be an effective and reliable alternative to the conventional complete mandibular denture. Fewer prosthetic complications were seen in overdentures retained with distal extension cantilever attachments.

Knowledge and practice of behavioral management principles among dentists treating adults with learning disabilities

This study investigated U.K. dentists' knowledge and practice of behavioral management principles (BMPs) as applied to adults with learning disabilities (AWLD). A postal questionnaire enquired into the dentists' experience in managing AWLD, utilization of behavioral management techniques, and knowledge of BMPs. The response rate was 41% (N = 53). Two groups were investigated: specialists (dentists registered on the Special Care Dentistry specialists' list, n = 37) and nonspecialists (dentists not on the list, n = 16). Although specialists treated more AWLD than nonspecialists, both groups of dentists reported they felt highly confident in managing AWLD. However, all dentists' knowledge of the principles of nonpharmacological BMPs was low. Specialists had a tendency to use a greater range of nonpharmacological behavioral management techniques compared to non-specialists. These results suggest that dental team members need more training in the theory and practice of BMPs, which might lead to less reliance on costly pharmacological interventions and a clinical experience that is more respectful of the dignity and independence of AWLD.