Orthodontic Programs Research Articles

Resident Evaluation of Orthodontic Programs in the United States

The objective of this study was to investigate the satisfaction of orthodontic residents in the United States with their programs and determine the scope of their training. Program chairs/directors of all sixty-five U.S. orthodontic graduate programs were contacted for permission to email their residents. A total of 335 residents from thirty-seven programs were invited to complete an anonymous, online, fifty-seven-item survey in May 2007. Data were categorized, and basic statistics were performed. A total of 136 (40.60 percent) residents completed the survey. Overall, 75.74 percent were satisfied with their program. Residents said they feel they receive appropriate didactic teaching sessions and dedicated academic time (60.29 percent). Most residents (92.70 percent) indicated their program offers training in numerous philosophies, while 80.29 percent said they have sufficient clinically based training and 59.85 percent said they have sufficient research-based training. A total of 57.66 percent said they will not complete more than thirty cases from start to finish and on average treat two orthognathic surgery, thirteen extraction, twenty-four nonextraction, and nine adult patients. Most (92.70 percent) said their program contains care for disabled or underserved patients; most (92.70 percent) said they feel they will be adequately prepared to provide unsupervised orthodontic care after graduation; and 54.41 percent said they think other specialties have a positive view of orthodontics. Only 58.09 percent indicated they have a formal interdisciplinary program for treating patients. We conclude that U.S. orthodontic residents are satisfied with their programs. They receive training in a variety of approaches; however, inadequacies in exposure to interdisciplinary teaching and a limitation of the number of cases started and completed were identified. These observations may be a result of program length due to the preponderance of twenty-four- to thirty-month programs.

Working with DICOM craniofacial images

The increasing use of cone-beam computed tomography (CBCT) requires changes in our diagnosis and treatment planning methods as well as additional training. The standard for digital computed tomography images is called digital imaging and communications in medicine (DICOM). In this article we discuss the following concepts: visualization of CBCT images in orthodontics, measurement in CBCT images, creation of 2-dimensional radiographs from DICOM files, segmentation engines and multimodal images, registration and superimposition of 3-dimensional (3D) images, special applications for quantitative analysis, and 3D surgical prediction. CBCT manufacturers and software companies are continually working to improve their products to help clinicians diagnose and plan treatment using 3D craniofacial images.

Advanced Orthodontic Education As Seen by the Prospective Resident

An interesting evolution is going on in the developing future of our discipline. You cannot read the media without becoming aware of the cost problems facing higher education in the United States. We still see a remarkable number of very high-quality applicants for advanced orthodontic programs, but the demographics and perhaps the behavior may be changing.If you go to the AAO member site and log in, click on meetings and education and click on accredited schools, you can find a listing of all of the schools in the United States and Canada with detailed data on their offerings to students. These data were derived from the report of the program directors or department chairs to the AAO.Among these data are a great many details of program length, cost, stipends, etc, which can impact heavily on future classes. For example, it probably will not be surprising to see that the hospital-based programs dominate the list of programs that are financially most beneficial to the student. What caught me by surprise was finding that the school-based programs are still more competitive for admission than the hospital-based programs based on the applications to acceptance ratio. Indeed, the best deal for the student results in a program paying students stipends that can result in over $150,000 net gain whatever tuition is charged (if there is any tuition at all). These figures are totals over the total length of the program, be it two or three years. The difference is that these students are treated as residents and funded similarly to medical (and some advanced dental) residents. Here are the top five programs with totals for the program as listed:At the other end of the list of schools are programs that result in $150,000 net gain to $195,000 net cost to the student. These programs are often in private schools, pay no stipends, and have a hefty tuition charge. That is a difference of over $300,000 in cost for a student to attend these programs as compared with the hospital-based programs. Here are the most expensive five programs with totals for the program as listed:This cost is above the room and board costs and, of course, are added on top of the debt that may have been incurred in the preceding prior bachelor and DDS programs. Thus, it is not surprising that we are graduating students with very considerable six-figure educational debts. If loans are part of the picture, these figures have long since used up the government-backed loans and require private loans with higher interest rates, making education even more costly.Is this a personal problem or does it have a cost in some other ways? Whatever other ways you may think of, it seems to me that it very likely could impact orthodontic practice. Can a new graduate with potential debts of this magnitude avoid being influenced when it comes time to make a judgment call for a patient? We all know treatment decisions that are left up to a patient will be strongly impacted by how they are presented by the doctor. Can a new graduate who was forced to carry educational debt of the magnitude that we see today still place the patient's best interest first? Imagine the situation where these debts all exist and are calling for repayment. At this point in your life you have put off new cars, buying a home, etc. The pressure to do the right thing for each patient could be jaundiced by these needs to stay in operation.This situation was not brought on by orthodontists. Schools have long seen orthodontic programs as programs that capture most of the best students. The clinic income issue is another whole story and is clearly viewed as a cash cow in some quarters. According to the 2006–2007 ADA Survey of Advanced Dental Education, orthodontics has the highest first-year tuition of any dental specialty program and the greatest differential between tuition cost and any stipend paid by any dental specialty.It is human nature to not deal with a situation like this until some clear damage has already occurred, even though we know that prevention is more efficient than treatment. In a sense, we are victims of orthodontics’ own achievements. Our predecessors left us great careers. It's time for our stewardship to take a greater role.

The Association of Malocclusion Complexity and Orthodontic Treatment Outcomes

To determine the relationship of the ABO Discrepancy Index (DI) to outcomes for routine malocclusions, and to ascertain whether significant trends in DI scores could be noted among annual samples of patients taken from 1998 to 2004. A total of 716 consecutive patients with permanent dentition from a large urban graduate orthodontics program were sampled over the 7-year span. A group of six researchers with a dental background were trained and calibrated in the various components of the DI method to ensure reproducible criteria and accurate recording of clinical and radiographic data across researchers. Data management and analyses were undertaken by two other investigators who were not involved in data coding. Only a weak positive association was seen between the DI and Objective Grading System (OGS) and Comprehensive Clinical Assessment (CCA) scores. The DI was not significantly related to a general time trend. The DI was found to be a reliable and relatively stable index for measuring malocclusion complexity in annual samples of patients. Although the DI is significantly related to outcomes for the most severe malocclusions, it was not a good predictor of outcome for more routine malocclusions. If the minimal acceptable outcome is defined as 30 OGS points, the mean DI (15.7) and the average OGS score (28.2) indicate that many of the malocclusions in patients in the present sample were of potential board quality.

Orthodontists’ and Orthodontic Residents’ Education in Treating Underserved Patients: Effects on Professional Attitudes and Behavior

The U.S. surgeon general's report on oral health in 2000 stressed the importance of providing dental care for underserved patient groups. Given that orthodontic treatment is less likely to be covered by dental plans than other procedures and is often considered an elective treatment, it is not surprising that access to orthodontic care is an especially severe problem for underserved patient groups. The purpose of this study was to explore the degree to which orthodontic residents and orthodontists perceived that their graduate orthodontic education had prepared them well to treat underserved patients and whether this education affected their professional attitudes and behavior concerning providing care for members of historically underserved patient groups. Survey data were collected from 135 residents in U.S. and Canadian graduate orthodontic programs and from 568 active members of the American Association of Orthodontists (AAO). While the majority of residents and orthodontists felt well prepared to treat patients from different ethnic/racial backgrounds (quality of clinical education: residents: 86.4 percent; orthodontists: 82.3 percent), considerably fewer respondents felt well prepared to treat patients on Medicaid (64.7 percent and 34.4 percent), pro bono cases (45.4 percent and 33.4 percent), patients with special needs (52.8 percent and 35 percent), patients with craniofacial anomalies (65.3 percent and 52.6 percent), and patients with developmental delays (45.5 percent and 30.5 percent). Perceptions of the quality of education correlated significantly with the professional attitudes and the actual/projected behavior concerning providing care for patients from these underserved patient groups. Given the lack of access to orthodontic care for patients from underserved patient groups, initiatives are needed to change this situation. These findings showed a clear relationship between how future orthodontists are educated about providing care for patients from underserved populations and their professional attitudes and behavioral intentions to provide care for individuals who historically have encountered access to care barriers. Dental education has to accept the responsibility to prepare future dental care providers to be able to treat patients from underserved groups.

Centric Relation: A Survey Study to Determine Whether a Consensus Exists Between Oral and Maxillofacial Surgeons and Orthodontists

The purpose of this study was to determine whether there is a consensus among oral and maxillofacial surgeons and orthodontists as to the definition of centric relation. A survey constructed from 5 definitions of centric relation as provided from the "Glossary of Prosthodontic Terms" was sent to the chairpersons of every oral and maxillofacial surgery and orthodontic program in the United States. Only full-time faculty members from each program were asked to respond to the survey. The different responses were analyzed statistically by chi(2) analysis and examined by use of 95% confidence intervals. We received 73 responses from the oral and maxillofacial surgeons and 64 from the orthodontists. There were 69 different programs represented in this survey. Orthodontists and surgeons had a significantly different response regarding the definition of centric relation (chi(2) = 28, df = 4, P < .0001). There was no difference between the 2 groups on the need for mounting models in centric relation for use in orthognathic surgery (chi(2) = 1, P > .6). Regarding the definition of centric occlusion, there was a significant difference between orthodontists and surgeons (chi(2) = 9.9, df = 1, P = .0070). The fourth and fifth questions had to do with centric relation/centric occlusion slide and the direction of movement. There was a significant difference between the 2 groups regarding mandibular movement (chi(2) = 28, df = 2, P < .0001). Surgeons were nearly unanimous in their opinion that the mandible would move anteriorly (88%), whereas there was more discordance among orthodontists. Within the orthodontic group, 50% indicated anterior movement and 47% indicated that either an anterior or posterior movement could occur. The surgeons were asked 1 additional question that the orthodontists were not. Forty-nine percent of the surgeons indicated that during a bilateral sagittal split osteotomy, the proximal segment should be seated vertically and posteriorly before rigid fixation. The results of this study show that there is a statistical lack of consistency among practitioners regarding an absolute definition of centric relation as it relates to orthognathic surgery. The inconsistency exists between specialties and within practitioners in each specialty.

Learning Styles of Orthodontic Residents

Significant challenges face many orthodontic residency programs, particularly a shortage of full-time experienced faculty members. Due to this shortage, it is critical that program directors design comprehensive curricula that incorporate the most effective and efficient teaching methods. It is theorized that teaching effectiveness and efficiency are optimized when the course design and content closely match students' learning preferences. This survey study was designed to distinguish the learning preferences of orthodontic residents utilizing Felder and Soloman's Index of Learning Styles, which assesses student learning preferences in four dimensions using dichotomous scales, thereby providing insight into how teaching strategies can best be structured. As a secondary focus, additional questions on the survey were asked to gain information about residents' access to the Internet and comfort level with online learning so as to address acceptance of web-based courses in response to the shortage of full-time faculty members. Orthodontic residents, contacted via email, were requested to complete an online survey; 261 responses were collected. The results indicate that orthodontic residents are highly visual learners and show a preference for sensing and sequential learning strategies. In terms of information technology, the residents are comfortable with and have adequate access to current technological assets; therefore, they may be well suited for inclusion of computer-based teaching modules and other multimedia devices in their residency curriculum.

Resident Evaluation of Orthodontic Programs in Canada

The purpose of this study was to investigate the satisfaction of Canadian orthodontic residents with their programs and determine the scope of their training. An anonymous online questionnaire was sent to all Canadian orthodontic residents in November 2006. Data were assembled and categorized by different variables, and chi-square comparative analyses were performed. Forty-four out of fifty-four residents responded, giving a participation rate of 81.48 percent. Overall, 86.36 percent of responding residents were satisfied with their program. Respondents said they felt they received the appropriate amount of formal didactic teaching sessions and dedicated and protected academic time. All residents indicated their programs offered training in numerous treatment philosophies: 93.18 percent said they have sufficient clinically based training, and 72.73 percent indicated that their research-based training was sufficient. All responding residents indicated they will complete more than thirty patients from start to finish, and 25 percent estimated completion of more than seventy patients by graduation. Residents said they will complete on average five orthognathic surgery, twenty-four extraction, thirty-one non-extraction, eight adult, and thirteen patients in the mixed dentition. Only 50 percent said their programs contained care for disabled or underserved patients. Most (86.36 percent) said they feel they will be adequately prepared to provide unsupervised orthodontic care after graduation. These orthodontic residents indicated they collaborate most with the disciplines of oral surgery, periodontics, and prosthodontics. However, only 52.27 percent indicated they have a formal interdisciplinary program for treating patients. We conclude from the study that Canadian orthodontic residents are satisfied with the didactic, clinical, and research aspects of their programs. They receive comprehensive instruction with the opportunity to complete a significant number of patients, employing a variety of treatment approaches.

Treatment outcomes in a graduate orthodontic clinic for cases defined by the American Board of Orthodontics malocclusion categories

The American Board of Orthodontics (ABO) discrepancy index (DI) quantifies the severity of a malocclusion. The ABO objective grading system (OGS) assesses the quality of orthodontic finishing. Indiana University's comprehensive clinical assessment (CCA) supplements the OGS to provide an instrument to determine clinical outcomes. The purposes of this article were to (1) determine whether treatment outcome is related to the type of malocclusion as defined by the ABO classification, (2) determine the fraction of finished orthodontic cases in the graduate orthodontics clinic that are within the ABO standards for passing the phase III clinical examination, (3) evaluate the contribution of each component of the OGS and the CCA to the total OGS and CCA scores, (4) determine the percentage of finished cases that meet the ABO case category specifications, and (5) identify problem areas to improve the quality of treatment for challenging malocclusions. Three hundred eighty-two cases that satisfied requirements for 8 of the ABO's malocclusion categories were selected from 989 consecutively finished cases from 1998 through 2003. They were evaluated by using the OGS, the CCA, and the DI. The average OGS score was 32.64, the average CCA score was 5.62, and the average DI score was 20.94. There was no significant difference in the OGS and the CCA scores among the categories. Categories 2, 5, 7, and 8 had a DI score that was significantly higher than the average for the entire sample. The OGS and CCA scores were positively correlated with the DI score, meaning that complex malocclusions are challenging to finish well. The most points lost for the OGS and the CCA were for occlusal contacts and treatment efficiency (length of treatment relative to the result), respectively. The fewest points lost were for interproximal contacts and vertical control, respectively. Furthermore, prematurely terminated cases (early debonds) had longer treatment times and higher (worse) OGS and CCA scores. This study demonstrates problems in treating complex malocclusions in a graduate orthodontics program and suggests methods for increasing the quality of clinical outcomes.

Application of distance learning to interactive seminar instruction in orthodontic residency programs

A series of experiments involving 3 orthodontic departments has shown that distance learning can be acceptable to residents and effective in teaching concepts that are fundamental to orthodontic practice. Residents in each department participated in distance seminars, clinical conferences, and clinical seminars via high-speed Internet connections. The acceptability of this form of instruction was judged from evaluation forms completed by the residents. Its effectiveness was judged from pretests and posttests on the seminar topics. The improvement from pretest to posttest scores after observing a sequence of distance seminars was similar to that with direct instruction. Orthodontic residents rated the educational experiences positively. Live participation in seminars via video conferencing was preferred to live observation or later observation of a recording, but observation provided similar improvement in test scores. The acceptability of the distance seminars appeared to be influenced by the instructor's personality and teaching style in facilitating interaction, the seminar subject, the residents' comfort level in dealing with this technology, and the sequence for interaction vs observation. Further development of recorded seminars with live follow-up discussions has the potential to supplement instruction in graduate orthodontic programs and help with the impending shortage of experienced full-time orthodontic faculty.

Black, white, or gray: Finding commonality on how orthodontists describe the areas between Angle’s molar classifications

Angle's system for classifying molar relationships has been the standard in orthodontics for over a century. The purpose of this study was to determine what orthodontic students are being taught about the terminology of molar relationships and the use of Angle's molar classification system. An e-mail survey was sent to the department chair or the program director of every orthodontic program in the United States, Canada, and Puerto Rico (n = 80). The survey included photos of models placed into 1/4 cusp, 1/2 cusp, and 3/4 cusp distal occlusions, and the participants were asked to classify them by selecting from a list of terms or writing 1 of their own. They were also asked whether they thought that the Angle molar classification was adequate for communication and diagnosis. Forty surveys were completed and returned. The results showed that a variety of terminology is being taught, and most educators do not use Angle's system as he defined it. About half of the respondents were dissatisfied with the Angle molar classification system. A modification of Angle's system that is more descriptive is needed.

Considerações para elaboração de protocolo de assistência ortodôntica em saúde coletiva

This study offers help for drawing up a community health orthodontic assistance protocol, especially for the public health system. A preventive and interceptive orthodontic program is suggested through the inclusion of approaches in existing healthcare programs that may help prevent malocclusions, extending the services offered by Basic Healthcare Units to include fitting space retainer appliances and interceptive procedures. Possible occlusion problems are discussed and rated as high or low priority for treatment, stressing occlusal deviations that should not be treated precociously. Preventive and interceptive orthodontic treatment should primarily be offered to children with deciduous and mixed dentition. The management and inclusion of orthodontic procedures can be deployed through the management of physical, human and financial resources, establishing access criteria for these services. The use of an appropriate orthodontic assistance protocol and correct planning of orthodontic actions could pave the way for preventive and interceptive procedures at the Basic Healthcare Units, while more resources could be allocated to setting up Specialty Reference Centers offering more complex corrective orthodontic procedures.

Quantitative assessment of post-graduate orthodontic program in Okayama University

Recently, the importance of evaluation of dental education has been emphasized. In order to achieve and maintain the high level of graduate student quality, quantitative assessment is essential for university educational programs. Especially in orthodontics, basic science is extremely important from clinical point of view. However, there has been no report that has quantitatively evaluated the outcome of post-graduate seminar in orthodontic program. Total of 18 graduate students in orthodontic graduate program in Okayama University from year 2002 to 2004 participated in this study. Quantitative assessment before and after the Proffit's reading seminar was evaluated among different chapters. As a result, significant improvement (approximately 30% increase) in the total average scores was observed in all 3 years. Furthermore, there seem to be common subjects that the students have difficulty in understanding. In conclusion, significant increase in scores after the seminar was observed in all examined 3 years, and the progress of the basic knowledge of orthodontics was clearly demonstrated by quantitative assessment. Furthermore, we may have to consider what subjects we need to concentrate in teaching the post-graduate students in the future.

Equipping orthodontic residency programs for interactive distance learning

Equipment for distance learning can be used to improve the quality of instruction in orthodontic programs. All departments now should have at least a point-to-point system to allow clinical faculty to provide instruction without being physically present on all occasions. For more instruction to be shared with other residency programs, a dual-streaming multipoint video conferencing system is needed. A basic system allows reception of this type of instruction, and an optimal system would allow originating and receiving such conferences. Recording interactive seminars so that they can be viewed later requires additional equipment so that postproduction editing and refinement can be accomplished. Lists of appropriate equipment for each level are provided.

Global issues with orthodontic education: a personal viewpoint

Orthodontic education and training has traditionally been passed on to disciples as ‘guru mantras’ since the time orthodontics gained recognition as a specialty. While American orthodontists and researchers perfected fixed appliances, to achieve the finest of tooth movement, Scandinavians and Europeans laid greater stress on functional appliances. Geography and barriers in communication led much of the good work, views and important clinical observations to be limited to their areas of origin. Today, the internet and technology have shrunk the world into a tiny village where several people can work on a single venture whilst sitting thousands of miles apart. This new situation warrants a ‘uniform curriculum and syllabus’ of orthodontic education around the world. At the same time, an orthodontist should be equipped to recognize the local needs of society. Probably, we need to define the ‘universal competencies’ of a graduate orthodontic specialist, in addition to the local competencies needed for working in a particular community or country. The latter may include familiarity and knowledge of the regional socio-cultural and economic aspects, language competencies and an appreciation of ‘regional norms of beauty’. With increased patient migration, orthodontists should be in a better position to provide quality orthodontic care to such transfer cases from across the globe. Returning to the issue of curriculum and training, orthodontic education (whether in different parts of the world or between universities in the same country) may have large variations. This has obvious impacts on the quality and competencies of the graduating orthodontists. These variables are related to pre-graduate training requirements, eligibility/selection criteria for admission to graduate orthodontic programmes, total course duration, and duration and content of preclinical work. Other important issues include:

A report of the ABO Resident Clinical Outcome Study (the pilot study)

A 4-year collaborative project between the American Board of Orthodontics (ABO) and 15 American orthodontic graduate programs concluded at the ABO Clinical Examination in February 2006. Fifty recent graduates (the pilot study group) presented cases that were treated in their graduate programs as partial fulfillment of the requirements for ABO certification. The examinees were tested by calibrated ABO examiners and required to satisfy traditional ABO standards. They presented appropriate case reports that contained the ABO's 3 measurement instruments. Thirty-nine practicing orthodontists (the control group) presented cases according to the traditional ABO Clinical Examination process. Ninety percent of the pilot study group and 85% of the control group successfully accomplished ABO certification. There was a difference of 2.38 points between the 2 groups for the mean total scores of the cases that passed. The pilot study group presented cases that met the historic averages for case complexity (discrepancy index). Residents in orthodontic programs are able to treat cases to ABO standards of quality.

ABO initial certification examination: Official announcement of criteria

In March 2005, when the American Board of Orthodontics (ABO) announced the change in the board-certification process, the specific criteria for the new Initial Certification Examination intended for recent graduates of orthodontic programs were not delineated. The board’s ultimate goals were to engage as many young orthodontists as possible in the certification process and to subsequently maintain and improve the quality of their expertise via periodic recertifications. The ABO directors believed that the results of the then-ongoing Orthodontic Resident Clinical Outcomes Study (the pilot study), combined with the opinions of current and previous ABO directors, ABO examiners, and orthodontic educators, should play significant roles in the formulation of a fair and equitable clinical examination by using cases treated during the resident’s graduate program. Consequently, the ABO obtained educators’ opinions in a survey and hosted an Educators’ Symposium in St Louis to seek input from the nation’s orthodontic teaching professionals. Former ABO directors and examiners were asked to suggest modifications of the Initial Certification Examination process after the 2006 Clinical Examination. The pilot study (PS) was completed in February 2006. Input from these diverse sources completed the information acquired by the board for final determination of the criteria for the Initial Certification Examination. This article will delineate the information that the ABO used to make

Assessing treatment outcomes for a graduate orthodontics program: Follow-up study for the classes of 2001-2003

Based on an initial 3-year study (1998-2000) of clinical outcomes, specific changes were made in the clinical protocol in the orthodontic clinic at Indiana University, Indianapolis, Ind. To evaluate these adjustments, a follow-up study with the same methods assessed the clinical outcomes for the next 3 years (2001-2003). The 3 changes introduced in 2000 were assessment of prefinish records, education of residents about previous outcomes, and more frequent practice evaluations by the program director. The American Board of Orthodontics (ABO) objective grading system (OGS) and a supplemental comprehensive clinical assessment (CCA) were used to evaluate the results for all patients completed by the classes of 2001 through 2003 (n = 437). The mean ABO OGS, CCA, and combined scores were 25.19 +/- 11.16, 4.38 +/- 2.74, and 29.57 +/- 13.01, respectively. A progressive improvement was noted from 2001 to 2003. The ABO OGS and the combined scores were significantly (P <.001) improved in 2001 through 2003 compared with 1998 through 2000. The CCA score tended to improve, but it was not significantly different. Significant improvements were seen for maxillary and mandibular first order, mandibular second order, mandibular third order, overjet, occlusal contacts, occlusal relationships, and root angulations (P <.001). As with the previous study, excessive treatment times correlated with worse clinical outcomes. Changes implemented by the graduate program were effective for improving treatment outcomes. Cast scores were more amenable to improvement than other more comprehensive outcomes.

Admissions to the Advanced Orthodontic Program at the University of Nevada, Las Vegas

Admissions to the Advanced Orthodontic Program at the University of Nevada, Las Vegas

Rationale for referring class II patients for early orthodontic treatment

The tendency of indicating early treatment (before growth spurt) when dealing with Angle Class II cases has been noticed, although there is no definite scientific evidence to justify such decision. The aim of this study was to identify the advantages and disadvantages to this approach and which appliances are used for this purpose. For that purpose, a questionnaire containing full records of a Class II patient was sent to two professors of each Orthodontic graduate program in Brazil (n=96, total 192), from which 107 were properly answered. Results demonstrated that the most used appliances were the headgear (80.4%), maxillary splint (50%) and Bionator (44.4%). The benefits most often quoted were increase of patient self-esteem (78.5%) and reduction in the incidence of incisors trauma (63.6%), while the main disadvantage was saturation of patient compliance (73.8%). Considering early Class II treatment, there is still no unanimity as to treating in one or two stages or in selection of appliances. However, the orthodontists should consider the physical situation of the patient, severity of cases and susceptibility of trauma to the maxillary incisors. It is crucial that updated information is given to parents, in order to justify this approach.