PURPOSE The purpose of this study was to calculate the projected primary care physician shortage, determine the amount and composition of residency growth needed, and estimate the impact of retirement age and panel size changes. METHODSWe used the 2010 National Ambulatory Medical Care Survey to calculate utilization of ambulatory primary care services and the US Census Bureau to project demographic changes. To determine the baseline number of primary care physicians and the number retiring at 66 years, we used the 2014 American Medical Association Masterfile. Using specialty board and American Osteopathic Association figures, we estimated the annual production of primary care residents. To calculate shortages, we subtracted the accumulated primary care physician production from the accumulated number of primary care physicians needed for each year from 2015 to 2035. RESULTSMore than 44,000 primary care physicians will be needed by 2035. Current primary care production rates will be unable to meet demand, resulting in a shortage in excess of 33,000 primary care physicians. Given current production, an additional 1,700 primary care residency slots will be necessary by 2035. A 10% reduction in the ratio of population per primary care physician would require more than 3,000 additional slots by 2035, whereas changing the expected retirement age from 66 years to 64 years would require more than 2,400 additional slots. CONCLUSIONSTo eliminate projected shortages in 2035, primary care residency production must increase by 21% compared with current production. Delivery models that shift toward smaller ratios of population to primary care physicians may substantially increase the shortage. INTRODUCTIONT he demands of an expanding, aging, and increasingly insured population have created concern about the sufficiency of our health care workforce. Already there are rising costs, unnecessary treatment, and undesirable levels of emergency department visits. [1][2][3] Provisions in the Patient Protection and Affordable Care Act (ACA) support primary care physicians with the aspiration that a reinvigorated primary care workforce can "bend the cost curve."4 Initiatives, such as Family Medicine for America's Health, aim to develop the next generation of primary care physicians but lack guidance regarding how training will need to change. 108Prior supply projections have assumed production will remain constant and estimated new primary care physicians based on overall physician supply growth. For instance, HRSA estimated that by 2020, the number of primary care physicians would increase 8% by assuming that 31.9% of new physicians will be primary care physicians. 10,11 There is no reason to believe that production of primary care physicians will remain static, however. According to Chen et al, only 25.2% of all residents graduating between 2006 and 2008 practiced primary care in 2011. 12 The same study estimated 40% of internal medicine residents do not subspecialize, a finding similar to figures from the AAMC.11 Simultane...

Because implant surface decontamination is challenging, air powder abrasive systems have been suggested as an alternative debridement method. This in vitro study investigated the effectiveness of different powder formulations and air pressures in cleaning implant surfaces and the extent of surface damage. A validated ink model of implant biofilm was used. Sterile 4.1 × 10 mm Grade 4 titanium implants were coated in a blue indelible ink to form a uniform, visually detectable biofilm‐like layer over the implant threads and mounted into a bone replica material with bony defects to approximate peri‐implantitis. Air powder abrasive treatments were undertaken using glycine, sodium bicarbonate, or calcium carbonate powder at air pressures of 25, 35, 45, and 55 psi. Digital macro photographs of the threads were stitched to give composite images of the threads, so the amount of ink remaining could be quantified as the residual area and expressed as a percentage. Implant surfaces were also examined with scanning electron microscopy to grade the surface changes. No treatment cleaned all the surface of the threads. The powders were ranked in order of decreasing effectiveness and decreasing surface change into the same sequence of calcium carbonate followed by sodium bicarbonate followed by glycine. Higher air pressure improved cleaning and increased surface change, with a plateau effect evident. All powders caused some level of surface alteration, with rounding of surface projections most evident. With air powder abrasive systems, there is a trade‐off between cleaning efficacy and surface damage. Using this laboratory model, sodium bicarbonate and calcium carbonate powders were the most effective for surface cleaning when used at air pressures as low as 25 psi.

Background: There is little information available regarding dental emergencies for children in Australia. The aim of this study was to investigate the reasons for dental emergency cases which were treated at a public oral health clinic in a low socioeconomic district in south-east Queensland. Methods: From a register kept at a public oral health clinic, we analysed the monthly number of emergency visits for children over a three-year period (January 2008 to August 2010) with respect to numbers treated, reasons for presentation and types of treatment rendered. Results: During the period 2008-2010, there was a mean of 196 ± 86 cases presenting for emergency care each month. The proportions of the various types of emergencies remained fairly consistent over the three-year period, with the majority presenting for caries related problems (74-75%), followed by trauma (8-9%), orthodontic treatment related (2-5%) and other reasons (16-11%). Between 8-11% of cases were preschool children who were added to the waitlist for treatment for caries under general anaesthesia at the public hospital. Conclusions: Trends in the past three years at a public oral health clinic in a low socioeconomic district in south-east Queensland show that dental caries constitute nearly three-quarters of all paediatric emergency appointments.

Background Two invasive group A streptococcus (iGAS) infection outbreaks occurred in Montreal in 2016 and 2017; one in a long-term care facility (type emm 118) and one in the community, primarily involving homeless people (type emm 74). Objective To describe two recent iGAS outbreaks in Montréal and highlight the challenges in dealing with these outbreaks and the need to tailor the public health response to control them. Methodology All cases of iGAS were investigated and the isolates were sent to the laboratory for emm typing. In both outbreaks, cases of superficial group A streptococcus (GAS) infection were identified, through 1) systematic case detection accompanied by screening for asymptomatic carriers among residents and employees of the long-term care facility and 2) sentinel surveillance among homeless people. Visits were made to community organizations providing homeless services (including shelters) and social networks were analyzed to establish whether there were any links among cases of GAS infection (both invasive and noninvasive) and locations frequented. In both outbreaks, recommendations were made to service providers regarding enhancement of infection prevention and control measures. Results In the long-term care facility, five cases of type emm 118 iGAS were identified over a 22-month period, one of which resulted in death. All residents were screened and no carriers were identified. Among the employees, 81 (65%) were screened and fourcarriers were identified. Of those, one was a carrier of type emm 118 GAS. All carriers were treated, and subsequent follow-up sampling on three carriers (including the one with emm 118) was negative. In the community, 23 cases of type emm 74 iGAS were detected over a 16-month period, four of which resulted in death. Half of the cases (n=12) were described as homeless, and six others were users of services for the homeless. Sentinel surveillance of superficial infections yielded 64 cultures with GAS, chiefly on the skin, including 51 (80%) of type emm 74. An analysis of the social networks revealed the large number and variety of resources for the homeless used by the cases. Visits to the community organizations providing homeless services revealed the heterogeneity and precariousness of some of these services, the difficulties encountered in applying adequate health and hygiene measures, and the high degree of mobility amongst those who use these services. Conclusion The detection and control of iGAS outbreaks in both long-term care establishments and among community organizations providing homeless services are very complex. An outbreak of iGAS can develop in the background over a ...

Dental implants are used extensively to replace missing teeth. To enhance their integration with the bones of the jaws, the surfaces of titanium dental implants are modified to make them hydrophilic, high energy, and microtextured. These same features make biofilm development occur readily upon exposure to the saliva. The presence of mature biofilms on dental implant surfaces drives local inflammatory responses in the adjacent soft and hard tissues (peri-implantitis), which leads to pathological loss of bone and the formation of a saucer shaped bone defects. This chapter examines the unique challenges posed by biofilms formed on highly complex dental implant surfaces, which are difficult to access for cleaning, and easily damaged by conventional cleaning approaches. We explore how biofilms can be removed from implant surfaces using a variety of novel methods, without causing surface damage or other undesirable modifications, and show how different laboratory and clinical models can be used to assess the performance of both conventional and novel methods of biofilm removal.

Children presenting with acute facial cellulitis represent the last stage in a pathway of failed clinical care that is associated with significant costs to both the individual family and the community. Further work is required to understand the barriers to children accessing timely and appropriate dental treatment.

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Subsurface remineralization can be promoted by the topical application of nanoparticles of casein phosphopeptide-amorphous calcium phosphate (CPP-ACP). To assess changes in enamel white spot lesions, an in situ proof-of-concept investigation was performed using 5 subjects (all of whom were healthy young adults) with a cross-over study design. Custom orthodontic brackets were attached to the buccal surfaces of the maxillary second premolar and first molar teeth. Each bracket had a recess that held a slab of enamel with a standardized 100 μm deep white spot lesion (WSL). Changes in mineral were evaluated in lesion cross sections using backscatter electron imaging (BSE) and electron probe microanalysis (EPMA). The following products were applied twice daily for 2 weeks: GC Tooth Mousse™ (CPP-ACP), Tooth Mousse Plus™ (CPP-ACFP), CPP-ACFP Mineral Enhanced (CPP-ACFP Enh), or the vehicle paste of CPP-ACFP containing 900 ppm fluoride. To ensure blinding, all products had identical flavours and packaging. For each subject, the products were used in a random sequence, with washout periods between products. Compared to the baseline situation, favourable changes in white spot lesions occurred with all products. Analysis of enamel samples in cross section showed improvements in mineral levels, as seen in BSE grey scale levels from the enamel surface through the lesion. These were accompanied by enhanced calcium and phosphorus levels as seen using EPMA. The ranking of products for subsurface mineral gain, from best to worst, was: CPP-ACFP = CPP-ACFP Enh > CPP-ACP > vehicle with fluoride. Rapid remineralization occurred in this clinical model, which is due to a combination of factors: the enamel slabs were located on tooth surfaces exposed to parotid saliva, the surfaces were brushed regularly to remove dental plaque biofilm, and compliance with twice daily topical use of products was high. Such model systems may be useful for screening new product formulations for their effect on enamel WSL.