Dental Care for Pregnant Women

BackgroundThe authors conducted a study to examine factors associated with general dentists' provision of care for pregnant women and the extent to which they provide comprehensive dental care.MethodsThe authors mailed an 86-item questionnaire to 1,000 practicing general dentists in North Carolina. Survey domains included provider knowledge about pregnancy and dental health, dental treatment practices, barriers to providing care, outcome expectancy, and personal and practice demographics. The primary dependent variables the authors analyzed were whether dentists provided any treatment to pregnant women and, among those who did, the extent to which they provided comprehensive services. The authors performed multivariate regression analyses to determine factors associated with dentists' provision of care to pregnant women (P < .05).ResultsA total of 513 surveys were returned (a response rate of 51.3 percent), of which 495 surveys had complete responses. The authors included the completed surveys in their analyses. The mean age of the respondents was 46 years. The results of multivariate analysis showed that respondents who perceived a lack of demand for services among pregnant women and provided preconception counseling were less likely to provide any treatment for pregnant patients than were those who perceived a demand for services and who did not provide preconception counseling, respectively. Dentists who were male, had a low knowledge score, provided preconception counseling and treated largely white populations of patients were less likely than female dentists, those who had moderate or high knowledge scores, and those who treated a population of minority patients to provide comprehensive care for pregnant women.ConclusionsMost general dentists in private practice provide care for pregnant women, but the authors found notable gaps in dental provider knowledge and comprehensive dental services available for pregnant women.Clinical ImplicationsAlthough many general dentists provide some dental care to pregnant women, more should be done to ensure that this care is comprehensive.     

An analysis of dentists' incomes, 1996-2009

BackgroundThe U.S. economy is beginning to recover from the most significant contraction since the Great Depression. Several sectors, including dentistry, have experienced reduced consumer demand and reduced earnings. Focusing on general practitioners, the authors analyzed trends in various factors that drive dentists' income to identify which of these factors are most important in explaining the recent decline. They then offer their views on future trends in dentists' net income levels.MethodsThe authors used data from a nationally representative survey of dentists maintained by the American Dental Association (ADA) and data from the Agency for Healthcare Research and Quality's Medical Expenditure Panel Survey to analyze trends in real gross billings per visit, rates of collection of gross billings, number of visits to a dentist, percentage of the population who visited a dentist, population to dentist ratio and average real practice expenses.ResultsThe authors found that the recent decrease in dentists' net income levels was driven primarily by a decrease in utilization of dental care on the part of the population. Moreover, this decline in dental care use, although most pronounced during the economic downturn, appeared to have started before the downturn began. This suggests that more factors than solely the economic recession are affecting changes in dental care utilization patterns.ConclusionsThe authors' findings suggest that average real net income for dentists may not necessarily recover to prerecession levels once economic conditions in the United States improve. This finding, combined with the potential implications of health care reform for dentistry, causes the authors to believe the future prospects related to dentists' net income levels remain uncertain.     

A marketing campaign to promote screening for oral cancer

BackgroundOrganizers of the Detroit Oral Cancer Prevention Project at the University of Michigan, Ann Arbor, launched a multifaceted media campaign targeted toward a high-risk population to raise awareness about oral cancer, educate the public regarding the importance of early detection and increase screening rates. The authors present data about the effectiveness of the campaign with regard to the screening behaviors of medical and dental providers.MethodsBefore the start of the campaign and during each of the three years of the campaign, the authors mailed surveys to random samples of physicians and dentists practicing in targeted and non-targeted areas.ResultsMore dentists than physicians reported screening patients routinely, and dentists reported that they referred more patients for biopsy or further evaluation compared with physicians. A larger proportion of dentists and physicians in the targeted area than in the nontargeted area reported that their patients had seen or heard the advertisements. A larger proportion of dentists in the targeted area than in the nontargeted area reported an increase in patients' questions and requests for screening, even after the authors accounted for demographic characteristics (adjusted odds ratio = 2.47).ConclusionsThe survey findings show that the media campaign was effective in influencing providers' screening for signs and symptoms of oral cancer.Clinical ImplicationsAn increase in patients' requests for screening as a result of the implementation of mass media campaigns may promote oral cancer screening and improve patients' chances of survival.     

Conference Report

Abstract

The criteria that dentists use to judge the need for orthodontic treatment are not clear. This study investigates variation in dentists' perception of orthodontic treatment need. Seventy-four dentists were asked to assess 320 dental casts in relation to aesthetic and dental health need. The results of this investigation revealed that the panel was divided as what constituted a need for orthodontic treatment on dental health grounds. It is suggested that one method of achieving a more uniform evaluation of orthodontic treatment need is the use of an occlusal index. Until an occlusal index is accepted and used by the profession, the distortion of need and demand for orthodontic treatment by dentists' unequal perceptions will continue.     

The effect of training on the use of tobacco-use cessation guidelines in dental settings

BackgroundAn increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists' tobacco-use–related attitudes and treatment behaviors.MethodsThe authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists' self-reported tobacco-use–related attitudes and behaviors and patients' reports of dentists' behaviors.ResultsSignificantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients' willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect.ConclusionDentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group.Clinical ImplicationsAlthough the workshop training was more successful than the self-study training, the latter's reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.     

The declining number of practicing African American dentists in Cuyahoga County, Ohio, 1970 through 2010

BackgroundThe authors tracked the declining number of practicing African American dentists and its relationship to the migratory patterns of the black community in Cuyahoga County, Ohio, from Jan. 1, 1970, through Dec. 31, 2010.MethodsThe authors conducted a longitudinal study in which they used the Geographic Information System (Environmental Systems Research Institute, Redlands, Calif.) to plot the location of each black-owned dental practice in Cuyahoga County in conjunction with the black population. They calculated the ages of the dentists by using birth dates posted on the Ohio State Dental Board's Web site and divided the dentists into five age groups.ResultsThe study results showed that dental practice distributions followed the migratory pattern of the black population from Cleveland to the surrounding suburbs. The number of black dentists in practice decreased from 1986 through 2010 in the Cleveland metropolitan area (Cuyahoga County), and 46.3 percent of the black dentists were projected to retire by 2020.ConclusionsThese results underscore the need to increase the number of black dentists in Cuyahoga County and nationwide. On the basis of the demographic data they found, the authors expect the number of black dentists to continue to decrease if no intervening circumstances occur.Practice ImplicationsThere were 48.8 percent fewer black dentists in Cuyahoga County in 2010 than there were in 1985. If this pattern continued until 2020, there could be a critical shortage of black dentists in Cuyahoga County.     

Reimbursement rates and policies for primary molar pit-and-fissure sealants across state Medicaid programs

BackgroundLittle is known about Medicaid policies regarding reimbursement for placement of sealants on primary molars. The authors identified Medicaid programs that reimbursed dentists for placing primary molar sealants and hypothesized that these programs had higher reimbursement rates than did state programs that did not reimburse for primary molar sealants.MethodsThe authors obtained Medicaid reimbursement data from online fee schedules and determined whether each state Medicaid program reimbursed for primary molar sealants (no or yes). The outcome measure was the reimbursement rate for permanent tooth sealants (calculated in 2012 U.S. dollars). The authors compared mean reimbursement rates by using the t test (α = .05).ResultsSeventeen Medicaid programs reimbursed dentists for placing primary molar sealants (34 percent), and the mean reimbursement rate was $27.57 (range, $16.00 [Maine] to $49.68 [Alaska]). All 50 programs reimbursed dentists for placement of sealants on permanent teeth. The mean reimbursement for permanent tooth sealants was significantly higher in programs that reimbursed for primary molar sealants than in programs that did not ($28.51 and $23.67, respectively; P = .03).ConclusionsMost state Medicaid programs do not reimburse dentists for placing sealants on primary molars, but programs that do so have significantly higher reimbursement rates.Practical ImplicationsMedicaid reimbursement rates are related to dentists' participation in Medicaid and children's dental care use. Reimbursement for placement of sealants on primary molars is a proxy for Medicaid program generosity.     

Dental prepayment: the past, present, and the future

Insurance now pays for slightly less than 50% of America's dental bill. The explosive growth in dental insurance in the 1970s and 1980s is traced to the tax effect (coverage paid for with pre-tax dollars offsets fees up to a point) and the insurance effect (costs for care can be projected, although improvements in oral health status are leading to lower projected costs). An equilibrium point appears to have been reached. Dentists must weigh the trade-offs between discounted fees and increased number of patients, and carriers must weight the trade-offs between smaller discounts and wider participation by dentists. There are no market forces forecast that will substantially change this equilibrium in the near future.     

Preventing dentists' involvement in torture: The developmental history of a new international declaration

BackgroundFor more than half a century, the risk of physicians participating in torture has received thoughtful attention in the field of medicine, and a number of international organizations have issued declarations decrying such involvement. Despite publications that provide evidence of dentists' having participated in torture as well, until recently the dental profession was quiescent on the subject.MethodsThe authors describe the historical background for a new declaration against dentists' participation in torture developed by the International Dental Ethics and Law Society and the Fédération Dentaire Internationale (FDI) World Dental Federation. They review various levels of involvement by dentists in torture and related activities in reference to existing World Medical Association declarations. Finally, they outline the process of drafting the new dental declaration, which was adopted by the FDI in October 2007.Clinical ImplicationsThe authors provide insight and guidance to clinicians who diligently serve their patients, unaware that they may face military or other pressures to participate in torture.     

Rural dentists: Does growing up in a small community matter?

BackgroundThe aging of the dental work-force has implications for both patients and dentists, especially those in rural and underserved areas. Anecdotal information regarding dental workforce trends indicates that students from rural communities are more likely to practice in rural communities than are students from urban areas. Although the medical literature supports this premise relative to physicians, there are no data to verify this statement relative to dentistry. Therefore, the authors decided to study whether this premise applies to dentistry.MethodsThe authors conducted a retrospective analysis of dental student records from a Midwestern dental school for the years 1980 through 2010 to determine if there was a statistical correlation between the size of a dental student's town of origin and the size of the community where he or she practiced after graduation. They also examined what role, if any, the student's sex played.ResultsDentists from rural areas were approximately six times more likely to practice in a rural area than were dentists from urban areas. Female dentists were only slightly less likely to practice in a rural community than were male dentists.ConclusionDentists from rural communities were more likely to practice in rural communities than were dental students from urban areas.Practice ImplicationsTo ensure future access to care in rural communities, rural dentists may want to recruit actively or work closely with dental students from rural areas when hiring associates or seeking purchasers for their dental practices.     

The case for dental preferred provider organizations

The dental PPO market is the fastest growing segment of the dental benefits business. As with traditional indemnity plans, dentists are reimbursed on a fee-for-service basis. Members can refer themselves to dentists of choice, including specialists, inside and outside the network. Employers' interest in DPPOs is expected to continue as they seek to control or reduce expenses associated with dental benefits plans. Dentist participation in managed care programs significantly lags medical, and fewer than half of practicing dentists participate in DPPOs. Negotiated discounts vary across carriers and geographic regions, generally ranging 15% to 30% off average fees. The American Dental Association predicts that dentists' participation in DPPOs will continue to increase, indicating further growth for these dental plans. There are financial incentives for members to stay in network.     

Repair or replacement of defective restorations by dentists in The Dental Practice-Based Research Network

BackgroundThe authors aimed to determine whether dentists in practices belonging to The Dental Practice-Based Research Network (DPBRN) were more likely to repair or to replace a restoration that they diagnosed as defective; to quantify dentists' specific reasons for repairing or replacing restorations; and to test the hypothesis that certain dentist-, patient- and restoration-related variables are associated with the decision between repairing and replacing restorations.MethodsThis cross-sectional study had a consecutive patient and restoration recruitment design. Practitioner-investigators (P-Is) recorded data for consecutively seen restorations in permanent teeth that needed repair or replacement. The DPBRN is a consortium of dental practitioners and dental organizations in the United States and Scandinavia. The collected data included the primary reason for repair or replacement, tooth surface or surfaces involved, restorative materials used and patients' demographic information.ResultsP-Is collected data regarding 9,484 restorations from 7,502 patients in 197 practices. Seventy-five percent (7,073) of restorations were replaced and 25 percent (2,411) repaired. Secondary caries was the main reason (43 percent, n = 4,124) for treatment. Factors associated with a greater likelihood of repairing versus replacing restorations (P N/A .05) included having graduated from dental school more recently, practicing in a large group practice, being the dentist who placed the original restoration, patient's being of an older age, the original restorative material's being something other than amalgam, restoration of a molar and the original restoration's involving fewer tooth surfaces.ConclusionsDPBRN dentists were more likely to replace than to repair restorations. Secondary caries was the most common reason for repairing or replacing restorations. Certain dentist-, patient- and restoration-related variables were associated with the repair-or-replace decision.Clinical ImplicationsThe selection of minimally invasive treatment for an existing restoration is critical, as it may affect the longevity of the tooth.     

Advancing infection control in dental care settings: Factors associated with dentists' implementation of guidelines from the Centers for Disease Control and Prevention

Background and OverviewThe authors set out to identify factors associated with implementation by U.S. dentists of four practices first recommended in the Centers for Disease Control and Prevention's Guidelines for Infection Control in Dental Health-Care Settings—2003.MethodsIn 2008, the authors surveyed a stratified random sample of 6,825 U.S. dentists. The response rate was 49 percent. The authors gathered data regarding dentists' demographic and practice characteristics, attitudes toward infection control, sources of instruction regarding the guidelines and knowledge about the need to use sterile water for surgical procedures. Then they assessed the impact of those factors on the implementation of four recommendations: having an infection control coordinator, maintaining dental unit water quality, documenting percutaneous injuries and using safer medical devices, such as safer syringes and scalpels. The authors conducted bivariate analyses and proportional odds modeling.ResultsResponding dentists in 34 percent of practices had implemented none or one of the four recommendations, 40 percent had implemented two of the recommendations and 26 percent had implemented three or four of the recommendations. The likelihood of implementation was higher among dentists who acknowledged the importance of infection control, had practiced dentistry for less than 30 years, had received more continuing dental education credits in infection control, correctly identified more surgical procedures that require the use of sterile water, worked in larger practices and had at least three sources of instruction regarding the guidelines. Dentists with practices in the South Atlantic, Middle Atlantic or East South Central U.S. Census divisions were less likely to have complied.ConclusionsImplementation of the four recommendations varied among U.S. dentists. Strategies targeted at raising awareness of the importance of infection control, increasing continuing education requirements and developing multiple modes of instruction may increase implementation of current and future Centers for Disease Control and Prevention guidelines.The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, Atlanta.The authors thank Jon Ruesch, who when this study was conducted was the director, Survey Center, American Dental Association, Chicago, for his effort in the collection of the data for this research project. Mr. Ruesch is now retired.     

Evaluating factors that affect the shade-matching ability of dentists,dental staff members and laypeople

BackgroundThe authors conducted a study to evaluate the influence of dentists' and nondentists' experience, age, sex, eye color and use of eyeglasses or contact lenses on tooth shade–matching ability.MethodsThe authors included 120 participants in this study conducted in Istanbul (periodontists, oral and maxillofacial surgeons, orthodontists, endodontists, pediatric dentists, prosthodontists, restorative dentists, general dentists in private practice, dental technicians, dental assistants, dental assistant students and laypeople). The authors assigned participants to one of three groups: group 1 was composed of prosthodontists, restorative dentists and dental technicians; group 2 consisted of other dental specialists and general dentists; and group 3 included dental assistants, dental assistant students and laypeople. The authors asked participants to match the shades of three artificial maxillary right central incisors (Vitapan acrylic teeth [shades 2L1.5, 1M2, 2R1.5], Vita Zahnfabrik, Bad Sa?ckingen, Germany) by using a shade guide system (Vita Toothguide 3D-Master, Vita Zahnfabrik). They calculated shade matching for the three color components (value, hue, chroma) and analyzed the results by using a χ² test.ResultsThe rate of success in matching the shade for IM2 was 53.3 percent for participants in group 1, 30 percent for participants in group 2 and 20 percent for participants in group 3 (P = .017). However, there were no significant differences between the three groups for shades 2L1.5 and 2R1.5. Professional experience (P = .003) and age (P = .027) were associated with shade-matching success for tooth shade 2L1.5 only. The results showed no statistically significant differences with respect to sex, eye color or use of eyeglasses or contact lenses.ConclusionsDental care professionals who routinely performed restorative procedures matched the shades better than did participants in other groups. Professional experience was associated positively with the outcome, while sex, eye color and use of eyeglasses or contact lenses did not have any effect on shade-matching results.Clinical ImplicationsTo improve shade-matching skills, clinicians should participate in hands-on courses, continuing education classes and other training programs.     

Dentists’ levels of evidence-based clinical knowledge and attitudes about using pit-and-fissure sealants

BackgroundAlthough the prevalence of pit-and-fissure sealants in children in the United States is low, the problem is magnified in low-income children. A small proportion of Florida's low-income children receive any preventive dental services, including sealants. The authors conducted a cross-sectional study to assess whether Florida's dentists provide sealants as a preventive measure in their practices, their attitudes and their levels of evidence-based clinical knowledge about appropriate sealant use according to the American Dental Association (ADA) recommendations. The authors also assessed whether the number of years since graduation and reliance on peers or colleagues for regular clinical information were associated with dentists’ knowledge.MethodsThe authors administered a 25-item pretested questionnaire to a convenience sample of general and pediatric dentists (n = 163) at the 2013 Florida National Dental Convention in Kissimmee, Fla. The authors conducted multivariate linear regression modeling to predict dentists’ levels of evidence-based clinical knowledge.ResultsYears since graduation (P = .2) and reliance on peers or colleagues for regular clinical information (P = .6) did not predict higher knowledge. Male dentists (P = .003) and those who accepted children enrolled in Medicaid as new patients (P = .01) had significantly more knowledge compared with their counterparts.ConclusionsMost participating dentists used sealants in their practices and had high levels of positive attitudes about using sealants. Overall knowledge regarding the appropriate use of sealants, however, was low.Practical ImplicationsFor practicing dental professionals, the authors recommend disseminating evidence-based recommendations for the use of dental sealants via continuing education courses and other possible modalities. They also recommend that dental schools update their existing courses or modules about sealants by integrating the ADA's recommendations.     

Differences in male and female dentists' practice patterns regarding diagnosis and treatment of dental caries: findings from The Dental Practice-Based Research Network

BackgroundA number of articles have addressed differences in productivity between male and female dentists, but little is known about differences between the sexes in practice patterns regarding caries management.MethodsIn this study, the authors surveyed general dentists who were members of The Dental Practice-Based Research Network (DPBRN) and who practiced within the United States. The survey included questions about dentists’, practices' and patients' characteristics, as well as prevention, assessment and treatment of dental caries. The authors adjusted the statistical models for differences in years since dental school graduation, practice model, full-time versus part-time status, and practice owner or employee status before making conclusions about sex differences.ResultsThree hundred ninety-three male (84 percent) and 73 female (16 percent) dentists participated. Female dentists recommended at-home fluoride to a significantly larger number of their patients than did male dentists, whereas male dentists had a preference for using in-office fluoride treatments with pediatric patients. Female dentists also chose to use preventive therapy more often at earlier stages of dental caries. There were few differences between the sexes in terms of diagnostic methods, time spent on or charges for restorative dentistry, and busyness of the practice.ConclusionsFemale DPBRN dentists differ from their male counterparts in some aspects of the prevention, assessment and treatment of dental caries, even with significant covariates taken into account.Practice ImplicationsThe practice patterns of female dentists suggest a treatment philosophy with a greater focus on caries prevention.     

Organization and overall job satisfaction among publicly employed,salaried dentists in Sweden and Denmark

Abstract

Background. In Sweden and Denmark, clinical dentistry is changing and public dentistry is in transition towards more market orientation. Dentists' overall job satisfaction is important for how public dentistry can fulfil the new expectations from patients, the public and politicians. Objectives. The aim of this study was to investigate what organizational factors were important for publicly employed salaried dentists' overall job satisfaction. Methods. A random sample of active, general dental practitioners (private and publicly employed) was selected in Denmark and in Sweden, and they received a postal questionnaire. The number of questionnaires was 1835 and the response rate was 68% (n = 1226). This study analysed only the publicly employed dentists. The sampling frame for the Swedish dentists was 431, response rate 68.9% (n = 297) and for the Danish ones 194, response rate 81.9% (n = 159). Multivariate regression was used with overall job satisfaction as a dependent variable. Results. Common organizational variables were important. The used model explained between 32% (Sweden) and 39% (Denmark) of the variance in overall job satisfaction. The only significant individual factor was less job satisfaction for Swedish dentists born outside Sweden. An organizational climate characterized by a focus on professional values was associated with job satisfaction in both countries. Among the Swedish dentists, number of colleagues and degree of influence were also important and among the Danish ones sufficient time for patients. Conclusions. Organizational factors had an impact on salaried publicly employed dentists' overall job satisfaction in both countries. The findings may have implications for other Human Service Organizations with employed professionals.     

Unilateral hyperplasia of the mandibular condylar process.: A histological,microradiographic, and autoradiographic examination of one case

Abstract

Objective. This study aimed at evaluating dentists' perceived reasons for replacement of restorations and ascertaining the differences arising from dentists' gender, time since graduation and working sector (salaried vs private). Materials and methods. A postal questionnaire was sent to a total of 592 working-age general dental practitioners in Finland, 57% (n = 339) responded. The dentists were asked to rank in order of priority the six most common reasons for replacement of composite in the incisors and posterior teeth and amalgam in the posterior tooth from a list of 12 reasons. Ranking order 1 was worth six points and order 6 one point; the non-ranked reasons were equal to zero. Differences in the means of the summed scores of caries-related (RC), fracture- and failure-related (RF) and miscellaneous (RO) groups were evaluated by ANOVA. The level of significance was set at p = 0.05. Results. For each of three restorations, the RF group comprised 48–56% of the sum-scores. Of the single reasons, secondary caries predominated (20–24%). For composite restorations in the incisors, the mean sum-score of the RO group was greater for private-sector dentists (p = 0.04). For composite restorations in the posterior teeth, the mean sum-score of RF group was higher for male than female dentists (p = 0.009). For amalgam, mean score for RF was 10.2, followed by RC (8.5) and RO (1.1). Conclusion. Secondary caries and various fractures and failures predominate as dentists' perceived reasons for replacement of restorations. Private dentists included miscellaneous reasons as one of their six reasons more often than did the salaried dentists. The complex process of treatment planning and decision-making is influenced by many as of yet unknown factors, calling for emphasis on investigating of perceptions.     

Counseling on Early Childhood Caries transmission by dentists

Objective: High levels of Streptococcus mutans on teeth of young children are predictive of Early Childhood Caries (ECC). Transmission from mother‐to‐child is common and studies have demonstrated treatment of the mother results in less ECC. The objective of this study was to determine how dentists have adopted the practice of counseling about ECC. Methods: In 2006 as part of a larger study on dental care for pregnant women, we surveyed 829 general dentists in Oregon. The questionnaire contained questions to capture the extent to which general dentists have adopted counseling pregnant women about ECC transmission, to describe personal and practice characteristics, and examine how dentists' views on the ease of adopting of new procedures related to ECC counseling. Multivariate logistic regression was used to identify separate and additive effects of demographic and practice characteristics, attitudes, and beliefs. Results: The adjusted odds of a dentist who strongly believed in the link between mothers and babies and provided ECC counseling were 1.60 (95% CI 1.3‐2.0, P < 0.01). The odds of a dentist who reported discussing ECC with staff members and provided counseling were 2.7 (95% CI 1.7‐4.3, P < 0.01). Male dentists were less likely to counsel patients than female dentists (Adjusted OR = 0.5, 95% CI 0.3‐1.0, p < 0.05). Conclusions: The strongest predictors of counseling patients about ECC were dentists' belief in the evidence of caries transmission and dentists' discussion of ECC during staff meetings.