I.   A.   Ambulatory Surgical Facilities - TOP

Modern ambulatory surgery evolved from hospital facilities and branched out into variations on the theme of providing high level of quality care at reduced costs. Listed below are the various types of facilities in which ambulatory surgery is currently performed:

  A. Hospital-integrated
  B. Hospital-segregated
  C. Freestanding-hospital satellite
  D. Freestanding-independent surgical center
  E. Physician's office-based surgery

Anderson LG. Outpatient surgery center accreditation. AORN Journal. 60(6):959-67, 1994.

The increase in outpatient surgery has spurred an interest in accreditation for ambulatory surgery centers. Several agencies accredit health care facilities, including the Joint Commission on the Accreditation of Healthcare Organizations (JCAHO). This article details one ambulatory surgery center's step-by-step actions toward obtaining JCAHO accreditation.

Apfelbaum JL, Schreider BD: Outpatient facility and personnel. In White P (ed): Outpatient Anesthesia, New York: Churchill Livingstone, 1990, pp 57-8l.

Reviews the advantages and disadvantages of each type of ambulatory surgery setting, including a brief historical review.

Arregui ME, Davis CJ, Arkush A, Nagan RF: In selected patients outpatient laparoscopic cholecystectomy is safe and significantly reduces hospitalization charges. Surg Laparosc Endosc 1:240, 1991

Our idea of appropriate procedures for ambulatory surgery is changing. In the past, cholecystectomy usually required an inpatient admission. Now, some centers perform the procedure on selected outpatients (generally healthy ones who live nearby) when an uneventful operative procedure is anticipated.

Berliner HS, Burlage RK: The walk-in chains: the proprietarization of ambulatory care. Int J Health Serv 17:585, 1987

Although free-standing, independent facilities continue to grow, some consumers prefer care in units affiliated with hospitals.

Cutter T, Korttila K, Apfelbaum J.- Organizational aspects economics, and patient flow. International Practice of Anaesthesia, vol, 2. Prys-Roberts C, Brown BR, Jr, eds. Oxford: Butterworth-Heinemann, pp. 121/1-9, 1996. This chapter includes concerns regarding facility design and location.

Davis JE: The major ambulatory surgical center and how it is developed. Surg Clin North Am 67:67l-692, 1987.

Reviews the pros and cons of the different types of ambulatory surgical units. The steps in the development of a unit are outlined.

Goodman AA, Mendez AL: Definitive surgery for breast cancer performed on an outpatient basis. Arch Surg 128:1149, 1993

In the past, patients undergoing definitive surgery on the breast have been hospitalized 1-7 days after surgery. Yet in one series of 221 patients undergoing various types of breast surgery, including modified radical mastectomies and axillary node dissection, no patients required hospital admission.

Guidelines for Optimal Office-based Surgery, second edition. Developed by the Board of Governors Committee on Ambulatory Surgical Care, American College of Surgeons.

Henderson JA: Ambulatory surgery: Past, present, and future. In Wetchler BV (ed): Anesthesia for Ambulatory Surgery, 2nd ed, Philadelphia: JB Lippincott, 1991, pp 1-27

Overview of the evolution of different types of ambulatory surgical facilities, with projections into the next decade.

Lannigan FJ, Martin-Hirsch DP, Basey E: Clinical audit: is day-case adenotonsillectomy safe? Br J Clin Pract 47:254, 1993

Tonsillectomy can be safely performed in ambulatory patients. Be careful, though, with patients who suffer from allergic episodes during the pollen season; have bleeding abnormalities or sickle cell anemia; are within five weeks of an acute attack of tonsillitis; have heart disease, sleep apnea, or congenital malformations; or experience bleeding within 8 hours of the procedure. Tonsillectomies for outpatients should be performed in the morning.

Lowell-Smith EG: Alternative forms of ambulatory care: implications for patients and physicians. Soc Sci Med 38:275, 1994

Describes the economic and other implications of ambulatory surgery. For example, such facilities are often for-profit and not located in rural or inner city areas.

Oskowitz SP, Berger MJ, Mullen L, et al. Safety of a freestanding surgical unit for the assisted reproductive echnologies. Fertility & Sterility. 63(4):874-9, 1995.

This was a prospective study to determine the safety of a freestanding surgical unit for assisted reproductive technology (ART), using the rate of unplanned admissions to a hospital within 24 hours of surgery. There were 11 hospital admissions (0.16%). The number of admissions after monitored anesthesia care was higher than expected compared with general anesthesia. Profiles of hospitalized patients showed no apparent differences from the nonhospitalized patients.

Pica-Furey W. Ambulatory surgery--hospital-based vs freestanding. A comparative study of patient satisfaction., AORN Journal. 57(5):1119-27, 1993.

This study found that patients in the freestanding facility were more satisfied with the courtesy and consideration of secretaries receptionists, the facility's appearance and convenience, the ease of delivering feedback, and the cost. It also demonstrated the unexpected benefit of superior postoperative teaching by the nursing staff.

Plapp A. Freestanding surgery centers must establish transfer plans. AORN Journal. 55(4):1099-100, 1992.

The quality of patient care in freestanding surgery centers in the United States must meet the same standards as that provided in inpatient facilities. Developing a plan for emergency patient transfer provides patients and staff members with the confidence and information necessary to handle transfers calmly and efficiently and it will ensure that the patient receives the best quality care available.

Rudkin GE, Bacon AK, Burrow B, et al. Review of efficiencies and patient satisfaction in Australian and New Zealand day surgery units: a pilot study. Anaesthesia & Intensive Care. 24(1):74-8, 1996.

A prospective study was designed in which information was collected on 826 patients over a two-week period. Three facility types were identified and results were statistically corrected for any differences that ASA status, age and surgical time may have made. Patient preoperative waiting time, recovery room times, delayed discharge time and unanticipated admission rates showed favourable outcome trends for freestanding facilities compared with hospital-integrated facilities where day patients had a shared recovery with inpatients. Similar trends were seen with patient opinions of waiting times and recovery periods.

Koch ME, Kain ZN, Ayoub C, Rosenbaum SH. The sedative and analgesic sparing effect of music. Anesthesiology 89(2):300-306, Aug 1998.

Dexter F. Design of appointment systems for preanesthesia evaluation clinics to minimize patient waiting times: a review of computer simulation and patient survey studies. Anesthesia & Analgesia 89(4):925-931, Oct 1999.

Johnstone RE. Strategies to control anesthetic practice costs. International Anesthesiology Clinics 36(1):59-63, Winter 1998.

Vitez TS, Macario A. Setting performance standards for an anesthesia department. Journal of Clinical Anesthesia 10(2):166-175, Mar 1998.

Klein JD. When will managed care come to anesthesia? Journal of Health Care Finance 23(3):62-86, Spring 1997.

Valenzuela RC, Johnstone RE. Cost containment in anesthesiology: a survey of department activities. Journal of Clinical Anesthesia 9(2):93-96, Mar 1997.

B. Office-Based Anesthesia - TOP

Office–based anesthesia and surgery has had a checkered past and has a bright future. The issues involved in assuring public safety is maintained while providing outpatient surgical services in the physician office–based setting (POBS) are many and complex. This bibliography attempts to walk you through the recent history and evolution of office-based anesthesia and surgery from many different perspectives. Hopefully, at some point in the very near future we can assure our patients that they are as safe having surgery and anesthesia no matter the setting.

1. Industry Trends - TOP

SMG Marketing Group, “Forecast of Surgical Volume in Hospital/Ambulatory Settings: 1981-2006”, 1999

SMG Marketing Group, “Freestanding Outpatient Surgery Centers Report: 1999 edition”, pp 27-28

Regulations/Standards/Guidelines

Office-based Anesthesia, “Considerations for Setting up and Maintaining a Safe Office Anesthesia Environment”, 2000, ASA Publication

ASA Guidelines for Office-Based Anesthesia, approved 10/13/99

Guidelines for Optimal Office-based Surgery, “American College of Surgeons”, 2 nd edition 1999

Joint Commission on Accreditation of Healthcare Organizations, “Office Based Surgery Standards, 2000

AANA, “Standards for Office-based Anesthesia Practice, 2000

AB 595, “Medical Board of California

NJAC, “Proposed Surgical and Anesthesia Standards in an Office-Setting”, 13:35 – 4A.1 – 4A.18  

2. Industry Press - TOP

AAAHC News Release, “AAAHC Establishes Quality Standards for Accrediting ‘Itinerant’ Anesthesia Organizations”, 3/29/99

AAAHC Update, “ Florida Requires Office-based Surgery Registration and Inspection”, Summer 2000, pp. 1

Healthcare Benchmarks, “Association Creates New Standard for Anesthesia; Accreditation Offered for Office Anesthesiologists”, July 1999, pp 78-79

Same-day Surgery, “NJ Sets Benchmark to Regulate Office Anesthesia”, “New Jersey Regulations Focus on Patient Safety”, “Proposal Encourages Office Surgery”, January 1999, pp 4-7

Modern Healthcare, “Doctors Move Surgeries into Offices”, September 6, 1999, pp 60

American Medical News, “Lidocaine Dose Question in Liposuction Deaths, 02/18/99, pp 30-31

American Medical News, “Anesthesiologists Decide to Lay Out Welcome Mat”, 1999

Barinholtz, David B., “A Call to Action”, Outpatient Surgery, Volume 2, No. 2, pg 80

3. Other Medical Society Activities - TOP

American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, Inc. “Policy Statement on Accreditation of Office Facilities”

Outpatient Surgery, “Plastic Surgeons OK Office Surgery Accreditation”, November 2000, pp 3-4

Communiqué from American Academy of Dermatology, January 28, 1999

4. Anesthesia Publications - TOP

Society for Office-based Anesthesia Newsletters, Published quarterly since Autumn 1996, Contact Society for Office-based Anesthesia, 2150 N. 107 th, Suite 205, Seattle, WA, 98133-9009, (206)-367-8704, email: sbinc@halcyon.com (Currently appears as part of the Journal of Clinical Anesthesiology)

Ellison N, “Perspectives on Office-based Anesthesia”, IARS 2001 review course lectures, pp 26-31

Turpin S, Diane JD, “ Florida Office-based Surgery Rules: The Fight for Patient Safety Continues”, ASA Newsletter, January 2001, Volume 65, No. 1, pp 23-24

Turpin S, Diane JD, “Year 2000 in Review: Highlights of State Legislative and Regulatory Activities”, ASA Newsletter, December 2000, Volume 64, No. 12, pp 6., 5

ASA Newsletter, “Task Force on Office-based Anesthesia Setting Precedents for a Growing Field”, May 2000, Volume 69(5):21-22, 35

Twersky, Rebecca S., MD, Showan, Ann M., MD, “Office-based Anesthesia Update: Guidelines, Education, and Support are Invaluable”, ASA Newsletter, April 1999, Volume 63(4):22-24

Moss, Ervin, MD, “Revelations: New Jersey Office Regulations Adopted”, ASA Newsletter, August 1998, Volume 62(8):17-19, 22.

Moss, Ervin, MD, “Practice Options: Flying Without a Net: Office-based Anesthesia in the 90’s”, ASA Newsletter, June 1997, Volume 61(6):26-28

Twersky, MD, Koch, MD, “Practice Options: Considerations in Setting up an Office-based Anesthesia Practice”, ASA Newsletter, June 1997, Volume 61(9):30-32

Joas, Thomas A., MD, “Practice Options: Office Based Anesthesia: An Overview”, ASA Newsletter, June 1997;61(6):24-25

Mihalcik, James A., MD, “The Anesthesiologist and Office-based Anesthesia Practice”, ASA Newsletter, May 1996;60(5):20-21

Twersky, Rebecca S., MD, “The Anesthesiologist in the Ambulatory Surgical Care Setting”, ASA Newsletter, May 1996;60(5):11-13

Laurito, C. E., “Office-based Anesthesia: A New Arena for a New Millennium”, In: Advances in Anesthesia, St. Louis: Mosby Year Book, Inc, 1998, 16: 29-59

Johnson, Joseph F., MD, “Office-based Anesthesia Comes to Forefront of Ambulatory Issues”, Ambulatory Anesthesia, 1997;12(2):1-3

Koch, Marc E., MD, “Office-based Anesthesiology: The New Perioperative Manager: Wearing Many Hats”, Ambulatory Anesthesia,1997;12(2):4-5, 12

DeJong, Rudolph H., MD, “Mega-dose Lidocaine Dangers Seen in ‘Tumescent’ Liposuction” APSF Newsletter, Fall 1999;14(3):25-27

Moss, Ervin, MD ”MD Office Safety Regs Striped in New Jersey”, APSF Newsletter, Winter 96-97;11(4):39-41

Anesthesia Malpractice Prevention, “Keep Office-based Surgery Safe”, June 1999;4(6):41-45

Anesthesia Malpractice Prevention, “Avoid Outpatient Pitfalls”, September 1997;2(9): 65-69

Anesthesia & Analgesia, “Propofol vs. Desflurane – Antiemetics for Office-based Anesthesia”, January 2001;92(1):95-99

Pembrook, Linda, “Anesthesiologists Should Move to Regulate Office-setting”, Anesthesiology News, October 2000, pp 124-125

Pembrook, Linda, “Liposuction Surgery Poses Unique Challenges to the Anesthesiologist”, Anesthesiology News, August 2000, pp 56-57

Prescott, Lawrence M., PhD, “Off-site Anesthesia Can be Treacherous”, Anesthesiology News, April 2000 pp 56-57

Pembrook, Linda, “Evolution of Ambulatory Surgery Must Continue to be Evidence-Based”, Anesthesiology News, October 1999, p 78

Pembrook, Linda, “Standards Must Follow Expansion in Ambulatory Surgery”, Anesthesiology News, June 1999

Pembrook, Linda, “Movement Afoot to Regulate Office-based Anesthesia, Anesthesiology News , June 1999, pp 1, 49-50

Anesthesiology News, “Regulation of Office Anesthesia Varies Among States”, June 1999

Pembrook, Linda, “Quality Improvement System Crucial in Office-Anesthesia”, Anesthesiology News, June 1999

The American Journal of Anesthesiology, “Back to the Future”, p 63

5. Lectures/Outlines from Anesthesia Meetings - TOP

Barinholtz, David, MD, “Office-based Anesthesia in 2001: An Anesthesia Odyssey”, Outline for ASA Meeting, February 2001

Barinholtz, David, MD, “Anesthesia for Office-based Cosmetic Surgery”, Outline from ASA Panel Discussion, ASA Meeting, October 2000

Mayer, David MD., “Regulations and Standards for Office-based Surgery and Anesthesia: Where are We Heading”, SAMBA Meeting 1998

Koch, M., Goldstein R., “The Office Anesthesiologist as a Perioperative Manager: Safety, Outcomes, and Practice Recommendations”, SAMBA Meeting 1998

6. Related Journal Articles - TOP

Friedberg, B., Siol J., “Clonidine Premedication Decreases Propofol consumption During Bispectral Index (BIS) Monitored Propofol–Ketamine Technique for Office-based Surgery”, Dermatolic Surgery 26(9):848-852, September 2000

Silber, et al., “Do Nurse Anesthetists Need Medical Direction by Anesthesiologists?”, (Abstract)

Silber, et al., “Hospital and Patient Characteristics Associated with Death After Surgery: A Study of Adverse Occurrence and Failure to Rescue”, Medical Care, 30:65A, 1992

Grazer F.M., DeJong, R.H., “Deaths From Liposuction”: Census Survey of Cosmetic Surgeons, Plastic, and Reconstructive Surgeons, 1999; 104:1

7. Economics - TOP

Outpatient Surgery, “Inhalant Costs”, January 2001, Volume 2, No. 1

Taylor, Dianne, “How to Cut Inhalant Costs”, Outpatient Surgery, January 2001, Volume 2, No. 1, pp 46-53

Lee, Judith, “The Internet: Could it Streamline Your Pre-op Procedures?”, Outpatient Surgery, January 2001, Volume 2(1):57-63

Outpatient Surgery, “In Michigan, ASCS and Blue Cross Continue to Tangle”, November 2000, Volume 1(10):4-6

Iqbal, Yasmine, “Should You Buy Supplies Online?”, Outpatient Surgery, November 2000, Volume 1(10):22-35

Deutsch, William, “Update on Anesthesia Drugs”, Outpatient Surgery, October 2000, Volume 1(9):46-58

8. Lay Press - TOP

KXAS TV Dallas, DFW Today, “Anesthesiology, January 01, 2001, 10 am (CT)

KNSD TV (NBC) San Diego, “Anesthesiology”, January 24, 2001, 5 am (PT)

42 Daily News at 10, WIAT TV (CBS, Birmingham), “Anesthesiology”, January 24, 2001, 10 pm (ET)

Allen, Jane, “Boom in Liposuction Treatment Carries Risk”, Associated Press, 1999)

MSNBC, Special Edition, “Cosmetic Surgery”, November 10,1999, 9 pm (ET

ABC TV, “Plastic Surgery”, 20/20, November 3, 1999, 10 pm (ET)

Hayden, Thomas and Sieder-Jordan, Jill, “Death by Nip and Tuck”, Newsweek, August 9, 1999, p 58 insert

Kalb, Claudia, “Our Quest to be Perfect”, Newsweek, August 9, 1999, pp 52-59 (Letter to the editor, re: above article – Barinholtz, David B., MD)

Zuger, Abigail, “Surgeons Leaving the OR for the Office”, New York Times, May 18, 1999, Science Section, pp 1-2

NBC Nightly News, “Lifeline/Office Anesthesia”, March 30, 1999, 6:30 pm (ET)

Neergard, Lauren, “Sedation Safety Alert”, Associated Press, Chicago Tribune, March 17, 1999

The Palm Beach Post, Associate Press, “Report: 18 Died After Basic Cosmetic Surgery”, March 7, 1999, p. 28a

Wall Street Journal, Extreme Liposuction is Exposing Patients to Unnecessary Risk”, January 18, 1999, p. 23a

Sun-Sentinel, “New Plastic Surgery Rules Shift Balance Toward Patient Welfare”, January 8, 1999, Editorial Section, p 26a

Associated Press, Dallas Morning News, “Suit in Girl’s Death Settled for 1.8 Million”, January 7, 1999, News Section, p 23a

Houston Chronicle, “Doctors settle in Death Suit”, January 7, 1999, Section a, p. 20

Snyder J., Steckner S., “Few Rules for State clinics; In-office Procedures Largely Unregulated”, The Arizona Republic, August 23, 1998, Front Section, p A1

Weis, Lillian, “Doctor in Death Probe Would Pay Fine Under State Deal”, Palm Beach Post, August 12, 1998, Local Section, p 3b

Landry, Sue, “Surgeries in Doctor’s Offices Concern Regulators”, St. Petersburg Times, May 23, 1998, City and State Section, p 3b

Cheney, Karen, “The Bookkeeper Will See You Now”, Money Magazine, March 1998, p 25 (inset)

Davis, Henry, “Surgery in Offices Targeted”, Buffalo News, March 10, 1998, p 1a

Miller, Susan R., “Nip and Tuck; Medical board could Crack Down on In-office Surgeries”, Broward Daily Business Review, February 5, 1998, p 1a

Davis, Henry, “Hunt for Low-Cost Care Cited in Death”, Buffalo News, September 29, 1997, p 1b

Kelleher, Susan, “Cosmetic Surgery by Dentists Condemned”, Orange County Register, November 6, 1991, Health and Science section, p 24

Office-based anesthesia, “Considerations for Setting Up and Maintaining a Safe Office Anesthesia Environment”, 2000, ASA Publication

Most of the publications referenced in this section do a good job of enumerating all the areas of concern when performing surgery and anesthesia in the office-based setting. The ASA task force on office-based anesthesia has done a particularly good job in putting together a concise, easy to follow approach to setting up and maintaining a safe office anesthesia practice. All areas are addressed including: credentialing, facilities and environment, peer review, quality improvement, risk management, and emergency preparedness to name a few. If one closely adheres to the recommendations, your office anesthesia practice should pass muster with any of the accrediting bodies.

American Society of Plastic Surgeons, American Society for Aesthetic Plastic Surgery, Inc., “Policy Statement on Accreditation of Office Facilities”

It is important to be aware of this policy statement as it is the first time a professional society has required its members to have their surgical facilities accredited or risk losing membership. Expect more such actions from surgical societies coinciding with state regulatory activities.

9. ASA Newsletter Articles - TOP

This is a collection of articles which have appeared over the past few years in ASA Newsletter related to office-based anesthesia. After one reads these articles one should have a good grasp of the many issues facing office-based anesthesia providers and what the current status of some of these issues in various states.

Koch M., Goldstein R., The Office Anesthesiologist as a Perioperative Manager: “Safety, Outcomes, and Practice Recommendations”, SAMBA meeting 1998.

Drs. Koch and Goldstein have, in this lecture, captured the essence of what are the salient differences between office anesthesia practice and traditional anesthesia practice. It summarizes what they have learned in setting up and running one of the most successful (and one of only 2 accredited) office anesthesia practices in the country.

Courtiss EH, Goldwyn RM, Joffe JM, Hanneberg AA: Anesthetic practices in ambulatory aesthetic surgery. Plastic and Reconstructive Surgery 93:792-801, 1994.

Courtiss EH, Kanter MA: The prevention and management of medical problems during office surgery. Plastic and Reconstructive Surgery 85:127-36, 1990.

Ellison, Norig, MD, “Perspectives on Office-based Anesthesia”, IARS 2001 review course lectures, pp 26-31

Dr. Ellison does a good job of succinctly articulating many of the big issues one must consider when venturing into office anesthesia practice. He also provides a nice historical perspective with parallels to the development of ambulatory anesthesia in the 70’s and 80’s. As Dr. Ellison points out we have a ways to go in terms of patient safety, standards of care, and regulatory oversight. But with the leadership of anesthesiologists we will make this venue as safe as any other.

Fullarton GM, Darling K, Williams J, MacMillian R, Bell G: Evaluation of the cost of laparoscopic and open cholecystectomy. Br J Surg 81:124-6, 1994.

Ganzberg SI, Weaver JM. Anesthesia for office-based oral and maxillofacial surgery. Dental Clinics of North America 43(3):547-562, viii., Jul 1999

Gimpelson RJ: Office hysteroscopy. Clinical Obstetrics and Gynecology 35:270-81, 1992.

Gradinger GP: Advantages and disadvantages of office surgery. Clinics of Plastic Surgery 10:309, 1983.

Grazer F.M., DeJong, R.H., “Deaths From Liposuction”: Census Survey of Cosmetic Surgeons, Plastic, and Reconstructive Surgeons, 1999; 104:1

This is the study that quotes a death rate of 1 in 5000 for in-office lipoplasty. The study (although flawed and the actual numbers are probably lower) does bring to the forefront the issue of a different and lower standard of care that exists in office-based surgical practice.

Jastak TJ, Peskin RM: Major morbidity or mortality from office anesthetic procedures: a closed-claim analysis of 13 cases. Anesthesia Progress 38:39-44, 1991.

Laskin DM: The regulation of office anesthesia. J Oral Surgery 34:395, 1976.

McDonald HP: Office ambulatory surgery in urology. Urol Clin of North America 14:27-30, 1987.

Phero JC, Driscoll KM, MacDonnell WA: Appropriate selection of anesthesia personnel for office dental anesthesia. Dental Clinics of North America 31:21-35, 1987.

Schulz LS: Cost analysis of office surgery clinic with comparison to hospital outpatient facilities for laparoscopic procedures. Int Surg 79:273-7, 1994.

Silber, et al., “Do Nurse Anesthetists Need Medical Direction by Anesthesiologists?”, (Abstract)

Silber, et al., “Hospital and Patient Characteristics Associated with Death After Surgery: A Study of Adverse Occurrence and Failure to Rescue”, Medical Care, 30:65A, 1992

This is the landmark University of Pennsylvania study that demonstrates a significantly higher failure-to-rescue rate when nurse anesthetists are supervised by non-anesthesiologists, as compared to anesthesiologists. The implications for office-based surgery and anesthesia is obvious.

Tobin TA: Office surgery: The surgical suite. Journal of Dermatol Surg Oncol 14:247-55, 1988.

Twersky R and Koch ME. Practice Options: Considerations in Setting Up an Office-Based Anesthesia Practice. ASA Newsletter 61(9), Sept. 1997.

Vallieres E, Verdant A: Ambulatory mediastinoscopy and anterior mediastinotomy. Ann Thorac Surg 52:1122-6, 1991.

White PF, Smith I: Ambulatory anesthesia: past, present and future. Int Anesth Clin 32:1-16, 1994.

Whitmire HC. Medicolegal considerations for office-based anesthesia in dentistry. Dental Clinics of North America 43(2):361-377, vii., Apr 1999.

Williams JE: Plastic surgery in the office surgical unit. Plastic and Reconstructive Surgery 52:513-9, 1973.

Yagiela JA. Office-based anesthesia in dentistry. Past, present, and future trends. Dental Clinics of North America 43(2):201-215, v., Apr 1999.

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