Jeffrey A Brinker, M.D.
- Professor of Medicine
- Joint Appointment in Radiology and Radiological Science
Interactions overview No interactions with frangula found; however purchase genf20 plus canada herbs coins, frangula (by Constituents virtue of its anthraquinone content) is expected to order genf20 plus 120pills without prescription rumi herbals pvt ltd share the major constituents of frangula are the anthraquinone some of the interactions of a number of other anthraquinone glycosides buy genf20 plus discount quest herbals. The frangulosides are the main components, containing laxatives, such as aloes, page 27 and senna, which include frangulin A and B, emodin derivatives, page 349. Of particular relevance are the interactions with chrysophanol and physcion glycosides, and free aglycones. Any effect on the drug transporter P-glycoprotein, shown in vitro,3 is also unlikely to be clinically significant, see Constituents protease inhibitors, page 202. Garlic products are produced from the bulbs (cloves) of For information on the pharmacokinetics of individual garlic and are usually standardised according to the content flavonoids present in garlic, see under flavonoids, page 186. Interactions overview Other sulphur compounds such as allylmethyltrisulfide, allylpropyldisulfide, diallyldisulfide, diallyltrisulfide, ajoene Case reports suggest that garlic may have additive blood and vinyldithiines, and mercaptan are also present. Garlic pressure-lowering effects with lisinopril, and may cause bleeding in those taking warfarin or fluindione. It has also also contains various glycosides, monoterpenoids, enzymes, G vitamins, minerals and flavonoids based on kaempferol and been suggested that any antiplatelet effects of garlic may be quercetin. Use and indications However, no interaction has been proven with any of these Garlic has been used to treat respiratory infections (such as drugs. It is believed to possess antihypertensive, antithrombotic, fibrinolytic, antimicrobial, benzodiazepines (such as midazolam), caffeine, chlorzox anticancer, expectorant, antidiabetic and lipid-lowering azone, dextromethorphan, docetaxel, gentamicin, paraceta properties. One study suggested that a high-fat diet did not affect the Pharmacokinetics absorption of some of the active constituents of garlic oil. For information on the interactions of individual flavonoids There are many active constituents in garlic and their roles present in garlic, see under flavonoids, page 186. Allicin is subject to a considerable first-pass effect and passes through the liver 1. Intake of garlic and its unstable compound and, as with ajoene, the vinyldithiins and bioactive components. An in vitro evaluation of human cytochrome P450 3A4 and P 2 glycoprotein inhibition by garlic. In vitro interactions of water soluble garlic components with human cytochromes P450. Inhibition of 3?6 5 4 cytochrome P-450 2E1 by diallyl sulfide and its metabolites. However, considering the In a single report, a patient taking lisinopril developed marked widespread use of garlic and garlic products, and the limited hypotension and became faint after taking garlic capsules. Nevertheless, bear the possibility in mind in the event of an unexpected response to A man whose blood pressure was 135/90mmHg while taking treatment. Dietary supplementation with aged garlic extract inhibits standing and was found to have a blood pressure of 90/60mmHg. Ajoene, the antiplatelet principle of garlic, synergistically potentiates the antiaggregatory action of prostacyclin, forskolin, pressure. The reasons for this interaction are not known, although indomethacin and dypiridamole [sic] on human platelets. Thromb Res (1986) 42, 303? garlic has been reported to cause vasodilation and blood pressure 11. Garlic + Benzodiazepines Garlic + Alcohol Garlic does not appear to affect the pharmacokinetics of alprazolam, midazolam or triazolam to a clinically relevant the interaction between garlic and alcohol is based on experi extent. Clinical evidence Evidence, mechanism, importance and management A study in 14 healthy subjects found that Kwai garlic tablets 600mg Garlic juice, from fresh garlic bulbs, inhibited the metabolism of twice daily for 14days did not affect the pharmacokinetics of a alcohol in mice. Garlic is a common ingredient in food and so it is single 2-mg dose of alprazolam. Combined effects of ethanol affect the metabolism of midazolam 8mg in young2 or elderly3 and garlic on hepatic ethanol metabolism in mice. Effects of inhibits the binding of fibrinogen to the fibrinogen receptor, which garlic (Allium sativum L. Drugs Aging There is a reasonable body of evidence, which suggests that aged (2005) 22, 525?39. In vitro interactions of water garlic herbal products may have antiplatelet properties. Clinical evidence Cytochrome P450 phenotypic ratios for predicting herb-drug interactions in humans. Effects of cytochrome P450 2E1 modulators on the pharmacokinetics No relevant data found. Importance and management Evidence for an interaction between garlic and caffeine appears to Garlic + Dextromethorphan come from two well-designed studies in humans. These studies suggest that garlic does not affect the metabolism of caffeine, and therefore an increase in caffeine adverse effects would not be Garlic does not appear to affect the pharmacokinetics of expected in those who also take garlic supplements. A study in 14 healthy subjects found that Kwai garlic tablets 600mg Cytochrome P450 phenotypic ratios for predicting herb-drug interactions in humans. Drugs Aging metabolism of debrisoquine 5mg in young2 or elderly3 healthy (2005) 22, 525?39. Therefore the dosage of Experimental evidence dextromethorphan would not need adjusting if patients also wish to A garlic constituent, diallyl sulfide 50mg/kg and 200mg/kg, was take garlic supplements. Effects of Garlic appears to inhibit the activity of the cytochrome P450 garlic (Allium sativum L.
Table 18 shows tion is important because extranodal lymphomas the spectrum of behaviors buy cheap genf20 plus on-line juvena herbals. Myeloid sarcoma is a leukemic deposit in an organ or tissue and should be coded to cheap genf20 plus on line herbals for ed the site of Table 18 order genf20 plus paypal herbs collision. The grade, diferentiation, or phenotype code provides sup Most cancer registries collect data only on plementary information about the tumor. Behavior codes /6, malig Cancer and carcinoma nant, metastatic site, and /9, malignant, uncertain The words cancer? and carcinoma? are ofen whether primary or metastatic site, are not gen (incorrectly) used interchangeably, for example erally used by cancer registries. For example, if a squamous cell cancer? is used for squamous cell person has a carcinoma that has spread to the lung carcinoma. To code the former as the latter would and the site of origin is unknown, the appropriate be reasonable. By far the largest number of in cancer? is used loosely and imprecisely as a part situ carcinomas are diagnosed in the cervix uteri. In recent years, several other closely related terms have been used by cytologists and pathologists, notably intraepithelial neoplasia. Unfortunately this (b) the behavior would be /3, and in (a) and (c) the description includes both carcinoma in situ and behavior would be /6 (metastatic), indicating that severe dysplasia. In the frst example (A) fve (unqualifed) is equivalent to in situ carcinoma can terms appear with their morphology codes. Each of apply the matrix system and change the behav these fve terms has the same four-digit morphol ior code to /1 (uncertain whether malignant or ogy code, 8140, indicating a neoplasm of glandular benign). It would not be used by cancer regis specimens from the same patient, for example: trars who, as previously explained, normally only (a) a biopsy, (b) the resected primary site, and (c) a include /2 (in situ) and /3 (malignant neoplasm, metastatic site (Table 19). Biopsy diagnosis: Supraclavicular lymph node, metastatic signet ring cell adenocarci C77. Metastatic site: Upper lobe bronchus, metastatic signet ring cell adenocarcinoma C34. If a diag benign, malignant, in situ, or uncertain whether nosis of malignant Brenner tumor? were reported, malignant or benign. Coding is sarcoma? would contradict current concepts and based on what the pathologist states. Assign the highest grade or diferentia code /2 could be attached to any of the four-digit tion code described in the diagnostic statement. Coders should use the appropriate mor Anaplastic phology code together with the proper grading 9 Grade or di? This may be useful when compar pathologists throughout the world, and many ing data coded according to the third edition of malignant tumors are not routinely graded. Words used to designate degrees of diferen is implicit in the four-digit histology code, and an tiation are listed in a separate column. However, some registries may wish little a tumor resembles the normal tissue from to retain the additional digit to identify cases in which it arose. Tere is great variability in the use of which the diagnosis is supported by immunophe descriptors by pathologists. When a diagnosis indicates two diferent degrees of grading or diferentiation, Code the higher number should be used as the grading code. Tus moderately diferentiated squamous 5 T-cell cell carcinoma with poorly diferentiated areas? 6 B-cell should be given the grading code 3. For example, complete coding of the Natural killer cell diagnosis anaplastic squamous cell carcinoma? 9 Cell type not determined, not stated or not applicable requires addition of the grading code 4? to the 22 4. It may be that the site given in a diagnosis is Some terms for neoplasms imply origin in cer diferent from the site indicated by the site-associ tain sites or types of tissue. To facilitate the coding of such terms, cinoma can arise in sites other than skin. Occasionally the appropriate code for the topography included the topography code appears in the 3-digit head in the diagnosis. For example, topography code ing and then applies to all terms included under C50. An underscore ( ) fol duct carcinoma? is used for a primary carcinoma lowing the decimal point indicates the existence of arising in the pancreas, coders should ignore the subsite codes. The appropriate fourth digit for the suggested breast topography code and assign the site reported should be added here. For example, a basal cell codes attached to morphology terms designate carcinoma of the face would be given the site code the usual site of origin of particular neoplasms. Similarly, the fourth diagnosis osteo-sarcoma of kidney, for which digit in the topography code (C70. A bone cancer (osteosarcoma) metastasis ogy term may be used when the topographic site to the kidney would be coded C41. For example, bile duct Myxofibrosarcoma? is the same as fibromyxo carcinoma? (8160/3) is a specifc histologic type, sarcoma, except that the word roots have been frequently found in both the intrahepatic bile inverted, and it should therefore also be coded ducts of the liver (C22. Hence there multiple morphology terms is no distinctive morphology code for minor salivary gland carcinoma. When no single code includes all nocarcinoma of the mouth or oral cavity are con diagnostic terms, use the numerically higher sidered to be of minor salivary gland origin, the code number if the diagnosis of a single tumor words minor salivary gland? should be ignored includes two modifying adjectives with diferent in a diagnosis such as minor salivary gland ade code numbers. In this When a single neoplasm is described by two example, the adenoid cystic carcinoma? (8200/3) modifying adjectives that have diferent codes, should be coded to the topographic site hard another type of coding difculty arises.
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The supplement was analysed and found to cheap genf20 plus 120pills online yucatan herbals contain the stated amount of synephrine (equivalent to generic 120 pills genf20 plus mastercard herbals best Bitter orange + Food a daily dose of about 30mg) generic genf20 plus 120pills online herbals forum, and none of the furanocoumarin, 6,7-dihydroxybergamottin. Note that bitter orange is commonly used as a Experimental evidence flavouring, and in marmalade, but this is not expected to result in a No relevant data found. The bitter orange supplement used here may not have interacted because of a lack of furanocoumarins. Bitter orange 71 However, its findings suggest that this bitter orange supple proposed mechanisms, it is possible that this applies only to ment is unlikely to affect the metabolism of midazolam. Phenylpropanoid esters such as the Interactions overview cimiracemates A?D, isoferulic and ferulic acids, and methylcaffeate are present, as are the quinolizidine alkaloids Black cohosh does not appear to interact with caffeine, including cytisine and N-methylcytisine. For a case report describing transplant rejection in a patient Use and indications taking a supplement containing alfalfa and black cohosh, see Black cohosh is widely used to treat peri and postmeno Alfalfa + Immunosuppressants, page 22. The extracts were standardised to 3% Experimental evidence triterpene glycosides and were given in doses of 100 times the No relevant data found. These data cannot reasonably be Importance and management extrapolated to patients being treated with an antineoplastic regimen Evidence appears to be limited to this one study, which suggests that for breast cancer, because the dose of black cohosh used was much black cohosh does not raise chlorzoxazone levels. In understood, they may have an important impact on the outcome of vivo effects of goldenseal, kava kava, black cohosh, and valerian on human cytochrome treatment for oestrogen-dependent breast cancer (see also Oestro P450 1A2, 2D6, 2E1, and 3A4/5 phenotypes. Alteration of the effects of cancer therapy agents on breast cancercells by the herbal medicine black cohosh. Black cohosh + Digoxin A standardised black cohosh extract did not alter the pharmacokinetics of digoxin in one study. Clinical evidence In a randomised study, 16 healthy subjects were given a black cohosh extract 20mg twice daily (standardised to 2. There were no significant changes in the Black cohosh does not significantly affect the pharmacokinetics pharmacokinetics of digoxin, and no serious adverse effects were reported. Clinical evidence Experimental evidence In a study in 12 healthy subjects, black cohosh root extract 1. Effect of milk thistle (Silybum marianum) and black cohosh Importance and management (Cimicifuga racemosa) supplementation on digoxin pharmacokinetics in humans. Evidence appears to be limited to this one study, which suggests that black cohosh does not raise caffeine levels. In vivo effects of goldenseal, kava kava, black cohosh, and valerian on human cytochrome P450 1A2, 2D6, 2E1, and 3A4/5 phenotypes. Assessing the clinical significance of botanical supplementation on human cytochrome P450 3A activity: comparison of a milk thistle and black cohosh product to rifampin and clarithromycin. In Black cohosh + Midazolam vivo effects of goldenseal, kava kava, black cohosh, and valerian on human cytochrome P450 1A2, 2D6, 2E1, and 3A4/5 phenotypes. Clinical evidence In a study in 19healthy subjects given black cohosh extract Black cohosh + Oestrogens or Oestrogen (standardised to triterpene glycosides 2. In addition, black cohosh had no effect on the duration of midazolam-induced Black cohosh contains oestrogenic compounds. For information on the pharmacokinetics of individual natural coumarins present Constituents in black haw, see under coumarins, page 297. The stem and root bark of black haw contain iridoid glycosides based on penstemide, with patrinoside and others. They also contain natural coumarins, such as scopoletin and aesculetin, and triterpenes, including oleanolic and ursolic acids. Although black haw Use and indications contains natural coumarins, the quantity of these constituents Traditionally black haw has been used as a uterine tonic, for is not established, and therefore the propensity of black haw preventing miscarriage in the latter stages of pregnancy, to to interact with other drugs because of their presence is reduce pain and bleeding after childbirth, and for dysmenor unclear. Blood Red Indian paint, Red puccoon, Red root, Sanguinaria, root extracts are also used as an antiplaque agent in some Tetterwort. No relevant pharmacokinetic data found specifically for bloodroot, but see berberine, page 58, for more details on Constituents this constituent. The rhizome contains isoquinoline alkaloids including sanguinarine, chelerythrine, sanguidaridine, oxysanguinar idine, berberine, coptisine, protopine and others. However, for the Use and indications interactions of one of its constituents, berberine, see under Bloodroot is found in cough preparations and topical berberine, page 58. Bogbean has been used for rheumatism, rheumatoid arthritis the name Bog myrtle, most commonly used for Myrica and other inflammatory diseases, and as a bitter tonic. Constituents Interactions overview Bogbean leaf contains the iridoids foliamenthin, 7? Some have suggested dihydrofoliamenthin, loganin, menthiafolin and sweroside; that bogbean may interact with anticoagulants, presumably polyphenolics such as caffeic, chlorogenic, protocatechuic based on its natural coumarin content, but the coumarins and ferulic acids, and flavonoids, including hyperin, present are not known to possess the structural requirements kaempferol, quercetin, rutin and trifolioside. For more information, ents include: the pyridine alkaloids gentianine and gentia see Natural coumarins + Warfarin and related drugs, nidine; triterpenes including lupeol, betulin and betulinic page 301. For information on the interactions of individual acid; carotenoids, such as carotene and loliolide; and the flavonoids present in bogbean, see under flavonoids, natural coumarins, scopoletin and braylin. Alkaloids are the main constituents of boldo leaf and these include boldine, isoboldine and dehydroboldine among Pharmacokinetics others. Extracts may be standardised to contain a minimum No relevant pharmacokinetic data found. One case report suggests present include low levels of ascaridole, which is toxic: it is that it may interact with warfarin. Boldo + Herbal medicines Mechanism B the mechanism of this apparent interaction remains unknown, and it is not known whether both herbs or just one was responsible for No interactions found. Both boldo and fenugreek have been reported to contain natural coumarins, but it is unclear whether they have any anticoagulant activity. See natural coumarins, page 297 for more information on the interactions of coumarin-containing herbs. Boldo + Warfarin and related drugs Importance and management Evidence is limited to one isolated case. Boneset is traditionally used for influenza, acute bronchitis Eupatorium chapmanii Small.
This value links the Site-Specific Data Items associated with adenocarcinoma of the lung: Separate Tumor Nodules  purchase genuine genf20 plus herbs for anxiety, Visceral and Parietal Pleural Invasion  discount genf20 plus 120 pills with visa herbals extracts, and Pleural Effusion  120 pills genf20 plus sale herbalshopcom. This data item will also be used to develop edits and could potentially be used for analysis. To develop a software algorithm that can be used to send the registrar to the right chapter/schema, this schema discriminator was developed. Note: If the physician suspects? or assigns? a specific head and neck subsite, the registrar is still to assign C760 so that the correct staging information can be abstracted. Workup shows no evidence of primary tumor, although physician states this may be a laryngeal primary based on best guess. Even though the primary site is suspected to be larynx, primary site would still be coded to C760. These cases are collected as unknown head and neck primary (C760), which will have no evidence of primary tumor. Code 0: Not occult Primary tumor is evident in the head and neck region; however, a specific primary site cannot be identified. This type of situation would be rare but would probably be diagnosed based on metastatic disease, including distant lymph nodes (Mediastinal [excluding superior mediastinal node(s)]) this case would be collected in the Ill-Defined Other schema, or Soft Tissue Other (if specified sarcoma). All Head and Neck Level data items are coded to 0 since there is no specific information about the levels. In other words, if regional nodes are known to be positive but the level(s) of nodes involved is unknown, code 0. Coding a Node That Overlaps Two Levels Note: If a lymph node is described as involving two levels, code both levels. Example: Multiple lymph nodes involved, level V documented, but the other levels not mentioned. The definitions of the levels are the same for all applicable head and neck sites. It is now only clinically relevant for unknown head and neck primaries with positive cervical (head and neck) lymph nodes and mucosal melanomas of the head and neck. Note 6: If information is available on some nodes, but the others are unknown, code what is known. Definition this data item is used to code the presence or absence of lymph node involvement for other head and neck lymph nodes. Coding Instructions and Codes Note 1: Physician statement of other head and neck lymph node involvement can be used to code this data item when no other information is available. Note 5: If involved regional node levels are documented as a range, and/or if the involved nodes overlap multiple levels, code 7. Code Description 0 No involvement in other head and neck lymph node regions 1 Buccinator (facial) lymph node(s) involved 2 Parapharyngeal lymph node(s) involved 3 Periparotid and intraparotid lymph node(s) involved 4 Preauricular lymph node(s) involved 5 Retropharyngeal lymph node(s) involved 6 Suboccipital/retroauricular lymph node(s) involved 7 Any combination of codes 1-6 8 Not applicable: Information not collected for this case (If this item is required by your standard setter, use of code 8 will result in an edit error. Definition this data item is used to code the size of involved lymph nodes and is recorded in millimeters. Coding guidelines Code the largest diameter of any involved regional lymph nodes for head and neck (cervical lymph nodes). Note 3: If the largest involved node is not examined pathologically, use the clinical node size. Note 4: Code 0 when lymph nodes are determined to be positive and physical examination does not indicate any signs of extranodal extension. Pathological measurement takes precedence over a clinical measurement for the same node. Only use these codes when the pathologist has used this terminology to indicate the lymph node size. Note 2: If the same largest involved node (or same level) is examined both clinically and pathologically, record the size of the node from the pathology report, even if it is smaller. A schema discriminator is necessary to distinguish between these primary sites so that the appropriate chapter/schema is used. Coding Instructions and Codes Note: A schema discriminator is used to discriminate for primary site C111: Posterior wall of nasopharynx. Chapter 10 is now for p16+ tumors, while Chapter 11 is for p16 negative tumors or where the p16 is not assessed or unknown. A schema discriminator is necessary to determine the p16 status so that the appropriate chapter/schema is used. Definition In addition to the tumor size (diameter, not depth), the presence of certain specific high-risk features is of prognostic significance for skin cancers of the head and neck. The cardia is defined as the opening or junction between the esophagus and the stomach, and it is between 0. This 2-cm boundary measurement is based on the Siewert classification of gastroesophageal cancers, which defines an area 2 cm above and 2 cm below the cardia or esophagogastric junction. Both of these areas are coded to primary site C160, so a discriminator is needed to get to the correct chapter. To determine whether a cancer of the cardia should be coded according to the esophagus schema or the stomach chapter, it is necessary to identify the midpoint or epicenter of the tumor. A schema discriminator is necessary to distinguish between these histologies so that the appropriate stage group table is used. Coding Instructions and Codes Note: A schema discriminator is used to discriminate for histology 8020/3: Undifferentiated carcinoma to determine which Stage Group table to use.
Thus discount genf20 plus 120 pills on line vhca herbals, the capstone team has broken down this barrier by each of these contributing factors generic genf20 plus 120 pills with amex herbs mac and cheese, and addressed each factor individually with specific recommendations buy genf20 plus 120 pills cheap wonder herbals. These contributing factors include: Medicaid reimbursement rates and dental hygienist legislation. In 2008, the Academy of General Dentistry published a white paper on increasing access to the oral care and stated, When states have raised the Medicaid reimbursement rates, the number of provider dentists have increased, which, in turn, has led to a direct increase in patients in 48 | Page 11 underserved areas receiving care. Kaiser Foundation and the National Academy for State Health Policy acknowledged that dentists? primary reason for refusing to accept Medicaid was the low reimbursement rates. Low Medicaid reimbursement rates not only severely reduce profit margins in dental practices, but also in some states, the rates 12 are so low that they do not even cover the cost of the procedure. The states of Alabama, Michigan, South Carolina, Tennessee, Virginia, and Washington have used increased reimbursement rates as a method to improve access to dental care. Michigan and Alabama have seen great success in increasing access of care and heightened levels of dental participation in the Medicaid program since changes were made to their reimbursement rates in 2000. Michigan, through the Healthy Kids Dental Program, strengthened a currently-existing contract with commercial dental insurers by reimbursing most dentists 100% of what they normally 13 charged for a procedure. As a result of the funds allocated by the Texas legislature to the Frew Advisory Committee in 2007, Texas nearly doubled the Medicaid reimbursement rates for many dental procedures. The line represents the actual number of dentists; the bars indicate the annual growth rate. The number of dentists actively participating in Medicaid did sharply increase after the rate raise in 2007. Figure 22 shows approximately a 67% increase in the amount of children enrolled in Medicaid since 2009. As the economic recession continued, more children began using Medicaid for health insurance. In this case, taking a step towards fair reimbursement rates expanded the number of dentists participating in the Medicaid program. In turn, more dentists are now available to treat the increasing number of children on Medicaid. However, the increased number of children on Medicaid means that the access gap only widening and there are still not enough dentists for all of the children that needed them. As previously discussed, even if all of the dentists in Texas were to accept Medicaid, many counties would still be left without access to a dentist. Approaches to eliminating this problem have varied across the nation; one strategy is decreasing regulations on dental hygienists and creating new dental professionals (dental therapists) to participate in providing dental care. Across thhe country, sttates noticedd an increase in access to dental care aafter deregullating their ppolicies on ddental hygiennists. Since the creation of tthis positionn, dental therapistss facilitated an additionaal 2,000 denttal visits perr year. Tooth deecay is five tiimes more common thann asthma andd affects 25%% of childrenn between thhe 22 ages of 66-11 years off age. Accordinng to the Ageency for Heaalthcare Reseearch and Quality, children fromm low-sociooeconomic faamilies are fifive times moore susceptibble to caries than children from familiees with higheer-socioeconnomic backggrounds; howwever, only 336 % of loww income cchildren see aa dentist for treatment coompared to tthe 70 % of children from higher-inccome 23 families tthat seek treatment. Therre are four coontributing ffacets: oral hhealth educaation, the rural// urban dividde, the afforddability of heealth care, cuultural differrences. Eachh of these faccets greatly varies in seveerity as well as the meanns in which too resolve thee problems tthese facets 52 | P age create. The capstone team has also included specific recommendations to address these four areas of the barrier to higher patient utilization. One factor that strongly contributes towards the high number of caries in low-income children, and the socioeconomic background of parents directly affects the amount of knowledge a child will receive at home 24,25 Limited knowledge about oral hygiene. During early developmental years children grow physically, children begin to understand social norms, and 26 develop cognitively as well as emotionally. This development stage shows how positive and 27 negative influences? can have dramatic effects on oral health in later years. By focusing on Medicaid-eligible children under age six,? the state facilitated 2. In addition to demonstrating an increase in dental health, this average also shows a trend developing of children making the 28 dentist a regular part of their routine and beginning to place value on having good oral health. The Official Journal of the American Academy of Pediatrics recommends that pediatricians take the primary role of educating parents of the importance of oral health. Pediatricians are instrumental in improving the dental care of patients by increasing their involvement?during 29 well-child care visits. Oral Health 30 Program is to educate and empower students to improve individual oral health hygiene. This program provides preparatory information for expecting parents, including adult and teen parents. The curriculum consists of three lesson plans and includes information on dental care for pregnant mothers, infants, and preschoolers. It also includes additional information on preventing and/or identifying tooth decay. The instruction material also includes a video in English or Spanish as well as a poster depicting tooth decay. This program is another way Texas children are being exposed to 53 | Page 31 dental caare at an earlyy age. Because oof the size off the state annd the varietyy of towns, ccities, and counties,, children whho do not livve in urban cities may haave a difficullt time findinng a dental professioonal to provide care.