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Purpose: The aim of this work was to evaluate the effectiveness of a gel with active oxygen in the prevention of MRONJ. Methods: Using split-mouth study design, twelve Wistar rats were used, females (n = 6) and males (n = 6). All rats received a weekly intravenous injection of zoledronate (80 μg / kg body weight in PBS) for 8 weeks. Then, the animals underwent surgery to remove the first and second right and left mandibular molars to induce osteonecrosis. The animals received topical application of oxygen gel (blue®m) on the right-side extraction site (Group T) 3 times a week until euthanasia after 6 weeks, with no intervention on the left side (Group C). The clinical parameters analyzed included the presence and dimension of bone exposure, suppuration and epithelialization. Results: Statistical analysis using chi-square and Mann-Whitney test (p value

Objective: To assess the knowledge of Brazilian dentists and final-year dental undergraduates concerning COVID-19. Material and Methods: We conducted a self-administered online questionnaire about the symptoms, incubation period, and transmission routes of COVID-19. In total, there were three questions addressing these topics and 15 correct answers, so each participant could score from 0 to 15 points. Besides that, data such as sex, age, education level, years of work experience and place of work were collected. All data were submitted to statistical analysis with a 5% significance level. Results: 476 participants were recruited. Regarding the respondents' perception of the most common symptoms of COVID-19, 99.4% responded fever, 95.2% cough, and 99.2% dyspnea. About the incubation period, 56.3% answered from 1 to 14 days. About the transmission routes, 98.3% recognized transmission through droplets, 80.3% through direct contact with infected persons, and 70.4% through indirect routes. The median knowledge score was 10 (4 – 14). Regarding the socio-demographic variables, participants aged 30 years or more had a higher score than those aged up to 29 years old (p=0.004). For education level, specialist dentists presented a higher score than undergraduates (p=0.006), general dentists (p=0.048) and Ph.D. (p=0.016). Participants with 15 years or more of work experience had a higher score than undergraduates (p=0.003). Concerning the workplace, participants working in the public sector had a higher score than those working in the private sector or universities (p=0.015). Conclusion: Participants recognized the main symptoms, incubation period, and transmission routes of the COVID-19 virus; however, the knowledge level of specialist dentists, older dentists, more experienced dentists, and dentists working in the public sector was higher than the other participants.

Abstract Background The advancement of contemporary dentistry is related to the improvement of existing techniques, materials, and technology, consistently for improving people’s oral health, which can ultimately reflect better quality of life. This study aimed to evaluate the oral-health-related quality of life (OHRQoL) of patients with atrophic jaws, who reported for the placement of long transmaxillary implants and posterior prosthetic rehabilitation. Twelve patients (n = 12), of both sexes, with a mean age of 55.83 ± 2.78 years, who were unable to receive conventional implants immediately because of lack of bone, received two long transmaxillary implants in a horizontal position, anteroposteriorly, one on each side, from the canine pillar to the maxillary tuberosity. After 6 months, the conventional clinical sequence for fabricating a fixed prosthesis type protocol or removable prosthesis type overdenture (MK1® system) was performed, when required to recover the lip volume. The Oral Health Impact Profile questionnaire (OHIP-14) was applied preoperatively and 6 months after rehabilitation using a prosthesis on the implants. The results were statistically analyzed using a significance level of 0.05. Results An improvement in the perception of OHRQoL was observed between the pre- and postoperative periods in the OHIP-14 total score and the domains related to functional limitation, physical pain, psychological discomfort, psychological disability, social disability, and handicap (p < 0.05). Conclusion It may be concluded that transmaxillary implant rehabilitation improves the OHRQoL.

Abstract Regenerative approaches using mesenchymal stem cells (MSCs) have been evaluated to promote the complete formation of all missing periodontal tissues, e.g., new cementum, bone, and functional periodontal ligaments. MSCs derived from bone marrow have been applied to bone and periodontal defects in several forms, including bone marrow aspirate concentrate (BMAC) and cultured and isolated bone marrow mesenchymal stem cells (BM-MSCs). This study aimed to evaluate the periodontal regeneration capacity of BMAC and cultured BM-MSCs in the wound healing of fenestration defects in rats. Methodology: BM-MSCs were obtained after bone marrow aspiration of the isogenic iliac crests of rats, followed by cultivation and isolation. Autogenous BMAC was collected and centrifuged immediately before surgery. In 36 rats, fenestration defects were created and treated with suspended BM-MSCs, BMAC or left to spontaneously heal (control) (N=6). Their regenerative potential was assessed by microcomputed tomography (µCT) and histomorphometry, as well as their cell phenotype and functionality by the Luminex assay at 15 and 30 postoperative days. Results: BMAC achieved higher bone volume in 30 days than spontaneous healing (p

The present study aimed to evaluate the effect of dipyridamole, an indirect adenosine 2A receptors (A2AR), on the osseointegration of titanium implants in a large, translational pre-clinical model. Sixty tapered, acid-etched titanium implants, treated with four different coatings ((i) Type I Bovine Collagen (control), (ii) 10 μM dipyridamole (DIPY), (iii) 100 μM DIPY, and (iv) 1000 μM DIPY), were inserted in the vertebral bodies of 15 female sheep (weight ~65 kg). Qualitative and quantitative analysis were performed after 3, 6, and 12 weeks in vivo to assess histological features, and percentages of bone-to-implant contact (%BIC) and bone area fraction occupancy (%BAFO). Data was analyzed using a general linear mixed model analysis with time in vivo and coating as fixed factors. Histomorphometric analysis after 3 weeks in vivo revealed higher BIC for DIPY coated implant groups (10 μM (30.42% ± 10.62), 100 μM (36.41% ± 10.62), and 1000 μM (32.46% ± 10.62)) in comparison to the control group (17.99% ± 5.82). Further, significantly higher BAFO was observed for implants augmented with 1000 μM of DIPY (43.84% ± 9.97) compared to the control group (31.89% ± 5.46). At 6 and 12 weeks, no significant differences were observed among groups. Histological analysis evidenced similar osseointegration features and an intramembranous-type healing pattern for all groups. Qualitative observation corroborated the increased presence of woven bone formation in intimate contact with the surface of the implant and within the threads at 3 weeks with increased concentrations of DIPY. Coating the implant surface with dipyridamole yielded a favorable effect with regard to BIC and BAFO at 3 weeks in vivo. These findings suggest a positive effect of DIPY on the early stages of osseointegration.

Introduction: Oral lichen planus is a chronic inflammatory disease affecting the mucosa. Objective: To report a clinical case of oral lichen planus in gingiva whose removal was carried out by the de-epithelialization technique of the affected areas. Case report: A 56-year-old female patient presented white plaques upon clinical examination that could not be removed by scraping. The treatment plan involved a biopsy and lesion removal by de-epithelialization, procedure not described in the literature up to date. This technique consisted of the removal of the plaques with the epithelial tissue from the gingiva using a 15c blade, leaving the connective tissue exposed. Clinical follow-up was performed at 3 and 10 days, and at 2, 3 and 15 months. Conclusions: De-epithelialization was a resolutive esthetic intervention for the case presented.

Oral mucosa serves as the primary barrier against pathogen invasions, mechanical stresses, and physical trauma. Although it is generally composed of keratinocytes and held in place by desmosomes, it shows variation in tissue elasticity and surface keratinization at different sites of the oral cavity. Wound healing undergoes four stages of tissue change sequences, namely haemostasis, inflammation, proliferation, and remodelling. The wound healing of oral hard tissue and soft tissue is largely dependent on the inflammatory response and vascular response, which are the targets of many research. Because of a less-robust inflammatory response, favourable saliva properties, a unique oral environment, and the presence of mesenchymal stem cells, oral wounds are reported to demonstrate rapid healing, less scar formation, and fewer inflammatory reactions. However, delayed oral wound healing is a major concern in certain populations with autoimmune disorders or underlying medical issues, or those subjected to surgically inflicted injuries. Various means of approach have been adopted to improve wound tissue proliferation without causing excessive scarring. This narrative review reappraises the current literature on the use of light, sound, mechanical, biological, and chemical means to enhance oxygen delivery to wounds. The current literature includes the use of hyperbaric oxygen and topical oxygen therapy, ultrasounds, lasers, platelet-rich plasma (PRP)/platelet-rich fibrin (PRF), and various chemical agents such as hyaluronic acid, astaxanthin, and Centella asiatica to promote angiogenesis in oral wound healing during the proliferation process. The arrival of a proprietary oral gel that is reported to improve oxygenation is highlighted.

Aim: The aim of the present study was to evaluate the microbial contamination in internal and external walls of cone morse implant walls. Methods: Eleven patients with edentulous mandibular posterior area were selected to received dental implants, divided into groups: submerged (S), non-submerged (NS), and immediately loaded (IL). Microbiological evaluations (microorganisms’ number, aerobic and anaerobic colony forming units (CFU) number and microorganisms’ qualification) were divided into internal and external collection of the implant walls, at different stages: T0 (surgical procedure), T2 (suture removal), T4 (reopening S group), T6 (suture removal S group), and T8 (abutment placement in S and NS). All data were submitted to statistical analyses, with confidence level of 0.05. Results: There was difference in number of microorganisms observed over time within the same group (p < 0.05). A difference was observed in CFU when evaluated within the same group over time (p < 0.05), except for the IL group. In internal collection, a predominance of non-formation of microorganisms was observed at T0 in all groups, while formation of Gram-positive Diplococci and Gram-positive Bacilli was observed at T8 (p>0.05). In external collection, an increase in number of microorganisms was observed at T0. Conclusion: There was no difference in microbial contamination among the evaluated groups. The microorganism’s colonization changed over time.

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The aim of this case series was to evaluate the effects of blue®m mouthwash on oral surgical wounds. Eleven patients underwent bilateral preprosthetic surgery and were instructed to apply the product only to the right side of the surgery. In this way, the right side corresponds to the test side and the left side (place without applying any type of solution) to the control side. After seven days of using the product (3 times a day), the following parameters were evaluated by means of a visual analogue scale: pain, changes in taste, and acceptance by the patient. Then, the level of tissue inflammation was assessed, by the number of pixels, using ImageJ® software. The main results show that the blue®m mouthwash was widely accepted by patients, reducing their pain. The number of inflammation pixels was lower on the test side (p

Previous reports demonstrated the utility of systemic application of growth hormone (GH) in the treatment of bone defects. Very few studies correlated bone repair efficacy with hepatic and renal side effects promoted by locally-delivered GH. The objectives of this study were to assess the bone repair properties along with hepatic and renal adverse effects promoted by local application of GH in a rat model. Thirty-two rats were randomly divided (4 groups; n = 8/group), as follows: (i) AB (autogenous bone + local application of saline solution [SS]), (ii) AB+ (autogenous bone + SS local application + SS irrigation), (iii) AB/GH+ (autogenous bone + SS local application + GH irrigation) and (iv) AB/GHL+ (autogenous bone + GH local application + GH irrigation). Critical-sized defects (diameter = 5.0 mm) were surgically created by a single operator in the calvaria of rats. Defects were filled with ground autogenous bone. Defects pertaining to AB+ and AB/GH+ received a mixture of autogenous bone and a SS-saturated (0.02 mL) collagen sponge covered with bovine cortical membrane. Defects in group AB/GHL+, were filled with the same biomaterials saturated with GH (0.02 mL). SS (0.1 mL) or GH (0.1 mL, equivalent to 0.4 IU) were applied locally on alternate days (8 weeks) in animals in groups AB, AB+ and AB/GH+ or AB/GHL+, respectively. Bone repair properties was determined in hematoxylin/eosin-stained slices using traditional histologic and histomorphometric techniques along with optical microscopy and digital image analysis. Statistical differences among groups was determined using Kruskal-Wallis and Tukey post hoc tests (α = 0.05). Histology results indicated that AB and AB+ displayed greater presence of autogenous bone as compared to AB/GH+ and AB/GHL+. Histomorphometric results indicated significantly higher osteoid matrix formation in AB and AB+ when compared to AB/GHL+ (p = 0.009). Kidneys and livers were found to have their glomeruli preserved in AB and AB+. Strong glomeruli necrosis and large areas of protein deposition were found in AB/GH+. Abnormal small-sized glomeruli were found in AB/GHL+. The utilization of autogenous bone graft associated with local application and irrigation with GH was shown to not improve the bone repair in calvarial critical-sized defects in a rat model.

Objective: evaluate the association between periodontal disease, preterm births and low birth weight neonates in a group of women from the city of Curitiba, PR, Brazil. Methods: in this case-control study, an evaluation was conducted of 51 mothers aged 16-40 years divided into two groups: those with a preterm delivery and low birth weight babies, and those without a preterm delivery but with low birth weight babies. Data about the mothers and the neonates were collected via questionnaires and medical record analysis. Periodontal examination was performed at six sites of each tooth present, except for the third molars. Results: it was found that 82.4 % of the women had had a normal delivery and 25.5 % a preterm delivery. 19.6 % of the babies weighed less than 2 500 g at birth, and 5.9 % of the women had periodontal disease. Conclusions: no association was found in the sample between periodontal disease and preterm delivery and low birth weight.

Ameloblastoma is an aggressive odontogenic tumor which typically occurs between third and fourth decade of life that often needs resective approach. Immediate reconstruction may show better results. The treatment of multicystic ameloblastoma in the mandible being a rare case that occurred in the late second decade of life, which was surgically removed along with the affected teeth with safety margins, and the region was immediately reconstructed using a vascularized graft, removed from the fibula. Its integration, in combination with osseointegrated dental implants and fixed implant-supported prostheses, restored chewing function and esthetics. After 6 years from fibular graft and 24 months of dental implants, an excellent outcome was observed, with oral health and normal functions properly restored, and the immediate reconstruction of the mandible in resective cases, associated with oral rehabilitation with dental implants, may be considered a suitable treatment option.

Facial and dental esthetics are the objectives of dental treatment, and, for this, it is necessary that specialties such as periodontics and orthodontics work together. The objective of this article is to report a clinical case with the solution of localized gingival recession after orthodontic treatment, using tunneled subepithelial connective tissue grafts with follow-up for 1 year. The patient underwent orthodontic treatment for 1 year. Prior to the start of treatment, a gingival recession of 5 mm was already present on tooth 31. One month after the completion of treatment, the patient was subjected to a tunneled subepithelial connective tissue graft, with the purpose of covering the exposed root. We observed the effectiveness of the procedure and patient satisfaction with the results obtained. The subepithelial connective tissue graft was successful in this case, and the collaboration of specialists is important to provide the best treatment for the patient.

Digital flow has become a part of currently practiced dentistry. Virtual planning ensures predictable aesthetic and functional rehabilitation, painless postoperative recovery, and better communication with patients, thus meeting their expectations. The purpose of this case report is to demonstrate the digital planning for the correction of a gummy smile with a personalized preparation using a piezoelectric surgical guide (PerioGuide) for gingival contouring and flapless osteotomy. The guide was designed using Nemo Studio software, based on the patient’s facial aesthetic analysis, through photos, videos, and facial scanning. These images were aligned with the scan and placed over the cone beam computed gingival tomography for prediction of results, based not only on the distance from the cementoenamel junction to the bone crest but also on the best gingival margin contour according to virtual aesthetic planning. Digital planning, combined with the use of a piezoelectric device, allows for a flapless guided surgical technique for gingival contouring and osteotomy. As a result, the surgical procedure is safer, faster, and more predictable with better postoperative outcomes.

Periodontal surgery associated with prior waxing, mock-up, and the use of digital tools to design the smile is the current trend of reverse planning in periodontal plastic surgery. The objective of this study is to report a surgical resolution of the gummy smile using a prior esthetic design with the use of digital tools. A digital smile design and mock-up were used for performing gingival recontouring surgery. The relationship between the facial and dental measures and the incisal plane with the horizontal facial plane of reference were evaluated. The relative dental height x width was measured, and the dental contour drawing was inserted. Complementary lines are drawn such as the gingival zenith, joining lines of the gingival and incisal battlements. The periodontal esthetic was improved according to the established design digital smile pattern. These results demonstrate the importance of surgical techniques and are well accepted by patients and are easy to perform for the professional. When properly planned, they provide the desired expectations. Periodontal Surgical procedures associated with the design digital smile facilitate the communication between the patient and the professional. It is, therefore, essential to demonstrate the reverse planning of the smile and periodontal parameters with approval by the patient to solve the esthetic problem.

In recent years, there have been a growing number of procedures involving dental implants. Most cases, though, are characterized by bone atrophy, especially horizontal atrophy. This clinical case aims to report a technique for the expansion of the horizontal alveolar ridge. A longitudinal fracture was created in the alveolar ridge to expand the bone, followed by immediate insertion of dental implants along with a particulate allogeneic bone graft. Eight implants were placed in the maxilla, and after 12 months, a surgical reopening was performed, along with rehabilitation with a protocol-type prosthesis, for which a zirconia infrastructure was made. The patient was observed during a 10-month follow-up period in which an effective osseointegration of all implants was achieved as a result of such a technique. The split-crest technique followed by the immediate placement of implants and a particulate allogeneic bone graft proved to be effective, with a predictable osseointegration.

Gingival recession is an oral health problem that affects a large part of the population. Several treatments are suggested in the current literature; among them is the use of buccal fat pad grafting. The objective of this case report is to describe the treatment of a Miller Class I gingival recession using a nonpedicled buccal fat pad graft immediately after performing the surgery for buccal fat pad removal (bichectomy technique). First, bilateral surgical removal of the buccal fat pad was performed with the main objective of eliminating oral mucosa biting. The recipient site was prepared to receive a portion of the fat pad that was cut and macerated in a size that was sufficient to cover the recession. The patient was followed up at 15, 30, 60, and 365 days postsurgery, and the results showed an elimination of the oral mucosa biting and complete coverage of the gingival recession. It was concluded that the nonpedicled buccal fat pad graft is another option for the treatment of Miller Class I recessions.

Gingivitis is still considered a major risk factor for the occurrence and progression of periodontal disease. The aim of the present study was to compare the long-term (1, 12, and 18 weeks) antiplaque and antigingivitis efficacies of two commercially available toothpastes, Colgate Total® (CT) and BlueM® (BM), against attached supragingival dental plaque and gingival inflammation in an experimental gingivitis model. A parallel double-blinded randomized clinical trial including 39 dental students who refrained from all plaque control methods (manual or chemical) for 7 days was conducted. After the establishment of clinical gingivitis, participants were randomized into two experimental groups (CT and BM). Plaque index (PI) and gingival index (GI) were then calculated according to Turesky’s modified Quigley and Hein index. Participants were assessed in four time periods (preclinical trial phase (W −1), gingivitis phase (W0), one week (W1), twelve weeks (W12), and eighteen weeks (W18)). Participants’ stimulated saliva was collected and cultured (either aerobically or anaerobically, 37°C, 48 hours) in each time period (W −1, W0, W1, W12, and W18) for the count of viable colonies. Obtained data were analyzed using 2-way ANOVA and Tukey’s test (α = 0.05). No significant differences were found (p>0.05) between experimental groups at W −1. Significant differences between groups were observed at W0 (p0.05) between dentifrices at W1, W12, and W18 for both GI and PI. The present study demonstrated that toothpastes containing active oxygen and lactoferrin (BM) have comparable antiplaque and antigingivitis efficacies with triclosan-containing toothpastes (CT).

Background: Novel multifunctional biomaterials were recently designed to allow for an optimized tissue regeneration process. Purpose: To comprehensively assess (photographic, radiographic and histological) the in vivo functionality of demineralized bovine bone matrix (DBM) associated with an experimental marine organic extract (MOE) from nacre in a sheep ectopic grafting model. Materials and methods: Synthesis of MOE was based on mixing powdered nacre (0.05 g, particles average size

The proteins Wnts are considered a key regulator of the early development of the skeleton. Aim: The aim of this study was to evaluate the presence of the protein Wnt10b as a marker of bone repair in critical size defects surgically created in the calvaria of rabbits treated with fragmented autogenous adipose tissue graft. Methods: A total of 28 rabbits were divided into two groups: the Control group (C) and Adipose Tissue Graft group (ATG). A CSD measuring 15 mm in diameter was created in the calvaria of each animal. In rabbits of the C group, the defect was filled only with blood clot, and in ATG group, the defect was filled with fragmented adipose tissue graft. The two groups were divided into two subgroups (n = 7) for euthanasia 15 and 40 days after surgery. Histological and immunohistochemically analyses were performed to evaluate the neoformed bone and the presence/concentration of Wnt10b protein. The Kruskal-Wallis test was performed to compare the means and standard deviations of the number of Wnt10b + cells/mm2 in both groups in each postoperative period. It was assumed a significance level of 5%. Results: After 40 days, the mean concentration of the protein Wnt10b in ATG group was 26.26 (+-6.97) significant higher (p

The containment of the elevator muscle of the upper lip and wing of nose was used for the treatment of patients with gummy smile. This technique had corrected esthetic alterations of smile, reducing the upper lip elevation, which results in a smaller gingival display. An upper lip lengthening as well as a reduction in the upper lip shortening when the patient smiled could be observed. The high smile line was corrected without compromising the labial harmony. This study presents an innovative and effective therapeutic option to obtain a natural and harmonious smile. The patient expressed a high degree of satisfaction.

The objective of this study was to classify the morphology of bifid mandibular canals and to evaluate their relationship with the roots of third molars, using cone beam computed tomography (CBCT) scans. The CBCT scans of 75 patients were analyzed and the bifurcations were classified according to Langlais et al. (1985). The relationship of bifurcation and third molars was established according to the following classification: class A - uninvolved, class B - close relationship, class C - intimate relationship and class D - absence of third molars. Data were submitted to descriptive statistics, and the results indicated that the patients' mean age was 48.2 (± 13.2) years. Unilateral bifurcation (Type 1) was the most frequent type (72.6%), followed by unilateral Type 2 (19.3%). Class D was the most frequent (57.33%), followed by class C (21.33%), class B (13.33%) and class A (8%). It could be concluded that most cases presented unilateral bifid mandibular canals extending to the third molar or adjacent regions, and when present, the roots seemed to be a continuation of the bifid mandibular canal

The occlusal vertical dimension (OVD) refers to the length of the face as determined by the amount of separation of the jaws. Its determination is important for the manufacture of restorations. However, defining the correct occlusal vertical dimension for edentulous patients is one of the most important steps for function and esthetics rehabilitation. Cephalometry is a standardized method of assessing dental and facial proportions and their interrelation. Additionally, cephalometric analysis of the facial vertical dimension can establish an individual pattern for each patient. This analysis should become a permanent part of each patient’s record. Hence, this study presented a case report with the use of cephalometry as an auxiliary tool in the rehabilitation of OVD. Clinical relevance showed that cephalometric analysis can be an accurate and convenient instrument to treatment planning and prognostic of oral rehabilitation. The reader should understand the clinical implications of using cephalometry as a tool in the rehabilitation of OVD.

Abstract The objective of this systematic review was to compare the conical internal connection (IC) with the external hexagonal connection (EH) on the occurrence of marginal bone loss (ΔMBL). Different databases were used to carry out the selection of the elected studies. The studies were judged according to the risk of bias as “high”, “low” and “unclear” risk. For the meta-analysis we included only studies that could extract the data of ΔMBL, survival rate (SR) and probing depth (PD). No statistically significant differences were found for ΔMBL data at one, three- and five-year survival rates between implant connections (p

Introduction: The transmission of viruses between species and the emergence of viral pandemics are threats to public health and with catastrophic aftermath for the population. Objective: The objective of this research was evaluated actions of Brazilian dentists concerning covid-19 during the first wave of the pandemic. Material and methods: The survey was conducted with a web-based questionnaire, from 8th July to 8th August 2020. The participants answered questions about socio-demographic factors, followed by actions towards the covid-19, that include service offered in the pandemic period, personal protective equipment (PPE), mode of prevention, emergency with a suspect case and urgency with a confirmed case. All data were submitted to descriptive and inferential statistics with a 5% significance level. Results: A total of 393 participants were recruited, 27.7% men and 72.3% women with a median age of 30 years (21 - 61). About service offered in the pandemic period 53.4 % of the participants answered to operate as a "usual service with a longer period between patients". Professionals who do not work in universities have adopted actions of "increasing the time between dental appointments" (p = 0.04) or "operate as usual" (p = 0,02). Nearly PPE, 48,9% wore an N-95 mask. Regarding mode of prevention, older and more experienced dentists adopted more preventive measures than younger and more experienced dentists (p > 0.05), in addition, men choose pre-procedural mouthwash with PVPI more than women (p = 0.014). Likewise, those who work at universities also choose pre-procedural mouthwash with PVPI more than those who do not work at universities (p = 0.004). The action regarding urgency and emergency care varied according to the educational level of the participant. Conclusion: It is important to emphasize that during this moment of uncertainty, it is necessary to be constantly aware of new scientific evidence. While generally accepting of federal and state recommendations, respondents seemed to desire more guidance during the initial phase of the pandemic. Some participants' actions towards covid-19 were divergences from the recommendations proposed by the regulatory agencies. [ABSTRACT FROM AUTHOR]