Compromised Resin Bond Strength After Enamel Bleaching

Compromised Resin Bond Strength After Enamel Bleaching EFFECT OF DIFFERENT ANTIOXIDANTS ON REVERSING COMPROMISED RESIN BOND STRENGTH AFTER ENAMEL BLEACHING: AN IN VITRO STUDY ABSTRACT Over years, one of the most frequent complaints that patients present with is that of stained teeth. With the advent of straightforward and fast procedures the craze for smile makeovers has risen. Bleaching is the most conservative treatment for discolored teeth compared with other treatments, such as veneers or crowns. Among the various undesirable effects of bleaching is the post treatment compromised enamel bond strength. The waiting period for bonding procedure after bleaching has been reported to vary from 24hrs to 4weeks. To overcome this delay in bonding, several antioxidant agents like 10% sodium ascorbatewith different application times after the bleaching procedure have been used. Hence, the purpose of this in vitro study was to evaluate and compare the effects and efficacy of 10% sodium ascorbate solution, 10%ÃŽ ±-Tocopherol solution, 10% grape seed extract solution and 10% guava seed extract solution on the bond strength between composite resin and bleached enamel after 1 0 minutes and 120 minutes of application. INTRODUCTION Discoloredteeth is a common problem affecting people of various ages. Etiology is multifactorial and different surfaces of tooth can take different stains. With the advent in esthetic dentistry, simple fast in-office and at home bleaching procedures have become effective and popular.1To state in layman’s words the term ‘in office bleaching’means bleaching techniques that are carried out in office. The demand of this technique has increased because of various advantages like: reduction in total treatment timeandgreater potential for immediate results that may enhance patient satisfaction and motivation. It utilizes a gel or liquid of hydrogen peroxide (35-38%) or carbamide peroxide(35%).2 The disadvantages associated with hydrogen peroxide as a bleaching agent include hypersensitivity and gingival irritation, reduced enamel microhardness andmicromorphological defects due to demineralization.4,5In addition, hydrogen and carbamide peroxide effect the bonding of enamel and dentin tissues when restorations are applied immediately after bleaching treatment.8 Various techniques have been proposed to resolve the clinical problems related to post bleaching compromised bond strength.Barghi and Godwin10 treated bleached enamel with alcohol before restoration,Cvitko and others11 proposed removal of the superficial layer of enamel, Sung etal12 suggested the use of the adhesives containing organic solvents. However, the general approach is to postpone any bonding procedure for a period from 4 daysto 4 weeks.13 To overcome this delay in bonding, application of various antioxidant agents like 10% sodium ascorbate, Vitamin E and Proanthocyanidins after the bleaching procedure have been proposed.14Vitamin E(ÃŽ ±-Tocopherol), acts as peroxyl radical scavenger and prevents the propagation of free radicals in tissues by reacting with them to form a tocopherol radical. This radical is then oxidized by a hydrogen donor and thus returned to its reduced state.15OligomericProanthocyanidins Complexes (OPC) are high molecular weight molecules consisting of monomeric flavan-3-ol cathechin and epicathechin. They are found in high concentrations in natural sources such as grapes, guavas, lemon tree bark and cranberries. It is a naturally occurringmetabolite and has been proven to be safe as an antioxidant in various clinical and dietary supplements. Although studies have shown the efficacy of sodium ascorbate9 and grape seed extract16 in reversal of reduced bond strength to bleached enamel, there is still a paucity of research onvitaminE(ÃŽ ±-Tocopherol) and proanthocyanidines derived from other fruits like guava as viable alternatives to sodium ascorbate. Moreover, studies have reported incongruous findings with concerns to absolute reversal of bond strength to base line levels after 10 minutes of application.17,18Therefore, increase in time of application and varying the concentration of antioxidants to neutralize the residual oxygen is warranted. Hence, the purpose of this in vitro study was to evaluate and compare the effects and efficacy of 10% sodium ascorbate solution, 10%ÃŽ ±-Tocopherol solution, 10% grape seed extract solution and 10% guava seed extract solution on the bond strength between composite resin and bleached enamel after 10 minutes and 120 minutes. The null hypothesis tested was that there is no difference in bond strength reduction reversal after application of different antioxidants for different application times after bleaching. MATERIALS AND METHOD Eighty freshly extracted human permanent maxillary central incisors extracted for periodontal reasons were collected and rinsed in 0.9% unbuffered saline. Labial surfaces of these teeth were flattened with 600 grit silicon carbide paper roots were embedded in acrylic resin block so that only the coronal portion was exposed. Individual moulds of tooth colouredself cure resin were prepared over the specimens. Modelling wax was used as a separator, so as to block the undercuts and also to provide space for antioxidant solution on the labial surface of the specimens. A customised cylindrical silver mould of 3mm diameter and 5mm height was also fabricated. For preparation of 10% antioxidant solutions, 10 gmsodium ascorbate powder(sd fine cHEM Limited, Mumbai)and 10 gmgrape seed extract powder(Biovea, USA) were dissolved in100ml of distilled water.For preparation of 10% alpha tocopherol, 10 ml alpha tocopherol(sd finecHEM Limited, Mumbai) was dissolved in 100 ml of ethyl alcohol. Soxhlet extraction method was used for the preparation of10% guava seed extract.40 gm of guava seedswere placed inside a thimble made from thick filter paper, which was loaded intothe main chamber of the Soxhlet extractor. The Soxhlet extractor was placed onto a flask containing 40 ml of ethyl alcohol as extraction solvent. The Soxhlet was then equippedwith a condenser. The solvent was heated to reflux. The chamber containing the solid material was slowly filled with warm solvent. When the Soxhlet chamber was almost full, the chamber was automaticallyemptied by a siphon side arm, with the solvent running back down to thedistillation flask. This cycle was repeated many times, over 5 hours.During each cycle, a portion of the non-volatile compound dissolved in thesolvent. After many cycles the desired compound was concentrated in thedistillation flask. After extraction, the solvent was removed, by means of a rotaryevaporator, 10 ml of this extract was then dissolved in 100 ml of distill ed water to make 10 % guava seed extract solution. Labial surfaces of seventy two specimens were bleached with Pola office one patient kit (SDI, Victoria, Autralia) according to manufacturer instructions. The gel was then completely rinsed off with water. These specimens were divided into five experimental groups and control group: Group I(n=16)treated with 10% sodium ascorbate solution Group II(n=16)treated with10% alpha tocopherol solution Group III(n=16)treated with10% grape seed extract solution Group IV(n=16)treatedwith 10% guava seed extract solution Group V(n=8)treated with no antioxidant solution Group VI(n=8)Control (unbleached specimens) Based on application period of antioxidants, groups I-IV were further subdivided as: Subgroup A(n=8)Antioxidant treatmentfor 10 minutesimmediately afterbleaching Subgroup B(n=8)Antioxidant treatment for 120 minutesimmediately afterbleaching The antioxidant solutions were refreshed after every 10 minutes in subgroup B. Specimens were then rinsed with water. Groups V VI did not receive any antioxidant treatment. Labial surfaces of all specimens of Subgroup A and B (Group I-IV), Group V and Group VI were etched with 37% phosphoric acid for 15 seconds, followed by rinsing with water for 20 seconds. Bonding agent (Adper single bond) was then applied and light cured for 20 seconds.Customised cylindrical silver mould was placed on the labial surface of each specimen and composite resin (Filtek Z 350 XT) was then placed in three increments so as to have a final build up of 3mm diameter and 5mm height. All specimens after composite build up were stored in distilled water for 24 hours and shear bond strength (SBS) testing was done using Universal Testing Machine (Banbros Engineering Pvt Ltd) at across head speed of 1mm per minute. Data was tabulated and subjected to statistical analysis. RESULTS Table 1: Mean Shear bond strength (MPa) in samples of Group I- IV The mean value for samples after bleaching and without application of any antioxidant agent (Group V) was 43.63 MPa. The mean value for samples in Group VI was 77.75 MPa. Bond strength of Subgroup IB (74.13+2.95) was found to be significantly higher (p+2.75). Bond strength of Subgroup IIB (75.88+3.04 units) was found to be higher than that of Subgroup IIA (55.13+1.81 units) and this difference was found to be statistically significant (p Bond strength of Subgroup IIB (76.75+1.75 units) was found to be higher than Subgroup IIA (64.75+2.12 units) and this difference was found to be statistically significant (p Though bond strength of Subgroup IVB (77.00+2.67 units) was found to be higher than that of Subgroup IVA (74.63+2.45 units) but this difference was not found to be statistically significant. Table 2: Analysis of variance in subgroup A Analysis of variance and box plot thereafter revealed statistically significant intergroup differences (p Table 3: Analysis of variance in subgroup B Analysis of variance and box plot thereafter revealed statistically significant intergroup differences (p Graph 1: Intra group Bond strength of different groups DISCUSSION Bleaching treatment focuses on the use of certain types of oxidizing agents, such as hydrogen peroxide, carbamide peroxide and sodium perborate, which, when decompose into free radicals initiate the bleaching reaction on dental tissues. The free radicals released, oxidize the pigments and coloring matters impregnated in the dental tissue; breaking the large aromatic chains of the darker coloring pigments and transforming into slightly lighter unsaturated linear chains. As the oxidizing process continues, these chains are converted into even lighter saturated linear chains, thus making the teeth whiter.52 However bleaching affects the tooth at structural and functional level.53 Previous studies have shown that the use of hydrogen peroxide or carbamide peroxide containing bleaching agents adversely affects the bond strength of resin composites to acid etched enamel when bonding is performed immediately after bleaching procedure.54,55,56 This problem is more significant when the desired results or esthetics after bleaching might not be achieved and the patient may wish for additional esthetic options like direct and indirect veneers or full coverage restorations.However studies also point out that this reduction in bond strength is temporary and the original bond strength values are achieved within 1-2 weeks in oral environment.19,22,56,57 Various methods have been proposed for reversal of reduced bond strength54,55,56,12immediately after the bleaching procedure.Kaya et al56, Han et al50 andThapa et al58 found that compromised bonding to acid etched bleached enamel and dentin can be reversed with sodium ascorbate.50,54,56 Ascorbic acid and its sodium salts are potent antioxidants that are capable of quenching reactive free radicals in biological systems.10 Alpha tocopherolallow free-radical polymerization of the adhesive resin to proceed without premature termination by restoring the altered redox potential of the oxidized bonding substrate and improves resin bonding.17 Proanthocyanidins are high-molecular-weight polymers comprising of monomeric flavan-3-ol (+)catechin and (−)epicathechins. In vitro studies have confirmed that OPCs are 50 times more effective than vitamin E and 20 times more powerful than vitamin C.48 To our knowledge, guava seed extract has not been studied as antioxidant to reverse the reduced bond strength after bleaching. Moreover,there is no specific recommendation with regards to application time of antioxidants. As the role of application time in complete reversal of reduced bond strength has not been extensively studied, the current study was carried out with the aim of evaluating and comparing the effects of guava seed extract,grape seed extract, sodium ascorbate and alpha tocopoherolin reversal of bond strength between bleached enamel and composite resin after 10 minutes and 120 minutes of application. Since, the protocol tested in the current study compared the antioxidant preparations in solution form, individual resin moulds were prepared for adequate contact of antioxidants with labial surface of the specimens. In clinical scenario, mould can be substituted by customized trays which can be worn by the patient in the desired area for appropriate time. To standardize the concentration of the antioxidants, 10% concentration was used in the present study, and also the previous studies have suggested that the application of 10% sodium ascorbate waseffective in reversing the compromised bonding to theoxidized enamel and dentin.61,64,33 Sodium ascorbate and alpha tocopherol solutions were prepared from the powder supplied but guava seed extract was prepared from seeds of white guava using soxhlet extraction method. The advantage of soxhlet extraction is that instead of manyportions of warm solvent being passed through the sample,just one batch of solvent is recycled and after extraction, the solvent is removed by means of a rotaryevaporator, yielding the extracted compound. The non-soluble portion of the extracted solid remains in the thimble, and is discarded.36 Kaya AD14 and Dabaset al62 determined the most effective time duration for the application ofsodium ascorbate to be 10 minutes. The authors also concluded that as the application period of the antioxidant increased, the bond strength of the composite on enamel tissue also increasedtill 120 minutes.14 In order to determine the fruition time for reversing the reduced bond strength, two application time periods for antioxidants that is 10 minutes and 120 minutes were choosen for the current study. Subgroup A samples received antioxidant treatment for 10 minutes and subgroup B samples for 120 minutes. The antioxidants were refreshed after every 10 minutes when applied for 120 minutes. The most frequently ignored guideline in the test protocol is following the ISO/TS 11405 specification (2003) i.e.‘a limitation of the bonding area is important’66,so to standardize the dimensions of composite cylinders which were fabricated over the labial surface of the specimens after the antioxidant treatment, preformed mold of silver with 3mm internal diameter and 5mm height was made. This silver mold was then placed over the individual specimens to build up the composite cylinders. The shear bond strength was evaluated using universal testing machine at a cross head speed of 1 mm/min as described in previous studies.15,17,19 The mean shear bond strength of Group VI (control) was 77.75 MPa and of Group Vwas 43.63MPa. This observation is in accordance with the results of other studies in the literature.68,69Many reasons have been proposed for reduction in bond strength after bleaching.71Lai et al54 stated that reduction in resin enamel bond strength to bleached etched enamel is likely to be caused by a delayed release of oxygen that affects the polymerization of resin components. Also Rueggeberg and Margeson70 proposed that release of oxygen, could either interfere with resin infiltration into etched enamel or inhibit polymerization of resins that cure via a free radical mechanism.Titleyet al56 stated that hydrogen peroxide causes denaturation of proteins in the organic components of the dentin and enamel and thus causing the alteration in organic and inorganic ratio with an increase in inorganic component.Titley et al,56Kalili et al,20Dishman et al8 stated that most acceptable version might be presence of the residual oxygen from the bleaching agent which inhibits resin polymerization. In the present study, after the application of respective antioxidants for 10 minutes, mean shear bond strengths of different groups were evaluated as 54.88MPa, 55.13 MPa, 64.75 and 74.63 MPa for group IA, II A, III A and IV A respectively. Except for Group IV A (guava extract solution), none of the antioxidants (Group IA, IIA, IIIA) showed complete reversal in bond strength when applied for 10 minutes. This corroborates with the findings of Thapaet al18, Sasaki et al17, Torres et al29. In the present study, after the application of respective antioxidants for 120 minutes, mean shear bond strengths of different groups were evaluated as 74.13 MPa, 75.86 MPa, 76.75 MPa and 77 MPa for group IB, II B, III B and IV B respectively. Thus complete reversal of reduced bond strength was achieved in all the experimental groups when applied for 120 minutes and is in accordance with the previous studies,17,18,29 which stated that bond strength increases with increase in antioxidant application time till 120 minutes.17,18 The results of the study demonstrate that guava seed extract have highest antioxidant activity both for 10 minutes and 120 minutes of application among all the antioxidants used in the present study. Further studies are required using higher concentrations of antioxidants and reducing their time of application so as to achieve complete reversal of reduced bond strength after enamel bleaching. CONCLUSION Within the limitation of the present study it could be concluded that: Immediate bonding of resin composite to bleached enamel results in reduced shear bond strength. Treatment of bleached enamel surface with 10 minutes application of 10% sodium ascorbate, 10% alpha tocopherol, 10% grape seed extract and 10% guava seed extract improves the reduced bond strength significantly immediately after bleaching, but only the application of 10%guava seed extract for 10 minutes reverses it to baseline levels. All the antioxidants after 120 minutes of application completely restored the reduced bond strength.

Service Cycle of Medical Tourism in India

One of the major practices in healthcare is the process of ‘patient outsourcing’, in the form of medical tourism or ‘Medical travel’.This form of business protocol is becoming hugely popular in the developed countries of the world, as it has tremendous benefits.   Medical tourism is a deliberate effort to combine health issues along with travel for tourism and leisure (Health Base, 2006, Recover Discover, 2007). Several organizations may be involved in the process of medical tourism including:-The governments – They are responsible for framing a policy that would ensure regulated flow of tourists from one part of the globe to another to enable effective healthcare provision.   Besides, it would also ensure that the tourists can obtain valid travel documents easily.Hospital Associations – Associations founded between the hospitals of the tourist and the destination country are required to communicate with each other so as to help in the flow of medical tourists.   This is to ensure that all ethical and legal issues are addressed, and an effective marketing communication system can exist.It would be ideal for the patient to first speak to his/her usual healthcare provider before seeking medical facilities in another nation.   Hospitals in the west can also consider recognizing and providing accreditation for hospitals in developing nations, so that the quality standards pre vailing is well-understood.Travel authorities – They are the authorities who are providing valid travel documents and permission required to enable medical treatment in another nation.   The authorities should understand the need and urgency for medical treatment and hence would have to permit such travel.Travel agencies – They would have to communicate with other parties in the destination to ensure that the health and travel needs of the tourist is meet, keeping in mind quality, cost-effectiveness and hassle-free processes.The travel agency would have to provide the travelers with customized packages that are cost-effective and seem attractive.   They would also have to market the health packages in the West, to demonstrate clear advantages to the ones existing at home. Ministry of Commerce and trade (Hutchinson, 2005, Heatlhbase, 2006 & American University, 2003).Through the process of globalization, many countries are beginning to closely review their economic strengths and risks.   If something is costly in one nation, immediately the resources present in other nations would be approached and utilized.In medical tourism, the individual would be using cost-effective options in order to fulfill their healthcare needs in areas where the limitations may be less.   These limitations can be several and can be utilized to the advantage of the individual.   Some of the limitations which can be met through medical tourism include:-Going from one nation where certain types of treatment are not available, to another where treatment is available.  Ã‚   Going from one country to another, where the quality of treatment is better, improved technology and where expertise in health is available, and innovative options are presentGoing from one country to another where treatment is provided in a more cost-effective manner Going from one nation to another where medical treatment including surgery is provided in a more timely manner (to reduce the w aiting periods for elective surgeries)Including the family members and seeking treatment away from home where the usual stressful factors would not be felt (Hutchinson, 2005, Heatlhbase, 2006 & American University, 2003)Medical tourisms can take place from one nation to another and from one region of a nation to another region within the same nation. The trend today is that many people from the western or developing nations (which have a very restrictive health setup) are moving to the east, where the practices and policies do favor provision of several benefits in healthcare. There are many unique features of the prospects of medical tourism:-The nations which serve as a market for medical tourisms are providing several attractive policies and practicesThey are using vary attractive marketing strategies to encourage business – An example of this would be to combine medical health visits with holidays to exotic tourist destinations.   Many people from the developed nations are finding such packages very attractive and are considering them as they are not only cheaper but also meet their customized needs, conveniently.The developing nations such as Thailand, India, Latin America and China, are offering more holistic kind of treatment and are providing several complementary and alternative treatments that deviate away from allopathic medicine.   Many of these treatments have proven to be effective.   Besides, the treatment facilities are provided in more natural kinds of environment, thus encouraging better healing and recovery (Hutchinson, 2005, Heatlhbase, 2006 & American University, 2003).Medical tourism can be held for various reasons including health and wellness tourism, reproductive purposes, alternative treatment strategies, preventive medical care, spa tourism, surgical tourism, dental tourism, diet and nutrition tourism, transplant tourism, cosmetic tourism, spiritual tourism or even for end-of-life purposes.Often the individual requiring health treatment would also like to include their family members in the process.   They would also like to take their family members along.   People also want to visit resorts and spas to get away from the usual humdrum.   Several theoretical frameworks have been proposed for Medical Tourism:-Consumer Motivation – Consumers may find the health packages offered at the destination nations cost-effective, of better quality and would also combining their travel needs Medical tourist motivation – Some people prefer traveling and getting treatment done in a foreign nation, away from home Push-pull motivation – This has been one of the most explanation to justify medical tourism.The pull factors are usually contributed to the attractiveness of the market and the various marketing strategies that have been employed.   The pull factors are tangible and are attributed by the destination.   The push factors are intangible and may need a lot of explanation.   So me of the push factors include:-  ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Fulfilling travel needs ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Preferences for certain destinations ·Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚  Ã‚   Travelers often have the intention of traveling for whatever need, even if a such a need can be fulfilled at home (Hongnaphadol, 2008)India has been one of the success stories of medical tourism in the world.   Thousands of tourists from various parts of the World including the US, UK, Australia, Middle East, European Union, etc, visit India every year for medical and surgical treatment.   India is also one of the sought out destinations for alternative forms of treatment including Yoga, Ayurveda, herbal medicine, massage therapy, etc.Effective collaborations between the tourism industry and the healthcare industry have existed in India to enable medical tourism to be a success.   This has been an initiative from both, private and public parties.   India has several other cha racteristics that have permitted medical tourism to prevail:-Rich culture and tradition – favoring tourism Natural characteristics of the country Traditional systems of medicine – which seem to be very attractive for the West Cultural competence of the professionals existing in IndiaLow waiting time Cost-effective treatment Good quality of medical care Pre-existing tourist destination Effective collaboration with organizations in the US/UK which would enable movement of touristsEasy currency conversion processes Good quality of education prevailing in India – Academic organizations are able to meet with the requirements of the healthcare industry Connectivity with international airports Good technology utilized in healthcare (Recover Discover, 2007).The service cycle of the medical tourism process and is an experience for the customer.   It starts even before the consumer meets the service provider to obtain an effective medical tourism package that would meet his/her travel and health needs.The process starts when the consumer understands that there is an unfulfilled health need which has to be met.   The process would go on and the several steps present including (as fulfilling health need is not a single transaction and involves several processes):-Meeting with the service provider Discussing an effective package that would meet their needs (the package would include several aspects including air and travel costs, hotel stay, food, consultation charges, investigation costs, treatment and surgical charges, medications costs, holiday packages, etc).The customer should be provided with a number of options and choice of destinations.   Negotiations should also be permitted. Purchasing the health/travel package Preparing to enter in the package Starting with the travelEntering and experiencing the destination country Getting used to the destination country Meeting the healthcare provider and ensuring that the electronic health records are received – the healthcare professionals should take an adequate history of the patient and should also conduct adequate diagnostic tests.Identifying the health problems and developing a plan to solve these problems Presenting the plan to the patient and taking the consent Initiating the treatment plan – May include several visits; The pre-treatment period may include several precautions, restrictions in diet, lifestyle, medications, travel, etcPost-treatment period – Taking adequate precautions regarding diet, lifestyle, exercise, rest, medications, etc.   The patient should be adequately informed of these so that they may be comfortable. Follow-up visits – Any additional treatment Advise or consultations before the patient goes back to the home nationFulfilling any other travel needs Returning back home Contact with the healthcare providers through telephone, e-mail, chat services, etc (Health Base, 2006, Wachovia, 2008, Monash University, 2004).Th e process may not be complete once the patient returns home.   This is because fulfilling health needs is a continuous process and the requirements are never ending.   At each of the steps, the customer would be having certain expectations.   The quality standards of the service are usually determined by the ability to fulfill the customer’s expectations and to meet as to what was promised in the initial package (contract).   Some of the expectations of the consumers include:-Having a high quality travel package which is cost-effective Finding the destination country comfortable and relaxing Getting used to the destination quickly Developing rapport with the new healthcare professionals and the healthcare system – Ability to clear all doubts and queries.The patient should be assured about the quality standards of the organization and the qualifications of the healthcare professionals.Preferable a standard prevailing at the home nation should be sought.   It i s also important that the processes existing in the hospital should be similar to that of the home nation.   The healthcare system prevailing should be culturally competent to that of the tourists.Able to meet with the precautions and advise from the healthcare professionals easily Undergoing the treatment processes without much complications, side-effects and negative events Resolving any problem the patient has during the treatment processes Enjoying the benefits of treatment Ability to contact the healthcare provider and fulfilling any problem (Health Base, 2006, Wachovia, 2008,)References:American University (2003). Globalization and Medical Tourism, Retrieved on August 15, 2008, from American University of Delaware Website: http://www.american.edu/ted/medical-tourism.htmHealth base (2006). Medical Tourism FAQs, Retrieved on August 15, 2008, from Health Base Website: https://www.healthbase.com/hb/pages/medical-tourism-faq.jsp#1Hongnaphadol, W. N. (2008). Medical Tourism, Retri eved on August 15, 2008, from Leeds University Website: www.leedsmet.ac.uk/research/W_Hognaphado-pm_1.ppHutchinson, B. (2005). Medical tourism growing worldwide, Retrieved on August 15, 2008, from University of Delaware Website: http://www.udel.edu/PR/UDaily/2005/mar/tourism072505.htmlMonash University (2004). The Cycle of Service, Retrieved on August 15, 2008, from Monash University Website: http://www.adm.monash.edu.au/cheq/support-services/cycle-service.htmlRecover Discover (2007). Medical Tourism – Medical Tourism India – Healthcare Tourism, Retrieved on August 15, 2008, from Recover Discover Website: http://www.recoverdiscover.com/Wachovia Corporation (2008). The Cycle Of Service – How To See Things from the Customer's Point of View, Retrieved on August 15, 2008, from Wachovia Corporation Website: http://www.wachovia.com/small_biz/page/0,,447_972_1697_1994_2016,00.html

Division of labour

Today, even simplest form of labor like, our day-to-day domestic work, is divided between services like house maids, milkman, laundry revise, daycare, transport services, along with restaurants or food deliveries. Most of the times, we do not realism how the concept of division of labor is more central to our lives than we think. Right from the beginning of the human life, to this day of again super-computers, the division of labor has made all the difference. The division of labor brings in greater productivity of labor. If not for this productivity, today would have been only slightly different than the ice ages.This basic need for division of labor comes from the human desire to lead a better life. According to Smith, part of what makes us human, Is our propensity to truck, barter, and exchange Items. If everyone were to produce everything they need, there would be very less scope for any sort of Innovation and a lot of time In would be wasted In changing tools and materials. But, with the help of the division of labor, leading to efficiencies and surpluses, each member of the society could trade the fruits of his/her labor for other objects that are needed.This would result in the improvement of quality of life and a win-win situation. Division of labor creates specialized knowledge of a reticular task. It saves the laborer time as the time needed to adjust to new physical or mental frame works is eliminated. Doing the same thing over and over, leads to innovation in the methods and tools employed in the task. If not for the extensive form of division of labor, the world wouldn't have been what it is today. The effective Dillon of labor Is limited by the market size.A vendor, who supplies to the only geography he has access to, can delve the labor to only a certain extent because, as productively Increases with the Dillon of labor, a large market Is needed o consume the products that it gives rise to. Thus as Eng as he doesn't have access to larger market, the further division of labor is meaningless. Over the last few centuries, the advances in technology gas connected the geographies all over the world and so, the accessing the markets of these geographies has become easier.Thus, many businesses that were previously supplying to limited markets of villages and small cities are now spreading rapidly over parts of the nations and those supplying to parts for a nation are taking over the world. So, in order to increase earplugs and productivity also over tight competition from others of their kind, they need to go for greater extent of division of labor. The sustain in the world of tight competition, be It In the global or local scale, the division of labor has to make best use of available resources.This Dillon of labor, Is based on cheaper and faster access to resources, local human talent, cost of manufacturing and consumer base, thus increasing their productivity. For example, a lot of companies located in might have their producti on units in china or software development in US, taking advantage of natural or human resources available the locality. This has given rise to division of labor geographically. Today, majority of businesses, have various parts of the same product manufactured in various parts of the world.Also, we see many cities or various parts of world emerging as specialists in particular businesses. Now businesses are moving to Africa and India where they can find more consumers. The world has become a small village. Everyday, we see many huge companies shutdown after having failed sustain in the competition to cater to the changing need for services and products, and many new ones taking over the globe. Unlike the old times, today people don't limit themselves to one particular Job, they look out for more Jobs that can fetch them more money.So, the increase in productivity achieved by division of labor at one Job, helps them divert their resources elsewhere to earn additional revenue. Today th e information technology may be decreasing the kind of information asymmetry that existed before. Division of labor is omnipresent, be it in political organizations where the government is divided into legislative, Judiciary and executive branches or in latherer systems, where we have different doctors for different ailments. Today, there are enormous number of types and many more are getting added each day.Also, in today's world, Adam Smith's Division of Labor has got a new meaning with the division of labor between the humans and machines. The human intellectual skill combined with physical strength of the machines has changed our lives like never before. The computers, which are machines of one particular type have created wonders. They have created a major upheaval in the nature of human work. On one hand there is a division of labor between humans and Computer and on the other hand, there is a fast growing division of labor within humans who can and who cannot do valued work in the economy filled with computers. L] In the old times, the division of labor based on labor was widespread. The male population was supposed to earn the bread, and the female population was assigned to take care of domestic work. Unlike those days, today we see more and more women entering Jobs that were previously reserved for males. As the society is slowly coming out of self-imposed superstitions and restrictions regarding the granting equal rights and opportunities to females, the competition between male and female for the various Jobs is increasing.Only the best suited for the Job, irrespective of the gender, get the Job. Thus, the gender based division of labor is losing its impact. This reinforces the statement of Adam Smith saying ‘Competition is the best influence for increasing productivity'. Everybody wants to live a better life. This best of everything. Minored to attract buyers with good quality products and services in this barter, and sustain in the competiti on with others, there is a need for greater radioactivity. And again comes the role of division of labor to achieve more productivity.

The s Account Of Wall Street - 1153 Words

Whether it be popular culture such as television shows or movies or real life scenarios society always finds work structure to be a captivating and dare I say entertaining. Melville’s account of Wall Street is an interesting one that explores characters that have some similar characteristics to modern day office settings. This paper will explore the different personalities described in â€Å"Bartleby the Scrivener†, discover how that relates to modern culture, and conclude with why people find it captivating. First the narrator is introduced, not by name, but it is easy to infer about him by the way he attempts to describe Bartleby and the other workers. He begins by saying â€Å"Ere introducing the scrivener, as he first appeared to me, it is fit I make some mention of myself, my employà ©s, my business, my champers, and general surroundings†, which once again says a lot more about the narrators personality (p.2402). The excessive use of â€Å"my† proves this man is egotistically driven and when reading on he continues to refer more to himself rather than his employees. This idea of a self centered boss who views himself as superior to his cohorts does not sound familiar at all right? Wrong! Many people may even have personal experience that coincides with Bartleby’s experiences of a self absorbed boss. There is a movie entitled, â€Å"Horrible Bosses† (2011) making 209.6 million dollar in the box office. This hilarious movie although over exaggerated is found to be highly entertaining inShow MoreRelatedEnron : Enron And Enron1298 Words   |  6 Pagesenergy markets. On their financial books Enron looked as they were doing extremely well and many investors sought out to buy Enron’s stocks. Enron net worth was about $70 billion, their shares traded for about $90 dollars each. Enron was known on Wall Street as a blue chip stock and was considered to be very stable and trustworthy. Enron was named the fifth lar gest company by Fortune 500. Enron lead the market in energy production, distribution, and trading. Stakeholder Analysis EnronRead MoreEnron : Enron And Enron1298 Words   |  6 Pagesenergy markets. On their financial books Enron looked as they were doing extremely well and many investors sought out to buy Enron’s stocks. Enron net worth was about $70 billion, their shares traded for about $90 dollars each. Enron was known on Wall Street as a blue chip stock and was considered to be very stable and trustworthy. Enron was named the fifth largest company by Fortune 500. Enron lead the market in energy production, distribution, and trading. Stakeholder Analysis EnronRead MoreCampbell Soup Case Study1106 Words   |  5 Pagesare able to justify their fradulent acts as a means of abiding with their personal code of ethics. 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