GIRFT and Measuring Outcomes in MCNs: endodontics in 646 teeth treated in Tier 2 (Primary Care) and Tier 3 (Secondary Care) settings in England.

AIM: This paper aims to assess the complexity, quality and outcome of endodontic treatment provided in Managed Clinical Networks (MCNs) in England to understand if we are "getting it right first time" (GIRFT). METHODS: In a convenient sample of endodontic treatments provided between May 2011 and April 2017, the complexity of teeth treated, the quality of treatment procedure, the radiographic appearance of root fillings, as well as clinical and radiographic healing were retrospectively assessed using records taken as part of treatment. Trained, calibrated examiners independently scored radiographs using previously published scoring systems. RESULTS: 646 teeth were followed up for 24.7 months (standard deviation [SD] 17.08). The average age of those patients treated was 46.7 years (SD 15.38) with 48.3% being male. Of teeth treated, 70.4% were of complexity level 3. 88.2% of teeth were asymptomatic, and 80% demonstrated complete radiographic healing. Procedural errors inhibited achieving correct working length and taper, with more voids within root canal fillings. When patency filing was reported as being carried out, complete radiographic healing was more likely. CONCLUSIONS: It is possible to collate outcome data in the NHS system, especially if there is provision for ongoing follow up and time allocated for collection of data. Endodontic treatment provided within primary and secondary care settings are of high quality, with outcomes being better with single operators carrying out high volumes of endodontic treatment.

Pulp therapy and root canal treatment techniques in immature permanent teeth: an update.

Background According to the Children's Dental Health Survey 2013, around one in ten children in Wales, Northern Ireland and England will have sustained dental trauma to a permanent incisor by the of age 15. Management of an exposed pulp in an immature permanent incisor is often urgent and has an impact on the long-term outcome of the tooth; therefore, it is essential that general dental practitioners feel confident in managing such a scenario to achieve an optimal outcome. This paper discusses the indications, technique, materials and outcomes.Aims This article aims to review the literature, which discusses various treatment modalities and materials for pulpal therapy and root canal treatment in the immature permanent tooth.Method Electronic searches were limited to English language, human studies, published within the past five years and the medical subject heading terms used were: direct pulp capping, apexogenesis, Cvek pulpotomy, full pulpotomy/pulpectomy, partial pulpotomy, apexification, non-vital pulp therapy and mineral trioxide aggregate apexification. Older, seminal articles identified through the references sections have also been included.Conclusion A number of options are available for the management of immature permanent teeth that have suffered an insult such as caries or trauma. This paper reviews the various methods of pulpal treatment, preservation therapy and root canal treatment options depending on the extent of the damage.

An impossible choice: MRONJ vs ORN? The difficulties of the decision-making process for head and neck cancer patients on long-term anti-angiogenic medication.

With increasing medical complexity of patients, including the widespread use of bisphosphonates and the increased incidence in head and neck cancer diagnosis, there are ever more difficult decisions to be made within restorative dentistry. The most morbid dental complication to avoid with both the use of bisphosphonate and radiotherapy to the jaws is necrosis of the jaws, ideally by avoiding dental extractions, usually for the entirety of the patient's lifetime. If these patients undergo a dental assessment before commencing such medical treatments, there is a window of opportunity for both dental extractions of teeth with a poor/hopeless prognosis and for appropriate emphasis on prevention. Treatment planning at this stage has the goal of avoiding further dental extractions completely in the future. However, not all patients have an ideal care pathway. This article describes a case with an impossible choice to be made with significant time pressure and during the most vulnerable of times in a patient's life. The short-, medium- and long-term challenges posed are discussed.

Complex Dentistry in General Practice - What Would You Do?

In 2019, in a world of instant gratification, what are the expectations of patients and dentists? Is training sufficient to meet these expectations? Decision-making in dentistry impacts the treatment choices patients are given, and may influence the outcomes of such treatment. It is therefore important to ensure as much standardisation as possible. In order to achieve this, it is important to know the current standard and the views of dentist as this will influence dental treatment planning. Clinical Relevance: This paper captures the treatment planning dilemmas of dentists, specifically of those in their Foundation training year, in order to aid targeting of training and development. Objective Statement: To understand treatment decisions of general dental practitioners and specialists.

Infective endocarditis and the heavily restored dentition: are clinicians becoming more complacent regarding prevention?

The use of antibiotic prophylaxis to reduce the risk of infective endocarditis (IE) in susceptible individuals is a topic which has historically prompted many controversial debates. In the past, dentists have been understandably unwilling to prescribe antibiotic prophylaxis for fear of deviating from the National Institute for Health and Care Excellence (NICE) guidelines. However, in 2016, NICE altered the wording of these guidelines. The subtle change in wording implied that the clinician could use their clinical judgement, alongside advice from cardiologists, to deem their patient high-risk enough to prescribe antibiotics. In this article we discuss the implications of the NICE guidelines, and present the case of a patient who historically received antibiotic prophylaxis due to a history of rheumatic fever. Following the old NICE guidelines of 2008 he no longer received this prescription. As a consequence, he went on to suffer from IE from an unexpected cause due to ineffective preventative advice.

Education and training in craft skills dentistry.

In order to best use available resources, the dental workforce needs to be sufficiently skilled to provide the correct treatment in the right place in the patient pathway, without need for escalation to secondary care. Education is a means to improve quality of healthcare with significance being placed on the proficiency of teaching and effectiveness of learning. The aim is to make the most efficient use of resources to upskill the existing workforce without significant reduction in the services that can be provided during training. With increasing academic demands on the undergraduate curriculum, there may be an expectation that general dental practitioners involved in vocational training now have a larger role to play in providing clinical training for the graduating dentists of the future. With this in mind, this article provides a narrative overview of the concepts to be considered in dental education and training. More education and training activities may be expected to take place in the workplace; therefore general dental practitioners may be at the forefront of providing high quality practice-based dental education and training in the future.

Early years postgraduate learning and training in prosthodontic dentistry: 2019 and beyond.

The intended outcome of dental education is to produce dental clinicians who have the knowledge, technical skills, personal attributes, values and professional outlook to deliver the highest level of patient care. Due to the development and improvement of dental materials and clinical techniques, combined with a steady rise in patient expectations and complaints, prosthodontics has developed into a dental speciality recognised by the General Dental Council. Going forward, there will be a requirement to provide complex and difficult operative and prosthodontic dentistry. Much will be replacement and repair of existing failing work, with the application and choice of newer materials and clinical approaches. How does the dental education sector respond to this challenge? This article attempts to discuss potential solutions for training and education, for all levels of prosthodontics in the UK.

British Society of Prosthodontics Debate on the Implications of the Minamata Convention on Mercury to Dental Amalgam--Should our Patients be Worried?.

In 2013, the Minamata Convention on Mercury called for a global phase-down of amalgam use, with a view to reduce environmental mercury pollution. This will significantly impact UK dentistry, given the still extensive use of amalgam in U.K. general dental practice. However, until now there has been little national discussion or debate. In Spring 2015, The British Society of Prosthodontics dedicated a significant part of its Annual Conference to debating the implications of this issue. Clinical case examples were discussed with audience interaction and voting facilitated using innovative Audience Response System Technology. A remarkable range of concerns and opinions were given. The debate elicited specific concerns amongst clinicians regarding the suitability of mercury-free alternatives to amalgam; particularly where cavities are large and extend beneath the gingival anatomy. There are also anecdotal reports of Dental Foundation (DF) dentists not being adequately taught the use of dental amalgam in undergraduate dental schools. CPD/CLINICAL RELEVANCE: Many clinicians, especially those treating patients for whom moisture control is challenging, feel that amalgam should remain available for clinicians to choose in certain clinical circumstances for the restoration of posterior teeth, even in the event of a complete phase-down.

Choosing the Right Dental Material and Making Sense of the Options: Evidence and Clinical Recommendations.

Decision-making is a fundamental aspect of clinical dentistry. Advances in technology and trends towards more conservative technologies have broadened the options available to patients and dentists, increasing the range of choices and opportunities to restore teeth. With such a broad range of dental materials, there are a number of factors to consider in making an appropriate choice. We present several decision-making dilemmas. Namely; how to restore worn lower anterior teeth, what to consider when replacing crowns, materials to consider when providing cuspal protection for posterior teeth, and finally the issues to consider when selecting a luting cement. The evidence supporting different clinical choices is considered in a discussion of the various dilemmas faced.

Interactive treatment planning in toothwear: are we doing it right?

UNLABELLED: Toothwear is now common, especially in younger patients, with high demand for the restoration of the damaged teeth which is likely to increase further over time. Fixed prosthodontic options range from direct composite resin to conventional tooth preparation and cemented indirect restorations. This paper summarizes the views of a variety of clinicians on a plan delivered to a patient with toothwear in secondary care and explores the possible reasons for the variation in decision-making in the treatment of toothwear. CLINICAL RELEVANCE: With levels of toothwear increasing, the clinician needs to be aware of the different treatment modalities which are appropriate.

Dental extractions prior to radiotherapy to the jaws for reducing post-radiotherapy dental complications.

BACKGROUND: Radiotherapy as part of head and neck cancer treatment leaves patients requiring much dental rehabilitation in a compromised environment that is difficult for the patient and the dental team to manage. OBJECTIVES: To assess the effects of maintaining the patient's natural dentition during radiotherapy in comparison to extracting teeth before radiotherapy in areas that are difficult to access by the patient and the dentist, should reduction in mouth opening occur after radiotherapy to the jaws. SEARCH METHODS: We searched the Cochrane Oral Health Group's Trials Register (to 22 November 2012), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 11), MEDLINE via OVID (1946 to 22 November 2012), EMBASE via OVID (1980 to 22 November 2012), CANCERLIT via PubMed (1950 to 22 November 2012), CINAHL via EBSCO (1980 to 22 November 2012) and reference lists of articles. We advertised for currently ongoing studies via the Cochrane Oral Health Group website and the Cochrane Oral Health Group Twitter feed.  SELECTION CRITERIA: Randomised controlled trials comparing extraction of teeth prior to radiotherapy with leaving teeth in situ during radiotherapy to the jaws. DATA COLLECTION AND ANALYSIS: Three review authors independently assessed the results of the searches for inclusion in the review.  MAIN RESULTS: No randomised controlled trials were found. AUTHORS' CONCLUSIONS: There are no randomised controlled trials to assess the effect of extracting teeth prior to radiotherapy compared to leaving teeth in the mouth during radiotherapy to the jaws.

Antimicrobial irrigants in endodontic therapy: 1. Root canal disinfection.

UNLABELLED: This paper highlights the importance of root canal disinfection. It discusses the different endodontic irrigants available and comments on how these can be used most effectively. CLINICAL RELEVANCE: Eliminating bacteria from the root canal system is an essential stage in endodontic therapy. Practitioners should be adequately informed and skilled in this vital aspect of endodontics.

Antimicrobial Irrigants in Endodontic Therapy. 2: Clinical Tips for Isolation and Irrigant Use.

This second article will concentrate on the clinical use of root canal irrigants, highlighting why commonly used techniques may be suboptimal and result in ineffective disinfection during endodontic therapy.

Soft tissue handling during implant placement.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were searched. Handsearching included several dental journals. Authors of all identified trials, an internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomised controlled trials (RCT). STUDY SELECTION: All RCT of root-form osseo-integrated dental implants comparing various techniques to handle soft tissues when placing dental implants were included. Outcome measures considered were: prosthetic and implant failures, aesthetics evaluated by patients and dentists, biological complications, postoperative pain, patient preference, ease of maintenance by patient, and width of the attached or keratinised mucosa. DATA EXTRACTION AND SYNTHESIS: Screening of eligible studies, assessment of the methodological quality of the trials and data extraction were conducted in duplicate and independently by two review authors. Authors were contacted for missing information. Results were expressed as random-effects models using mean differences for continuous outcomes, and risk ratios for dichotomous outcomes, with 95% confidence intervals. Heterogeneity was to be investigated, including both clinical and methodological factors. RESULTS: Eight RCT were identified and five trials, which included 140 patients in total, were selected. Two trials (comprising 100 patients) compared flapless placement of dental implants with conventional flap elevation, two trials (20 patients) crestal versus vestibular incisions. On a patient (rather than per-implant) basis, implants placed with a flapless technique and implant exposures performed with a laser induced significantly less postoperative pain than flap elevation. There were no statistically significant differences for any of the other analyses. CONCLUSIONS: Flapless implant placement is feasible and has been shown to reduce patient postoperative discomfort in appropriately selected patients. Sufficient, reliable evidence is not available for recommendations to be made about which techniques or materials for incision or suture are most beneficial to patients. This is also the case for techniques to correct or augment perimplant soft tissues or to increase the width of keratinised or attached mucosa. Properly designed and conducted RCT are needed to provide reliable answers to these questions.

No difference between failure rates of early and conventionally loaded implants.

DATA SOURCES: The Cochrane Oral Health Group's Trials Register, Cochrane Central Register of Controlled Trials, Medline and Embase were searched. Handsearching included several dental journals. Authors of all identified trials, an internet discussion group and 55 dental implant manufacturers were contacted to find unpublished randomised controlled trials (RCT). STUDY SELECTION: RCT were selected of root-form osseo-integrated oral implants that had a followup of 6 months-1 year and which compared the same osseo-integrated root-form implants immediately (within 1 week), early (1 week-2 months) and conventionally loaded (after 2 months), giving the following outcome measures: failures, implant failures and marginal bone levels on intra-oral radiographs. DATA EXTRACTION AND SYNTHESIS: Data were independently extracted, in duplicate, by two review authors. Authors were contacted for details of randomisation and withdrawals and a quality assessment was carried out. The Cochrane Oral Health Group's statistical guidelines were followed. RESULTS: Twenty RCT were identified and 11 trials comprising a total of 300 patients were included. Six trials compared immediate versus conventional loading, three early versus conventional loading and two immediate versus early loading. On a patient, rather than per implant basis, there were no statistically significant differences for any of the meta-analyses. CONCLUSIONS: It is possible to successfully load dental implants immediately or early after their placement in selected patients, but not all clinicians achieve optimal results when loading the implant immediately. A high degree of primary implant stability (high value of insertion torque) seems to be one of the prerequisites for a successful immediate/ early loading procedure. More well-designed RCT are needed. Priority should be given to trials comparing immediately versus early loaded implants to improve patient satisfaction and decrease treatment time and trials should be reported according to the CONSORT guidelines (http://www.consort-statement.org/).