The impact of clinical audit on antibiotic prescribing in general dental practice.

OBJECTIVE: To reduce the number of antibiotics inappropriately prescribed by general dental practitioners, and to increase overall prescription accuracy. DESIGN: A prospective clinical audit carried out between September and March of 2002-3 and 2003-4. SETTING: General dental practices in Eastern England. SUBJECTS AND METHODS: The pre-audit antibiotic prescribing practices of 212 general dental practitioners were recorded over an initial six week period. On each occasion this included which antibiotic had been chosen, together with its dose, frequency and duration, as well as the clinical condition and reason for which the prescription had been raised. When related to prophylaxis, the patient's medical history was also noted. Following education on contemporary prescribing guidelines, presentations which illustrated the practitioners' previous errors, and the agreement of standards to be achieved, the process was repeated for another six weeks, and the results compared. RESULTS: In the pre-audit period, 2,951 antibiotic prescriptions were issued, and during the audit this was reduced by 43.6% to 1,665. The majority were for therapeutic reasons, with only 10.5% and 13.6% for medical prophylaxis during the pre-audit and audit periods respectively. Over both periods, amoxicillin and metronidazole were the two most commonly prescribed antimicrobials (63.4% and 21.2% respectively). In the pre-audit period, only 43% of all prescriptions were error free in dose, frequency, and/or duration of use, but this rose significantly to 78% during the audit. Equally, using contemporary published guidelines, out of all the prescriptions made in the pre-audit period, only 29.2% were deemed to be justified, as compared to 48.5% during the audit. CONCLUSIONS: Clinical audit, in conjunction with education, and prescribing guidelines can favourably change antibiotic prescribing patterns among general dental practitioners.

A restorative-orthodontic treatment approach in the older patient.

This report presents a case requiring a combination of restorative dentistry and orthodontic treatment in a mature adult patient. Occlusal splint and periodontal therapies were used initially. Orthodontic treatment combined the use of the occlusal splint and fixed appliance in the maxillary arch. Sectional fixed appliances were used in the mandibular arch. The final restorations were fixed--movable bridges in the mandibular arch and a removable tooth and mucosally borne prosthesis in the maxilla. Retention of the orthodontic result was provided by the fixed prostheses in the lower arch and the continued wear of a full coverage maxillary occlusal splint at night served to prevent relapse of the upper teeth.

Quality assurance. A project on patient waiting times at appointment in an orthodontic department.

A quality assurance project to establish patient waiting time at appointments was undertaken over a four-week period during the spring of 1989. The Orthodontic Department was selected as one of two departments in the Birmingham General Hospital/Birmingham Dental Hospital unit site that was to participate in the programme initiated at the District Health Authority management level. Patient waiting periods for a total of 142 clinical sessions were assessed. Fifty per cent of patients were kept waiting and 50 per cent were seen either earlier or at their appointed time. The mean period of time that patients were kept waiting past their appointment time was 9.4 min (+/- 10.9). On clinics for which patients arrived late the mean time that they were kept waiting increased to a mean of 18.9 min (+/- 9.1). Data from 92 patient questionnaires established that they considered a reasonable mean time of waiting to be 16.1 min (+/- 7.9). Five recommendations were proposed as a result of this quality assurance initiative and their implementation is discussed.

Multi-disciplinary treatment planning for the restorative patient.

Many older patients present requiring a multi-disciplinary approach to treatment aimed at restoring their dentition to health, satisfactory function, and appearance. The restorative dentist with specialist knowledge of periodontics, and fixed and removable prosthodontics is well qualified to provide a treatment plan to achieve these goals. The basic principles of formulating a treatment plan are discussed and a case presented which required a combination of occlusal therapy, periodontics, orthodontics and fixed and removable prosthodontics.

An echocardiographic study of localized subaortic hypertrophy.

A prospective echocardiographic investigation was undertaken to determine the prevalence and significance of localized subaortic hypertrophy in 1000 consecutive patients presenting for a routine echocardiographic examination. Localized septal hypertrophy was diagnosed when the subaortic septum was hypertrophied (greater than 1.4 cm) and was 50% thicker than the mid-point of the septum. Patients with hypertrophic cardiomyopathy and fixed subvalvular aortic stenosis were excluded. Eight cases of localized subaortic hypertrophy were identified. In 7 the appearances of the left side of the interventricular septum were similar with an apparently sigmoid shape (reversed S on its side) and in 1 with associated mitral stenosis the septum was a tapered wedge. All patients with localized subaortic hypertrophy had left ventricular hypertrophy (left ventricular mass or posterior wall thickness greater than 2 SD from normal) with a normal size cavity due to aortic valve disease (2 patients were also hypertensive). Of the 180 patients with aortic valve disease, localized subaortic hypertrophy was found in 10% of those with left ventricular hypertrophy and 33% of those with asymmetrical septal hypertrophy (septum to posterior wall ratio of greater than 1.5:1). There was no evidence of subaortic stenosis by pulsed and continuous wave doppler echocardiography (8 cases) and cardiac catheterization (6 cases). The aetiology of this discrete localized muscular bulge is unclear but is presumably due to change in shape of the septum with left ventricular hypertrophy. However, this finding has important implications as a cause of asymmetrical septal hypertrophy and because of the possible false diagnosis of subvalvular stenosis and its effect on ultrasound measurements.

Recurrent swelling of the upper lip. A case report.

Recurrent swelling of the lips may be due to a number of causes. A case is presented of recurrent swelling of the upper lip caused by trauma from a displaced and apically dilacerated 1. There was abnormal development of 32 which were also displaced although 123 appeared unaffected. The surgical, endodontic and orthodontic management of this problem is discussed.

Effects of a school visit dental health programme upon the attitudes of undergraduate dental students in England.

A programme of structured school visits during the dental undergraduate course was used to assess attitudes and changes of attitudes of dental students to aspects of dental health education. Participating students showed the greater changes of attitude towards community dental health education and developed better understanding of correct dietary and oral hygiene advice. However, in spite of these attitude changes the participating students were not convinced that this type of dental health education was very effective in the prevention of dental disease.

The mortality and morbidity of young survivors of myocardial infarction.

The mortality and morbidity of 150 young (less than 45 years) survivors of myocardial infarction was studied prospectively over a 10-year period. Thirty-seven deaths (36 due to coronary artery disease) occurred from one month to 10 years after myocardial infarction and the cumulative 10-year mortality was 27 per cent compared with 5 per cent in the general population. High initial lactate dehydrogenase levels and continued cigarette smoking after infarction were associated with a poor long-term survival. Angina was present at some time during follow-up in 60 per cent of patients. Severe limitation of exercise tolerance was present in 18 per cent, and 16 per cent had radiological evidence of cardiomegaly. Left ventricular failure occurred in 13 patients and carried a very poor prognosis. Unemployment in 95 men who survived 10 years was 32 per cent, half of whom had never returned to work following infarction, compared with a regional value of 7 per cent. We have shown that there is a prolonged and persistent mortality and morbidity in young survivors of myocardial infarction with a high level of male unemployment. Careful rehabilitation should reduce the economic loss to the community together with persuasive advice against cigarette smoking.

Variation in cephalometric reference lines.

The use of intracephalic reference lines in cephalometric assessment is valid only if these lines bear some constant relationship to the true horizontal and to each other. Otherwise, the use of a true horizontal would give the benefit that cephalometric assessment would be based on the same standards as clinical judgment. In using a true horizontal, however, the radiograph must be taken with the head in a reproducible natural posture. A study was carried out to assess the reproducibility of a natural head posture using a simple positioning method in a standard cephalostat, and to assess the variation in the relationship of the sella-nasion, Frankfort, maxillary and mandibular reference lines, to a true horizontal and to each other. Though in their mean inclinations the Frankfort and the maxillary reference lines were almost parallel to each other and to the true horizontal, the range of variation for all the reference lines was considerable. The range of variation in the reference lines was greater than the error of reproduction of head position, and the range of variation of the slope of the mandibular line was no greater than that for the slope of each of the other three lines. The sella-nasion line was reproduced more accurately that the other reference lines, using a digitizer. The possibilities of a simple cephalometric analysis based on a true horizontal are outlined.

Left ventricular function in diabetes mellitus. I: Methodology, and prevalence and spectrum of abnormalities.

Frequent abnormalities of left ventricular function were detected in 212 established diabetic patients using non-invasive techniques. Diabetics without angina or heart failure (n = 185) were significantly different from normal subjects (n = 50) in beat-to-beat variation, ratio of pre-ejection period to left ventricular ejection time, pre-ejection period index, isovolumic relaxation time, and interval from minimal dimension to mitral valve opening. Diabetics with angina (n = 18) were similar to control subjects with angina (n = 25); they showed a significant dimension change during the isovolumic period as compared with other diabetics and normals. Sixteen diabetics without angina also showed outward motion during the isovolumic period (incoordinate relaxation) and 13 had abnormal systolic time intervals. Four diabetics suffered a myocardial infarction during the study period; all had previously shown incoordination. Comparison of diabetics with a diastolic blood pressure below 100 mmHg and between 100 and 125 mmHg showed that the latter had a thicker posterior wall; the enlarged systolic dimension and reduced fractional shortening were the result of the inclusion of five of the 11 diabetic subjects with heart failure in the hypertensive group. Insulin-dependent diabetics tend to have more pronounced abnormalities of left ventricular function than those not requiring insulin. Patients selected from a diabetic clinic frequently have impaired left ventricular function, and ventricular hypertrophy, when present, in primarily caused by hypertension.

Discriminatory ability of caries diagnosis from bitewing radiographs in caries prophylactic trials.

The discriminatory ability of radiological criteria in common use in clinical trials was tested on 99 female teenagers selected from a larger sample taking part in a 3-year caries prophylactic clinical trial. Four radiological caries diagnostic criteria were selected as generally representative of those in current use following a comprehensive review of the literature. A significant preventive effect was evident from the radiographic examination after 3 years. At this time a significant difference between mean DFS increments was recorded when enamel lesions were omitted (P smaller than 0.05). Although preventive treatment effects were evident at all diagnostic levels, the discriminatory abilities differed. The criterion "involvement of amelodentinal junction but not beyond" was most discriminatory.