Resective Treatment of Peri-implantitis: Clinical and Radiographic Outcomes After 2 Years.

A prospective case series was performed to examine the clinical and radiographic changes to peri-implant tissues 2 years after resective treatment of peri-implantitis, including an apically positioned flap, osteoplasty, and implantoplasty. In total, 25 patients with 40 titanium implants of multiple brands and advanced peri-implantitis were included in this study. After 2 years, all implants survived, mean probing pocket depth was reduced from 8.7 to 3.3 mm, and bone level remained stable in 92.5% of the implants. Findings suggest the approach of an apically positioned flap combined with osteoplasty and implantoplasty as an effective and reliable strategy against peri-implantitis, although increased gingival recessions may limit its application in esthetic areas.

Integrating community service learning in undergraduate dental education: A controlled trial in a residential facility for people with intellectual disabilities.

AIMS: The present report describes an oral health promotion project in a residential facility for people with intellectual disabilities as a strategy to implement community service learning in undergraduate dental education. METHODS AND RESULTS: Two undergraduate students developed a project aimed to improve the oral health in residents with intellectual disabilities by educating caregivers. The impact was investigated by a pretest-posttest design, evaluating residents' plaque and gingival indexes and caregivers' knowledge, behavior, attitude, and self-efficacy. Findings demonstrated that within a semester, it was possible for students to obtain a limited but positive impact on the local community. DISCUSSION AND CONCLUSION: Based on the experiences at Ghent University, the following guidelines were suggested to implement service learning in a dental curriculum that renders both a positive impact on student learning and the local community : (1) integrate community service learning in multiple years in the curriculum; (2) use a stepwise approach from theory to exercises to extramural experiences; (3) create a partnership with a local organization; (4) organize long-term projects and annual follow-up to increase the impact; (5) involve supervisors from both the university and the local organization; and (6) establish an evidence based approach to benefit the quality of projects and to facilitate students to develop research competences.

Assessment of periodontal bone level revisited: a controlled study on the diagnostic accuracy of clinical evaluation methods and intra-oral radiography.

OBJECTIVES: The accuracy of analogue and especially digital intra-oral radiography in assessing interdental bone level needs further documentation. The aim of this study was to compare clinical and radiographic bone level assessment to intra-surgical bone level registration (1) and to identify the clinical variables rendering interdental bone level assessment inaccurate (2). MATERIALS AND METHODS: The study sample included 49 interdental sites in 17 periodontitis patients. Evaluation methods included vertical relative probing attachment level (RAL-V), analogue and digital intra-oral radiography and bone sounding without and with flap elevation. The latter was considered the true bone level. Five examiners evaluated all radiographs. RESULTS: Significant underestimation of the true bone level was observed for all evaluation methods pointing to 2.7 mm on average for analogue radiography, 2.5 mm for digital radiography, 1.8 mm for RAL-V and 0.6 mm for bone sounding without flap elevation (p < 0.001). Radiographic underestimation of the true bone level was higher in the (pre)molar region (p ≤ 0.047) and increased with defect depth (p < 0.001). Variation between clinicians was huge (range analogue radiography 2.2-3.2 mm; range digital radiography 2.1-3.0 mm). CONCLUSION: All evaluation methods significantly underestimated the true bone level. Bone sounding was most accurate, whereas intra-oral radiographs were least accurate. Deep periodontal defects in the (pre)molar region were most underrated by intra-oral radiography. CLINICAL RELEVANCE: Bone sounding had the highest accuracy in assessing interdental bone level.

Intraoral radiography lacks accuracy for the assessment of peri-implant bone level - a controlled clinical study.

PURPOSE: The aim of this study was to compare clinical and radiographic bone level assessments to intra-surgical bone level registration around implants with peri-implantitis and to identify the clinical variables rendering peri-implant bone level assessment accuracy. MATERIALS AND METHODS: The study sample included 50 implants with peri-implantitis in 23 patients. Registration methods included probing of the vertical distance between the implant/abutment interface and the bottom of the pocket (= VPD), intraoral radiography, bone sounding without flap elevation and intra-surgically assessed interproximal bone level. The latter was considered the true bone level (gold standard). Twenty clinicians evaluated all radiographs. RESULTS: VPD and intraoral radiography resulted in a significant underestimation of the true bone level by 1.0 mm (95% CI: 0.495-1.585; P < 0.001) and 2.3 mm (95% CI: 1.650-2.980; P < 0.013) respectively. Bone sounding without flap elevation did not differ significantly from the true bone level (mean difference 0.2 mm; 95% CI: -0.775 - 0.335; P = 0.429). Duplicate magnification registration of 50 implants resulted in excellent intra- and inter-rater reliability (ICC intra ≤ 0.99; ICC inter = 0.964; P < 0.001). Radiographic underestimation was significantly affected by defect depth (P < 0.001). Variation among clinicians was substantial (mean underestimation range 1.1 mm to 3.8 mm); however, clinical experience had no impact on radiographic underestimation (P = 0.796). CONCLUSIONS: Bone sounding without flap elevation was the best predictor of peri-implant bone level, whereas intraoral radiography was the most inferior. Consequently, peri-implantitis may be under-diagnosed if examination is only based on radiographs. Conflict-of-interest statement: Prof Hugo De Bruyn is associated with education and research collaboration agreements with Dentsply Sirona and Southern Implants, on behalf of Ghent University. Prof Cosyn has a collaboration agreement with Nobel Biocare. All other authors declare that they have no conflict of interest.

Competence profiles in undergraduate dental education: a comparison between theory and reality.

BACKGROUND: Competence profiles are purposed to provide a blueprint in support to develop and/or benchmark the learning outcomes of undergraduate dental curricula. This study aims to investigate whether a competence profile as proposed by academic- and clinical experts is able to represent the real clinical reality. METHODS: A questionnaire was developed including questions about gender and age, perception about required competences, and educational organisation and was distributed among Flemish dentists via email and on paper during a symposium. The data was analysed using descriptive statistics, Chi-square and non-parametric Mann-Whitney U-tests. RESULTS: A total of 312 questionnaires were completed (=6.5% of dentist population, with similar gender and age characteristics). All competences in the European competence profile were rated between 7.2 and 9.4 on a 10-point scale. In dentists under 50 years, females rated the importance of identifying/managing anxiety and abnormal patient behaviour; and promoting/improving oral health as significantly higher than males. In dentists of 50 years and above, females rated 8 competences significantly higher than males, including obtaining/recording a complete history; identifying/managing anxiety and abnormal patient behaviour; obtaining/interpreting radiography; identifying temporomandibular and associated disorders; identifying orthodontic needs; awareness of own limitations/when to refer; managing dental urgencies; and basic-life-support/defibrillation. Clinical practice management was most frequently reported as additional competence to address in dental education. Furthermore, the respondents suggested an undergraduate dental curriculum based on 34% theoretical education, 26% preclinical skills training, and 40% clinical education and 86% agreed with a duration of 5 years. Finally, the respondents also illustrated the dynamic nature of dentistry including a reduction of amalgam fillings, a shift from individual practice to group practices, an increased administrative load, and more assertive patients. CONCLUSION: Findings in the present study suggest the validation of the proposed competences for graduating European dentists within the clinical reality of dental professionals in daily practice. Nevertheless, the results have also demonstrated heterogeneity regarding gender and age within the dentist population and emphasised a continuously evolving dental profession and required competences. Hence, to maintain high quality of dental care, a strategy should be developed in which dental curricula are continuously benchmarked against an evolving clinical reality.

Attitude of dental hygienists, general practitioners and periodontists towards preventive oral care: an exploratory study.

INTRODUCTION: Promoting oral hygiene and stimulating patient's responsibility for his/her personal health remain challenging objectives. The presence of dental hygienists has led to delegation of preventive tasks. However, in some countries, such as Belgium, this profession is not yet legalized. The aim of this exploratory study was to compare the attitude towards oral-hygiene instructions and patient motivational actions by dental hygienists and by general practitioners/periodontists in a context without dental hygienists. MATERIALS AND METHODS: A questionnaire on demographics (six items), oral-hygiene instructions (eight items) and patient motivational actions (six items) was distributed to 241 Dutch dental hygienists, 692 general practitioners and 32 periodontists in Flanders/Belgium. Statistical analysis included Fisher's exact-test, Pearson's chi-square test and multiple (multinomial) logistic regression analysis to observe the influence of profession, age, workload, practice area and chair-assistance. RESULTS: Significant variance was found between general practitioners and dental hygienists (in 13 of 14 items), between general practitioners and periodontists (in nine of 14 items) and between dental hygienists and periodontists (in five of 14 items). In addition to qualification, chair-assistance was also identified as affecting the attitude towards preventive oral care. CONCLUSION: The present study identified divergence in the application of, and experienced barriers and opinions about, oral-hygiene instructions and patient motivational actions between dental hygienists and general practitioners/periodontists in a context without dental hygienists. In response to the barriers reported it is suggested that preventive oriented care may benefit from the deployment of dental hygienists to increase access to qualified preventive oral care.

Facilitating Dental Student Reflections: Using Mentor Groups to Discuss Clinical Experiences and Personal Development.

Despite the consensus on the importance of reflection for dental professionals, a lack of understanding remains about how students and clinicians should develop their ability to reflect. The aim of this study was to investigate dental students' and mentors' perceptions of mentor groups as an instructional method to facilitate students' reflection in terms of the strategy's learning potential, role of the mentor, group dynamics, and feasibility. At Ghent University in Belgium, third- and fourth-year dental students were encouraged to reflect on their clinical experiences and personal development in three reflective mentor sessions. No preparation or reports afterwards were required; students needed only to participate in the sessions. Sessions were guided by trained mentors to establish a safe environment, frame clinical discussions, and stimulate reflection. Students' and mentors' perceptions of the experience were assessed with a 17-statement questionnaire with response options on a five-point Likert scale (1=totally disagree to 5=totally agree). A total of 50 students and eight mentors completed the questionnaire (response rates 81% and 89%, respectively). Both students and mentors had neutral to positive perceptions concerning the learning potential, role of the mentor, group dynamics, and feasibility. The mean ideal total time for sessions in a year was 99 minutes (third-year students), 111 minutes (fourth-year students), and 147 minutes (mentors). Reported reflective topics related to patient management, frustrations, and practice of dentistry. Overall mean appreciation for the experience ranged from 14.50 to 15.14 on the 20-point scale. These findings about students' and mentors' positive perceptions of the experience suggest that mentor groups may be a potentially valuable strategy to promote dental students' reflection.

Using clinical cases to stimulate active learning in a short periodontal continuing professional development course.

A case-based approach was used in a two-day periodontal continuing professional development course as a strategy to stimulate active learning. The present study investigates the outcome of this course format in terms of feasibility, perceived efficiency as a learning approach and reported individual learning goals. The study was performed in five identical courses entitled'risk analysis and treatment in periodontal patients'at Malmö University between 2011-2014. Before the course, clinical cases were used to activate participants' prior knowledge and to attune their focus on the course content. During the course, cases were discussed to synchronise theory with practical application. A pre- and end-course questionnaire were developed to evaluate participants' characteristics (age, clinical expertise, experience and expectations), perceptions on feasibility and instructiveness and emerged individual learning goals. The participants (39 dentists and 78 dental hygienists) reported an average preparation time of 62 minutes (range 2-190) and had positive perceptions on the accessibility, instructiveness and difficulty of cases. Expectations ranged between refreshing, acquiring new knowledge and mastering the course subject. Most reported learning goals were related to daily clinical practice including the development of a treatment plan, when to continue non-surgical treatment or to extract teeth/perform surgery, the approach to periodontitis, how to motivate non-compliant patients and when to refer. Conclusion: The use of clinical cases to stimulate active learning in a short-term continuing professional development periodontal course was positively perceived by the dentists and dental hygienists in terms of feasibility and learning potential.

"Should I prioritize medical problem solving or attentive listening?": the dilemmas and challenges that medical students experience when learning to conduct consultations.

OBJECTIVE: Communication skills can be trained alongside clinical reasoning, history taking or clinical examination skills. This is advocated as a solution to the low transfer of communication skills. Still, students have to integrate the knowledge/skills acquired during different curriculum parts in patient consultations at some point. How do medical students experience these integrated consultations within a simulated environment and in real practice when dealing with responsibility? METHODS: Six focus groups were conducted with (pre-)/clerkship students. RESULTS: Students were motivated to practice integrated consultations with simulated patients and felt like 'real physicians'. However, their focus on medical problem solving drew attention away from improving their communication skills. Responsibility for real patients triggered students' identity development. This identity formation guided the development of an own consultation style, a process that was hampered by conflicting demands of role models. CONCLUSION: Practicing complete consultations results in the dilemma of prioritizing medical problem solving above attention for patient communication. Integrated consultation training advances this dilemma to the pre-clerkship period. During clerkships this dilemma is heightened because real patients trigger empathy and responsibility, which invites students to define their role as doctor. PRACTICE IMPLICATIONS: When training integrated consultations, educators should pay attention to students' learning priorities and support the development of students' professional identity.

Exploring the relation between online case-based discussions and learning outcomes in dental education.

Online case-based discussions, parallel to theoretical dental education, have been highly valued by students and supervisors. This study investigated the relation between variables of online group discussions and learning outcomes. At Ghent University in Belgium, undergraduate dental students (years two and three) are required to participate in online case-based discussion groups (five students/group) in conjunction with two theoretical courses on basic periodontics and related therapy. Each week, a patient case is discussed under supervision of a periodontist, who authored the case and performed the treatment. Each case includes treatment history and demand, intra- and extraoral images, and full diagnostic information with periodontal and radiographic status. For this retrospective study, data were obtained for all 252 students in forty-three discussion groups between 2009 and 2012. Spearman's rank correlations were calculated to investigate the relation among group dynamics (number of group posts and views), individual student contributions (number of individual posts, newly introduced elements, questions, and reactions to other posts), supervisors' interventions (number of posts and posed questions), and learning outcomes (examination result). The results showed that learning outcomes were significantly related to the number of student posts (Spearman's rho (ρ)=0.19), newly introduced elements (ρ=0.21), reactions to other posts (ρ=0.14), number of supervisors' interventions (ρ=0.12), and supervisors' questions (ρ=0.20). These results suggest that individual student contributions during online case-based discussions and the provided supervision were related to learning outcomes.

A novel Medical Achievement Self-efficacy Scale (MASS): a valid and reliable tool.

In search for an instrument to measure overall curriculum impact, we developed a Medical Achievement Self-efficacy Scale (MASS) and presented it to medical students enrolled in the different years of the integrated Ghent curriculum. The research aim was to study the validity and reliability of this new scale. MASS items were constructed based on the end terms of the Ghent curriculum, as it is related to the general competency frameworks of CanMEDs and the Five-star Doctor. The scale includes at least two items for each CanMEDS competency domain. Items were examined by seven experts in view of content and face validity. This resulted in an MASS version, containing 18 items, to be rated on a five-point Likert scale. This version was piloted on 94 undergraduate medical students enrolled at the Catholic University of Leuven. The final version was presented to 1066 undergraduate medical students enrolled at Ghent University. Reliability of the MASS scale was high (α=0.89). As expected, self-efficacy scores increased significantly over the years (F=39.11, p<0.001). In view of determining predictive validity, regression analysis was carried out to predict students' academic achievement from self-efficacy scores. As expected, MASS scores significantly predicted Maastricht Progress Test scores (F=108.18, p<0.001).

Does reflection have an effect upon case-solving abilities of undergraduate medical students?

BACKGROUND: Reflection on professional experience is increasingly accepted as a critical attribute for health care practice; however, evidence that it has a positive impact on performance remains scarce. This study investigated whether, after allowing for the effects of knowledge and consultation skills, reflection had an independent effect on students' ability to solve problem cases. METHODS: Data was collected from 362 undergraduate medical students at Ghent University solving video cases and reflected on the experience of doing so. For knowledge and consultation skills results on a progress test and a course teaching consultation skills were used respectively. Stepwise multiple linear regression analysis was used to test the relationship between the quality of case-solving (dependent variable) and reflection skills, knowledge, and consultation skills (dependent variables). RESULTS: Only students with data on all variables available (n = 270) were included for analysis. The model was significant (Anova F(3,269) = 11.00, p < 0.001, adjusted R square 0.10) with all variables significantly contributing. CONCLUSION: Medical students' reflection had a small but significant effect on case-solving, which supports reflection as an attribute for performance. These findings suggest that it would be worthwhile testing the effect of reflection skills training on clinical competence.

Impact of three alternative consultation training formats on self-efficacy and consultation skills of medical students.

BACKGROUND: Conducting a consultation is a core competence of medical professionals. Consultation training of medical students centers on clinical, communication, reasoning and reflection skills. The training incorporates practice with a standardized simulated patient and supervising physician, to prepare for real patient encounters. To meet the request for more training, while dealing with an increasing student population and limited staff availability, alternative formats of consultation training were developed and evaluated. AIM: To investigate the impact of three consultation training formats on students' self-efficacy beliefs and their consultation skills acquisition. The three formats comprised (1) traditional training with supervising physician, (2) autonomous training with feedback from simulated patients and peers, without direct supervision and (3) online training based on video fragments and answering guiding questions. METHODS: A quasi-experimental pre/posttest study was set up, with random assignment of students to a training condition. The differential impact was tested on two dependent measures: self-efficacy and consultation performance. Self-efficacy was tested with a nine-item scale and the cognitive component of consultation performance was tested on the base of responses to a standardized video case. RESULTS: The autonomous training has a significant positive effect on students' self-efficacy (p=0.016). The traditional training and the online training did only positively influence the cognitive component of the consultation competence (p<0.001 and p=0.003). CONCLUSIONS: Each consultation training contributes to the learning process in a different way. In order to achieve optimum learning effects, medical educators should be aware of the particular impact of specific trainings on the cognitive and motivational side of skills and pursue a balanced mixture of instructional formats.

Using video-cases to assess student reflection: development and validation of an instrument.

BACKGROUND: Reflection is a meta-cognitive process, characterized by: 1. Awareness of self and the situation; 2. Critical analysis and understanding of both self and the situation; 3. Development of new perspectives to inform future actions. Assessors can only access reflections indirectly through learners' verbal and/or written expressions. Being privy to the situation that triggered reflection could place reflective materials into context. Video-cases make that possible and, coupled with a scoring rubric, offer a reliable way of assessing reflection. METHODS: Fourth and fifth year undergraduate medical students were shown two interactive video-cases and asked to reflect on this experience, guided by six standard questions. The quality of students' reflections were scored using a specially developed Student Assessment of Reflection Scoring rubric (StARS®). Reflection scores were analyzed concerning interrater reliability and ability to discriminate between students. Further, the intra-rater reliability and case specificity were estimated by means of a generalizability study with rating and case scenario as facets. RESULTS: Reflection scores of 270 students ranged widely and interrater reliability was acceptable (Krippendorff's alpha = 0.88). The generalizability study suggested 3 or 4 cases were needed to obtain reliable ratings from 4th year students and ≥ 6 cases from 5th year students. CONCLUSION: Use of StARS® to assess student reflections triggered by standardized video-cases had acceptable discriminative ability and reliability. We offer this practical method for assessing reflection summatively, and providing formative feedback in training situations.

Factors confounding the assessment of reflection: a critical review.

BACKGROUND: Reflection on experience is an increasingly critical part of professional development and lifelong learning. There is, however, continuing uncertainty about how best to put principle into practice, particularly as regards assessment. This article explores those uncertainties in order to find practical ways of assessing reflection. DISCUSSION: We critically review four problems: 1. Inconsistent definitions of reflection; 2. Lack of standards to determine (in)adequate reflection; 3. Factors that complicate assessment; 4. Internal and external contextual factors affecting the assessment of reflection. SUMMARY: To address the problem of inconsistency, we identified processes that were common to a number of widely quoted theories and synthesised a model, which yielded six indicators that could be used in assessment instruments. We arrived at the conclusion that, until further progress has been made in defining standards, assessment must depend on developing and communicating local consensus between stakeholders (students, practitioners, teachers, supervisors, curriculum developers) about what is expected in exercises and formal tests. Major factors that complicate assessment are the subjective nature of reflection's content and the dependency on descriptions by persons being assessed about their reflection process, without any objective means of verification. To counter these validity threats, we suggest that assessment should focus on generic process skills rather than the subjective content of reflection and where possible to consider objective information about the triggering situation to verify described reflections. Finally, internal and external contextual factors such as motivation, instruction, character of assessment (formative or summative) and the ability of individual learning environments to stimulate reflection should be considered.