[Good oral care deserves to be better integrated into primary care]. / Goede mondzorg verdient een betere integratie in de eerstelijnszorg.

Oral and general health are inextricable. In primary care, the fields of care by general practioners, youth healthcare, healthcare for older people and oral care are all distinctly separated. Healthcare professionals are increasingly confronted with the complexity and increase in Noncommunicable diseases (NCD's) and an aging population. The aetiology of NCD's in primary care concern the professional fields of all healthcare professionals mentioned, meaning that lifestyle-related risks might be prevented more effectively through collaboration. In primary care, the number of medically compromised people is on the rise and healthcare professionals encounter each other's patients, whose risks remain invisible to them. Through collaboration such problems could be faced more effectively. Better integration of oral care into primary care can also contribute to the quality of care and safety of care receivers, and reduce further inequality. In order to better design this integration with the help of innovation, more practicebased research and implementation is needed.

[Series: Education and the dentist in 2025. Evidence-based clinical practice guidelines for an academic learning line 'quality and safety in oral care']. / Serie: Onderwijs en de tandarts anno 2025. Op bewijs gebaseerde praktijkrichtlijnen in de opleiding; voorstel tot een academische leerlijn 'kwaliteit en veiligheid van mondzorg'.

Education in the field of quality and safety in oral care still needs further development, both for students and teachers. Based on the current development of clinical practice guidelines in the field of oral care in the Netherlands, this article describes a proposal for implementing this as a 'quality of oral care' learning line in the dental school curricula. Within clinical educational practice and scientific training, students should become familiar with the development, assessment and application of clinical practice guidelines. Some proposals for embedding this new learning line in the curriculum are given. In order to further shape the learning line, close cooperation between the three dental schools and the Kennisinstituut Mondzorg (Institute for Knowledge Translation in Oral Care) in the Netherlands is recommended.

[Evidence-based clinical oral healthcare guidelines 4. Adherence requires an implementation strategy]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 4. Toepassing vergt een implementatiestrategie.

Adherence to clinical guidelines requires support in practice. However, systematic implementation of evidence-based guidelines is not common practice in oral healthcare. The Knowledge Institute Oral Care (KiMo) offers the opportunity to take into account potential barriers and facilitators during the development of evidence-based clinical practice guidelines. These factors which are relevant to the guideline and the oral healthcare practice provide the ingredients for a tailor-made programme of implementation that has a scientific basis. Elements of any implementation programme are the quality indicators derived from the oral healthcare guidelines. These indicators should fit, on the one hand, the specific goals of the guidelines (patient safety, effectiveness, efficiency, patient-centred, timeliness, accessibility) and, onthe other hand, the various perspectives of the different stakeholders, such as patients, caregivers, health insurers and inspectorate. These quality indicators provide information on adherence to the guidelines, the results of a certain treatment and the success of the implementation strategy, all with the aim to improve the quality of oral healthcare.

[Evidence-based clinical practice guidelines in oral care 2: process and content of evidence-based guideline development]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 2. Proces en inhoud van evidencebased richtlijnontwikkeling.

In 2014, an advisory report was published by a national working committee concerning how the current, applied method of evidence-based guideline development in healthcare can be used in oral care in a national guideline programme. In an independent Institute of Knowledge Translation in Oral Care, as yet to be established, primary and secondary oral care providers will participate in the programme in order to improve the quality of oral care in the Netherlands. With the launching of the Institute of Knowledge Translation in Oral Care, clinical guideline development will have the benefit of a structural approach, in which 3 successive steps can be distinguished: preparation, development and authorisation. In each of these steps, oral care providers and associations will be actively involved. In this way the aim is to give as much consideration as possible to the needs of those in the field of oral care in the choice of topics for guideline development and to secure the specific character of oral care in the actual establishment of guidelines for clinical practice.

[Evidence-based clinical practice guidelines (CPGs) in oral care 1. Societal-, professional- and care-related perspective]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 1. Maatschappelijk, professioneel en zorginhoudelijk perspectief.

Some decades ago the need for clinical decision-making based on the best available evidence, and in that way providing accountability for professional services to society, was emerging in health care. The main purpose was to translate innovative knowledge from reliable resources into clinical practice to prevent inappropriate and unsafe care. In oral care it is also diserable to carry out improvements and to make treatment decisions more transparent. Evidence-based decision-making is not self-evident, and the development and the use of evidence-based clinical practice guidelines are in their infancy. Recently, national agreement has been reached among professional associations, scientific societies and educational institutions regarding the content of a national structure for the development of evidence-based guidelines within an independent institute for knowledge translation (KiMo).

[The preprosthetic treatment focusing on single- or multi-unit fixed dental prostheses]. / De voorbereidende behandeling voor een behandeling met kronen en bruggen.

The preprosthetic treatment is a phase of the so-called patient-centred oral healthcare cycle. The goal of the preprosthetic treatment is the elimination of pathological conditions and of uncertainties and risks to the greatest extent possible. Teeth in a reduced occlusal system can be distinguished functionally as strategic, non-strategic, and undesirable. The most important objective of the preprosthetic treatment is to establish a positive prognosis for the strategic teeth. Specific aspects relevant to the preprosthetic treatment are: referral to a specialist, requesting a second opinion, inserting 1 or more oral implants, transitional treatments, and occlusal adjustments. Subsequently, the preprosthetic treatment is evaluated to assess whether healthy circumstances have been established for the intended treatment with single- or multi-unit fixed dental prostheses.

[The integration of science in the clinical dental programme at the University of Nijmegen]. / Integratie van wetenschap in de kliniek van de Nijmeegse opleiding tandheelkunde.

To be able to make a well founded clinical decision on the basis of evidence, the concept of 'evidence based practice' offers a solution by making it possible to select the appropriate knowledge from the increasing amount of scientific clinical information. Competence is required to put the concept (combining the best available scientific clinical evidence, experience and skills of the dentist and preferences of the patient) into practice. To prepare the undergraduate student for future clinical practice, the Nijmegen dental school has adopted evidence based practice to be implemented from the first year of dental training. The experiences of both students and lecturers are modest. The probable reason is that many clinical decisions are (can be) taken on the basis of experience and routine. The challenge is to base life-long learning on the practice of evidence based dentistry.

[Patient safety in general dental practice 2009]. / Patiëntveiligheid in tandartspraktijken in 2009.

In recent years various studies have been published which indicate that adverse events in health care facilities are the result of structural factors. In 2009 a national study was carried out in the Netherlands to gain insight into patient safety in primary care settings, including general dental practices. In 20 randomly selected practices, patient records were investigated and oral care professionals reported, during a period of 2 weeks, adverse events which occurred. For each practice, 2 researchers screened, with the help of a checklist, 50 randomly selected patient records covering a period of 1 year. A total of 8 preventable adverse events were found in the 1000 patient records (0.8%). Anonymous reports made during the 2 weeks of the research period resulted in 7 adverse events. Practically all of the adverse events had to do with diagnostics and treatment and resulted in limited harmful consequences for patients. On the basis of these results, oral care in general dental practice would appear to be safe, but the concept 'patient safety' is not at all or only minimally active among general dental practitioners. Regarding patient safety performance, improvement in the quality of record-keeping would be desirable.

Impact of guideline implementation on patient care: a cluster RCT.

In Western European countries, dentists use standardized procedures, rather than individualized risk assessment, for routine oral examinations. The predictive hypothesis was that guideline implementation strategies based on multifaceted interventions would be more effective in patient care than the dissemination of guidelines only. A cluster-randomized trial was conducted, with groups of general dental practitioners (GDPs) as the unit of randomization. Patients were clustered within practices and prospectively enrolled in the trial. Patient data were collected from registration forms. The primary outcome measure was guideline-adherent recall assignment, and a secondary outcome measure was guideline-adherent bitewing frequency. The interventions consisted of online training, guideline dissemination, and educational sessions. For low-risk patients, guideline-adherent recall increased in the intervention group (+8%), which differed from the control group (-6.1%) (p = 0.01). Guideline-adherent bitewings showed mixed results. We conclude that multifaceted intervention had a moderate but relevant effect on the performance of GDPs, which is consistent with other findings in primary care.

[The role of guidelines and systematic reviews in oral healthcare]. / De rol van richtlijnen en systematische literatuuroverzichten in de tandheelkundige zorgverlening.

Clinical practice guidelines are a very appropriate means of keeping up to date, effectively and efficiently, with knowledge on a specific clinical topic. These are a compilation of clinical expertise retrieved from daily practice, scientific evidence derived from journals and the opinions of patients, which together form the core of the treasury of ideas of evidence-based dentistry. The development of clinical practice guidelines should be carried out according to a strictly defined procedure. In this procedure systematic reviews of literature should be used. The Cochrane Collaboration is an organization that develops reliable systematic reviews. Clinical practice guidelines are an essential part of evidence-based dentistry. The evidence-based approach should be fully integrated in dental education and in daily dental practice. The establishment of a national centre for evidence-based development and implementation of dental clinical practice guidelines, in cooperation with other healthcare professionals, should have the highest priority, in order to maintain the quality of oral healthcare in professional hands.

Dental check-up frequency: preferences of Dutch patients.

OBJECTIVE: In 1995, the requirement to visit the dentist for a check-up every six months in The Netherlands was replaced by the obligation to get a routine examination no more than once a year. The aim of this study was to determine patients' opinions about this change in policy, and to assess their preferences regarding frequency and content of regular dental check-up visits. Possible associations between patients' preferences for regular dental check-ups and a number of antecedent variables, such as dental attitudes, were examined as well. BASIC RESEARCH DESIGN: Patients' preferences for regular dental check-ups were assessed by means of a questionnaire, containing a 19-item Likert-type scale, twelve visual analogue scales and seven forced choice items. Items assessing various background variables and a selection of items of the Dental Attitude Questionnaire were also added. This questionnaire was administered to patients of seven dental practices. A total of 428 patients completed the questionnaire. RESULTS: Results indicated that patients prefer to have regular dental check-ups. Patients' evaluation of six-monthly dental check-up visits was significantly more positive than their evaluation of flexible, individualized, check-up frequencies. Factors positively associated with a higher preference for regular dental check-up visits were female gender, being more satisfied with one's teeth, less cynicism toward dental health care professionals and more intrinsic motivation to maintain one's oral health. CONCLUSIONS: Patients seem to prefer to attend their dentist regularly, at fixed intervals of about six months. This fact should be taken into account when deciding about the most appropriate interval between dental examinations.

Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults.

BACKGROUND: The prophylactic removal of asymptomatic impacted wisdom teeth is defined as the (surgical) removal of wisdom teeth in the absence of local disease. Impacted wisdom teeth have been associated with pathological changes, such as inflammation of the gums around the tooth, root resorption, gums- and alveolar bone disease, damage of the adjacent teeth, the development of cysts and tumours. Several other reasons to justify prophylactic removal have also been given. Wisdom teeth do not always fulfil a functional role in the mouth. When surgical removal is carried out in older patients the risk of more postoperative complications, pain and discomfort increases. Nevertheless, in most developed countries the prophylactic removal of trouble-free wisdom teeth, either impacted or fully erupted, has long been considered as 'appropriate care'. Prudent decision-making, with adherence to specified indicators for removal, may reduce the number of surgical procedures by 60% or more. It has been suggested that watchful monitoring of asymptomatic wisdom teeth may be an appropriate strategy. OBJECTIVES: To evaluate the effect of prophylactic removal of asymptomatic impacted wisdom teeth in adolescents and adults compared with the retention of these wisdom teeth. SEARCH STRATEGY: The following electronic databases were searched:The Cochrane Oral Health Group Trials Register (4 August 2004), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 4 August 2004), PubMed (1966 to 4 August 2004), EMBASE (1974 to 4 August 2004). There was no restriction on language. Key journals were handsearched. An attempt was made to identify ongoing and unpublished trials. SELECTION CRITERIA: All randomised or controlled clinical trials (RCTs/CCTs) comparing the effect of prophylactic removal of asymptomatic impacted wisdom teeth with no-treatment (retention). DATA COLLECTION AND ANALYSIS: Assessment of relevance, validity and data extraction were conducted in duplicate and independently by three reviewers. Where uncertainty existed, authors were contacted for additional information about randomisation and withdrawals. A quality assessment of the trials was carried out. MAIN RESULTS: Only three trials were identified that satisfied the review selection criteria. Two were completed RCTs and both assessed the influence of prophylactic removal on late incisor crowding in adolescents. One ongoing RCT was identified, but the researchers were unable to provide any data. They intend to publish in the near future and information received will be included in updates. Although both completed trials met the inclusion criteria of the review, regarding participants characteristics, interventions and outcomes assessed, different outcomes measures were assessed which prevented pooling of data. AUTHORS' CONCLUSIONS: No evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults. There is some reliable evidence that suggests that the prophylactic removal of asymptomatic impacted wisdom teeth in adolescents neither reduces nor prevents late incisor crowding.

[The routine oral examination in The Netherlands. An orientation from the perspective of general dental practitioners]. / Het periodiek tandheelkundig controleonderzoek in Nederland. Een oriëntatie vanuit het tandartsperspectief.

In The Netherlands the routine oral examination (ROE) can be characterized as an important tool in dental care. As a result of the changing prevalence of oral diseases of the Dutch population the content of the routine oral examination has changed over time. A representative survey among general dental practitioners has been carried out to investigate the professional performance in the routine oral examination. Participants consisted of a random, stratified sample of 619 dentists, of whom 521 (85%) responded. The Dutch general dental practitioners use the routine oral examination mainly for detecting dental caries and to asses the status of the restorations. About 50% of the responders use a standard recall interval for all patients whereas the other half takes individual patient factors into consideration when determining the recall interval. Both groups differ significantly on the variables: 'time spend on the routine oral examination', 'the amount of diagnostic activities', 'the registration in patient dental records' and 'the frequency of using bitewing radiographs'. In the perspective of quality of dental care a national reconsideration of the routine oral examination by professionals and patients is advocated. The instrument of choice would be the use of evidence-based clinical practice guideline development procedures.

[Routine dental examination as evaluation tool in clinical cariology]. / Het periodiek tandheelkundig controleonderzoek als evaluatie-instrument in de klinische cariologie.

As a result of the caries prevalence of the Dutch population the character of the routine dental examination is changing. Caries screening remains relevant for high caries risk individuals but the interpretation of early caries lesions deserves more attention, especially the assessment of progression of caries lesions in time. Diagnosis of caries by dental practitioners in the Netherlands mainly consists of visual inspection in combination with bitewing radiography and both methods play an important role in the timing of bitewing radiographs and forthcoming recall visits for oral health examination. The content and frequency of the routine dental examination are discussed in relation to the individual risk prediction as relevant aspects of quality of dental care in the Netherlands.

[Topics in clinical dentistry. Trends in the Dutch dental literature]. / Onderwerpen in de klinische tandheelkunde. Trends in de Nederlandstalige tandheelkundige literatuur.

Aim of the study was to evaluate a method for selecting topics suitable for developing dental clinical practice guidelines in the Netherlands, based on an analysis of Dutch dental journals. A search for dental clinical topics was conducted by analysing Dutch dental journals, magazines and series over the period 1992-1997. The numbers of publications per topic were plotted against the publication years. The number of publications as well as the value of the slope of the linear regression were considered to be indicators of the importance of a topic. 'Dental implants (indication)' had the highest number of publications, followed by 'orthodontic treatment planning' and 'periodontology (indication)'. The topic 'practice hygiene' showed the highest value of the slope of the linear regression, followed by 'TMJ dysfunction' and 'dental implants (indication)'. With this method, it is feasible to detect changes and tendencies in the Dutch dental literature. It permits a selection of clinically relevant topics over a time span. It was concluded that this method may be very useful in the selection of a topic, but should probably be combined with other methods.