Continuing dental care for Highlands elderly: current practice and attitudes of dental practitioners and home supervisors.

OBJECTIVE: To investigate current practice and attitudes of Highland dentists and home supervisors to continued dental care of elderly residents. METHODS: A cross-sectional questionnaire was designed to survey the current practice and attitudes of Highland dentists and residential care supervisors in their provision of dental care for the elderly at home and in long stay accommodation. RESULTS: The response rate was 94% of dentists and 79% of homes. Despite 86% of dentists providing domiciliary care and 93% of homes transport to a surgery, no more than a quarter of residents had had contact with a dentist in the previous year. The distribution of residents varied with dependant individuals living in nursing units and the least dependant in residential homes. Only 1% of all residents were totally bed bound. Domiciliary patients were less likely to receive continuing care compared with those seen in a surgery and 75% of homes had to initiate dental care. In terms of patient referral, the majority of GDPs would refer uncooperative patients, salaried dentists would refer those with complex medical histories and community dentists would refer those requiring complex treatments. A dental assessment was undertaken in 46% of homes and 81% of these kept a record of dental care. CONCLUSION: This study highlights the need for a co-ordinated, seamless continuing dental care service, tailored to the actual needs of the elderly individuals it is designed to serve, particularly in a remote and rural area.

Selection for vocational/general professional training--the Dundee undergraduate experience.

Vocational training has been mandatory within the dental profession since 1993 but, despite this, there is continued disquiet surrounding the application process. This paper collates and summarizes the experiences of applicants from one dental school, to inform debate and assist in the continued evolution of the process of application for vocational training.

The Structured Clinical Operative Test (SCOT) in dental competency assessment.

INTRODUCTION: This paper describes a method of assessment of invasive clinical procedures which are currently being devised, and which are perceived to be a method that may be used to complement OSCEs in overall clinical skills assessment. OBJECTIVE: The objective of the Structured Clinical Operative Tests (SCOT) is to introduce a greater level of objectivity to the assessment of operative clinical skills. Invasive or irreversible clinical operative procedures from a large part of dental undergraduate training and are by their very nature precluded from OSCE scenarios. It is also important to test intraoperative skills, communication skills and contingency management, and performance of these with awareness of the psychosocial context and ethical framework. The paper describes the use of checklists in the monitoring of clinical operative skills in a more authentic clinical situation using the SCOT. FORMATIVE ASSESSMENT: Continuous assessment should a) record achievement of competency in as objective a manner as possible and b) should encourage continuous self-evaluation. In the SCOT the students reflect on their clinical performance and in consultation with their supervisors record their plans to improve their competence in that skill or procedure in the future. This is done immediately on completion of a clinical task while the experience is still fresh in the mind. This encourages deep reflective learning as opposed to superficial factual learning which is characteristic of the more traditional curriculum, and is described as supervisor validated self-assessment. DISCUSSION: The discussion outlines how SCOTs can be practically implemented and integrated into the undergraduate curriculum and an example of a SCOT is appended to the paper. The scope for using SCOTs in postgraduate assessment such as in VT/GPT is also described.

Scope of the OSCE in the assessment of clinical skills in dentistry.

INTRODUCTION: The objective structured clinical examination (OSCE) is now an accepted tool in the assessment of clinical skills in dentistry. There are however no strict or limiting guidelines on the types of scenario that are used in the OSCE examinations and experience and experimentation will inevitably result in the refinement of the OSCE as a tool for assessment. AIM: The aim of this study was to compare and contrast different types of clinical operative skills scenarios in multi-station OSCE examinations. METHODOLOGY: Student feedback was obtained immediately after the sitting of an OSCE examination on two different occasions (and two different cohorts of students). The same questionnaire was used to elicit the responses. RESULTS: The questionnaire feedback was analysed qualitatively with particular regard to student perception of the usefulness and validity of the two different kinds of OSCE scenarios. CONCLUSIONS: OSCE scenarios which involve phantom heads are perceived to lack clinical authenticity, and are inappropriate for the assessment of certain clinical operative skills. While the OSCE is useful in the examination of diagnostic, interpretation and treatment planning skills, it has apparent limitations in the examination of invasive operative procedures.

Dental evaluation of scuba diving mouthpieces using a subject assessment index and radiological analysis of jaw position.

OBJECTIVE: To compare two experimental scuba mouthpieces with a commercially available design. METHODS: A laboratory study using six men to assess effort, muscle pain, muscle fatigue, facial discomfort, tooth discomfort, and loss of lip sensation using a visual analogue scale. Cephalometric radiographs and analysis of jaw position with each mouth piece were also used. RESULTS: Fully customised mouthpieces caused the least discomfort, muscle pain, fatigue, and effort. They also resulted in the least mandibular displacement from the resting position. Radiographic analysis of jaw position showed that the fully customised design resulted in the least displacement from normal jaw position. CONCLUSIONS: A fully customised design gives the greatest comfort, least effort, and least mandibular displacement. This design is recommended, particularly for divers who experience temporomandibular dysfunction associated with diving.

Scottish consortium for development and education in dental primary care.

A national consortium for dental primary care in Scotland has been formed as a result of integrated planning by groups involved in managing and delivering postgraduate dental education in Scotland. In 1998 a partnership was formed with representatives from the Scottish Council for Postgraduate Medical and Dental Education (SCPMDE) and the three Scottish dental institutions at Dundee, Edinburgh and Glasgow Universities. The principal aim of the Consortium is to promote evidence-based dental care through postgraduate education and research. The activities of the Consortium will provide a broadly based adjunct to current postgraduate provision with partner institutions contributing in different ways. Since its inception the Consortium has focused on two main areas: 'Higher Training' for Primary Care. Scottish Dental Practice Based Research Network.

Masseteric hypertrophy?: preliminary report.

We report radiological and histological investigations of a patient who presented with the masseteric hypertrophy. Sections of the patient's masseter muscles were also investigated using a series of histological techniques. The histological and morphometric analysis of the patient's masseter muscle showed numerous small fibres, which indicated that the masseteric enlargement was not the result of classic fibre hypertrophy. We suggest that the use of the term 'hypertrophy' in this condition may be misleading.

CD31 (PECAM-1) exists as a dimer and is heavily N-glycosylated.

CD31 (PECAM-1) is a highly abundant cell surface glycoprotein expressed on hemopoietic and endothelial cells where it functions as a homophilic adhesion and signaling receptor. Since dimerization and appropriate glycosylation are important features in the regulation of cell surface interactions and signal transduction, we studied the pattern of glycosylation as well as the ability of CD31 to undergo dimerization, both in solution and when expressed on cell membranes. CD31 is heavily glycosylated, with an approximate carbohydrate content of 21%. Nineteen neutral and thirteen sialylated glycans were identified. Ultracentrifugation analysis showed that soluble recombinant CD31 exists in equilibrium between a monomer and a dimer with an approximate dissociation constant of 12.5 microM. Chemical cross-linking studies of both soluble and membrane-expressed CD31 confirmed that CD31 exists as a dimer. These studies suggest that, like E-cadherin, PECAM-dimerization is likely to play a role in CD31 adhesion and signaling.

Homophilic PECAM-1(CD31) interactions prevent endothelial cell apoptosis but do not support cell spreading or migration.

PECAM-1 (CD31) is a highly abundant cell surface glycoprotein expressed on haemopoietic and endothelial cells. As well as mediating homophilic (PECAM-1/PECAM-1) adhesion, PECAM-1 can also bind the integrin alphavbeta3. Both PECAM-1 and alphavbeta3 have been shown to have roles in regulating angiogenesis, endothelial tube formation and in the case of alphavbeta3, endothelial cell apoptosis. In this study we show that despite being expressed at equivalent levels, endothelial alphavbeta3 is not a ligand for PECAM-1. Rather, PECAM-1 supports homophilic binding on HUVEC with similar characteristics to those we have previously reported for leukocytes and becomes tyrosine phosphorylated after homophilic PECAM-1 and integrin/fibronectin engagement. Immunoprecipitation studies show that in addition to SHP-2, tyrosine phosphorylated PECAM-1 can interact with at least four other phosphoproteins in pervanadate stimulated HUVEC. While PECAM-1/PECAM-1 interactions support robust endothelial cell adhesion, they do not support cell spreading or migration. In addition PECAM-1 homophilic adhesion rescues HUVEC from serum deprivation-induced apoptosis. Taken together our results indicate that PECAM-1 homophilic interactions play an important role in interendothelial cell adhesion, survival and signalling.

Residues on both faces of the first immunoglobulin fold contribute to homophilic binding sites of PECAM-1/CD31.

CD31 (PECAM-1) is a member of the immunoglobulin superfamily whose extracellular domain is comprised of six immunoglobulin-like domains. It is widely expressed on endothelium, platelets, around 50% of lymphocytes, and cells of myeloid lineage. CD31 has been shown to be involved in interendothelial adhesion and leukocyte-endothelial interactions, particularly during transmigration. CD31-mediated adhesion is complex, because CD31 is capable of mediating both homophilic and multiple heterophilic adhesive interactions. Here we show that the NH2-terminal (membrane-distal) immunoglobulin domain of CD31 is necessary but not sufficient to support stable homophilic adhesion. Key residues forming the binding site within this domain have been identified by analysis of 26 single point mutations, representing the most systematic analysis of a fully homophilic interaction between immunoglobulin superfamily family members to date. This revealed five mutations that affect homophilic binding. Uniquely, the residues involved are exposed on both faces of the immunoglobulin fold, leading us to propose a novel mechanism for CD31 homophilic adhesion.

Electromyographic evidence for a digastric reflex evoked by perioral stimuli in humans.

Electromyographic recordings (EMGs) were made using skin surface electrodes placed over the anterior digastric muscle in seven subjects. In every case, short bursts of electrical stimuli to the upper lip produced a response in the EMG that had a minimum latency of 62.0 +/- 10.8 ms (mean +/- SD). By contrast, no responses were seen when single pulse stimuli were applied. In 6/7 subjects, the minimum stimulation intensity that produced the reflex was described as being sharp or painful. In three additional experiments, single motor units were recorded within the digastric muscle using needle electrodes. In two of these experiments, there was evidence of reflex activity 60-110 ms after the application of painful electrical stimuli to the lip. These findings confirm that perioral stimuli can evoke a digastric reflex in humans and suggest that this reflex requires the summation that results from successive volleys of impulses in a large number of nociceptive afferent neurones.

The effect of chronic periodontal disease on human jaw muscles: a pilot study using computed tomography.

Patients with chronic periodontal disease sometimes complain of difficulty in masticating hard foods. Computed tomography (CT) was used to investigate the cross-sectional area (CSA) and density of the masseter and medial pterygoid muscles in a pilot study of 12 healthy female subjects aged 30-39 years. Six subjects (the 'diseased' group) had suffered from chronic periodontal disease and had, on average, 40% bone loss. Their disease had been treated by scaling and root planning and had remained clinically stable for at least 6 months before their inclusion in the study. The six age-matched 'control' subjects had no history of periodontal disease. All bone-loss measurements were evaluated as a percentage of root length. At defined scan planes, sections of both muscles were readily identified. Results from the 'diseased' group as compared with the 'control' group revealed that in the former the CSA of masseter and medial pterygoid was reduced significantly by 25% and 10%, respectively. There were no significant differences in the X-ray density of both muscles between the two groups, which indicated a similar fibro-fatty content. These findings indicate a reduction in the masticatory force that may be utilized by patients with reduced periodontal support and may help explain their masticatory difficulties.

Defining, conferring and assessing the skills of the dentist.

The task facing educators in dentistry is never an easy one. It is an area where as many questions as answers arise. This paper looks at how the skills that a dentist needs can be defined and the best way to confer them.

Identification of alpha v beta 3 as a heterotypic ligand for CD31/PECAM-1.

CD31 (PECAM-1) is a member of the immunoglobulin gene superfamily (IgSF) and has an important role in a number of endothelial cell functions including angiogenesis, inflammation, integrin activation and cell-cell adhesion. CD31 has both homotypic and heterotypic adhesive properties and in common with other IgSF members contains multiple functional domains. Using chimaeric fusion proteins of CD31 and a panel of haematopoietic cell lines we show that CD31 can bind cells in a predominantly homotypic or heterotypic manner depending on the cell line used. Heterotypic binding was found to be cation and temperature dependent and enhanced by Mn2+: all features of integrin mediated binding. Using a panel of anti-CD31 and anti-integrin antibodies we show that alpha v beta 3 is a ligand for CD31 on the monocytic cell line U937. The specificity of the interaction between alpha v beta 3 and CD31 was further confirmed by solid phase binding assays and the use of alpha v beta 3 transfected cells which bound CD31 specifically. Furthermore, we have mapped the binding site for alpha v beta 3 to domains 1 and 2 of CD31. The interaction of CD31 with alpha v beta 3 may be important in many aspects of endothelial function including leukocyte-endothelial transmigration and angiogenesis.

The design and construction of customised mouthpieces for subaqua diving.

Previous studies have shown that many subaqua divers suffer from temporomandibular joint dysfunction and related problems associated with the use of commercially available diving mouthpieces. This paper highlights factors which play a role in the development of these problems, defines essential features required in mouthpiece design and describes a technique for the construction of a fully customized mouthpiece.

Tomographic measurements of age changes in the human parotid gland.

This study involved 48 subjects of both sexes with ages ranging from 22 years to 90 years. Computerised tomography was used to scan the right and left parotid gland. Gland mean density was calculated in Hounsfield units and regression graphs drawn. A significant fall in gland density was noted with subject age but no differences were noted between male and female subjects. A significant correlation was observed between the mean density of right and left glands in the same individuals. It is postulated that the fall in gland density is related to an increase in fibro-fatty tissue within the gland. This study provides evidence that age related changes occur in the human parotid gland from youth to old age. This work supports the earlier findings of Scott's who studied the superficial lobe of the parotid gland histologically and found an increase in adipose tissue in this area of the gland with age.

The effects of attentional factors on an inhibitory jaw reflex in man.

Electromyographic recordings (EMGs) were made from the active masseter muscle, of the inhibitory reflex evoked by application of electrical stimuli to the skin of the upper lip in fifteen human subjects. In control sequences, the reflex had a mean latency of 42 +/- 1.1 ms and a mean duration of 45 +/- 2.1 ms. The magnitude of the reflex (measured by integration of the EMG) was reduced (by 18 +/- 7.0%, n = 11; P < 0.05, Student's t test) while the subjects concentrated on a visual feedback signal in order to maintain a steady level of EMG activity. It was further reduced (by 25 +/- 3.6%, n = 10; P < 0.001, Student's t test) when the subjects additionally undertook mental calculations (the 17-times table). These effects were predominantly in the later parts of the responses. They occurred regardless of whether the baseline activity in the masseter muscle was inadvertently raised or lowered during the conditioning procedures. It is concluded that attentional factors can modulate jaw reflexes in man by exerting an influence on the reflex pathway at a point prior to the motoneurones. The underlying mechanism may involve the activation of descending inhibitory pathways and/or a facilitation of mechanisms underlying excitatory responses in jaw closing muscles.

The effects of inhibitory controls triggered by heterotopic noxious stimuli on a jaw reflex evoked by perioral stimuli in man.

Electromyographic recordings (EMGs) were made from the active masseter muscle of the inhibitory reflex evoked by application of electrical stimuli to the skin of the upper lip in 11 human subjects. In control sequences, the reflex had a mean latency and duration of 41 +/- 1.7 and 44 +/- 2.6 ms, respectively. The magnitude of the reflex (measured by integration of the EMG) was significantly reduced by the application of cold (3 degrees C) or hot (47-48 degrees C) but not warm (38-46 degrees C) water to a hand or foot. The strongest stimuli (3 or 48 degrees C) produced mean reductions of the reflex magnitude in the range of 62-85%. These effects occurred regardless of whether the background activity in the masseter was raised or lowered during the application of the thermal stimuli. Thus, activity in nociceptive nerves from widespread areas of the body can modulate jaw reflexes in man by exerting an influence on the reflex pathway at a point before the motor neurones. This may involve the system of 'diffuse noxious inhibitory controls', which have been shown to depress limb flexion reflexes and neuronal activity in the spinal dorsal horn and trigeminal nuclear complex.

Changes in human jaw muscles with age and dental state.

The effects of ageing and dental state on the cross-sectional area and density of two jaw muscles, the masseter and medial pterygoid, were investigated using computed tomography. The study involved 84 male and 70 female subjects between the ages of 20 and 90 years. The cross-sectional area of both muscles showed a significant reduction with age; values for female subjects being found in the lower range of the distribution. When consideration was given to the presence or absence of a natural dentition, the cross-sectional area of both muscles in edentulous subjects showed a greater decrease throughout the age range studied. There was a significant decrease in the density of the muscles with increasing age. Previously, this has been interpreted to indicate a progressive increase in fat and fibrous tissue. Subject gender and the absence of teeth appeared to have little effect on this parameter. Changes in the cross-sectional area and density of these muscles would appear to be consistent with a general age related change of muscle tissue in the body as a whole and may specifically indicate a reduction in the masticatory forces which can be or are being utilised by ageing patients, many of whom have no remaining natural dentition.

Alzheimer's disease.

Alzheimer's disease (AD) is a debilitating and progressive disease that can affect dental practice in a number of ways. Not only will increasing numbers of AD patients be treated by dentists in the future but the dentist and members of his family may also be unfortunate enough to become affected. In the United Kingdom, nearly 10% of the population over 65 years of age, and more than 20% of those over 80 years develop progressive deterioration of memory, resulting in a breakdown of intellectual capacity and personality. More than half of those are suffering from AD. The purpose of this review is to describe the aetiology and behavioural aspects of this distressing disease and to highlight some problems that the dentist may encounter when treating those patients.