Routine oral examination: clinical vignettes, a promising tool for continuing professional development?

OBJECTIVES: To develop content for an educational system for dental professionals to be used for patient-tailored evidence-based decisions regarding routine oral examinations (ROEs) and to test the model as a tool in dental education. METHODS: Initially, an electronic database was developed comprising conclusive data of a structured literature search and 27 ROE clinical cases which were selected on predefined criteria. A RAND-modified Delphi procedure was successfully conducted with 31 multidisciplinary dental experts. Twenty-one selected risk factors for oral disease were assessed for feasibility and subsequently modelled into 19 risk based clinical vignettes, each representing a specific group of ROE-patients. Each vignette comprised all relevant clinical and non-clinical data. Expert judgements were collected including ROE-content, risk level, bitewing frequency and recall interval. Feedback regarding evidence was provided for each of the topics. A pilot with 35 experienced General Dental Practitioners (GDPs) was conducted to assess the reliability of the model for continuing professional development (CPD). Decisions made on content screening items, bitewing frequencies and recall interval were compared with expert opinions. RESULTS: A comprehensive set of clinical vignettes was developed. Expert consensus was reached with regard to risk factors to be applied, content of ROE-items, bitewing frequency and recall interval. Differences between GDPs and experts were found especially concerning recall length in low-risk patient groups. CONCLUSIONS: Clinical vignettes provide a promising educational instrument for CPD to improve clinical performance. Further research is needed to test the reliability of these set of 19 vignettes.

Routine oral examinations in primary care: which predictors determine what is done? A prospective clinical case recording study.

OBJECTIVES: Elements of a routine oral examination (ROE) in dental practice may be determined by patients' oral status, as recommended by prevailing knowledge, as well as by other factors. Our aim was to identify patient and GDP characteristics associated with aspects of oral health assessment (OHA) and clinical management (CM) in patients with various oral conditions. METHODS: A prospective observational study was performed, based on clinical case recording of 1059 ROEs by 128 GDPs. A clinical case recording form was used to record oral health assessment, diagnoses made, and clinical management for each ROE. Multilevel logistic regression analyses (with random coefficients) were performed. RESULTS: Overall, 'patients' age' in domains OHA as well as CM was the most salient predictor, while 'positive attitude to periodontal screening' showed to be a prominent GDP-factor. Patient characteristics mostly involved in OHA and CM were 'disease-free period' (odds ratios from 0.21 to 0.66), 'oral health compliance' (odds ratios from 0.32 to 0.65) and 'risk for periodontal disease' (odds ratios from 1.79 to 4.97). 'Continuing professional development' (odds ratios from 2.54 to 4.95), 'mean reading hours' (odds ratios from 2.25 to 4.48) and 'cooperation with peers' (odds ratios from 2.78 to 3.72) showed to be significant GDP-predictors. CONCLUSIONS: ROEs are determined by patient oral health status, particularly by aspects of oral health compliance and risk for oral disease, but also by GDP characteristics. The latter may reflect perceptions of a professional role, which need to be considered in efforts to improve the quality of ROE in oral care.

Routine oral examination: clinical performance and management by general dental practitioners in primary care.

The aim of this clinical study was to explore the contents of routine oral examinations (ROE), carried out by Dutch general dental practitioners (GDPs), in relation to the oral health status of regularly attending patients. An observational study was performed, based on clinical case recording. Using The Data Station Project of the Dutch Dental Association as the study base, 215 GDPs were recruited, of whom 131 participated in the study. A clinical case-recording form was developed to document clinical behavior. The contents assessed concerned patient characteristics, contents of the ROE visit, diagnoses made, and clinical behavior in response to ROE findings. This study showed substantial variation in clinical behavior related to specific ROE domains, including patient history and record keeping, whereas GDPs acted consistently on other domains, such as clinical examination and recall length assessment. Furthermore, the ROE performance was more strongly associated with GDP characteristics than with patient characteristics. The mean ROE time was 10 min, and recall intervals were most frequently assigned at 6 months, irrespective of the oral condition. This study highlights a need for continuing education to promote risk-based oral screening. Further research is needed to identify factors responsible for the variation in GDP performance, just as research on clinical practice guideline implementation methods is warranted.

A cluster randomised controlled trial in primary dental care based intervention to improve professional performance on routine oral examinations and the management of asymptomatic impacted third molars: study protocol.

BACKGROUND: Routine oral examination (ROE) refers to periodic monitoring of the general and oral health status of patients. In most developed Western countries a decreasing prevalence of oral diseases underpins the need for a more individualised approach in assigning individualised recall intervals for regular attendees instead of systematic fixed intervals. From a quality-of-care perspective, the effectiveness of the widespread prophylactic removal of mandibular impacted asymptomatic third molars (MIM) in adolescents and adults is also questionable. Data on the effectiveness of appropriate interventions to tackle such problems, and for promoting continuing professional development in oral health care are rare. METHODS/DESIGN: This study is a cluster randomised controlled trial with groups of GDPs as the unit of randomisation. The aim is to determine the effectiveness and efficiency of small group quality improvement on professional decision-making of general dental practitioners (GDPs) in daily practice. Six peer groups ('IQual-groups') shall be randomised either to the intervention arm I or arm II. Groups of GDPs allocated to either of these arms act as each other's control group. An IQual peer group consists of eight to ten GDPs who meet in monthly structured sessions scheduled for discussion on practice-related topics. GDPs in both trial arms receive recently developed evidence-based clinical practice guidelines (CPG) on ROE or MIM. The implementation strategy consists of one interactive IQual group meeting of two to three hours. In addition, both groups of GDPs receive feedback on personal and group characteristics, and are invited to make use of web-based patient risk vignettes for further individual training on risk assessment policy. Reminders (flow charts) will be sent by mail several weeks after the meeting. The main outcome measure for the ROE intervention arm is the use and appropriateness of individualised risk assessment in assigning recall intervals, and for the MIM-intervention group the use and appropriateness of individualised mandibular impacted third molar risk management. Both groups act as each other's control. Pre-intervention data will be collected in study months one through three. Post-intervention data collection will be performed after nine months.

Influence of composite resin consistency and placement technique on proximal contact tightness of Class II restorations.

PURPOSE: To investigate the influence of composite resin consistency and placement technique on proximal contact tightness of Class II composite resin restorations. MATERIALS AND METHODS: A manikin model (KaVo Dental) was used with an artificial first molar in which a standardized MO preparation was ground. This preparation was duplicated 360 times. Cavities were restored using Clearfil Photo Bond (Kuraray) combined with one of three composite resins of different consistencies: a low-viscosity (X-Flow, Dentsply), a medium-viscosity (Clearfil AP-X, Kuraray) and a high-viscosity composite (Tetric Ceram HB, Ivoclar Vivadent). Each composite was combined with 6 different matrix systems and separation techniques (n = 20). Groups 1 and 2: precontoured metal circumferential matrix (KerrHawe 1101-c) in a Tofflemire retainer combined either with hand instrument (OptraContact, Ivoclar Vivadent) or separation ring (Composi-Tight Gold, Garrison Dental Solutions). Group 3: pre-contoured metal sectional matrix (Lite-Flex, Danville Materials) with separation ring. Groups 4 and 5: pre-contoured metal circumferential dead-soft matrix (Adapt SuperCap, KerrHawe) with or without separation ring. Group 6: flat metal circumferential matrix (OptraMatrix, Ivoclar Vivadent) in a Tofflemire-retainer with hand instrument (OptraContact). Proximal contact tightness was measured using the Tooth Pressure Meter (University of Technology, Delft). To determine the effect of experimental variables on the proximal contact tightness, a multiple linear regression model was constructed. RESULTS: Measurements in group 6 were not possible; therefore, this group was excluded. The use of medium- or high-viscosity instead of a low-viscosity composite resin resulted in statistically significantly tighter proximal contacts (p < 0.01). The use of a separation ring resulted in a large, statistically significant increase (p < 0.001) in contact tightness, while the use of a hand instrument resulted in a small, statistically significant increase of contact tightness (p = 0.017). No statistically significant differences were found when a dead-soft matrix or a sectional matrix was used instead of a Tofflemire (p = 0.159, p = 0.261, resp.). CONCLUSION: Use of a separation ring when restoring a Class II composite resin restoration has a greater influence on the obtained proximal contact tightness compared to the influence of the consistency of the composite resin.

Predictors of recall assignment decisions by general dental practitioners performing routine oral examinations.

The aim of this study was to explore the decision-making behavior of general dental practitioners (GDPs) in performing routine oral examinations (ROEs). Change over time was studied by comparing data from a cohort sample of participants in two surveys in 2000 and 2005. A written questionnaire was sent to 809 dentists (509 responses were obtained) and 475 (61%) were used for analysis. Of the respondents, 347 also participated in the survey in 2000. The mean number of diagnostic ROE items per ROE was 6.9 (standard deviation = 1.7). Groups of GDPs were distinguished based on their answer to the question 'Do you apply for all patients a fixed recall interval between two successive ROEs?' and four personal profiles. Of the GDPs, 38.5% (n = 183) assigned fixed recall intervals (Fxs) for all patients. Individual recall intervals (Ivs) were applied by 61.5% (n = 292) of GDPs, depending on specific selected patient characteristics and risk factors. Logistic regression showed that GDPs applying Fxs also used fixed periods between successive bitewing radiographs. Furthermore, GDPs applying Ivs conducted more frequent periodontal screening and, in the event of periodontal problems, were more inclined to prescribe radiographs. Over a 5 yr period, a shift towards Ivs assignment (from 49% in 2000 to 61.5% in 2005) was found. Differences in assigned recall intervals (Fxs/Ivs) by GDPs are determined by three clinical ROE predictors and two GDP profiles. A shift towards a more individual assessment was found between 2000 and 2005 in the way that Dutch GDPs are dealing with the assignment of recall interval frequency.

Effectiveness of clinical practice guideline implementation on lower third molar management in improving clinical decision-making: a randomized controlled trial.

The objective of this study was twofold, namely to evaluate the effectiveness of a dental clinical practice guideline on the management of asymptomatic impacted lower third molars (i) on referral rates and (ii) on dentists' change in knowledge. A two-arm cluster randomized controlled trial, with pre- and post-test assessments, was conducted. A guideline was implemented by multifaceted interventions (i.e. feedback, reminders, and an interactive meeting). The effect was evaluated after 1 yr by repeating the baseline questionnaire and by monitoring the number of patients who were referred for removal of their asymptomatic impacted mandibular third molars. Instruments were questionnaires for detecting changes in knowledge, patient records, and panoramic radiographs. The knowledge of dentists regarding asymptomatic mandibular third molar management was found to increase significantly in the intervention group as compared to the control group. There was no statistically significant difference between the groups in guideline-consistent patient referral rates at the post-test assessment. It was concluded that the methodology employed for dissemination and implementation of a clinical practice guideline on asymptomatic mandibular third molar management improves dentists' knowledge on this topic and is effective in improving decision-making in simulated cases; however, no clinical effect was demonstrated.

Routine oral examination: differences in characteristics of Dutch general dental practitioners related to type of recall interval.

OBJECTIVES: The aim of this study was to explore differences in behaviour (characteristics and opinions) among general dental practitioners (GDPs), using either a fixed (Fx) or an individualized recall interval (Iv) between successive routine oral examinations (ROEs). METHODS: In the year 2000, data were collected by means of a written questionnaire sent to a random stratified sample of 610 dentists of whom 521 responded, of which 508 (83%) were used for analysis. RESULTS: Two groups of GDPs were distinguished based on their answer to the question: 'Do you apply for all patients a fixed recall interval between two successive ROEs?' Fifty-one per cent of the GDPs (n=257) applied Fxs for all patients, generally for a period of 6 months. Ivs were applied by 49% (n=251) of GDPs, depending on the determination of specific patient characteristics. Logistic regression analysis showed that GDPs applying Fxs also used fixed periods between successive bitewing radiographs for all patients. Furthermore, dentists applying Ivs required more time to conduct an ROE, partly because of a more extensive periodontal screening. GDPs applying Fxs, adhered more to the opinion that a fixed recall regime (every 6 months, as existed before 1995) should be re-introduced, whereas the GDPs in support of Ivs were more in favour to support the opinion that the ROE is 'an excellent instrument for effective, individualized oral care'. CONCLUSIONS: Dutch GDPs differ in the way they deal with the determination of recall interval frequency. These are also specific differences in performance and opinions regarding ROE. With the changing prevalence of oral diseases and the skewed distribution within populations, further research is advocated on consistent decision making to determine the most appropriate recall policy in preventing oral disease.

Development of clinical practice guidelines: evaluation of 2 methods.

The aim of this study was to compare 2 methods for developing a clinical practice guideline (CPG) on the management of asymptomatic, impacted mandibular third molars. Outcome measures were the mean time invested by the participants for each method, the quality of the CPGs measured using the Appraisal of Guidelines for Research and Evaluation (AGREE) indicator and observations of the group discussions. We used a national consensus procedure following the Rand modified Delphi procedure (2 panels) and a local consensus procedure (2 existing dental peer groups). The mean time spent was about equal for the 2 methods. The quality of the CPGs developed by the expert panels was higher than that of the CPGs developed by the dental peer groups. Observation indicated that all group processes were influenced by the chairperson. We concluded that the expert panel method is suitable for developing reliable CPGs on a national or regional level.

The influence of providing a clinical practice guideline on dental students' decision making.

The aim of this study was to assess the effect of the provision of a clinical practice guideline (CPG) on dental students' decisions to remove asymptomatic, impacted lower third molars. All dental students, who in 2001 were in the 3rd, 4th or 5th (final) year of their study at the Nijmegen College of Dental Sciences, were invited to participate. A pre-test-post-test control group design was used. Given 36 patient cases, all dental students were asked to assess the need for removal of asymptomatic, impacted lower third molars. All pre-test respondents were randomly allocated to the control or intervention group. After the provision of a CPG to the intervention group, both groups were asked to assess the same cases again. Frequencies of decisions to remove the third molars were calculated. Chi-square tests and anova were used to test the influence of study year and gender on the drop-out rate and on the effect of the provision of a CPG on students' treatment decisions. The decrease in indications to remove third molars by the intervention group was statistically significant (P < 0.05). In the control group, no significant decrease was observed. It was concluded that the provision of a CPG significantly influences dental students' decision making about treatment in a third-molar decision task. Students who used the CPG showed more guideline-conformed decision making.

Reliability and validity issues of laser fluorescence measurements in occlusal caries diagnosis.

OBJECTIVES: Recently, a device for detecting occlusal caries lesions based on laser fluorescence measurements (DIAGNOdent) has been introduced. The reliability (reproducibility) and validity of this laser-fluorescence device were investigated. METHODS: In the in vitro part of the study, 49 permanent molars were measured by two observers using two DIAGNOdent devices. In addition, visual inspection was performed. The teeth were sectioned to measure the actual depth and area of the caries lesions. In the in vivo part of the study, 45 sites at the occlusal surfaces of permanent molar teeth in 13 patients were measured by two observers using two DIAGNOdent devices, manufactured in two successive years. RESULTS: The reliability of both DIAGNOdent devices expressed in the intraclass correlation coefficient (ICC=0.90 for observer 1, and 0.88 for observer 2) was high, and so was the interobserver reliability (ICC=0.85 for the 1998-device, ICC=0.90 for the 1999-device). The correlation between DIAGNOdent measurements and the actual depth of the caries lesions was lower than that of visual inspection by one observer, yet higher than that of a second observer. The specificities of visual inspection (0.94 and 0.88) were higher than those of the DIAGNOdent devices, whereas the sensitivities of the DIAGNOdent devices (0.93-1.00) exceeded those of visual inspection The validity of the DIAGNOdent, expressed as the area under the receiver operating characteristic curve, was not statistically significantly different from that of visual inspection (P>0.05). The DIAGNOdent measurements showed a higher association with the enamel part of the caries lesion than with the dentinal part. CONCLUSIONS: The DIAGNOdent is suitable for monitoring small caries lesions. Because of the high reproducibility of DIAGNOdent devices produced in successive years, a DIAGNOdent device may be replaced by a new one. Due to the higher specificity, visual inspection should be preferred to diagnose occlusal caries lesions in populations with a low caries prevalence.

Development of clinical practice guidelines for dentists: methods for topic selection.

OBJECTIVES: The aim of this study was to compare four methods for assessing the preferences of the dental profession for topics to be considered for the development of clinical practice guidelines. METHODS: The methods were: (1) a survey among dentists, (2) an analysis of topics discussed in dental peer groups, and (3) screening of dental journals. A fourth method was obtained from method number 3. The frequencies of the reported topics were calculated for each of the methods. For the fourth method, the number of publications per topic were plotted against the year of publication, and the slope of the linear regression line was used as an indicator. Within each of the four methods, the topics were ranked according to the frequency in which they were reported, and to the slope value. The reliability of the methods was tested by the "item-rest sum correlation", which is the correlation of the rank positions of one method with the sum of the rank positions obtained by the remaining three methods. RESULTS: In using all methods, a total of 1027 topics were obtained. Reclassification resulted in 34 topics. Moderate item-rest sum correlations ranging from 0.34 to 0.48 were found for all methods, indicating that the rank order of every method moderately predicts the sum of the rank orders obtained by all other methods. The topic 'prevention of cross-infection' had the highest overall rank position. CONCLUSION: It is concluded that the four applied methods appeared to provide a consistent ranking of potential topics. In view of the fact that the questionnaire method is generally applicable, this method should be preferred for assessing dentists' preferences for topics to be considered for the development of clinical practice guidelines.

Effect of selected literature on dentists' decisions to remove asymptomatic, impacted lower third molars.

The aim of this study was to assess the effect of studying selected literature on dentists' decisions to remove asymptomatic, impacted lower third molars. A pre-test-post-test control group design was used. Given 36 patient cases, two groups of 16 general dental practitioners each were asked to assess the need for removal of asymptomatic impacted lower third molars. The cases were classified by three parameters: 'position of the third molar', 'impaction type', and 'patient age'. After studying selected literature on this subject by the intervention group, both groups were asked to assess the same cases again. Frequencies of decisions to remove the third molars were calculated. For each participant, tables were composed by crosstabulating the indication to remove a third molar with each of the three parameters. T-tests were used to test the significance of the difference between pre-test and post-test decisions. The overall number of indications to remove asymptomatic, impacted lower third molars decreased by 37% in the intervention group. In the control group, the difference between pre- and post-test was not statistically significant. It was concluded that the provision of selected literature significantly influences treatment decision making by dentists in a third molar decision task.