Audit to assess the quality of communication between operators and technicians in a fixed prosthodontic laboratory: educational and training implications.

OBJECTIVE: This audit aimed to assess the quality of communication between dental students/qualified dentists and dental technicians, increase the percentage of satisfactorily completed laboratory prescriptions and reduce the number of errors that can result from poor communication. A subsidiary aim was to educate students and staff in this respect. METHOD: An audit of laboratory prescription completion was conducted within Dundee Dental Hospital. Four hundred and eighteen prescriptions for indirect fixed restorations completed by dental undergraduates and qualified staff were audited over a three month period (first audit cycle). Educational reminders on laboratory prescriptions were then provided to undergraduates and qualified staff, a further three hundred and twenty-two prescriptions were audited (second audit cycle) and compared with the first cycle. RESULTS: Satisfactorily completed prescriptions increased from 28% to 43% following basic educational intervention. However, this percentage still signifies a poor level of completion and the need for improvement. Some aspects of the prescription were completed better than others, but overall the standard remained poor with a significant number failing to comply with guidelines set by the UK General Dental Council, the European Union's Medical Devices Directive and the British Society for Restorative Dentistry (BSRD). CONCLUSION: Further undergraduate and staff training on laboratory prescription writing will be necessary through staff training events and developments in the undergraduate curriculum.

Decision-making and preventive non-surgical therapy in the context of a European Core Curriculum in Cariology.

This paper is part of a series of papers towards a European Core Curriculum in Cariology for undergraduate dental students. The European Core Curriculum in Cariology is the outcome of a joint workshop of the European Organisation for Caries Research (ORCA) together with the Association for Dental Education in Europe (ADEE), which was held in Berlin from 27 to 30 June 2010. The present paper covers decision-making and non-surgical treatment. In particular, it will provide some background information on this part of the European core curriculum. The dentist, on graduation, must be competent at applying the principles of prevention of dental hard tissue disease processes (primary prevention) and progression when it has manifested itself (secondary prevention). The competences should apply in differing ways to patients of all ages. Goals of prevention should be clearly defined in order for outcomes to be evaluated, and a dentist should be competent at determining these outcomes. Although this concept is recognised by many academics and experts, clinical teaching, practice and health insurance coverage frequently emphasise surgical treatment. There are many reasons and obstacles that might account for this, and this paper suggests some reasons why this might be and makes suggestions for how these can be addressed in the future. One factor that is essential in the provision of a preventive, non-surgical approach is that of communication with the patient. However, this unfortunately takes less space in the dental curricula compared with technical skills aimed at restorative procedures; this weighting needs to be more equally balanced.

Effect of different time intervals between examinations on the reproducibility of ICDAS-II for occlusal caries.

AIM: To evaluate intra- and interexaminer reproducibility of ICDAS-II on occlusal caries diagnosis when different time intervals were allowed to elapse between examinations. A subsidiary aim was to determine whether collapsing the codes would influence this reproducibility. METHODS: The occlusal surfaces of 50 permanent posterior teeth were investigated by 3 trained examiners using ICDAS-II at baseline, 1 day, 1 week and 4 weeks after baseline. RESULTS: Weighted kappa values for intra- and interexaminer reproducibility were 0.76-0.93. CONCLUSION: The time span did not have a major impact on assessing intra- and interexaminer reproducibility. Collapsing ICDAS-II codes had no impact on examiner reproducibility.

Clinical performance of two visual scoring systems in detecting and assessing activity status of occlusal caries in primary teeth.

This study aimed to compare the clinical performance of two sets of visual scoring criteria for detecting caries severity and assessing caries activity status in occlusal surfaces. Two visual scoring systems--the Nyvad criteria (NY) and the ICDAS-II including an adjunct system for lesion activity assessment (ICDAS-LAA)--were compared using 763 primary molars of 139 children aged 3-12 years. The examinations were performed by 2 calibrated examiners. A subsample (n = 50) was collected after extraction and histology with 0.1% red methyl dye was performed to validate lesion depth and activity. The reproducibility of the indices was calculated (kappa test) and ROC analysis was performed to assess their validity and related parameters were compared using McNemar's test. The association between the indices and with the histological examination was evaluated using Spearman's correlation coefficient (r(s)). Visual criteria showed excellent reproducibility both regarding severity (NY: 0.94; ICDAS-II: 0.91) and activity (NY: 0.90; LAA: 0.91). The NY and LAA showed good association in caries activity assessment (r(s) = 0.88; 95% CI = 0.86-0.89; p < 0.001). Nevertheless, considering only cavitated lesions, this association was not significant (p > 0.05). Concerning the severity, both indices presented similar validity parameters. At D2 threshold, the sensitivity was higher for NY (NY = 0.87; ICDAS = 0.61, p < 0.05). Regarding activity status, NY showed higher specificities and accuracies. In conclusion, NY and ICDAS-II criteria are comparable and present good reproducibility and validity to detect caries lesions and estimate their severities, but the LAA seems to overestimate the caries activity assessment of cavitated lesions compared to NY.

Validity and reproducibility of ICDAS II in primary teeth.

The aim of this in vitro study was to assess the validity and reproducibility of the ICDAS II (International Caries Detection and Assessment System) criteria in primary teeth. Three trained examiners independently examined 112 extracted primary molars, ranging from clinically sound to cavitated, set up in groups of 4 to mimic their anatomical positions. The most advanced caries on the occlusal and approximal surfaces was recorded. Subsequently the teeth were serially sectioned and histological validation was undertaken using the Downer and Ekstrand-Ricketts-Kidd (ERK) scoring systems. For occlusal surfaces at the D(1)/ERK(1) threshold, the mean specificity was 90.0%, with a sensitivity of 75.4%. For approximal surfaces, the specificity and sensitivity were 85.4 and 66.4%, respectively. For occlusal surfaces at ICDAS code > or =3 (ERK(3) threshold), the mean specificity and sensitivity were 87.0 and 78.1%, respectively. For approximal surfaces, the equivalent values were 90.6 and 75.3%. At the D(3) threshold for occlusal surfaces, the mean specificity and sensitivity were 92.8 and 63.1%, and for approximal surfaces 94.2 and 58.3%, respectively. Mean intraexaminer reproducibility (Cohen's kappa) ranged from 0.78 to 0.81 at the ICDAS code > or =1 cut-off and at the ICDAS code > or =3 cut-off from 0.74 to 0.76. Interexaminer reproducibility was lower, ranging from 0.68 to 0.70 at the ICDAS code > or =1 cut-off and from 0.66 to 0.73 at the ICDAS code > or =3 cut-off. In conclusion, the validity and reproducibility of the ICDAS II criteria were acceptable when applied to primary molar teeth.

In vitro comparison of Nyvad's system and ICDAS-II with Lesion Activity Assessment for evaluation of severity and activity of occlusal caries lesions in primary teeth.

This in vitro study of occlusal surfaces on primary molars aimed to: (1) evaluate the reproducibility of the Nyvad and ICDAS-II visual systems in detecting caries; (2) to test the accuracy of the systems in estimating lesion depth, and (3) to examine the association between the Nyvad system and the Lesion Activity Assessment system, an adjunct to ICDAS-II. Two samples of extracted primary molars (sample 1, n = 38; sample 2, n = 69) were evaluated independently by 2 examiners. In this in vitro study, evaluation of plaque in the Nyvad system was not possible. Histology (sample 2) was used to validate lesion depth. Area under ROC curves (A(z)), sensitivity, specificity and percent agreement of both systems were calculated at D1, D2 and D3 thresholds. Both systems showed kappa for intra- and inter-examiner agreement >0.86 and good correlation with histology: Spearman rho = 0.73 (Nyvad) and 0.78 (ICDAS-II). They presented similar performances except that ICDAS-II showed significantly higher sensitivity (Nyvad 0.89; ICDAS 0.92) and A(z) (Nyvad 0.85; ICDAS 0.90) for the D1 threshold. The correlation between the systems for lesion activity (Cramer's V) was 0.71. Therefore, both visual systems are reliable and can estimate caries lesion depth on primary teeth. Under in vitro conditions, there is no major difference between the Nyvad system and Lesion Activity Assessment in assessing caries activity.

Traditional operative treatment options.

Operative intervention should be avoided, whenever possible, by adopting a preventive approach. Timely management of early caries can lead to arrest and possibly remineralization of the lesion rendering operative intervention unnecessary. The dentist must judge when the tooth tissue has become sufficiently demineralized to allow bacterial ingress leading to irreversible changes in the tissue. Once a decision has been made to restore a tooth, the clinician must decide, from a series of traditional operative treatment options, what materials should be used in the restoration and what preparation will achieve good retention and best preservation of tooth structure. With the development of new adhesive materials and a more conservative approach, a new era of minimally invasive dentistry has dawned. Improvements in the properties of composite materials have made them the choice for coronal aesthetic restorations: for posterior restorations involving load-bearing occlusal surfaces, amalgam is still the most commonly used material in UK dental practice; glass ionomer materials also have a place in minimally invasive dentistry--patterns of use differing in different counties. The numbers of studies investigating minimal caries removal are relatively limited; there are still scope and need for research in this field.

Novel operative treatment options.

There are an increasing number of more novel options available for operative intervention. This chapter outlines a series of operative treatment options which are available to the modern clinician to select from once a decision has been made to treat a carious lesion operatively. A series of novel methods of caries removal have been described; including chemomechanical caries removal, air abrasion, sono-abrasion, polymer rotary burs and lasers. There are also novel approaches to ensure complete caries removal and novel approaches for the management of deep caries. A novel question increasingly asked by clinicians is: does all the caries need to be removed? Operative management options here include: therapeutic fissure sealants, ultraconservative caries removal, stepwise excavation and the Hall technique. In conclusion, there is now a growing wealth of evidence that questions the traditional methods of caries removal and restoring the tooth. In parallel, there is a growing movement exploring the merits of therapeutically sealing caries into the tooth. This philosophy is alien to many of today's dentists and, until further randomized controlled trials are carried out in primary care, prudent caution must be exercised with this promising approach. Research is required into techniques which will allow monitoring of sealed caries to detect any rare, but insidious, failures. These novel techniques are an alternative way of managing the later stages of the caries process from a sounder biological basis and have marked potential benefits to patients from treatment, pain and outcome perspectives.

Accuracy and reproducibility of conventional radiographic assessment and subtraction radiography in detecting demineralization in occlusal surfaces.

Subjective interpretation of paired digital radiographic images viewed side by side to assess occlusal lesion progression, arrest or remineralization is difficult. The aim of this study was to compare the accuracy and reproducibility of a digital subtraction radiography technique and visual assessment of paired digital images in detecting changes in mineral content within occlusal cavities. Forty molar teeth with occlusal cavities were placed in arches and baseline digital radiographs taken. Nineteen teeth were randomly selected and had acid placed in the cavities and digital images taken after 3, 6, 12, 18 and 24 h of acid exposure. Paired baseline images and those taken at the various time intervals were examined side by side and assessed for demineralization by five examiners. Subtraction images prepared from the paired images were assessed in the same way. One fifth of the images were re-examined to determine intra-examiner reproducibility. After 12 h or longer the diagnostic accuracy (mean area under the ROC curve = 0.92-0.98 for subtraction radiography), intra-examiner and inter-examiner reproducibility for detection of demineralization from the subtraction images was significantly better than viewing the paired images side by side (p < 0.01). The subtraction radiography system used was found to be more accurate and reproducible than visual assessment of paired digital images. As such the technique shows promise for monitoring occlusal lesion progression in clinical studies.

Preformed metal crowns for decayed primary molar teeth.

BACKGROUND: Preformed metal crowns (PMCs) are recommended by the British Society of Paediatric Dentistry (BSPD) for restoring badly broken down primary molar teeth. However, few dental practitioners adopt this technique in clinical practice, citing cost and clinical difficulty as reasons for this. Whilst there is a subjective impression by clinical academics that PMCs provide a more durable restoration than filling materials, there appears to be little evidence within the literature to support this. OBJECTIVES: The primary aim of this systematic review was to compare clinical outcomes for primary molar teeth restored using PMCs compared to those restored with filling materials. SEARCH STRATEGY: The literature was searched using: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 3); MEDLINE (1966 to August 2005); EMBASE (1980 to August 2005); System for Information on Grey Literature in Europe (SIGLE) (1976 to August 2005). Relevant publications' reference lists were reviewed for relevant articles. The most recent search was carried out on 24 August 2005. SELECTION CRITERIA: Randomised controlled trials (RCTs) that assessed the effectiveness of PMCs compared with filling materials or where there had been no treatment in children with untreated tooth decay in one or more primary molar teeth. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed the title and abstracts for each article from the search results to decide whether it was likely to be relevant. Full papers were obtained for relevant articles and all three review authors studied these. MAIN RESULTS: Forty-seven records were retrieved by the search strategies of which some were duplicates. Of these, 14 studies were scrutinised. No studies met the inclusion criteria and six studies were excluded from the review as they were either retrospective in design or reported as prospective outcomes but not randomised. No data were available for extraction and analysis and therefore, no conclusion could be made as to whether PMCs were more successful than filling materials for restoring primary molar teeth. AUTHORS' CONCLUSIONS: No RCTs were available for appraisal. Whilst this technique is recommended by the BSPD for use in clinical practice, the evidence to support this is not strong, consisting mainly of case reports and uncontrolled studies. It is important that the absence of evidence for PMCs is not misinterpreted as evidence for their lack of efficacy. There is a strong need for prospective RCTs comparing PMCs and fillings for managing decayed primary molar teeth. The lower levels of evidence that have been produced, however, have strength in that the clinical outcomes are consistently in favour of PMCs, despite many of the studies placing PMCs on the most damaged of the pair of teeth being analysed.

Complete or ultraconservative removal of decayed tissue in unfilled teeth.

BACKGROUND: The treatment of deep dental decay has traditionally involved removal of all the soft demineralised dentine before a filling is placed. However this has been challenged in three groups of studies which involve sealing soft caries into the tooth. The three main groups either remove no caries and seal the decay into the tooth, remove minimal (ultraconservative) caries at the entrance to a cavity and seal the remaining caries in, or remove caries in stages over two visits some months apart to allow the pulp time to lay down reparative dentine (the stepwise excavation technique). OBJECTIVES: To test the null hypothesis of no difference in the incidence of damage or disease of the nerve of the tooth (pulp), progression of decay and longevity of restorations irrespective of whether the removal of decay had been minimal (ultraconservative) or complete. SEARCH STRATEGY: The Cochrane Oral Health Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, PubMed and EMBASE databases were searched. The reference lists in relevant papers were checked. SELECTION CRITERIA: Randomised controlled trials and controlled clinical trials comparing minimal (ultraconservative) caries removal with complete caries removal in unrestored permanent and deciduous teeth. DATA COLLECTION AND ANALYSIS: Outcome measures recorded were exposure of the nerve of the tooth (pulp) during caries removal, patient experience of symptoms of pulpal inflammation or necrosis, progression of caries under the filling, time until the filling was lost or replaced. Due to the heterogeneity of the included studies the overall estimate of effect was calculated using a random-effects model. MAIN RESULTS: Four studies met the inclusion criteria; two stepwise excavation studies and two ultraconservative caries removal studies. Partial caries removal in symptomless, primary or permanent teeth reduces the risk of pulp exposure. We found no detriment to the patient in terms of pulpal symptoms in this procedure and no reported premature loss or deterioration of the restoration. AUTHORS' CONCLUSIONS: The results of this systematic review reject the null hypothesis of no difference in the incidence of damage or disease of the nerve of the tooth (pulp) irrespective of whether the removal of decay had been minimal (ultraconservative) or complete and accepts the null hypothesis of no difference in the progression of decay and longevity of restorations. However, the number of included studies is small and differ considerably. Partial caries removal is therefore preferable to complete caries removal in the deep lesion, in order to reduce the risk of carious exposure. However, there is insufficient evidence to know whether it is necessary to re-enter and excavate further but studies that have not re-entered do not report adverse consequences.

Visual and tactile assessment of arrested initial enamel carious lesions: an in vivo pilot study.

Accurate and reliable assessment of caries activity is important for determining appropriate treatment needs. The aim of this pilot study was to determine whether dentists could differentiate between the appearances (visual and tactile) of lesions inactivated by regular professional oral hygiene and those control lesions which were not cleaned (active). After a 3- to 4-week study period involving 10 children, with 4 similar carious lesions each, it was found that dentists were not able to reliably and reproducibly determine the subtle visual and tactile differences between active and inactive enamel lesions from a one-off clinical examination.

Post and core systems, refinements to tooth preparation and cementation.

With a plethora of post systems available, it is often difficult to decide which one to use. This is made more difficult by the fact that new posts are introduced before existing ones are fully evaluated in laboratory and clinical studies. This paper therefore describes the different post types and the main advantages and disadvantages of each. In addition, the choice of post system will influence whether further tooth preparation is required and will dictate which luting cement and core material are most appropriate. Whilst the choice of post will, for many dentists, be driven by personal preference and a history of clinical success, there are certain pit falls to avoid and these are outlined.

Weakened anterior roots--intraradicular rehabilitation.

This paper highlights the fact that many anterior teeth requiring restoration are severely weakened having wide, flared canal spaces, and thin dentinal walls that are prone to fracture. Traditionally these teeth have been restored using metal posts and are often unsuccessful because of lack of retention or root fracture. This paper describes how mineral trioxide aggregate (MTA) can be used to form an immediate apical seal rather than waiting months for apexification. Weakened roots can be reinforced using dentine bonding agents and composite resin and if insufficient coronal tooth structure is present a quartz-fibre post can be placed to retain a composite core.

Restoration of the root-filled tooth: pre-operative assessment.

This is the first in a series of four papers related to the management of root canal treated teeth. When teeth compromised by extensive restorations become non-vital, suggestions have been given as to how root canal treatment can be carried out with the greatest chance of success. Once root canal treated, either by a previous dentist or by the current dentist, a review of the assessment process that should be carried out prior to placing costly indirect definitive restorations is given. It will be clear that post-retained restorations are mainly reserved for anterior or single-rooted teeth, posterior teeth rarely requiring a post for core retention. The second paper in this series describes the basic tooth preparation that should be carried out prior to placing a post. Depending on the type of post system used, further modifications to tooth preparation may be required and the cementation techniques may also have to be modified. The third paper therefore discusses the various post types, when and how they should be used for optimum results. The final paper addresses reinforcement and restoration of compromised root canals, such as those with immature, open apices, or those that have been over-prepared for previous post-retained restorations.

Tooth preparation for post-retained restorations.

Failure of root canal treatment and/or post crowns can be avoided in many cases if appropriate tooth preparation is carried out. This paper discusses the rationale for the timing of post placement following root canal treatment and appropriate methods for removal of gutta-percha prior to post space preparation. The basic principles of post space preparation are described, which should reduce the risk of weakening the root unnecessarily, causing damage to the periodontium and post perforation.

Peer review amongst restorative specialists on the quality of their communication with referring dental practitioners.

OBJECTIVE: A peer review study was carried out to assess the written communication between consultants and specialist registrars in restorative dentistry with the referring general dental practitioners. METHODS: Seven people took part in the study and each presented referral and reply letters for five patients whom they had seen for consultation. The referral letters were used for information only and were not used in the peer review process. Each participant inspected the referral and reply letters from the other six participants. The reply letters were anonymously peer reviewed by using a proforma containing agreed criteria in relation to appropriate factors to include in the reply letter. The reviewer also ranked the letter in relation to overall quality on a 1-10 point scale. RESULTS: It was found that the participants' letters generally conformed positively with the agreed criteria although there were some differences between individuals. There were particular problems identified in relation to tooth notation. Reply letters commonly used different forms of tooth notation to the referring practitioners. CONCLUSIONS: The ranking of the letters generally indicated that the participants' replies were judged to be favourable by their peers. There may be scope for continuing this study in relation to peer review by other groups of professionals, in particular practitioners in primary dental care.

Fibre-based post systems: a review.

OBJECTIVES: This article presents a review of published literature examining fibre-based endodontic post systems. DATA SOURCES: A MEDLINE search was carried out for any articles in dental journals pertaining to fibre-based post systems. Wherever possible articles cited were obtained from the journals and where this was not possible abstracts were obtained. Where no abstract was available the article was not considered for evaluation. DATA EXTRACTION: Articles were reviewed by a single observer and subject to meeting inclusion criteria were included in the review. Fifty-nine articles were considered suitable for inclusion. DATA SYNTHESIS: Articles were divided into categories and a subjective description of the articles was made. CONCLUSIONS: Review indicated that (1) most published literature on fibre-based posts took the form of laboratory analyses; (2) evidence for carbon-fibre posts far exceeds that for quartz-fibre posts; (3) laboratory evidence was contradictory and could not be used to inform practice reliably; (4) few clinical studies have been carried out though these have suggested fibre based posts may be clinically appropriate for restoration of the endodontically treated tooth; and (5) controlled prospective clinical trials evaluating fibre-based posts should be undertaken to inform use for clinical practice.