Dental students' perception of their approaches to learning in a PBL programme.

AIM: To compare dental students' perceptions of their learning approaches between different years of a problem-based learning (PBL) programme. The hypothesis was that in a comparison between senior and junior students, the senior students would perceive themselves as having a higher level of deep learning approach and a lower level of surface learning approach than junior students would. This hypothesis was based on the fact that senior students have longer experience of a student-centred educational context, which is supposed to underpin student learning. PARTICIPANTS AND METHODS: Students of three cohorts (first year, third year and fifth year) of a PBL-based dental programme were asked to respond to a questionnaire (R-SPQ-2F) developed to analyse students' learning approaches, that is deep approach and surface approach, using four subscales including deep strategy, surface strategy, deep motive and surface motive. The results of the three cohorts were compared using a one-way analysis of variance (ANOVA). A P-value was set at <0.05 for statistical significance. RESULTS: The fifth-year students demonstrated a lower surface approach than the first-year students (P = 0.020). There was a significant decrease in surface strategy from the first to the fifth year (P = 0.003). No differences were found concerning deep approach or its subscales (deep strategy and deep motive) between the mean scores of the three cohorts. CONCLUSIONS: The results did not show the expected increased depth in learning approaches over the programme years.

A predictive model for alternative admission to dental education.

AIM: To compare academic progress and performance of students admitted through two admission systems and to analyse the predictive power of different components in an alternative admission. SAMPLE AND METHODS: The subjects were students admitted to the dental programme at Malmö University, Sweden. The grade admission group was admitted on grades from secondary school (n = 126) and the alternative admission group via an alternative admission procedure (n = 157). The alternative admission procedure consisted of the following components: problem-solving matrices, spatial capacity tested with folding and tin models, manual dexterity, capacity for empathy and interview. Comparisons were made for academic progress (dropouts from the programme and study rate) and academic performance (examinations failed and outcomes of a comprehensive clinical examination). Spearman correlation was calculated for each component of the alternative admission procedure and academic progress as well as academic performance. Multivariate analyses were also carried out. RESULTS: Compared to the grade admission group, the alternative admission group presented lower rate of dropouts (3% vs. 20%, P < 0.001) and a larger proportion graduated within the expected time (88% vs. 60%, P < 0.01). There was no difference between the groups concerning academic performance. Capacity of empathy was correlated with study rate and outcomes of the clinical examination. The matrices predicted low proportion failed examinations and high students' self-assessments in the clinical examination. Predictive power of folding was limited and so was that of the interview. Manual dexterity was not correlated with academic progress or performance. CONCLUSIONS: Results support further development of admission selection criteria, particularly emphatic capacity that predicts important student academic achievements.

Effective dose of cone beam CT (CBCT) of the facial skeleton: a systematic review.

OBJECTIVE: To estimate effective dose of cone beam CT (CBCT) of the facial skeleton with focus on measurement methods and scanning protocols. METHODS: A systematic review, which adhered to the preferred reporting items for systematic reviews (PRISMA) Statement, of the literature up to April 2014 was conducted. Data sources included MEDLINE®, The Cochrane Library and Web of Science. A model was developed to underpin data extraction from 38 included studies. RESULTS: Technical specifications of the CBCT units were insufficiently described. Heterogeneity in measurement methods and scanning protocols between studies made comparisons of effective doses of different CBCT units and scanning protocols difficult. Few studies related doses to image quality. Reported effective dose varied across studies, ranging between 9.7 and 197.0 µSv for field of views (FOVs) with height ≤5 cm, between 3.9 and 674.0 µSv for FOVs of heights 5.1-10.0 cm and between 8.8 and 1073.0 µSv for FOVs >10 cm. There was an inconsistency regarding reported effective dose of studies of the same CBCT unit with the same FOV dimensions. CONCLUSION: The review reveals a need for studies on radiation dosages related to image quality. Reporting quality of future studies has to be improved to facilitate comparison of effective doses obtained from examinations with different CBCT units and scanning protocols. A model with minimum data set on important parameters based on this observation is proposed. ADVANCES IN KNOWLEDGE: Data important when estimating effective dose were insufficiently reported in most studies. A model with minimum data based on this observation is proposed. Few studies related effective dose to image quality.

Variation in costs of cone beam CT examinations among healthcare systems.

OBJECTIVES: To analyse the costs of cone beam CT (CBCT) in different healthcare systems for patients with different clinical conditions. METHODS: Costs were calculated for CBCT performed in Cluj (Romania), Leuven (Belgium), Malmö (Sweden) and Vilnius (Lithuania) on patients with (i) a maxillary canine with eruption disturbance, (ii) an area with tooth loss prior to implant treatment or (iii) a lower wisdom tooth planned for removal. The costs were calculated using an approach based on the identification, measurement and valuation of all resources used in the delivery of the service that combined direct costs (capital equipment, accommodation, labour) with indirect costs (patients' and accompanying persons' time, "out of pocket" costs for examination fee and visits). RESULTS: The estimates for direct and indirect costs varied among the healthcare systems, being highest in Malmö and lowest in Leuven. Variation in direct costs was mainly owing to different capital costs for the CBCT equipment arising from differences in purchase prices (range €148 000-227 000). Variation in indirect costs were mainly owing to examination fees (range €0-102.02). CONCLUSIONS: Cost analysis provides an important input for economic evaluations of diagnostic methods in different healthcare systems and for planning of service delivery. Additionally, it enables decision-makers to separate variations in costs between systems into those due to external influences and those due to policy decisions. A cost evaluation of a dental radiographic method cannot be generalized from one healthcare system to another, but must take into account these specific circumstances.

Dentists reflect on their problem-based education and professional satisfaction.

AIM: To determine the way in which Malmö University dental graduates perceive their problem-based dental education and evaluate their professional satisfaction. METHOD: The first five cohorts (graduating in years 1995-1999) of the problem-based curriculum were invited to participate. Of 166 graduates, 77% responded to a questionnaire comprising 20 questions on aspects of their dental education, professional situations and interest in postgraduate education. They were asked to rank their perception of their dental education and satisfaction with their professional situation on a visual analogue scale (VAS) with endpoints ranging from 'Not at all' (1) to 'Very well' (10). For other statements, the markings were made on a Likert scale from 1 (not important/not satisfied) to 5 (very important/very satisfied). There were also open-ended questions. RESULTS: Most respondents perceived their education to prepare them well for a career in dentistry (median score VAS 8), and 90% rated above six on a VAS for their professional satisfaction as dentists. Importance and satisfaction were highly correlated with principles of the curriculum: holistic view, oral health, lifelong learning, integration between theory and clinic, and clinical competence. Forty-five per cent of the graduates noted the problem-based learning approach as the most valuable asset of their education, and 19% cited training in oral surgery as a deficit. Of the respondents, 77% expressed interest in specialist training and 55% in research education. CONCLUSION: Problem-based education was perceived to prepare graduates well for their profession, and their professional satisfaction was high.

Antibiotic prophylaxis in oral healthcare - the agreement between Swedish recommendations and evidence.

BACKGROUND: Almost all (17/20) Swedish counties have pharmaceutical committees that establish recommendations for the use of antibiotic prophylaxis in oral healthcare.Objective To evaluate the evidence for the use of antibiotic prophylaxis in oral healthcare and the agreement between Swedish recommendations and evidence. MATERIAL AND METHODS: We conducted a systematic literature search in PubMed and the Cochrane Controlled Trials Register. The MeSH terms 'antibiotic prophylaxis' and 'dentistry' were used in the database search. Abstracts were reviewed according to specific inclusion and exclusion criteria. A total of 186 articles were read in full text by the four authors independently. Data extraction and interpretation of data was carried out using a pre-defined protocol. In the end, one case-control study was included for evaluation of evidence. RESULTS: The case-control study included patients with specific cardiac conditions. The study reported a 49% protective efficacy (odds ratio: 0.51) of antibiotic prophylaxis for first-time episodes of endocarditis within 30 days of procedure. This result was not statistically significant. The quality of the evidence was low. No studies were evaluated on patients with other medical conditions. The recommendations included several cardiac and other medical conditions for which there is a lack of evidence or no evidence to support the use of antibiotic prophylaxis. CONCLUSIONS: There is a lack of evidence to support the use of antibiotic prophylaxis. To avoid the risk of adverse events from antibiotics and the risk of developing resistant bacterial strains, the use of antibiotic prophylaxis should be minimised and recommendations in Sweden should be revised to be more evidence-based.

Evidence-based care and the curriculum.

An evidence-based (EB) approach has been a significant driver in reforming healthcare over the past two decades. This change has extended across a broad range of health professions, including oral healthcare. A key element in achieving an EB approach to oral healthcare is educating our practitioners, both current and future. This involves providing opportunities integrated within simulated and actual clinical settings for practitioners to learn and apply the principles and processes of evidence-based oral healthcare (EBOHC). Therefore, the focus of this discussion will be on ways in which EBOHC and associated research activities can be implemented into curricula, with the aim of improving patient care. This paper will initially define the scope of EBOHC and research, what these involve, why they are important, and issues that we need to manage when implementing EBOHC. This will be followed by a discussion of factors that enable successful implementation of EBOHC and research into curricula. The paper concludes with suggestions on the future of EBOHC and research in curricula. Key recommendations related to curricula include strengthening of the culture of a scientific approach to education and oral healthcare provision; complete integration of EBOHC into the curriculum at all levels; and faculty development to implement EBOHC based on their needs and evidence of effective approaches. Key recommendations to support implementation and maintenance of EBOHC include recognition and funding for high-quality systematic reviews and development of associated methodologies relevant for global environments; building global capacity of EBOHC researchers; research into improving translation of effective interventions into education and healthcare practice, including patient-reported outcomes, safety and harms, understanding and incorporation of patient values into EB decision-making, economic evaluation research specific to oral healthcare and effective methods for changing practitioner (faculty) behaviours; and extend access to synthesized research in 'user friendly' formats and languages tailored to meet users' needs. Realizing these recommendations may help to improve access to effective healthcare as a basic human right.

The oral ecosystem: implications for education.

We propose a model that is applicable to oral health education. The model describes the oral cavity in a complexity-based ecological context. This concept includes the premise that factors from different organisational levels (biological, individual, community, society) interact in a complex way with the potential to 'stress' the ecosystem and thereby provoke changes. This mode of action complies with the understanding of the oral cavity as a complex adaptive system. An ecological model is actively used in the undergraduate problem-based curriculum at the Faculty of Odontology, Malmö University, Sweden and has recently been applied as a conceptual basis for the new dental curriculum being established at the University of Tromsø in Northern Norway. The purpose is to encourage and promote an ecological, health-oriented view and to stimulate reflections on premises for oral health and diseases in an integrated context.

Formation of a hard tissue barrier after pulp cappings in humans. A systematic review.

AIM: To evaluate the evidence on the formation of a hard tissue barrier after pulp capping in humans. METHODOLOGY: A PubMed and CENTRAL literature search with specific indexing terms and a hand search were made. The authors assessed the level of evidence of each publication as high, moderate or low. Based on this, the evidence grade of the conclusions was rated as strong, moderately strong, limited or insufficient. RESULTS: The initial search process resulted in a total of 171 publications. After reading the abstracts and hand searching the reference lists of the retrieved publications, 107 studies were retrieved in full-text and interpreted. After the interpretation, 21 studies remained and were included in the systematic review and given a level of evidence. No study had a high level of evidence, one study had moderate and 20 studies had a low level of evidence. There was heterogeneity between the studies; therefore, no meta-analysis was performed. The majority of studies on pulp capping using calcium hydroxide based materials reported formation of hard tissue bridging, studies on other pulp capping materials such as bonding agents presented inferior results. The evidence grade was insufficient. CONCLUSIONS: Insufficient evidence grade does not necessarily imply that there is no effect of a pulp capping procedure or that it should not be used. Rather, the insufficient evidence underpins the need for high-quality studies.

Third molar treatment outcome: a comparison of patients' preferences in Sweden and Wales.

AIM: To elucidate and compare patients' outcome preferences for removal and retention of mandibular third molars in Sweden and Wales. SUBJECTS AND METHOD: The subjects comprised patients referred and scheduled for removal of one or both mandibular third molars in Sweden and Wales. The multi-attribute utility (MAU) methodology was applied to study patients' preferences for outcomes of removal and retention of the mandibular third molar. RESULTS: Relative weighting of domains was similar in the two countries. "Home and social life" received the highest relative weighting in Sweden and "general health and wellbeing" in Wales. "Your appearance" received the lowest relative weighting in both countries. In both Sweden and Wales operative jaw fracture was considered to be the outcome with most impact, and dentigerous cyst and imbricated incisors the least impact. Outcome ranking was similar in both countries and operative outcomes were considered by patients to be more detrimental to health than retention outcomes. CONCLUSIONS: This comparison showed that patients' preferences in Sweden and Wales were similar and that the outcomes of surgery were considered worse after third molar removal than retention. Patient-orientated treatment decisions were less subject to variation than clinician-orientated decisions.

Continuing professional development--global perspectives: synopsis of a workshop held during the International Association of Dental Research meeting in Gothenburg, Sweden, 2003. Part 1: access, funding and participation patterns.

There appears to have been little previous research interest in continuing professional development (CPD) of dentists and the oral health team. This paper presents data and information on the following aspects of CPD in 17 countries in Asia, Australasia, Europe and North America: availability of different types of CPD, its providers, data on uptake of CPD courses and activities, and funding of CPD. The results indicate that lectures and hands-on skills courses were held in all 17 countries but the use of the Internet to deliver CPD was by no means universal. CPD was funded from a variety of sources including universities, governments and commercial companies. However, the only universal source of funding for CPD was dentists themselves. Data on participation were available from only three countries. Research issues based on these results will be listed in a second paper.

Continuing professional development--global perspectives: synopsis of a workshop held during the International Association of Dental Research meeting in Gothenburg, Sweden, 2003. Part 2: regulatory and accreditation systems and evidence for improving the performance of the dental team.

This paper is the second in a series of two that report on continuing professional development (CPD). Details of the informants and the methodologies used were reported in the first paper. This paper reports the data and information presented on the topics of regulatory and accreditation systems for CPD and evidence that CPD improves the performance of the oral health team. By June 2003, participation in CPD was mandatory in most of the states of the USA, all Canadian Provinces, the UK and Latvia and was likely to become mandatory in a number of other countries in the near future. A variety of accreditation systems were reported including collecting CPD points, which in some countries were weighted depending on the type of CPD activity, and re-certification examinations. Very few studies for the effectiveness of dental CPD were identified. However, in general it was concluded that there is little evidence for the effectiveness of CPD for the oral health team. The main recommendation from this study is that a systematic review of the effectiveness of CPD in improving the performance of the oral health team and patient based outcomes be undertaken. A range of other research questions was also identified including: how can CPD be best matched to clinicians' needs rather than demands?

Dentists' decisions on prophylactic removal of mandibular third molars: a 10-year follow-up study.

OBJECTIVES: In recent years, several critical outcome studies concerning the prophylactic removal of mandibular third molars have been published. These would appear to motivate a more restrictive approach today as compared with 10 years ago. The aim of the present study was to examine dentists' decisions on the prophylactic removal of impacted mandibular third molars over a 10-year period. METHODS: Thirty-six cases were selected so as to represent an equal distribution of males and females, ages, angular position and degree of impaction of the molar. Twenty-six general dental practitioners (GDPs) and 10 oral surgeons judged the same cases on two occasions 10 years apart. RESULTS: Calculated for each category of dentists, there was no significant difference in the mean number of molars designated for removal between the two occasions. Two GDPs and three oral surgeons presented a higher removal rate, whereas five GDPs presented a lower removal rate on the second occasion as compared to the first one. The dentists presented a considerable interindividual variation in removal rate, between 0 and 22 molars on the first occasion and between 0 and 25 molars on the second occasion. CONCLUSION: In the decisions on prophylactic removal of mandibular third molars, there has been no change over the last 10 years towards a more noninterventionist attitude. Thus, the dentists seem not to have been influenced by the evidence that this intervention is not cost-effective.

Comparison of decisions regarding prophylactic removal of mandibular third molars in Sweden and Wales.

OBJECTIVE: To test the hypothesis that Swedish dentists schedule more mandibular third molars for prophylactic removal compared with UK dentists and oral surgeons. DESIGN: Clinical and radiographic information relating to a stratified sample of 36 disease-free mandibular third molars (equal distribution of males and females, patients' age, angular position and degree of impaction) was presented to 26 general dental practitioners (GDPs) and 10 oral surgeons in Sweden and 18 GDPs and 10 oral surgeons in Wales who were asked to decide whether or not the third molars should be removed. RESULTS: There was no evidence of any difference in mean number of molars scheduled for removal by the GDPs, but the Swedish oral surgeons scheduled significantly more third molars for removal than oral surgeons in Wales. CONCLUSION: The less interventionist approach among oral surgeons in the UK may reflect the development and application of authoritative guidelines in the UK and an extensive debate concerning appropriateness of prophylactic removal there.

Decision analysis in dentistry--the last 30 years.

OBJECTIVES: To review publications in dentistry of decision analyses during the last 30 years. METHODS: A systematic review of the English literature from 1969 to 1998 was performed using specified indexing terms. The number of retrieved articles in dentistry was compared with the number of articles in medicine. The quality of articles in dentistry presenting a decision tree with utilities and a sensitivity analysis was judged using a published peer review process. We report weaknesses of the analyses together with selected applications. RESULTS: Sixty-seven articles were published on decision analysis in dentistry. Whilst the number of articles published in medicine has accelerated there has been a decline in the last four years in dental publications. Only 22 of the articles in dentistry presented a decision analysis with utilities and a sensitivity analysis. CONCLUSIONS: Current weaknesses of the decision analyses reported were: opaque basic assumptions in the description of the analysis, lack of data on patient preferences and of reliable data on the chances of the long-term effects and side effects of intervention together with an absence of sensitivity analyses. The decision analysis approach complements that of "evidence-based health care" by enabling the best empirical evidence to be used in clinical practice. Formal methods such as decision analysis will promote the rational use of existing knowledge. For it to do this the quality of research data will have to improve in dentistry. Furthermore decision analysis is important in education to demonstrate explicitly how decisions might be arrived at and improved.

The outcomes of mandibular third molar removal and non-removal: a study of patients' preferences using a multi-attribute method.

The aim was to study patients' preferences about outcomes of mandibular third molar removal and non-removal using multi-attribute utility (MAU) methodology. The study comprised three stages. Stage 1: Elicitation of domains, i.e. main areas of patients' lives which could be affected by third molar removal and non-removal. Stage 2a: Interdomain weighting was obtained by relative weighting of the domains elicited in Stage 1. Stage 2b: Intradomain weighting obtained by patients' designation of values for different health states of each domain. Stage 3: Rating of outcomes. The patients were asked to imagine experiencing a variety of outcomes of mandibular third molar removal and non-removal, described in 19 short vignettes. The numbers of patients interviewed for the three stages were 30, 78, and 55, respectively. Five domains were identified. The mean relative weightings were approximately equal for the domains "Home and social life" and "General health and well-being", followed in order of importance by 'Job and studies" and "Health and comfort of mouth, teeth and gums". "Your appearance" received the lowest mean relative weighting. The vignette, which described the presence of a fluid-filled sac and suggested that this tooth must be removed, received the highest mean preference (least effect on patients' lives). The lowest mean preference (most effect on patients' lives) was generated by the vignette, which stated that the jaw was broken and that the teeth must be wired together for 6 weeks. We conclude that, from the patient's perspective, outcomes of non-removal were preferable to outcomes of mandibular third molar removal.