Impact of stress on dentists' clinical performance. A systematic review.

INTRODUCTION: Dentistry is recognised as a stressful profession and dentists perceive their profession to be more stressful than other healthcare professions. While earlier studies have shown a link between stress and well-being among dentists, whether stress negatively impacts their clinical performance is an important and open question. We do know, however, that stress is associated with reduced performance in other health (and non-health) related professions. OBJECTIVES: This systematic review aimed to answer the question: how does stress impact on dentists' clinical performance? METHODS: This systematic review was registered in PROSPERO (CRD42016045756). The CINHAL, Embase, Medline, PsycINFO, EThOS and OpenGrey electronic databases were searched according to PRISMA guidelines. Two reviewers independently screened the citations for relevance. The citation list of potentially eligible papers was also searched. Prospective empirical studies were considered for inclusion. The inclusion criteria were applied at the full-text stage by the two same reviewers independently. RESULTS: The search yielded 3535 titles and abstracts. Twelve publications were considered potentially eligible, eleven of which were excluded as they did not meet the predefined inclusion criteria. CONCLUSIONS: This systematic review identified a gap in the literature as it found no empirical evidence quantifying the impact of stress on dentists' clinical performance. Prospective well-designed experimental simulation studies, comparing stress with non-stress situations on clinical performance and decision making, as well studies evaluating prospectively real-life dentists' performance under stress are warranted.

What's in a bin: A case study of dental clinical waste composition and potential greenhouse gas emission savings.

BACKGROUND: Dental practices have a unique position as dental staff use a high number of dental materials and instruments on a daily basis. It is unclear how dentists' and dental care professionals' choices and behaviours around selecting and using materials impact on the amount of unnecessary waste production. Although there are a number of articles exploring the quality and quantity of waste in dental practices, there are no studies on organisational strategies to decrease unnecessary waste. There is no clear economic analysis of the impact on associated cost to dental practices which consequently can affect the access of dental care for disadvantaged groups. METHODS: This study used an audit approach to explore the potential for sustainability in dental practice by measuring the nature and quantity of dental clinical waste, and assessing the feasibility of measuring the financial costs and potential carbon savings in the management of dental clinical waste. CONCLUSIONS: The data from our study would appear to support the view that it is possible to reduce carbon emissions and increase profitability. Successful implementation of an environmentally sustainable approach to waste management will be dependent on the practicalities involved and the financial incentives for adopting such practices.

Social anxiety in orthognathic patients.

There is evidence that patients seeking orthognathic treatment may be motivated by social anxiety disorder (SAD). The aim of this study was to investigate SAD in orthognathic patients using the Brief Fear of Negative Evaluation Scale (BFNES) and to compare these findings with those of the general population. This was a cross-sectional, questionnaire study conducted in two parts. Firstly, a national survey was conducted to yield data for the BFNES from a large, random sample of the UK general population. Secondly, orthognathic patients completed the BFNES. The BFNES scores are reported in two formats: the original 12-item scale (O-BFNES) and a shorter eight-item version (S-BFNES). With regards to the national survey, 1196 individuals participated. The mean O-BFNES score was 29.72 (standard deviation (SD) 9.39) and S-BFNES score was 15.59 (SD 7.67). With regards to the orthognathic sample, 61 patients participated. The mean O-BFNES score was 39.56 (SD 10.35) and the mean S-BFNES score was 24.21 (SD 8.41). Orthognathic patients had significantly higher scores than the general UK population (P<0.001), and multiple linear regression revealed that age, gender, and patient status were all independent predictors of BFNES scores. From the results of this study, orthognathic patients experience significantly higher levels of social anxiety than the general population.

Student perceptions of a spiral curriculum.

AIM: The aim of this study was evaluation of constructive alignment of student perceptions to a spiral curriculum, as a pre-requisite to successful learning. METHOD: A survey was undertaken to evaluate student thoughts and experiences of a spiral curriculum, by participation in an anonymous voluntary questionnaire. Students were asked to rate their thoughts on their understanding, perceived benefit of and confusion with their spiral curriculum at the current time and retrospectively during previous years, and to answer free-text questions on the impact, effects on learning and future suggestions for their spiral curriculum. RESULTS: Sixty (86%) students completed the questionnaire. Understanding the spiral curriculum worked enhanced with time, with the benefit of the spiral curriculum being felt more conclusively in the latter years, and the majority of students not being confused by the spiral curriculum. Those students who were most confused by the spiral curriculum were the ones who were least likely to appreciate its benefits. The opportunity for consolidation of previously visited knowledge was a perceived predominant advantage, with re-visitation of topics helping to deepen understanding and learning. Clarity on the depth of knowledge at each stage prevents information overload. A spiral curriculum must spiral and not be a repetition of previously delivered topics. CONCLUSIONS: This study provided insights into students' perceptions of an integrated spiral curriculum, and whilst predominantly positive, there are challenges to enhance the student experience. The spiral curriculum provides an opportunity to revisit and consolidate learning to the apparent benefit of the student.

Identifying dentists' attitudes towards prevention guidance using Q-sort methodology.

OBJECTIVE: To gain insight into the attitudes and motivating factors of dentists working in the English National Health Service (NHS) towards prevention guidance. DESIGN: Q-methodology: an established hybrid quantitative/qualitative technique used in the social sciences to categorise subjects based on their views by considering factors as part of their overall decision-making profile. SETTING: General Dental Practices offering care under an NHS contract. SUBJECTS AND METHODS: NHS dentists (n = 26) placed 36 statements about prevention guidance derived from an earlier study into a distribution grid that ranked the statements from "most agree" to "most disagree". Principal components factor analysis was applied to determine the principal patterns in the rankings of statements. RESULTS: Analysis indicated a total of six distinct profiles within the responses, of which three profiles had at least six dentists loading onto them. The first profile was strongly characterised by dentists who appear motivated to provide prevention but financial and time constraints prevent them from doing so. The second was characterised by dentists using prevention guidance but restricting its use to only certain patients. The third was characterised by dentists who appeared "health-focused". They placed importance on working to prevention guidance, but were keen to have greater patient and professional support in achieving this. CONCLUSION: In this group of dentists Q-methodology identified three main profiles to the delivery of prevention guidance.

Person-centred care in dentistry--the patients' perspective.

OBJECTIVES: To develop an understanding of the key features of person-centred care (PCC) in relation to general dental practice from a patient's perspective. BACKGROUND: PCC is acknowledged as an important dimension of quality with 'patient experience' increasingly used as a marker of quality within the NHS. A Dental Quality and Outcomes Framework (DQOF) is currently being piloted in the UK, which includes patient experience as one of the three domains. It is recognised that there is limited understanding of PCC within dentistry, with little evidence published on the subject. METHODS: This study uses qualitative methods to explore the views of 16 purposively sampled patients living in Southwest England. In-depth semi-structured interviews were recorded, transcribed, coded and analysed thematically. RESULTS: PCC was viewed as key in the delivery of high-quality care. Dimensions of PCC were identified and categorised as relational or functional aspects of care. Relational aspects of care were viewed as being central to the delivery of PCC with five components identified and named: connection, attitude, communication, empowerment and feeling valued. Functional aspects of care were identified as healthcare system and physical environment and were noted to influence PCC to a variable degree. CONCLUSION: A model of PCC in dentistry is proposed which has been generated from empirical evidence that represents the views of patients. It is hoped that this may inform and influence development of a tool to measure PCC within any future version of the DQOF.

Body mass index as a predictive factor of periodontal therapy outcomes.

Body mass index (BMI) and obesity are associated with the prevalence, extent, and severity of periodontitis. This study investigated the predictive role of overweight/obesity on clinical response following non-surgical periodontal therapy in patients with severe periodontitis. Two hundred sixty adults received an intensive course of non-surgical periodontal therapy. Periodontal status at baseline and 2 months was based upon probing pocket depths (PPD), clinical attachment levels (CAL), and whole-mouth gingival bleeding (FMBS) as assessed by two calibrated examiners. Generalized estimating equations (GEE) were used to estimate the impact of BMI and overweight/obesity on periodontal treatment response while controlling for baseline status, age, smoking status (smoker or non-smoker), and full-mouth dental plaque score. BMI (continuous variable) and obesity (vs. normal weight) were associated with worse mean PPD (p < .005), percentage of PPD > 4 mm (p = .01), but not with FMBS (p > .05) or CAL (p > .05) at 2 months, independent of age, smoking status, or dental plaque levels. The magnitude of this association was similar to that of smoking, which was also linked to a worse clinical periodontal outcome (p < .01). BMI and obesity appear to be independent predictors of poor response following non-surgical periodontal therapy.

Barriers and facilitators that influence the delivery of prevention guidance in health service dental practice: a questionnaire study of practising dentists in Southwest England.

UNLABELLED: Objective: OBJECTIVE: To investigate the barriers and facilitators influencing the delivery of prevention in accordance with a national guideline (Delivering Better Oral Health, Department of Health England) in health service dental practice. DESIGN: Self-completion questionnaire. SETTING: Health service general dental practices. SUBJECTS AND METHODS: Questionnaires were sent via two mailings to all 508 dentists registered to work in health service general dental practice in Devon, South West England. RESULTS: In total 266 questionnaires were returned (52% response rate). Examples of barriers and facilitators were evident at various organisational levels of dentistry. These were principally the healthcare system, practice (dental office) arrangements and professional factors. Respondents gave positive responses to questions concerning the flexibility (53%) and benefit of the guideline (63%) and they tended to indicate that they didn't perceive problems in changing their old routines (58%). Opinion was divided among respondents on whether they felt patients followed their advice (49%). There was overall agreement that delivering prevention in practice is problematic if there are insufficient staff (68%), facilities (53%) and time (60%). Encouragingly most respondents felt adequately trained to deliver the evidence based prevention guidance (59%). CONCLUSIONS: This study has identified some barriers and facilitators to the delivery of prevention guidance in this group of health service dentists with no single factor viewed consistently as more important than any others. A further qualitative study is planned to investigate in more depth the reasons underpinning the responses given in this study.

Patient-centred care in general dental practice: sound sense or soundbite?

This paper explores the concept of patient-centred care as a dimension of quality as applied to dentistry and provides a systematic review of the literature. The new NHS dental contract, which is currently being piloted in England, is committed to delivering improvements in quality. The Dental Quality and Outcomes Framework has been developed as a tool to measure quality and focuses on three key dimensions: clinical effectiveness, safety and patient experience. A systematic review of the literature reveals a lack of information pertaining to patient-centred care within dentistry, and in particular general dental practice. It would also suggest that there is currently a poor evidence base to support the use of the current patient reported outcome measures as indicators of patient centredness.

The prevalence of opportunistic pathogens associated with intraoral implants.

AIMS: The aim of this study was to determine the prevalence and proportions of opportunistic pathogens harboured on orthodontic retainers. METHODS AND RESULTS: First, Staphylococcus spp. and Candida spp. were isolated from the retainer's inner surface and from other mucosal surfaces of the subject's mouth by routine bacterial culture. The prevalence and proportions of these micro-organisms on retainers was compared in different areas of the mouth within a group of retainer wearers, and mucosal carriage was compared to a group of nonretainer wearers. Staphylococcus spp. were isolated from 50% of the retainers and comprised on average 8·4% of the viable microbiota. Candida spp. comprised 0·13% of the viable microbiota and were recovered from 66·7% of the retainers. Neither genus was isolated from nonretainer wearers. Second, the two most commonly worn retainers manufactured from different materials were sampled; again Staphylococcus spp. and Candida spp. were recovered; however, no statistical differences were observed between the devices. CONCLUSIONS: Opportunistic, nonoral, pathogenic micro-organisms were recovered from orthodontic retainers. SIGNIFICANCE AND IMPACT OF THE STUDY: It is possible that an orthodontic retainer could be a reservoir for opportunistic pathogens and act as a source of cross-, self- and re-infection.

Comparison of the instructional efficacy of an internet-based temporomandibular joint (TMJ) tutorial with a traditional seminar.

There has been growing interest in the use of virtual learning environments (VLEs) by universities over the past decade to supplement traditional teaching methods. In this study a tutorial providing information about the temporomandibular joint (TMJ), temporomandibular disorders and teaching of a thorough TMJ examination was developed on a VLE platform to enable students to enhance their examination and diagnostic skills. The success of this VLE tutorial was compared with conventional teaching by a cross-over trial. Thirty students were initially randomly allocated to one of two groups; Group 1 completed the VLE tutorial and Group 2 attended the face-to-face seminar in the first instance. The groups then crossed over and had the other method of teaching provided. The findings from the cross-over trial and the students' feedback indicated that no differences were found between either teaching modes, and both are equally effective at delivering information to students. In addition, the order in which the students received the teaching did not make a difference, but giving the teaching twice reinforced their knowledge. There is a strong case to be made for introducing clinical lectures on a VLE platform, and this form of e-learning is, in general, well perceived by new generations of students.

The influence of varying maxillary incisal edge embrasure space and interproximal contact area dimensions on perceived smile aesthetics.

OBJECTIVE: The aim of this study was to determine the influence of incisal edge embrasure space and interproximal contact area dimensions on perceived smile aesthetics. DESIGN: Cross-sectional study. SETTING: Postgraduate dental teaching hospital. METHODS: A photograph of a smiling female, displaying only the lips and maxillary teeth was digitally altered. First, the proportions of the incisal edge embrasure spaces were modified to produce five different images. Secondly, the lengths of the interproximal contact areas were altered to produce five different images. The two sets of photographs were ranked from 'most attractive' to 'least attractive' by 35 dentists, 35 dental technicians and 35 patients. RESULTS: An embrasure space arrangement where the size of the embrasures increases progressively distally from the midline was deemed most attractive; absence of embrasure spaces was deemed least attractive. In assessing the interproximal contact areas, all groups assessed an arrangement where the areas between the teeth were equal (and 50% the length of the central incisor) as most attractive, and where the contact areas increased in length progressively distally from the midline as least attractive. There were few statistically significant differences between the groups in these perceptions. CONCLUSION: Whilst there is broad agreement in what the participant groups deem to be aesthetic, our findings do not wholly correspond to the 'ideals' that have been previously suggested in the dental literature.

Potential oral manifestations of cardiovascular drugs.

OBJECTIVE: The aim of this work was to determine the frequency and nature of oral manifestations secondary to use of cardiovascular drugs. METHODS: Five hundred and thirty one patients attending an adult cardiology clinic in Saudi Arabia were questioned about the occurrence of oral dryness, dysgeusia, or burning sensation and were clinically evaluated for the presence of oral mucosal or gingival disease. Data were statistically analyzed with chi-squared tests, odds ratios and Student's t-test. RESULTS: Oral symptoms and/or signs were recorded in 75 (14.1%) patients with xerostomia being the most common (7.5%), followed by lichenoid (lichen planus-like) lesions (3.6%) and dysgeusia (1.9%). Xerostomia was significantly more frequent in patients with a history of diabetes mellitus and in female patients (P < 0.05). There were no statistically significant differences (P > 0.05) between patients with or without oral manifestations when age, gender, cardiovascular risk factor, cardiac disease, type of cardiac drug used or the number of medications were assessed. There was a trend for xerostomia to be less frequent in patients receiving therapy with angiotensin converting enzyme inhibitors and a slight trend of xerostomia to be more likely with increased number of non-cardiac and total number of agents per subject. The number of non-cardiac and total medications taken by patients with potential oral manifestations tended to be greater than that of patients without oral manifestations. CONCLUSIONS: The frequency of potential oral manifestations in patients receiving cardiovascular agents was 14.1%. The occurrence and character of the oral manifestations had no significant relation with individual cardiac drugs, although there was a trend for oral manifestations to be likely with increasing number of drugs.

The oral health status of adults with a visual impairment, their dental care and oral health information needs.

AIM There is little information available concerning the impact of visual impairment upon oral health. The present study sought to identify the oral health and experiences of adults with a visual impairment together with the nature, source and access to oral health information. In addition the study evaluated the oral health status of a group of individuals with a visual impairment with respect to oral health markers, treatment choice and attendance patterns in comparison to a reference group from the general population in the United Kingdom. METHOD One hundred adults with a visual impairment were examined and completed a questionnaire concerning their experience of oral health care and available information sources. The information collected was directly compared with data from the Adult Dental Health Survey 1998 for the south region of England. RESULTS The present group of individuals with a visual impairment had better oral hygiene practices, and similar levels of oral hygiene and hard tissue disease to those of a comparable group of the Adult Dental Health Survey 1998 (ADHS 1998). However 24% of those with a visual impairment were not registered with a dentist and 26% of the patients wished for appropriate information concerning oral health care. CONCLUSIONS There is a need to develop oral health promotion that ensures patients with a visual impairment have appropriate information regarding oral health care and its provision.

Orthodontic referral behaviour of West Sussex dentists.

OBJECTIVES: 1) To examine the orthodontic referral behaviour of dentists and 2) to examine dentists' familiarity with the Index of Orthodontic Treatment Need (IOTN). DESIGN: Postal questionnaire survey. SETTING: West Sussex Primary Care Trust (PCT) from September to December 2006. SUBJECTS AND METHODS: Questionnaires were sent to all dentists listed on the West Sussex PCT database, except those assumed not to make orthodontic referrals (n = 325). RESULTS: Two hundred and twenty-nine questionnaires were returned, representing a 70% response rate. Fifty-two percent of dentists in West Sussex correctly identified which type of orthodontic provider to refer three different malocclusions using picture tests. Twenty percent of dentists made correct decisions on the timing of referral for three different malocclusions using picture tests. IOTN is not routinely used by 76% of West Sussex dentists when making an orthodontic referral. CONCLUSIONS: This study provides evidence that there is a need for postgraduate training or the development of referral guidelines to assist West Sussex dentists in making referrals for orthodontic treatment to the most appropriate provider at the most appropriate time. If dentists are to act as gatekeepers of orthodontic provision on the NHS there is a need to provide more support and education for them about the use of IOTN.

Factors which influence working patterns of orthodontists in the United Kingdom.

OBJECTIVE: To describe factors which influence the current working patterns of orthodontists in the United Kingdom. DESIGN AND SETTING: A cross-sectional postal questionnaire to orthodontic specialists in the United Kingdom. SUBJECTS: All those on the specialist list in orthodontics held by the General Dental Council in 2006-2007. MATERIALS AND METHODS: The data gathered included demographic details (gender, ethnicity, age, professional status and number of children), calendar year of achieving professional qualifications and current working patterns, together with details of any career breaks taken and geographical location of work. RESULTS: The response rate was 81.5%. Male and female orthodontists were seen to have different working patterns. The difference was statistically significant with male orthodontists undertaking clinical work on average 1.5 sessions more per week than their female colleagues. The calendar year of completion of undergraduate studies and the number of children an orthodontist has can significantly affect the number of clinical sessions they work each week. In recent years it has been observed that there is greater ethnic diversity among the workforce but ethnic origin appeared to have a minimal effect on the number of clinical sessions worked each week. The amount and length of career breaks taken by female orthodontists was greater than their male colleagues. In addition, there continues to be an uneven distribution of orthodontists throughout the United Kingdom. CONCLUSION: Many factors influence the current working patterns of orthodontists in the United Kingdom. However, it may be the inequitable regional distribution of orthodontists throughout the United Kingdom which is of greatest significance to orthodontic workforce planning for the future.

Investigation of the effect of a proprietary dental waterline disinfectant on shear bond strengths of Panavia 21 to enamel and dentine.

This study investigated the effect of 'Alpron mint', a dental unit waterline disinfectant, on shear bond strengths between 'Panavia 21' resin based cement and tooth tissue. Eighty-eight human premolar tooth specimens were prepared in either enamel (N=44) or dentine (N=44). Half the specimens within each group were irrigated with an Alpron mint solution and the other half with distilled water (control) prior to application of Panavia 21 resin luting cement. There was no significant difference in shear bond strengths for both enamel and dentine with Alpron mint irrigation compared with distilled water (P = 0.245).

Hospital admissions for dental care in children: England 1997-2006.

OBJECTIVE: To determine the pattern of hospital admissions for dental care of children and adolescents between 1997 and 2006. DESIGN: Retrospective analysis of data from the Hospital Episodes Statistics (HES) database (1 April 1997 to 30 March 2006) if the patient was aged up to 17 years old and their primary diagnosis was a dental condition. OUTCOME MEASURES: Primary diagnosis, treatment provided, socioeconomic status. RESULTS: There were 517,885 NHS episodes of care for dental conditions in 470,113 children. Over half of the admissions were primarily for dental caries and 80% of all the admissions involved extractions. The peak age for caries-related extractions was five years old. There was a steady increase in the annual number of episodes of care with most of the increased activity attributable to a 66% increase in extractions for caries. More episodes of care were provided for children who lived in relatively deprived areas compared to more affluent areas. CONCLUSIONS: Data from the HES highlights a major public health issue. Caries is a preventable disease yet the number of children being admitted for elective extractions of teeth due to caries was increasing yearly. Further investigation to determine some of the underlying reasons for this trend is required.