A review of strategies to stimulate dental professionals to integrate smoking cessation interventions into primary care.

OBJECTIVE: To summarise evidence regarding the effectiveness of various implementation strategies to stimulate the delivery of smoking cessation advice and support during daily dental care. BASIC RESEARCH DESIGN: Search of online medical and psychological databases, correspondence with authors and checking of reference lists. Only studies were selected which examined a support strategy to promote tobacco use cessation having a component to be delivered by a dentist, dental hygienist or dental assistant in the daily practice setting. Furthermore only controlled studies and systematic reviews were included. Methodological quality and outcomes were independently summarised and checked by two reviewers. RESULTS: Eight studies met the inclusion criteria: 4 addressed strategies aimed at the dental professional and 4 addressed strategies aimed at both professional and patient. Only 4 of the studies were of a good quality. The 8 studies used combinations of implementation strategies, which made it difficult to evaluate the effectiveness of distinct components. Professional education appeared to enhance motivation for smoking cessation activities and advice giving. Organisational interventions (e.g., protocols, involvement of the whole team, referral possibilities) and incorporation of patient-oriented tools also contributed to the delivery of smoking cessation interventions. CONCLUSIONS: Multifaceted support strategies positively influence dental professionals' knowledge of smoking and smoking cessation, their motivation to give advice and their performance. As only 4 studies were of good methodological quality, it was not possible to draw firm conclusions about specific components. Additional research is needed to unravel which strategies best stimulate the provision of smoking cessation advice and support during daily dental practice.

Experienced barriers and facilitators for integrating smoking cessation advice and support into daily dental practice. A short report.

In a controlled study, primary care dental professionals in the intervention group were encouraged to provide smoking cessation advice and support for all smoking patients with the help of a stage-based motivational protocol. The barriers and facilitators reported by the dental professionals on two occasions for their efforts to incorporate smoking cessation advice and counselling into daily patient care are summarised here. Lack of practice time and anticipated resistance on the part of the patient were cited as barriers by over 50% of the dental professionals in the first interviews. Periodontal treatment and the presence of smoking-related diseases were mentioned as the most important stimuli. The experience-based interviews revealed key points for the implementation of smoking cessation advice and support in daily dental care. Education on the associations between smoking and oral health, vocational training on motivational interviewing and the offering of structured advice protocols were identified as promising components for an implementation strategy to promote the involvement of dental professionals in the primary and secondary prevention of tobacco addiction.

Are oral health complaints related to smoking cessation intentions?

OBJECTIVE: Smoking influences oral health in several ways (such as the occurrence of periodontitis, teeth discolouration and oral cancer); therefore, smoking behaviour should be addressed in dental care. Dentists can play a role in primary and secondary prevention of tobacco dependence. They see their patients repeatedly over time. This study investigates whether oral health complaints can be seized as an opportunity to start smoking cessation counselling. METHODS: A structured patient questionnaire in a sample of 1101 smokers (52.1% women, mean age 40.4 years) in a convenience sample of 87 primary care dental practices. The I-change model was used to describe factors influencing behavioural change. Dependent factors such as intention to quit smoking and related factors (attitude, social support and self-efficacy) were analysed in relation to independent factors such as oral health complaints (gingiva problems, gingiva inflammation, oral cancer and discoloured teeth) using a general linear model (univariate analysis), multinomial logistic regression analysis and multiple linear regression analysis. RESULTS: A total of 56.3% had discoloured teeth, 27% of the smokers had a problem with their gums and 15.7% had gingiva inflammation. We found no direct relation between oral health complaints and the intention to quit smoking. However, teeth discolouration was positively related to attitudes towards smoking cessation [ß, Confidential interval (95%); 1.92 (1.45-2.40 for advantages and -0.86(-1.18 to -0.53) for disadvantages] and negatively to self-efficacy regarding quitting [-2.69 (-3.49 to 1.88)]. CONCLUSIONS: We found no direct relation between oral health complaints and the intention to quit smoking, but oral health complaints and especially teeth discolouration were related to factors influencing the quit intention. Patients with discoloured teeth are more likely to have a positive attitude towards smoking cessation but are uncertain to persist smoking cessation. It is suggested that teeth discolouration can be a good entrance for addressing smoking cessation in daily dental practice.

Impact of guideline implementation on patient care: a cluster RCT.

In Western European countries, dentists use standardized procedures, rather than individualized risk assessment, for routine oral examinations. The predictive hypothesis was that guideline implementation strategies based on multifaceted interventions would be more effective in patient care than the dissemination of guidelines only. A cluster-randomized trial was conducted, with groups of general dental practitioners (GDPs) as the unit of randomization. Patients were clustered within practices and prospectively enrolled in the trial. Patient data were collected from registration forms. The primary outcome measure was guideline-adherent recall assignment, and a secondary outcome measure was guideline-adherent bitewing frequency. The interventions consisted of online training, guideline dissemination, and educational sessions. For low-risk patients, guideline-adherent recall increased in the intervention group (+8%), which differed from the control group (-6.1%) (p = 0.01). Guideline-adherent bitewings showed mixed results. We conclude that multifaceted intervention had a moderate but relevant effect on the performance of GDPs, which is consistent with other findings in primary care.

[Dentistry and society]. / Tandheelkunde en samenleving.

In an editorial in the British Dental Journal (2007) E.J. Kay raised the question whether dentist-general practitioners have to be educated in dental schools affiliated with (academic) hospitals. Her hypothesis is that some 95% of graduating dentists enter in general practice and that the educational environment therefore should be there as well. In the present reaction it is argued that this is a bad idea because the complete separation of dental education from the academic medical environment would mean a drastic and undesirable limitation and impoverishment of the curriculum. At the same time it is not denied that outreach programmes in a dental school curriculum can be very meaningful.

What determines the provision of smoking cessation advice and counselling by dental care teams?

OBJECTIVE: To investigate determinants of the provision of smoking cessation advice and counselling by various dental professionals in the dental team (dentists, dental hygienists and prevention auxiliaries). DESIGN: Cross-sectional design. SETTING: Sixty-two general dental practices in the Netherlands. METHODS: Multivariate logistic analyses of self-reported counselling behaviour collected from questionnaires for dentists (n = 72), dental hygienists (n = 31) and prevention auxiliaries (n = 50) in general dental practices. MAIN OUTCOME MEASURES: Stimuli and barriers for smoking cessation counselling and advice behaviour to patients with or without oral health problems. RESULTS: Dental hygienists provided more general cessation advice and counselling than dentists. However, when patients had oral complaints, dentists counselled more often compared to prevention auxiliaries. The support from experienced colleagues positively influenced the provision of advice and counselling as well as the perceived self-efficacy for all kinds of dental professionals. CONCLUSIONS: The provision of general smoking cessation advice to patients with no acute oral complaints can be improved by more involvement of the dentist and/or task delegation to prevention auxiliaries and dental hygienists. Social support is important in encouraging more smoking cessation advice and counselling. Implementation strategies for support of smoking cessation in dental care should focus on creating a positive advice culture among colleagues.

[Stop smoking advice for patients who smoke: feasible in the dental practice?]. / Stopadvies aan rokende patiënten: haalbaar in de tandartspraktijk?

Smoking may cause periodontal diseases and raises the chance of getting oral cancer. The Dutch Guideline for the Treatment of Tobacco Addiction recommends that dental professionals explicitly advise all patients who smoke to stop smoking. In 12 dental practices a study was made of how the guidelines could be implemented. The strategy consisted of a patient protocol for minimal, one-time cessation advice or for more intensive supervision, a patient leaflet, centralized training for the dental team, and repeated monitoring with feedback on the patients' experience of the behaviour that they have been advised to follow. Before the training and again 3 months after, professionals (n = 38) and an a-select sample of smoking patients (n = 197) completed questionnaires. A majority of patients was receptive to cessation advice of a dentist (95%) or counseling (68%). After 3 months it appeared that patient behaviour as reported by patients with respect to all points of the patient protocol had significantly improved.

Curriculum content, structure and ECTS for European dental schools. Part II: methods of learning and teaching, assessment procedures and performance criteria.

This paper presents a brief context of dental undergraduate curricular structure and content and lays out the Association for Dental Education in Europe's views on requirements and recommendations for learning, teaching and assessment procedures/performance.

Quality assurance and benchmarking: an approach for European dental schools.

This document was written by Task Force 3 of DentEd III, which is a European Union funded Thematic Network working under the auspices of the Association for Dental Education in Europe (ADEE). It provides a guide to assist in the harmonisation of Dental Education Quality Assurance (QA) systems across the European Higher Education Area (EHEA). There is reference to the work, thus far, of DentEd, DentEd Evolves, DentEd III and the ADEE as they strive to assist the convergence of standards in dental education; obviously QA and benchmarking has an important part to play in the European HE response to the Bologna Process. Definitions of Quality, Quality Assurance, Quality Management and Quality Improvement are given and put into the context of dental education. The possible process and framework for Quality Assurance are outlined and some basic guidelines/recommendations suggested. It is recognised that Quality Assurance in Dental Schools has to co-exist as part of established Quality Assurance systems within faculties and universities, and that Schools also may have to comply with existing local or national systems. Perhaps of greatest importance are the 14 'requirements' for the Quality Assurance of Dental Education in Europe. These, together with the document and its appendices, were unanimously supported by the ADEE at its General Assembly in 2006. As there must be more than one road to achieve a convergence or harmonisation standard, a number of appendices are made available on the ADEE website. These provide a series of 'toolkits' from which schools can 'pick and choose' to assist them in developing QA systems appropriate to their own environment. Validated contributions and examples continue to be most welcome from all members of the European dental community for inclusion at this website. It is realised that not all schools will be able to achieve all of these requirements immediately, by definition, successful harmonisation is a process that will take time. At the end of the DentEd III project, ADEE will continue to support the progress of all schools in Europe towards these aims.

The long-term effect of a composite resin restoration on proximal contact tightness.

OBJECTIVE: The aim of this study was to investigate changes in proximal contact tightness up to 6 months after the restorative treatment. MATERIALS AND METHODS: In a randomised clinical trial Class II composite resin restorations were placed in 52 patients. Proximal contact tightness was measured before, directly after, and 6 months after treatment. These data were analysed statistically using linear regression and t-tests. RESULTS: Proximal contacts, that increased in tightness as result of the treatment tend to loose tightness after a 6-months period but remain tighter than before treatment. Proximal contacts, that decreased after treatment hardly change after 6 months. CONCLUSIONS: A change in contact tightness after restorative treatment will not always remain stable over time.

Curriculum structure and the European Credit Transfer System for European dental schools: part I.

This paper presents a proposed curriculum structure and system of European Credit Transfer (ECTS) for undergraduate dental schools throughout Europe. It is the result of the work of a Taskforce ('Taskforce II'), appointed by DentEd, a thematic network of European dental schools and the Association for Dental Education in Europe (ADEE). There has been pan-European discussion of the document in draft stages (it was distributed to 200 dental schools) and following amendment, it was agreed formally at the National Assembly of ADEE in Athens, Greece, in September 2005. The main elements of the paper relate to: (i) a description of the framework proposed with relevance to the Bologna recommendations and common directive on recognition for professional qualifications as they apply to Dentistry; (ii) the structure of an undergraduate dental curriculum; (iii) student exchange and ECTS. In addition, the paper presents a series of requirements, guidelines and recommendations for action. ADEE expects that the 'requirements' proposed will be followed by dental schools in Europe, whilst the 'guidelines' and 'recommendations' also provided are open to local interpretation. The paper is also published on the ADEE website.

Student evaluation of a problem-oriented module of clinical medicine within a revised dental curriculum.

As part of a revised dental curriculum, a 3(rd) year module on medical subjects was developed based on a mixture of self-study and problem-oriented approach using cases. Pairs of students had to select a specific medical problem and solve a paper patient case using a problem-solving cycle. Results were presented in working groups and by writing an essay. The quality of the presentations was assessed by colleague students and by the teacher supervisor; the expert teacher in the field graded the essay. The results contributed for 40% to the overall grade of the module. A questionnaire filled out by 94% of the participating students showed that 85% of the students agreed in preferring this way of handling medical problems as compared with conventional, lecture-based education. Almost all of them enjoyed the provided opportunity to give a case presentation. The problem-oriented model was assessed as useful by 73% of the students. Knowledge concerning the topic chosen turned out to be higher than knowledge of other topics. Although this study cannot prove that this mode of education actually results in a better ability to cope with medical problems, it may contribute in several ways to the final competences in the area of general medicine in the undergraduate dental curriculum.

Profile and competences for the European dentist.

This paper presents the profile and competences for the European Dentist as approved by the General Assembly of the Association for Dental Education in Europe at its annual meeting held in Cardiff in September 2004. A task-force drafted the document, which was then sent to all European Dental Schools. Reactions received were used to amend the document. European dental schools are expected to adhere to the profile and the 17 major competences but the supporting competences may vary in detail between schools. The document will be reviewed in 5 years time. This paper will be disseminated to ministries of health, national dental associations and dental specialty associations or societies in Europe and these organisations will be asked to offer their comments. This information will be used in the reviewing process to be started in 2007. It is hoped that the availability of this document will assist dental schools in Europe to further harmonize and improve the quality of their curricula.

Interventions for treating asymptomatic impacted wisdom teeth in adolescents and adults.

BACKGROUND: The prophylactic removal of asymptomatic impacted wisdom teeth is defined as the (surgical) removal of wisdom teeth in the absence of local disease. Impacted wisdom teeth have been associated with pathological changes, such as inflammation of the gums around the tooth, root resorption, gums- and alveolar bone disease, damage of the adjacent teeth, the development of cysts and tumours. Several other reasons to justify prophylactic removal have also been given. Wisdom teeth do not always fulfil a functional role in the mouth. When surgical removal is carried out in older patients the risk of more postoperative complications, pain and discomfort increases. Nevertheless, in most developed countries the prophylactic removal of trouble-free wisdom teeth, either impacted or fully erupted, has long been considered as 'appropriate care'. Prudent decision-making, with adherence to specified indicators for removal, may reduce the number of surgical procedures by 60% or more. It has been suggested that watchful monitoring of asymptomatic wisdom teeth may be an appropriate strategy. OBJECTIVES: To evaluate the effect of prophylactic removal of asymptomatic impacted wisdom teeth in adolescents and adults compared with the retention of these wisdom teeth. SEARCH STRATEGY: The following electronic databases were searched:The Cochrane Oral Health Group Trials Register (4 August 2004), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE (1966 to 4 August 2004), PubMed (1966 to 4 August 2004), EMBASE (1974 to 4 August 2004). There was no restriction on language. Key journals were handsearched. An attempt was made to identify ongoing and unpublished trials. SELECTION CRITERIA: All randomised or controlled clinical trials (RCTs/CCTs) comparing the effect of prophylactic removal of asymptomatic impacted wisdom teeth with no-treatment (retention). DATA COLLECTION AND ANALYSIS: Assessment of relevance, validity and data extraction were conducted in duplicate and independently by three reviewers. Where uncertainty existed, authors were contacted for additional information about randomisation and withdrawals. A quality assessment of the trials was carried out. MAIN RESULTS: Only three trials were identified that satisfied the review selection criteria. Two were completed RCTs and both assessed the influence of prophylactic removal on late incisor crowding in adolescents. One ongoing RCT was identified, but the researchers were unable to provide any data. They intend to publish in the near future and information received will be included in updates. Although both completed trials met the inclusion criteria of the review, regarding participants characteristics, interventions and outcomes assessed, different outcomes measures were assessed which prevented pooling of data. AUTHORS' CONCLUSIONS: No evidence was found to support or refute routine prophylactic removal of asymptomatic impacted wisdom teeth in adults. There is some reliable evidence that suggests that the prophylactic removal of asymptomatic impacted wisdom teeth in adolescents neither reduces nor prevents late incisor crowding.

[Learn your whole life to learn]. / Leren levenslang te leren.

Lifelong learning is no longer an option for dentists but rather a necessity, an obligation. In this contribution a survey is presented of all persons and institutions involved in the supply for continuing professional development (CPD). Subsequently the role will be discussed of the government, the universities, the professional organizations, the scientific associations and the scientific dental journals. The most decisive factor however is the own responsibility of the individual dental practitioner to keep learning a life long. Future developments will be touched upon shortly.

[The routine oral examination in The Netherlands. An orientation from the perspective of general dental practitioners]. / Het periodiek tandheelkundig controleonderzoek in Nederland. Een oriëntatie vanuit het tandartsperspectief.

In The Netherlands the routine oral examination (ROE) can be characterized as an important tool in dental care. As a result of the changing prevalence of oral diseases of the Dutch population the content of the routine oral examination has changed over time. A representative survey among general dental practitioners has been carried out to investigate the professional performance in the routine oral examination. Participants consisted of a random, stratified sample of 619 dentists, of whom 521 (85%) responded. The Dutch general dental practitioners use the routine oral examination mainly for detecting dental caries and to asses the status of the restorations. About 50% of the responders use a standard recall interval for all patients whereas the other half takes individual patient factors into consideration when determining the recall interval. Both groups differ significantly on the variables: 'time spend on the routine oral examination', 'the amount of diagnostic activities', 'the registration in patient dental records' and 'the frequency of using bitewing radiographs'. In the perspective of quality of dental care a national reconsideration of the routine oral examination by professionals and patients is advocated. The instrument of choice would be the use of evidence-based clinical practice guideline development procedures.

Clinical practice guidelines in dentistry: opinions of dental practitioners on their contribution to the quality of dental care.

OBJECTIVES: To assess the opinions of general dental practitioners regarding the development and importance of clinical practice guidelines and their contribution to the quality of dental care. METHODS: A questionnaire was sent to a representative sample of 1656 dentists in the Netherlands. Factor analysis was conducted to identify scales of variables, and a reliability analysis was conducted to verify the reliability of the identified scales. The effect of the independent variables is expressed as odds ratio per scale part (standard deviation, SD). Regression analyses were conducted to study determinants of the opinions on clinical guidelines. RESULTS: The response rate was 73%; 54% of the respondents supported the development of clinical practice guidelines for dentists. Most respondents indicated that clinical practice guidelines could be used as a checklist, as a support in daily clinical decision making, and as a basis for continuing dental education. The factor analyses yielded four scale factors-contribution of guidelines to effectiveness of care (OR 1.95/SD), contribution of guidelines to professional autonomy (OR 1.70/SD), contribution of guidelines to quality of care (OR 2.52/SD), and contribution of guidelines to collaboration (OR 1.49/SD)-which complied with the criterion of Cronbach's alpha >0.60. Multiple regression analysis with the four scale factors as dependent variables yielded only extremely low correlations for practice and dentist characteristics (R(2)=0.01-0.04). CONCLUSIONS: Only about 50% of dentists support the development and implementation of clinical guidelines. Guidelines are seen as helpful in the provision of continuing dental education and as a support in daily clinical decision making. The most important barrier to successful implementation of clinical practice guidelines is the fear of dental practitioners that guidelines will reduce their professional autonomy. Practice and dentist characteristics are unrelated to dentists' opinions on clinical practice guidelines.

[Caries profunda: current views and treatment concepts]. / Caries profunda: huidige inzichten en behandelconcepten.

Current insight of the caries process demands new, more selective and less invasive techniques and methods for excavation. Nowadays the biological aspects of teeth and pulp tissue in reaction to caries need to be respected and even used. The general practitioner is confronted with a wide range of new techniques and methods and needs to choose the best suitable. The purpose of this article is to inform the general practitioner about the current views concerning treatment of caries profunda and the different treatment concepts. Thereby the authors hope to assist the general practitioner in their choice for the proper treatment.