Assessing a training programme for primary care dental practitioners in endodontics of moderate complexity: Pilot data on skills enhancement and treatment outcomes.

Aims: To explore the impact of dedicated training to extend the skills of primary care practitioners on the quality of endodontic care, using clinical, radiographic and patient-related outcomes. Methods: The quality of endodontic treatment performed at the beginning and end of training to become dentists with extended skills (DES) in endodontics was assessed in vitro and in vivo from endo-training blocks and self-reported logbooks containing clinical notes and radiographs respectively. The quality of endodontic care delivered by DES post-training was measured using clinical and radiographic outcomes. Patient-related outcomes were assessed using a self-report questionnaire, including the Oral Health Impact Profile ­ Endodontic Outcome Measure (OHIP-EOM). Results: Data on eight dentists were examined pre-and post-training, five of whom participated in further follow-up investigations on the quality of endodontic care delivered to their patients. Significant improvements in skills were seen for all domains in vitro (p <0.05), and for all domains of the clinical treatment process, and achieving the correct working length of the root filling as seen by radiography in vivo (p <0.05). The quality of the clinical process was maintained following training. Positive patient outcome (OHIP-EOM) scores were recorded (mean score of 34.72, SD = 10.74, n = 120 pre-treatment and 25.85, SD = 7.74, n = 47 representing reduced impact at follow-up). The majority of patients reported being satisfied, or very satisfied, with the service they received (72.5%, n = 98); would use the service again (68.1%, n = 92); and would recommend the service to friends and family (74.8%, n = 101). Conclusions: Findings suggest that training for dentists working in practice can be successful in enhancing skills and changing practice, with evidence of high patient satisfaction and good clinical and patient-related outcomes. Pilot results must be interpreted with caution and further research is required.

Feasibility of assessing training of primary care dental practitioners in endodontics of moderate complexity: mapping process and learning.

Objectives: To explore the feasibility of measuring quality of endodontic care provided by general dental practitioners (GDPs), using clinical, radiographic and patient-related outcomes, as well as understanding practitioner views and estimating financial costs. Methods: Multi-faceted mixed-methods two-part study involving retrospective analysis of the educational component (course assessments, endodontic training blocks and analysis of a sample of teeth treated at the beginning and end of training), and prospective analysis of patients treated by these dentists after completion of training. Participant: Dentists working in and patients treated in primary dental care in London. Intervention: Twenty-four-month training in endodontics. Comparison: Dentists enrolled in the training at different time points. Outcome: Measuring outcome of endodontic treatment. Results: Eight dentists (mean 36 years, SD = 8.2 years) participated in training. Subsequently, five of these dentists (mean 34.2 years, SD = 7.08 years) contributed to the prospective study and recruited 135 patients. Thirty-five patients completed all patient-related outcome questionnaires, and of these there were 16 cases with complete clinical and radiographic data (12%) at follow-up (10.1­36.4 months). Preliminary analysis revealed that a minimum of 45 cases of complete data would be required for multivariate analysis, requiring the recruitment of in excess of 375 patients to future studies to account for this level of loss to follow-up. Conclusions: Findings suggest it is possible to carry out mixed-methods and treatment-related outcome-based research in primary care. Measurement/data capture tools developed were tested and used successfully in measuring the adherence to treatment processes and outcome of endodontic treatment.

Development of quality measurement instruments for root canal treatment.

AIM: To devise measurement instruments for 'quality' of root canal treatment to assess training and outcome of general dental practitioners working within primary care settings. METHOD: Scoring systems relating to quality of root canal treatment were developed using expert consensus and published literature. Domains scored included the Treatment Process, Quality of the Obturation, Clinical Healing, Radiographic Healing and Tooth Complexity. Scoring systems were applied to 10 clinical cases treated by each dentist at the beginning and 10 cases treated at the end of their clinical training and 135 cases treated after completion of training. The dentists recorded the treatment process and clinical healing in clinical logs. Two examiners independently scored the radiographs after undertaking calibration and training. Inter- and intra-examiner reliability of scoring radiographic outcomes was tested using Cohen's Kappa statistics. RESULTS: An instrument was created with four domains to assess quality (two for process and two for outcome of root canal treatment), and a measure of case complexity. Domains of treatment process (n = 240 teeth), outcome (n = 32 teeth) and complexity (n = 215 teeth) were scored using radiographs. The Kappa scores for intra-examiner reliability between 0.22 and 1, whilst inter-examiner reliability ranged between 0.18 and 0.99. CONCLUSION: Evidence-based scores for assessment of the quality (process and outcome) and complexity (structure) of root canal treatment were devised. They were reliable, provided that clinicians were trained in record keeping and examiners have in depth training and calibration in the use of the instruments.

Dentists with extended skills: the challenge of innovation.

BACKGROUND: The aim was to obtain stakeholders' views on the former London Deanery's joint educational service development initiative to train dentists with a special interest (DwSIs) in endodontics in conjunction with the National Health Services (NHS) and examine the models of care provided. METHODS: A convergent parallel mixed methods design including audit of four different models of care, semi-structured interviews of a range of key stakeholders (including the DwSI trainees) and questionnaire surveys of patients and primary care dentists. RESULTS: Eight dentists treated over 1,600 endodontic cases of moderate complexity over a two year training period. A retrospective audit of four schemes suggested that first molars were the most commonly treated tooth (57%; n = 341). Patients who received care in the latter stages of the initiative were 'satisfied' or 'very satisfied' with the service (89%; n = 98). Most dental practitioners agreed that having access to such services would support the care of their patients (89%; n = 215) with 88%; (n = 214) supporting the view that DwSIs should accept referrals from outside of their practice. CONCLUSION: This initiative, developed to provide endodontic care of medium complexity in a primary care setting, received wide support from stakeholders including patients and primary care dentists. The implications for care pathways, commissioning and further research are discussed.

Direct composite restorations for the worn mandibular anterior dentition: a 7-year follow-up of a prospective randomised controlled split-mouth clinical trial.

The purpose of this study was to report on the 7-year follow-up of 15 patients who took part in a prospective randomised controlled split-mouth trial to evaluate the performance and patient satisfaction of 107 direct composite restorations bonded to their worn anterior mandibular dentition. This is the continuation of a study by Poyser et al., which investigated the performance of the same direct composite restorations on this cohort of patients at 2.5 years. The results of the present study suggest that direct composite restorations bonded to the worn anterior mandibular dentition to have an approximate survival of 85% at the 7-year follow-up. Approximately 53% of patients experienced survival of all of their restorations. Pre-operative circumferential preparation did not influence restoration survival, patient satisfaction or other clinical variables (restoration staining, marginal discolouration, shade match, surface roughness and marginal adaptation). The time taken to initially build-up the restorations was shown to be statistically significant with a longer procedural time meaning less chance of the restoration being present at 7 years. This treatment modality exhibited no biological complications for the teeth, supporting periodontium or TMJ apparatus. The placement of these restorations provided an improvement in the aesthetics of the teeth, a reduction in the concern over the longevity of the worn lower anterior teeth, and improvements with regard to sensitivity experienced with hot or cold foods or drinks. Marginal breakdown was the most frequently recorded clinical complication. Thus, for the majority of patients, the restorations offered a high degree of patient satisfaction and required an acceptable level of maintenance in the 7-year follow-up period.

Antimicrobial irrigants in endodontic therapy: root canal disinfection (part 1).

This paper highlights the importance of root canal disinfection. It discusses the different endodontic irrigants available and comments on how these can be used most effectively.

The evaluation of direct composite restorations for the worn mandibular anterior dentition - clinical performance and patient satisfaction.

This prospective split-mouth clinical trial evaluated the performance and patient satisfaction of 168 Herculite XRV direct composite restorations bonded to the worn anterior dentition of 18 patients with localized anterior tooth surface loss. One hundred and six of these restorations were placed on the mandibular anterior teeth. The restorations increased the anterior occlusal vertical dimension between 0.5 and 5 mm and the posterior occlusal contacts were restored after a mean duration of 6.2 months (range: 3-13 months) in 14 out of the 15 'Dahl' sub-group patients. The restorations were evaluated after 2.5 years of service by five examiners. Four patients and 23 mandibular restorations were lost to follow-up. Multiple clinical and restorative variables were assessed to determine their influence on restoration performance. Complete failure occurred in 6% of the restorations. Circumferential preparation and height of the restorative addition did not influence the performance of the restorations. A Visual Analogue Scale (VAS) was used to assess the patient's opinion regarding sensitivity, aesthetics, longevity and function of the worn mandibular anterior teeth. A statistically significant difference (95% CI) was found between the pre-operative and 1-month review VAS responses for aesthetics and longevity and this was maintained at the 2.5-year review. Direct composite restorations placed at an increased occlusal vertical dimension are a simple and time-efficient method of managing the worn mandibular anterior dentition. Patient's acceptance and adaptation to the technique is good and the results are accompanied with a high level of patient satisfaction that is maintained for the medium-term.

A life threatening event from poorly managed dental pain--a case report.

The history of a patient who suffered encephalopathy and coma is presented. A 25-year-old female consumed large quantities of cold water over several weeks, to control long-term dental pain. This eventually led to dilution hyponatraemia, followed by a seizure and encephalopathy. The patient made a good recovery after spending three days in neurological intensive care. Conventional endodontic therapy immediately resolved her symptoms following recovery from this life-threatening episode. Prior to her admission the patient had experienced difficulties in gaining access to effective emergency dental care. Her problems could have been avoided if appropriate management had been provided sooner. The dental profession should be aware of the potential life-threatening risk when continued water consumption is used to control the long-term pulpitic pain. Primary care agencies should ensure that information on local emergency dental services is well disseminated to the population. Dental surgeons should be able to manage acute dental pain.

The Dahl Concept: past, present and future.

The Dahl appliance was described nearly 30 years ago. This removable metal bite platform was used to create inter-occlusal space, in a localised part of the mouth, to facilitate the placement of restorations on worn anterior teeth. The Dahl concept is traditionally associated with the management of worn teeth. However, the same principles can be successfully and safely applied to a variety of clinical situations. This has simplified the management of historically complex problems. The advantages are the preservation of tooth tissue and the long-term benefits that brings. This paper reviews the literature related to the Dahl concept and how the concept has developed. There is a discussion regarding possible future applications and research.

Evidence-based dentistry: endodontic failure--how should it be managed?

OBJECTIVE: To review the evidence on the most appropriate management of failed endodontic treatment. DATA SOURCES: Appropriate articles were selected from the international literature. RESULTS: There was good evidence that conventional endodontic treatment is associated with a successful outcome in a significant proportion of cases. The results of surgical treatment are more difficult to interpret since account should be made of the status of the existing root filling. However, there is evidence of an increased success rate with a satisfactory orthograde root filling. CONCLUSIONS: It is difficult to make direct comparisons from cited studies to advance a clear argument in support of one treatment modality. However, it is judged that a conventional endodontic retreatment approach is the most appropriate in the first instance, providing access to the root canal is possible. This does not preclude a subsequent surgical approach. Teeth that are permanently restored soon after retreatment are more successful than those which are not. There are significant challenges in setting up prospective research studies to directly address the problem of the failed root filing.

The clinical evolution of the 'Dahl Principle'.

The restorative management of patients with localised tooth wear is a major challenge to the dental profession. There is rarely adequate interocclusal space available to place restorations without the need for extensive tooth preparation or the involvement of many unaffected teeth. In 1975, a method was described which created interocclusal space by the use of a partial coverage appliance made of cobalt chromium alloy. The technique reduced the need for more invasive palatal reduction. This paper, with the aid of clinical case examples, highlights the development and evolution of the original removable appliance. However, there remains a need for further clinical studies to evaluate fully these techniques.

The re-establishment of molar occlusion following orthognathic surgery.

The effect on distal molar occlusion following mandibular orthognathic surgery is highlighted. Two cases are presented in which at the completion of orthodontic/surgical treatment a stable molar occlusion was re-established by adjunctive restorative treatment. The clinical problem highlighted, illustrates the importance of restorative support for patients with residual post-orthodontic and post-surgical occlusal problems.

Modern restorative management of advanced tooth-surface loss.

This article describes the restorative management of a case of advanced, localised tooth-surface loss using modern materials and techniques. Particular emphasis is placed on the conservation of tooth structure while providing restorations with optimum physical and aesthetic characteristics.

Tooth-surface loss related to pregnancy-induced vomiting.

We present a clinical case of tooth-surface loss affecting the palatal surfaces of the upper incisors, caused by prolonged pregnancy-induced vomiting. The patient was successfully treated, first orthodontically and then with indirect composite palatal veneers. As dental practitioners, we should be aware of this problem when screening pregnant patients, as early diagnosis and prevention are important.

Crown lengthening: a clinical review.

The use of crown lengthening surgery as an adjunct to restorative therapy was first suggested by Rosen and Gitnick. This technique is designed to increase the clinical crown heights of teeth requiring restoration following extensive wear through attrition, abrasion and erosion. This loss of tooth tissue and resulting clinical crown height may be localized to a few teeth or affect the entire dentition. This clinical problem is reflected by the increasing number of reports of treatment of the worn dentition.

Management of a tooth affected by idiopathic coronal resorption.

This article reports on the restoration of a permanent mandibular canine affected by significant idiopathic coronal resorption. A particular restorative approach and the alternative treatment options are discussed. The need for careful examination of diagnostic radiographs is emphasized.

A comparison of the dentine-removing characteristics of two endosonic units.

The purpose of this study was to compare the dentine-removing characteristics of size 25 K-files activated by the Cavi-Endo and Piezon-Endo units. The influence of power-setting, direction of file oscillation, interfacial force and operator-assisted movement were studied. Filing was performed on flat surfaces of dentine and impressions of the instrumented surfaces revealed characteristic patterns of dentine removal corresponding to the area of contact with the file which was quantified using a Reflex microscope. Differences in dentine removal as affected by the power output of the two systems were only apparent when the maximum power-setting on the Cavi-Endo was compared with the maximum recommended for root canal preparation on the Piezon-Endo. The Cavi-Endo removed significantly more dentine than the Piezon-Endo. When operator-assisted movement of the file was superimposed, both systems removed significantly more dentine than without assisted filing, However, the Piezon-Endo now removed significantly more dentine than the Cavi-Endo. This difference was more apparent when the file oscillated perpendicular to the dentine surface, compared with oscillation parallel to the substrate. An increase in the interfacial force from 30 g to 60 g resulted in a greater reduction in dentine removal by the Cavi-Endo compared with the Piezon-Endo. Thus, at a 30 g interfacial force there were insignificant differences between the endosonic units but at 60 g, the Piezon-Endo removed significantly more dentine than the Cavi-Endo. The dentine-removing characteristics of the two endosonic units tested are very different under certain conditions. These findings may have important clinical implications.

The replacement of missing maxillary central incisor teeth incorporating a midline diastema with a fixed-fixed resin-retained bridge.

The replacement of maxillary central incisor teeth with the maintenance of a midline diastema can create considerable problems for the restorative dental surgeon. This case report illustrates the treatment of such a case using a fixed-fixed resin-retained bridge with a modified palatal connector. Alternative treatment options are discussed.

Diagnostic dilemma: an unusual presentation of an infected nasopalatine duct cyst.

The pertinent literature on nasopalatine duct cysts is reviewed. A case is reported in which a nasopalatine duct cyst infected by Actinomyces presented clinically with unusual features. The clinical findings could have been confused with an early acute periapical abscess arising from an incisor tooth. The relevant aspects of diagnosis are discussed.