Reliability and validity of a continuous pain registration procedure.

BACKGROUND: Conventional pain rating scales [i.e. visual analogue scales (VAS) or numerical rating scales (NRS)] only provide a summary for different levels of pain felt, while the duration of these levels is not accounted for. If pain can be rated continuously, the area under the curve (AUC) of varying pain intensity over time can be calculated, which integrates varying pain intensity with duration. The present study examined the reproducibility and validity of a continuous pain rating procedure. METHODS: Twenty-eight healthy volunteers participated. Pain was induced using constant current delivered to the non-dominant forearm using bipolar electrodes. Pain was rated continuously on an electronic VAS monitored by a computer. For each participant, the level of current needed to achieve a weak, mild, slightly moderate and moderate level of pain was determined (part I). Next, participants were asked to rate the painfulness of six periods of electrical stimulation (part II). Unknown to the participants, they were presented with the four levels of current obtained in part I, where the level of current for mild and moderate pain was presented twice (in order to assess consistency). The order of presentation was randomized for all subjects. RESULTS: In general, participants produced reliable mean AUCs. In addition, the AUC of pain intensity over time could clearly discriminate between the four levels of pain used in the present study. DISCUSSION: A continuous pain registration procedure, using an AUC approach, may be a promising direction to explore. Results can be improved by allowing more training on the use of the electronic VAS.

Survey response of oral and maxillofacial surgeons on invasive procedures in patients using antithrombotic medication.

The aim was to evaluate the management strategies of Dutch oral and maxillofacial surgeons when performing invasive dental or oral surgery in patients using oral antithrombotic medication (OAM). In November 2009 a survey was mailed to all 213 members of the Dutch Society for Oral and Maxillofacial Surgery. A response rate of 57% was achieved with 79 surveys returned through mail and 38 surveys answered through the Internet. The results show that many different treatment strategies are advocated by Dutch oral and maxillofacial surgeons, regarding preferred international normalised ratio (INR) value and continuation or discontinuation of OAM prior to invasive dental or oral surgery. The risk of bleeding during or after an invasive dental procedure was overestimated. A need for a practice guideline on this topic was expressed by 73% of respondents.

Diagnosis, treatment and prevention of ankle sprains: an evidence-based clinical guideline.

Ankle injuries are a huge medical and socioeconomic problem. Many people have a traumatic injury of the ankle, most of which are a result of sports. Total costs of treatment and work absenteeism due to ankle injuries are high. The prevention of recurrences can result in large savings on medical costs. A multidisciplinary clinical practice guideline was developed with the aim to prevent further health impairment of patients with acute lateral ankle ligament injuries by giving recommendations with respect to improved diagnostic and therapeutic opportunities. The recommendations are based on evidence from published scientific research, which was extensively discussed by the guideline committee. This clinical guideline is helpful for healthcare providers who are involved in the management of patients with ankle injuries.

Non-participation in a randomized controlled trial: the effect on clinical and non-clinical variables.

Studies reporting clinical and non-clinical parameters of participants and non-participants of clinical trials are scarce. In the available studies non-participants were likely to show less favourable outcomes than participants on both socioeconomic parameters as well as on caries experience. However, the impact of non-participation on the total sample of the research population is not established. In the present study, as part of baseline data collection for a randomized controlled trial on caries-preventive strategies, 346 parents of children 6.0 years (± 3 months) of age were approached to let their child participate. Sixty parents refused, but 56 of them were willing to fill out the same set of questionnaires and to allow their child to be clinically examined once. Parents from participating children had higher socioeconomic status, were more often of autochthonous origin and scored better on knowledge questions than parents of non-participating children. Furthermore, parents of participating children reported a higher willingness to invest, were more likely to hold on to regular meals and their child had lower levels of plaque compared to non-participating children. Surprisingly, the participating children had higher dmfs scores than the non-participating children. Their care index (fs/ds + fs) was higher than that of non-participating children. Based on the findings of this study, the presumption that non-participating children will show less favourable clinical outcomes cannot be supported. Although participants differed from non-participants, they did not differ from the total population. It is suggested that the external validity of a randomized controlled trial on caries-preventive strategies is not necessarily affected by non-participation bias.

[The complexity of the concept oral health-related quality of life]. / De complexiteit van het concept mondgezondheid-gerelateerde levenskwaliteit.

The methods uses most often for developing and analyzing questionnaires, such as the explorative factor analysis and Cronbach's alpha, presume that psychological constructs are latent (imperceptible) and that there is a reflective-measurement model with the underlying assumption of local independence. Local independence means that the latent variable explains why the variables observed are related. Many questionnaires for measuring oral health-related quality of life are analyzed as if they were based on a reflective-measurement model assuming local independence. This assumption requires these questionnaires to contain solely items reflecting instead of determining oral health-related quality of life. The tenability of this assumption is questionable.

Attitudes towards oral health among parents of 6-year-old children at risk of developing caries.

OBJECTIVES: Parental attitudes are likely to play a role in achieving and maintaining a desired level of oral health in children. To be useful in individually delivered caries prevention programmes, parental attitudes should be identified at individual level. Q-methodology has been proved successful in identifying attitudes in a wide range of disciplines but in dentistry Q-studies are scarce. In this study Q-methodology was used to identify parents' prevailing attitudes towards the oral health of their children. METHODS: Thirty-nine parents ranked 37 statements regarding the dental health behaviour they apply to their 6-year-old child. They later explained their rankings during a short interview. In Q-methodology, rather than reporting one average composite attitude and opinion, various combinations of opinions and attitudes concerning these statements are identified using by-person factor analysis. RESULTS: Based on their beliefs, attitudes and cognitions, five categories of parents were found: (i) conscious and responsible, (ii) trivializing and fatalistic, (iii) appearance-driven and open-minded, (iv) knowledgeable but defensive and (v) conscious and concerned. CONCLUSIONS: Q-methodology appears to be a fruitful way to structure the complexity of parents' opinions and attitudes towards their children's dental health. It appears that Q-methodology provides comprehensive clusters of individual attitudes, based on various levels of responses to a wide range of questions. The five identified profiles may be useful in developing tailor-made prevention strategies in caries prevention.

Perceptions of Dutch orthodontic patients and their parents on oral health-related quality of life.

OBJECTIVE: To test the hypotheses that 1) there is no difference between orthodontic patients' and their parents' reports of patients' oral health-related quality of life, and 2) there are no gender differences. MATERIALS AND METHODS: The sample consisted of 182 orthodontic patients (age range, 8-15) and their parents. Respondents were required to complete the Child Oral Health Impact Profile (COHIP). Items were divided into five different subscales, and scores on all subscales were compared between and within groups. Also, scores on six additional items regarding treatment expectations and global health perception were compared. Two hypotheses were tested: first, that no differences between parents and patients would be detected, and second, that no differences between boys and girls would be found. RESULTS: The first hypothesis could not be rejected. Only a few minor differences between parents and patients were found. The second hypothesis was rejected. Differences between boys and girls were found on the subscales Emotional Well-Being and Peer Interaction, indicating that girls experience more effects of oral health on their quality of life than do boys. CONCLUSIONS: Parents' reports on their children's oral health-related qualities of life were in agreement with reports of the orthodontic patients. This suggests that parents are suitable alternatives to their children in surveys measuring oral health-related quality of life.

The Dental Discomfort Questionnaire: the basis of a 'Toothache Traffic Light'.

AIM: Firstly to provide an overview of the combined results of the studies done with the Dental Discomfort Questionnaires (DDQ) and second to present a behaviour checklist, a 'Toothache Traffic Light', based on the DDQ, which could possibly be used to raise awareness for toothache among parents and healthcare providers and to improve communication. METHODS: A total of 652 DDQ were analysed to compare the prevalence of toothache related behaviours between children without caries, children with caries but without toothache, and children with caries and toothache. The children had a mean age of 44.6 months (SD+/-10.9). STATISTICS: Chi-square tests were conducted to compare the items of the DDQ between the three groups and predictors of toothache were determined using a binary logistic regression analysis. RESULTS: All items of the DDQ were displayed more often by the children with caries and toothache than by children with only caries or without both caries or toothache. The behaviours: "Reaching for the cheek while eating", "Pushing away something nice to eat", "Problems brushing upper or lower teeth" and "Problems chewing" were found to be the most indicative for the presence of toothache. Finally, 7 toothache related behaviours were combined in the checklist. Using the results of this survey the 'Toothache Traffic Light' was developed as a possible tool for determining toothache in very young children. CONCLUSIONS: All behaviours together could form a checklist that can possibly teach parents, guardians and teachers which behaviours to look for when they suspect a child to have toothache.

Dental treatment under general anaesthesia: the short-term change in young children's oral-health-related quality of life.

AIM: This was to assess the short-term change in children's oral-health-related quality of life (OHRQoL) and family impact after dental treatment under general anaesthesia (GA) in the Netherlands. STUDY DESIGN: A pretest-posttest design was used. METHODS: Children (< 8 years) referred to a clinic for specialized paediatric dentistry and who needed treatment under GA were selected to participate and divided across two groups. Fifty out of 80 parents/children couples participated, one group of parents filled out the questionnaires on behalf of their child before and after treatment (N = 31), and the other group only after treatment (N = 19). The questionnaires used were the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS) and Parental Perceptions Questionnaire and Family Impact Scale (PPQ and FIS, forming the OHRQoL score). The oral health was assessed using the decayed-missing-filled surfaces or teeth index (dmfs/dmft) for the primary dentition from the status praesens after treatment. RESULTS: There was a significant difference between the pre- and posttest-scores in group A for both the short version and the long version (short: t = 5.088, df = 20, p < 0.001 and long: t = 6.279, df = 20, p < 0.001). There was no statistically significant difference in CFSS-DS scores before and after treatment (group A) (t = 1.815, df = 13, p = 0.093). CONCLUSIONS: The children's OHRQoL improved after treatment under GA according to their parents. As expected, dental fear did not change and should be dealt with after treatment to avoid a child's dental fear to persist in the future. A shorter version of the PPQ and FIS seems useful to assess OHRQoL in very young children.

On the reliability of a dental OSCE, using SEM: effect of different days.

AIM: The first aim was to study the reliability of a dental objective structured clinical examination (OSCE) administered over multiple days, and the second was to assess the number of test stations required for a sufficiently reliable decision in three score interpretation perspectives of a dental OSCE administered over multiple days. MATERIALS AND METHODS: In four OSCE administrations, 463 students of the year 2005 and 2006 took the summative OSCE after a dental course in comprehensive dentistry. The OSCE had 16-18 5-min stations (scores 1-10), and was administered per OSCE on four different days of 1 week. ANOVA was used to test for examinee performance variation across days. Generalizability theory was used for reliability analyses. Reliability was studied from three interpretation perspectives: for relative (norm) decisions, for absolute (domain) and pass-fail (mastery) decisions. As an indicator of reproducibility of test scores in this dental OSCE, the standard error of measurement (SEM) was used. The benchmark of SEM was set at <0.51. This is corresponding to a 95% confidence interval (CI) of <1 on the original scoring scale that ranged from 1 to 10. RESULTS: The mean weighted total OSCE score was 7.14 on a 10-point scale. With the pass-fail score set at 6.2 for the four OSCE, 90% of the 463 students passed. There was no significant increase in scores over the different days the OSCE was administered. 'Wished' variance owing to students was 6.3%. Variance owing to interaction between student and stations and residual error was 66.3%, more than two times larger than variance owing to stations' difficulty (27.4%). The SEM norm was 0.42 with a CI of +/-0.83 and the SEM domain was 0.50, with a CI of +/-0.98. In order to make reliable relative decisions (SEM <0.51), the use of minimal 12 stations is necessary, and for reliable absolute and pass-fail decisions, the use of minimal 17 stations is necessary in this dental OSCE. CONCLUSIONS: It appeared reliable, when testing large numbers of students, to administer the OSCE on different days. In order to make reliable decisions for this dental OSCE, minimum 17 stations are needed. Clearly, wide sampling of stations is at the heart of obtaining reliable scores in OSCE, also in dental education.

Changes in children's dental fear: a longitudinal study.

AIM: The study aimed to evaluate the development of dental fear in a low fear group and a fearful group of children aged between 8 and 13 years of age and to assess the differences between these groups over time taking into account general variables, such as gender, and treatment variables, such as restorations. Furthermore it was evaluated to what extent general variables and treatment variables predict the change in dental fear or dental fear at later age. STUDY DESIGN: A three-year longitudinal study. METHODS: 401 parents completed the Children's Fear Survey Schedule-Dental Subscale (CFSS-DS), 218 of them repeating this after a 3-year interval. Dental records were used to collect the clinical data, starting from the children's first dental appointment and the CFSS-DS was used to assess the child's dental fear. RESULTS/STATISTICS: Analysis of variance for repeated measures showed an interaction effect between fear level and mean total CFSS-DS score. Regression analyses applied to the mean total CFSS-DS score at the second measurement moment and the change in total CFSS-DS score between both measurement moments revealed that little variance could be explained by the treatment variables over the various periods, such as extractions in the first period, and that child-characteristic variables could not predict much variance. Independent-samples t-tests showed a significant difference in means for extractions over the whole period between the fearful group (mean=1.73, SD+/-1.18) and low fear group (mean= 0.68, SD+/-2.01) (t=-4.05, p<0.001, n=218). Also the frequency of Behavioural Management Problems (BMP) over the whole period differed between these groups (fearful group: mean=1.40, SD+/-1.90 and low fearful group: mean= 0.40, SD+/-0.93) (t= -4.58, p<0.001, n=218). CONCLUSION: The effect of treatment variables and subjective experiences on child dental fear seems to diminish over time. Findings support the theoretical framework of conditioning and gradual exposure in children to prevent dental fear.

Dental anxiety and psychological functioning in children: its relationship with behaviour during treatment.

AIM: In this study the relationship between the levels of dental anxiety, psychological functioning and earlier experience with dental injections are examined and the possible influence of these factors on children's behaviour before and during a local anaesthesia injection. METHODS: A total of 128 children (4-11 years) were included. The level of dental anxiety and the psychological functioning were measured using the 'Children's Fear Survey Schedule' (CFSS-DS) and the 'Strengths and Difficulties Questionnaire' (SDQ). Based on video recordings the anxiety behaviour was scored on the Venham-scale. RESULTS: There was a positive correlation between levels of dental anxiety, psychological functioning and anxiety behaviour before and during the dental injection. In particular children with emotional problems or peer problems tended to show more anxiety behaviour before the injection and children with emotional or hyperactivity problems tend to show more anxiety behaviour during the injection. Furthermore, the younger children (below 6 years of age), with previous dental experience in the past 6 months, tended to display more anxiety behaviour both before and during the injection than children without or with experience from longer ago. CONCLUSION: The level of dental anxiety and psychological functioning and recent previous dental experience are important factors in determining which child is likely to display more anxiety and uncooperative behaviour during treatment and therefore potentially need more attention to be able to cope well with dental treatment.

[Dental procedures for patients using oral anticoagulation: new insights]. / Bloedige ingrepen bij patiënten met antitrombotica: nieuwe inzichten.

What treatment is appropriate for a patient who has to undergo an invasive dental procedure if that patient is using medication that influences the blood coagulation system? Should the medication be stopped before the invasive procedure, with the risk of complications involving re-thrombosis? Or should the procedure be carried out without adjusting the medication? What is the risk of bleeding complications? Recent studies appear to indicate that temporarily stopping medication is in many cases unnecessary and can even harm the patient. In recent decades dentists have received a great number of diverse recommendations. In this article recent research in this field is summarized and evaluated. The authors advocate the development of evidence-based clinical guidelines.

Pain behaviour and distress in children during two sequential dental visits: comparing a computerised anaesthesia delivery system and a traditional syringe.

OBJECTIVE: To compare the pain and distress response of children receiving a local anesthesia injection using a computerised device (Wand) or a traditional syringe over two consecutive treatment sessions and to study whether the response to the two injection techniques was different for high or low dentally anxious children. DESIGN: Randomised controlled trial. SETTING: Secondary dental care practice specialised in treating children. SUBJECTS AND METHODS: Children were selected and randomly allocated to the Wand or traditional injection condition. Parents completed the Dental Subscale of the Children's Fear Survey Schedule (CFSS-ds). Based on video recordings of the injections, for each 15 seconds, the occurrence of five pain related behaviours was registered and a score was given on the Venham distress scale. Children rated their pain after each injection. INTERVENTION: Over two consecutive treatment sessions one group received two local anaesthesia injections with the traditional syringe and the other group received two injections with the Wand. OUTCOME MEASURES: The mean number of pain related behaviours, the mean distress scores and the self-reported pain scores were compared. Based on the CFSS-ds subjects were split into highly and low dentally anxious children. RESULTS: One hundred and forty-seven subjects participated in the study: aged 4-11 years, 71 girls. Based on the behaviour displayed during the local anaesthesia injection and the self-reported pain after the injection, no difference could be found between an injection with the traditional syringe or the Wand over the first or second treatment session. However, on the first treatment session, highly anxious children reported more pain (p = 0.001), displayed more pain related behaviour (p = 0.002) and more distress (p <0.001) than low anxious children in reaction to the local anaesthesia injection. CONCLUSION: No clear difference in the response of referred children could be found between an injection with the Wand or the traditional syringe. Level of dental anxiety was found to be an important factor in the response of children to a local anaesthesia injection.

Using the Maslach Burnout Inventory among dentists: burnout measurement and trends.

OBJECTIVES: To extend our knowledge about the applicability of the Maslach Burnout Inventory (MBI) among dentists and to investigate trends in burnout risk among dental professionals. METHODS: The structure of the MBI is examined among two independent, representative samples of dentists (n = 493 and 497, respectively). Moreover, results are compared to those of other independently-practicing health professionals (i.e., general practitioners and physiotherapists). In addition, the percentage of dentists that are at risk for burnout are compared in samples from 1997, 2000, and 2001. RESULTS: Correlations between the Emotional Exhaustion and Depersonalization subscales among dentists were higher than those found elsewhere. Additionally, a considerable increase in burnout risk was found since 1997. CONCLUSIONS: It was confirmed that the MBI can be considered a suitable instrument for use among dentists. It is argued that certain specific aspects of entrepreneur-like occupations are reflected in deviating responses to the MBI. Given the clear increase in burnout risk found, this topic should remain under investigation among dentists.

Language background and OSCE performance: a study of potential bias.

AIM: To investigate whether Non-Native dental students perceive drawbacks in their education and examination experience because of their lack of language proficiency and to test whether prolonging Objective Structured Clinical Examination (OSCE) test-station duration improves their performance. MATERIALS AND METHODS: Dental students (n = 345) completed a questionnaire about their native country, their language background and the possible drawback they perceived in dental education and examination because of their language proficiency. Students were marked as 'native', when they were born in the Netherlands with Dutch as native language or 'Non-Native' when they were born outside the Netherlands, raised with a non-Dutch native language, or raised bilingually. A sample of 108 students was assessed by an OSCE testing a periodontal course with nine test-stations. Test-station topics were: (1) history taking, (2) measuring attachment level, (3) educating patients, (4) tracing a radiograph, (5) root-planing, (6) writing a prescription, (7) diagnostics and prognostics, (8) differential diagnostics and (9) writing a referral letter. The first five test-stations mentioned were of 5-min duration. The other four test-stations were provided in two modes: either with a short (5 min) or longer (10 min) version. Every student took at random two long and two short test-stations. RESULTS: In the group of 345 questionnaire responders, Non-Native students (n = 116) perceived significantly more drawback in education and examination than Native students (n = 229) (P < 0.001). When Non-Native students speak Dutch at home, around 38% of them reported perceived drawbacks in education, whereas when they speak their native language at home, around 60% reported perceived drawbacks in education (P = 0.005). In the periodontal OSCE (n = 108), the Native group (n = 70) had significantly higher total scores than the Non-Native (n = 38), (P = 0.009, d = 0.53). The Non-Native group had significantly lower mean scores in the communication station 'educating patients' (P = 0.034, d = 0.42). Prolonged test-station duration from 5 to 10 min had no positive effect in all experimental test-stations in the Native and Non-Native group. Female students in the Native group out-performed male in a communication test-stations. Female students in Native and Non-Native groups were found to be more successful in 'tracing bone loss on radiographs'. CONCLUSION: Non-Native students perceived a drawback in dental education and examination because of their language proficiency in Dutch, which is confirmed by their actual OSCE performance. Prolonging the time for a test-station did not improve OSCE performance of Non-Native students. It is recommended that students with problems in language ability need additional tuition and practice.

Dental Discomfort Questionnaire for young children following full mouth rehabilitation under general anaesthesia: a follow-up report.

AIM: The aim of the present study was firstly to assess the persistence of pain related behaviours of the Dental Discomfort Questionnaire (DDQ) and secondly to complete a follow-up study to assess the effect of dental treatment on pain related behaviours in preschool children. METHODS: The 9-question DDQ instrument was used to assess dental pain related behaviours in a group of preverbal children. The test-retest analysis questionnaire was filled out twice by 44 parents on behalf of their referred child. For the follow-up study the questionnaire was filled out by 71 parents before and after all dental disease was completed. RESULTS: A strong correlation for the test-retest was found over a 2 month period before treatment. When the behaviour items were compared independently before and after treatment it appeared that after treatment all but one behaviour (i.e. bite with molar instead of teeth) was displayed less often. Overall, after treatment all children had a lower mean DDQ score. CONCLUSIONS: Dental treatment of children leads to reduced toothache related behaviours and subsequently to a better quality of life. The DDQ is a sensitive instrument to measure dental discomfort before and after restorative treatment if and when the follow-up period is short. The DDQ can possibly support healthcare providers, teachers and parents in their assessment of toothache in young children.

[Dentists' opinion about their dental education from 1997 to 2004 in Amsterdam, The Netherlands]. / Tandartsen over hun opleiding van 1997 tot 2004.

By sending out 715 questionnaires to their alumni, the Department of Social Dentistry at the Academic Centre for Dentistry obtained the opinion of their graduates on the quality of their training. Of the alumni 50,9% responded, 57,4% of whom felt that they were sufficiently experienced to work independently in dentistry. Almost 70% of the respondents were of the opinion that the treatment of patients during the educational program fits in well with the treatment in practice. Many alumni however thought it advisable to acquire more hands-on experience, both in specific operations and in a year of practical training. Although 65,9 to 84,1% of alumni were (very) satisfied with their instructors, 61% of them said there was room for improvement in their didactic skills. The outcome of this survey shows that most respondents are content with their training. The results largely correspond to those of earlier surveys and offer opportunities to optimize education in dentistry.

Implementing an Objective Structured Clinical Examination (OSCE) in dental education: effects on students' learning strategies.

OBJECTIVES: To investigate the effect of an Objective Structured Clinical Examination (OSCE) on dental students' learning strategies and competence to manage periodontal diseases in patients. The implemented OSCE was expected to be superior to the existing Written Exam in fostering the acquisition of clinical competencies in terms of study strategies that are more oriented towards clinical practice, longer study time, greater clinical proficiency, and more realistic self-assessment. MATERIAL AND METHODS: After a clinical course in periodontology, 72 third year dental students were assessed summatively, either using a Written Exam or an OSCE (P-OSCE). The students were informed beforehand about the assessment formats. The self-assessed clinical competence, study time and strategies (i.e. practice with a manikin, peers and patient case) were evaluated by means of a questionnaire. After a comprehensive dental care course, all 72 students were assessed by an overall end-of-year OSCE, in which three periodontal stations were included 'measuring pockets', 'educating patients' and 'tracing an X-ray with bone-loss'. The competence of the previous Written Exam group and the P-OSCE group was investigated by determining the mean scores and pass-fail scores of three periodontal test-stations as well as the total score of the end-of-year OSCE. The degree of realistic self-assessment was studied by correlating the self-assessed competencies as evaluated by means of the questionnaire with the total score of the end-of-year OSCE. RESULTS: Self-assessed clinical competence, study time and study strategies showed no differences between the P-OSCE and the Written Exam-group. The clinical competence determined in the test-station 'measuring pockets' in the end of year overall OSCE was higher for the P-OSCE group (P = 0.05) when compared with the Written Exam group; the two groups performed equally well in the test station 'educating patients', whereas the performance in 'tracing an X-ray with bone-loss' was better in the Written Exam group. This group also had a higher total score in the end-of-year OSCE (P = 0.05). The degree of realistic self-assessment was higher in the P-OSCE group than in the Written Exam group: in the P-OSCE group the self-assessed clinical competencies correlated significantly with the total score of the overall end-of-year OSCE (P < or = 0.05). CONCLUSIONS: No effects of the implementation of an OSCE in undergraduate periodontal education were observed in study strategies, but the implementation of an OSCE in undergraduate periodontal education appears to stimulate learning, resulting in greater achievement of specific clinical competence and a greater level of realistic self-assessment.