American dental hygienists' attitudes towards chairside medical screening in a dental setting.

OBJECTIVES: Targeted screening for medical conditions in a dental setting can be an effective strategy for early identification of individuals at increased disease risk. Dentists, patients and physicians have a favourable attitude towards this strategy. Given that dental hygienists (DHs) are involved in preventive and educational activities, this seems like a natural extension to their roles. We report on the attitudes of American DHs towards chairside medical screening. METHODS: A 5-point Likert scale (1 = very important/willing, 5 = very unimportant/unwilling) survey was mailed to a nationwide random sample of US practicing DHs. Descriptive statistics were used for all questions, and the Friedman nonparametric analysis of variance was used for multi-element questions. RESULTS: A total of 3133 respondents returned the completed questionnaires for an effective response rate of 49.2% and a margin of error 1.8%. The majority of respondents felt it was important to perform/conduct chairside screening for hypertension (94%), diabetes mellitus (89%), cardiovascular disease (85%), HIV (79%) and hepatitis infection (78%); were willing to refer a patient for medical consult (94%), conduct screening that yields immediate results (85%); and were willing to collect the data/samples needed (57-95%). The most important considerations were dentist/owner support (98%), training (97%), patient willingness (98%) and time (98%). CONCLUSION: Similar to dentists, physicians and patients, the majority of the DHs had a favourable attitude towards chairside medical screening. Integrating the DH into screening activities is likely to require additional training and education regarding the diseases of interest, something that could be accomplished through continuing education courses and eventually incorporation into the educational curriculum.

Clinical research and diagnostic efficacy studies in the oral and maxillofacial radiology literature: 1996-2005.

OBJECTIVES: The aim of this study was to determine the level of evidence that is published in the oral and maxillofacial radiology (OMR) literature. METHODS: OMR papers published in Dentomaxillofacial Radiology and Oral Surgery, Oral Medicine, Oral Pathology, Oral Radiology and Endodontology between 1996 and 2005 were classified using epidemiological study design and diagnostic efficacy hierarchies. The country of origin and number of authors were noted. RESULTS: Of the 725 articles, 384 could be classified with the epidemiological study design hierarchy: 155 (40%) case reports/series and 207 (54%) cross-sectional studies. The distribution of study designs was not statistically significant across time (Fisher's exact test, P = 0.06) or regions (P = 0.89). The diagnostic efficacy hierarchy was applicable to 246 articles: 71 (29%) technical efficacy and 166 (67%) diagnostic accuracy studies. The distribution of efficacy levels was not statistically significant across time (P = 0.22) but was significant across regions (P < 0.01). Authors from Japan produced 26% of the papers with a mean ± standard deviation of 5.78 ± 1.98 authors per paper (APP); American authors, 23% (3.78 ± 1.72 APP); and all others, 51% (3.76 ± 1.51 APP). CONCLUSION: The OMR literature consisted mostly of case reports/series, cross-sectional, technical efficacy and diagnostic accuracy studies. Such studies do not provide strong evidence for clinical decision making nor do they address the impact of diagnostic imaging on patient care. More studies at the higher end of the study design and efficacy hierarchies are needed in order to make wise choices regarding clinical decisions and resource allocations.

Modeling multivariate binary responses with multiple levels of nesting based on alternating logistic regressions: an application to caries aggregation.

Clustered binary responses are commonly encountered in dental research. Data analysis may include modeling both the marginal response probabilities (i.e., risk) and the dependence structure between pairs of responses (i.e., aggregation). While second-order generalized estimating equations (GEE2) is a well-known approach for such data, alternating logistic regressions (ALR) is a computationally efficient alternative method, especially for large clusters. We illustrate ALR with an application to caries aggregation using a dataset with 3 levels of nesting: tooth surfaces within an interproximal (IP) region, IP regions within a jaw, and jaws within a subject. Caries lesions appear to aggregate strongly within subjects with a spatially distributed risk. The minimum within-IP-region odds ratio (OR) was 2.25 (95% confidence interval 1.15, 4.41), and the within-IP-region ORs were always greater than the between-IP-region ORs. ALR is a convenient and useful regression technique for explicit modeling of the dependence structure, and may be applicable to other dental research problems involving clustered or nested responses.

Attributes and practices of oral and maxillofacial radiology departments in US and Canadian dental schools.

OBJECTIVE: To assess the actual state of oral and maxillofacial radiology departments in US and Canadian dental schools against the ideal characteristics defined by the American Academy of Oral and Maxillofacial Radiology (AAOMR) 1997 position paper. STUDY DESIGN: Cross-sectional survey of all 65 US and Canadian dental schools. RESULTS: Sixty-four surveys were returned (98%). At most schools, oral and maxillofacial radiology (OMR) was an identifiable division of a department, established policies, and had operational authority for radiographic practices in the primary radiology clinic. The majority of full-time faculty (72%) had formal training in OMR; the majority of part-time faculty (86%) did not. Full-time faculty spent approximately 60% of their time teaching, with the remainder of their time divided among research and scholarship, faculty practice, and service. Routine x-ray equipment was universally available; advanced imaging technologies were not. OMR faculty involvement in the interpretation of radiographs varied across diseases and conditions. Most published scholarship (85%+) was produced by full-time faculty. Average output was 1 paper per person per year, but a relatively small cadre of OMR faculty generated most papers. CONCLUSIONS: In some attributes, the status of OMR closely approximated the ideal characteristics established in the AAOMR report. Among the remaining attributes, bridging the difference between the actual and the ideal will be the challenge for the next 5 years.

Use of radiology practice guidelines and compliance with accreditation standards in US and Canadian dental schools.

In 1992 and 1997, all US and Canadian dental schools were surveyed by mail regarding the preferred initial radiographic examination prescribed for non-emergency, comprehensive-care patients (dentulous adults, edentulous adults, and children). In both survey years, a minority of US and Canadian dental schools reported using selection criteria for dentulous adults and children, while nearly all schools reported doing so for edentulous adults. The purpose of this secondary analysis was to investigate the relationship between the use of radiology selection criteria (vs. predetermined routine examinations) in US and Canadian dental school clinics and three factors: (1) the credentials of the chief-of-service, (2) institutional funding, and (3) geographic region. "Credentials of the chief-of-service" is the single factor significantly related to the distributions of radiographic examinations prescribed for dentulous adults in both years (Fisher exact test, p < or = 0.02). There are no statistically significant relationships for edentulous adults or children in either year. Multivariate analyses (logistic regression) of the 1997 data reveal that institutions with a credentialed chief-of-service are 2.39 times more likely to report using selection criteria than institutions with a noncredentialed chief-of-service; private institutions are 1.13 times more likely than public institutions, and Canadian schools are 3.65 times more likely than US schools. A similar trend was identified for children. Analysis of the 1992 data revealed similar trends for the credentials of the chief-of-service and the geographic region, but showed no association between institutional funding source and the use of selection criteria. Contrary to accreditation standards, most US and Canadian dental schools obtained pre-determined routine radiographic examinations on most new patients. However, the presence of a credentialed chief-of-service had a positive effect on the use of selection criteria for dentulous adults and children.

Prevalence of skeletal and dental anomalies and normal variants seen in cephalometric and other radiographs of orthodontic patients.

Pretreatment cephalometric radiographs may contain important incidental findings that require attention before orthodontic therapy. A review of the cephalometric and dental radiographs of 325 consecutive healthy orthodontic patients revealed 431 notable findings of the skull, cervical spine, and maxillofacial complex. Most of these findings were nonpathologic anomalies or normal variants. If recognized as such by the orthodontist, no further evaluation would be required, thus avoiding unnecessary costs and patient anxiety. However, there were 15 findings (3.5%) that required additional evaluation by physicians or oral and maxillofacial surgeons before or concurrent with the initiation of orthodontic therapy. Familiarity with the appearance and prevalence of skeletal and dental anomalies and normal variants seen in cephalometric radiographs, and the ability to separate those that require follow-up from those that do not, is an important facet of orthodontic practice.

Dosimetry and cost of imaging osseointegrated implants with film-based and computed tomography.

Thermoluminescent dosimeters were used to measure radiation doses at craniofacial sites in a tissue-equivalent phantom during film-based multidirectional tomography with the Tomax Ultrascan (Incubation Industries, Ivyland, Pa.) and during computed tomography with the Elscint Excel 2400 (Elscint Corp., Tel Aviv, Israel). Mean absorbed doses for presurgical mandibular and maxillary canine and molar implant assessments were converted to equivalent doses, which were then multiplied by published weighting factors and summed to give effective doses. The computed tomography device consistently delivered higher doses than the Tomax Ultrascan to all anatomic locations; the differences were most pronounced when only one or two implant sites were evaluated. The reasons for the dose disparities are considered both anatomically and procedurally. A survey of examination cost revealed film-based multidirectional tomography to be less expensive than computed tomography.

Characteristics of an oral and maxillofacial radiology department. Report of the ad hoc Department Characteristics Committee of the American Academy of Oral and Maxillofacial Radiology.

Oral and maxillofacial radiology is a dynamic and multifaceted discipline that plays a critical role in patient care, the education of general dentists and dental specialists, and the academic health of the dental school. Diagnostic and treatment advances in temporomandibular joint disorders (TMD), implants trauma and orthognathic surgery, and craniofacial abnormalities depend heavily on conventional and advanced imaging techniques. Oral and maxillofacial radiology contributes to the education of pre- and post-doctoral dental students with respect to biomedical and clinical knowledge, cognitive and psychomotor skills, and the professional and ethical values necessary to properly prescribe, obtain, and interpret radiographs. The development of an active and successful oral and maxillofacial radiology department, division, or section requires the committment of institutional resources. This document may serve as a guide to dental schools committed to excellence in oral and maxillofacial radiology.

Digital radiology. Facts and fictions.

Dental digital radiology is a rapidly changing field. The advantages and disadvantages are presented with an understanding that attention to fundamentals is paramount. The message for the near future is cautious optimism.

Trends in the prescription of radiographs for comprehensive care patients in U.S. and Canadian dental schools.

Results of this 1992 survey are compared to results from 1977 and 1987 surveys to establish long-term trends in radiographic prescribing practices for dentulous adult comprehensive care patients in U.S. and Canadian dental schools. The major trends include a decline in prescribing both an intraoral full-mouth series and panoramic radiograph (46 percent to 19 percent to 9 percent of schools from 1977 to 1987 to 1992, respectively). These changes were complemented by an increase in prescribing a full-mouth series only (32 percent to 48 percent to 57 percent, respectively), and an increase in the use of selection criteria (2 percent to 19 percent to 26 percent, respectively). Between 1987 and 1992 there was little change in the preferred examination for the edentulous adult patient, and small changes in the preferred examination for the child patient.

Subtraction radiography to assess reproducibility of patient positioning in cephalometrics.

Subtraction radiography is a way to measure differences in landmark positions between cephalometric films without using tracings that introduce another source of error. This method was used to evaluate the reproducibility of head positioning in 54 pairs of cephalometric films taken within hours of each other, before and after splint removal in orthognathic surgery patients. There were no statistically significant changes in two cranial and four maxillary landmarks; the expected changes in mandibular landmark served to validate the method. The results suggest that patient positioning is not a major contributor to the error of cephalometric methods.

Assessing dental practice quality by evaluating radiology items.

The DEMCAD dental office assessment instrument was developed to evaluate practice quality using Donebedian's quality assessment model of structure, process, and outcome. This previously validated instrument takes about six hours to complete. Subsequent analysis was undertaken to determine whether an abbreviated office assessment based on the evaluation of radiology items was sufficiently sensitive, specific, and practical to be used as a screening instrument for identifying dental offices with very low evaluation scores. Data for this analysis were obtained from 300 volunteer general dental practices evaluated in the field testing of the DEMCAD instrument. The nine radiology structure items predicted very poorly the overall structure scores. However, 13 radiology process items predicted overall process scores quite accurately. Four of the 13 radiology process items (periodontal diagnoses recorded, interdental bone shown on x-rays, caries diagnoses recorded, and current x-rays mounted) produced a combined R2 of .58. These four radiology variables predicted the 10 percent of the dental practices with the lowest overall process score with 87 percent sensitivity and 93 percent specificity. This analysis showed that an abbreviated dental practice process quality assessment using oral radiology items in an audit of patients' records may be feasible as a screening test for dental office assessment.

An evaluation of radiographic equipment and procedures in 300 dental offices in the United States.

As part of the development and testing of a dental practice quality assessment instrument, data were gathered regarding the radiological practices of a nationwide sample of 300 general dentistry offices. The distribution of assessment scores was compared for practice size (solo versus nonsolo) and practice age (1-19 years versus 20 or more years). Practice habits varied widely, from a high of 99% of the offices using a leaded apron to a low of 23% of the offices having a written policy regarding the use of ionizing radiation. Most offices successfully managed administrative items such as mounting and dating radiographs. However, for items such as radiographic exposure, tissue coverage, and radiographic interpretation, general performance was fair.

The effect of lesion size, restorative material, and film speed on the detection of recurrent caries.

The purpose of this investigation was to study the effect of the size of carious lesions, radiographic density of composite and amalgam restorative materials, and film speed on the radiographic detection of simulated recurrent caries. Radiographs were made of extracted premolars with either large or small recurrent carious lesions simulated adjacent to Class II amalgam or composite restorations with both E-speed and D-speed intraoral film. For each restorative material, teeth that had no simulated caries were compared with teeth that had small and large simulated caries. Recurrent caries is detected best when the lesion is adjacent to radiopaque composite restorations, and detection is poorest when the lesion is next to radiolucent composite restorations. Large carious lesions are identified correctly more often than small lesions, although many lesions are not detected at all, especially those adjacent to radiolucent composite materials. There is no difference between E-speed and D-speed film for the detection of recurrent carious lesions.

Efficacy of dental radiographic practices: options for image receptors, examination selection, and patient selection.

Many technical factors and treatment philosophies affect the way dental radiology is practiced. Some, like minimum tube filtration, are legislated. Others, like proper darkroom techniques, are universally acknowledged as essential. Still others, like the selection of an image receptor and the selection of the type of examination, are the subject of much discussion and debate. This article addresses some of the more controversial options and choices facing dental practitioners by reviewing the standard assessment techniques available to help make appropriate decisions, by summarizing and analyzing available data, and by offering recommendations for practice.

Efficacy of panoramic radiography in dental diagnosis and treatment planning.

We compared treatment decisions based on a clinical examination alone with decisions based on an examination plus a panoramic radiograph to determine whether the panoramic radiograph increased the diagnostic yield and consequently affected treatment. Provisional treatment plans, based on a screening clinical examination alone (n = 33), or on a screening clinical examination plus panoramic radiograph (n = 43), were compared with final treatment plans based on a complete diagnostic assessment (including all necessary radiographs). For this analysis, the final treatment plan was considered correct and used as the gold standard. The two groups used in the comparison were equivalent in age, gender, and final treatment plan needs. The availability of a panoramic radiograph did not improve the accuracy with which provisional treatment plans predicted the number of teeth requiring composites, amalgams, crowns, or extraction, nor did it improve the accuracy of the assessment of the periodontal status (Wilcoxon rank sum, alpha = 0.05). The proportion of patients who had an intra-oral full-mouth series as part of the complete diagnostic work-up was essentially the same for both groups (58% and 60%, respectively); the availability of the panoramic film did not reduce the need for full-mouth series radiographs for the development of the final treatment plans.

Duplication of the premolar dentition.

Multiple supernumerary teeth, often associated with various syndromes, is a relatively uncommon isolated dental anomaly. We present a case of a 9-year-old black male patient with complete duplication of the premolar dentition and premolarization of the permanent canines.