[Series: Education and the dentist in 2025. The external practical internship: a taste of professional dental practice]. / Serie: Onderwijs en de tandarts anno 2025. De externe praktijkstage: proeven aan de beroepsuitoefening als tandarts.

The practical training in dental schools in the Netherlands is largely organised within the walls of the educational institution, while many other medical educational programmes provide practical training to a large extent in the professional environment. The external practical internship is a form of practical learning with which positive experience has been gained in foreign dental schools, both by students and dentist-supervisors. The Dutch dental schools have a joint plan to set up practical internships in dental practices for master's students in the final year of their education. The aim of such an internship is that students in the last phase of their programme learn to apply the acquired knowledge and skills in an actual professional environment. This includes both clinical and dental treatment and the ability to organise oral health care for patients and everything that comes with it. This article describes the outline of this programme.

[Series: Education and the dentist in 2025. Evidence-based clinical practice guidelines for an academic learning line 'quality and safety in oral care']. / Serie: Onderwijs en de tandarts anno 2025. Op bewijs gebaseerde praktijkrichtlijnen in de opleiding; voorstel tot een academische leerlijn 'kwaliteit en veiligheid van mondzorg'.

Education in the field of quality and safety in oral care still needs further development, both for students and teachers. Based on the current development of clinical practice guidelines in the field of oral care in the Netherlands, this article describes a proposal for implementing this as a 'quality of oral care' learning line in the dental school curricula. Within clinical educational practice and scientific training, students should become familiar with the development, assessment and application of clinical practice guidelines. Some proposals for embedding this new learning line in the curriculum are given. In order to further shape the learning line, close cooperation between the three dental schools and the Kennisinstituut Mondzorg (Institute for Knowledge Translation in Oral Care) in the Netherlands is recommended.

[Therapeutic prescription of antibiotics and NSAID's by dentists in the Netherlands]. / Therapeutisch voorschrijven van antibiotica en NSAID's door tandartsen in Nederland.

Late in 2015 the Royal Dutch Dental Association (KNMT) conducted a study of the therapeutic prescription of antibiotics and NSAIDs by dentists in general practice in the Netherlands and the factors influencing their decisions. Of the 1,087 dentists contacted 367 (34%) completed the online questionnaire. In the 4 weeks preceding the study they had prescribed an antibiotic to 1.3% of their patients on average. A fifth (20%) found it difficult to decide whether an anti-inflammatory drug is indicated and/or whether this should be an antibiotic or a NSAID. Questioned about medication decisions (whether or not antibiotics are indicated) in 11 fictional cases, 11% of respondents judged every case correctly. 39% undertreated, 24% overtreated and 26% both undertreated and overtreated. In the last two categories, dentists with non-Dutch degrees are overrepresented. More than half (55%) of the respondents say they need a guideline for prescribing antibiotics in dental treatment and 28% (also) need postgraduate education on this matter.

Caries Progression Rates Revisited: A Systematic Review.

Caries progression seems to follow universal, predictable rates, depending largely on the caries severity in populations: the higher the caries severity, the higher the progression rates. Quantification of these rates would allow prediction of future caries increments. Our aim was to describe caries progression rates in the primary and permanent dentition in Western populations (not in lesions) of children and adolescents. Therefore, we systematically searched MEDLINE-PubMed, Embase, CINAHL, and the Cochrane library for studies reporting caries progression data. Eligibility criteria were reporting empirical data from at least 2 full-mouth dental caries examinations in a closed cohort during a follow-up of at least 3 y, a first examination after 1974, a second examination before the age of 22 y, caries assessed as dentine caries (d3/D3), and caries reported in dmfs/DMFS (decayed, missing, and filled surfaces), dmft/DMFT (decayed, missing, and filled teeth), or caries-free participants. Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, we described the results for the primary and permanent dentition in a systematic review, performed a meta-analysis for the caries incidence rate in the permanent dentition, and conducted multivariate, hierarchical meta-regression analyses for the caries incidence rate and the increments in DMFS and DMFT. Of the 6,343 unique studies retrieved, 43 studies (56,376 participants) were included for systematic review and 32 for meta-analyses (39,429 participants). The annual decline in caries-free children in the permanent dentition ranged from 0.8% to 10.2%. The annual increment ranged from 0.07 to 1.77 in DMFS and from 0.06 to 0.73 in DMFT. The pooled caries incidence rate was 0.11 (0.09-0.13) per person-year at risk. Meta-regression analyses showed that the methods of individual studies influenced pooled caries incidence rates and increments in DMFS and DMFT. This should be taken into account in planning and evaluation of oral health care services. However, the caries incidence rate is promising for prediction of future caries increments in populations.

[Instruction in dental radiology]. / Scholing in de tandheelkundige radiologie.

The diagnostic use of oral radiology is an essential part of daily dental practice. Due to the potentially harmful nature of ionising radiation, the clinical use of oral radiology in the Netherlands is framed by clinical practice guidelines and regulatory requirements. Undergraduate students receive intensive theoretical and practical training in practical and theoretical radiology, with the aim of obtaining the 'Eindtermen Stralingshygiëne voor Tandartsen en Orthodontisten'-certificate, which is required for legal permission to use oral radiology in dental practice. It is recommended that the curriculum be expanded to include the areas of knowledge required to qualify for the 'Eindtermen Stralingshygiëne voor het gebruik van CBCT-toestellen door tandartsen' (the certificate for the use of conebeam radiology by dentists). The general dental practitioner is faced with changing laws and regulations in all areas of practice. One of the most significant legal changes in the field of dental radiology was the introduction of the new radiation protection and safety rules in 2014. Moreover, a large group of dentists is also being confronted with the transition from conventional to digital images, with all its challenges and changes in everyday practice.

Caries preventive measures in orthodontic practice: the development of a clinical practice guideline.

OBJECTIVES: White spot lesions (WSLs) are a side effect of orthodontic treatment, causing esthetic problems and a risk of deeper enamel and dentine lesions. Many strategies have been developed for preventing WSLs, but great variability exists in preventive measures between orthodontists. This study developed statements on which a clinical practice guideline (CPG) can be developed in order to help orthodontists select preventive measures based on the best available evidence. MATERIALS AND METHODS: A nominal group technique (RAND-e modified Delphi procedure) was used. A multidisciplinary expert panel rated 264 practice- and evidence-based statements related to the management of WSLs. To provide panel members with the same knowledge, a total of six articles obtained from a systematic review of the literature were read by the panel in preparation of three consensus rounds. According to the technique, a threshold of 75% of all ratings within any 3-point section of the 9-point scale regarding a specific statement was accepted as consensus. RESULTS: After the first and second consensus rounds, consensus was reached on 37.5 and 31.1% of statements, respectively. For the remaining 31.4% of statements, consensus was reached during a 4-h consensus meeting. CONCLUSIONS: Statements on the management of WSLs derived from a systematic literature review combined with expert opinion were formally integrated toward consensus through a nominal group technique. These statements formed the basis for developing a CPG on the management of WSLs before and during orthodontic treatment.

[Evidence-based clinical guidelines in dental practice 6. Guidelines for clinical practice in dental education]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 6. Praktijkrichtlijnen in de opleiding tot tandarts.

In response to the initiatives of the Kennisinstituut Mondzorg (Institute for Knowledge Translation in Oral Care), the importance of effective education in the area of guidelines is increasing. Future dentists will, after all, be confronted with new guidelines and need to be able to integrate them in their daily practice. Various guidelines and protocols have been established within the 3 dental schools. For students and instructors, however, the motivation for these guidelines and protocols is not always sufficiently clear. In addition, the terms guideline, clinical practice guideline and protocol are used interchangeably, resulting in terminological confusion. Embedding within and coordination with theoretical education is also still limited in all programmes and it is proposed that the 3 dental schools collaborate on this issue. Finally, it is advised to replace the term 'evidence-based' with 'evidence-informed' because this indicates more clearly that other factors (patients opinion, available financial means, etc.) play a role in the final choice of treatment in a specific situation.

[Evidence-based clinical oral healthcare guidelines 4. Adherence requires an implementation strategy]. / Evidencebased klinische praktijkrichtlijnen in de mondzorg 4. Toepassing vergt een implementatiestrategie.

Adherence to clinical guidelines requires support in practice. However, systematic implementation of evidence-based guidelines is not common practice in oral healthcare. The Knowledge Institute Oral Care (KiMo) offers the opportunity to take into account potential barriers and facilitators during the development of evidence-based clinical practice guidelines. These factors which are relevant to the guideline and the oral healthcare practice provide the ingredients for a tailor-made programme of implementation that has a scientific basis. Elements of any implementation programme are the quality indicators derived from the oral healthcare guidelines. These indicators should fit, on the one hand, the specific goals of the guidelines (patient safety, effectiveness, efficiency, patient-centred, timeliness, accessibility) and, onthe other hand, the various perspectives of the different stakeholders, such as patients, caregivers, health insurers and inspectorate. These quality indicators provide information on adherence to the guidelines, the results of a certain treatment and the success of the implementation strategy, all with the aim to improve the quality of oral healthcare.

[The impact of frailty on the oral care behaviour and dental service use of elderly people]. / De invloed van kwetsbaarheid op mondzorggedrag en tandartsbezoek van ouderen.

In order to explore how the level of frailty and various frailty factors affect the dental service use and oral self-care behaviour of frail elderly people, 51 frail elderly people were interviewed. Additional information on age, gender, living situation, prosthetic status, self-reported health and oral health, chronic diseases and an index for frailty was collected. A thematic qualitative analysis of the collected data reveals that frail elders maintain long-established oral hygiene routines as long as possible to sustain a sense of self-worth. When burdened by severe health complaints they discontinue visits to the dentist first and oral hygiene routines subsequently. A loss of confidence in the results of dental service use, the trivializing of complaints and a diminishing sense of the importance of oral health play a role in these developments. Frail elderly people also experience psychological and social barriers to oral healthcare and dental service use when they are institutionalized.

[The integration of science in the clinical dental programme at the University of Nijmegen]. / Integratie van wetenschap in de kliniek van de Nijmeegse opleiding tandheelkunde.

To be able to make a well founded clinical decision on the basis of evidence, the concept of 'evidence based practice' offers a solution by making it possible to select the appropriate knowledge from the increasing amount of scientific clinical information. Competence is required to put the concept (combining the best available scientific clinical evidence, experience and skills of the dentist and preferences of the patient) into practice. To prepare the undergraduate student for future clinical practice, the Nijmegen dental school has adopted evidence based practice to be implemented from the first year of dental training. The experiences of both students and lecturers are modest. The probable reason is that many clinical decisions are (can be) taken on the basis of experience and routine. The challenge is to base life-long learning on the practice of evidence based dentistry.

[Prevention of white spots during orthodontic treatment with fixed appliances]. / Wittevleklaesies tijdens orthodontische behandeling: preventief beleid.

Orthodontic treatment with fixed appliances involves a significant risk of enamel demineralization. The aim of this study was three-fold: to gain insight into a) the preventive measures which are applied as standard practice in The Netherlands in orthodontics, b) when the use of fluoride rinses is initiated, and c) which concentrations and frequencies of use are recommended. A questionnaire was sent to all orthodontists in private practice in The Netherlands. Completed questionnaires were returned by 154 of the orthodontists (response rate 81%). A basic practice protocol for preventing demineralization was used at the start of treatment by 93%. The majority (90%) recommended to use fluoride rinse once daily. They generally (85%) recommended to do this in the evening immediately after toothbrushing. The authors recommend rinsing at another moment than after tooth brushing, in order to increase the number of fluoride moments during the day, which enhances the effectiveness of this measure in preventing caries.

[Patient safety in general dental practice 2009]. / Patiëntveiligheid in tandartspraktijken in 2009.

In recent years various studies have been published which indicate that adverse events in health care facilities are the result of structural factors. In 2009 a national study was carried out in the Netherlands to gain insight into patient safety in primary care settings, including general dental practices. In 20 randomly selected practices, patient records were investigated and oral care professionals reported, during a period of 2 weeks, adverse events which occurred. For each practice, 2 researchers screened, with the help of a checklist, 50 randomly selected patient records covering a period of 1 year. A total of 8 preventable adverse events were found in the 1000 patient records (0.8%). Anonymous reports made during the 2 weeks of the research period resulted in 7 adverse events. Practically all of the adverse events had to do with diagnostics and treatment and resulted in limited harmful consequences for patients. On the basis of these results, oral care in general dental practice would appear to be safe, but the concept 'patient safety' is not at all or only minimally active among general dental practitioners. Regarding patient safety performance, improvement in the quality of record-keeping would be desirable.

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.

[Quality of dental care: new ideas of the government]. / Kwaliteit van zorg: nieuwe ideeën van de overheid.

In the 1990s the Dutch government imposed several laws to strengthen the position of the patient and to improve the quality of care. These laws did not always have the intended outcome. Recently the Ministry of Public Health, Welfare and Sport launched the programme, 'The 7 rights of the patient in health care: investing in health care relations'. Three of these rights will have a strong influence on Dutch general dental practices: the right to choice and choice-information, the right concerning coordination among oral health care providers, and the right to low-threshold complaint and disagreement procedures. Most of these rights already exist in current legislation. Especially the right to choice and choice-information means that the dentist has to provide his patients not only with information concerning treatment but also with information on his dental practice, such as waiting times, the experience of other patients and opening times.

5-Year survival of ART restorations with and without cavity disinfection.

OBJECTIVES: The null-hypothesis tested was that there is no difference between the survival of ART restorations with, and without, cavity disinfection among adolescents after 5 years. METHODS: Eligible students were allocated to one of the treatment groups. One operator placed a total of 90 restorations, 45 each per treatment group, in ninety 14-15 year olds. Restorations were evaluated on replica models at baseline and after 1 and 5 years, by two calibrated and independent evaluators using the ART criteria. The independent variables were gender, mean DMFT score at baseline, cavity size (small/large), cavity type (single-/multiple surfaces) and disinfected cavity (yes/no). Statistical analyses were done using the Kaplan-Meier method and log-rank test. RESULTS: The cumulative survival percentage and standard error for the 61 ART restorations with and without disinfection at evaluation year 5 were 85% (S.E.=6.1%) and 80% (S.E.=7.1%), respectively: not significantly different (p=0.37) from each other. The cumulative survival percentage and standard error for all ART restorations was 97% (S.E.=2.0%) at evaluation year 1 and 82% (S.E.=4.7%) at year 5, and it was 85% (S.E.=5.4%) for single- and 77% (S.E.=9%) for multiple-surface ART restorations at year 5. The cumulative survival percentage of all ART restorations at evaluation year 5 was statistically significant higher for boys than for girls (p=0.03). CONCLUSIONS: Disinfecting a cavity cleaned according to ART with a 2% chlorhexidine solution is unnecessary. It is useful to introduce the ART approach systematically into the healthcare system in Egypt.

[The role of guidelines and systematic reviews in oral healthcare]. / De rol van richtlijnen en systematische literatuuroverzichten in de tandheelkundige zorgverlening.

Clinical practice guidelines are a very appropriate means of keeping up to date, effectively and efficiently, with knowledge on a specific clinical topic. These are a compilation of clinical expertise retrieved from daily practice, scientific evidence derived from journals and the opinions of patients, which together form the core of the treasury of ideas of evidence-based dentistry. The development of clinical practice guidelines should be carried out according to a strictly defined procedure. In this procedure systematic reviews of literature should be used. The Cochrane Collaboration is an organization that develops reliable systematic reviews. Clinical practice guidelines are an essential part of evidence-based dentistry. The evidence-based approach should be fully integrated in dental education and in daily dental practice. The establishment of a national centre for evidence-based development and implementation of dental clinical practice guidelines, in cooperation with other healthcare professionals, should have the highest priority, in order to maintain the quality of oral healthcare in professional hands.

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.

[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.

[Routine dental examination as evaluation tool in clinical cariology]. / Het periodiek tandheelkundig controleonderzoek als evaluatie-instrument in de klinische cariologie.

As a result of the caries prevalence of the Dutch population the character of the routine dental examination is changing. Caries screening remains relevant for high caries risk individuals but the interpretation of early caries lesions deserves more attention, especially the assessment of progression of caries lesions in time. Diagnosis of caries by dental practitioners in the Netherlands mainly consists of visual inspection in combination with bitewing radiography and both methods play an important role in the timing of bitewing radiographs and forthcoming recall visits for oral health examination. The content and frequency of the routine dental examination are discussed in relation to the individual risk prediction as relevant aspects of quality of dental care in the Netherlands.