Respect for Patients' Autonomy

BackgroundRespect for patients' autonomy is an ethical principle in health care highlighted in the ADA Principles of Ethics and Code of Professional Conduct. The author presents a case example to illustrate its importance in dentistry.MethodsUsing a clinical example of disrespect for patients' autonomy, the author underscores the importance of incorporating normative ethical principles in patient-dentist relationships.ConclusionsRespect for patients' autonomy sustains healthy boundaries between patients and the clinician. It underscores the importance of providing patient education and counsel without attempting to persuade or manipulate patients for dentists' benefit.Practice ImplicationsRespect for patients' autonomy is a fundamental principle of health care ethics that patients expect dentists to follow. The author encourages dentists to incorporate this principle into every patient encounter.     

Management of painful temporomandibular disorders: Methods and overview of The National Dental Practice-Based Research Network prospective cohort study

BackgroundPatients often seek consultation with dentists for temporomandibular disorders (TMDs). The objectives of this article were to describe the methods of a large prospective cohort study of painful TMD management, practitioners’ and patients’ characteristics, and practitioners’ initial treatment recommendations conducted by The National Dental Practice-Based Research Network (the “network”).MethodsParticipating dentists recruited into this study treated patients seeking treatment for painful TMDs. The authors developed self-report instruments based on well-accepted instruments. The authors collected demographics, biopsychosocial characteristics, TMD symptoms, diagnoses, treatments, treatment adherence, and painful TMDs and jaw function outcomes through 6 months.ResultsParticipating dentists were predominately White (76.8%) and male (62.2%), had a mean age of 52 years, and were general practitioners (73.5%) with 23.8% having completed an orofacial pain residency. Of the 1,901 patients with painful TMDs recruited, the predominant demographics were White (84.3%) and female (83.3%). Patients’ mean age was 44 years, 88.8% self-reported good to excellent health, and 85.9% had education beyond high school. Eighty-two percent had pain or stiffness of the jaw on awakening, and 40.3% had low-intensity pain. The most frequent diagnoses were myalgia (72.4%) and headache attributed to TMDs (51.0%). Self-care instruction (89.4%), intraoral appliances (75.4%), and medications (57.6%) were recommended frequently.ConclusionsThe characteristics of this TMD cohort include those typical of US patients with painful TMDs. Network practitioners typically managed TMDs using conservative treatments.Practical ImplicationsThis study provides credible data regarding painful TMDs and TMD management provided by network practitioners across the United States. Knowledge acquired of treatment recommendations and patient reports may support future research and improve dental school curricula.     

Deciding about patients' requests for extraction

Background and OverviewDentists frequently are faced with patients' requests for an extraction, sometimes of the entire dentition. In this article, the authors offer guidelines to help dentists and oral surgeons make decisions regarding such requests for extraction.ConclusionsIn most cases of patients' requesting extractions, the ethical principle of nonmaleficence will play a decisive role in the dentist's decision making. In cases in which the request appears influenced by a specific mental condition such as a phobia of dental treatment, extraction rarely is justifiable.Practice ImplicationsDental professionals should keep in mind that they cannot be forced to carry out treatment that is at odds with the ethical principle of nonmaleficence or that is outside of the bounds of accepted treatment. To aid dentists in making treatment decisions in such cases, the authors present a flowchart that integrates possible considerations.     

Progress and trends in patients' mindset on dental implants. I: level of information, sources of information and need for patient information

Objectives: Little is known about the level of information on implant dentistry in the public. A representative opinion poll on dental implants in the Austrian population was published in 2003 (Clinical Oral Implants Research 14:621–642). Seven years later, the poll was rerun to assess the up‐to‐date information level and evaluate recent progress and trends in patients' mindset on dental implants. Material and methods: One thousand adults – representative for the Austrian population – were presented with a total of 19 questionnaire items regarding the level and the sources of information about dental implants as well as the subjective and objective need for patient information. Results: Compared with the survey of 2003, the subjective level of patient information about implant dentistry has significantly increased in the Austrian population. The patients' implant awareness rate was 79%. The objective level of general knowledge about dental implants was still all but satisfactory revealing unrealistic patient expectations. Three‐quarters trusted their dentists for information about dental implants, while one‐quarter turned to the media. The patients' wish for high‐quality implant restorations was significantly higher than in 2003, yet the majority felt that only specialists should perform implant dentistry. Conclusions: This representative survey reveals that dentists are still the main source of patient information, but throws doubt on the quality of their public relations work. Dentists must improve communication strategies to provide their patients with comprehensible, legally tenable information on dental implants and bridge information gaps in the future. To cite this article:
Pommer B, Zechner W, Watzak G, Ulm C, Watzek G, Tepper G. Progress and trends in patients' mindset on dental implants. I: level of information, sources of information and need for patient information.
Clin. Oral Impl. Res. 22 , 2011; 223–229
doi: 10.1111/j.1600‐0501.2010.02035.x     

Is there a higher prevalence of tinnitus in patients with temporomandibular disorders? A systematic review and meta‐analysis

The aim of this study was to determine whether there exists a higher prevalence of tinnitus in patients with temporomandibular disorders (TMDs) than in patients without TMDs. A systematic review was conducted in PubMed/MEDLINE for articles published between January 1992 and April 2018 in accordance with the PRISMA statement. Studies were included in this review only if they assessed TMDs using the research diagnostic criteria (RDC)/TMD or DC/TMD. A total of five studies were included in the systematic review, and a random‐effects meta‐analysis of three of the studies was conducted. In all of the selected studies, the prevalence of tinnitus was higher in patients with TMDs (35.8% to 60.7%) than in patients without TMDs (9.7% to 26.0%). The odds ratio of suffering from tinnitus among patients with TMDs was 4.45 (95% CI 1.64‐12.11. P = 0.003). Thus, despite the limitations of the included studies, this review demonstrates that the prevalence of tinnitus in TMD patients is significantly higher than that in patients without TMD.     

Temporomandibular disorder patients' journey through care

Durham J, Steele J, Moufti MA, Wassell R, Robinson P, Exley C. Temporomandibular disorder patients’ journey through care. Community Dent Oral Epidemiol 2011; 39: 532–541. © 2011 John Wiley & Sons A/S Abstract – Temporomandibular disorders (TMDs) are a common group of chronic disorders (illnesses) that health care providers can find difficult to diagnose and explain. Similar difficulties in the diagnosis of other chronic conditions have been shown to have a negative impact on health. An understanding of TMD patients’ experiences and journey through care could indicate time points and strategies to help patients. Objective: To develop a robust empirically derived map of TMD sufferers’ journey through care. Methods: A qualitative study using semi‐structured interviews was undertaken using a purposive sample of patients with TMDs. Analysis followed the principles of the constant comparative method where data collection and thematic analysis occurred concurrently and continued until data saturation (n = 29). Results: The experiences of patients could be grouped into three key stages: genesis of problem, seeking help in primary care and secondary care intervention. A wide variety of negative effects were described throughout these stages. An empirically derived map of the patients’ reported journey through care emerged. Conclusions: The experiences of patients with TMDs mirror experiences of other types of chronic illness. Mapping the journey through care for TMDs highlights the potential for interaction between the stages of the journey and the individual’s illness. It may be possible to target interventions at specific stages on the map to help minimize the psychosocial effects of TMDs.     

Is there an association between otologic symptoms and temporomandibular disorders?: An evidence-based review

BackgroundThe aim of this article is to discuss the scientific evidence available on the pathophysiology and management of otologic complaints in patients with temporomandibular disorders (TMDs).Types of Studies ReviewedThe authors conducted an electronic search in MEDLINE, Web of Science and ScienceDirect and retrieved all the relevant peer-reviewed journal articles available in English on the topic. No time restriction was applied.ResultsNo consensus exists on the management of otologic symptoms in patients with concomitant TMD. The scientific evidence suggests that conservative or reversible TMD therapy might provide relief. However, this evidence is scarce and low, thus further studies with larger sample sizes and better designed methodological frameworks are needed. Until such evidence is available, dentists and orofacial pain specialists should treat TMD patients using current guidelines and refer those with otologic symptoms to an otolaryngologist.Practical ImplicationsGiven the wide range of potential pathophysiologies and treatments for each otologic symptom described in the TMD patient, close collaboration with otolaryngologists is essential to achieve the best patient care.     

Oral health‐related quality of life in patients with tooth wear

The aim of this study was to investigate the impact of tooth wear (TW) on patients' oral health‐related quality of life. A total of 198 participants were included in the study. They belonged to the following four different diagnostic categories: 51 patients with TW, 46 patients with painful temporomandibular disorders (TMD), 43 complete denture wearers and 58 healthy controls. The Dutch version of the Oral Health Impact Profile (OHIP‐NL) was used to assess the patients' oral health‐related quality of life. The results of the study show that patients with TW have an impaired oral health‐related quality of life compared with healthy controls (P < 0·001). Furthermore, the impact of TW and of edentulousness do not differ significantly, while both of these oral conditions seem to have a lower impact on quality of life compared with painful TMD (P < 0·05). It was concluded that TW has a negative impact on patients' quality of life. This impact is comparable with that of edentulousness.     

Occupation as a potential contributing factor for temporomandibular disorders,bruxism, and cervical muscle pain: a controlled comparative study

The aim of the study was to compare the prevalence of cervical muscle pain (CMP) and myogenic temporomandibular disorders (MFP) among female dentists, high‐tech workers, and a group of subjects employed in other occupations; to investigate the associations among CMP, MFP, and bruxism in those groups; and to evaluate the influence of work‐related stress on MFP and CMP. Evaluation was based on clinical examinations of MFP and CMP and self‐reported questionnaires concerning pain and stress. The diagnosis of sleep bruxism was adapted using the validated diagnostic criteria of the American Academy of Sleep Medicine (International Classification of Sleep Disorders (ICSD‐2), 2005, Westchester, IL), whilst the diagnosis of awake bruxism was made on the basis of a questionnaire. The odds of a subject with MFP experiencing concurrent CMP or bruxism (sleep and/or awake) ranged from 2.603 to 3.077. These results suggest that high‐tech workers and dentists are at greater risk for developing temporomandibular disorders (TMDs) and CMP when compared with general occupation workers, as defined in this study. Furthermore, the associations shown here between TMDs and CMP highlight the importance of palpating neck musculature as part of any routine examination of TMD.     

Ethics in dentistry.

In this article I would like to do two things: to discuss the foundations of ethical thinking in general, and to link this discussion to the particular concern of dentists. My argument is divided in three sections: Firstly, I shall attempt to define the term 'ethics' and briefly outline the context for the discussion of professional ethics. Secondly, I would like to draw attention to the categories and approaches in ethical thinking and also to the complexity of any adequate ethical reflection. In my third and final section I shall try to make a few suggestions in terms of how dentists could incorporate ethical thinking in their understanding of the dental profession.     

Factors related to the willingness of Palestinian dentists to treat patients with blood‐borne diseases

This study aimed to explore, using groups of simulated patients, the willingness of Palestinian dentists to treat patients with blood‐borne diseases. Simulated patients conducted a telephone survey of a random sample of dentists registered with the Palestinian Dental Association. A random system was used to assign dentists to one of two groups, in which simulated patients randomly identified themselves with either human immunodeficiency virus (HIV) or hepatitis B virus (HBV) and asked for a dental appointment. Three‐hundred and four dentists (76%) responded to our telephone survey. Sixty‐six per cent accepted requests for appointments and 34% declined the appointment requests. Sixty‐eight per cent of the dentists declined appointment requests from patients with HIV and 32% declined appointments from patients with HBV. Dentist's gender, ‘blood‐borne disease type’, ‘place of private practice’, ‘country of graduation’ and ‘years since graduation’ were all significant predictors in the final logistic model. More than one‐third of our respondents declined appointment requests from patients with blood‐borne disease, two‐thirds of which were for patients who identified themselves as having HIV. Education and training programmes are needed to improve attitudes of dentists – especially female dentists, older dentists and dentists practising in northern governorates – towards patients with blood‐borne diseases.     

Evaluation of oro‐facial function in young subjects with temporomandibular disorders

The aim of this study was to evaluate bite force (BF) and oro‐facial functions at different dentition phases (initial‐mixed, intermediate‐mixed, final‐mixed and permanent dentition) in children and adolescents diagnosed with temporomandibular disorders (TMDs). The sample was selected from four public schools in Piracicaba, São Paulo, Brazil. Of the 289 participants recruited, aged 8–14 years old, 46 were placed into the TMD group. TMD was diagnosed using Axis I of the Research Diagnostic Criteria for Temporomandibular Disorders (2011). Oro‐facial functions were evaluated using the Nordic Orofacial Test‐Screening (NOT‐S), which involves both an interview and a clinical examination. BF was measured using a digital gnathodynamometer. Age and body mass index (BMI) were also considered. The data were analysed by the following tests: Kolmogorov–Smirnov test, Student's t‐test, Spearman and Pearson coefficients, Qui‐square test, Fisher's exact or binomial test, as indicated. Moreover, univariate and multivariable logistic regression were applied. For the TMD group, scores associated with NOT‐S interview and NOT‐S total were higher than for the control group (P = 0·033 and P = 0·0062, respectively). No differences in BF between genders or groups (P > 0·05) were detected. Variables included in the multivariate logistic regression were BMI and NOT‐S total. Based on this analysis, NOT‐S total was associated with TMDs. Reported sensory function was the specific domain within NOT‐S interview that established the significant difference between the groups (P = 0·021). The TMD group also had a greater number of alterations in the face‐at‐rest domain of the NOT‐S exam (P = 0·007). Concluding, it did not detect an association between TMDs and either dentition phase or BF. Instead, BF correlated with age and BMI. Oro‐facial dysfunction was associated with TMD in the studied sample, but this association may be bidirectional, requiring further researches.     

Good ethical practice in the dental treatment of patients with HIV/AIDS

Patients with HIV/AIDS have challenged the ethics of the dental profession. The seriousness, infectious character and social stigma of the illness have led to a range of ethical dilemmas about the treatment of such patients. This paper attempts to resolve some of the more difficult questions through exploring the moral boundaries of the rights and duties of both patients and dental practitioners. To accomplish this aim, the moral foundation for the general clinical duties of care is outlined, especially the obligations of providing treatment to a high standard, respecting the rights of patients to informed consent and doing both without personal prejudice. After illustrating why these duties require moral character as well as intellectual understanding, their practical consequences are outlined for specific issues in the treatment of seropositive patients. It is argued that patients should never be tested without their informed consent and that dentists have a duty to display courage, sensitivity and rigorous respect for confidentiality in the treatments they offer. The obligations of seropositive dentists are also considered, including their own obligations for disclosure toward regulatory authorities and patients. The moral debt which the dental profession owes to seropositive patients is highlighted.     

Progress and trends in patients' mindset on dental implants. II: implant acceptance, patient-perceived costs and patient satisfaction

Objectives: Compared with widespread investigations on dental implant survival and biologic parameters, patient‐based outcomes of implant dentistry have been neglected for years and are now becoming more popular. The aim of this representative opinion poll was to assess the up‐to‐date patients' mindset on dental implants and draw comparisons with the results published in 2003. Material and methods: One thousand adults – representative for the Austrian population – were presented with a total of 16 questionnaire items regarding acceptance and subjectively perceived costs of dental implant treatment as well as patient satisfaction with implant‐supported rehabilitation. Results: The implant acceptance rate was 56%, while 23% of the interviewees decidedly rejected implant treatment (same rate as in 2003), especially those over 50 years of age. Only 5% had themselves undergone implant treatment and 22% reported to know someone fitted with implants. The estimated costs of implant treatment were significantly higher than those in 2003, and three‐quarters felt that the prize was too high and that the sick fund or social security agencies should bear them. Satisfaction scores were significantly higher among interviewees wearing implant‐supported rehabilitations compared with those with conventional fixed or removable dentures. Conclusions: Little has changed in patients' attitude toward dental implants compared with the representative opinion poll in 2003. Neither implant acceptance nor implant prevalence in the Austrian population demonstrated upward trends. Professional public relations efforts are indicated to drop resentments and increase patient acceptance of dental implants as a treatment modality. To cite this article :
Pommer B, Zechner W, Watzak G, Ulm C, Watzek G, Tepper G. Progress and trends in patients' mindset on dental implants. II: implant acceptance, patient‐perceived costs and patient satisfaction.
Clin. Oral Impl. Res. 22 , 2011; 106–112.
doi: 10.1111/j.1600‐0501.2010.01969.x     

Validity of three screening questions (3Q/TMD) in relation to the DC/TMD

Temporomandibular disorders (TMD) are common but seem to be largely undetected within general dental care. To improve dentists’ awareness of these symptoms, three screening questions (3Q/TMD) have been introduced. Our aim was to validate 3Q/TMD in relation to the diagnostic criteria for TMD (DC/TMD), while taking into account the severity level of the symptoms. The study population consisted of 7831 individuals 20–69 years old, who had their routine dental check‐up at the Public Dental Health Service in Västerbotten, Sweden. All patients answered a health declaration, including the 3Q/TMD regarding frequent temporomandibular pain, pain on movement and catching/locking of the jaw. All 3Q‐positives (at least one affirmative) were invited for examination in randomised order. For each 3Q‐positive, a matched 3Q‐negative was invited. In total, 152 3Q‐positives and 148 3Q‐negatives participated. At examination, participants answered 3Q/TMD a second time, before they were examined and diagnosed according to DC/TMD. To determine symptom's severity, the Graded Chronic Pain Scale and Jaw Functional Limitation Scale‐20 (JFLS‐20) were used. In total, 74% of 3Q‐positives and 16% of 3Q‐negatives met the criteria for DC/TMD pain or dysfunction (disc displacements with reduction and degenerative joint disorder were excluded). Fifty‐five per cent of 3Q‐positives had a TMD diagnosis and CPI score ≥3 or a JFLS‐20 score ≥5, compared to 4% of 3Q‐negatives. The results show that the 3Q/TMD is an applicable, cost‐effective and valid tool for screening a general adult population to recognise patients in need of further TMD examination and management.     

The challenges and effects of globalisation on forensic dentistry

This paper deals with the challenges faced by forensic dentists in a world in which globalisation has become a reality. People travelling across the globe on a daily basis become victims of violent crime, terrorist attacks, human displacement, natural and man made disasters. This has forced colleagues in the profession to participate in joint operations exposing inadequacies which need urgent attention. Forensic dentists practise in isolation creating their own rules and regulations oblivious to the greater global community. No international protocols exist for the many procedures practised by the profession. Possible solutions to the complex problems are offered. These include co‐operation with colleagues around the globe while striving for the highest levels of quality control, standardisation, reliability, impartiality, reproducibility and ethical accountability.     

Knowledge and competence in temporomandibular disorders among Swedish general dental practitioners and dental hygienists

Objective: The aim of this study was to investigate knowledge and competence in temporomandibular disorders (TMD) among dentists and dental hygienists working in the public dental service (PDS) in Sweden.

Materials and methods: The study population comprised all general dentists (n?=?110) and dental hygienists (n?=?80) working in the PDS in two Swedish counties: Kronoberg (K) and Blekinge (B). The participants filled out a questionnaire comprised of 15 questions.

Results: The results of these questions are presented. The overall response rate for the general dentists was 87%, while the rate for the dental hygienists was 71%. Statistically significant differences between the general dentists in the two counties were found regarding the following: education in the field of TMD over the last 5 years (K: 37%, B: 73%), evaluation of occlusion when examining patients with suspected TMD (‘always’: K: 61%, B: 82%), and a desire for consultation of the OFP (orofacial pain)/TMD specialist by telephone (K: 71%, B: 44%). Regarding the dental hygienists, there was a statistically significant difference concerning the use of the treatment modality ‘reassurance’ (K: 41%, B: 7%).

Conclusions: The majority of the dental care providers in both counties – irrespective of professional category – had a positive attitude towards patients with TMD. Knowledge and competence in the field are sparse and require postgraduate education. There is a great need of an OFP/TMD specialist for more complicated patients and a need to implement updated knowledge and competence in the PDS in these two counties.     

Perceptions of the dental profession: a comparative analysis through scale development

Dentistry is a science‐based profession that has a close interaction with people and society. However, despite this close interaction, perceptions of the dental profession by both patients and dental professionals have received little research attention. The purpose of this study was to compare the perceptions of dentists, dental students, and patients toward the dental profession through the development and testing of the Dental Profession Perceptions Scale (DPPS). The DPPS contains a total of 17 items measured on a 5‐point Likert response scale. The DPPS showed excellent internal reliability (Cronbach's α = 0.92) and test–retest reliability (r = 0.93). Explanatory and confirmatory factor analyses of the DPPS showed that dentists’, dental students’, and patients’ perceptions of the dental profession could be grouped according to ‘status’, ‘human’, and ‘scientific’ factors. There were no statistically significant differences between participants’ DPPS total or sub‐scale scores according to dental group, gender, or income. The DPPS developed can be used in future studies as a psychometrically sound measuring tool. Further studies should examine the factors that may affect the perceptions of the dental profession in different societies and cultures.     

Self‐management programmes in temporomandibular disorders: results from an international Delphi process

Self‐management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self‐management appropriate for the treatment of patients with TMD, identify the components of that self‐management currently being used and create sufficiently clear and non‐overlapping standardised definitions for each of those components. A four‐round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self‐management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self‐management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self‐management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self‐exercise; self‐massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus‐derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.