Peer review amongst restorative specialists on the quality of their communication with referring dental practitioners

OBJECTIVE: A peer review study was carried out to assess the written communication between consultants and specialist registrars in restorative dentistry with the referring general dental practitioners. METHODS: Seven people took part in the study and each presented referral and reply letters for five patients whom they had seen for consultation. The referral letters were used for information only and were not used in the peer review process. Each participant inspected the referral and reply letters from the other six participants. The reply letters were anonymously peer reviewed by using a proforma containing agreed criteria in relation to appropriate factors to include in the reply letter. The reviewer also ranked the letter in relation to overall quality on a 1-10 point scale. RESULTS: It was found that the participants' letters generally conformed positively with the agreed criteria although there were some differences between individuals. There were particular problems identified in relation to tooth notation. Reply letters commonly used different forms of tooth notation to the referring practitioners. CONCLUSIONS: The ranking of the letters generally indicated that the participants' replies were judged to be favourable by their peers. There may be scope for continuing this study in relation to peer review by other groups of professionals, in particular practitioners in primary dental care.     

Appraisal of a standardised periodontal referral proforma.

AIM: The primary objective was to assess the standard of new-patient referral communications to the Periodontology Department of a teaching hospital and evaluate any differences in referral quality between referrals that used a standardised proforma and conventional letters. Secondary objectives were to evaluate the potential influence on referral performance of age, postgraduate qualifications and country of qualification of the referring practitioners. DESIGN: A retrospective analysis of a randomised sample of all referral letters and proformae received during a nine-month period. SETTING: Letters and referral proformae received by the Periodontal Department of the teaching hospital between 1 January and 30 September 1995 were surveyed. METHODS: An objective Categorisation System for Periodontal Referral Quality (CSPRQ) was devised and tested for inter- and intra-examiner reproducibility. The referral communications in the random sample were then categorised for quality. The year, country of qualification (UK or non-UK) and possession or otherwise of postgraduate qualifications for each of the referring dentists was ascertained from the Dentists' Register. A Standard Normal Deviants (SND), or Z-test was applied to the resulting data. OUTCOME MEASURES: Acceptability or unacceptability of referral letters and proformae, related to the age (assessed by year of qualification), country of qualification and possession or otherwise of postgraduate qualifications. RESULTS: A random sample of 378 referral communications (from a total of 2663) was analysed. Sixty-three of the random sample were referral proformae. The use of the referral proforma was associated with a highly significantly better (P < 0.01) referral performance, than the use of referral letters. There was a trend for referrals from the small numbers of practitioners who were Fellows in Dental Surgery or Masters of Science to be better than those from other practitioners. There was also a trend for use of the referral proforma to enhance the referral performance of practitioners who had been qualified for more than 20 years. Use of the referral proforma highly significantly (P < 0.01) improved the quality of referrals from non-UK qualified practitioners. CONCLUSIONS: In this study, the quality of periodontal referrals was associated for the better with the use of a referral proforma.     

Endodontic 'Solutions'. Part 2: An audit comparing current practice in Belfast with UK and Republic of Ireland Dental Schools

Endodontic lubricants, irrigating solutions and medicaments help reduce the microbial load within root canals. Primary and secondary cases involve different microbes. Each'solution'or combinations thereof could play a significant role but no detailed guidelines exist on their use. An audit was undertaken to compare current practice in Belfast Dental School to the others across the UK and Republic of Ireland (ROI). This audit highlighted three main differences between Belfast and other dental schools. Many other institutions utilized other irrigants besides sodium hypochlorite (NaOCl), different intracanal medicaments, including calcium hydroxide, and higher concentrations of NaOCl. Having gathered this information, we ask, 'Is there sufficient evidence to change the endodontic regime currently used at Belfast Dental School?'. Using the findings from the literature review (Part 1), we introduce new evidence-based protocols for primary and secondary cases for use in Belfast Dental School. Clinical Relevance: In the absence of detailed clinical guidelines on the use of endodontic lubricants, irrigants and medicaments in primary and secondary cases, it is important to be aware of current practice in UK and ROI dental schools where dentists and specialists are trained.     

A review of referrals of new patients to the paediatric department of a teaching hospital during a six-month period in 2004.

AIMS: The aims of this review were to assess the reasons why patients were referred to a specialist dental paediatric unit and the quality of the referral letters received. MATERIAL AND METHOD: All patients referred to the paediatric consultation clinic at the Liverpool University Dental Hospital from January 2004 to July 2004 were included in the review. The reasons for their referral, as stated by the referring practitioners, were compared with the clinical findings from initial assessments in the consultation clinic and the quality of referral letters was assessed. RESULTS: Ninety-nine out of a total of 102 referrals were from general dental practitioners. Sixty were girls and 42 boys. Their mean age was 9.5 years. The commonest reason (25 patients) was for treatment under general anaesthesia. In 90 (88.2%) cases the main reason for referral stated in the letters was consistent with the findings of the clinical assessment in the consultant clinic. All 102 letters included the patient's name, address, date of birth and telephone number and 89 (87.3%) were dated. However, only 25 (24.5%) included any mention of medical history and fewer than 30% included details of any treatment provided by the referring practitioner. CONCLUSIONS: The vast majority of patients were referred for good reasons. The quality of the referral letters was generally poor. The use of a structured referral pro forma could improve the quality of the referral.     

An audit of the quality of referral letters received by the Department of Oral and Maxillofacial Surgery, Dublin Dental School and Hospital

One hundred consecutive referral letters, sent by dental practitioners to the Department of Oral and Maxillofacial Surgery, Dublin Dental School and Hospital, were audited in terms of quality. The audit was based on the Scottish Intercollegiate Guidelines Network (SIGN) recommendations of 1998. The audit demonstrated that in general referral letters required modification and did not give the clinician the required information. This paper sets out the results of the audit and suggests a template that should be used for future referrals.     

Current status of the cast metal inlay: a survey of dental schools in the UK and Hong Kong

This study reports on the current status of the gold inlay in the undergraduate curriculum of Dental Schools in the UK and at the Prince Philip Dental Hospital, Hong Kong, to determine if the decline in the use of the cast gold inlay over the past 20 years is reflected in teaching at undergraduate level. A questionnaire, which was mailed to all the heads of departments of conservative dentistry in the UK, was designed to determine current teaching in respect of cast inlays. The results show that although the majority of UK dental schools continue to teach direct and indirect inlay techniques, a minority (4 and 5 respectively) no longer incorporate a practical exercise in this teaching. Reasons cited for the discontinuation of the technique are varied but the availability of simpler, more conservative techniques is emphasized. Examination of the treatment records at the Prince Philip Dental Hospital, Hong Kong, where the Class II inlay technique is taught both theoretically and practically, shows that only a small proportion of all posterior cast restorations fitted between May 1983 and April 1988 were inlays (4.6 per cent).     

The Council of Heads and Deans of Dental Schools: 75 years

For three quarters of a century the Council of Heads and Deans of Dental Schools (CHDDS) has met to discuss issues relating to the UK and Irish dental schools. In this, the 75(th) anniversary year, it seems timely to review the work of the Council to date.     

A survey of undergraduate education in dental implantology in UK dental schools

The aim of this study was to ascertain knowledge on current teaching of implant dentistry in the undergraduate curriculum of Dental Schools in the UK. Information on the teaching modalities, including year of introduction of implant dentistry into undergraduate curriculum, departments involved in teaching, format of teaching, use of adjunctive teaching aids, and types of implant systems used in undergraduate teaching was collected by means of a questionnaire, which was sent to all undergraduate dental schools in the UK. Based on a 100% response rate, the findings indicate that all dental schools in the UK reported that they included dental implantology in their undergraduate curriculum; however there were marked variations in the content and delivery of the teaching.     

Influence of NICE guidelines on removal of third molars in a region of the UK

We investigated compliance in the West Midlands, UK with the guidelines issued by the National Institute of Clinical Excellence (NICE) on the indications for the removal of third molars. We audited the practice at three departments of maxillofacial surgery that take referrals from three districts of the West Midlands. Of a total of 300 referral letters 217 (72%) specified a NICE-compliant diagnosis. A total of 267 patients (89%) were advised to have third molars removed and all three units achieved 100% compliance with NICE guidelines. There was a concordance of diagnosis of 69% between referring general dental practitioners and attending oral surgeons (concordance was 79% if only those referral letters that carried a specific indication were considered). Disease-free wisdom teeth made up a mean of only 6% of all referrals.     

The future of the profession--a survey of dental school applicants

PURPOSE: To gather background information about applicants to the dental undergraduate course, and ascertain the factors involved in their decision to study dentistry. METHOD: Applicants attending for interview at Dundee and Manchester Dental Schools completed anonymous questionnaires. The useable response rate was 94% (n = 436). RESULTS: There were equal numbers of male and female applicants to the two schools as a whole. Although there was a much broader ethnic mix in the applicants to Manchester, the overall proportion of minority ethnic groups was considerably greater than in the UK population as a whole. Seventy-five per cent came from professional backgrounds, although marked differences were apparent between ethnic groups. A quarter had family relations who were dentists, and 30% were related to doctors. Over half (53%) decided to apply within the last year, with popular motivating factors including a general interest in dentistry, a desire to help people and to work with their hands. Dentistry was the first choice of career of 89%, with medicine the most popular alternative. CONCLUSION: Valuable information was gathered from these prospective dental students regarding their backgrounds and the decision process involved in their career selection. This will prove beneficial when developing the recruitment process and allow appropriate tailoring to the target audience.     

A comparison of diagnostic screening data derived from general dental practitioners and periodontists used for initial treatment planning in periodontitis patients

As the quality of clinical information contained in referral letters for specialist care may determine the initial decisions as to appropriate treatment for patients, it is important that this information is objective and accurate. The use of a standardised questionnaire for this purpose improves the quality of information received, but it is not known how accurate this information is if used in the decision-making process for treatment planning. The aim of this study was to compare the clinical assessment data derived from a standardised questionnaire used by referring patients to a specialist periodontal unit. Equivalent data recorded by dentists and periodontists were compared to establish whether the data were consistently reproducible, and therefore usable for deciding on the appropriate initial phase of treatment for patients. Data from 50 patients referred for periodontal treatment planning and specialist care in which the questionnaires from the general dental practitioner and the subsequent periodontal assessment were available were compared. All of the patients were medically healthy and were not taking any long-term medication. The patients were selected based on the retrospective availability of equivalent clinical data from the questionnaires and consultation in the periodontal department at the Eastman Dental Hospital, London. The equivalence or disparity in the identification of different cofactors, and the community periodontal index of treatment need (CPITN) (basic periodontal examination, BPE) scores recorded by referring dentists (GDP), and periodontists (EDH, Eastman Dental Hospital) were annotated and compared. A level of equivalence of over 50% of assessments was demonstrated between referring dentists and periodontists in the variables of oral hygiene, smoking, bleeding on probing and restorative factors, as well as in the recorded scores of the CPITN (BPE) screening system. It can be concluded that the use of questionnaires for referral for specialist services is useful to not only improve and standardise the quality and extent of the relevant clinical information received, but may also be a valuable resource that may be used in the initial decision-making process for screening patients to the appropriate level of periodontal care. However, the limitations of this observational study preclude drawing any definitive conclusions in the absence of a more carefully controlled study designed specifically to overcome these limitations.     

Appropriate consent and referral for general anaesthesia - a survey in the Paediatric Day Care Unit, Barnsley DGH NHS Trust, South Yorkshire

BACKGROUND: In November 1998 the General Dental Council introduced guidelines for dental practitioners when referring a patient for general anaesthesia (GA). The practitioner is required to explain the risks associated with GA and the alternatives, give a detailed medical history and a clear justification for providing GA in the letter of referral. METHOD: A survey was administered on 202 parents or guardians, which aimed to investigate whether they felt that their dental practitioners had advised them of any risks of GA prior to referral. A record was also made if any reasons were given for the provision of GA in the letter of referral. RESULTS: The majority of the parents or guardians (66%) felt that they were not informed of any of the risks of GA and 25% felt that they were. From the letters of referral, 37% contained a reason for GA and 63% did not give any reason or justification for GA. CONCLUSION: There is evidence that referring practitioners do not adequately explain the risks of the anaesthetic to parents or guardians of children undergoing GA. There is also a lack of clear justification in the letters of referral for providing GA. PRACTICE IMPLICATION: It is essential that the alternatives and the risks of GA are discussed and if GA is still required, a clear justification should be contained in the letter of referral as part of informed consent. More importantly the referring practitioner should keep a contemporaneous record of this, preferably with a signature from the parent or guardian on agreement of referral.     

An assessment of the quality of referral letters sent to a specialist periodontist during a nine month period

There have been concerns about the quality of referral letters received by specialist periodontists. This retrospective study aimed to assess the quality of all referral letters received over a nine month period, by a specialist periodontist working in a publicly financed community clinic, and to compare the results with those obtained from a study which assessed referral letters received by the periodontal department of a London teaching hospital during the same period. After the assessors had trained for intra- and inter-examiner reproducibility, the letters were assessed using the Categorisation System for Periodontal Referral Quality (CSPRQ) (Snoad et al., 1999). The year and country of qualification (UK or non-UK), and possession or otherwise of postgraduate qualifications for each of the referring dentists was ascertained from the UK Dentists Register. The results from this study and those from the hospital study were statistically tested using the Chi-squared test. Before the studies commenced the assessors achieved 100% inter-examiner reproducibility when applying the CSPRQ. A total of 114 letters was received, six of which were excluded. Of the remaining 108, 38 were categorised as of an acceptable standard. There were differences in the performance of dentists from different age groups in that 56% of letters from those qualified from 10-20 years, 29% of those from dentists qualified < 10 years and 27% of those qualified > 20 years were of an acceptable standard. The results were broadly similar to those of the hospital study except that there was a statistically significant difference (P< 0.05) between the quality of referrals from dentists qualified between 10 and 20 years and those with non-UK primary qualifications. It was concluded that the overall quality of referral letters assessed in this study was poor and that the CSPRQ provided a highly reproducible technique for assessing the quality of periodontal referral letters.     

Computer literacy and attitudes of dental students and staff at the University of the West Indies Dental School

Introduction:  The University of the West Indies (UWI) Dental School is planning to implement computer-based information systems to manage student and patient data. In order to measure the acceptance of the proposed implementation and to determine the degree of training that would be required, a survey was undertaken of the computer literacy and attitude of all staff and students.
Methodology:  Data were collected via 230 questionnaires from all staff and students.
Results:  A 78% response rate was obtained. The computer literacy of the majority of respondents was ranked as 'more than adequate' compared to other European Dental Schools. Respondents < 50 years had significantly higher computer literacy scores than older age groups (P < 0.05). Similarly, respondents who owned an email address, a computer, or were members of online social networking sites had significantly higher computer literacy scores than those who did not (P < 0.05). Sex, nationality and whether the respondent was student/staff were not significant factors. Most respondents felt that computer literacy should be a part of every modern undergraduate curriculum; that computer assisted learning applications and web-based learning activity could effectively supplement the traditional undergraduate curriculum and that a suitable information system would improve the efficiency in the school's management of students, teaching and clinics.
Conclusion:  The implementation of a computer-based information system is likely to have widespread acceptance among students and staff at the UWI Dental School. The computer literacy of the students and staff are on par with those of schools in the US and Europe.     

Integrated teaching of basic and clinical sciences in anxiety and pain management

Like many other UK Dental Schools, Leeds Dental Institute has undertaken a commitment to integrated learning within its new curriculum. From an educational viewpoint, contextualisation of learning presents opportunities for deeper levels of learning. This can be particularly useful in embedding basic sciences in the dental curriculum. The General Dental Council in their document `The First Five Years' endorse this approach to learning. The Year 1 Anxiety and Pain Management course has been designed to integrate basic and clinical sciences, interdisciplinary learning and learning with other members of the dental team. This paper describes the structure of the course, its place within the horizontal and vertical learning themes, as well as describing the response of staff and students to this type of course.     

Future opportunities for research in primary dental care: developing research to support the commissioning of care.

On 23rd November 2005, there was a first for the Faculty of General Dental Practice (UK) [FGDP(UK)] when it hosted an open, national research study day, funded by the Department of Health. The study day followed on from a national Research and Development in Primary Dental Care meeting, 'Reflection and Moving Forward', held in Manchester in March 2004.     

Facilitators and barriers to improving the quality of referrals for potential oral cancer

The quality and content of referral letters are important for prioritisation of patients who may have oral cancer. Referrals letters to the Oral Medicine Clinic at Birmingham Dental Hospital were analysed and practitioners interviewed. Whilst acceptable for general purposes, most letters did not contain sufficient information to allow effective prioritisation. Interviews disclosed a misunderstanding amongst practitioners about the way in which referrals were handled. A number of barriers to increasing the information included in letters were identified. Referral guidelines and a standardised proforma might help improve the ability of the service to operate a fast-track system.     

UK dental students' ability and confidence in applying the Index of Orthodontic Treatment Need and determining appropriate orthodontic referral

Introduction

The aim was to assess the ability and confidence of UK undergraduate dental students in applying the Index of Orthodontic Treatment Need (IOTN) and determining appropriate orthodontic referral.

Materials and Methods

This was a cross-sectional survey using a case-based online questionnaire. Fourth and fifth year undergraduate dental students were recruited from UK dental schools through their university and social media. Six cases were presented and participants were asked to provide an IOTN score and judgement about referral. Participants were asked about their confidence, experience and orthodontic teaching.

Results

Sixty-nine responses were returned. A quarter of participants reported having used IOTN before in a clinical setting. Clinical experience with IOTN influenced confidence. Familiarity with making orthodontic referrals was low and only one participant reported having made an orthodontic referral. Correct IOTN scores were given by 68% of participants for a large 14 mm overjet (5a) case, 43% of participants for an impacted canine (5i) case and 26% of participants for an impacted premolar (5i) case. Incorrect IOTN was most common in hypodontia cases with only 19% correctly identifying mild hypodontia (4h) and 28% identifying severe hypodontia (5h). For the majority of cases, incorrect answers about referral were due to confusion between specialist practitioner and orthodontic consultant pathways.

Conclusions

Dental students' ability and confidence in correctly applying the IOTN Dental Health Component and selecting the appropriate referral pathway was inadequate. Responses suggest a lack of clinical experience in assessing patients, applying the IOTN and making referrals. The low response rate is disappointing and limits the scope for making recommendations.