Treating dental patients who use oral antithrombotic medication: a survey of dentists in the Netherlands

BackgroundFor many years, international guidelines have advised health care professionals not to adjust oral antithrombotic medication (OAM) regimens before invasive dental procedures. The authors conducted a study to examine the opinions of Dutch general dentists regarding the dental care of patients receiving treatment with these medications.MethodsThe authors invited via e-mail 1,442 general dentists in the Netherlands to answer a 20-item Internet-based questionnaire that they developed. Survey items consisted of questions about medical history taking, number of patients in the dental practice receiving OAM therapy, frequency of consulting with medical and dental colleagues and suggested dental treatment of patients during various invasive dental procedures.ResultsA total of 487 questionnaires were returned (response rate of 34 percent). The mean age of respondents was 47 years, and 77 percent were male. The majority of dentists responded that they obtain medical histories, but that they did not know how many of their patients were receiving OAM treatment. Dentists reported that they consult with medical colleagues frequently about antithrombotic medication. Ninety-one percent of respondents stated that they obtained their medical knowledge primarily in dental school. More than 50 percent of the dentists reported that they were not familiar with the international normalized ratio. The majority of dentists responded that they felt a need for clinical practice guidelines.ConclusionsAccording to the results of our survey, most dentists remain cautious when performing invasive dental procedures in patients who are treated with OAMs. Moreover, survey respondents tended to estimate that the risk of bleeding during dental procedures when OAM therapy is continued is higher than the risk of rethrombosis when use of antithrombotic medication is interrupted.Clinical ImplicationsA growing proportion of elderly patients and those with medically complex conditions are being treated in dental practices in the Netherlands. Consequently, more needs to be done to ensure that dentists are offered evidence-based guidance when treating patients who receive OAMs.     

How willing are dentists to treat young children?: A survey of dentists affiliated with Medicaid managed care in New York City, 2010

BackgroundDespite recommendations for children to have a dental visit by the age of 1 year, access to dental care for young children, including children enrolled in Medicaid, remains limited. The authors conducted a survey to assess the availability of dentists to see young children enrolled in Medicaid managed care (MMC) in New York City (NYC), to determine barriers to the provision of dental care to young children and, within the context of MMC, to identify strategies to facilitate the delivery of dental care to children.MethodsThe authors mailed a survey to assess the provision of dental services to young children and perceived barriers and facilitators to 2,311 general dentists (GDs) and 140 pediatric dentists (PDs) affiliated with NYC MMC. A total of 1,127 surveys (46 percent) were received. The authors analyzed the responses according to provider type, youngest aged child seen, provider’s ability to see additional children and practice location. The authors compared responses by using the χ² test.ResultsFewer than one-half (47 percent) of GDs saw children aged 0 through 2 years. Provider type, years in practice and percentage of Medicaid-insured patients were associated significantly (P χ .005) with youngest age of child seen. Among respondents seeing children aged 0 through 2 years, PDs were significantly more likely to provide preventive therapy (P = .004) and restorative treatment (P χ .001). Additional training and access to consulting PDs were identified by GDs as potential facilitators to seeing young children.ConclusionA high proportion of NYC GDs affiliated with MMC do not see young children.Practice ImplicationsNinety-four percent of NYC MMC– affiliated dentists are GDs, but 53 percent of GD respondents did not see children aged 0 through 2 years in their practices. Improving access to dental care for young children requires changes in GDs’ practices, possibly by means of additional training and access to consulting PDs.     

Concordance between clinical practice and published evidence: Findings from The National Dental Practice-Based Research Network

BackgroundDocumenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network (“the network”).MethodsNetwork dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent (“1”) or inconsistent (“0”) with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.ResultsThe authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).ConclusionDentists reported a medium-range concordance between practice and published evidence.Practical ImplicationsEfforts to bring research findings into routine practice are needed.     

Pain catastrophizing in dental patients: Implications for treatment management

Background”Pain catastrophizing“ refers to an exaggerated negative mental set brought to bear during an actual or anticipated painful experience. A patient's perception of a dental care experience as catastrophic can result not only in poor satisfaction with the therapy but also in avoidance of necessary treatments, resulting in the deterioration of oral health.MethodsThe author reviewed literature regarding pain catastrophizing regarding dental treatment as well as behavioral models related to catastrophizing.ResultsPeople who catastrophize show excessive attention to pain (rumination), exaggerate the threat value of pain (magnification) and feel unable to cope with their suffering (helplessness). During dental treatments, greater pain catastrophizing is associated with increased pain, dental anxiety and negative thoughts regarding pain and dental procedures.ConclusionsIt is important that clinicians identify dental patients who catastrophize so as to plan and provide the best treatment for their needs.Practical ImplicationsTo manage the care of patients who catastrophize, the clinician can actively probe patients' pain experience, help them reappraise threat, manipulate their attention to pain and improve dentist-patient communication.     

Dental treatment intensity in frail older adults in the last year of life

BackgroundPalliative care focusing on pain and infection is recommended for patients who are terminally ill. It is difficult to implement this strategy in practice because of the lack of clear guidelines. The authors conducted a study to examine dental treatment provided to a group of long-term care (LTC) residents in the last year of life.MethodsThe authors retrospectively followed 197 LTC residents (60 years or older) in the last year of life to death. On the basis of the dental services patients received between the new patient examination and death, the authors categorized the patients into three groups: no care (NC), limited care (LC) and usual care (UC). The authors developed a multivariable continuation ratio logit model with shared regression coefficients across two logits to identify the factors associated with the end-of-life dental care pattern.ResultsThe authors found that 50.8 percent of the patients received NC before death. Among those who received treatment, 62.9 percent received UC, and 60.7 percent of the patients in the UC group had completed their treatment in the last three months of life. A three-month increment in survival and having dental insurance resulted in 1.74 (95 percent confidence interval [CI], 1.32–2.30) and 2.59 (95 percent CI, 1.03–6.52) times greater odds, respectively, of receiving some dental treatment before death. Neither survival nor dental insurance, however, was associated with dental care intensity in the last year of life (that is, UC versus LC).ConclusionsWhile most of the patients who were in the last year of life received insufficient dental care, comprehensive treatment was provided commonly to frail patients at the end of life, raising questions about quality of care.Practical ImplicationsPalliative oral health management needs to be revisited to improve quality of care for frail older adults at the end of life.     

Hepatitis B virus transmissions associated with a portable dental clinic,West Virginia, 2009

BackgroundAlthough hepatitis B virus (HBV) transmission in dental settings is rare, in 2009 a cluster of acute HBV infections was reported among attendees of a two-day portable dental clinic in West Virginia.MethodsThe authors conducted a retrospective investigation by using treatment records and volunteer logs, interviews of patients and volunteers with acute HBV infection as well as of other clinic volunteers, and molecular sequencing of the virus from those acutely infected.ResultsThe clinic was held under the auspices of a charitable organization in a gymnasium staffed by 750 volunteers, including dental care providers who treated 1,137 adults. Five acute HBV infections—involving three patients and two volunteers—were identified by the local and state health departments. Of four viral isolates available for testing, all were genotype D. Three case patients underwent extractions; one received restorations and one a dental prophylaxis. None shared a treatment provider with any of the others. One case volunteer worked in maintenance; the other directed patients from triage to the treatment waiting area. Case patients reported no behavioral risk factors for HBV infection. The investigation revealed numerous infection control breaches.ConclusionsTransmission of HBV to three patients and two volunteers is likely to have occurred at a portable dental clinic. Specific breaches in infection control could not be linked to these HBV transmissions.Practical ImplicationsAll dental settings should adhere to recommended infection control practices, including oversight; training in prevention of bloodborne pathogens transmission; receipt of HBV vaccination for staff who may come into contact with blood or body fluids; use of appropriate personal protective equipment, sterilization and disinfection procedures; and use of measures, such as high-volume suction, to minimize the spread of blood.     

Acceptance among and impact on dental practitioners and patients of American Heart Association recommendations for antibiotic prophylaxis

BackgroundThe 2007 American Heart Association (AHA) guidelines for the prevention of infective endocarditis (IE) called for a major reduction in the number of patients recommended for antibiotic prophylaxis (AP) and redefined the dental procedures considered to put these patients at risk of acquiring the infection. The purpose of the authors' study was to determine the acceptance of these changes among and the impact of the changes on dentists and their patients.MethodsThe authors sent a survey to a random sample of 5,500 dentists in the United States.ResultsNinety-five percent of the 878 respondents indicated that they saw patients who receive AP. More than 75 percent were either satisfied or very satisfied with the AHA guidelines, and the respondents indicated that they believed almost three-quarters of their patients also were pleased. Seventy percent of dentists, however, had patients who took antibiotics before a dental procedure even though the guidelines no longer recommend it.ConclusionsAcceptance of the 2007 guidelines appears to be high, but controversy remains. Additional scientific data are needed to resolve these issues.Practical ImplicationsThe 2007 AHA guidelines have greatly simplified the identification of patients who need AP for dental procedures, given that, in general, far fewer people with cardiac abnormalities are considered to be at risk as a result of invasive procedures. Some physicians, however, continue to prescribe antibiotics for some patients whom the AHA no longer considers to need them. Patients also may choose to continue this practice themselves. There is ongoing controversy surrounding this common clinical question in dental practice, and the next guidelines from the AHA may change on the basis of data from future clinical studies.     

Advancing infection control in dental care settings: Factors associated with dentists' implementation of guidelines from the Centers for Disease Control and Prevention

Background and OverviewThe authors set out to identify factors associated with implementation by U.S. dentists of four practices first recommended in the Centers for Disease Control and Prevention's Guidelines for Infection Control in Dental Health-Care Settings—2003.MethodsIn 2008, the authors surveyed a stratified random sample of 6,825 U.S. dentists. The response rate was 49 percent. The authors gathered data regarding dentists' demographic and practice characteristics, attitudes toward infection control, sources of instruction regarding the guidelines and knowledge about the need to use sterile water for surgical procedures. Then they assessed the impact of those factors on the implementation of four recommendations: having an infection control coordinator, maintaining dental unit water quality, documenting percutaneous injuries and using safer medical devices, such as safer syringes and scalpels. The authors conducted bivariate analyses and proportional odds modeling.ResultsResponding dentists in 34 percent of practices had implemented none or one of the four recommendations, 40 percent had implemented two of the recommendations and 26 percent had implemented three or four of the recommendations. The likelihood of implementation was higher among dentists who acknowledged the importance of infection control, had practiced dentistry for less than 30 years, had received more continuing dental education credits in infection control, correctly identified more surgical procedures that require the use of sterile water, worked in larger practices and had at least three sources of instruction regarding the guidelines. Dentists with practices in the South Atlantic, Middle Atlantic or East South Central U.S. Census divisions were less likely to have complied.ConclusionsImplementation of the four recommendations varied among U.S. dentists. Strategies targeted at raising awareness of the importance of infection control, increasing continuing education requirements and developing multiple modes of instruction may increase implementation of current and future Centers for Disease Control and Prevention guidelines.The findings and conclusions in this report are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention, Atlanta.The authors thank Jon Ruesch, who when this study was conducted was the director, Survey Center, American Dental Association, Chicago, for his effort in the collection of the data for this research project. Mr. Ruesch is now retired.     

Reimbursement rates and policies for primary molar pit-and-fissure sealants across state Medicaid programs

BackgroundLittle is known about Medicaid policies regarding reimbursement for placement of sealants on primary molars. The authors identified Medicaid programs that reimbursed dentists for placing primary molar sealants and hypothesized that these programs had higher reimbursement rates than did state programs that did not reimburse for primary molar sealants.MethodsThe authors obtained Medicaid reimbursement data from online fee schedules and determined whether each state Medicaid program reimbursed for primary molar sealants (no or yes). The outcome measure was the reimbursement rate for permanent tooth sealants (calculated in 2012 U.S. dollars). The authors compared mean reimbursement rates by using the t test (α = .05).ResultsSeventeen Medicaid programs reimbursed dentists for placing primary molar sealants (34 percent), and the mean reimbursement rate was $27.57 (range, $16.00 [Maine] to $49.68 [Alaska]). All 50 programs reimbursed dentists for placement of sealants on permanent teeth. The mean reimbursement for permanent tooth sealants was significantly higher in programs that reimbursed for primary molar sealants than in programs that did not ($28.51 and $23.67, respectively; P = .03).ConclusionsMost state Medicaid programs do not reimburse dentists for placing sealants on primary molars, but programs that do so have significantly higher reimbursement rates.Practical ImplicationsMedicaid reimbursement rates are related to dentists' participation in Medicaid and children's dental care use. Reimbursement for placement of sealants on primary molars is a proxy for Medicaid program generosity.     

Community factors predicting dental care utilization among older adults

BackgroundFew investigators have studied the influence of community factors on dental care utilization among older adults. The authors' objective in this study was to investigate the effect of community factors on dental care utilization after adjustment for individual factors.MethodsUsing data from a cross-sectional survey of Ohio residents, the authors assessed dental care utilization in a sample of 2,166 adults 65 years or older. They linked individual-level dental care utilization, predisposing factors (age, sex, race or ethnicity, marital status, education), enabling factors (poverty, dental insurance) and need-related factors (physical and mental health problems) with county-level data (socioeconomic environment and health resource environment) from the 2010 Area Health Resource Files (from the U.S. Department of Health and Human Services) and the American Community Survey (from the 2006-2010 U.S. census). By using multilevel logistic regression models, the authors evaluated the association between dental care utilization and community factors after adjustment for individual factors.ResultsThe results indicated that individual factors such as being female, married and nonpoor and having a higher educational level and private dental insurance were associated with higher odds of having utilized dental care. Furthermore, older adults living in a county with a higher dentist-to-population ratio were more likely to use dental services even after the authors adjusted the results for the individual-level factors (odds ratio = 1.10; P = .03).ConclusionsCounty-level dentist-to-population ratio has independent effects on older adults' dental care utilization even after adjustment for individual-level characteristics.Practical ImplicationsA comprehensive policy plan is required to intervene at both the individual and community levels to improve dental care utilization among older adults. By understanding the factors influencing dental care utilization among older adults, U.S. dentists will be better positioned to meet the dental needs of this population.     

Combining ibuprofen and acetaminophen for acute pain management after third-molar extractions: Translating clinical research to dental practice

BackgroundEffective and safe drug therapy for the management of acute postoperative pain has relied on orally administered analgesics such as ibuprofen, naproxen and acetaminophen, or N-acetyl-p-aminophenol (APAP), as well as combination formulations containing opioids such as hydrocodone with APAP. The combination of ibuprofen and APAP has been advocated in the last few years as an alternative therapy for postoperative pain management. The authors conducted a critical analysis to evaluate the scientific evidence for using the ibuprofen-APAP combination and propose clinical treatment recommendations for its use in managing acute postoperative pain in dentistry.Types of Studies ReviewedThe authors used quantitative evidence-based reviews published by the Cochrane Collaboration to determine the relative analgesic efficacy and safety of combining ibuprofen and APAP. They found additional articles by searching the Ovid MEDLINE, PubMed and http://ClinicalTrials.gov databases.ConclusionsThe results of the quantitative systematic reviews indicated that the ibuprofen-APAP combination may be a more effective analgesic, with fewer untoward effects, than are many of the currently available opioid-containing formulations. In addition, the authors found several randomized controlled trials that also indicated that the ibuprofen-APAP combination provided greater pain relief than did ibuprofen or APAP alone after third-molar extractions. The adverse effects associated with the combination were similar to those of the individual component drugs.Practical ImplicationsCombining ibuprofen with APAP provides dentists with an additional therapeutic strategy for managing acute postoperative dental pain. This combination has been reported to provide greater analgesia without significantly increasing the adverse effects that often are associated with opioid-containing analgesic combinations. When making stepwise recommendations for the management of acute postoperative dental pain, dentists should consider including ibuprofen-APAP combination therapy.     

Dental care providers' and patients' perceptions of the effect of health information technology in the dental care setting

BackgroundThe use of electronic health records (EHRs) in dental care and their effect on dental care provider-patient interaction have not been studied sufficiently. The authors conducted a study to explore dental care providers' interactions with EHRs during patient visits, how these interactions influence dental care provider-patient communication, and the providers' and patients' perception of EHR use in the dental clinic setting during patient visits.MethodsThe authors collected survey and interview data from patients and providers at three dental clinics in a health care system. The authors used qualitative and quantitative methods to analyze data obtained from patients and dental care providers.ResultsThe provider survey results showed significant differences in perceptions of EHR use in patient visits across dental care provider groups (dentists, dental hygienists and dental assistants). Patient survey results indicated that some patients experienced a certain level of frustration and distraction because of providers' use of EHRs during the visit.ConclusionsThe provider survey results indicated that there are different perceptions across provider groups about EHRs and the effect of computer use on communication with patients. Dental assistants generally reported more negative effects on communication with patients owing to computer use. Interview results also indicated that dental care providers may not feel comfortable interacting with the EHR without having any verbal or eye contact with patients during the patient's dental visit.Practical ImplicationsA new design for dental operatories and locations of computer screens within the operatories should be undertaken to prevent negative nonverbal communication such as loss of eye contact or forcing the provider and patient to sit back to back, as well as to enhance patient education and information sharing.     

Rubber dam use during root canal treatment: Findings from The Dental Practice-Based Research Network

Background

1. Download : Download full-size image

The Dental Practice-Based Research Network (DPBRN) provided a means to investigate whether certain procedures were performed routinely. The authors conducted a study to quantify rubber dam use during root canal treatment (RCT) among general dentists and to test the hypothesis that certain dentist or practice characteristics were associated with rubber dam use.MethodsDPBRN practitioner-investigators (P-Is) answered a questionnaire that included items about rubber dam use and other forms of isolation during RCT. DPBRN enrollment questionnaire data provided information regarding practitioner and practice characteristics.ResultsA total of 729 (74 percent) of 991 P-Is responded; 524 were general dentists who reported providing at least some RCTs and reported the percentage of RCTs for which they used a rubber dam. Of these 524 P-Is, 44 percent used a rubber dam for all RCTs, 24 percent used it for 51 to 99 percent of RCTs, 17 percent used it for 1 to 50 percent of RCTs, and 15 percent never used it during RCT. Usage varied significantly by geographic region and practice type. The use of cotton rolls and other forms of isolation also was reported.ConclusionsSimilar to other reports in the literature, not all DPBRN general dentists used a rubber dam during RCT.Clinical ImplicationsBecause the clinical reference standard is to use a rubber dam during RCT, increasing its use may be important.     

Restoration of noncarious tooth defects by dentists in The Dental Practice-Based Research Network

BackgroundThe authors conducted a study to quantify the reasons for restoring noncarious tooth defects (NCTDs) by dentists in The Dental Practice-Based Research Network (DPBRN) and to assess the tooth, patient and dentist characteristics associated with those reasons.MethodsData were collected by 178 DPBRN dentists regarding the placement of 1,301 consecutive restorations owing to NCTDs. Information gathered included the main clinical reason, other than dental caries, for restoration of previously unrestored permanent tooth surfaces; characteristics of patients who received treatment; dentists’ and dental practices’ characteristics; teeth and surfaces restored; and restorative materials used.ResultsDentists most often placed restorations to treat lesions caused by abrasion, abfraction or erosion (AAE) (46 percent) and tooth fracture (31 percent). Patients 41 years or older received restorations mainly because of AAE (P < .001). Premolars and anterior teeth were restored mostly owing to AAE; molars were restored mostly owing to tooth fracture (P < .001). Dentists used directly placed resin-based composite (RBC) largely to restore AAE lesions and fractured teeth (P < .001).ConclusionsAmong DPBRN practices, AAE and tooth fracture were the main reasons for restoring noncarious tooth surfaces. Pre-molars and anterior teeth of patients 41 years and older are most likely to receive restorations owing to AAE; molars are most likely to receive restorations owing to tooth fracture. Dentists restored both types of NCTDs most often with RBC.     

Designing a safety checklist for dental implant placement: A Delphi study

BackgroundComplications during and after dental implant placement can be a hindrance to successful treatment. Checklists are emerging as useful tools in error reduction in various fields. The authors selected a Delphi panel to explore the appropriate clinical practices involved in implant placement, with the objective of formulating a safety checklist that would aid in reducing errors.MethodsThe authors administered a Delphi method survey to an expert panel of 24 board-certified periodontists to determine if consensus existed regarding the critical steps involved in implant placement. They defined consensus as 90 percent agreement among participants. Using the Delphi data, the authors designed a safety checklist for implant placement.ResultsThe panelists generated 20 consensus statements regarding essential steps in implant placement. The authors divided the statements into preoperative, intraoperative and postoperative phases. To determine the rationale for consensus decisions, the authors conducted a thematic qualitative analysis of responses to all open-ended questionnaire items, asking panel members how or why a particular procedure was performed.ConclusionThe panelists reached a consensus regarding the steps they considered critical in implant placement. Further research is needed to assess the acceptance and effectiveness of this type of checklist in a clinical setting.Practical ImplicationsThe authors developed a checklist that may be useful in reducing errors in placement of dental implants. If effective, this checklist ultimately will aid in minimizing risk and increasing implant success rates, especially for inexperienced practitioners, dental students, surgical residents and dental implant trainees (that is, dentists undergoing training to place implants through continuing education courses).     

The declining number of practicing African American dentists in Cuyahoga County, Ohio, 1970 through 2010

BackgroundThe authors tracked the declining number of practicing African American dentists and its relationship to the migratory patterns of the black community in Cuyahoga County, Ohio, from Jan. 1, 1970, through Dec. 31, 2010.MethodsThe authors conducted a longitudinal study in which they used the Geographic Information System (Environmental Systems Research Institute, Redlands, Calif.) to plot the location of each black-owned dental practice in Cuyahoga County in conjunction with the black population. They calculated the ages of the dentists by using birth dates posted on the Ohio State Dental Board's Web site and divided the dentists into five age groups.ResultsThe study results showed that dental practice distributions followed the migratory pattern of the black population from Cleveland to the surrounding suburbs. The number of black dentists in practice decreased from 1986 through 2010 in the Cleveland metropolitan area (Cuyahoga County), and 46.3 percent of the black dentists were projected to retire by 2020.ConclusionsThese results underscore the need to increase the number of black dentists in Cuyahoga County and nationwide. On the basis of the demographic data they found, the authors expect the number of black dentists to continue to decrease if no intervening circumstances occur.Practice ImplicationsThere were 48.8 percent fewer black dentists in Cuyahoga County in 2010 than there were in 1985. If this pattern continued until 2020, there could be a critical shortage of black dentists in Cuyahoga County.     

Tooth preservation or implant placement: A systematic review of long-term tooth and implant survival rates

BackgroundFor the past few decades, dental implants have served as reliable replacements for missing teeth. However, there is an increasing trend toward replacing diseased teeth with dental implants.Types of Studies ReviewedThe authors conducted a systematic review of long-term survival rates of teeth and implants. They searched the MEDLINE database for relevant publications up to March 2013. They considered studies in which investigators assessed the long-term effectiveness of dental implants or that of tooth preservation. They included only studies that had follow-up periods of 15 years or longer.ResultsThe authors selected 19 articles for inclusion. Investigators in nine studies assessed the tooth survival rate, whereas investigators in 10 studies assessed the implant survival rate. When comparing the overall long-term (that is, 15 years or more) tooth loss rate with that of implants, the authors observed rates ranging between 3.6 and 13.4 percent and 0 and 33 percent for teeth and implants, respectively. They could not perform a meta-analysis because of the substantial differences between the studies.Practical ImplicationsThe results of this systematic review show that implant survival rates do not exceed those of compromised but adequately treated and maintained teeth, supporting the notion that the decision to extract a tooth and place a dental implant should be made cautiously. Even when a tooth seems to be compromised and requires treatment to be maintained, implant treatment also might require additional surgical procedures that might pose some risks as well. Furthermore, a tooth can be extracted and replaced at any time; however, extraction is a definitive and irreversible treatment.     

A retrospective review of clinical international normalized ratio results and their implications

BackgroundWarfarin is a key element in therapy for atrial fibrillation, deep venous thrombosis (DVT), stroke (cerebrovascular accident) and cardiac valve replacement. Often, patients’ warfarin blood levels are not tightly controlled with regard to accepted therapeutic ranges, by virtue of the drug’s unpredictable nature.MethodsThe authors searched 16,017 active clinical charts for active patients of record from the three campuses of the School of Dentistry, Marquette University (MU), Milwaukee, for the years 2009 and 2010. Dental records of 315 patients contained entries including “INR,” the abbreviation for the term “international normalized ratio.” Only 247 of those records contained an indication of whether the patient’s INR values were within therapeutic range. The authors found that 1.96 percent of the total MU dental clinic patient population had a history of warfarin use.ResultsWhen the authors compared the INR values for patients with diagnoses of atrial fibrillation, DVT, stroke and cardiac valve replacement, they found that INR values for 107 of the 247 patients (43.3 percent) were not within therapeutic range for the respective diagnoses. For example, only 50 percent of the patients being treated for atrial fibrillation presented themselves for surgical dental treatment while their INR values were in tight control.ConclusionThe INR values for a significant number of dental patients are not within the therapeutic range for their medical conditions. These patients need to seek follow-up care from their medical care providers.Clinical ImplicationsScreening for INR in the dental office—especially before invasive dental treatment such as periodontal surgery, tooth extraction and dental implant placement—can help prevent postoperative complications. It also can aid the clinician in evaluating whether a patient’s INR is within therapeutic range and, subsequently, whether the patient’s physician needs to adjust the warfarin dosage.     

The effectiveness of using a patient simulator to teach light-curing skills

BackgroundThe authors evaluated the effectiveness of using a patient simulator (MARC Patient Simulator [MARC PS], BlueLight analytics, Halifax, Nova Scotia, Canada), to instruct dental students (DS) on how to deliver energy optimally to a restoration from a curing light. Five months later, the authors evaluated the retention of the instruction provided to the DS.MethodsToward the end of the DS&apos; first year of dental education, the authors evaluated the light-curing techniques of one-half of the class of first-year DS (Group 1) before and after receiving instruction by means of the patient simulator. Five months later, they retested DS in Group 1 and tested the remaining first-year DS who were then second-year DS and who had received no instruction by means of the patient simulator (Group 2). They gave DS in Group 1 and Group 2 MARC PS instruction and retested them. The authors also the tested fourth-year DS (Group 3) and dentists (Group 4) by using the MARC PS before giving any instruction by means of the MARC PS.ResultsThe results of one-way analysis of variance (ANOVA) showed that there were no significant differences in the ability of dentists and DS to light cure a simulated restoration before they received instruction by means of the patient simulator (P = .26). The results of two-way ANOVA and Fisher protected least significant difference tests showed that after receiving instruction by means of the patient simulator, DS delivered significantly more energy to a simulated restoration, and this skill was retained. There were no significant differences between DS in Group 1 and Group 2 after they had received instruction by means of the patient simulator.ConclusionsThe abilities of dentists and DS to light cure a simulated restoration were not significantly different. Hands-on teaching using a patient simulator enhanced the ability of DS to use a curing light. This skill was retained for at least five months.Practical ImplicationsThe education provided to dentists and DS is insufficient to teach them how to deliver the optimum amount of energy from a curing light. Better teaching and understanding of the importance of light curing is required.