A closer look at diagnosis in clinical dental practice: part 3. Effectiveness of radiographic diagnostic procedures

This article, the third in a series, uses the tools described in the first 2 articles to examine some of the radiographic diagnostic procedures that are employed regularly in dental practice. With a general grounding in the meaning of terms such as sensitivity, specificity, thresholds, kappa coefficients, and predictive values, the reader should now be a more discerning user of the operating characteristic data for dental diagnostic procedures. By re-examining some of these procedures in terms of their effectiveness, accuracy and validity, dental practitioners should be able to use the procedures in a more targeted manner and gain the maximum benefit from their results. With a better understanding of the value of a diagnostic test, the clinician's decision-making process will be far better informed. For example, knowing that a certain radiographic view is associated with a 60% false-positive rate for identifying occlusal caries will preclude blind trust in the results and will help the informed clinician attribute a realistic weight to the radiographic findings. This article considers diagnostic procedures in common use in North American practice, with special emphasis on radiography.     

A closer look at diagnosis in clinical dental practice: part 4. Effectiveness of nonradiographic diagnostic procedures and devices in dental practice

This article, the fourth in a series, examines nonradiographic procedures and devices such as standard clinical and visual examination, apex locators, vitality testers and colour shade guides in light of the tools described in the first 2 articles in the series. A variety of nonradiographic indices and scales are used in detecting periodontal disease and monitoring and assessing its treatment. The reliability of these diagnostic procedures directly affects treatment success, decisions to initiate more aggressive clinical interventions, and the ability to make an informed prognosis about the course of the disease. However, in many instances, the dependability of the measurements remains to be established.     

A closer look at diagnosis in clinical dental practice: part 5. Emerging technologies for caries detection and diagnosis

Parts 5 and 6 of this series examine innovations in diagnostic and management procedures and assess their potential to become everyday tools of the dental clinician. This paper examines some of the diagnostic tools supporting a philosophical shift in mainstream dental practice from concern with extensively decayed teeth to a focus on detecting incipient demineralized tissues. With the latter approach, the incipient carious process can be reversed by promoting enamel remineralization and thus eliminating the need for restorative intervention. Numerous methods and devices have been developed to detect, diagnose and monitor such lesions, and several have been produced in versions that may appeal to dental practitioners. This paper considers 3 of these methods and devices: the DIAGNODent laser device, quantitative light-induced fluorescence and the Digital Imaging Fiber-Optic Transillumination device. Each technique is illustrated, the research on its effectiveness is assessed to determine usefulness to the practitioner, and the comparative advantages of the 3 adjunct tools are discussed.     

A closer look at diagnosis in clinical dental practice: part 1. Reliability, validity, specificity and sensitivity of diagnostic procedures

Dentists are involved in diagnosing disease in every aspect of their clinical practice. A range of tests, systems, guides and equipment--which can be generally referred to as diagnostic procedures--are available to aid in diagnostic decision making. In this era of evidence-based dentistry, and given the increasing demand for diagnostic accuracy and properly targeted health care, it is important to assess the value of such diagnostic procedures. Doing so allows dentists to weight appropriately the information these procedures supply, to purchase new equipment if it proves more reliable than existing equipment or even to discard a commonly used procedure if it is shown to be unreliable. This article, the first in a 6-part series, defines several concepts used to express the usefulness of diagnostic procedures, including reliability and validity, and describes some of their operating characteristics (statistical measures of performance), in particular, specificity and sensitivity. Subsequent articles in the series will discuss the value of diagnostic procedures used in daily dental practice and will compare today's most innovative procedures with established methods.     

A closer look at diagnosis in clinical dental practice: part 6. Emerging technologies for detection and diagnosis of noncaries dental problems

The final article of this series examines some recent innovations in diagnostic procedures for noncaries dental problems and assesses the potential for new endodontic and periodontal methods to become everyday tools of the dental clinician.     

Admission systems to dental school in Europe: a closer look at Flanders

Dental education in Europe faces enormous challenges. One deals with the admission to dental school. Although admission procedures vary considerably across Europe, a characteristic of some systems is that the same procedure is used across students who will ultimately pursue different majors (medical or dental). This is based on the assumptions that there is no significant difference in these students’ scores and that the requirements for medicine and dentistry are equal. This study examines these assumptions in the admission exam ‘Medical and Dental Studies’ in Flanders. Students who pass may choose whether they start medical or dental education. Over an 8‐year period (2000–2007), admission exam scores of students starting medicine (n = 4492) were compared to those of students starting dentistry (n = 547). Second, the validity of this exam is examined for both medical and dental education. It was found that students starting dentistry had a significantly lower total score on the admission exam than students starting medicine. Differences were especially striking for the cognitive part of the admission exam. For both medical and dental students, the admission exam score was a valid predictor of academic grades in the first 3 years, although correlations were lower for dental education. These results have implications for admission procedures in countries where the same system is used for both majors. The findings that students who have a lower score choose dental education and that the validity of the exam is slightly lower for dentistry, raise questions about using the same admission exam for two obviously different majors.     

The use of diagnostic data in clinical dental practice.

This article has briefly introduced the dental clinician to the principles and practical application of diagnostic decision analysis. There are trade-offs and uncertainties in the process of arriving at a diagnosis, but they can be understood and controlled. First, the clinician must understand the significance of disease prevalence and assign to the patient an initial probability of disease being present. The clinician must then determine if further diagnostic measurements or tests are warranted. If so, the appropriate test must be selected, based on the ability of the test to revise the initial pretest probability. When a diagnostic test is positive, the clinician must know the probability that disease is actually present. The clinician must also know the probability that disease is actually present if the test result is negative. The astute clinician will calculate the posttest probabilities before proceeding with a test and will base treatment decisions on test results in accordance with predetermined test and test-treatment thresholds.     

Evidence-based research in alternative protocols to dental implantology: a closer look at publication bias

Several techniques exist for the surgical placement of dental implants. The aim of this study was to assess systematically, the efficacy of these protocols by the evidence-based perspective. Five best-case studies involving 607 early/immediately loaded implants and 300 conventionally loaded implants were identified by examining the available literature and rigorous inclusion/exclusion criteria. Overall analyses demonstrated a 98.4 percent success rate for the early/immediate procedure and a 95.3 percent for the conventional protocol. Success rates in the articles reviewed were based on implant survival over a follow-up period of between one to two years. A meta-analysis was generated to evaluate the presented evidence and to aid in decision-making. Despite its common implementation, this technique presents many caveats, among which publication bias is one of the most common. To investigate the possible presence of publication bias, a funnel plot analysis complemented several statistical tests. By means of the systematic investigation of dental implants, the authors' results confirm the presence of publication bias in implant dentistry literature, which strongly suggests that clinicians ought not base their decisions solely on the results presented by a few published studies. Rather, it is recommended that clinicians cautiously draw conclusions and seek studies that present accountable and clinically relevant results. Furthermore, it is suggested that clinicians attend seminars to learn of the effective advances in evidence-based dentistry, so as to develop the ability to easily detect inadequate literature due to attempted correlation with the most current research. It is also recommended that additional research is necessary to analyze which fields of research are more prone to bias, thus forewarning clinicians before formulating clinical conclusions.     

Saliva and dental caries: diagnostic tests for normal dental practice.

Salivary diagnostics is now entering the surgery of the modern dentist, although no test yet available is so specific and sensitive that caries can be diagnosed from saliva samples only. The present tests are useful for estimating the caries activity due to bad dietary habits (salivary lactobacilli), establishing the presence of infection (salivary mutans streptococci), and identification of salivary yeasts for the determination of the medical condition of the patient. Buffer capacity reveals the most important host response factor acting against caries, while measures of flow rate form the diagnostic basis for treatment planning. These tests, alone or in combination, are now so easy to perform that they should be used in every dental practice.     

A numb chin and bottom lip: a closer look at the symptoms

The numb chin syndrome, not due to trauma, dental pathology, preprosthetic surgery or orthognatic surgery, is an uncommon pathological condition. In patients with a numb chin a malignant disease or a metastasis of an (un)known malignancy has to be considered.     

A closer look at General Dental Service orthodontics in England and Wales. I: Factors influencing effectiveness.

OBJECTIVE: To evaluate factors influencing effectiveness in General Dental Service (GDS) orthodontics. DESIGN: Retrospective analysis of systematic 2% sample of GDS (England and Wales) cases. METHOD: Records of cases were collected during 1991. Assessment involved occlusal indices and data from National Health Service forms for 1,411 cases. Multivariate analyses were used with Peer Assessment Rating Index (PAR) score at Finish as the outcome indicator. RESULTS: Dual arch fixed appliances: achieved lower Finish PAR scores than other appliances; only 1.5% of the variance was explained, by treatment time and Dental Health Component of the Index of Orthodontic Treatment Need (DHC). Finish PAR was unaffected by Starting PAR. All other appliances: the model explained 25% of the variance for Finish PAR, which varied with Starting PAR and DHC scores. Social class had effects of little clinical significance, but the data suggested availability of orthodontic treatment was poorer in 'manual class' areas. Orthodontic qualifications, number of arches treated and mixed dentition starts had no significant effects when submitted to multivariate analysis. CONCLUSIONS: The importance of appliance selection is reinforced: dual arch fixed appliances are generally more consistent. Lower social class areas may be poorly provided with orthodontic services.     

A survey of dental practice and equipment characteristics.

The aim of this study was to determine what would be regarded as essential equipment required for setting up a dental practice and the cost thereof. This information could be useful for the newly qualified dentist. Seventy five completed questionnaires returned from a randomly selected group of practising dentists were analysed to obtain this information. Equipment costs were obtained from a dental supply house and are tabulated. Guidelines recommended for setting up a practice include determining the type of service to be rendered, selecting the equipment required for this purpose, seeking expert financial advice and commencing the practice on a conservative basis with only the essential items of equipment.     

Rational dental care: part 2. A case history

Treatment planning and managing the care of an elderly, frail patient can be complicated by a variety of modifying factors. To understand the patient"s needs, one must understand the environment in which the patient functions. This second in a series of 2 articles presents a case history of a frail, older adult to illustrate some of the social, medical and community problems that are involved in caring for elderly persons.     

Xerostomia: diagnosis and management in dental practice

Xerostomia is a subjective sensation of oral dryness. It is caused by many factors, among them, hypo/hyper salivation. This article covers the etiology, local and systemic factors related to dryness of the mouth, its diagnosis, and clinical and at-home management of the syndrome. It also reviews the role of dental hygiene intervention to improve and promote the patient's quality of life. It is hoped this review will help dental health care providers better respond to patients afflicted with xerostomia.     

Decision processes in the management of dental disease. Part 2: Rationalizing dental treatment decisions in clinical practice.

Continuing from a previous paper, the authors outline methods that dental practitioners should use in making decisions in clinical practice. Using the analysis techniques described in both articles the dentist will be able to focus on key issues in the decision-making process and, perhaps as importantly, ignore issues that are peripheral. This article demonstrates a method (decision analysis) in which the practitioner can incorporate this information into the process of deciding which dental treatment to offer.