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 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 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 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.     

A closer look at diagnosis in clinical dental practice: part 2. Using predictive values and receiver operating characteristics in assessing diagnostic accuracy

When a clinician is planning to use a diagnostic test or procedure, it is important to establish the likelihood that an individual patient is affected by the condition or disease; this determination depends on predictions that are affected by various features of the diagnostic procedure. In this regard, sensitivity and specificity are limited because they describe the results of a procedure in a dichotomous way: the result is either positive or negative. However, many clinical procedures are not dichotomous, such as probing of periodontal pockets or assessment of radiographs for caries, and in these situations, a range of features is examined to produce a degree of certainty regarding the presence or absence of disease. This article examines predictive values and receiver operating characteristic (ROC) analysis, an algorithm that combines various statistical features of diagnostic procedures to assess the effectiveness of nondichotomous procedures without imposing an arbitrary threshold.     

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.     

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.     

Effectiveness of barrier devices,high-volume evacuators,and extraoral suction devices on reducing dental aerosols for the dental operator: A pilot study

BackgroundThe COVID-19 pandemic has increased the importance of minimizing exposure to aerosols generated during dental procedures. The authors’ objective was to measure the aerosolized particles in the breathing zone of operators using several facial protection and filtration methods.MethodsTwenty-one dentists performed maxillary anterior incisor veneer preparations using a microscope and drape and loupes with or without a face shield. In each test condition, the following 3 levels of filtration were tested: no filtration, a high-volume evacuator [HVE], and an HVE with an extraoral suction device. Measurements were made using a mass monitor attached to the operator’s chest with inlet within 10 inches of the operator’s face.ResultsThe authors found that the microscope and drape provided the lowest levels of aerosolized particles compared with loupes with or without a face shield (P < .001). There was no detectable difference in the concentration of particles between operators wearing a face shield and wearing loupes alone (P = .47). The particles in each test condition were lowered when an HVE was used (P < .001) and further lowered with an extraoral suction device.ConclusionsThe findings of this study suggest that the use of a surgical microscope and bag barrier drape, HVE, and extraoral suction device result in the lowest concentration of aerosolized particles. The face shield did not appear to offer any protection from aerosolized particles. HVE and extraoral suction were effective in decreasing aerosols regardless of the type of facial protection used.Practical ImplicationsDentists can reduce exposure to aerosols with a drape, HVE, and extraoral suction.