Patient assessment in general dental practice – risk assessment or clinical monitoring?

Clinical assessment for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults

BACKGROUND

The early detection of oral cavity squamous cell carcinoma (OSCC) and oral potentially malignant disorders (OPMD), followed by appropriate treatment, may improve survival and reduce the risk for malignant transformation respectively. This is an update of a Cochrane Review first published in 2013.

OBJECTIVES

To estimate the diagnostic test accuracy of conventional oral examination, vital rinsing, light-based detection, mouth self-examination, remote screening, and biomarkers, used singly or in combination, for the early detection of OPMD or OSCC in apparently healthy adults.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 20 October 2020), MEDLINE Ovid (1946 to 20 October 2020), and Embase Ovid (1980 to 20 October 2020). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases. We conducted citation searches, and screened reference lists of included studies for additional references.

SELECTION CRITERIA

We selected studies that reported the test accuracy of any of the aforementioned tests in detecting OPMD or OSCC during a screening procedure. Diagnosis of OPMD or OSCC was provided by specialist clinicians or pathologists, or alternatively through follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction, and quality assessment were carried out by at least two authors independently and in duplicate. Studies were assessed for methodological quality using the Quality Assessment of Diagnostic Accuracy Studies 2 (QUADAS-2). We reported the sensitivity and specificity of the included studies. We provided judgement of the certainty of the evidence using a GRADE assessment.

MAIN RESULTS

We included 18 studies, recruiting 72,202 participants, published between 1986 and 2019. These studies evaluated the diagnostic test accuracy of conventional oral examination (10 studies, none new to this update), mouth self-examination (four studies, two new to this update), and remote screening (three studies, all new to this update). One randomised controlled trial of test accuracy directly evaluated conventional oral examination plus vital rinsing versus conventional oral examination alone. There were no eligible studies evaluating light-based detection or blood or salivary sample analysis (which tests for the presence of biomarkers for OPMD and OSCC). Only one study of conventional oral examination was judged as at overall low risk of bias and overall low concern regarding applicability. Given the clinical heterogeneity of the included studies in terms of the participants recruited, setting, prevalence of the target condition, the application of the index test and reference standard, and the flow and timing of the process, the data could not be pooled within the broader categories of index test. For conventional oral examination (10 studies, 25,568 participants), prevalence in the test accuracy sample ranged from 1% to 51%. For the seven studies with prevalence of 10% or lower, a prevalence more comparable to the general population, the sensitivity estimates were variable, and ranged from 0.50 (95% confidence interval (CI) 0.07 to 0.93) to 0.99 (95% CI 0.97 to 1.00); the specificity estimates were more consistent and ranged from 0.94 (95% CI 0.88 to 0.97) to 0.99 (95% CI 0.98 to 1.00). We judged the overall certainty of the evidence to be low, and downgraded for inconsistency and indirectness. Evidence for mouth self-examination and remote screening was more limited. We judged the overall certainty of the evidence for these index tests to be very low, and downgraded for imprecision, inconsistency, and indirectness. We judged the evidence for vital rinsing (toluidine blue) as an adjunct to conventional oral examination compared to conventional oral examination to be moderate, and downgraded for indirectness as the trial was undertaken in a high-risk population.

AUTHORS' CONCLUSIONS

There is a lack of high-certainty evidence to support the use of screening programmes for oral cavity cancer and OPMD in the general population. Frontline screeners such as general dentists, dental hygienists, other allied professionals, and community healthcare workers should remain vigilant for signs of OPMD and OSCC.

Dental therapists compared with general dental practitioners for undertaking check-ups in low-risk patients: pilot RCT with realist evaluation

Background

Many dental ‘check-ups’ in the NHS result in no further treatment. The patient is examined by a dentist and returned to the recall list for a further check-up, commonly in 6 or 12 months’ time. As the oral health of regular dental attenders continues to improve, it is likely that an increasing number of these patients will be low risk and will require only a simple check-up in the future, with no further treatment. This care could be delivered by dental therapists. In 2013, the body responsible for regulating the dental profession, the General Dental Council, ruled that dental therapists could see patients directly and undertake check-ups and routine dental treatments (e.g. fillings). Using dental therapists to undertake check-ups on low-risk patients could help free resources to meet the future challenges for NHS dentistry.

Objectives

The objectives were to determine the most appropriate design for a definitive study, the most appropriate primary outcome measure and recruitment and retention rates, and the non-inferiority margin. We also undertook a realist-informed process evaluation and rehearsed the health economic data collection tool and analysis.

Design

A pilot randomised controlled trial over a 15-month period, with a realist-informed process evaluation. In parallel, we rehearsed the health economic evaluation and explored patients’ preferences to inform a preference elicitation exercise for a definitive study.

Setting

The setting was NHS dental practices in North West England.

Participants

A total of 217 low-risk patients in eight high-street dental practices participated.

Interventions

The current practice of using dentists to provide NHS dental check-ups (treatment as usual; the control arm) was compared with using dental therapists to provide NHS dental check-ups (the intervention arm).

Main outcome measure

The main outcome measure was difference in the proportion of sites with bleeding on probing among low-risk patients. We also recorded the number of ‘cross-over’ referrals between dentists and dental therapists.

Results

No differences were found in the health status of patients over the 15 months of the pilot trial, suggesting that non-inferiority is the most appropriate design. However, bleeding on probing suffered from ‘floor effects’ among low-risk patients, and recruitment rates were moderately low (39.7%), which suggests that an experimental design might not be the most appropriate. The theory areas that emerged from the realist-informed process evaluation were contractual, regulatory, institutional logistics, patients’ experience and logistics. The economic evaluation was rehearsed and estimates of cost-effectiveness made; potential attributes and levels that can form the basis of preference elicitation work in a definitive study were determined.

Limitations

The pilot was conducted over a 15-month period only, and bleeding on probing appeared to have floor effects. The number of participating dental practices was a limitation and the recruitment rate was moderate.

Conclusions

Non-inferiority, floor effects and moderate recruitment rates suggest that a randomised controlled trial might not be the best evaluative design for a definitive study in this population. The process evaluation identified multiple barriers to the use of dental therapists in ‘high-street’ practices and added real value.

Future work

Quasi-experimental designs may offer more promise for a definitive study alongside further realist evaluation.

Trial registration

Current Controlled Trials ISRCTN70032696.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 3. See the NIHR Journals Library website for further project information.

Indoor Air Pollution with Fine Particles and Implications for Workers’ Health in Dental Offices: A Brief Review

(1) Background: Indoor air pollution can affect the well-being and health of humans. Sources of indoor pollution with particulate matter (PM) are outdoor particles and indoor causes, such as construction materials, the use of cleaning products, air fresheners, heating, cooking, and smoking activities. In 2017, according to the Global Burden of Disease study, 1.6 million people died prematurely because of indoor air pollution. The health effects of outdoor exposure to PM have been the subject of both research and regulatory action, and indoor exposure to fine particles is gaining more and more attention as a potential source of adverse health effects. Moreover, in critical situations such as the current pandemic crisis, to protect the health of the population, patients, and staff in all areas of society (particularly in indoor environments, where there are vulnerable groups, such as people who have pre-existing lung conditions, patients, elderly people, and healthcare professionals such as dental practitioners), there is an urgent need to improve long- and short-term health. Exposure to aerosols and splatter contaminated with bacteria, viruses, and blood produced during dental procedures performed on patients rarely leads to the transmission of infectious agents between patients and dental health care staff if infection prevention procedures are strictly followed. On the other hand, in the current circumstances of the pandemic crisis, dental practitioners could have an occupational risk of acquiring coronavirus disease as they may treat asymptomatic and minimally symptomatic patients. Consequently, an increased risk of SARS-CoV-2 infection could occur in dental offices, both for staff that provide dental healthcare and for other patients, considering that many dental procedures produce droplets and dental aerosols, which carry an infectious virus such as SARS-CoV-2. (2) Types of studies reviewed and applied methodology: The current work provides a critical review and evaluation, as well as perspectives concerning previous studies on health risks of indoor exposure to PM in dental offices. The authors reviewed representative dental medicine literature focused on sources of indoor PM10 and PM2.5 (particles for which the aerodynamic diameter size is respectively less than 10 and 2.5 μm) in indoor spaces (paying specific attention to dental offices) and their characteristics and toxicological effects in indoor microenvironments. The authors also reviewed representative studies on relations between the indoor air quality and harmful effects, as well as studies on possible indoor viral infections acquired through airborne and droplet transmission. The method employed for the research illustrated in the current paper involved a desk study of documents and records relating to occupational health problems among dental health care providers. In this way, it obtained background information on both the main potential hazards in dentistry and infection risks from aerosol transmission within dental offices. Reviewing this kind of information, especially that relating to bioaerosols, is critical for minimizing the risk to dental staff and patients, particularly when new recommendations for COVID-19 risk reduction for the dental health professional community and patients attending dental clinics are strongly needed. (3) Results: The investigated studies and reports obtained from the medical literature showed that, even if there are a wide number of studies on indoor human exposure to fine particles and health effects, more deep research and specific studies on indoor air pollution with fine particles and implications for workers’ health in dental offices are needed. As dental practices are at a higher risk for hazardous indoor air because of exposure to chemicals and microbes, the occupational exposures and diseases must be addressed, with special attention being paid to the dental staff. The literature also documents that exposure to fine particles in dental offices can be minimized by putting prevention into practice (personal protection barriers such as masks, gloves, and safety eyeglasses) and also keeping indoor air clean (e.g., high-volume evacuation, the use of an air-room-cleaning system with high-efficiency particulate filters, and regularly maintaining the air-conditioning and ventilation systems). These kinds of considerations are extremely important as the impact of indoor pollution on human health is no longer an individual issue, with its connections representing a future part of sustainability which is currently being redefined. These kinds of considerations are extremely important, and the authors believe that a better situation in dentistry needs to be developed, with researchers in materials and dental health trying to understand and explain the impact of indoor pollution on human health.

Perceptions and attitudes toward performing risk assessment for periodontal disease: a focus group exploration

Background

Currently, many risk assessment tools are available for clinicians to assess a patient’s periodontal disease risk. Numerous studies demonstrate the potential of these tools to promote preventive management and reduce morbidity due to periodontal disease. Despite these promising results, solo and small group dental practices, where most people receive care, have not adopted risk assessment tools widely, primarily due to lack of studies in these settings. The objective of this study was to explore the knowledge, attitudes, and beliefs of dental providers in these settings toward risk-based care through focus groups.

Methods

We conducted six focus group sessions with 52 dentists and dental hygienists practicing in solo and small group practices in Pittsburgh, PA and New York City (NYC), NY. An experienced moderator and a note-taker conducted the six sessions, each including 8–10 participants and lasting approximately 90 min. All sessions were audio-recorded and transcribed verbatim. Two researchers coded the focus group transcripts. Using a thematic analysis approach, they reviewed the coding results to identify important themes and selected representative excerpts that best described each theme.

Results

Providers strongly believed identifying risk factors could predict periodontal disease and use this information to change their patients’ behavior. A successful risk assessment tool could assist them in educating and changing their patient’s behaviors to adopt a healthy lifestyle, thus enabling them to play a major role in their patients’ overall health. However, to achieve this goal, it is essential to educate all dental providers and not just dentists on performing risk assessment and translating the results into actionable recommendations for patients. According to study participants, the research community has focused more on translating research findings into a risk assessment tool, and less on how clinicians would use these tools during patient encounters and if it affects a patients’ risk or outcome.

Conclusions

Dental practitioners were open to performing risk assessment as routine care and playing a bigger role in their patients’ overall health. Recommendations to overcome major barriers included educating dental providers at all levels, conducting more research about their adoption and use in real-world settings and developing appropriate reimbursement models.

Electronic supplementary material

The online version of this article (10.1186/s12903-018-0550-2) contains supplementary material, which is available to authorized users.

Validity and reliability of remote dental screening by different oral health professionals using a store-and-forward telehealth model

Objective This study was conducted to evaluate the validity and reliability of intraoral photographic assessments by different members of a dental team as a means for dental screening in children.Methods The intraoral photographic records of 126 children (2 to 18 years old) were obtained from routine clinical records taken before dental treatment. Intraoral photographs were obtained using a DSLR camera and then uploaded to a cloud-based server using store-and-forward telehealth technology. Images were reviewed by an expert panel to formulate a benchmark screening baseline, to which the screeners' data were compared. The photographic assessments conducted by a mid-level dental practitioner (MLDP) and dentist, were compared to the benchmark expert panel assessment.Results The screeners' assessments by means of intraoral photography, when compared to the expert panel assessment had a sensitivity value of 82-89% and specificity value of 97%. The inter-examiner agreement between the expert panel assessment and photographic method (assessed by a dentist and MLDP), was almost perfect, with a kappa score ranging from 0.82 to 0.88. The mean DFT/dft score for the children as determined by the expert panel's review and photographic assessment ranging from 5.41 to 5.79, with mean scores between the two assessment methods not significantly different (P = 0.746).Conclusion Our results suggested that oral health professionals (other than dentists) have the potential to screen for caries from intraoral photographs with the same diagnostic accuracy and reliability as dentists. This strategy has implications for supporting the use of MLDPs such as dental therapists or hygienists to screen for oral disease using telehealth.

Cost savings from a teledentistry model for school dental screening: an Australian health system perspective

Objective The aim of the present study was to compare the costs of teledentistry and traditional dental screening approaches in Australian school children. Methods A cost-minimisation analysis was performed from the perspective of the oral health system, comparing the cost of dental screening in school children using a traditional visual examination approach with the cost of mid-level dental practitioners (MLDPs), such as dental therapists, screening the same cohort of children remotely using teledentistry. A model was developed to simulate the costs (over a 12-month period) of the two models of dental screening for all school children (2.7 million children) aged 5–14 years across all Australian states and territories. The fixed costs and the variable costs, including staff salary, travel and accommodation costs, and cost of supply were calculated. All costs are given in Australian dollars. Results The total estimated cost of the teledentistry model was $50 million. The fixed cost of teledentistry was $1 million and that of staff salaries (tele-assistants, charters and their supervisors, as well as information technology support was estimated to be $49 million. The estimated staff salary saved with the teledentistry model was $56 million, and the estimated travel allowance and supply expenses avoided were $16 million and $14 million respectively; an annual reduction of $85 million in total. Conclusions The present study shows that the teledentistry model of dental screening can minimise costs. The estimated savings were due primarily to the low salaries of dental therapists and the avoidance of travel and accommodation costs. Such savings could be redistributed to improve infrastructure and oral health services in rural or other underserved areas. What is known about the topic? Caries is a preventable disease, which, if it remains untreated, can cause significant morbidity requiring costly treatment. Regular dental screening and oral health education have the great potential to improve oral health and save significant resources. The use of role substitution, such as using MLDPs to provide oral care has been well acknowledged worldwide because of their ability to provide safe and effective care. The teledentistry approach for dental screening offers a comparable diagnostic performance to the traditional visual approach. What does this paper add? The results of the present study suggest that teledentistry is a practical and economically viable approach for mass dental screening not only for isolated communities, but also for underserved urban communities. The costs of the teledentistry model were substantially lower than the costs associated with a conventional, face-to-face approach to dental screening in both remote and urban areas. The primary driver of net savings is the low salary of MLDPs and avoidance of travel and overnight accommodation by MLDPs. What are the implications for practitioners? The use of lower-cost MLDPs and a teledentistry model for dental screening has the potential to save significant economic and human resources that can be redirected to improve infrastructure and oral care services in underserved regions. In the absence of evidence of the economic usefulness of teledentistry, studies such as the present one can increase the acceptance of this technology among dental care providers and guide future decisions on whether or not to implement teledentistry services.

Comparison of risk assessment based on clinical judgement and Cariogram in addition to patient perceived treatment need

Background

Predicting future risk for oral diseases, treatment need and prognosis are tasks performed daily in clinical practice. A large variety of methods have been reported, ranging from clinical judgement or “gut feeling” or even patient interviewing, to complex assessments of combinations of known risk factors. In clinical practice, there is an ongoing continuous search for less complicated and more valid tools for risk assessment. There is also a lack of knowledge how different common methods relates to one another. The aim of this study was to investigate if caries risk assessment (CRA) based on clinical judgement and the Cariogram model give similar results. In addition, to assess which factors from clinical status and history agree best with the CRA based on clinical judgement and how the patient’s own perception of future oral treatment need correspond with the sum of examiners risk score.

Methods

Clinical examinations were performed on randomly selected individuals 20–89 years old living in Skåne, Sweden. In total, 451 individuals were examined, 51 % women. The clinical examination included caries detection, saliva samples and radiographic examination together with history and a questionnaire. The examiners made a risk classification and the authors made a second risk calculation according to the Cariogram.

Results

For those assessed as low risk using the Cariogram 69 % also were assessed as low risk based on clinical judgement. For the other risk groups the agreement was lower. Clinical variables that significantly related to CRA based on clinical judgement were DS (decayed surfaces) and combining DS and incipient lesions, DMFT (decayed, missed, filled teeth), plaque amount, history and soft drink intake. Patients’ perception of future oral treatment need correlated to some extent with the sum of examiners risk score.

Conclusions

The main finding was that CRA based on clinical judgement and the Cariogram model gave similar results for the groups that were predicted at low level of future disease, but not so well for the other groups. CRA based on clinical judgement agreed best with the number of DS plus incipient lesions.

Determining the optimal model for role substitution in NHS dental services in the UK: a mixed-methods study

Background

Maximising health gain for a given level and mix of resources is an ethical imperative for health-service planners. Approximately half of all patients who attend a regular NHS dental check-up do not require any further treatment, whereas many in the population do not regularly attend. Thus, the most expensive resource (the dentist) is seeing healthy patients at a time when many of those with disease do not access care. Role substitution in NHS dentistry, where other members of the dental team undertake the clinical tasks previously provided by dentists, has the potential to increase efficiency and the capacity to care and lower costs. However, no studies have empirically investigated the efficiency of NHS dental provision that makes use of role substitution.

Research questions

This programme of research sought to address three research questions: (1) what is the efficiency of NHS dental teams that make use of role substitution?; (2) what are the barriers to, and facilitators of, role substitution in NHS dental practices?; and (3) how do incentives in the remuneration systems influence the organisation of these inputs and production of outputs in the NHS?

Design

Data envelopment analysis was used to develop a productive efficiency frontier for participating NHS practices, which were then compared on a relative basis, after controlling for patient and practice characteristics. External validity was tested using stochastic frontier modelling, while semistructured interviews explored the views of participating dental teams and their patients to role substitution.

Setting

NHS ‘high-street’ general dental practices.

Participants

121 practices across the north of England.

Interventions

No active interventions were undertaken.

Main outcome measures

Relative efficiency of participating NHS practices, alongside a detailed narrative of their views about role substitution dentistry. Social acceptability for patients.

Results

The utilisation of non-dentist roles in NHS practices was relatively low, the most common role type being the dental hygienist. Increasing the number of non-dentist team members reduced efficiency. However, it was not possible to determine the relative efficiency of individual team members, as the NHS contracts only with dentists. Financial incentives in the NHS dental contract and the views of practice principals (i.e. senior staff members) were equally important. Bespoke payment and referral systems were required to make role substitution economically viable. Many non-dentist team members were not being used to their full scope of practice and constraints on their ability to prescribe reduced efficiency further. Many non-dentist team members experienced a precarious existence, commonly being employed at multiple practices. Patients had a low level of awareness of the different non-dentist roles in a dental team. Many exhibited an inherent trust in the professional ‘system’, but prior experience of role substitution was important for social acceptability.

Conclusions

Better alignment between the financial incentives within the NHS dental contract and the use of role substitution is required, although professional acceptability remains critical.

Study limitations

Output data collected did not reflect the quality of care provided by the dental team and the input data were self-reported.

Future work

Further work is required to improve the evidence base for the use of role substitution in NHS dentistry, exploring the effects and costs of provision.

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Caries Risk Assessment Item Importance: Risk Designation and Caries Status in Children under Age 6

BACKGROUND

Caries risk assessment (CRA) is widely recommended for dental caries management. Little is known regarding how practitioners use individual CRA items to determine risk and which individual items independently predict clinical outcomes in children under age 6-years.

OBJECTIVES

Assess the relative importance of pediatric CRA items in dental providers' decision-making regarding patient risk and in association with clinically evident caries, cross-sectionally and longitudinally.

METHODS

CRA information was abstracted retrospectively from electronic patient records of children initially ages 6-72 months at a university pediatric dentistry clinic (N=3810 baseline; N=1315 with follow-up). The 17-item CRA form included caries risk indicators, caries protective items, and clinical indicators. Conditional random forests classification trees were implemented to identify and assign variable importance to CRA items independently associated with baseline high-risk designation, baseline evident tooth decay, and follow-up evident decay.

RESULTS

Thirteen individual CRA items, including all clinical indicators and all but one risk indicator, were independently and statistically significantly associated with student/resident providers' caries-risk designation. Provider-assigned baseline risk category was strongly associated with follow-up decay, which increased from low (20.4%), moderate (30.6%), to high/extreme risk patients (68.7%). Of baseline CRA items, before adjustment 12 were associated with baseline decay and 7 with decay at follow-up; however, in the conditional random forests models, only the clinical indicators (evident decay, dental plaque, and recent restoration placement) and one risk indicator (frequent snacking) were independently and statistically significantly associated with future disease, for which baseline evident decay was the strongest predictor.

CONCLUSIONS

In this predominantly high-risk population under caries-preventive care, more individual CRA items were independently associated with providers' risk determination than with future caries status. These university dental providers considered many items in decision-making regarding patient risk, suggesting that in turn, these comprehensive CRA forms could also aid individualized care, linking risk assessment to disease management.

Malignant transformation of oral leukoplakia: a systematic review of observational studies

The aim of this systematic review was to ascertain the malignant transformation rate of oral leukoplakia and the associated risk factors.

METHOD

Published literature was searched through several search engines from 1960 to the end of December 2013. The inclusion criteria included 'leukoplakia', 'pre-cancer', 'malignant transformation', 'follow-up' and 'outcome'. Two reviewers extracted the data independently and also assessed the quality of evidence.

RESULTS

The search strategy resulted in 1032 abstracts or full-text articles, of which 24 met the inclusion criteria. There was much variation in the definitions used by the various authors in their original reports to define oral leukoplakia or in the criteria used to recruit their patients for follow-up. The estimated overall (mean) malignant transformation rate for the total population described in these 24 studies amounts to 3.5% (405/11423), with a wide range between 0.13% and 34.0%. Based on the evidence presented, the features that stand out as significant determinants contributing to malignant potential of OL include advanced age, female sex, leukoplakia exceeding 200 mm(2) , non-homogeneous type (eg. erythroleukoplakia) and the higher grades of dysplasia.

CONCLUSION

The review indicates that drawing meaningful evidence-based conclusions are difficult from retrospective studies of this nature. However, many of the determinants exposed in the review require further investigation by well-designed prospective studies.

Risk assessment - can we achieve consensus?

OBJECTIVE

The object of this conference paper was to review and discuss caries risk assessment in general practice from the questions i) 'Why', ii) 'When', and iii) 'How'.

METHOD

Narrative review.

RESULTS

i) Patient caries risk assessment is the basic component in the decision-making process for adequate prevention and management of dental caries and for determination of individual recall intervals. ii) Caries risk assessment should always be performed at a child's first dental visit and then regularly throughout life, and especially when social or medical life events are occurring. iii) There are several risk assessment methods and models available for but the evidence for their validity is limited. Although there is no clearly superior method for predicting future caries, the use of structured protocols combining socioeconomy, behavior, general health, diet, oral hygiene routines, clinical data, and salivary tests or computer-based systems are considered best clinical practice. The accuracy ranges between 60% and 90%, depending on age. Caries risk assessment is more effective in the selection of patients at low risk than those with high caries risk.

CONCLUSION

As evidence suggests that past caries experience is far from ideal but the most important single risk component for more caries at all ages, any clinical sign of likely active demineralization on smooth, occlusal, and proximal tooth surfaces should be taken as a signal for the implementation of individually designed preventive and disease management measures.

The efficacy of screening for common dental diseases by hygiene-therapists: a diagnostic test accuracy study

Regularly attending adult patients are increasingly asymptomatic and not in need of treatment when attending for their routine dental examinations. As oral health improves further, using the general dental practitioner to undertake the "checkup" on regular "low-risk" patients represents a substantial and potentially unnecessary cost for state-funded systems. Given recent regulatory changes in the United Kingdom, it is now theoretically possible to delegate a range of tasks to hygiene-therapists. This has the potential to release the general dental practitioner's time and increase the capacity to care. The aim of this study is to compare the diagnostic test accuracy of hygiene-therapists when screening for dental caries and periodontal disease in regularly attending asymptomatic adults who attend for their checkup. A visual screen by hygiene-therapists acted as the index test, and the general dental practitioner acted as the reference standard. Consenting asymptomatic adult patients, who were regularly attending patients at 10 practices across the Northwest of England, entered the study. Both sets of clinicians made an assessment of dental caries and periodontal disease. The primary outcomes measured were the sensitivity and specificity values for dental caries and periodontal disease. In total, 1899 patients were screened. The summary point for sensitivity of dental care professionals when screening for caries and periodontal disease was 0.81 (95% CI, 0.74 to 0.87) and 0.89 (0.86 to 0.92), respectively. The summary point for specificity of dental care professionals when screening for caries and periodontal disease was 0.87 (0.78 to 0.92) and 0.75 (0.66 to 0.82), respectively. The results suggest that hygiene-therapists could be used to screen for dental caries and periodontal disease. This has important ramifications for service design in public-funded health systems.

Minimal intervention dentistry II: part 2. Management of caries and periodontal risks in general dental practice

The long-term clinical management of caries and periodontal diseases requires a double approach, one that is concerned with both treatment and prevention. Dentists should recognise the risk factors and their likely triggers to be able to implement the right strategy as early as the diagnostic phase. This comprehensive assessment can easily be done in general practice. All it takes is to combine the patient's general information with the systemic and behavioural factors, and the clinical observations with the local factors. The resulting patient profile can thus effectively support treatment by providing the necessary explanations, advice or prescriptions in relation with the clinical procedures. The modifiable risk factors need to be monitored and the behaviours changed to stabilise or limit disease progression. The practitioner's active approach is meant to meet the patient's demand for preventive counselling.

The accuracy of caries risk assessment in children attending South Australian School Dental Service: a longitudinal study

OBJECTIVES

To determine the accuracy of the caries risk assessment system and performance of clinicians in their attempts to predict caries for children during routine practice.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

Data on caries risk assessment conducted by clinicians during routine practice while providing care for children in the South Australian School Dental Service (SA SDS) were collected from electronic patient records. Baseline data on caries experience, clinicians' ratings of caries risk status and child demographics were obtained for all SA SDS patients aged 5-15 years examined during 2002-2005.

OUTCOME MEASURE

Children's caries incidence rate, calculated using examination data after a follow-up period of 6-48 months from baseline, was used as the gold standard to compute the sensitivity (Se) and specificity (Sp) of clinicians' baseline ratings of caries risk. Multivariate binomial regression models were used to evaluate effects of children's baseline characteristics on Se and Sp.

RESULTS

A total of 133 clinicians rated caries risk status of 71 430 children during 2002-2005. The observed Se and Sp were 0.48 and 0.86, respectively (Se+Sp=1.34). Caries experience at baseline was the strongest factor influencing accuracy in multivariable regression model. Among children with no caries experience at baseline, overall accuracy (Se+Sp) was only 1.05, whereas it was 1.28 among children with at least one tooth surfaces with caries experience at baseline.

CONCLUSIONS

Clinicians' accuracy in predicting caries risk during routine practice was similar to levels reported in research settings that simulated patient care. Accuracy was acceptable in children who had prior caries experience at the baseline examination, while it was poor among children with no caries experience.

Clinical assessment to screen for the detection of oral cavity cancer and potentially malignant disorders in apparently healthy adults

BACKGROUND

The early detection and excision of potentially malignant disorders (PMD) of the lip and oral cavity that require intervention may reduce malignant transformations (though will not totally eliminate malignancy occurring), or if malignancy is detected during surveillance, there is some evidence that appropriate treatment may improve survival rates.

OBJECTIVES

To estimate the diagnostic accuracy of conventional oral examination (COE), vital rinsing, light-based detection, biomarkers and mouth self examination (MSE), used singly or in combination, for the early detection of PMD or cancer of the lip and oral cavity in apparently healthy adults.

SEARCH METHODS

We searched MEDLINE (OVID) (1946 to April 2013) and four other electronic databases (the Cochrane Diagnostic Test Accuracy Studies Register, the Cochrane Oral Health Group's Trials Register, EMBASE (OVID), and MEDION) from inception to April 2013. The electronic databases were searched on 30 April 2013. There were no restrictions on language in the searches of the electronic databases. We conducted citation searches, and screened reference lists of included studies for additional references.

SELECTION CRITERIA

We selected studies that reported the diagnostic test accuracy of any of the aforementioned tests in detecting PMD or cancer of the lip or oral cavity. Diagnosis of PMD or cancer was made by specialist clinicians or pathologists, or alternatively through follow-up.

DATA COLLECTION AND ANALYSIS

Two review authors independently screened titles and abstracts for relevance. Eligibility, data extraction and quality assessment were carried out by at least two authors independently and in duplicate. Studies were assessed for methodological quality using QUADAS-2. We reported the sensitivity and specificity of the included studies.

MAIN RESULTS

Thirteen studies, recruiting 68,362 participants, were included. These studies evaluated the diagnostic accuracy of COE (10 studies), MSE (two studies). One randomised controlled of test accuracy trial directly evaluated COE and vital rinsing. There were no eligible diagnostic accuracy studies evaluating light-based detection or blood or salivary sample analysis (which tests for the presence of bio-markers of PMD and oral cancer). Given the clinical heterogeneity of the included studies in terms of the participants recruited, setting, prevalence of target condition, the application of the index test and reference standard and the flow and timing of the process, the data could not be pooled. For COE (10 studies, 25,568 participants), prevalence in the diagnostic test accuracy sample ranged from 1% to 51%. For the eight studies with prevalence of 10% or lower, the sensitivity estimates were highly variable, and ranged from 0.50 (95% confidence interval (CI) 0.07 to 0.93) to 0.99 (95% CI 0.97 to 1.00) with uniform specificity estimates around 0.98 (95% CI 0.97 to 1.00). Estimates of sensitivity and specificity were 0.95 (95% CI 0.92 to 0.97) and 0.81 (95% CI 0.79 to 0.83) for one study with prevalence of 22% and 0.97 (95% CI 0.96 to 0.98) and 0.75 (95% CI 0.73 to 0.77) for one study with prevalence of 51%. Three studies were judged to be at low risk of bias overall; two were judged to be at high risk of bias resulting from the flow and timing domain; and for five studies the overall risk of bias was judged as unclear resulting from insufficient information to form a judgement for at least one of the four quality assessment domains. Applicability was of low concern overall for two studies; high concern overall for three studies due to high risk population, and unclear overall applicability for five studies. Estimates of sensitivity for MSE (two studies, 34,819 participants) were 0.18 (95% CI 0.13 to 0.24) and 0.33 (95% CI 0.10 to 0.65); specificity for MSE was 1.00 (95% CI 1.00 to 1.00) and 0.54 (95% CI 0.37 to 0.69). One study (7975 participants) directly compared COE with COE plus vital rinsing in a randomised controlled trial. This study found a higher detection rate for oral cavity cancer in the conventional oral examination plus vital rinsing adjunct trial arm.

AUTHORS' CONCLUSIONS

The prevalence of the target condition both between and within index tests varied considerably. For COE estimates of sensitivity over the range of prevalence levels varied widely. Observed estimates of specificity were more homogeneous. Index tests at a prevalence reported in the population (between 1% and 5%) were better at correctly classifying the absence of PMD or oral cavity cancer in disease-free individuals that classifying the presence in diseased individuals. Incorrectly classifying disease-free individuals as having the disease would have clinical and financial implications following inappropriate referral; incorrectly classifying individuals with the disease as disease-free will mean PMD or oral cavity cancer will only be diagnosed later when the disease will be more severe. General dental practitioners and dental care professionals should remain vigilant for signs of PMD and oral cancer whilst performing routine oral examinations in practice.

Caries risk assessment in young adults: A 3-year validation of clinical guidelines used in Public Dental Service

OBJECTIVES

To validate a risk classification model according to the Public Dental Service (PDS) guidelines with the actual 3-year caries outcome in terms of predictive values.

MATERIALS AND METHODS

All 19-year-old patients registered at eight public dental clinics in Skåne, Sweden were invited to participate (n = 1699). The study group who completed the baseline examination consisted of 1295 subjects, representing 10% of the age group attending the public dental care in the region. A risk classification of each patient in four categories was made by the patient's regular team according to the guidelines. At the follow-up 3 years later, 75.8% were accessible. The final examinations included bitewing radiographs and the actual caries increment for 982 patients was calculated.

RESULTS

At baseline, 11.9% were assessed as being at 'high' or 'very high' risk. The dropouts had significantly more caries than the remaining patients (p < 0.05). The general disease activity was low, but those grouped into the two highest risk groups displayed significantly more new caries than those at lower risk (p < 0.05). With a cut-off value ΔDFS > 0 vs DFS = 0, the sensitivity was 81% and the specificity 56% for 'low' risk vs any risk. By combining the 'low' and 'some' risk categories, the PDS model generated an improved specificity (94%).

CONCLUSIONS

The risk assessment scheme used by the Public Dental Service for young adults relied basically on past and current caries activity and 65-70% of the patients were correctly classified. The model was most effective to screen out patients with low caries risk.

Protocol for diagnostic test accuracy study: the efficacy of screening for common dental diseases by dental care professionals

Background

The bulk of service delivery in dentistry is delivered by general dental practitioners, when a large proportion of patients who attend regularly are asymptomatic and do not require treatment. This represents a substantial and unnecessary cost, given that it is possible to delegate a range of tasks to dental care professionals, who are a less expensive resource. Screening for the common dental diseases by dental care professionals has the potential to release general dental practitioner’s time and increase the capacity to care for those who don't currently access services. The aim of this study is to compare the diagnostic test accuracy of dental care professionals when screening for dental caries and periodontal disease in asymptomatic adults aged eighteen years of age.

Methods/design

Ten dental practices across the North-West of England will take part in a diagnostic test accuracy study with 200 consecutive patients in each practice. The dental care professionals will act as the index test and the general dental practitioner will act as the reference test. Consenting asymptomatic patients will enter the study and see either the dental care professionals or general dental practitioner first to remove order effects. Both sets of clinicians will make an assessment of dental caries and periodontal disease and enter their decisions on a record sheet for each participant. The primary outcome measure is the diagnostic test accuracy of the dental care professionals and sensitivity, specificity, positive predictive value and negative predictive values will be reported. A number of clinical factors will be assessed for confounding.

Discussion

The results of this study will determine whether dental care professionals can screen for the two most prevalent oral diseases. This will inform the literature and is apposite given the recent policy change in the United Kingdom towards direct access.

The contemporary approach to tooth preservation: minimum intervention (MI) caries management in general practice

The minimum intervention (MI) approach summarises a clinical, evidence-based rationale for the preventive and cause-related approach to oral diseases in general and to caries in particular. MI oral care with respect to the management of patients suffering from dental caries is a concept based on an updated understanding of the histopathological carious process as well as the development of diagnostic technologies and adhesive, bioactive restorative materials. A patient-centred MI care plan for use in general dental practice is described, detailing the four phases of identifying disease, controlling/preventing disease, refurbishing/repairing tooth surfaces/restorations and recall consultations.

Caries risk assessment in young adults using Public Dental Service guidelines and the Cariogram--a comparative study

OBJECTIVES

To investigate the caries risk profiles in young adults and to compare the risk classification using the Public Dental Service (PDS) guidelines with a risk assessment program, the Cariogram.

MATERIALS AND METHODS

All 19-year-old patients registered at eight public dental clinics were invited to participate (n = 1699). The study group who completed the baseline examination consisted of 1295 subjects representing 10% of all 19 year-olds attending dental care at the PDS in Skåne, Sweden. A risk classification of each patient was made by the patient's regular team according to the PDS guidelines. A research team collected whole saliva samples and information from a questionnaire and a structured interview in order to calculate risk according to the Cariogram model.

RESULTS

The mean DFS value was 4.9 and 23% of the patients were registered as caries-free (DFS = 0). The PDS risk classification was predominantly based on past caries and/or present caries activity. The majority was classified as 'some risk', while 16.7% were assessed as being of 'high' or 'very high risk'. The corresponding value for the two highest risk groups in the Cariogram model was 17.4%. The agreement between the two models was found acceptable (77.5%) for those assessed as low risk, while discrepancies were disclosed among those classified with higher risks.

CONCLUSIONS

Although the proportion of subjects assessed with high or very high risk was similar using the PDS guidelines and the Cariogram model, the agreement between the models was fair. An acceptable agreement was only disclosed for the low risk category.

Clinical outcomes of single-visit oral prophylaxis: a practice-based randomised controlled trial

BACKGROUND

Practice-based general dental practitioners routinely provide "scale and polish" or "oral prophylaxis" to patients attending their practices. Despite its routine provision, there is no evidence to support the clinical effectiveness of single-visit scale and polish, nor the frequency at which it should be provided. A recent systematic review recommended that future trials investigating scale and polish should involve dental practice patients.

METHODS

A practice-based parallel randomised controlled trial with 24-month follow-up was conducted. Healthy adults (Basic Periodontal Examination [BPE] codes <3) were randomly assigned to 3 groups (6-month, 12-month, or 24-month interval between scale and polish). The primary outcome was gingival bleeding with the hypothesis that 6-monthly scale and polish would result in lower prevalence than 12-month or 24-month frequency. Follow-up measurements were recorded by examiners blinded to the allocation. 125, 122 and 122 participants were randomised to the 6-month, 12-month and 24-month groups respectively. Complete data set analyses were conducted for 307 participants: 107, 100, and 100 in the 6-month, 12-month and 24-month groups respectively. Chi-square test and ANOVA were used to compare treatment groups at follow-up. Logistic regression and ANCOVA were used to estimate the relationship between outcome and treatment group, adjusted for baseline values. Multiple imputation analyses were also carried out for participants with incomplete data sets.

RESULTS

Prevalence of gingival bleeding at follow-up was 78.5% (6-month), 78% (12-month) and 82% (24-month) (p = 0.746). There were no statistically significant differences between groups with respect to follow-up prevalence of plaque and calculus. Statistically significant differences detected in the amount (millimetres) of calculus were too small to be clinically significant. Seventeen (4.6%) participants were withdrawn from the trial to receive additional treatment.

CONCLUSIONS

This trial could not identify any differences in outcomes for single-visit scale and polish provided at 6, 12 and 24 month frequencies for healthy patients (with no significant periodontal disease). However, this is the first trial of scale and polish which has been conducted in a general practice setting and the results are not conclusive. Larger trials with more comprehensive measurement and long-term follow up need to be undertaken to provide a firm evidence base for this intervention. This trial informs the design of future practice-based trials on this subject.