Evidence Based Dentistry Journal

There are two articles by me in the latest Evidence Based Dentistry Journal - one an interview with Debora Matthews, a teacher of EBD in Canada, and the other a Dental Evidence Based Topic (DEBT) on whether crowns are better than large fillings on vital posterior teeth.

Hope you enjoy them.

Cheers.

Dental Trauma Guide

I thought I had blogged about this a while ago but realise now I must have just mentioned it to a few students on clinic.

This online guide has been put together by the guys who have done a massive amount of research into trauma in Copenhagen, Denmark.

I recommend a look-in.

http://www.dentaltraumaguide.org/

Ultrasonic power and root surface damage

Some 4th year students were concerned about the amount of power they should use when using an ultrasonic scaler for root debriding and the damage that could be done if too much power is used.

My understanding is that the more power we use with the ultrasonic the more risk of damage there is to the tooth surface. But rather than make an unfounded claim I thought I'd have a quick look on TRIP for some evidence while I'm sitting at a garage having my tyres changed...that's what I do when I have a day of annual leave :(

My search was: dentine AND (removal OR damage OR scratch*) AND (ultrasonic OR cavitron)

This brought up several papers but the one that seems most relevant was this one:

Ultrasonic scaler oscillations and tooth-surface defects.
http://jdr.sagepub.com/content/88/3/229/F3.expansion.html

This was a lab study that showed that increasing the power from low to high on two types of ultrasonic scaler increased the depth of defect created in the dentine by up to 4 times. There was also an increase in damage done when doubling the force applied, but this was not as significant as the power setting change.

I grant that the defects created even with high power are just 0.1mm deep after limited instrumentation. But if we were to reinstrument the same area many times in a patient's lifetime this could become quite significant, risking damage to the pulp. (I wonder also if the defect wouldn't be another plaque trap too, which would kind of defeat the objective of root surface debridement).

This is just one study but it seems to be an indication to keep the power as low as possible to do the job required. Let me know if you read other research on this.

Recording feedback

Last week I experimented with recording the feedback I gave to students on my smartphone and then emailing the recording to the student. I need to gather feedback myself on whether this is useful - and whether students actually listen to it. However, in the meantime I intend to use it anyway since it doesn't take much to press record and actually allows me to listen to myself giving feedback too.

I should remember to do this with all students as I give feedback but if I'm supervising you and we are discussing something that you think you might want to listen to again at a later stage then remind me to record.

TILT

I have been involved in piloting a new website for medical and dental professionals to share their learning.

It's called TILT, which stands for "Today I Learnt That..." and I think has the potential to really help groups of clinicians with a similar interest to learn from each other.

I set up a group as part of the pilot called BLTrip and a few students and I shared some learning during the pilot. Now that the site is fully up and running I'd like to invite others to join in.

http://tilt.tripdatabase.com/

PICO questions

Since I referenced PICOs in my last blog I thought I'd mention them here as they offer a great structure to help us find evidence for intervention studies. It's all about asking a clear and concise question so that you can - hopefully - find a clear answer.

The P bit stands for the patient or problem you are concerned about.

Let's imagine a 50 year old lady who had a load of amalgams placed mainly when she was young. She's read that dentists crown patients' teeth when they've got big fillings in because it stops them from breaking and losing their teeth.


What's the P here? The P is a problem in a patient - in this case a patient with heavily restored teeth.

The I bit relates to the intervention. In this case the I is a crown (or an onlay). You want to know, as this lady's dentist, whether or not you should crown some of her teeth and - if you're going to - which ones. So you want to compare placing a crown against not placing a crown to know if the crown is better.

So C is your comparison or control. In this case that is a filling - either amalgam or composite. If all we looked at was the survival time of a crown, without comparing it to the filling, we wouldn't know whether the filling might last just as long - or even longer.

Finally O is the outcome or outcomes you're interested in. What matters to the patient in this case? She is probably worried about losing her teeth. So the bottom line will be - does placing a crown mean that she'll keep that tooth longer than if she had just left it with a filling?

Another outcome might also be which restoration has to be replaced most frequently, or what the long term cost is of each treatment. And an outcome that is often forgotten is whether there are any adverse effects: does the tooth die, does it fracture catastrophically so it has to be extracted, does one cause mouth cancer?

We usually decide on one main outcome that really interests us. In this case I'd go for whether or not the tooth was retained longer as without this information it's very difficult to decide whether one is more cost-effective, for example.

So the PICO question here would be:

For an adult patient with an MOD or larger restoration in a molar tooth (P) does a crown or onlay (I) rather than a composite or amalgam (C) result in the tooth being retained longer (O)?

So why do this? Well, if you're going to search for evidence one way or the other - even if it means asking an expert (even though they lie way down the bottom on the hierarchies of evidence) - it is important to have a clear question. From this you can create a search strategy to use with Medline or the Cochrane Library and in a short time you can identify any good papers that might help you answer your question.

For more on this have a look at the Centre for Evidence Based Dentistry website

Managing avulsed teeth...

A few students and I were discussing management of avulsed teeth today. Wanting to find the best evidence of what to do when an adult walks in with their tooth in their hand we searched TRIP Database using the term avulsed tooth, which led us to a couple of systematic reviews looking at management of avulsed teeth and how long to splint them. Try it yourself if you're interested and see what you learn.

Later on I wanted to find some evidence based guidelines on trauma generally so popped 'Dental Trauma' into TRIP instead. This resulted in the following paper: Clinical guideline on management of acute dental trauma at the National Guideline Clearinghouse.

This guideline from 2007 has a succinct summary of what to do for the different types of trauma. It's not perfect in its methodology but appears to be pretty thorough.

The National Guideline Clearinghouse can be a useful site to visit if you're trying to find evidence about interventions. It's one of many online aids now available to help us make more informed decisions about healthcare.

One other paper I came across was a structured search to answer the PICO: How long should we wait for a pulp extirpation after a replantation of an avulsed permanent tooth? (If you're unsure what a PICO is let me know and I'll blog on it...and if you're not in the library you will need to log into Athens to read the paper). The basic take home messages were:

1. for replanted teeth with closed apices (i.e. very low chance of the pulp being revascularised) elective extirpation of the pulps should be performed within 14 days. 
2. for teeth with open apices, pulps should be extirpated when there is evidence of pulpal necrosis. 
3. pulpal extirpation is beneficial in the control of inflammatory resorption but has no proven benefit in control of replacement resorption or other aspects of healing.

Cheers.

New scenario - normal versus abnormal on bite wing radiographs

I have created another learning exercise, this time to help read bite wing radiographs.

It's under 'Scenario based learning' in the BDS013 Outreach section of Blackboard.

There are just two cases at the moment. As I build the number of cases I'll update the package.

Feedback, as ever, always welcome.

Diagnosis

What is a diagnosis? This question comes up regularly on the clinic.

I see this as the beginning of the management of a patient - an essential step in determining not only treatment but also prognosis. It is a label that categorises a patient to help us help them.

As such, I don't necessarily see a diagnosis as only something relating to what we would normally recognise as a 'disease', that is, caries, perio, apical abscess, etc. A diagnosis may relate to other problems the patient has:

1. orthodontic problem (e.g. crowding or increased overjet) 
2. aesthetic problem (e.g. a median diastema that causes this particular patient concern - a problem others might not see as such)  
3. functional problem (e.g. a lack of alveolar ridge, which results in problems retaining a denture)

A diagnosis does not necessarily mean we have to - or be able to - treat. There are pros and cons to most things and we would need to explain each to the patient. But by having a diagnosis we identify the problem and can agree it with the patient. Then we can work out how to manage it with the patient.

Rosacea

We had a patient with Rosacea this week. She didn't know what medication she was on but had been on it for several months. Since I wasn't up to date on the presentation and management of Rosacea myself I had a look on TRIP, which led to the following clinical knowledge summaries site:

http://www.cks.nhs.uk/rosacea/view_whole_topic#-335673

I'm certainly better informed about this condition as a result of this...

Scenarios

I will work on some more scenarios over the summer. If you haven't had a look at the one I've already posted on Blackboard, please do. I'd appreciate feedback on this ( tell me if you got lost, bored, challenged, frustrated...) and on other topics that you think would be useful to you.

The main aim of these is to encourage students to think things through and to develop responses as different information becomes available.

Risk management in clinical practice. Part 1. Introduction

I'd recommend students having a look at this article by Len D'Cruz from Dental Protection. It is applicable to student and qualified dentists alike.

The article reinforces the need for adequate note keeping. One common shortcoming among dentists generally, it seems, is that diagnoses are not recorded.

You can get to the paper by clicking on the title above with your Athens account or it's in the 'Outreach' section on Blackboard as a pdf.

Student Fitness to Practice - click here to see it

The GDC in April published its Student Fitness to Practice guidance.

The document covers:

(a) the types of professional behaviour and health standards expected of dental students;
(b) how fitness to practise can affect registration with us;
(c) when and how to make decisions about fitness to practise; and
(d) the key elements in student fitness to practise procedures.

Essentially students are treated very similarly to qualified dentists. I think this is sensible - and most students uphold these high standards already. Nonetheless, it's worth having a look at so you're familiar with what the GDC expects.

New scenario based learning module - Managing a patient complaining of pain

I've just put up on Blackboard a scenario based learning module that will hopefully help students manage a patient complaining of pain.

The idea is to present a scenario and let you work through it. Sometimes you'll make good decisions, other times less good decisions.

This is a first with this software and will need some work to make it visually more appealing. I'd appreciate comments from students particularly about:

1. whether it helped structure the diagnostic process
2. the length
3. the level of difficulty

All other feedback also appreciated.

Cheers

New videos - ultrasonic scaler use and the interspace brush

I've put up some more videos on Blackboard. They demonstrate how I would encourage you to use:

• an ultrasonic scaler

• an interspace brush (that's not the same as an interdental brush by the way)

I mention these things in the video, but just to re-emphasise the points:

• ultrasonics are potentially damaging from two points of view:

• they can remove tooth tissue - so turn the power down and don't stick the tip against the tooth
• they can traumatise the periodontium - so instrument pockets carefully whilst debriding the root surface thoroughly

• there are more efficient ways to use scaler tips - i.e. side on

Using an ultrasonic scaler in a safe but efficient way is a skill that can take time to master.

Please do not assume that by simply sticking it into the pocket the job is done. If you're unsure how to use the scaler ask your perio tutor next time you see them, or me next time you're out here.

13/06/2012 These videos are available on YouTube now:

Introduction 1
http://www.youtube.com/watch?v=DHteQ9A7BpI&feature=g-user-u

Introduction 2
http://www.youtube.com/watch?v=EfZnZdzyNrg&feature=relmfu

Using in a patient
http://www.youtube.com/watch?v=cRN0MqjWMKY&feature=relmfu

TRIP Database

Some of the third (coming on fourth...) years out there will know I've been asking people to search the TRIP database to find out about when to recall patients for check-ups.

This database is useful if you want to get to higher level information quickly - that is, clinical practice guidelines, systematic reviews and good primary studies.

However, it will not provide you with an exhaustive list of papers. For this you'll need to go back to Medline or Embase.

A nice element of TRIP is being able to save your searches automatically and to record anything you learnt whilst reading the paper. For this you'll need to register - but it's free and very simple.

I encourage you to start asking questions and searching for answers using TRIP