Nicole S. Kimmes

Bond strength of self-etch adhesives to pre-etched enamel

OBJECTIVE Bond strengths of composite resin to enamel using four self-etch adhesive (SEA) systems were compared with the bond strength of an etch-and-rinse adhesive (ERA) system, for both polished enamel and enamel pre-etched with phosphoric acid. The objective was to determine if the pre-etching would increase the bond strengths of the SEA systems to match the ERA system. METHODS Ten specimens were used for each adhesive to determine 24-h resin composite to enamel shear bond strengths (SBS) to polished (4000 grit) human enamel and this was repeated for the SEA systems for enamel that was pre-etched with phosphoric acid for 15s. SEM analysis was made to assess the degree of etching and resin penetration into enamel for each of the adhesive systems. Data were analyzed by a two factor ANOVA with a Tukey HSD post hoc test. RESULTS The SBS to polished enamel for all four SEA systems were statistically significantly lower (p<0.05) than the ERA control, but with pre-etched enamel there were no statistically significant differences (p>0.05) between any of the adhesive systems. All four of the SEA systems demonstrated statistically significant increases in bond strength between bonding to polished and pre-etched enamel, ranging from 27% to 86%. The results of SEM analysis showed no differences in the resin penetration patterns of any of the adhesives for enamel that was etched with phosphoric acid. SIGNIFICANCE Pre-etching enamel may enhance the bond strength of SEA systems to values comparable with those found with ERA adhesive systems, which may improve their overall performance in clinical use.

Effect of Enamel Etching Time on Roughness and Bond Strength

The current study examined the effect of different enamel conditioning times on surface roughness and bond strength using an etch-and-rinse system and four self-etch adhesives. Surface roughness (Ra) and composite to enamel shear bond strengths (SBS) were determined following the treatment of flat ground human enamel (4000 grit) with five adhesive systems: (1) Adper Single Bond Plus (SBP), (2) Adper Prompt L-Pop (PLP), (3) Clearfil SE Bond (CSE), (4) Clearfil S3 Bond (CS3) and (5) Xeno IV (X4), using recommended treatment times and an extended treatment time of 60 seconds (n = 10/group). Control groups were also included for Ra (4000 grit surface) and SBS (no enamel treatment and Adper Scotchbond Multi-Purpose Adhesive). For surface roughness measurements, the phosphoric acid conditioner of the SBP etch-and-rinse system was rinsed from the surface with an air-water spray, and the other four self-etch adhesive agents were removed with alternating rinses of water and acetone. A Proscan 2000 non-contact profilometer was used to determine Ra values. Composite (Z100) to enamel bond strengths (24 hours) were determined using Ultradent fixtures and they were debonded with a crosshead speed of 1 mm/minute. The data were analyzed with ANOVA and Fishers LSD post-hoc test. The etch-and- rinse system (SBP) produced the highest Ra (microm) and SBS (MPa) using both the recommended treatment time (0.352 +/- 0.028 microm and 40.5 +/- 6.1 MPa) and the extended treatment time (0.733 +/- 0.122 microm and 44.2 +/- 8.2 MPa). The Ra and SBS of the etch-and-rinse system were significantly greater (p < 0.05) than all the self-etch systems and controls. Increasing the treatment time with phosphoric acid (SBP) and PLP produced greater surface roughness (p < 0.05) but did not result in significantly higher bond strengths (p > 0.05).

Detection and characterization of usability problems in structured data entry interfaces in dentistry

BACKGROUND Poor usability is one of the major barriers for optimally using electronic health records (EHRs). Dentists are increasingly adopting EHRs, and are using structured data entry interfaces to enter data such that the data can be easily retrieved and exchanged. Until recently, dentists have lacked a standardized terminology to consistently represent oral health diagnoses. OBJECTIVES In this study we evaluated the usability of a widely used EHR interface that allow the entry of diagnostic terms, using multi-faceted methods to identify problems and work with the vendor to correct them using an iterative design method. METHODS Fieldwork was undertaken at two clinical sites, and dental providers as subjects participated in user testing (n=32), interviews (n=36) and observations (n=24). RESULTS User testing revealed that only 22-41% of users were able to successfully complete a simple task of entering one diagnosis, while no user was able to complete a more complex task. We identified and characterized 24 high-level usability problems reducing efficiency and causing user errors. Interface-related problems included unexpected approaches for displaying diagnosis, lack of visibility, and inconsistent use of UI widgets. Terminology related issues included missing and mis-categorized concepts. Work domain issues involved both absent and superfluous functions. In collaboration with the vendor, each usability problem was prioritized and a timeline set to resolve the concerns. DISCUSSION Mixed methods evaluations identified a number of critical usability issues relating to the user interface, underlying terminology of the work domain. The usability challenges were found to prevent most users from successfully completing the tasks. Our further work we will determine if changes to the interface, terminology and work domain do result in improved usability.

Fatigue of enamel bonds with self-etch adhesives

OBJECTIVE Fatigue testing of adhesive bonds to tooth structures in conjunction with bond strength testing can provide more useful information for examining the effectiveness of dental adhesives. The purpose of this study was to determine the shear bond strength (SBS) and shear fatigue limit (SFL) of composite to enamel bonds using modern adhesive systems. METHODS Twelve specimens each were used to determine 24-h resin composite (Z100-3M ESPE) to enamel shear bond strengths with an etch-and-rinse system (ERA), Adper Single Bond Plus (SB), and four self-etch adhesives (SEA)--Adper Prompt-L-Pop (PLP), Clearfil SE (CSE), Clearfil S(3) (CS3) and Xeno IV (X4). A staircase method of fatigue testing was used in a four-station fatigue cycler to determine the SFL of composite to enamel bonds with the adhesives (16-20 specimens for each adhesive) at 0.25 Hz for 40,000 cycles. ANOVA and Tukeys post hoc test were used for the SBS data and a modified t-test with Bonferroni correction was used for comparisons of the SFL. RESULTS The SBS and SFL of the etch-and-rinse system were significantly greater (p<0.05) than those of the four self-etch adhesives. The SBS and SFL of CSE were also significantly greater than for the other three self-etch systems. The ratio of SFL to SBS was highest with the etch-and-rinse system and the ratio became increasing smaller in the same order that the values for SBS decreased with the self-etch systems. SIGNIFICANCE The lower fatigue limits for composite to enamel bonds obtained with the self-etch adhesive systems may indicate that greater enamel margin breakdown will occur with restorations where these systems are used for bonding.

Are three methods better than one? A comparative assessment of usability evaluation methods in an EHR

OBJECTIVE To comparatively evaluate the effectiveness of three different methods involving end-users for detecting usability problems in an EHR: user testing, semi-structured interviews and surveys. MATERIALS AND METHODS Data were collected at two major urban dental schools from faculty, residents and dental students to assess the usability of a dental EHR for developing a treatment plan. These included user testing (N=32), semi-structured interviews (N=36), and surveys (N=35). RESULTS The three methods together identified a total of 187 usability violations: 54% via user testing, 28% via the semi-structured interview and 18% from the survey method, with modest overlap. These usability problems were classified into 24 problem themes in 3 broad categories. User testing covered the broadest range of themes (83%), followed by the interview (63%) and survey (29%) methods. DISCUSSION Multiple evaluation methods provide a comprehensive approach to identifying EHR usability challenges and specific problems. The three methods were found to be complementary, and thus each can provide unique insights for software enhancement. Interview and survey methods were found not to be sufficient by themselves, but when used in conjunction with the user testing method, they provided a comprehensive evaluation of the EHR. CONCLUSION We recommend using a multi-method approach when testing the usability of health information technology because it provides a more comprehensive picture of usability challenges.

Adhesive Bond Strengths to Enamel and Dentin Using Recommended and Extended Treatment Times

This study examined the effect of different enamel and dentin conditioning times on the shear bond strength of a resin composite using etch-and-rinse and self-etch adhesive systems. Shear bond strengths were determined following treatment of flat ground human enamel and dentin surfaces (4000 grit) with 11 adhesive systems: 1) AdheSE One Viva Pen-(ASE), 2) Adper Prompt L-Pop-(PLP), 3) Adper Single Bond Plus-(SBP), 4) Clearfil SE Bond-(CSE), 5) Clearfil S3 Bond-(CS3), 6) OptiBond All-In-One-(OBA), 7) OptiBond Solo Plus-(OBS), 8) Peak SE-(PSE), 9) Xeno IV-(X4), 10) Xeno V-(X5) and 11) XP Bond-(XPB) using recommended treatment times and an extended treatment time of 60 seconds (n = 10/group). Composite (Z100) to enamel and dentin bond strengths (24 hours) were determined using Ultradent fixtures and debonded with a crosshead speed of 1 mm/minute. The data were analyzed with a three-way Analysis of Variance (ANOVA) and Fishers LSD post hoc test. The highest shear bond strengths (MPa) to enamel were achieved by the three etch-and-rinse systems at both the recommended treatment time (SBP-40.5 +/- 6.1; XPB-38.7 +/- 3.7; OBS- 35.2 +/- 6.2) and the extended treatment time (SBP-44.5 +/- 8.1; XPB-40.9 +/- 5.7; OBS-35.0 +/- 4.5). Extending the enamel treatment time did not produce a significant change (p > 0.05) in bond strength for the 11 adhesive systems tested. OBS generated the highest (46.2 +/- 7.9) bond strengths to dentin at the recommended treatment time. At the extended treatment time X4 (42.2 +/- 11.7), PSE (42.1 +/- 9.7) and OBS (41.4 +/- 8.0) produced the highest bond strengths to dentin. The bond strength change between recommend and extended treatment times was significant (p < 0.05) for PSE, but the other 10 systems did not exhibit any significant change.

Treatment planning in dentistry using an electronic health record: implications for undergraduate education

OBJECTIVE Treatment planning, an essential component of clinical practice, has received little attention in the dental literature and there appears to be no consistent format being followed in the teaching and development of treatment plans within dental school curricula. No investigation, to our knowledge, has been carried out to explore the subject of treatment planning since the advent of electronic health record (EHR) use in dentistry. It is therefore important to examine the topic of treatment planning in the context of EHRs. METHODS This paper reports on how 25 predoctoral dental students from two U.S. schools performed when asked to complete diagnosis and treatment planning exercises for two clinical scenarios in an EHR. Three calibrated clinical teaching faculty scored diagnosis entry, diagnosis-treatment (procedure) pairing, and sequencing of treatment according to criteria taught in their curriculum. Scores were then converted to percent correct and reported as means (with standard deviations). RESULTS Overall, the participants earned 48.2% of the possible points. Participants at School 2 earned a mean of 54.3% compared with participants at School 1, who earned 41.9%. Students fared better selecting the appropriate treatment (59.8%) compared with choosing the correct diagnoses (41.9%) but performed least favorably when organizing the sequence of their treatment plans (41.7%). CONCLUSION Our results highlight the need to improve the current process by which treatment planning is taught and also to consider the impact of technology on the fundamental skills of diagnosis and treatment planning within the modern educational setting.

Dental clinical research: an illustration of the value of standardized diagnostic terms

Abstract Objective Secondary data are a significant resource for in‐depth epidemiologic and public health research. It also allows for effective quality control and clinical outcomes measurement. To illustrate the value of structured diagnostic entry, a use case was developed to quantify adherence to current practice guidelines for managing chronic moderate periodontitis (CMP). Methods Six dental schools using the same electronic health record (EHR) contribute data to a dental data repository (BigMouth) based on the i2b2 data‐warehousing platform. Participating institutions are able to query across the full repository without being able to back trace specific data to its originating institution. At each of the three sites whose data are included in this analysis, the Dental Diagnostic System (DDS) terminology was used to document diagnoses in the clinics. We ran multiple queries against this multi‐institutional database, and the output was validated by manually reviewing a subset of patient charts. Results Over the period under study, 1,866 patients were diagnosed with CMP. Of these, 15 percent received only periodontal prophylaxis treatment, 20 percent received only periodontal maintenance treatment, and only 41 percent received periodontal maintenance treatment in combination with other AAP guideline treatments. Conclusions Our results showed that most patients with CMP were not treated according to the AAP guidelines. On the basis of this use case, we conclude that the availability and habitual use of a structured diagnosis in an EHR allow for the aggregation and secondary analyses of clinical data to support downstream analyses for quality improvement and epidemiological assessments.

The importance of using diagnostic codes

To the Editor: We are a group of academic dentists who have developed a comprehensive dental diagnostic terminology and codes and implemented them. Our work has been catalyzed by the Consortium for Oral Health– Related Informatics (COHRI), a collaboration of 20 dental academic centers. The primary objective of COHRI is to share data for research and quality improvement purposes. One of the work products of this group was to create dental diagnostic terminology and codes. These terms and codes incorporated all of the existing dental diagnostic concepts, including the oral health concepts encompassed by the International Classification of Diseases (ICD,) 9th and 10th editions. In addition, the diagnostic terms and codes were further developed to allow for finer granularity of diagnoses, a limitation of the ICD system. These diagnostic terms and codes were developed through a consensus process within COHRI and now include 13 major classifications of disease and 1,321 terms and codes. These diagnostic terms and codes will continue to evolve with the profession, as we have instituted a biannual update process. We are currently funded by the National Institute of Dental and Craniofacial Research to enhance and implement diagnostic terminology and codes in an electronic health record. One objective of our grant is to increase the utilization of diagnostic terms and codes by lowering the barrier to documenting diagnoses in a standardized fashion. As part of our effort, we are in the process of creating a validated mapping of diagnostic terminology to the currently accepted dental procedure codes, thereby reinforcing the link between diagnosis and treatment. We agree with Dr Miller’s description that as part of dental education, the student has to learn to make a diagnosis before making the treatment plan, just as the dental practitioner needs to determine a diagnosis and then make a treatment plan. These are core values of why we implemented the diagnostic terminology and codes within a treatment plan module in the electronic health record (Axium; Exan Corp., Vancouver, Canada). The treatment plan module guides the student and practitioner through the steps of collecting data, identification of problems, determination of one or more diagnoses and then the construction of different options for a treatment plan. Dr Miller mentioned several benefits to the standardized documentation of dental diagnoses, i.e., the use of a common language and standard criteria, the requirement of evidence for use of diagnostic codes, the ability to track relationships between diagnoses and treatment, and qualitative and quantitative outcome measures that contribute to improvements in public health. We agree wholeheartedly with Dr Miller’s observations and would like to add that standardized diagnostic terms also enhance patient communication and the sharing of data across practices. Attempts at standardizing diagnostic codes in the past have not gained traction owing in part to fragmentation of efforts to create coding systems as well as the absence of meaningful incentives, as pointed out by Dr Miller. Through COHRI, it has been possible to ensure widespread acceptance of a common diagnostic terminology. The Diagnostic Terminology and Codes (2011) is protected under copyright to ensure their integrity and is available through a license.