Simon Stone

Curriculum content and assessment of pre-clinical dental skills: A survey of undergraduate dental education in Europe

INTRODUCTION Since 1981, the qualifications for various healthcare professionals across the European Union have enjoyed mutual recognition in accordance with the EU Directive 81/1057/EEC. Whilst the directive includes dental practitioners, it is recognised that significant variation exists in curriculum structure, content and scope of practice across institutions. This article aimed to explore pan-European practice in relation to curriculum content, teaching and learning strategies and assessment of pre-clinical dental skills. METHOD A request to complete an online questionnaire, in English, was sent electronically to skills leads at all Association of Dental Education in Europe member schools. The questionnaire collected information in relation to institution and country, regulatory requirements to demonstrate safety, details of specific pre-clinical skills courses, learning materials and teaching staff. RESULTS Forty-eight institutions, from 25 European countries responded. Seven countries (n=7, 28%) reported no requirement to demonstrate student operative safety prior to patient treatment. Several core and operative clinical skills are common to the majority of institutions. The most commonly taught core skills related directly to the clinical environment such as cross-infection control and hand washing. The least common were skills that indirectly related to patient care, such as communication skills and working as a team. CONCLUSION There are clear differences within European pre-clinical dental education, and greater efforts are needed to demonstrate that all European students are fit to practice before they start treating patients. Learning outcomes, teaching activities and assessment activities of pre-clinical skills should be shared collaboratively to further standardise curricula.

Dental pain in the medical emergency department: a cross-sectional study

The aim of this study was to examine the number of patients attending a medical emergency department (MED) with dental problems over a three-year period. This cross-sectional study was carried out as part of a service evaluation. Data were collected via a database search of patient attendances at the MED using free text and the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) for oral and dental diagnoses. Data were analysed using descriptive statistics, t-test and chi-squared tests. Over the three-year period, there were 2504 visits to the MED for dental-related complaints, accounting for 0·7% of all attendances. The majority of patients were male (53·9%), with a mean age of 29 (s.d. 19·4) years for men, and 32 (s.d. 19·7) years for females. The mean index of multiple deprivation per cent rank was 35·0%. The most common diagnosis was unspecified dental disorder. Ten per cent of dental attendances to MED were repeat attendances by the same patients. In conclusion, patient attendances at MED for dental problems account for 0.7% of all attendances. MED may not be the most appropriate place for these patients to attend, in terms of care pathways, and also for economic reasons. The reasons why patients attend MED for dental problems clearly warrant further research.

Effect of topical neuromodulatory medications on oral and skin keratinocytes

BACKGROUND Neuromodulatory medications (NMs), such as amitriptyline, carbamazepine and gabapentin, are used as topical preparations for the management of neuropathic orofacial pain (NOP) and have produced promising preliminary results. The aim of this study was to investigate the effects of three aforementioned NMs on cell lines relevant to the orofacial tissues in vitro as no published studies have examined the effect of these topical NMs. METHODS Cellular viability was measured using alamarBlue® , testing cumulative and specific time point effects of NMs on human skin keratinocytes and oral keratinocytes. Effects of the NMs on cell counts were investigated by CCK-8 assay. Drug concentrations released from NM orabase pastes after 30-min incubation were measured by high-performance liquid chromatography. Using these clinical concentrations, morphological changes and cytokine expression were investigated using scanning electron microscopy (SEM) and human inflammatory antibody array (AAH), respectively. RESULTS Cumulative and specific time point viability and cell count methods revealed that amitriptyline caused a significant decrease in cellular viability and counts in both cell lines. Carbamazepine also had significant effects after long-term exposure and at higher concentrations, whilst gabapentin had little demonstrable effect. SEM confirmed the cytotoxicity of amitriptyline, whilst AAH revealed no significant changes in cytokine expression following amitriptyline, carbamazepine or gabapentin exposure compared with control. CONCLUSIONS The results raise concerns about the safety of topical amitriptyline as it was cytotoxic to skin and oral keratinocytes in both exposure times and concentrations, whilst carbamazepine was cytotoxic only at high concentrations and after longer exposure times and gabapentin had no demonstrable effects.

Internal carotid artery aneurysm presenting as orofacial pain

OBJECTIVES We report a case of an internal carotid artery aneurysm presenting as orofacial pain. METHOD Case report and discussion. RESULTS A 59-year-old patient presented with a four-year history of chronic oral pain accompanied by a right-sided occipital headache. No local organic pathology was detected, and a provisional diagnosis of persistent idiopathic facial pain was made. A neurosurgery referral was made to exclude neurovascular pathology, which resulted in the detection of an aneurysm originating from the right posterior communicating artery. This was successfully treated by coil embolisation, with subsequent resolution of symptoms. CONCLUSION In this patient, an atypical history of pain with no other neurological signs or symptoms, other than accompanying occipital headache, led to the discovery of an intracranial aneurysm. This case highlights the need for appropriate referral and imaging in cases in which the clinical history and findings are not classical, and also emphasises the need for interdisciplinary management.

Core Build-Ups and Post Placement

This part of the chapter will emphasise the need to: Distinguish between a core build-up acting simply as a space-filler or forming a substructure for the extra-coronal restoration. Replace existing restorations, so what remains of a tooth can be properly assessed. Be aware of tooth restorability indices, but use your own clinical judgement to decide which teeth can be reliably restored. Decide if the extra-coronal restoration might be better bonded directly to the tooth without a core build-up. Choose an appropriate core build-up material, prepare features in teeth to aid retention and employ appropriate adhesive bonding. Ensure the extra-coronal restoration is extended sufficiently onto sound tooth beyond the core build-up to give a “ferrule effect”.

Viability of Posts and Cores

This chapter will emphasise the need to: Remove existing restorations prior to root treatment or retreatment to assess restorability and preserve as much tooth tissue as possible Consider all options if a tooth is unrestorable, including implants for tooth replacement Consider if a post is necessary. Alternatively, use the pulp chamber and to a lesser extent root canal anatomy for core retention. Bleaching may be required to avoid the risk of aesthetic failure If a post is needed, make sure it is retentive but also strong enough to resist distortion or fracture. If it fails, it should not be too difficult to retrieve Avoid posts that actively engage dentine and create internal stresses Ensure coronal coverage for protection, particularly of the posterior teeth.

Immunological Reactions to Materials

This chapter will emphasise the need to: Distinguish between toxicity and hypersensitivity to a dental material Recognise the characteristics of a Type 1 (immediate, potentially life-threatening) reaction and Type IV (delayed). Both can occur in relation to materials used in restoring teeth, but Type IV reactions occur more commonly Appreciate that various Type IV reactions may occur with base alloys, and composites but oral lichenoid lesions (OLL) occur most commonly to amalgam Refer OLL for a specialist opinion as this Type IV reaction is difficult to differentiate from lichen planus Ask for appropriate testing to be carried out by a dermatologist to determine which restorative materials can be used for a patient with OLL Choose replacement materials not only on the results of immunological testing but also to ensure fitness for purpose dentally.

Preserving Pulp Vitality

This chapter will emphasise the need for risk management to minimise pulp damage and its consequences: Informed consent—the risks of preparation should be discussed with patients and documented. In the case of crown and veneer preparations extended into dentine, this should routinely include the risk that the pulp may devitalise over time, along with the likely consequences and need for remedial treatment Tooth preparation—should be carried out with effective water coolant and with light pressure to reduce frictional heat and vibration. Avoid desiccating preparations by the overenthusiastic use of compressed air Restoration margins—both for provisional and definitive restorations should be optimally fitting and sealed Oral hygiene—patients may need instruction in controlling the biofilm around the roots and margins of restored teeth, not only for periodontal reasons but also for pulpal health.