Near-infrared imaging in orthodontic intraoral scanners for early interproximal caries detection.

INTRODUCTION: Intraoral scanners commonly used in orthodontic offices now offer near-infrared imaging (NIRI) technology, advertised as a screening tool to identify interproximal caries. This study aimed to evaluate the reliability and validity of NIRI detection of interproximal carious lesions in a common intraoral scanner (iTero Element 5D; Align Technology, San Jose, Calif) with and without bitewing radiograph complement, compared with a microcomputed tomography (micro-CT) reference standard. METHODS: Extracted human posterior teeth (premolars and molars) were selected for early (noncavitated) interproximal carious lesions (n = 39) and sound control surfaces (n = 47). The teeth were scanned via micro-CT for evaluation by 2 blinded evaluators using consensus scoring. The teeth were mounted to simulate anatomic interproximal contacts and underwent a NIRI scan using iTero Element 5D and bitewing radiographs. Two trained, calibrated examiners independently evaluated (1) near-infrared images alone with clinical photograph, (2) bitewing radiograph alone with clinical photograph, and (3) near-infrared images with bitewing radiograph and clinical photograph in combination, after at least a 10-day washout period between each evaluation. RESULTS: Interrater reliability was highest for NIRI alone (k = 0.533) compared with bitewing radiograph alone (k = 0.176) or in combination (k = 0.256). NIRI alone showed high specificity (0.83-0.96) and moderate sensitivity (0.42-0.63) compared with a micro-CT reference standard. Dentin lesions were significantly more reliably detected than enamel lesions. CONCLUSIONS: After rigorous training and calibration, NIRI can be used with moderate reliability, high specificity, and moderate sensitivity to detect noncavitated interproximal carious lesions.

Developing entrustable professional activities for general dentistry at the University of North Carolina.

INTRODUCTION: As part of curriculum innovation, the University of North Carolina (UNC) Adams School of Dentistry identified core entrustable professional activities (EPAs) that graduates must demonstrate for practice readiness. This paper describes the development of the UNC EPAs and the perceptions of the general dentistry faculty. METHODS: Upon establishing a blueprint of knowledge, skills, and attitudes of UNC graduates, using a distributed leadership approach, faculty teams developed EPAs focused on the patient care process. The American Dental Education Association Compendium of Clinical Competency Assessments and Commission on Dental Accreditation Standards informed the team's work. Perceptions of the assessment framework were examined using a questionnaire completed by 13 general dentistry faculty considering the importance, accuracy, and agreement of each EPA, associated domains of competence, and encounter management on a 6-point rating scale. RESULTS: Distributed leadership was a useful strategy in EPA development to disperse decision-making and build ownership. Through multiple iterations, four EPAs (assessment, plan of care, collaborative care, and provision of care) with associated sub-EPAs emerged. EPAs included a description, required knowledge and skills, and rubrics for assessment. The general dentistry faculty reported a high level of importance, accuracy, and agreement with EPAs, domains of competence, and encounter management. DISCUSSION: EPAs provide a standardized manner to describe the comprehensive work dentists perform, shifting away from individual competencies. The UNC EPAs provide the foundation for longitudinal measures of competence preparing graduates for independent practice. With limited EPAs frameworks available in dentistry, we aim to inform the development and implementation of EPAs across dental education.

Using a change management model to develop and implement dental curricula: A case study.

Curriculum transformation is a guiding principle and driving force to continued institutional growth and innovation in oral health education. The transformation process starts from the need and desire for change to achieve the strategic goals of curriculum invocation. The design and implementation process must follow a systematic approach to ensure the oral health curricula are meeting the demands of preparing learners for their future careers and are in line with the institutional strategic goals and processes. The process of curriculum transformation needs to be carefully crafted and implemented to include all constituents and have clear and measurable outcomes to define its path and results. The University of North Carolina at Chapel Hill Adams School of Dentistry is undergoing the journey of oral health curriculum innovation and transformation. The goal of this paper is to describe the change management process using Kotter's organizational model that may apply to other schools aiming to innovate dental curricula.

Comparison of incidental findings on cone beam computed tomographic and 2-dimensional images.

Cone beam computed tomography (CBCT) provides a 3-dimensional (3D) view of the patient and has a high frequency of incidental findings (IFs) that do not relate to the area of interest. Many of these IFs are not always visible on 2-dimensional (2D) intraoral or panoramic radiographs. Thus, the aim of the present study was to assess the IFs that did or did not appear on 3D vs 2D images. Significant IFs were recorded from a review of 510 CBCT reports by board-certified oral and maxillofacial radiologists. The IFs on CBCTs with 5-, 8-, and 11-cm fields of view (n = 170 per group) were recorded. A subset of these significant IFs was also viewed on intra-oral and panoramic radiographs to determine whether they were or were not visible in 2D imaging. A total of 677 significant IFs were discovered on 302 (59.2%) of the 510 reports. When a subset of 293 IFs was reviewed on intraoral and panoramic imaging, 112 (38.2%) were not visible on 2D radiographs, while 50 (17.1%) could not be confirmed with certainty. The frequency of significant IFs on CBCT imaging is high and increases with larger fields of view. A substantial number of these findings could not be seen on 2D radiographs, implying that many IFs are visible only on 3D images. Clinicians who order CBCT scans need to carefully review the volume in its entirety, regardless of previous imaging, so as not to miss any significant and relevant findings.

Preparing for implementation of an entrustable professional activity assessment framework.

Following the adoption of competency-based education in dentistry in the 1990s, entrustable professional activities (EPAs) were introduced in the field of medicine in the mid-2000s to help educators better determine the competence of trainees. More recently, the field of dental education has begun exploring EPAs as a framework for assessing competence while ensuring compliance with accreditation standards. This paper explores one dental school's process of preparing for implementation of a major curriculum change using an EPA assessment framework, shifting away from the use of singular assessments for competency determination to a global and longitudinal approach using a constellation of data to determine practice readiness. This paper describes how the EPA framework was developed, including the complementary capacities, assessment tool development and programming, and data reporting to follow learner progression and determine practice readiness. We discuss lessons learned leading up to implementation, and we position this perspective as a space to describe opportunities and complexities to consider when using a longitudinal assessment system. We attend to the tension between the current language of Commission of Dental Accreditation Standards as "competencies" and the evolving conversation of operationalizing EPAs while addressing accreditation Standards. To do this, we describe the process of finalizing our EPA framework and preparing for initial implementation in a new curriculum.

Faculty perspectives of an entrustable professional activity (EPA) framework in predoctoral dental education.

PURPOSE: The entrustable professional activity (EPA) framework is an assessment approach used to define the educational outcomes of a program by outlining discrete work tasks learners are expected to perform independently upon graduation. This study outlines the development and evaluation of an EPA framework for predoctoral dental education at the University of North Carolina Adams School of Dentistry. METHODS: The draft EPA framework was created in collaboration with a group of faculty members and included 15 statements that were mapped to relevant Commission on Dental Accreditation standards. The draft EPA framework was distributed to faculty via an electronic survey, requesting participants to evaluate whether the EPAs were well-defined; observable; measurable; expected of a general dentist; transferable to other practice settings; and required application of relevant knowledge, skills, and attitudes. In addition, participants were asked to identify the percentage of graduates who could perform these tasks independently and whether learners must be able to perform the list of EPAs upon graduation. RESULTS: Sixty-eight faculty members completed the survey (72% response rate); participants represented all divisions across the school and had extensive dental practice experiences. Overall, participants agreed the EPAs met the defined criteria and were considered important for graduates to be able to demonstrate. Feedback from faculty voiced support for the EPA framework and identified concerns regarding the implementation due to potential faculty calibration and time constraints. CONCLUSION: Evidence from this study supports additional research to explore how the EPA framework can be further developed in predoctoral and postgraduate dental education programs.

Bitewing radiography dosimetry of a stationary intraoral tomosynthesis imaging system.

OBJECTIVES: This study assessed effective doses (E) from conventional and stationary intraoral tomosynthesis (s-IOT) radiography for posterior bitewing (PBW) examinations and evaluated the effect of sensor attenuation. STUDY DESIGN: An adult human tissue-equivalent phantom and optically stimulated luminescent dosimeters were used. Series of 4 PBW radiographs were acquired with circular and rectangular collimation. s-IOT PBW radiographs were acquired with built-in rectangular collimation. Radiographs were acquired without and with a sensor in the beam path. RESULTS: E (in µSv) was 15.7 and 8.2 for conventional-circular, 4.6 and 1.1 for conventional-rectangular, and 11.9 and 5.9 for s-IOT in sensor-absent and sensor-present scenarios, respectively. For sensor-absent exposures, E for conventional-rectangular was 29.3% and E for s-IOT was 75.8% of the conventional-circular dose. With the sensor present, these values were 13.4% and 72.0%, respectively (P < .001). Sensor-present E was lower than sensor-absent E for all modalities (P < .001). Reductions in equivalent doses were similar to effective dose reductions. CONCLUSIONS: For PBW examinations, E for s-IOT was smaller than for conventional radiography with circular collimation, but larger than for conventional radiography with rectangular collimation. The presence of a sensor maintained these differences but reduced E for all modalities.

The role of stationary intraoral tomosynthesis in reducing proximal overlap in bitewing radiography.

OBJECTIVES: This study examined the utility of stationary intraoral tomosynthesis (s-IOT) in opening proximal contacts in bitewing radiography. METHODS: 11 DENTSPLY Rinn Dental X-ray Teaching and Training Replica mannequins (Model #546002, Elgin, Ill) were imaged with a prototype s-IOT device (Surround Medical Systems, Morrisville, NC) and standard bitewing (SBW) technique. Premolar and molar bitewings were acquired with each system. Image receptor holders were used to position receptors and aid in the alignment of the position indicating devices. An expert operator (having more than 5 years of experience in intraoral radiography) acquired the images with the s-IOT prototype and standard intraoral X-ray devices. Images were assessed to analyze percentage overlap of the proximal surfaces using the tools available in ImageJ (NIH, Bethesda Maryland). RESULTS: 253-paired surfaces were included in the analysis. The difference in overlap was statistically significant with standard bitewing (SBW) images resulting in a median overlap of 13%, a minimum of 0%, a maximum of 100% and an interquartile range of 40%. s-IOT resulted in a median overlap of 1%, a minimum of 0%, a maximum of 37% and an interquartile range of 0%. The s-IOT prototype substantially reduced proximal surface overlap compared to conventional bitewing radiography. CONCLUSIONS: The use of s-IOT reduced proximal contact overlap compared to standard bitewing radiography for an experienced radiographer. Stationary intraoral tomosynthesis may be a potential alternative to SBW radiography, reducing the number of retakes due to closed contacts.

Characterization and preliminary imaging evaluation of a clinical prototype stationary intraoral tomosynthesis system.

PURPOSE: Technological advancements in dental radiography have improved oral care on many fronts, yet diagnostic efficacy for some of the most common oral conditions, such as caries, dental cracks and fractures, and periodontal disease, remains relatively low. Driven by the clinical need for a better diagnostic yield for these and other dental conditions, we initiated the development of a stationary intraoral tomosynthesis (s-IOT) imaging system using carbon nanotube (CNT) x-ray source array technology. Here, we report the system characterization and preliminary imaging evaluation of a clinical prototype s-IOT system approved for human use. METHODS: The clinical prototype s-IOT system is comprised of a multibeam CNT x-ray source array, high voltage generator, control electronics, collimator cone, and dynamic digital intraoral detector. During a tomosynthesis scan, each x-ray source is operated sequentially at fixed, nominal tube current of 7 mA and user-specified pulse width. Images are acquired by a digital intraoral detector and the reconstruction algorithm generates slice information in real time for operator review. In this study, the s-IOT system was characterized for tube output, dosimetry, and spatial resolution. Manufacturer specifications were validated, such as tube current, kVp, and pulse width. Tube current was measured with an oscilloscope on the analog output of the anode power supply. Pulse width, kVp, and peak skin dose were measured with a dosimeter with ion chamber and high voltage accessory. In-plane spatial resolution was evaluated via measurement of MTF and imaging of a line pair phantom. Spatial resolution in the depth direction was evaluated via artifact spread measurement. The size of the collimated radiation field was evaluated for compliance with FDA regulations. A dental phantom and human specimens of varying pathologies were imaged on a clinical 2D intraoral imaging system as well as s-IOT for comparison and to explore potential clinical applications. RESULTS: The measured tube current, kVp, and pulse width values were within 3% of the set values. A cumulative peak skin dose of 1.12 mGy was measured for one complete tomosynthesis scan using a 50-ms pulse per projection view. Projection images and reconstruction slices revealed MTF values ranging from 8.1 to 9.3 cycles/mm. Line pair imaging verified this result. The radiation field was found to meet the FDA requirements for intraoral imaging devices. Tomosynthesis reconstruction slice images of the dental phantom and human specimens provided depth resolution, allowing visibility of anatomical features that cannot be seen in the 2D intraoral images. CONCLUSIONS: The clinical prototype s-IOT device was evaluated and found to meet all manufacturer specifications. Though the system capability is higher, initial investigations are targeting a low-dose range comparable to a single 2D radiograph. Preliminary studies indicated that s-IOT provides increased image quality and feature conspicuity at a dose comparable to a single 2D intraoral radiograph.

Nightguard vital bleaching: side effects and patient satisfaction 10 to 17 years post-treatment.

STATEMENT OF THE PROBLEM: The long-term patient satisfaction and safety of nightguard vital bleaching (NGVB) requires further evaluation. PURPOSE OF THE STUDY: The purpose of this study was to evaluate patients' satisfaction and identify side effects of NGVB up to 17 years post-treatment. MATERIALS AND METHODS: Thirty-one participants who had completed previous NGVB studies using 10% carbamide peroxide were contacted at least 10 years post-treatment (range 10-17 years, average 12.3 years). Participants reported shade satisfaction (very satisfied [VS], partially satisfied [PS], or not satisfied [NS]) as well as potential complications. Participants had teeth # 6 to 11 examined for tooth vitality, gingival inflammation (Löe's Gingival Index [GI]), and radiographically for external cervical resorption (ECR). RESULTS: All of the participants had successful lightening of their teeth. Sixty-one percent (19) had not retreated their teeth. Of those who had not retreated their teeth and who responded to the question of whitening satisfaction, 31% (4/13) were VS, 54% (7/13) were PS, and 15% (2/13) were NS with their current shade. Of those who had retreated their teeth, all were VS or PS. Ninety-one percent of the examined teeth had GI = 0 (normal), 7% had GI = 1 (mild inflammation), and 2% had GI = 2 (moderate inflammation). Sixty-nine percent of teeth tested responded to a cold stimulus. Radiographs did not detect ECR or apical lesions. No participant reported having a gingival biopsy post-treatment, and 87% would whiten again. CONCLUSIONS: Patient satisfaction with NGVB may last as long as 12.3 years in average (range 10-17 years) post-treatment. GI and ECR findings were considered within the normal expectations for the sample studied, suggesting minimal clinical post-NGVB side effects up to 17 years. CLINICAL SIGNIFICANCE: Nightguard vital bleaching provides patient satisfaction with minimal side effects up to 17 years post-treatment.