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.

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.

The development of a dental diagnostic terminology.

There is no commonly accepted standardized terminology for oral diagnoses. The purpose of this article is to report the development of a standardized dental diagnostic terminology by a work group of dental faculty members. The work group developed guiding principles for decision making and adhered to principles of terminology development. The members used an iterative process to develop a terminology incorporating concepts represented in the Toronto/University of California, San Francisco/Creighton University and International Classification of Diseases (ICD)-9/10 codes and periodontal and endodontic diagnoses. Domain experts were consulted to develop a final list of diagnostic terms. A structure was developed, consisting of thirteen categories, seventy-eight subcategories, and 1,158 diagnostic terms, hierarchically organized and mappable to other terminologies and ontologies. Use of this standardized diagnostic terminology will reinforce the diagnosis-treatment link and will facilitate clinical research, quality assurance, and patient communication. Future work will focus on implementation and approaches to enhance the validity and reliability of diagnostic term utilization.

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 Fisher's 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.

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 Fisher's 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).

Gender-based differences in satisfaction with academic preparation and practice experiences.

The purpose of this study was to investigate the effect that practice patterns and other variables had on graduates' level of satisfaction with dental school preparation and satisfaction with several career experiences and to determine if any gender-based differences occurred in these findings. Dentists who graduated from Creighton University School of Dentistry between 1985 and 2005 were surveyed regarding demographic factors, practice characteristics, satisfaction with educational preparation, and satisfaction with practice experiences. The response data were analyzed using Spearman's rho, multiple regression analysis, and the Pearson product moment. As a result of this analysis, no statistically significant differences were found between male and female dentists who graduated from Creighton University between 1985 and 2005 with respect to satisfaction with academic preparation and postgraduation practice experiences. The findings indicate that gender is not associated with graduates' level of satisfaction with their academic preparation while in dental school and their practice experiences.

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 Tukey's 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.

Transitory paresis of the lateral pterygoid muscle during a posterior superior alveolar nerve block--a case report.

The posterior superior alveolar nerve (PSAN) is a major sensory branch of the maxillary division of the trigeminal nerve. A PSAN block is a dental nerve block used for profound anesthesia of the maxillary molars. Complications arising from the PSAN block include hematoma formation, transient diplopia, blurred vision, and temporary blindness. This article presents a case of temporary paresis in the lateral pterygoid muscle following a PSAN block that utilized a 27-gauge long needle. The anatomical parameters and pathogenesis of such a complication are reviewed.

Comparison of clinician agreement during visualization of conventional and digitized bitewing radiographs.

Digital technology is becoming more common in dental practices. Indirect digitization of radiographs can be an alternative to direct digital systems. This study was designed to evaluate intra-observer, inter-observer, and inter-technique agreement of proximal caries diagnosis on bitewing radiographs before and after indirect digitization. Four bitewing radiographs were obtained from 50 dental students. Conventional films were digitized with a flatbed scanner at 150 and 300 dpi. Three observers recorded the presence and depth of caries on 1,642 proximal surfaces for the conventional and digitized radiographs. Radiographs were evaluated twice (one week apart), using each viewing technique. Intra-observer, inter-observer, and inter-technique agreement (Kw) were determined. The intra-observer, inter-observer, and inter-technique agreements of proximal caries diagnosis on bitewing radiographs before and after indirect digitization were moderate to good.

Effect of ViscoStat and ViscoStat Plus on composite shear bond strength in the presence and absence of blood.

PURPOSE: To examine the effects of the hemostatic agents ViscoStat and ViscoStat Plus on the shear bond strength (SBS) of composite resin (CR) to dentin in the presence and absence of blood. MATERIALS AND METHODS: Sixty permanent teeth mounted in acrylic were randomly divided into 5 groups (n = 12): (1) control, C; (2) ViscoStat, VS; (3) ViscoStat Plus, VS+; (4) ViscoStat and blood, VS/B; (5) ViscoStat Plus and blood, VS+/B. Groups 2 and 3 were exposed to VS and VS+, respectively. Freshly drawn human blood was placed on groups 4 and 5 immediately followed by VS and VS+, respectively. Specimens remained undisturbed for 1 min and were rinsed with tap water for 1 min. All groups were etched with 35% phosphoric acid and were bonded utilizing the Ultradent bonding clamp, Optibond Solo Plus, and Z-250 composite resin. Following water storage for 48 hrs at 37 degrees C, specimens were debonded in an Instron test frame at a crosshead speed of 0.5 mm/min. Statistical analysis was done with one-way analysis of variance. RESULTS: The mean SBS+/-SD in MPa were C: 44.2+/-4.8, VS: 42.3+/-8.7, VS+: 46.2+/-7.8, VS/B: 43.0+/-6.4, VS+/B: 44.0+/-8.1. ANOVA revealed no significant difference (p > 0.05) between SBS of VS or VS+ and the control with or without blood present. ostatic CONCLUSION: This controlled laboratory study concluded that the use of ViscoStat or ViscoStat Plus as a hem agent does not have a significant effect on the shear bond strength of composite resin to dentin when using Optibond Solo Plus.

Etiology of xerostomia and dental caries among methamphetamine abusers.

This study reviews the peripheral effects of methamphetamine on the salivary acini, the pathogenesis of methamphetamine-induced xerostomia, and its anecdotal relationship to dental caries. Methamphetamine is a sympathomimetic central stimulant which is abused for its euphoric effects. Its pharmacological action is exerted indirectly by sustaining high levels of catecholamines in the synaptic cleft and directly by binding to the postsynaptic adrenergic receptors. Methamphetamine abusers report subjective perception of xerostomia, which cannot be explained by the direct peripheral action of methamphetamine on the secretory acini. The drug may cause a decrease in salivary flow rate by centrally inhibiting salivatory nuclei via stimulation of alpha-2 receptors in the brain. Drug mediated dehydration state may influence the perception of dry mouth in abusers. The decreased salivary flow rate, either due to a central inhibitory action of methamphetamine or generalised dehydration, likely contributes to the increased occurrence of dental caries. Five cases of methamphetamine abuse are presented, three of whom experienced rampant dental caries. A direct association between methamphetamine abuse and the occurrence of rampant caries was not clear.

Aberrant root formation: review of root genesis and three case reports.

The mechanism of root formation and tooth eruption is a complex process which is not fully understood. Prior to a tooth emerging into the oral cavity, root genesis is initiated by derivatives of the enamel organ. The dental follicle mediates an eruption pathway allowing for movement of the developing tooth in a coronal direction. As the tooth moves towards the oral cavity, root formation occurs passively in the resulting space. Failure of the enamel organ and dental follicle to properly coordinate may result in complications in the eruption process. This clinical report presents 3 cases of isolated, unerupted teeth with dysmorphology of the roots. The process of root development and tooth eruption is also briefly reviewed.