Preparedness for practice of newly qualified dental professionals in Australia - educator, employer, and consumer perspectives.

BACKGROUND: Limited data regarding the perspectives of other observers (i.e. those who educate, employ or receive care from) of new graduates' preparedness to practice is available. The present study aimed to explore perceptions of different observers regarding the preparedness to practice and work readiness of newly qualified dental professionals. This broader range of perspectives is crucial to inform the development of educational programs, including continuing professional development, for newly qualified dental professionals, by clarifying the skills, knowledge and behaviours expected by the dental profession and wider public. RESULTS: Nineteen individual qualitative interviews were undertaken. Interview participants included clinical demonstrators (n = 9; 2 Oral Health Therapists; 5 Dentists; and 2 Prosthetists), dental course convenors (n = 4), representatives of large employers (n = 2), and consumers (n = 4). According to this diverse group of respondents, dental students receive adequate theoretical and evidence-based information in their formal learning and teaching activities, which prepares them for practice as dental professionals. There were no specific clinical areas or procedures where preparedness was highlighted as a major concern. Notwithstanding this, specific graduate skills which would benefit from further training and consolidation were identified, including areas where higher levels of experience would be beneficial. Nonetheless, respondents indicated that new graduates were aware of their limitations and had developed self-discipline and ethics that would allow them to identify conditions/situations where they would not have the experience or expertise to provide care safely. CONCLUSIONS: From an observer perspective, dental students appeared to have gained adequate theoretical and evidence-based information in their formal learning and teaching activities to prepared them to commence practicing safely as dental professionals. Areas were identified in which new graduates were underprepared and when transitional support may be required.

Preparedness for practice of newly qualified dental practitioners in the Australian context: an exploratory study.

BACKGROUND: The current study explored the perspectives of preparedness for dental practice from a range of relevant stakeholders (i.e., educators, employers, final-year students, graduates, practitioners, and professional associations) using an anonymous online survey in which participants described either their preparedness for practice, or the preparedness of graduates they have encountered, across six domains. RESULTS: A total of 120 participants completed the survey. Participants were from several Australian states and territories; regional, rural, and urban locations; and working in the public and private sector. Students and new graduates generally felt prepared for activities in all the identified domains. Stakeholders reported consistently that the knowledge of dental profession graduates was at the required level to enter practice in Australia in a safe way. Activities involving the knowledge of clinical entrepreneurship and financial solvency were the dimensions where students and graduates felt least prepared (e.g., explaining fees, negotiating finances). In the domains involving clinical and technical competencies, students and new graduates self-assessed as less prepared around managing dental trauma and medical emergencies. On the other hand, activities around social and community orientation, and to a lesser extent professional attitudes and ethical judgements, were the dimensions where students and graduates felt the most prepared. CONCLUSIONS: Present findings indicate that there appear to be good standards of preparedness for practice for graduate dental professionals. This exploratory study provides insights into the nature of preparedness for Australian dental professionals and provides a basis for targeting education and professional development to address areas of need.

When to intervene in the caries process? An expert Delphi consensus statement.

OBJECTIVES: To define an expert Delphi consensus on when to intervene in the caries process and on existing carious lesions using non- or micro-invasive, invasive/restorative or mixed interventions. METHODS: Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference. RESULTS: Carious lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations will be placed for reasons of form, function and aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated carious lesions which are cleansable. Cavitated lesions which are not cleansable usually require invasive/restorative management, to restore form, function and aesthetics. In specific circumstances, mixed interventions may be applicable. On occlusal surfaces, cavitated lesions confined to enamel and non-cavitated lesions radiographically extending deep into dentine (middle or inner dentine third, D2/3) may be exceptions to that rule. On proximal surfaces, cavitation is hard to assess visually or by using tactile methods. Hence, radiographic lesion depth is used to determine the likelihood of cavitation. Most lesions radiographically extending into the middle or inner third of the dentine (D2/3) can be assumed to be cavitated, while those restricted to the enamel (E1/2) are not cavitated. For lesions radiographically extending into the outer third of the dentine (D1), cavitation is unlikely, and these lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds. CONCLUSIONS: Comprehensive diagnostics are the basis for systematic decision-making on when to intervene in the caries process and on existing carious lesions. CLINICAL RELEVANCE: Carious lesion activity, cavitation and cleansability determine intervention thresholds. Invasive treatments should be applied restrictively and with these factors in mind.

Resin infiltration of developmentally hypomineralised enamel.

BACKGROUND: Molar incisor hypomineralisation (MIH) is a problematic condition with several characteristics for which infiltrant resins could theoretically improve clinical outcomes. AIM: To investigate whether caries infiltrant resin can penetrate MIH-affected enamel. DESIGN: Molar incisor hypomineralisation lesions (n = 21) were infiltrated using either the standard protocol or with the addition of a sodium hypochlorite (NaOCl) irrigation step. Lesions were sectioned and examined microscopically for infiltrant penetration before undergoing Vickers hardness testing. The surfaces of several lesions were also examined using scanning electron microscopy (SEM). RESULTS: Infiltrant resin could penetrate MIH lesions; however, the pattern was erratic. Two lesions were confined to inner enamel, and no infiltration occurred. On average, the resin penetrated to a depth of 0.67 ± 0.39 mm and 23.1 ± 15.2% of the area of the lesion. Microhardness increased in areas of resin penetration by 1.0 ± 0.7 GPa representing a proportional increase of 2.2 ± 2.5 times. There were no significant differences in results based on either the infiltration protocol or the type of MIH lesion. CONCLUSION: Caries infiltrant resin is capable of penetrating MIH enamel lesions; however, the pattern, extent, and change in hardness produced are currently unpredictable.

The Impact of Molar Incisor Hypomineralisation on Children and Adolescents: A Narrative Review.

Molar incisor hypomineralisation (MIH) is a qualitative developmental enamel defect with a prevalence of 13% worldwide. This review aims to outline the current evidence regarding the impact of MIH on children's oral health and, more broadly, their day-to-day activities. MIH is associated with negative sequelae, including hypersensitivity, post-eruptive breakdown, the rapid development of carious lesions and poor aesthetics. Other concerns pertain to the clinical management of MIH and include difficulty in achieving local anaesthesia, increased dental fear and anxiety (DFA) and increased behaviour management problems. Oral health-related quality of life (OHRQoL) is the most standardised measure of patient impact; however, no instruments have been validated for use in MIH populations. The few existing observational studies investigating the impact of MIH on OHRQoL in children have produced conflicting results. Interventions to alleviate hypersensitivity and improve aesthetics had a positive impact on the OHRQoL of MIH-affected children. Multiple methodological issues make it difficult to measure the impact of MIH, including heterogeneity in the MIH severity classification, an overlap in the indices used to diagnose dental caries and MIH as well as the subjectivity of outcome measures for hypersensitivity and DFA.

An International Investigation of Molar Incisor Hypomineralisation (iMIH) and Its Association with Dental Anomalies: Development of a Protocol.

BACKGROUND: Molar incisor hypomineralisation (MIH) is a common disorder of tooth development, which has recently been found to be associated with a higher prevalence of hypodontia. The aim of this international multicentre study is to determine the association between MIH and other developmental anomalies in different populations. METHODS: Investigators were trained and calibrated for the assessment of MIH and dental anomalies and ethical approvals obtained in each participating country. The study aimed to recruit 584 children with MIH and 584 children without MIH. Patients aged 7-16 years who attend specialist clinics will be invited to participate. Children will undergo a clinical examination to determine the presence and severity of MIH, using an established index. The presence of any other anomalies, affecting tooth number, morphology, or position, will be documented. Panoramic radiographs will be assessed for dental anomalies and the presence of third permanent molars. Statistical analysis, using a chi squared test and regression analysis, will be performed to determine any differences in dental anomaly prevalence between the MIH and non-MIH group and to determine any association between dental anomalies and patient characteristics. CONCLUSION: This large-scale study has the potential to improve understanding about MIH with benefits for patient management.

Evaluation of a community-based early childhood caries (ECC) intervention in Cambodia.

OBJECTIVE: To critically evaluate an early childhood caries (ECC) intervention performed by non-dental primary healthcare providers. METHODS: This mixed-methods investigation includes data from three sources: (a) a pilot non-randomized controlled trial to examine clinical outcomes at four health centres; (b) stakeholder focus group interviews; and (c) a survey of parents whose children were exposed to the intervention. The pilot study involved four Community Health Centres in rural Cambodia whereby mother-child (6-24 months of age)dyads received oral health education (OHE), toothbrushes, fluoride toothpaste and fluoride varnish on up to six occasions as part of the routine vaccination schedule. Outcomes were as follows: presence of ECC; impacts on oral health-related quality of life (OHRQoL); stakeholder perceptions of intervention delivery; and parental perceptions of fluoride varnish. RESULTS: Participants in the intervention group had six times lower odds of developing ECC than those in the comparison group after controlling for socio-economic status (OR 0.13). Those in the intervention group also had a large reduction OHRQoL scale scores. Key knowledge and practice gaps were identified among stakeholders. Surveyed parents had favourable views of the fluoride varnish placement by medical professionals, and four out of five stated that they would recommend fluoride varnish for other children. Primary healthcare providers, commune council representatives and community health promoters supported oral health interventions being provided in CHCs. CONCLUSIONS: OHE and fluoride varnish interventions provided by non-dental primary health workers were feasible and acceptable for stakeholders in a Cambodian setting. The intervention group had lower ECC experience and better OHRQoL at 2 years of age.

Pre-Outplacement Perceptions of Dental Students Regarding Rural Oral Health Practice and Associated Factors.

Rural outplacement programs have been offered by Australian universities to encourage dental students to consider rural careers. The dental curricula should be designed to provide graduates with a good understanding of oral health issues that rural oral health care workers face. Pre-outplacement perceptions of dental students on rural practice are considered imperative to review and update the outplacement programs; however, they have not been investigated in detail. An online, anonymous, voluntary survey was conducted among the first-year dental students. The responses were solicited on the level of awareness and understanding of rural oral health, intention to practice in rural locations and factors informing the appeal of rural dental practice. The mean of a seven-point Likert scale revealed that most students had some level of perceived knowledge and awareness of rural communities and oral health. Students with rural affiliation were more likely to have the intent to practise rurally after graduation (p = 0.001). For short-term rural practice, students overall expressed positive intention. Greater job opportunities were the main motivating factor, while the distance from family and friends was the main deterring factor for practising rurally. Rural affiliation influences the intent to practise rurally on graduation. The pre-outplacement perceptions, in this study, are comparable with post-outplacement observations reported in the literature.

When to intervene in the caries process? A Delphi consensus statement.

Objectives To define an expert Delphi consensus on when to intervene in the caries process and existing carious lesions.Methods Non-systematic literature synthesis, expert Delphi consensus process and expert panel conference.Results Lesion activity, cavitation and cleansability determine intervention thresholds. Inactive lesions do not require treatment (in some cases, restorations may be placed for form, function, aesthetics); active lesions do. Non-cavitated carious lesions should be managed non- or micro-invasively, as should most cavitated lesions which are cleansable. Cavitated lesions which are not cleansable usually require minimally invasive management. In specific circumstances, mixed interventions may be applicable. Occlusally, cavitated lesions confined to enamel/non-cavitated lesions extending radiographically into deep dentine may be exceptions. Proximally, cavitation is hard to assess tactile-visually. Most lesions extending radiographically into the middle/inner third of dentine are assumed to be cavitated. Those restricted to the enamel are not cavitated. For lesions extending radiographically into the outer third of dentine, cavitation is unlikely. These lesions should be managed as if they were non-cavitated unless otherwise indicated. Individual decisions should consider factors modifying these thresholds.Conclusions Comprehensive diagnosis is the basis for systematic decision-making on when to intervene in the caries process and existing lesions.

Aetiology of molar-incisor hypomineralization: a critical review.

OBJECTIVE: The objective of this study was to assess the strength of evidence for the aetiology of molar-incisor hypomineralization (MIH), often as approximated by demarcated defects. METHOD: A systematic search of online medical databases was conducted with assessment of titles, abstracts, and finally full articles for selection purposes. The level and quality of evidence were then assessed for each article according to Australian national guidelines. RESULTS: Of 1123 articles identified by the database search, 53 were selected for review. These covered a variety of potential aetiological factors, some of which were grouped together for convenience. The level of evidence provided by the majority of papers was low and most did not specifically investigate MIH. There was moderate evidence that polychlorinated biphenyl/dioxin exposure is involved in the aetiology of MIH; weak evidence for the role of nutrition, birth and neonatal factors, and acute or chronic childhood illness/treatment; and very weak evidence to implicate fluoride or breastfeeding. CONCLUSION: There is currently insufficient evidence in the literature to establish aetiological factor/s relevant for MIH. Improvements in study design, as well as standardization of diagnostic and examination protocols, would improve the level and strength of evidence.

SEAL Cambodia-Evaluation of a modified protocol for placement of Fuji VII® Fissure Sealants at one and two years.

OBJECTIVES: In order to address the severe caries burden among Cambodian children and limited access to dental care this study had two objectives: (1) To evaluate the caries preventive effect of hand-mixed GIC Fissure Sealants (FS) placed on first permanent molars of 6-8 year-old Cambodian children using two protocols in the SEAL Cambodia Project and (2) validate the SEAL Cambodia population-based intervention. METHODS: The study had four groups, two cohorts, and investigated two clinical protocols (original and modified) for FS placement to compare caries preventive fraction. Three groups were followed up at 1y and two were followed up at 2y. The modified protocol involved control of the temperature of the material, the timing of mixing and placement, and adjustment of the occlusion. Data analysis examined differences in caries incidence by group. RESULTS: At 1 and 2 y, 62.8%, and 68.0% follow-up rates were achieved, respectively. The baseline mean dmft for the first and second cohorts was 8.0 (SD 3.9) and 9.9 (SD 4.3) respectively. The original protocol did not render a statistically significant preventive benefit. A preventive fraction of 89.1% at 1 y and 32.3% at 2 y was achieved using the modified protocol in the second cohort (P < 0.05). Children with baseline dmft> 8 realised half the preventive fraction at 2 y compared to those with dmft <8 (22.3% and 45.8% respectively). CONCLUSIONS: The modified FS protocol increased the caries preventive effect, although it was lower than that reported in other studies. CLINICAL SIGNIFICANCE: This study builds evidence for the use of glass ionomer cement Fissure Sealants (FS) for the prevention of caries at a population level. It showed that improving the field-based clinical protocol for application of FS had a large impact on clinical success.

Structural, mechanical and chemical evaluation of molar-incisor hypomineralization-affected enamel: A systematic review.

OBJECTIVES: To systematically assess and contrast reported differences in microstructure, mineral density, mechanical and chemical properties between molar-incisor-hypomineralization-affected (MIH) enamel and unaffected enamel. METHODS: Studies on extracted human teeth, clinically diagnosed with MIH, reporting on the microstructure, mechanical properties or the chemical composition and comparing them to unaffected enamel were reviewed. Electronic databases (PubMed, Embase and Google Scholar) were screened; hand searches and cross-referencing were also performed. RESULTS: Twenty-two studies were included. Fifteen studies on a total of 201 teeth investigated the structural properties, including ten (141 teeth) on microstructure and seven (60 teeth) on mineral density; six (29 teeth) investigated the mechanical properties and eleven (87 teeth) investigated the chemical properties of MIH-affected enamel and compared them to unaffected enamel. Studies unambiguously found a reduction in mineral quantity and quality (reduced Ca and P content), reduction of hardness and modulus of elasticity (also in the clinically sound-appearing enamel bordering the MIH-lesion), an increase in porosity, carbon/carbonate concentrations and protein content compared to unaffected enamel. FINDINGS: were ambiguous with regard to the extent of the lesion through the enamel to the enamel-dentin junction, the Ca/P ratio and the association between clinical appearance and defect severity. CONCLUSIONS: There is an understanding of the changes related to MIH-affected enamel. The association of these changes with the clinical appearance and resulting implications for clinical management are unclear. CLINICAL SIGNIFICANCE: MIH-affected enamel is greatly different from unaffected enamel. This has implications for management strategies. The possibility of correlating the clinical appearance of MIH-affected enamel with the severity of enamel changes and deducing clinical concepts (risk stratification etc.) is limited.

Characterisation of developmentally hypomineralised human enamel.

OBJECTIVES: To investigate and clarify physical and chemical properties of enamel affected by molar incisor hypomineralisation (MIH). METHODS: A series of in vitro studies were performed on extracted molars affected by MIH and sound teeth for controls. Tooth sections underwent Vickers microhardness testing before lapping and subsequent transverse microradiographic analysis and examination under polarised light microscopy. Carbonate content was determined by CO2 release from acid digestion. Unprepared and fractured surfaces were examined under scanning electron microscopy. RESULTS: MIH-affected molars demonstrated a severe degree of hypomineralisation with an average mineral content of only 58.8%vol% mineral. Vickers microhardness was significantly reduced in MIH compared with controls (1.8±1.1 v 4.4±1.0 GPa, p<0.05) and polarised light microscopy revealed the bulk of MIH lesions had a porosity of ≤5% but also substantial areas of ≥10% and smaller areas exceeding 25% porosity. A surface layer was frequently observed on both intact and broken-down lesions and cervical regions of MIH teeth were typically spared. Carbonate content of MIH enamel was higher than control samples (6.6±2.1 v 4.4±1.1 wt%, p<0.05). Scanning electron microscopy showed that both the enamel rod and surface ultrastructure were defective. Clinical characteristics did not consistently correlate with all properties. CONCLUSIONS: The properties of MIH-affected enamel significantly differ from those of normal enamel and were highly variable, however some common characteristics were observed. Implications for aetiology and clinical management are discussed.