Oral Medicine for undergraduate dental students in the United Kingdom and Ireland-A curriculum.

INTRODUCTION: Oral Medicine focuses on care for patients with chronic, recurrent and medically related disorders of the orofacial region that are distinct from diseases of the periodontal and tooth tissues, with an emphasis on non-surgical management. At present, there are no shared outcomes for Oral Medicine to define the standards to be achieved before new graduates become registered dentists engaged with ongoing professional development. CURRICULUM: We present a consensus undergraduate curriculum in Oral Medicine agreed by representatives from 18 Dental Schools in the United Kingdom and Republic of Ireland. The scope of Oral Medicine practice includes conditions involving the oral mucosa, salivary glands, neurological system or musculoskeletal tissues that are not directly attributable to dental (tooth and periodontium) pathology. Account is taken of the priorities for practice and learning opportunities needed to support development of relevance to independent clinical practice. The outcomes triangulate with the requirements set out by the respective regulatory bodies in the UK and Republic of Ireland prior to first registration and are consistent with the framework for European undergraduate dental education and greater harmonisation of dental education. CONCLUSIONS: This curriculum will act as a foundation for an increasingly shared approach between centres with respect to the outcomes to be achieved in Oral Medicine. The curriculum may also be of interest to others, such as those responsible for the training of dental hygienists and dental therapists. It provides a platform for future collective developments with the overarching goal of raising the quality of patient care.

The dental manifestations and orthodontic implications of hypoparathyroidism in childhood.

The presence of short dental roots can present challenges to the orthodontist both in terms of identifying its aetiology and in subsequent treatment planning. Uncommon causes include hypoparathyroidism and pseudohypoparathyroidism, where short roots may be seen in combination with other oral manifestations including enamel hypoplasia secondary to low calcium levels. This case report highlights these features and the orthodontic treatment proposed.

Nystatin and miconazole: pharmacological and clinical evidence regarding interactions with warfarin.

OBJECTIVE: A retrospective case series published in 2012 concluded that miconazole and nystatin used as topical antifungal drugs appear to interact equally strongly with warfarin. If confirmed, this finding has significant implications for clinical practice. This study evaluates the evidence. MATERIALS AND METHODS: Evidence from the pharmacology literature, the medical literature and the 'yellow card' adverse drug reaction surveillance reports was analysed regarding possible interactions of nystatin and miconazole with warfarin. RESULTS: There is strong evidence to support the derangement of warfarin anticoagulation by miconazole oral gel in all areas of evidence studied. No postulated mechanism of interaction, no additional published reported cases and no supportive data from adverse drug reports were identified which would corroborate the case for a significant interaction between nystatin and warfarin. CONCLUSION: Miconazole and nystatin used as topical antifungal drugs do not interact equally strongly with warfarin. Miconazole oral gel can clearly interact with warfarin to cause derangement of anticoagulation. Nystatin appears unlikely to interact with warfarin.

Loss-of-function mutations in the cathepsin C gene result in periodontal disease and palmoplantar keratosis.

Papillon-Lefèvre syndrome, or keratosis palmoplantaris with periodontopathia (PLS, MIM 245000), is an autosomal recessive disorder that is mainly ascertained by dentists because of the severe periodontitis that afflicts patients. Both the deciduous and permanent dentitions are affected, resulting in premature tooth loss. Palmoplantar keratosis, varying from mild psoriasiform scaly skin to overt hyperkeratosis, typically develops within the first three years of life. Keratosis also affects other sites such as elbows and knees. Most PLS patients display both periodontitis and hyperkeratosis. Some patients have only palmoplantar keratosis or periodontitis, and in rare individuals the periodontitis is mild and of late onset. The PLS locus has been mapped to chromosome 11q14-q21 (refs 7, 8, 9). Using homozygosity mapping in eight small consanguineous families, we have narrowed the candidate region to a 1.2-cM interval between D11S4082 and D11S931. The gene (CTSC) encoding the lysosomal protease cathepsin C (or dipeptidyl aminopeptidase I) lies within this interval. We defined the genomic structure of CTSC and found mutations in all eight families. In two of these families we used a functional assay to demonstrate an almost total loss of cathepsin C activity in PLS patients and reduced activity in obligate carriers.

Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland - a curriculum.

The technical aspects of dentistry need to be practised with insight into the spectrum of human diseases and illnesses and how these impact upon individuals and society. Application of this insight is critical to decision-making related to the planning and delivery of safe and appropriate patient-centred healthcare tailored to the needs of the individual. Provision for the necessary training is included in undergraduate programmes, but in the United Kingdom and Ireland there is considerable variation between centres without common outcomes. In 2009 representatives from 17 undergraduate dental schools in the United Kingdom and Ireland agreed to move towards a common, shared approach to meet their own immediate needs and that might also be of value to others in keeping with the Bologna Process. To provide a clear identity the term 'Clinical Medical Sciences in Dentistry' was agreed in preference to other names such as 'Human Disease' or 'Medicine and Surgery'. The group was challenged to define consensus outcomes. Contemporary dental education documents informed, but did not drive the process. The consensus curriculum for undergraduate Clinical Medical Sciences in Dentistry teaching agreed by the participating centres is reported. Many of the issues are generic and it includes elements that are likely to be applicable to others. This document will act as a focus for a more unified approach to the outcomes required by graduates of the participating centres and act as a catalyst for future developments that ultimately aim to enhance the quality of patient care.

Wrong tooth extraction: further analysis of "never event" data.

The NHS in England requires the reporting of defined "never events" that are directly related to patients' safety. Analysis of data from 2012-2015 has been published previously in this journal. An examination of continuing data from 2015-2019 shows that "wrong tooth/teeth removed" has not reduced in frequency and it still remains a common "wrong-site surgery" event accounting for between 16% and 24% of wrong-site surgery never events and 7%-10% of all never events reported. Hospitals and community Trusts remain the main source of such reports, although some now originate from primary-care-based dental settings. Further efforts have focused on prevention, and the implementation of existing measures to reduce the risk of wrong tooth extraction, is warranted.

Oral cancer and tobacco: developments in harm reduction.

Oral squamous cell carcinoma is associated with the use of tobacco products. The predominant addictive substance in tobacco is nicotine, however, the major carcinogenic substances are in the other components of the tobacco leaf. The highest risk from tobacco use arises from combustion in the form of cigarettes. While cigarette consumption remains prevalent in the developing world, in the UK the rates of smoking are falling. In Sweden, modified smokeless tobacco in the form of snus has been available for many years and has contributed to reduced levels of smoking. In high income countries, new forms of tobacco consumption and nicotine delivery products have been developed over the last few years. These include heat-not-burn cigarettes and electronic cigarettes, and these products are now being actively marketed by many companies, including the tobacco industry. This paper reviews this changing pattern of tobacco and nicotine consumption and the current evidence regarding the risk of these products causing oral cancer.

Morbidity and mortality associated with the interaction of miconazole oral gel and warfarin.

Oral candidiasis is a frequently encountered oral fungal infection which can be treated with systemic and topical antifungal agents. Warfarin is a widely used oral anticoagulant. The interaction of miconazole oral gel and warfarin, causing potentiation of anticoagulant activity, has been documented over many years with evidence of occurrence in multiple settings and is a significant patient safety risk. This dangerous interaction remains underappreciated by dentists, doctors, pharmacists and patients, with resulting significant morbidity and mortality still occurring. This paper reports on recent developments concerning this interaction, and the important patient safety issues involved. In situations where topical treatment for oral candidiasis is indicated, nystatin should be prescribed instead of miconazole oral gel in patients taking warfarin, unless close monitoring and titration of the anticoagulant effect is undertaken.

Sleep bruxism: an overview for clinicians.

Bruxism is characterised by clenching or grinding of the teeth due to contraction of the masseter, temporalis and other jaw muscles. Bruxism may lead to masticatory muscle hypertrophy, tooth surface loss, fracture of restorations or teeth, hypersensitive or painful teeth and loss of periodontal support. Sleep bruxism has previously been viewed as a dysfunctional movement or pathological condition, whereas it is now accepted as a centrally controlled condition with various systemic risk factors. It has been postulated that sleep bruxism may have a protective role during sleep, for example in relation to airway maintenance or in stimulating saliva flow. A diagnosis of sleep bruxism may be made via patient report and clinical interview, clinical examination, intraoral appliances or recording of muscle activity. Bruxism in itself does not require treatment: management is only indicated where problems arise as a result of bruxism. Oral appliances primarily aim to protect the dentition from damage caused by clenching/grinding, although they may reduce muscle activity. Irreversible occlusal adjustments have no basis in evidence in the management of bruxism. Behavioural strategies include biofeedback, relaxation and improvement of sleep hygiene. Administration of botulinum toxin (Botox) to the masticatory muscles appears to reduce the frequency of bruxism, but concerns have been raised regarding possible adverse effects. Dentists should be aware of the potential aetiology, pathophysiology and management strategies of sleep bruxism.

The use and understanding of dental notation systems in UK and Irish dental hospitals.

Aim To identify the types of dental notation systems used in dental hospitals, and their perceived advantages and disadvantages. In addition, to record the dental notation used in patient referral letters.Method A self-completed questionnaire survey asking about the use of dental notation systems was distributed to 16 dental hospitals in the UK and Ireland in the summer of 2016. In addition, dentist referrals to the Restorative Dentistry department of the University Dental Hospital of Manchester were sequentially assessed for the dental notation used.Results Twelve hospitals replied. In order of frequency, the notation systems in use were the Alphanumeric, the Palmer, and the Federation Dentaire Internationale system. No hospital used the Universal system. Perceived advantages and disadvantages of each of the different systems were volunteered. One hundred and twenty-four referral letters were assessed and 100 were identified where dental notation was used. The majority used Alphanumeric notation.Conclusion A variety of dental notation systems remain in use in dental hospitals. The move to electronic recording and communication of information regarding teeth is encouraging the use of the Alphanumeric system. General dental practitioners are predominantly using the Alphanumeric system as their notation of choice in referral letters to the Restorative Dentistry department in Manchester.

Patient safety: reducing the risk of wrong tooth extraction.

Over recent years there has been an increased emphasis on improving patient safety in all branches of medicine, with reducing wrong tooth extraction being a priority in dentistry. The true incidence of wrong tooth extraction is unknown but it is considered an avoidable harm and is a significant source of dental litigation. Interventions to reduce wrong tooth extraction include educational programmes encompassing human factor training, patient assisted identification, the use of checklists, marking of surgical sites and implementation of patient safety guidelines. Identified risk factors which make wrong tooth extraction more likely include; suboptimal checks and/or cross checking of relevant clinical information, unclear diagnosis, unclear documentation, ambiguity regarding notation of molar teeth, orthodontic extractions, and extractions where there are multiple carious teeth and extractions in the mixed dentition. Accurate and timely reporting of wrong tooth extraction incidents followed by analysis and sharing of findings together with implementation of improved practice will help to minimise risks of wrong tooth extraction.

Wrong tooth extraction: an examination of 'Never Event' data.

The NHS in England has identified several adverse incidents that involve patients, including operations done at the wrong site, as "never" events. We examined published data from the period April 2012 to October 2015 and found that "wrong tooth/teeth removed" is the most common "wrong site" event, and accounted for between 20% and 25% of wrong site surgery never events, and 6% - 9% of all "never" events. All "wrong tooth/teeth removed" events seem to have been reported only by hospitals or Community Trusts. It is important to find out how these events are recorded and to find ways to prevent them.

Cochrane and the COMET initiative: developing the evidence base in oral medicine.

All clinicians in medicine and dentistry aim to deliver evidence-based practice; however, it is widely recognised that the current evidence base for interventions in oral medicine, as with many other specialties, is of a low quality. The highest level of evidence is considered to be the systematic review and meta-analysis. The Cochrane Collaboration and the Cochrane Oral Health group produce high quality systematic reviews, however, despite the large number of trials carried out for treatments in oral medicine, the results are often not able to be utilised to guide clinical care due to the various methodological limitations of the trials including the heterogeneity of outcome measures used. To improve the strength of the evidence base this will need to change. The Comet initiative aims to support the development of core outcome sets which are used to allow homogeneity of outcome measures in trials and therefore will allow pooling of data for meta-analysis in future systematic reviews. This paper explores the complexities involved in producing evidence for oral medicine interventions and introduces an approach for developing core outcome sets in oral medicine.

Surgical safety checklists and understanding of Never Events, in UK and Irish dental hospitals.

Aim To identify the procedures in dental hospitals where a surgical safety checklist is used and in addition, in England, to identify the understanding of hospitals regarding patient safety incidents requiring reporting as Never Events to NHS England.Method A self-completed questionnaire survey asking about the use of checklists was distributed to 16 dental hospitals associated with undergraduate dental schools in the UK and Ireland in the summer of 2015. For hospitals in England (10), additional questions regarding their understanding of incidents to be reported as Never Events were asked.Results Thirteen hospitals replied (8 in England). All use a surgical safety checklist in an operating theatre setting. Ten use a surgical safety checklist in an outpatient setting for the extraction of teeth. There is variable use of checklists for other procedures. The majority of English hospitals thought that the reporting of a 'Never Event' was required following wrong tooth extraction in whatever setting it occurred, including general dental practice.Conclusion Surgical safety checklists are increasingly used in dental hospitals, especially for oral surgery procedures. Beyond 'wrong tooth extraction', English dental hospitals have different understandings of what other oral and dental procedures require reporting as Never Events to NHS England.

Methotrexate and oral ulceration.

Methotrexate is well established in the drug treatment of various neoplastic diseases. More recently it has become increasingly used as a once-weekly, low-dose treatment of disorders such as psoriasis and rheumatoid arthritis. Clinical trials have shown its effectiveness in these conditions and it is likely that dentists will encounter patients taking this drug in general dental practice. Oral ulceration can occur as a side effect of methotrexate therapy. This may be due to lack of folic acid supplementation or overdosage due to confusion regarding its once-weekly regime. Illustrations of these problems, which have initially presented in a dental setting, are given. Important drug interactions of methotrexate relevant to dentistry are discussed.

Decreased light intensity alters the perception of day length by male European starlings (Sturnus vulgaris).

The breeding season of wild starlings is controlled by photoperiod. Full breeding condition is attained during exposure to lengthening days in the spring, and photorefractoriness ensues. The reproductive system of starlings will not subsequently be stimulated by long day lengths until photorefractoriness is dissipated by the short day lengths experienced in the autumn and winter. Unlike most studies on avian photoperiodism, this investigation involved manipulation of light intensity of a fixed photoperiod rather than of photoperiod itself. Photosensitive starlings transferred from short days to long days of different light intensities underwent graded reproductive responses according to the light intensity they experienced. Testes size in the group in the lowest intensity (3 lux) increased faster than that in controls on short days of normal intensity, but they did not become photorefractory. Testes size increased in the groups on 13, 45, and 108 lux and subsequently became photorefractory. However, the 13- and 45-lux groups required more time to become photorefractory than did the 108-lux group. The responses observed were similar to those seen in starlings exposed to different photoperiods (e.g., 11 h light:13 h dark [11L:13D], 13L:11D, 16L:8D, 18L:6D), even though all were on the same 18L:6D photoperiod. Initially, the results appear to challenge the external coincidence model for photoperiodic time measurement, but consideration of the phase response curve of the circadian rhythm of photoinducibility in starlings and the way in which it might be affected by low light intensities refute this challenge.

Comparative accuracy of different members of the dental team in detecting malignant and non-malignant oral lesions.

OBJECTIVES: Role substitution between primary care dentists (PCDs) and dental hygienists and therapists is increasingly being used in a number of different countries. Opponents to this development argue that it is unsafe and frequently cite the potential for missing oral malignancy as an inherent danger. The aim of the present study was to determine the comparative diagnostic test accuracy of different members of the dental team when differentiating between standardised photographs of mouth cancer, potentially malignant disorders and benign oral lesions. METHODS: A total of 192 dental professionals, comprising 96 PCDs, 63 DH-Ts, nine hospital-based dental staff and 24 other dental professionals were sampled purposively. Following orientation, participants were asked to score 90 clinical photographs that depicted cases of oral squamous cell carcinoma, potentially malignant disorders and non-malignant lesions of the oral mucosa. For each photograph participants were asked to determine whether they felt the lesion was representative of carcinoma, a potentially malignant disorder (test positive), or whether the lesion was benign (test negative). They were also asked to record their confidence in their decision on a 0-10 scale. Judgement decisions were compared against the known histopathological diagnosis of each lesion. Sensitivity and specificity were calculated for each participant and clinical group. RESULTS: The diagnostic test accuracy of PCDs and DH-Ts was similar. There was a median sensitivity of 81% Interquartile range (IQR) 19%) for PCDs and 77% (IQR 19%) for DH-T, with specificity of 73% (IQR 16%) and 69% (IQR 17%) respectively. DH-Ts missed fewer frank malignant lesions compared to PCDs. CONCLUSION: The performance of PCDs and DH-Ts when differentiating between mouth cancer, potentially malignant disorders and benign lesions is comparable. DH-Ts should be regarded as being as competent as PCDs as front-line healthcare workers with regard to detection of mouth cancer. However, considerable heterogeneity in detection was found within both clinical groups, suggesting that training remains paramount.

Incorporating lag effects in register-based age-of-onset distributions in schizophrenia.

Epidemiological studies often use age-of-first-admission from psychiatric case registers to estimate age-of-onset in schizophrenia. Retrospective, interview-based methods have shown that there is a delay between onset of symptoms and eventual contact with psychiatric services, and that this delay can vary both among individuals and at different ages. This delay or lag can confound the interpretation of first admission data such as age-of-onset. To evaluate the potential impact of this factor, we constructed a flexible mathematical model which integrates age-at-first-admission with estimates of this lag, which were derived from interview-based studies and clinical judgement. We applied this model to age-of-first-admission data for 4218 patients with ICD8/9 schizophrenia drawn from a state-wide psychiatric register. Both the raw age-of-first-admission distribution curve and the transformed data ('estimated age-of-onset') reinforce previous findings that (a) there is a wide range of age-of-onset and (b) the shapes of the curves differ between the sexes. Inspection of the mathematically derived distribution supports the proposition that (a) transformation for a lag effect produces a lower onset age and (b) including a variable length of lag produces a change in shape of the distribution. We propose that the mathematical transformation of age-of-first-admission data may have heuristic value, but requires further empirical data on which to base the assumptions of the model.

Schizophrenia and the influenza epidemics of 1954, 1957 and 1959: a southern hemisphere study.

The dates of birth of patients who were admitted with schizophrenia to public hospitals in Queensland between the years 1972 and 1988 were examined for associations between risk of schizophrenia and influenza epidemics. The hypothesis that infants born between four and six months after an influenza epidemic onset have increased risk of schizophrenia was examined for the 1954, 1957 and 1959 epidemics. After the 1954 epidemic there was a significant excess of male schizophrenia births four months after the onset of the epidemic. In 1957, there was a significant excess of female schizophrenia births in the fifth month after the onset of the epidemic. The 1959 epidemic was not associated with any significant excess.