Prostate MRI: access to and current practice of prostate MRI in the United States.

PURPOSE: MRI of the prostate has increasingly become more important in clinical medicine because of the risk of over-detection of low-grade, low-volume prostate cancer, as well as because of the poor sampling of transrectal ultrasound-guided prostate biopsy in high-risk patients. We sought to determine the access, imaging protocols, and indications for MRI imaging of the prostate in the United States. METHODS: A brief survey was sent through mailing lists to members of the Society of Abdominal Radiology and Texas Radiological Society. RESULTS: Thirty-six academic centers responded to the survey, 88.9% of which routinely perform prostate MRI. Nine centers routinely performed imaging at 1.5T with an endorectal coil (25%), 11 performed at 3.0T without an endorectal coil (31%), and 10 performed at 3.0T with an endorectal coil (28%). All institutions used T1-weighted axial and orthogonal T2-weighted sequences. Most groups used diffusion-weighted imaging (94.7%) and dynamic contrast enhancement (81.6%). Only 21.1% of groups performing prostate MRI routinely performed MR spectroscopy as part of their protocol. CONCLUSIONS: Prostate MRI is becoming a commonly performed examination at academic institutions, with most locations performing prostate MRI at minimum standards. There is a need to educate nonacademic practices regarding the addition of functional MRI techniques to anatomic techniques, increase the number of institutions that regularly perform prostate MRI, and increase access to direct MRI-guided biopsy in institutions that perform prostate MRI on a regular basis.

The prevalence and risks of early childhood caries (ECC) in Toronto, Canada.

AIM: To determine the prevalence and risks of early childhood caries (ECC) among children less than 71 months of age in Toronto, Canada, and to evaluate the association between parental/caregiver depression and ECC. METHODS AND MATERIALS: A secondary analysis of data previously collected by the Toronto Public Health as part of the 2003 Toronto Perinatal and Child Health Survey was performed. The 90-item survey was conducted over the telephone to 1,000 families with children from zero years (birth) to six years of age. Parents/caregivers were asked about factors related to the development and health of their children. For this study, only children younger than six years of age (less than 71 months) were included (n=833). The primary outcome of interest was self-reported and measured by the response to the question of whether a physician/dentist had ever told the parent/caregiver his/her child had ECC. RESULTS: The prevalence of ECC was 4.7 percent (37 of 791 children). The child's age, his/her history of dental visits, teeth brushing, the use of fluoridated toothpaste, the parent's/caregiver's depressive tendencies, the language spoken at home, and the household annual income were all significant in the bivariate analysis. Multiple logistic regression identified four factors associated with ECC: the child's age (being three years of age or older), having at least one parent/caregiver with depression, not speaking English at home, and having an annual household income less than $40,000 in Canadian dollars (CAD). CONCLUSION: While a child's age, home language, and household income are known risks for ECC, the finding that parental/caregiver depression may be related to ECC is new. CLINICAL SIGNIFICANCE: Multiple risk factors are involved in the development of early childhood caries. Of particular importance are demographic (e.g., child's age), social (e.g., annual household income), and psychosocial factors (e.g., parental/caregiver depression) that are indirectly linked to ECC. More attention needs to be placed on understanding the role and process by which these factors influence the development of ECC.

A retrospective analysis of referral patterns for oral radiologic consultation over 3 years in Ontario, Canada.

OBJECTIVES: To determine the types of practitioners who most commonly refer and the film type and diagnostic entities that are most frequently submitted for oral radiologic consultation in Ontario, Canada. STUDY DESIGN: A total of 430 referral letters and responses from 2 Ontario oral radiologists from 2003 to 2005 were analyzed. Data collected included the specialty of the referring practitioner, the film type(s) submitted, the radiographic density of the entity of interest, and the interpretation by the radiologist. RESULTS: General practitioners (58.9%) and oral surgeons (21.5%) were the most frequently referring practitioner types, representing 1.2% and 17.1% respectively of each group practicing in Ontario. Also, 18.2% of oral pathologists referred. Panoramic radiographs (79.5%) were included in referrals more often than intraoral radiographs (46.0%). Of the entities, 37.0% were radiopacities, 27.4% were radiolucencies, and 13.5% had mixed radiopaque-radiolucent density. The radiologists interpreted normal features (55.6%) most often. CONCLUSION: Panoramic radiographs with normal findings were submitted to oral radiologists for consultation most frequently in Ontario.

A comparative study of the health care systems of Canada and Saudi Arabia: lessons and insights.

INTRODUCTION: Understanding the structure of a health care system is essential in improving public health policies and health outcomes. OBJECTIVES: To describe and compare the health care systems of Canada and Saudi Arabia; to discuss possible lessons that could be learned from both for policy-making purposes. METHODS: A comprehensive method was used to describe the national health care systems of both countries. For each country, the system is described by: context, ownership, delivery, financing, organisational structure, target groups, and comprehensiveness of services. RESULTS: In Canada, the Medicare system provides comprehensive medical services except for dental, optometric, chiropractic, pharmacologic and home care services. The dental care system is financed privately (94%) and is owned and delivered by private for-profit dental practitioners. In Saudi Arabia, the government sector is owned, delivered, and financed by the government and provides free comprehensive medical and dental services. The same services are provided by the private sector, but under governmental supervision. Among the relevant lessons: access to care, accountability, quality assurance, mix and reimbursement of providers. CONCLUSIONS: Canada can learn about different approaches to socialising the dental care system. Saudi Arabia can improve the implementation of quality assurance practices and management.

Lack of oral care policies in Toronto daycares.

OBJECTIVES: Currently, there is a deficit of information on policies regarding oral hygiene practices in Toronto daycares. It is unknown if any tooth-brushing programs are in existence and if children are permitted to follow professional advice on oral hygiene. The main objectives of this investigation were to a) determine the prevalence of oral care policies in daycares and b) examine the availability of resources. METHODS: Telephone interviews were conducted with daycare supervisors using a pretested questionnaire. Summary statistics and the chi-square test were used to analyze the results. RESULTS: Two hundred forty-nine questionnaires were completed (response rate of 99.6 percent), representing 38 percent of the total daycare population (650) in Toronto. Eighty-three percent did not have a policy on oral care and 11 percent would not cede to requests from parents or medical professionals to brush teeth. However, 50 daycares indicated that their centers used to have a tooth-brushing program, and most (79 percent) were open to establishing an oral care policy. Fifteen percent reported not having proper sinks for tooth brushing. CONCLUSIONS: Many daycares do not have a policy regarding oral hygiene. A policy that encourages and provides guidance on safe tooth-brushing procedures is needed and may improve the oral health of preschool children.

Introducing dental students to evidence-based decisions in dental care.

Practicing evidence-based dentistry is a process of lifelong and self-directed learning. Teaching evidence-based dentistry to dental students is the key to increasing the uptake of evidence-based treatments and practices in dentistry. This article describes the procedures undertaken to teach undergraduate dental students at the University of Toronto Faculty of Dentistry how to produce systematic reviews as a module in clinical epidemiology. Nine selected reports have been summarized as examples of the outputs of this module. At the end of the module, students are asked to participate in a survey and anonymously fill out a questionnaire to evaluate the module. Students' evaluation of the module in the 2005-06 (n= 64) and 2006-07 (n=57) academic years were extracted for data analysis. Overall, the majority of students found the module an enjoyable way of learning that has improved their ability to gather information, apply existing evidence to a clinical question, evaluate information, and further develop their communication skills. This module was also effective in raising students' awareness of the importance of evidence-based clinical practice. It is essential to establish the fundamentals of evidence-based practice during the undergraduate curriculum to assist dental students in learning the skills to practice evidence-based dentistry.

Structured or unstructured personnel interviews?

The challenge for health care managers is finding, hiring and retaining appropriately qualified and motivated employees. One useful method of gaining information about and insight into a candidate is interviewing, which can be classified as structured, unstructured or semi-structured. The disadvantages of unstructured interviews are reviewed; ways to enhance the psychometric properties of interviews by adding structure are reviewed and summarized; and the possible reasons for underutilization of structured interviews are explored.

Systematic review of the association between respiratory diseases and oral health.

BACKGROUND: The purpose of this review was to investigate evidence for a possible etiological association between oral health and pneumonia or other respiratory diseases. METHODS: The following data sources were used: Ovid MEDLINE (In-Process & Other Non-Indexed Citations, Daily Update, and OLDMEDLINE); Cumulative Index to Nursing & Allied Health Literature; Evidence Based Medicine of Cochrane Central Register of Controlled Trials; Cochrane Database of Systematic Reviews; Database of Abstracts of Reviews of Effects; EMBASE; Health and Psychosocial Instruments; HealthSTAR; International Pharmaceutical Abstracts; PubMed; and Google Scholar from the earliest record until July 2005. Studies were selected from randomized controlled clinical trials and longitudinal, cohort, case-control, and epidemiological studies. Searches were limited to English language and human studies. RESULTS: A total of 728 articles were searched for relevancy, determined by article title, abstract, and full copy, resulting in a yield of 19 studies that met our inclusion criteria. These articles were read and scored independently by the reviewers to obtain the evidence for this review: 1) the potential risk factors for pneumonia were identified as the presence of cariogenic and periodontal pathogens, dental decay, and poor oral hygiene in five studies; 2) a weak association between periodontal disease and chronic obstructive pulmonary disease (COPD) was identified in four poor to fair studies; and 3) 10 studies were retained providing evidence that interventions aiming to improve oral health reduced the progression or occurrence of pneumonia. CONCLUSIONS: 1) There is fair evidence (II-2, grade B recommendation) of an association of pneumonia with oral health (odds ratio [OR]=1.2 to 9.6 depending on oral health indicators). 2) There is poor evidence of a weak association (OR<2.0) between COPD and oral health (II-2/3, grade C recommendation). 3) There is good evidence (I, grade A recommendation) that improved oral hygiene and frequent professional oral health care reduces the progression or occurrence of respiratory diseases among high-risk elderly adults living in nursing homes and especially those in intensive care units (ICUs) (number needed to treat [NNT]=2 to 16; relative risk reduction [RRR]=34% to 83%).

Why do we need an oral health care policy in Canada?

Although health care is a right of citizenship, severe inequities in oral health and access to care persist. This paper provides information on the financing, organization and delivery of oral health services in Canada. It concludes that dental care has largely fallen out of consideration as health care. The increasing costs of dental insurance and disparities in oral health and access to care threaten the system"s sustainability. The legislation that allows the insured to receive tax-free care and requires all taxpayers to subsidize that expenditure is socially unjust. Unless an alternative direction is taken, dentistry will lose its relevance as a profession working for the public good and this will be followed by further erosion of public support for dental education and research. However, never before have we had the opportunity presented by high levels of oral health, the extensive resources already allocated to oral health care, plus the support of other organizations to allow us to consider what else we might do. One of the first steps would be to establish new models for the delivery of preventive measures and care that reach out to those who do not now enjoy access.

Is regular visiting associated with lower costs? Analyzing service utilization patterns in the first nations population in Canada.

OBJECTIVES: Using an administrative database of dental service records from the Non-Insured Health Benefits (NIHB) program of Health Canada for 1994-2001, the authors set out to test whether regular visitors had lower program expenditures. METHODS: The age-specific mean expenditures per client were compared among those with regular examinations in 8, 7 and fewer years. The study further examined the effect of regular visiting over the first 6 years on expenditures in the last 2 years. "Continuity of care" was measured by the numbers of consecutive years prior to 2000 in which clients had a regular examination. In a "gap analysis" individuals were classified according to the number of years prior to 2000 since they last had an initial or recall examination. Mean expenditures per client were analyzed by age group and type of service. FINDINGS: Over the 8-year period, clients with regular visits had the highest expenditures. In both the continuity of care and gap analyses, the findings were generally consistent; the more that clients visited over the first 6 years, the higher the expenditures in the final 2 years. Clients with more "regular" (initial and recall) examinations received a relatively standard, age-specific, pattern of service but incurred greater expenditures compared to clients with fewer regular, or longer gaps in, examinations. CONCLUSION: The observations of the authors in this client group do not support the thesis that regular visiting is associated with lower expenditures on dental care.

Prions in dentistry--what are they, should we be concerned, and what can we do?

OBJECTIVE: To briefly review the characteristics of prions, the risk of transmission and implications for infection control in dentistry. METHODS: The literature on prion disease in the context of dentistry up to March 2005 was reviewed using the PubMed, MEDLINE, Cumulative Index to Nursing & Allied Health Literature, Google Scholar databases and the Web sites of the departments of health of countries affected by the disease. RESULTS: The sporadic form of Creutzfeldt-Jakob disease (CJD) is the most common human prion disease; the mean age of those affected to date is 68 years, the mortality rate is 85% within 1 year, and the average death rate is 1 per million persons. Variant CJD (vCJD) affects people (mean age 26 years) with a history of previous extended periods of residence in certain countries, mainly in the United Kingdom. Currently, there is no evidence of human-to-human transmission of CJD or vCJD following casual or intimate contact or blood transfusion, nor is there evidence of iatrogenic transmission of vCJD in a health care setting. Furthermore, there is no evidence indicating increased occupational risk of CJD or vCJD among health workers or clustering of vCJD among people associated with a dental practice. The risk of transmission of prions through dentistry is unknown but is thought to be very low if appropriate infection control measures are taken. CONCLUSIONS: The theoretical risk of transmission of prion disease through dental treatment emphasizes the need to maintain optimal standards of infection control and decontamination procedures for all infectious agents, including prions.

Comparison of remifentanil with fentanyl for deep sedation in oral surgery.

PURPOSE: The aim of this study was to compare recovery for oral surgery patients given a deep sedation regimen of midazolam, propofol, and remifentanil with a standard control of fentanyl in place of remifentanil. MATERIALS AND METHODS: This investigation was designed as a randomized, prospective, single-blinded controlled study. Group 1, the control, received midazolam 0.03 mg/kg, fentanyl 1 microg/kg, and propofol initially at 140 microg/kg/min. Group 2 received midazolam 0.03 mg/kg, remifentanil: propofol (1:500) given at an initial propofol infusion rate of 40 microg/kg/min. Outcome measures included time to response to verbal command, Aldrete score = 9, Postanesthesia Discharge Scoring System = 7, and assessment by the Digit Symbol Substitution Test. RESULTS: Forty-seven subjects were entered in the study. Baseline findings were homogenous between the 2 groups. Subjects in group 2 recovered earlier (P < .005) and required less propofol for both the induction (0.8 +/- 0.4 versus 1.2 +/- 0.6 mg/kg; mean +/- SD, P < .01) and maintenance of deep sedation (46 +/- 9 versus 131 +/- 17 microg/kg/min; P < .005). There were minor differences in vital signs. CONCLUSIONS: This study demonstrated that this remifentanil regimen provided significantly more rapid recovery and used significantly less propofol compared with the fentanyl regimen.

Early childhood caries and infant oral health: Paediatricians' and family physicians' knowledge, practices and training.

OBJECTIVES: To assess the knowledge of early childhood caries and to examine the current preventive oral health-related practices and training among Canadian paediatricians and family physicians who provide primary care to children younger than three years. METHODS: A cross-sectional, self-administered survey was mailed to a random sample of 1928 paediatricians and family physicians. RESULTS: A total of 1044 physicians met the study eligibility criteria, and of those, 537 returned completed surveys, resulting in an overall response rate of 51.4% (237 paediatricians and 300 family physicians). Six questions assessed knowledge of early childhood caries; only 1.8% of paediatricians and 0.7% of family physicians answered all of these questions correctly. In total, 73.9% of paediatricians and 52.4% of family physicians reported visually inspecting children's teeth; 60.4% and 44.6%, respectively, reported counselling parents or caregivers regarding teething and dental care; 53.2% and 25.6%, respectively, reported assessing children's risk of developing tooth decay; and 17.9% and 22.3%, respectively, reported receiving no oral health training in medical school or residency. Respondents who felt confident and knowledgeable and who considered their role in promoting oral health as "very important" were significantly more likely to carry out oral health-related practices. CONCLUSION: Although the majority of paediatricians and family physicians reported including aspects of oral health in children's well visits, a reported lack of dental knowledge and training appeared to pose barriers, limiting these physicians from playing a more active role in promoting the oral health of children in their practices.

Developing management information from an administrative database of dental services: identifying factors that influence costs.

OBJECTIVE: We describe service patterns and compare changes in program expenditures with the Consumer Price Index over eight years in a dental program with a controlled-fee schedule offered to Canadian First Nations and Inuit people. METHODS: We obtained the computerized records of dental services for the period from 1994 to 2001. Each record identified the date and type of service, region and type of provider, age of the client and encrypted identifying information on clients, bands, and providers. We classified the individual services into related types (diagnostic, preventive, etc.). We aggregated the records by client and developed indices for the numbers of clients, mean numbers of services per client, cost per service, and prices. FINDINGS: Over the 8 years, 16.0 million procedures, totaling 811.8 million dollars, were provided to 538,034 different individuals, approximately 76% of the eligible population. Restorative procedures accounted for 36% of all expenditures followed by diagnostic (12.7%), preventive (12.2%), and orthodontic (8.9%) services. For much of the period, increases in program expenditures were exceeded by increases in the Consumer Price Index. This was consistent with fewer services per client, a less expensive mix of services, and relatively flat prices. However, in 2000 and 2001 higher prices and more clients resulted in increasing expenditures. CONCLUSIONS: Program expenditures were influenced by different factors over the study period. In the final two years, increasing expenditures were driven by price increases and increasing numbers of clients, but not by increasing numbers of services per client, nor a 'richer' mix of services.

Access and care: reports from Canadian dental education and care agencies.

Representatives of faculties of dentistry and agencies working to improve the oral health of groups with restricted access to dental care were invited to address the access and care symposium held in Toronto in May 2004. They told of their clients" sometimes desperate needs in graphic terms. The agencies" response ranged from simple documentation of the need, to expression of frustration with current trends and the apparent indifference of policy makers, to the achievement of some success in arranging alternative models of care. The presenters consistently identified the need to change methods of financing dental education and both the financing and models of care delivery to meet the needs of those with restricted access to oral health care.

The use of administrative databases to assess oral health care.

OBJECTIVE: We examined the potential for research using administrative databases containing dentists' claims to identify both the type of health services research questions addressed and the strength of the evidence that is achieved in such studies. METHODS: We searched Medline (1966 to March, 2003), retrieved additional reports from personal files, reviewed the literature cited in the relevant articles and conducted electronic searches on investigators' surnames. Information from relevant articles was abstracted into tables and the strength of the evidence for each was classified. RESULTS: Thirty-eight studies met our inclusion criteria. Researchers have used administrative databases of dental records to examine provider practices, the longevity or consequences of dental interventions, the prevalence of dental conditions, and patient factors that determined care, and to establish quality assurance criteria or standards of care. The strongest designs were prospective or case-control (Level II-2). CONCLUSION: Studies analyzing administrative databases have the advantage of size and economy but are subject to several threats to their validity and are seldom population-based. The strongest designs occurred with investigation of the longevity or consequences of care. Several studies demonstrated the benefit of linking the service data to patient or provider characteristics. The study of dentists' claims data appears under exploited, especially in the area of identifying and recommending changes in dental health care policies.

The influence of dental insurance on institutionalized older adults in ranking their oral health status.

To assess whether dental insurance influences how institutionalized older adults ages 65 and older rank their oral health status, a census survey was designed for residents of Durham's (Canada) Municipal Homes for the Aged. The odds ratio (OR) and the Cochran & Mantel-Haenszel's OR were used to estimate the crude and adjusted effect of dental insurance on oral health status, respectively. Overall, 64 percent participated in the interview. Oral health status was ranked as "good," "very good" or "excellent" by 57 percent of the participants. This ranking was clearly unrelated to the residents having dental insurance, as only 28 percent had dental coverage. Significant effect modifiers included age, dental status and whether the participant had visited the dentist within the last year. Dental insurance positively influenced how dentate participants ranked their oral health status (OR = 2.26; 95 percent CI = 1.19; 4.28). In edentulous participants, age and visiting the dentist within the last year modified the effect of dental insurance on oral health status. Having dental insurance reduced the odds of reporting "good," "very good" or "excellent" oral health (OR = 0.20; 95 percent CI = 0.08; 0.49) among the participants ages 85 and older who did not visit the dentist within the last year; however, the opposite was true for their younger counterparts who visited the dentist within the last year (OR = 7.20; 95 percent CI = 1.08; 47.96). In this population, therefore, dental insurance was associated with higher oral health status rank among the dentate, but its effect on the edentulous population depended on age and the pattern of visiting the dentist.

A macroeconomic review of dentistry in Canada in the 1990s.

OBJECTIVES: To document the trends in expenditures on dental health care services and the number of dental health care professionals in Canada from 1990 to 1999. METHODS: Information on dental and health expenditures, numbers of dentists, hygienists and dental therapists, and the population of Canada and the provinces were obtained from the Canadian Institute for Health Information; data on numbers of denturists were obtained from regional bodies and from Health Canada. Information on the costs of other disease categories was taken from studies by Health Canada (1993 and 1998). International comparisons were made on the basis of data published by the Organisation for Economic Co-operation and Development (OECD). Indices of change over the decade (in which the 1990 value served as the baseline [100]) were calculated. RESULTS: By 1999, the supply of all types of dental care providers had increased to 1 for every 904 people. Dental expenditures during the 1990s increased by 64% overall and by 49% per capita, a rate of increase that exceeded both inflation and costs of health care. Although the public share of dental costs decreased from 9.2% to 5.8%, the direct costs of dental care increased to rank second (6.30 billion dollars) after those for cardiovascular diseases (6.82 billion dollars). Among the OECD nations, Canada had the fourth highest per capita dental expenditures and the second lowest per capita public dental expenditures. CONCLUSIONS: The direct economic costs of dental conditions increased during the 1990s from 4.13 billion dollars to 6.77 billion dollars. Over the same period, the public share for expenditures on dental health care services declined.

Prevalence of dental caries among 7- and 13-year-old First Nations children, District of Manitoulin, Ontario.

PURPOSE: Dental caries is a disease that, although decreasing in the non-Aboriginal child population, remains high for Canadian Aboriginal and Native American children and adolescents. To address dental health issues in First Nations in the District of Manitoulin, Noojmowin Teg Health Centre initiated a multiphase collaborative research project with the department of community dentistry at the University of Toronto. The purpose of this paper was to identify the prevalence of dental caries in children 7 or 13 years of age and to compare these data with published data for the same age groups from other First Nations communities in Canada. METHODS: All children 7 or 13 years of age who were in elementary schools on a reserve in 7 First Nations communities were eligible for a dental health examination as part of the survey. Children attending school off the reserve in 6 of the communities were also eligible. RESULTS: A total of 66 children (56% 7-year-old children, 62% girls) were examined. The mean caries score (deft+ DMFT) for 7-year-old children was 6.2; the mean decayed, extracted, filled permanent teeth (DMFT) score for 13-year-old children was 4.1. Overall, 96% of children had 1 or more past or active carious lesion. CONCLUSION: Results indicate that dental caries is highly prevalent and increasing in severity in this population.