Undergraduates' self-reported clinical experience, confidence and perspectives of hospital and outreach paediatric dentistry: a three-year multi-centre evaluation.

A variety of educational approaches exist within U.K. dental schools, and institutions are constantly striving to improve the quality of their graduates. This study aimed to evaluate the self-reported confidence in, and clinical exposure to, paediatric dentistry at three U.K. dental schools (Liverpool, Manchester and Sheffield) over a three year period. Seventy-five percent of final year BDS undergraduates at the three dental schools completed an anonymous questionnaire capturing student self-reported clinical experience in seven core paediatric dentistry treatment skills, both in hospital and outreach settings. Visual analogue scales were used to record self-assessed confidence levels in aspects of paediatric dentistry and students were also asked to provide a written reflection of both their hospital and outreach placements. The results revealed that despite the variety of educational approaches taken, undergraduates reported very similar levels of clinical experience and confidence. Significant interschool differences in student experience were found with respect to the management of carious primary molars, believed to be a result of individual schools favouring different treatment regimes. Although outreach placements were seen as essential for gaining adequate student experience, the need to improve the consistency of teaching between hospital and outreach centres was highlighted. The study also emphasises the need to take care when using clinical targets in undergraduate teaching and identifies the potential benefits of undergraduate training in inhalation sedation. Finally, despite changes to the paediatric programmes with respect to dental trauma management, students remained lacking in confidence suggesting the need for further development.

Undergraduate experience and self-assessed confidence in paediatric dentistry: comparison of three UK dental schools.

Previous studies have suggested that dental students may not receive sufficient clinical experience in core paediatric dentistry skills. This study aimed to compare dental undergraduates' self-reported experience and confidence in paediatric dentistry within three UK dental schools (Liverpool, Manchester and Sheffield). In April/May 2009, 147 final year dental students completed an anonymous questionnaire which captured their experience of seven core clinical skills in both hospital and outreach settings. A visual analogue scale was also employed to record perceived levels of confidence for six generic activities including: examination, diagnosis and treatment planning; patient selection for treatment under general anaesthesia; operative dentistry; preventive dentistry; management of dento-alveolar trauma, and provision of routine care for children on qualification. The key finding was that Liverpool, Manchester and Sheffield dental students received comparable clinical experiences in paediatric dentistry, which appeared to satisfy the requirements of the General Dental Council's The first five years. One hundred percent had carried out fissure sealants and restorations, and 87-98% had experience of extractions. Outreach placements were crucial in ensuring students had sufficient opportunity to undertake core skills, notably extractions and pulp therapies. All students reported a lack of confidence in dental trauma management which warrants greater emphasis in the undergraduate curriculum.

An urgent referral of a suspected case of child abuse.

A 3-year-old girl was referred to the unit of paediatric dentistry by her dentist with regard to a metal nail lodged in the alveolus above 53. The child's mother was making allegations of child abuse against the child's father. This case describes the processes that were followed in order to reach a diagnosis and safeguard the child. This case also highlights the need to fully investigate all cases of reported or suspected abuse and to follow proper procedures to ensure the interests of the victim and accused are protected.

The views of dentists on their participation in a primary care-based research trial.

AIMS: To determine the attitudes and opinions of dentists undertaking research in primary care dental practices, about the value of research in primary care. METHOD: The data were collected during a face-to-face interview utilising a schedule of open and closed questions, which were used to guide the interview. RESULTS: Twenty-seven of the 40 primary care dentists (67.5%) who had participated in a five-year primary care clinical trial completed the interview. All the respondents believed that primary care research was important and should be of relevance to their practice, but only 12 (44%) thought it was important they carried out this research. The majority (96%) of respondents felt it did not pay financially to do research as a primary care practitioner and 12 (44%) thought research in primary care was too time consuming, but 25 (92%) were prepared to get involved in a primary care research group. Five (56%) salaried service (SS) practitioners and 14 (78%) general dental services (GDS) dentists felt they did not have enough experience, skills or knowledge to conduct their own research. Significantly more salaried dentists compared with GDS dentists felt adequately supported to do primary care research. CONCLUSION: Future research in primary care should be focused on topics primary care practitioners feel of use to their clinical practice. A method of funding practitioners and providing time for them to complete research away from their clinical duties is necessary. There is a need for collaborative working with an academic institution, which can provide training and academic support for practitioners.

Distress related to dental extraction for children under general anaesthesia and their parents.

AIM: The aims of this study were to observe levels of distress in children and their parents before and after extractions under general anaesthesia (GA) and to assess the effect of age, gender and the number of extractions on distress. DESIGN: a randomized comparative trial. Setting University Dental Hospital of Manchester. SUBJECTS AND METHODS: Two hundred and one children, together with their parents took part in this study. Immediately before GA, the Modified Child Smiley Faces Scales (MCSFS) and Modified Adult Smiley Faces Scales (MASFS) were completed by a trained observer for children and accompanying parents respectively, and again on recovery from anaesthesia and 15 minutes postoperatively. RESULTS: There were generalised increases in mean distress scores for children when comparing the pre-operative with the postoperative scores. However, mean distress scores for parents reduced at recovery and 15 minutes postoperatively and were less than the mean distress scores for children. There was no correlation between the child and parent distress scores preoperatively, postoperatively and 15 minutes postoperatively. There were significant increase in median distress scores for younger children compared to the older children at recovery and 15 minutes postoperatively (P0.05). Children who had 8 - 14 teeth extracted demonstrated higher levels of distress than those who had 1 - 7 teeth extracted (P0.05). CONCLUSION: Extraction of teeth under general anaesthesia does produce distress in children and their parents. Child and parental distress were not related. Both age and number of teeth extracted appear to influence the level of distress in children.

The use of general anaesthesia for the extraction of children's teeth. Results from two UK dental hospitals.

AIM: To study the reasons forgiving children a general anaesthetic (GA) for the extraction of teeth, in two different paediatric dentistry centres and to compare them with draft guidelines disseminated for discussion by the British Society of Paediatric Dentistry (BSPD). METHODS: Data were collected on children who required GA extractions over a two month period (1st may to 30th June 2004) at the Paediatric Dental Units of Liverpool University Dental Hospital (LUDH) and the University Dental Hospital of Manchester (UDHM). The information collected included date of birth, gender, date of referral, date of assessment and date of GA. The reason for the GA was noted in terms of the proposed BSPD guidelines for short GA. RESULTS: A total of 264 and 268 children required extractions under GA at LUDH and UDHM respectively. At LUDH the main reason in 189 (72%) children was severe pulpitis requiring immediate relief of pain where a child does not have the intellectual maturity to cope with treatment under local analgesia (LA). This was followed by failed extractions under LA in 53 (20%) children. This reason is not listed under the proposed BSPD guidelines. At UDHM the main reason for GA in 114 (42%) children was symptomatic teeth causing pain in more than two quadrants (or in two quadrants necessitating the use of bilateral inferior dental blocks). CONCLUSIONS: There were differences in the clinical rationale for GA between children attending the two centres. Further information is needed to refine the proposed guidelines on the use of GA for dental extractions in paediatric dentistry. The guidelines need to be flexible and updated to reflect changes in practice and service provision.

Intraoperative local anaesthesia for paediatric postoperative oral surgery pain--a randomized controlled trial.

The aim of this study was to improve the pain experience for children following oral surgery under general anaesthesia. To this end, the efficacy and safety of intraoperative local anaesthetic (2% lidocaine with 1:200,000 epinephrine) for postoperative pain control was investigated. In a randomized controlled trial, 142 patients aged 12 years or less, who were scheduled for dental extractions under general anaesthesia, received local anaesthesia or saline intraoral injection after induction of anaesthesia. There was statistically no significant difference between groups for pain scores recorded preoperatively, on waking, at 30 min, at 24h, or for distress scores recorded preoperatively, on waking and at 30 min. 'Severe' pain scores were recorded for 13% of treatment and 12% of control patients and 'very severe' for 13% of treatment and 10% of control patients on waking. These rates were similar at 30 min but reduced at 24h. Lip/cheek biting injuries occurred in one control and three treatment patients. Intraoperative local anaesthesia has been found to be effective for pain control following a range of other surgical procedures, but we did not find it to be effective in reducing postoperative pain or distress in children after oral surgery. Reasons may include unfamiliarity with altered orofacial sensation.

The frequency of repeat general anaesthesia for teeth extractions in children.

AIM: The purpose of this study was to determine the frequency of repeat extractions under general anaesthesia (GA) in children. METHODS: The dental hospital records of patients attending for outpatient GA extractions at Liverpool University Dental Hospital, Liverpool, UK, between January and March 2003 were examined retrospectively. A data collection form was used to record the relevant information. RESULTS: A total of 278 patients with a mean age of 6.5 years (SD = 2.2 years) were seen for GA extractions. Of those, 33 patients (11.9%) with a mean age of 4.9 years (SD = 2 years) at the time of their initial GA had had a previous or would undergo a subsequent episode of GA extraction. The mean interval between repeat GA was 2.3 years (SD = 1.6 years). Fifteen cases (45.5%) had the repeat GA within 2 years. Radiographs were available as part of the assessment process for 84 (34.3%) of the 245 patients who had had a single episode of GA. However, of the 33 patients who had had a repeat GA, only seven (21.2%) had radiographs available at the time of the initial GA. Regarding the number of teeth extracted, a significant difference (P < 0.01) was found between the number of teeth extracted in patients who had had a single GA (mean = 4.6, SD = 2.5), compared with those extracted at the initial GA for the repeat GA group (mean = 3.2, SD = 2). CONCLUSION: The frequency of repeat GA is relatively low, but there is a need for appropriate treatment planning incorporating the use of radiographs to reduce this even further.

Establishment and evaluation of a trauma clinic based in a primary care setting.

OBJECTIVES: The aim of this study was to establish and evaluate a referral centre for the treatment of children with traumatized teeth in an area remote from a dental hospital. SETTING: The study was conducted in a Community Dental Service clinic in Cheshire, UK. METHODS: A dentist from the Cheshire Community Dental Service was trained in the treatment and management of traumatized teeth. Invite referrals to the trauma clinic in a health centre. The number and types of patients referred and treated at the trauma clinic were monitored. In addition, the parents of referred children and referring dentists were asked to comment on the acceptability of the service. RESULTS: During the first 12 months, 49 patients with 74 traumatized teeth were referred to the trauma clinic. The majority of the patients were referred by their dentist because problems arose following their initial management. Both parents and referring dentists were very satisfied with the service. CONCLUSIONS: The trauma clinic fulfilled a clinical need, and was well received by the parents of children referred to the clinic and by the local dentists.

A double-blind randomized controlled trial investigating the effectiveness of topical bupivacaine in reducing distress in children following extractions under general anaesthesia.

OBJECTIVE: This study was designed to investigate the effectiveness of topical bupivacaine (0.25%) in reducing postoperative distress following extraction of teeth under general anaesthesia in children. DESIGN: The study was a double-blind randomized controlled trial. SETTING: The study was conducted in a dental hospital. SAMPLE: The sample comprised 135 children aged between 2 and 12 years of age who were undergoing outpatient general anaesthesia for simple dental extractions. METHODS: The children were randomly allocated to one of two groups: the bupivacaine group (the study group) comprised 68 children whilst the sterile water group (the control group) comprised 67. Following the extraction of their teeth, children had swabs soaked in the appropriate solution placed over the exposed teeth sockets. A five-point face scale was employed by an independent observer to evaluate the distress for each child. Evaluation of distress was made preoperatively, on recovery from the general anaesthetic, and again, 15 min following recovery from the anaesthetic. RESULTS: There were no statistically significant differences between the mean distress scores for the bupivacaine and sterile water groups preoperatively, postoperatively or 15 min postoperatively. For both groups, however, there were significant increases in distress scores between the preoperative and 15 min postoperative assessment scores. CONCLUSION: Extraction of teeth under general anaesthesia does cause distress in children. There is no evidence that topical bupivacaine reduces this distress when compared to sterile water.

The development of referral guidelines for dentists referring children for extractions under general anaesthesia.

OBJECTIVE: To develop a set of guidelines for referral of children for simple extractions under general anaesthesia and to determine if services providing general anaesthetic extractions comply with the guidelines. DESIGN: The guidelines were developed with reference to published literature and experts in the field. Patient's records were used to determine the compliance with the guidelines. SETTING: Community dental services in the North West of England in 2000. SUBJECTS: One hundred and ninety six sets of patient records of children attending to have teeth extracted under general anaesthesia were studied. RESULTS: The mean age of the 196 children was 6.8 years (SD = 2.5 years) and ranged from 2.7 to 15.8 years. Caries was the prime reason for extractions (182; 93b). Of the 196 children who received a general anaesthetic, 103 (53%) dentists had complied with the general anaesthetic referral guidelines whilst 93 (47%) had not. There was wide variation in compliance across 11 trusts in the North West of England. The lowest compliance was 25% and the highest 93%. CONCLUSION: This study has demonstrated that there can be considerable agreement amongst a group of experts on what constitutes clear justification for extracting teeth under general anaesthesia. However there can be marked variation in compliance with these guidelines.

Good occlusal practice in children's dentistry.

The difference between paediatric dentistry and most other branches of dentistry is that in the child the occlusion is changing. Consequently 'Good Occlusal Practice' in children is a matter of making the right clinical decisions for the future occlusion. The clinician needs to be able to predict the influence that different treatment options will have on the occlusion when the child's development is complete.

Inhalation sedation: a viable alternative to general anaesthesia?

This paper reports three cases in which young children were treated successfully using inhalational sedation instead of general anaesthesia.

The use of tricalcium phosphate to preserve alveolar bone in a patient with ectodermal dysplasia: a case report.

The prosthodontic management of the child with ectodermal dysplasia is made difficult because of the under-development of the alveolar ridges. This paper describes a case where tricalcium phosphate was placed in sockets immediately following the extraction of the primary incisor teeth to help maintain alveolar bone width, offering a valuable alternative treatment option in the prosthodontic management of the child patient with ectodermal dysplasia.

Dentinal dysplasia type I: report of a case.

A case of dentinal dysplasia type I is presented. This rare hereditary disturbance of dentine is characterized by short-rooted teeth with sharp conical apical constrictions, aberrant growth of dentine in the pulp chamber leading to reduced pulp space in permanent teeth and total pulpal obliteration in the primary dentition. Clinical, radiographic and histopathological material from a 7-year-old boy, showing the typical features of this disorder in which teeth are prematurely lost through periapical abscesses, cysts or spontaneous exfoliation, is described. A review of the theories of pathogenesis of this condition is included. Management of patients with dentinal dysplasia is difficult and a discussion of the shortcomings of various treatment strategies, including conventional endodontic therapy, periapical curettage and retrograde root filling, and a preventive regimen, are discussed. In this case, despite diagnosis being made at an early age and the provision of regular dental care, the patient is now losing teeth because of spontaneous abscess formation.

A clinical guide to the endodontic treatment of non-vital immature permanent teeth.

A meticulous clinical technique is required for the successful endodontic treatment of non-vital immature permanent incisors. This paper describes the clinical procedures used to produce a hard tissue barrier in the open apex against which a gutta percha and zinc oxide-eugenol root filling is condensed.

The clinical use of the Nd:YAG laser in paediatric dentistry for the removal of oral soft tissue.

This article considers the clinical use of the Nd:YAG laser for soft tissue surgery in paediatric dentistry. If the claims made about its performance and properties are true then the Nd:YAG laser should be a very useful additional clinical tool for dentists treating children.

Evidence-based research in the primary dental care setting.

Evidence based practice is now recognised as an important topic for all health professionals, and rightly so. It is essential that clinical procedures we offer to our patients or drugs that we prescribe have been scientifically proven to be of benefit.