Do dental undergraduates think that Thiel-embalmed cadavers are a more realistic model for teaching exodontia?

INTRODUCTION: Teaching exodontia to novice undergraduates requires a realistic model. Thiel-embalmed cadavers retain the flexibility of the soft tissues and could be used to teach exodontia. OBJECTIVE: The objective was to determine whether Thiel-embalmed cadavers were perceived to be a more realistic model by undergraduates in comparison with mannequins. MATERIALS AND METHODS: Over a period of 4 years (2011-2014), students were randomly assigned into two groups: those taught exodontia on mannequins only (NT) and those who also experienced cadaveric teaching (T). This was followed by an assessment. RESULTS: There were 174 students in the T group and 108 in the NT group. Sixty-five per cent of the T group and 69% of the NT group provided feedback. Ninety-eight per cent (98%) felt that they had been advantaged by being included in the group compared with 95% in the NT who felt disadvantaged. The majority (98%) thought that using the cadavers was advantageous and gave a realistic feel for soft tissue management (89%) and that it was similar to managing a patient (81%). Self-reported confidence in undertaking an extraction was not different between the two groups (P=.078), and performance in the extraction assessment was not significantly different between the two groups over the 4 years (P=.8). CONCLUSION: The Thiel-embalmed cadavers were well received by the students who found it a more realistic model for exodontia than a mannequin, even though this did not impact on their performance in a following assessment. Future work on these cadavers may be expanded to include surgical procedures.

A national follow-up survey of UK graduates opinion of undergraduate oral surgery teaching.

INTRODUCTION: A national follow-up survey was undertaken to determine whether dental graduates from 2009 perceived that their undergraduate oral surgery education had equipped them for general dental practice 4 years after graduating. MATERIALS AND METHODS: Graduates from the same 13 United Kingdom dental schools who had taken part in the original survey were invited to take part in this follow-up online survey. Their contact details were identified via the general dental council register, social media and alumni groups. RESULTS: In total, 161 responded (2009b) which represents 16% of the graduates of the original survey in 2009a. A similar percentage of these respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practice (83% and 79% in 2009a and 2009b, respectively). Most respondents (99% in both years) reported confidence in undertaking simple forceps exodontia. Confidence in surgical exodontia was poor in both surveys, but one area that appeared improved in the follow-up related to the sectioning of teeth (84% in 2009b compared with 49% in 2009a). Areas of weakness identified in 2009 were reported to be improved in the follow-up. CONCLUSION: This follow-up survey supports the findings of the original survey. Future longitudinal studies would allow institutions to identify possible weaknesses in their curriculum and to track the career development of their graduates and facilitate robust data collection.

A national survey of UK final year students' opinion of undergraduate oral surgery teaching.

BACKGROUND: A national survey was undertaken to establish a baseline of our final year students' perception of how their undergraduate oral surgery education has equipped them for key areas of general dental practice. MATERIALS AND METHODS: Questionnaires were distributed to the 13 UK schools with final year students, towards the end of the academic year in 2009. The questionnaires were completed anonymously and were optically scanned. RESULTS: In total, 632 questionnaires were returned, which represents 66% of the students of the graduating year. The majority (83%) of the respondents perceived that the teaching in oral surgery had given them sufficient knowledge to undertake independent practise. Most respondents (99%) felt confident to perform forceps exodontia, but confidence in the various aspects of surgical exodontia was lower. A majority (83%) had experience of an outreach scheme performing forceps exodontia (75%) and surgical exodontia (16%) in this environment. Twenty per cent indicated a desire to undertake a career in oral surgery, 6% in oral and maxillofacial surgery and 35% in another speciality. CONCLUSION: This survey suggests that the majority of the students perceive that the oral surgery education has prepared them well for key areas of general practice. It also suggests that there is, however, a need to provide further improvement in the delivery of surgical skills and knowledge.

Dental student suturing skills: a multicentre trial of a checklist-based assessment.

BACKGROUND: The assessment of clinical skills is essential to determine whether an undergraduate is competent to perform the tasks outlined in the curriculum. Such assessments in dentistry have historically not been subjected to large scale validity and reliability testing due the relatively small student numbers at each institute. The aims of this study were to test the validity and reliability of a standardised, checklist-based, suturing objective structured clinical examination (OSCE) and then to perform a multicentre trial to determine its performance over a large cohort of students. MATERIALS AND METHODS: A total of seven UK schools agreed to take part in the trial. To test the validity and reliability of the checklist, the examiner at each institution reviewed and scored video footage of 10 students performing the assessment. Each institution then carried out the assessment providing a checklist score and a global score for each of their own students. RESULTS: The assessment was well received by the staff, with acceptable inter-examiner variability. In total, 496 students completed the suturing OSCE with a success rate of 81% with a variation between schools of between 66% and 96%. A significant correlation was found between the checklist score and the global score (r = 0.361, P = 0.000). No one item on the checklist was found to be a determinant factor in the outcome of the OSCE. CONCLUSIONS: This checklist-based assessment of suturing skills was found to have face and content validity. Its reliability was promising, but merits further investigation. There may be an argument for the standardisation of the assessment of this core surgical skill throughout several UK-based dental schools.

The retention of suturing skills in dental undergraduates.

BACKGROUND: The ability to place sutures is an essential skill in dentistry. In our institution, the introduction of a video teaching aid and a checklist-based assessment has improved the standardisation of teaching as well as the transparency and objectivity of the assessment of suture skills. The aim of this study was to determine whether this skill once acquired is retained in the short term. MATERIALS AND METHODS: The same cohort of 67 fourth-year students performed the same assessment at two different time points 2 months apart. The first was a formative assessment and the second was a summative assessment. Feedback was collected on both occasions. RESULTS: On the first sitting of the assessment, 93% of the students were successful compared with 79% on the second occasion. Student feedback was similar on both occasions with 77% and 75% reporting that they thought it was an easy exam. On the first occasion, 27% thought that it was a stressful examination compared with 43% on the second occasion, which may have affected their performance. CONCLUSIONS: These findings suggest that regular reinforcement is required to avoid deterioration of suturing skills even in the short term. This might involve exposing the students to surgery earlier in the course and introducing regular formative assessments which the students appear to associate with less stress.

A generic consensus assessment of undergraduate competence in forceps exodontia in the United Kingdom.

UNLABELLED: The assessment of competence in clinical skills has become more frequent in published healthcare curricula and syllabuses recently. There are agreed mechanisms for the assessment of competence in the post-graduate environment, but no consensus within the undergraduate curriculum. This paper seeks to develop an agreed generic checklist for the assessment of competence in forceps exodontia. MATERIALS AND METHODS: A modified Delphi process was undertaken with representatives from all UK dental schools (n = 13) to develop a generic checklist for the assessment of competence in forceps exodontia. A content analysis of the assessments employed by each school was used to help discussion and inform the Delphi process. RESULTS: Seven schools currently employ a summative assessment of competence in forceps exodontia, with the majority employing a structured clinical objective test (n = 6). From the seven assessments, there were a total of 29 putative items and 10 putative domains identified for a generic checklist. These were reduced to five domains and 19 items through the content analysis and Delphi process, and a generic overarching checklist was created. CONCLUSION: Using this generic checklist, it may now be possible to pool data inter-institution to perform more powerful analyses on how our students obtain, or fail to obtain competence in forceps exodontia.

The assessment of suturing skills of dental undergraduates.

INTRODUCTION: To improve the assessment of suturing skills, we firstly developed a checklist based assessment. As an aid to the teaching of suturing skills a video was subsequently developed. MATERIALS AND METHODS: To validate the checklist a cohort of 57 final year students were videoed performing the formative suturing assessment which was assessed by two examiners independently. Two cohorts of third year students took part in the formal assessment but only the second cohort of students would have access to the video. RESULTS: The first cohort of 58 third year students' success rate was 93% and 1 year later 94% of 53 third year students were successful. One hundred per cent of the first cohort and 98% of the second cohort thought that the exam was a fair assessment of suturing skills. The majority of students thought that the checklist was helpful (94% and 93%). However, 62% and 55% thought that the assessment was a stressful experience. However, only 80% of the first cohort compared with 98% of the second cohort thought that they could now place sutures in intra-oral wounds. CONCLUSION: Our findings suggest that checklist based assessments of suturing skills were well received by the students and improved the objectivity and transparency of the assessment process. Further work is required to determine if teaching initially on a tabletop model can be transferred to the dental clinical situation.

Oral surgery undergraduate teaching and experience in the United Kingdom: a national survey.

The aim of this work was to determine the structure, mode of delivery, mode of assessment and staffing of the oral surgery undergraduate curriculum within UK dental schools. A questionnaire was distributed by e-mail in January 2006 to each of the 15 dental schools with undergraduate dental degree programmes in Ireland and the UK. Those providing feedback then met to clarify any areas as required. Thirteen completed questionnaires were returned. There were a total of 55 academics involved in the teaching of oral surgery at these 13 institutions. Over the three clinical years the mean number of clinical sessions was 51. The mean staff student ratio for supervision of forceps exodontia was 1:5. On average 51 teeth were extracted by each student in the clinical years. The mean staff student ratio for surgical extractions was 1:2. The mean number of surgical extractions for each student was 6. All schools formatively assessed competency in forceps exodontia and 9 of 13 assessed surgical extractions. Summative assessment of exodontia was done in six schools and surgical extractions in 4 of 13 schools. All 13 schools deliver teaching programmes designed to meet the requirements of the frameworks governing the central curriculum. There were, however, variations between individual schools in the content and delivery of the oral surgery clinical teaching programmes. There were dramatic variations in the numbers of academic staff involved and some institutions relied on their NHS colleagues to deliver the clinical teaching.

UK national curriculum for undergraduate oral surgery subgroup for teaching of the Association of British Academic Oral and Maxillofacial Surgeons.

This article describes a curriculum in oral surgery for undergraduate dental education in the United Kingdom prepared by the Education Subgroup of The British Academic Oral and Maxillofacial Surgeons. This group is made up of representatives from each of the 13 UK Dental Schools, one Irish Dental School and one Post-graduate Institute. The document represents a group consensus of an undergraduate UK oral surgery curriculum that is founded on the frameworks outlined by the General Dental Council, the Quality Assurance Agency for Higher Education and the Association for Dental Education in Europe. Our curriculum document is more prescriptive than the information available in the aforementioned documents. It is based on UK undergraduate oral surgery experience and thus attempts to set achievable core competencies and, in a few areas, challenges the available curriculum and related documentation.

Interventions for the treatment of oral and oropharyngeal cancers: surgical treatment.

BACKGROUND: Oral and oropharyngeal cancers can be managed by surgery alone or with any combination of radiotherapy, chemotherapy and immunotherapy/biotherapy. Opinions on the surgical treatment, the optimal combinational therapy and the sequence of treatments in combinational therapy varies enormously. OBJECTIVES: To determine which surgical treatment modalities for oral and oropharyngeal cancers lead to the best outcomes compared with other surgical, radiotherapy, chemotherapy or immunotherapy/biotherapy combinations. SEARCH STRATEGY: Electronic search of the Cochrane Oral Health Group Trials Register, CENTRAL, MEDLINE, OLDMEDLINE, EMBASE, AMED and the National Cancer Trials Database. Reference lists from relevant articles were searched and the authors of eligible trials were contacted. Date of the most recent searches: July 2007. SELECTION CRITERIA: Randomised controlled trials of surgery alone or in combination with chemotherapy, radiotherapy or immunotherapy/biotherapy for the treatment of primary oral or oropharyngeal cancer or both. DATA COLLECTION AND ANALYSIS: A minimum of two review authors conducted data extraction. Risk ratios were calculated for dichotomous outcomes at different time intervals, and hazard ratios were extracted or calculated for disease-free survival, total mortality, and disease-related mortality. Additional information from trial authors was sought. Data on adverse events were collected from the trial reports. MAIN RESULTS: Thirty-one trials satisfied the inclusion criteria, only 13 of which were assessed as low risk of bias. Trials were grouped into 12 main comparisons. There were no trials that compared different surgical modalities of the primary tumour itself. However, there were a number of trials comparing different approaches to managing the cervical lymph nodes. The majority of treatment regimens under evaluation were surgery in combination with other modalities. As individual treatment regimens within each comparison varied, meta-analysis was inappropriate in most instances. Only two trials could be pooled, comparing concomitant radio/chemotherapy (with surgery) versus radiotherapy (with surgery). A statistically significant difference was shown for disease-free survival (hazard ratio 0.77, 95% confidence interval (CI): 0.64 to 0.92) and total mortality (hazard ratio 0.78, 95% CI: 0.64 to 0.95) in favour of the concomitant chemotherapy and radiotherapy (with surgery) arm. No other treatment regimens showed consistent statistically significant results across the outcomes measured. AUTHORS' CONCLUSIONS: There is some evidence that concomitant radio/chemotherapy (with surgery) is more effective than radiotherapy (with surgery) and may benefit outcomes in patients with more advanced oral and oropharyngeal cancers. As these trials were based on head and neck studies, future studies should evaluate this treatment regimen specifically in oral and oropharyngeal cancers separately and also address tumour staging and its impact on outcomes. In general, future studies are encouraged to evaluate site-specific and stage-specific data for oral and oropharyngeal cancers. Future trials should include health-related quality of life assessment as an outcome measure. There is a need for a consolidated standardised approach to reporting adverse events.

Extraction of RNA from archival tissues and measurement of thrombospondin-1 mRNA in normal, dysplastic, and malignant oral tissues.

Thrombospondin-1 (TSP-1) is an extracellular matrix glycoprotein implicated in the regulation of angiogenesis and tumour development. Our objectives were to ascertain the quantity and quality of RNA extracted from archival, formalin-fixed, paraffin embedded, oral tissues and their application in measuring the concentrations of TSP-1 mRNA in these tissues. We compared three techniques of isolation of RNA as well as related experimental variables. TSP-1 mRNA was measured in specimens of normal, dysplastic, and malignant oral tissues by real-time reverse transcriptase polymerase chain reaction (RT-PCR). RNA suitable for analysis by real-time RT-PCR was obtained by the three techniques tested, although the yield varied depending on the protocol used (range 0.2-3.6 microg/mm(3)). The mean (S.D.) concentrations of TSP-1 mRNA relative to 18S were 21.1 (7.2) in normal oral tissues (n=9), 11.0 (8.2) in dysplastic tissue (n=8) and 7.3 (5.3) in carcinomatous tissue (n=17). The difference between normal and carcinomatous specimens was significant (p=0.01). This reduction in expression of TSP-1 mRNA from normal to dysplasia to carcinoma may favour the angiogenic drive that accompanies the development of oral tumours.

Vascularity and expression of vascular endothelial growth factor in oral squamous cell carcinoma, resection margins, and nodal metastases.

The role of vascularity as a predictor of the likelihood of lymph node metastases in oral cancer is not clear. To that end, the vascularity and expression of vascular endothelial growth factor (VEGF) was assessed at three specific regions: the tumour (inside and around the tumour); the resection margin; and the regional lymph nodes. Formalin-fixed paraffin-embedded specimens from 26 oral cancers (11 with no involved nodes and 15 with involved nodes) were stained immunohistochemically and examined. Staining for VEFG was significantly greater in the tumour than in the other sites. No significant differences were found in the intensity of staining in the primary tumour, resection margins, or nodes between cases in which the nodes were involved and in which they were not involved. We found no correlation between vascularity and VEGF staining, suggesting that VEGF is not the primary or only stimulator of angiogenesis in oral cancer. Greater understanding of the mechanisms of metastasis will lead to new treatments. The evidence that is accumulating for oral cancer suggests that such treatments may be better targeted at preventing lymphatic spread, rather than vascular spread.

Indications for and anticipated difficulty of third molar surgery: a comparison between a dental hospital and a specialist high street practice.

OBJECTIVE: To investigate the indications for and anticipated difficulty of third molar surgery between two different referral settings. DESIGN: A prospective study involving completion of a proforma pre- and post-operatively. SETTING: A dental teaching hospital and a specialist surgical dentistry practice in 2003. SUBJECTS AND METHODS: Patients referred for the assessment of their third molars were recruited. Details of the clinical and radiographical assessment for each patient were recorded pre-operatively and the extent of surgery required post-operatively. RESULTS: The main indication for referral for third molar extraction was pericoronitis in both centres. A larger number of patients were assessed and treated in a shorter period of time at the surgical dentist compared with the dental hospital. The surgical dentist was accurate in his assessment of the difficulty of surgery 96% of the time compared with 66% for the dental hospital staff. CONCLUSIONS: This study highlights the benefits for patients in being treated by a surgical dentist. As dental students require exposure to surgical dentistry in order to attain a level of competence, a reduction in the number of patients being referred to dental hospitals may impact upon students' ability to both assess and perform surgical procedures. This may mean that undergraduates will be less able to fulfil the recommendations of the General Dental Council. An outreach programme for final year dental students to surgical dentistry practices would benefit all concerned.

The effect of the antibody used and method of quantification on oral mucosal vascularity.

A vast literature exists on angiogenesis particularly with regard to understanding tumour growth and development. This is no less true for oral cancer, where slight variations in protocols may invalidate comparison between studies. The influence of tissue processing, and the specific antibody and method of quantification used to identify blood vessels was assessed with respect to oral mucosal vascularity. The angiogenic profile of 20 frozen sections of clinically normal oral mucosa were compared with 16 paraffin-embedded specimens. Eight of the frozen specimens had matched paraffin-embedded tissue. Vascular antigens were identified immunohistochemically using four antibodies and blood vessel density was measured by three methods. CD31 and von Willebrand's factor (vWF) counts were higher than alpha-smooth muscle actin and alphanubeta3. Results for CD31 were higher in frozen tissue than paraffin-embedded tissue. Significantly more CD31-positive vessels were found in frozen tissue in the cohort of matched samples. For paraffin-embedded tissue vWF gave higher values for vascularity than CD31. The variation in antibody reaction to these markers of blood vessels suggests that the antibody employed and method of fixation is more important than the method of quantification used. Comparison of the results for fresh frozen tissue and paraffin-processed tissue suggests that this is acceptable for vWF but not for CD31.

Evidence for a field change effect based on angiogenesis in the oral mucosa? A brief report.

The concept of field cancerisation was proposed to explain the development of second primary tumours in the upper aerodigestive tract. The formation of new blood vessels (angiogenesis) has been shown to accompany oral disease progression, however, little is known about its potential role as an indicator of field cancerisation. The aims of this study were to compare the angiogenic profile of normal oral mucosa from oral cancer patients with that sampled from cancer-free patients to seek evidence for differences that might be termed a field change. Oral mucosal tissue (NC) was obtained from 25 oral cancer patients from a site at least 1 cm distant from the primary tumour and was compared with normal oral mucosa (NN) from a further 20 non-cancer patients. The vascularity of the tissue was investigated immunohistochemically using four antibodies and three methods of quantitation. Vascularity was significantly higher in the NC group than the NN with all four markers (p<0.01). Significantly higher indices of vascularity were found for patients who were smoker/drinkers in the NC group (p<0.05). The increased vascularity may provide a rationale for anti-angiogenic drug therapy for tertiary prevention.

Development of a structured clinical operative test (SCOT) in the assessment of practical ability in the oral surgery undergraduate curriculum.

Competence in undergraduate oral surgery involves assessment of the students' knowledge, practical skill and attitude. The assessment of practical skills can be achieved using a formative assessment method such as the structured clinical operative test (SCOT) which uses a checklist for the assessment of a clinical task. The aim of this study was primarily to determine whether SCOTs could be integrated into the oral surgery undergraduate course, and secondarily to collect feedback from both the students and the staff on this assessment. A validated checklist was used by trained examiners to assess the performance of 49 students in their second clinical year undertaking simple exodontia. Feedback was collected from the students by questionnaire and from the staff by interview. The SCOT was well received by both students and staff. The main problem highlighted by the students was the perceived inter-examiner variability and by the staff, the disruptive effect on the clinics. The checklist must be objective enough to prevent misinterpretation. Despite these limitations, the SCOT provides a more objective assessment and serves to highlight weaker students, allowing them to be targeted for closer supervision and instruction as well as providing the students with a tool to measure their progress in oral surgery. The use of peer assessment by students may alleviate the burden on the staff.

Vascular endothelial growth factor (VEGF) expression in oral tissues: possible relevance to angiogenesis, tumour progression and field cancerisation.

The aim of this study was to assess whether vascular endothelial growth factor (VEGF) expression in oral tissues is associated with angiogenesis, disease progression or field cancerisation. Vascularity and VEGF immunoreactivity were quantified in 68 archival specimens including normal oral mucosa (NOM), dysplasia (DYS) and squamous cell carcinoma (SCC). Vascularity increased significantly with disease progression; it was also higher in NOM adjacent to SCC than in NOM from healthy tissue, suggesting an association with field cancerisation. VEGF expression in epithelial cells was evaluated using two antibodies and three indices. VEGF indices and vascularity were not directly correlated. The expression of VEGF was similar in all DYS and NOM specimens, whether or not adjacent to a concurrent lesion. A comparison of SCC with NOM or DYS led to opposite results, depending on the VEGF antibody and index used. We conclude that VEGF expression in the oral mucosa may play a physiological role, but does not appear to be associated with angiogenesis, field cancerisation or transition to dysplasia. Further studies concerned with tumour development require examining specific VEGF isoforms and standardisation of the methodology.

Expression of vascular endothelial growth factor in normal and tumour oral tissues assessed with different antibodies.

Expression of vascular endothelial growth factor (VEGF) in oral tissues was assessed using different antibodies. Quantitative and topographical differences were observed between paraffin and cryostat sections. Two polyclonal antibodies (PC36, PC37) differing in their cross-reactivity with VEGF121 (not recognized by PC36), were used to stain serial cryostat sections of normal oral mucosa (n = 8) and squamous cell carcinoma (n = 7). The expression of VEGF in the epithelium was overall higher with PC37 than with PC36, the difference being significant in normal oral mucosa (p = 0.001) but not in squamous cell carcinoma samples (p = 0.094). With PC36, VEGF expression was significantly higher in squamous cell carcinoma than in normal oral mucosa specimens, whereas the opposite was true with PC37. Our results suggest that the relative levels of isoform 121 to that of 165 (and possibly others) may be different in the tissues examined, with VEGF121 preferentially expressed in normal oral mucosa. Previously published conflicting results may, therefore, be due to the presence of variable ratios of VEGF isoforms in the tissues examined, combined with differences in the cross-reactivity of the antibodies used. VEGF isoforms 121, 165 and (for the first time) 189 were detected in two frozen oral tissues by polymerase chain reaction amplification. Quantification of specific VEGF isoforms will be required in future studies concerned with the clinical value of VEGF expression.