Development and preliminary evaluation of a new screening instrument for atypical odontalgia and persistent dentoalveolar pain disorder.

AIM: To develop and preliminarily evaluate a new screening instrument for atypical odontalgia (AO) or persistent dentoalveolar pain disorder (PDAP). To evaluate the instrument's performance in detecting AO/PDAP amongst a heterogeneous group of orofacial pain conditions and pain-free controls and empirically compare its performance with an established neuropathic screening instrument (S-LANSS), which is the best available standard. METHODS: The study design was cross-sectional; subjects recruited included a convenience sample of pain-free controls (n = 21) and four groups of orofacial pain conditions: AO/PDAP (n = 22); trigeminal neuralgia (n = 21); temporomandibular disorder (n = 41); and acute dental pain (n = 41). The instrument's internal reliability and factor structure were examined alongside its sensitivity and specificity and ROC-determined threshold score. RESULTS: The 9 AO/PDAP-specific items were found to moderately correlate with the S-LANSS (r = 0.58; P < 0.01). The 14-items of the full instrument were examined using exploratory factor analysis and reduced to ten items in a two-factor structure that explained 96% of the variance. This 10-item final instrument had a ROC area of 0.77 (95% CI: 0.67; 0.88), sensitivity of 77% (95% CI: 55; 92%), and specificity of 69% (95% CI: 60; 77%) with an intentionally higher false-positive rate than false-negative rate. In contrast, the S-LANSS exhibited sensitivity of 32% (95% CI: 14;55%) and specificity of 78% (95% CI: 70;85%) with less optimal false-positive versus false-negative rates. CONCLUSION: This preliminary study confirms the new screening instrument for AO/PDAP merits progression to field testing.

Dental pain in the medical emergency department: a cross-sectional study.

The aim of this study was to examine the number of patients attending a medical emergency department (MED) with dental problems over a three-year period. This cross-sectional study was carried out as part of a service evaluation. Data were collected via a database search of patient attendances at the MED using free text and the 10th revision of the International Statistical Classification of Diseases and Related Health Problems (ICD-10) for oral and dental diagnoses. Data were analysed using descriptive statistics, t-test and chi-squared tests. Over the three-year period, there were 2504 visits to the MED for dental-related complaints, accounting for 0·7% of all attendances. The majority of patients were male (53·9%), with a mean age of 29 (s.d. 19·4) years for men, and 32 (s.d. 19·7) years for females. The mean index of multiple deprivation per cent rank was 35·0%. The most common diagnosis was unspecified dental disorder. Ten per cent of dental attendances to MED were repeat attendances by the same patients. In conclusion, patient attendances at MED for dental problems account for 0.7% of all attendances. MED may not be the most appropriate place for these patients to attend, in terms of care pathways, and also for economic reasons. The reasons why patients attend MED for dental problems clearly warrant further research.

Self-management programmes in temporomandibular disorders: results from an international Delphi process.

Self-management (SM) programmes are commonly used for initial treatment of patients with temporomandibular disorders (TMD). The programmes described in the literature, however, vary widely with no consistency in terminology used, components of care or their definitions. The aims of this study were therefore to construct an operationalised definition of self-management appropriate for the treatment of patients with TMD, identify the components of that self-management currently being used and create sufficiently clear and non-overlapping standardised definitions for each of those components. A four-round Delphi process with eleven international experts in the field of TMD was conducted to achieve these aims. In the first round, the participants agreed upon six principal concepts of self-management. In the remaining three rounds, consensus was achieved upon the definition and the six components of self-management. The main components identified and agreed upon by the participants to constitute the core of a SM programme for TMD were as follows: education; jaw exercises; massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. This Delphi process has established the principal concepts of self-management, and a standardised definition has been agreed with the following components for use in clinical practice: education; self-exercise; self-massage; thermal therapy; dietary advice and nutrition; and parafunctional behaviour identification, monitoring and avoidance. The consensus-derived concepts, definitions and components of SM offer a starting point for further research to advance the evidence base for, and clinical utility of, TMD SM.

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.

Pain and problems: a prospective cross-sectional study of the impact of dental emergencies.

One-third of the population will only attend the dentist for an acute problem, often waiting a period of time before presenting. The objective of this study was to investigate the levels of pain in patients presenting for a dental emergency and the impact this had on their quality of life. Questionnaires were provided to adult patients attending dental emergency services over 1 week. Demographic and clinical details were collected. Quality of life was measured using EQ-5D-5L. Pain and the interference it caused were examined using the graded chronic pain scale. Data were analysed in STATA using descriptive statistics, Mann-Whitney and chi-squared tests. Results showed that majority of patients (64%) seen were male; the mean age was 36 (±14) years. Forty six per cent of patients reported having a general dental practitioner. One-third of the patients had attended this service previously for emergency care, and 13% consulted for the same problem. The mean duration of pain was 17·7 (±52·3) days prior to seeking care. The mean characteristic pain intensity was 53·6 (±23·6). The mean disability score was 43·4 (±33·6). The mean EQ-5D-5L score was 0·57 (±0·27). In conclusion, a large number of patients attend the emergency dental services despite being 'registered' with a general dental practitioner. A proportion of these individuals will re-attend for the same condition. Patients will often be in pain for over 2 weeks before attending, which may have a significant impact on their quality of life. Further research is warranted to investigate these care-seeking behaviours and patterns.

Perspectives on next steps in classification of oro-facial pain - part 1: role of ontology.

The purpose of this study was to review existing principles of oro-facial pain classifications and to specify design recommendations for a new system that would reflect recent insights in biomedical classification systems, terminologies and ontologies. The study was initiated by a symposium organised by the International RDC/TMD Consortium Network in March 2013, to which the present authors contributed. The following areas are addressed: problems with current classification approaches, status of the ontological basis of pain disorders, insufficient diagnostic aids and biomarkers for pain disorders, exploratory nature of current pain terminology and classification systems, and problems with prevailing classification methods from an ontological perspective. Four recommendations for addressing these problems are as follows: (i) develop a hypothesis-driven classification structure built on principles that ensure to our best understanding an accurate description of the relations among all entities involved in oro-facial pain disorders; (ii) take into account the physiology and phenomenology of oro-facial pain disorders to adequately represent both domains including psychosocial entities in a classification system; (iii) plan at the beginning for field-testing at strategic development stages; and (iv) consider how the classification system will be implemented. Implications in relation to the specific domains of psychosocial factors and biomarkers for inclusion into an oro-facial pain classification system are described in two separate papers.

Perspectives on next steps in classification of oro-facial pain - part 2: role of psychosocial factors.

This study was initiated by a symposium, in which the present authors contributed, organised by the International RDC/TMD Consortium Network in March 2013. The purpose of the study was to review the status of biobehavioural research - both quantitative and qualitative - related to oro-facial pain (OFP) with respect to the aetiology, pathophysiology, diagnosis and management of OFP conditions, and how this information can optimally be used for developing a structured OFP classification system for research. In particular, we address representation of psychosocial entities in classification systems, use of qualitative research to identify and understand the full scope of psychosocial entities and their interaction, and the usage of classification system for guiding treatment. We then provide recommendations for addressing these problems, including how ontological principles can inform this process.

Healthcare pathway and biopsychosocial impact of persistent dentoalveolar pain disorder: a qualitative study.

AIM: To examine persistent dentoalveolar pain disorder (PDAP) patients' reported experiences of the biopsychosocial impacts of the condition and its healthcare pathway. METHODS: Qualitative semi-structured interviews were conducted with a university-based cohort of PDAP patients. One interviewer used an open-ended, evolving, topic guide, and all interviews were recorded and transcribed verbatim. Data collection and analysis continued until saturation (n = 20). The principles of the constant comparative method were followed, and frameworks were used to help organize and analyse the data. RESULTS: PDAP exerts significant biopsychosocial impacts on the individual. These impacts occur across a wide variety of everyday activities including employment, personal relationships and social activities. The conceptualization and acceptance of PDAP are difficult for patients given the reinforcement of multiple ineffective dental treatments perceived as targeting the source of their pain. CONCLUSION: There is an urgent need for earlier identification of PDAP cases in order to minimize the negative biopsychosocial effects of multiple dental interventions incorrectly applied to treat the symptom of pain.

Timing interventions in relation to temporomandibular joint closed lock duration: a systematic review of 'locking duration'.

Temporomandibular joint (TMJ) 'closed lock' (CL) is a clinical condition causing TMJ pain and limited mouth opening (painful locking) that is mostly attributed to disc displacement without reduction (DDwoR), or less commonly to anchored disc phenomenon (ADP). Both conditions are described clinically as CL that can be 'acute' or 'chronic' depending on the duration of locking. There is, however, no consensus about the duration of locking that defines the acute state and its effect on the success of interventions. This review paper, therefore, aims to provide: (i) a narrative review of the pathophysiological need for early intervention in DDwoR and the clinical implications of acute/chronic CL stages on the management pathway; (ii) a systematic review investigating the effects of locking duration on the success of interventions for CL management. Electronic and manual searches until mid-August 2013 were conducted for English-language studies of any design investigating the effects of non-surgical and surgical interventions for acute or chronic CL (DDwoR or ADP). A total of 626 records were identified, and 113 studies were included. Data extraction and quality assessment were completed for all included studies. Included studies were, however, heterogeneous and mostly of poor-quality leading to contradictory and inconsistent evidence on the effect of the duration of locking on treatment outcomes. Future high-quality trials investigating the effect of CL duration on treatment outcome are needed. At present, early intervention by 'unlock' mandibular manipulation seems to be the most practical and realistic approach that can be attempted first in every CL patient as an initial diagnostic/therapeutic approach.

Filling in the Gaps. Making Sense of Living with Temporomandibular Disorders: A Reflexive Thematic Analysis.

INTRODUCTION: Persistent, painful temporomandibular disorders (TMDs) are challenging to manage and usually require the active engagement of patients. To achieve this, it is necessary to understand the complex and multifactorial nature of persistent pain. Many dental professionals have little education about persistent pain and may prefer to offer structural management and advice. This research aims to explore how people understand their persistent TMD and how this understanding has been influenced by their treatment providers. METHODS: Twenty-one people were recruited to represent a diversity of experience with persistent TMD. Interviews followed a semistructured topic guide. Themes were constructed through reflexive thematic analysis to represent how people made sense of their symptoms and the messages that they had picked up through their treatment journey. RESULTS: Participants described examples of conflicting opinions and inconsistent management recommendations. They rarely recalled collaborative discussions about the nature and complexity of their symptoms and different options for treatment. This experience is represented by a single theme, "a medical merry-go-round." Subthemes of "a medical journey to nowhere-participants' frustrated attempts to find medical management that will end their pain" and "is it me?-participants' questioning their role in persisting pain" kept participants on the merry-go-round, while symptom resolution and participants' emerging development of a holistic understanding of their TMD pain provided exit points. Understanding pain holistically tended to be helpful and typically occurred despite rather than because of the advice given in routine treatment settings. CONCLUSION: Participants in this study had not typically found their pain management within dental and medical settings to have helped them to construct meaning and understand their experiences of painful TMD. However, understanding symptoms holistically was experienced as beneficial. This study suggests that improved communication and signposting within services for persistent TMD may be beneficial to patients with TMD pain. KNOWLEDGE TRANSFER STATEMENT: Results of this study confirm that being offered a series of anatomically based, singular-cause explanations for persisting pain symptoms had been experienced as unhelpful by the participants who had sought help for their TMD. Participants highlighted the importance of accurate and collaborative communication and of dental professionals explicitly adopting and communicating a biopsychosocial understanding of pain to their patients who have TMD. Results highlight that some people can struggle to manage persisting pain with minimal support. Signposting patients to appropriate services and resources may help them to understand more about the nature of persistent pain and methods of managing it.

Barriers to Accessing Primary Dental Care in Adults with Alcohol Dependence: A Qualitative Study.

BACKGROUND: People with alcohol dependence (AD) frequently experience oral health problems, but their dental attendance is poor, with limited evidence to the reasons why from their perspective. OBJECTIVE: To explore perceived barriers, motivators, and facilitators to accessing primary dental care in people with AD. METHODS: Qualitative study consisting of remote one-to-one and group semistructured interviews with a convenience sample of adults with lived experience of AD in northern England. Data were audio-recorded, transcribed, and coded. A reflexive thematic analysis method was used; use of COM-B model informed data interpretation. RESULTS: Twenty adults with lived experience of AD participated in 18 one-to-one interviews and 1 group interview (of 3 participants). Barriers to access were fear and physical, social, and environmental factors (physical effects of AD, financial barriers, nonprioritization of oral health). Motivators to access were pain and prioritization of oral health. Facilitators to access were patterns of alcohol use (i.e., sobriety) and dental service provision within recovery services. CONCLUSIONS: Fear of "the dentist" is a major barrier to accessing dental care, and pain is the primary motivator, among people with AD, although neither are unique to this population. Fear and physical, social, and environmental barriers to access contribute to problem-oriented attendance, which negatively affect oral health outcomes. Opportunity to facilitate attendance increases when a person is in remission from AD through their physical capabilities improving. Increasing capability and opportunity can influence attendance beyond the automatic motivation of pain. Provision of dental care within recovery services could facilitate access to care. Understanding the "web of causation" is key to developing any intervention to improve dental access in people with AD. Further research is needed from the perspective of other adult populations with lived experience of AD, as well as of dental professionals, to gain deeper insight into barriers, facilitators, and possible solutions. KNOWLEDGE TRANSFER STATEMENT: The results of this study can help dental professionals understand factors affecting access to primary care in people with alcohol dependence to provide knowledge that may reduce stigma surrounding the disease. Results also demonstrate areas for intervention development for public policy.

Aspects of training in clinical medical sciences in dentistry (human disease): recent graduates' perspectives from a UK dental school.

Teaching the management of medical emergencies is an important part of most courses in Clinical Medical Sciences in Dentistry (Human Disease). The aim of this study was to examine which medical emergencies graduates from the School of Dental Sciences at Newcastle University had experienced 1 year after qualification and their perceptions of their ability to assess a patient's fitness for treatment or to manage a medical emergency. The study instrument was a computer readable questionnaire. Very few emergencies had been experienced in general practice at this stage of their career, but all respondents either strongly agreed or agreed that their training had adequately equipped them to assess a patient's medical history and deal with medical emergencies. There were, however, aspects of the course that upon reflection that clearly needed to be addressed, including the use of different teachers for aspects of the medical emergency teaching.

The Longitudinal Relationship between Jaw Catching/Locking and Pain.

Orofacial pain and joint-related dysfunction can negatively affect daily jaw function. A common cause for limitations in jaw movements is joint-related dysfunction such as various forms of catching and locking. However, knowledge is limited regarding the development and natural course of joint-related jaw dysfunction and its relationship to the onset and course of orofacial pain. Therefore, the aim was to evaluate the incidence, prevalence, and gender differences in jaw catching/locking over time and in relation to orofacial pain in the general population. Data from 3 validated screening questions on orofacial pain and jaw catching/locking were collected from all routine dental checkups in the Public Dental Health Services in Västerbotten, Sweden, from 2010 to 2017. Logistic generalized estimating equation was used to account for repeated observations and Poisson regression for incidence analysis. In total, 180,308 individuals (aged 5-104 y) were screened in 525,707 dental checkups. In 2010, based on 37,647 individuals, the prevalence of self-reported catching/locking was higher in women than in men (3.2% vs. 1.5%; odds ratio, 2.11; 95% confidence interval [CI], 1.83-2.43), and this relationship and magnitude remained similar throughout the study period. The annual incidence rate was 1.1% in women and 0.5% in men. Women were at a higher risk than men for reporting both first onset (incidence rate ratio [IRR], 2.29; 95% CI, 2.11-2.49) and persistent (IRR, 2.31; 95% CI, 2.04-2.63) catching/locking. For the onset subcohort (n = 135,801), an independent onset of orofacial pain or jaw catching/locking exclusively was reported by 84.1%, whereas a concurrent onset was reported by 13.4%. Our findings of higher incidence, prevalence, and persistence in women than in men indicate that the gender differences seen for orofacial pain are evident also for jaw catching/locking. The findings also suggest independent onset of self-reported catching/locking and orofacial pain, which reinforces the pathophysiological differences between these conditions.

Does empathy change in first-year dental students?

INTRODUCTION: Professionalism is a central tenet of the dental undergraduate curriculum. Dental undergraduate curricula and standards expect the dentist to put the patient's interests first, and in this respect, an important attitude is empathy. OBJECTIVE: This study examined the self-reported empathy levels of first-year dental students before and after an early analytical exposure to behavioural sciences and the clinical encounter. METHOD: First-year dental undergraduates were given an attitudinal questionnaire to complete before and after the behavioural science course. The questionnaire consisted of the HP version of the Jefferson Scale of Physician Empathy and the Patient-Practitioner Orientation Scale. Paired non-parametric tests and Spearman's Rho correlations, along with simple descriptive statistics, were used to test the statistical significance of observations. RESULTS: A total of 66 paired questionnaires were returned, giving a response rate of 75%. There were no correlations between age and total mean score of JSPE or PPOS, and no gender differences. There was a significant increase (P<0.01) in empathy as measured by the JSPE between pre- and post-course scores. The PPOS did not record any significant change in the sharing, caring or total scale scores pre- to post-course. CONCLUSION: The modified JSPE has potential utility in assessing the cognitive-affective aspect of dental students' empathy. Using the JSPE, short-term measurable empathy changes can be detected in first-year dental undergraduates after the structured and assessed analytical introduction to the clinical encounter and environment.

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.

Dyskeratosis Congenita and Squamous Cell Cancer of the Head and Neck: A Case Report and Systematic Review.

OBJECTIVES: Dyskeratosis congenita (DC) is a progressive congenital disorder that predisposes patients to squamous cell cancers (SCC) of the head and neck. We report a case of a patient who underwent primary osteocutaneous free flap for mandibular SCC followed by additional treatments for positive margins and discuss a systematic review on therapeutic management for this patient population. METHODS: Case report of a 39-year-old male with DC who underwent resection and reconstruction with a fibular free flap for mandible SCC, followed by revision surgery and adjuvant radiotherapy for positive margins. A systematic review was completed afterward with the following terms: "dyskeratosis congenita" AND "oral cancer" OR "head and neck" OR "otolaryngology" on Medline and Web of Science for articles between 1980 and 2021. In total, 12 articles were included that reported on DC and SCC in the head and neck. RESULTS: Of the case reports that were included in this review, half the patients had recurrence within 1 year of primary treatments. Only 2 patients did not require revision surgery, adjuvant, or salvage therapy. Half of patients that received radiation therapy had severe side effects. CONCLUSIONS: This is the largest review of DC and SCC in the head and neck. Based off our case report and review, these patients have aggressive disease that often requires multi-modality treatment. Consideration should be taken in regards to reports of side effects with radiation therapy.

Waterline Disinfectants Reduce Dental Bioaerosols: A Multitracer Validation.

Oral microbes are dispersed during dental treatment and reduction methods have been proposed, but dental unit waterline (DUWL) disinfectants have received little attention; specifically, the effect on viruses has not been studied. This study aims to 1) investigate the effect of DUWL disinfectants on viral dispersion in dental bioaerosols and 2) establish a dual-tracer system using live bacteriophage and fluorescein supported by optical particle measurement. Bacteriophage MS2 was used as a viral tracer and fluorescein as a fluorescent tracer. Validation experiments were conducted to exclude interference of one tracer with the other or of DUWL disinfectants on detection methods. Simulated "saliva" containing the tracers was infused into the mouth of a dental mannequin during 10-min dental procedures with an air turbine handpiece (n = 3 replicates). Aerosols and droplets were sampled in an enclosed dental operatory using air samplers and settlement onto sterile filter papers. Bacteriophage was quantified using plaque assays and reverse transcription quantitative polymerase chain reaction (RT-qPCR). Fluorescein was quantified fluorometrically. The effect of DUWL disinfectants on total aerosol concentration was assessed in separate experiments using an optical particle counter. DUWL disinfectants reduced bacteriophage viability, and interference between tracers was not observed. In simulated clinical procedures, the disinfectant ICX reduced bacteriophage detection substantially (P < 0.001; 2-way analysis of variance). MS2 RNA was detected in all experimental samples but not negative controls. Samples positive on RT-qPCR but not plaque assays may indicate that virions at distant sites are nonviable. Fluorescein tracer showed good agreement with the bacteriophage tracer. DUWL disinfectants designed for continuous presence in irrigants reduce the dispersion of viable virus in dental bioaerosols during simulated procedures. Their use may therefore be important for routine infection control and as a mitigation factor during infectious disease outbreaks. Future studies should explore this using a range of viruses and other microbes.

Dental Attendances to General Medical Practitioners in Wales: A 44 Year-Analysis.

One-third of the UK population is composed of problem-oriented dental attenders, seeking dental care only when they have acute dental pain or problems. Patients seek urgent dental care from a range of health care professionals, including general medical practitioners. This study aimed to identify trends in dental attendance at Welsh medical practices over a 44-y period, specifically in relation to dental policy change and factors associated with repeat attendance. A retrospective observational study was completed via the nationwide Secure Anonymised Information Linkage (SAIL) Databank of visits to general medical practice in Wales. Read codes associated with dental diagnoses were extracted for patients attending their general medical practitioner between 1974 and 2017. Data were analyzed with descriptive statistics and univariate and multivariable logistic regression. Over the 44-y period, there were 439,361 dental Read codes, accounting for 288,147 patient attendances. The overall attendance rate was 2.60 attendances per 1,000 patient-years (95% CI, 2.59 to 2.61). The attendance rate was negligible through 1987 but increased sharply to 5.0 per 1,000 patient-years in 2006 (95% CI, 4.94 to 5.09) before almost halving to 2.6 per 1,000 in 2017 (95% CI, 2.53 to 2.63) to a pattern that coincided with changes to National Health Service policies. Overall 26,312 patients were repeat attenders and were associated with living in an area classified as urban and deprived (odds ratio [OR], 1.22; 95% CI, 1.19 to 1.25; P < 0.0001) or rural (OR, 0.84; 95% CI, 0.83 to 0.85; P < 0.0001). Repeat attendance was associated with greater odds of having received an antibiotic prescription (OR, 2.53; 95% CI, 2.50 to 2.56; P < 0.0001) but lower odds of having been referred to another service (OR, 0.75; 95% CI, 0.70 to 0.81; P < 0.0001). Welsh patients' reliance on medical care for dental problems was influenced by social deprivation and health policy. This indicates that future interventions to discourage dental attendance at medical practitioners should be targeted at those in the most deprived urban areas or rural areas. In addition, health policy may influence attendance rates positively and negatively and should be considered in the future when decisions related to policy change are made.

Local Exhaust Ventilation to Control Dental Aerosols and Droplets.

Dental procedures produce aerosols that may remain suspended and travel significant distances from the source. Dental aerosols and droplets contain oral microbes, and there is potential for infectious disease transmission and major disruption to dental services during infectious disease outbreaks. One method to control hazardous aerosols often used in industry is local exhaust ventilation (LEV). The aim of this study was to investigate the effect of LEV on aerosols and droplets produced during dental procedures. Experiments were conducted on dental mannequins in an 825.4-m3 open-plan clinic and a 49.3-m3 single surgery. Ten-minute crown preparations were performed with an air-turbine handpiece in the open-plan clinic and 10-min full-mouth ultrasonic scaling in the single surgery. Fluorescein was added to instrument irrigation reservoirs as a tracer. In both settings, optical particle counters (OPCs) were used to measure aerosol particles between 0.3 and 10.0 µm, and liquid cyclone air samplers were used to capture aerosolized fluorescein tracer. In addition, in the open-plan setting, fluorescein tracer was captured by passive settling onto filter papers in the environment. Tracer was quantified fluorometrically. An LEV device with high-efficiency particulate air filtration and a flow rate of 5,000 L/min was used. LEV reduced aerosol production from the air-turbine handpiece by 90% within 0.5 m, and this was 99% for the ultrasonic scaler. OPC particle counts were substantially reduced for both procedures and air-turbine settled droplet detection reduced by 95% within 0.5 m. The effect of LEV was substantially greater than suction alone for the air-turbine and was similar to the effect of suction for the ultrasonic scaler. LEV reduces aerosol and droplet contamination from dental procedures by at least 90% in the breathing zone of the operator, and it is therefore a valuable tool to reduce the dispersion of dental aerosols.

Invited commentary: Issues with assessing competence in undergraduate dental education.

Competence of practising dentists is an issue that is being addressed in both the undergraduate and postgraduate environment in dental education. The Association of Dental Education in Europe has opened the debate further with guidelines for qualifying dentists in Europe. This puts further pressure on dental schools to produce graduates who are transparently competent. This invited commentary examines the differing concepts of competence and how they might be assessed in the undergraduate dental curriculum.