Mobility in Community Dwelling Older Adults: Predicting Successful Mobility Using an Instrumented Battery of Novel Measures.

Mobility in older adults is associated with better quality of life. However, evidence suggests that older people spend less time out-of-home than younger adults. Traditional methods for assessing mobility have serious limitations. Wearable technologies provide the possibility of objectively assessing mobility over extended periods enabling better estimates of levels of mobility to be made and possible predictors to be explored. Eighty-six community dwelling older adults (mean age 79.8 years) had their mobility assessed for one week using GPS, accelerometry and self-report. Outcomes were: number of steps, time spent in dynamic outdoor activity, total distance travelled and total number of journeys made over the week. Assessments were also made of personal, cognitive, psychological, physical and social variables. Four regression models were calculated (one for each outcome). The models predicted 32 to 43% of the variance in levels of mobility. The ability to balance on one leg significantly predicted all four outcomes. In addition, cognitive ability predicted number of journeys made per week and time spent engaged in dynamic outdoor activity, and age significantly predicted total distance travelled. Overall estimates of mobility indicated step counts that were similar to those shown by previous research but distances travelled, measured by GPS, were lower. These findings suggest that mobility in this sample of older adults is predicted by the ability to balance on one leg. Possible interventions to improve out-of-home mobility could target balance. The fact that participants travelled shorter distances than those reported in previous studies is interesting since this high-functioning subgroup would be expected to demonstrate the highest levels.

Assessing a training programme for primary care dental practitioners in endodontics of moderate complexity: Pilot data on skills enhancement and treatment outcomes.

Aims: To explore the impact of dedicated training to extend the skills of primary care practitioners on the quality of endodontic care, using clinical, radiographic and patient-related outcomes. Methods: The quality of endodontic treatment performed at the beginning and end of training to become dentists with extended skills (DES) in endodontics was assessed in vitro and in vivo from endo-training blocks and self-reported logbooks containing clinical notes and radiographs respectively. The quality of endodontic care delivered by DES post-training was measured using clinical and radiographic outcomes. Patient-related outcomes were assessed using a self-report questionnaire, including the Oral Health Impact Profile ­ Endodontic Outcome Measure (OHIP-EOM). Results: Data on eight dentists were examined pre-and post-training, five of whom participated in further follow-up investigations on the quality of endodontic care delivered to their patients. Significant improvements in skills were seen for all domains in vitro (p <0.05), and for all domains of the clinical treatment process, and achieving the correct working length of the root filling as seen by radiography in vivo (p <0.05). The quality of the clinical process was maintained following training. Positive patient outcome (OHIP-EOM) scores were recorded (mean score of 34.72, SD = 10.74, n = 120 pre-treatment and 25.85, SD = 7.74, n = 47 representing reduced impact at follow-up). The majority of patients reported being satisfied, or very satisfied, with the service they received (72.5%, n = 98); would use the service again (68.1%, n = 92); and would recommend the service to friends and family (74.8%, n = 101). Conclusions: Findings suggest that training for dentists working in practice can be successful in enhancing skills and changing practice, with evidence of high patient satisfaction and good clinical and patient-related outcomes. Pilot results must be interpreted with caution and further research is required.

Feasibility of assessing training of primary care dental practitioners in endodontics of moderate complexity: mapping process and learning.

Objectives: To explore the feasibility of measuring quality of endodontic care provided by general dental practitioners (GDPs), using clinical, radiographic and patient-related outcomes, as well as understanding practitioner views and estimating financial costs. Methods: Multi-faceted mixed-methods two-part study involving retrospective analysis of the educational component (course assessments, endodontic training blocks and analysis of a sample of teeth treated at the beginning and end of training), and prospective analysis of patients treated by these dentists after completion of training. Participant: Dentists working in and patients treated in primary dental care in London. Intervention: Twenty-four-month training in endodontics. Comparison: Dentists enrolled in the training at different time points. Outcome: Measuring outcome of endodontic treatment. Results: Eight dentists (mean 36 years, SD = 8.2 years) participated in training. Subsequently, five of these dentists (mean 34.2 years, SD = 7.08 years) contributed to the prospective study and recruited 135 patients. Thirty-five patients completed all patient-related outcome questionnaires, and of these there were 16 cases with complete clinical and radiographic data (12%) at follow-up (10.1­36.4 months). Preliminary analysis revealed that a minimum of 45 cases of complete data would be required for multivariate analysis, requiring the recruitment of in excess of 375 patients to future studies to account for this level of loss to follow-up. Conclusions: Findings suggest it is possible to carry out mixed-methods and treatment-related outcome-based research in primary care. Measurement/data capture tools developed were tested and used successfully in measuring the adherence to treatment processes and outcome of endodontic treatment.

An evaluation of a two-site pilot model for dental foundation training.

Objectives To evaluate the feasibility, strengths, weaknesses, and challenges of a two-site model of dental foundation training.Methods A mixed methods approach was used to evaluate the two-site pilot. Qualitative interviews and focus groups were employed to gain an in-depth understanding of the expectations, experiences and concerns of the stakeholders. Additionally, purposefully designed questionnaires were used to rate different elements of the training.Results Participants included 12 foundation dentists, 15 educational supervisors and seven assistant educational supervisors. An increased breadth of clinical experience, a more variable case-mix, feedback from two teams of supervisors, and the experience of working within two different practices with two different teams and cultures were perceived to be the main strengths. The key challenges reported by the trainers were increased workload, a perceived disruption to the continuity of patient-care and perceived difficulties in establishing professional relationships.Conclusions This paper reports on the evaluation of a new model of dental foundation training in London. It highlights potential advantages and drawbacks of providing dental foundation training in two dental practices. Given the limitations of the of evaluation reported in this paper, additional work is required to establish the feasibility and effectiveness of the two-site training model.

The experience of dentists who gained enhanced skills in endodontics within a novel pilot training programme.

Objective To explore the experiences of primary care dentists following training to enhance endodontic skills and their views on the implications for the NHS.Design Qualitative study using anonymised free text questionnaires.Setting Primary care general dental services within the National Health Service (NHS) in London, United Kingdom.Subjects and methods Eight primary care dentists who completed this training were asked about factors affecting participant experience of the course, perceived impact on themselves, their organisation, their patients and barriers/facilitators to providing endodontic treatment in NHS primary care. Data were transferred verbatim to a spreadsheet and thematically analysed.Intervention 24-month part-time educational and service initiative to provide endodontics within the NHS, using a combination of training in simulation lab and treatment of patients in primary care.Results Positive impacts were identified at individual (gains in knowledge, skills, confidence, personal development), patient (more teeth saved, quality of care improved) and system levels (access, value for money). Suggested developments for future courses included more case discussions, teaching of practical skills earlier in the course and refinement of the triaging processes. Barriers to using the acquired skills in providing endodontic treatment in primary care within the NHS were perceived to be resources (remuneration, time, skills) and accountability. Facilitators included appropriately remunerated contracts, necessary equipment and time.Conclusion This novel pilot training programme in endodontics combining general practice experience with education/training, hands-on experience and a portfolio was perceived by participants as beneficial for extending skills and service innovation in primary dental care. The findings provide insight into primary dental care practitioners' experience with education/training and have implications for future educational initiatives in support of systems innovation within the NHS.

Development of quality measurement instruments for root canal treatment.

AIM: To devise measurement instruments for 'quality' of root canal treatment to assess training and outcome of general dental practitioners working within primary care settings. METHOD: Scoring systems relating to quality of root canal treatment were developed using expert consensus and published literature. Domains scored included the Treatment Process, Quality of the Obturation, Clinical Healing, Radiographic Healing and Tooth Complexity. Scoring systems were applied to 10 clinical cases treated by each dentist at the beginning and 10 cases treated at the end of their clinical training and 135 cases treated after completion of training. The dentists recorded the treatment process and clinical healing in clinical logs. Two examiners independently scored the radiographs after undertaking calibration and training. Inter- and intra-examiner reliability of scoring radiographic outcomes was tested using Cohen's Kappa statistics. RESULTS: An instrument was created with four domains to assess quality (two for process and two for outcome of root canal treatment), and a measure of case complexity. Domains of treatment process (n = 240 teeth), outcome (n = 32 teeth) and complexity (n = 215 teeth) were scored using radiographs. The Kappa scores for intra-examiner reliability between 0.22 and 1, whilst inter-examiner reliability ranged between 0.18 and 0.99. CONCLUSION: Evidence-based scores for assessment of the quality (process and outcome) and complexity (structure) of root canal treatment were devised. They were reliable, provided that clinicians were trained in record keeping and examiners have in depth training and calibration in the use of the instruments.

Rising to the challenge.

R. S. Austin, K. Ranshi, E. Jones, R. Watt, P. Briggs discuss training our future dental leaders and managers to make a positive difference against a background of ever-increasing complexity in NHS organisations.

Topical delivery of diclofenac into and across equine skin from a novel liquid diclofenac epolamine formulation.

The aim was to investigate diclofenac delivery into and across equine skin in vitro using Franz diffusion cells from a novel diclofenac epolamine (DIC-EP; 1.3%) formulation and to compare the results to those of Surpass® (1% diclofenac sodium liposomal cream) and a 1% aqueous solution of diclofenac sodium. Skin was harvested from the lower legs of Freiberger geldings immediately after slaughter and sliced to a thickness of ~2 mm. Skin samples were divided into two groups [Group 1: 1 year old (n = 2) and Group 2: 6-8 years old (n = 3)]. Cumulative permeation of diclofenac in Groups 1 and 2 after 24 h using diclofenac sodium solution was 1.91 ± 0.27 and 1.76 ± 0.34 µg/cm2 , respectively. The values for Surpass® and DIC-EP were 3.2 ± 0.8/3.3 ± 0.7 µg/cm2 and 230 ± 59/89.2 ± 32.5 µg/cm2 , respectively. Thus, diclofenac permeation from DIC-EP was significantly greater and appeared to show an age-dependent effect. Mathematical modelling showed that the DIC-EP formulation significantly increased diclofenac partitioning into the skin and a linear correlation was observed between steady-state flux and the partition parameter. Greater skin deposition of diclofenac was also observed with DIC-EP. These preliminary results suggest that the DIC-EP formulation may be effective in treating inflammatory conditions in horses.

Balancing the risks and benefits associated with cosmetic dentistry - a joint statement by UK specialist dental societies.

Cosmetic dentistry has become increasingly popular, largely as a result of social trends and increased media coverage. This understandable desire for the alleged 'perfect smile' needs to be tempered with an appropriate awareness of the significant risks associated with invasive cosmetic procedures such as veneers and crowns. Patients need to be properly informed that elective removal of healthy enamel and dentine can result in pulpal injury and poorer periodontal health in the longer term, particularly if they are young. The duty of candour means that they ought to be informed that aggressive reduction of sound tooth tissue is not biologically neutral and results in structural weakening of their teeth. Less invasive procedures such as bleaching on its own or for example, combined with direct resin composite bonding, can satisfy many patient's demands, while still being kinder to teeth and having much better fall-back positions for their future requirements. It is the opinion of the British Endodontic Society, British Society for Restorative Dentistry, Restorative Dentistry UK, Dental Trauma UK, British Society of Prosthodontics and the British Society of Paediatric Dentistry that elective invasive cosmetic dental treatments can result in great benefit to patients, but that some aggressive treatments used to achieve them can produce significant morbidities in teeth which were previously healthy. This is a worrying and growing problem with many ethical, legal and biologic aspects, but many adverse outcomes for patients who request cosmetic dental improvements are preventable by using biologically safer initial approaches to treatment planning and its provision.

Dentists with extended skills: the challenge of innovation.

BACKGROUND: The aim was to obtain stakeholders' views on the former London Deanery's joint educational service development initiative to train dentists with a special interest (DwSIs) in endodontics in conjunction with the National Health Services (NHS) and examine the models of care provided. METHODS: A convergent parallel mixed methods design including audit of four different models of care, semi-structured interviews of a range of key stakeholders (including the DwSI trainees) and questionnaire surveys of patients and primary care dentists. RESULTS: Eight dentists treated over 1,600 endodontic cases of moderate complexity over a two year training period. A retrospective audit of four schemes suggested that first molars were the most commonly treated tooth (57%; n = 341). Patients who received care in the latter stages of the initiative were 'satisfied' or 'very satisfied' with the service (89%; n = 98). Most dental practitioners agreed that having access to such services would support the care of their patients (89%; n = 215) with 88%; (n = 214) supporting the view that DwSIs should accept referrals from outside of their practice. CONCLUSION: This initiative, developed to provide endodontic care of medium complexity in a primary care setting, received wide support from stakeholders including patients and primary care dentists. The implications for care pathways, commissioning and further research are discussed.

Flexion strength of the toes in the normal foot. An evaluation using magnetic resonance imaging.

Flexion of the toes may be active from muscle contraction or passive from the reversed windlass function of the plantar aponeurosis. The aim of this study was to estimate the flexion moments the muscles of the foot and long digital flexors may be capable of generating and compare these calculations with published data. Magnetic resonance images were used to measure the maximal cross-sectional area of the foot muscles and long digital flexors, along with the radius of curvature of the metatarsal heads. Using known physiological data the maximal flexion moments the muscles may be able to generate at the metatarsophalangeal (MTP) joints were calculated. The methodology overestimates muscle strength and flexion moments at the metatarsophalangeal joints. The calculated maximal flexion moment at the 1st MTP joint is 4.27-6.84 Nm, for the 2nd, 3rd and 4th MTP joints 3.06-4.91 Nm, and the 5th MTP joint 0.47-0.75 Nm. The flexion moments the muscles may generate at the MTP joints do not account for the flexion forces seen in normal walking. Given that maximal strength is not used in normal walking, we conclude that the reversed windlass mechanism of the plantar aponeurosis must be important in normal function of the toes.

Direct composite restorations for the worn mandibular anterior dentition: a 7-year follow-up of a prospective randomised controlled split-mouth clinical trial.

The purpose of this study was to report on the 7-year follow-up of 15 patients who took part in a prospective randomised controlled split-mouth trial to evaluate the performance and patient satisfaction of 107 direct composite restorations bonded to their worn anterior mandibular dentition. This is the continuation of a study by Poyser et al., which investigated the performance of the same direct composite restorations on this cohort of patients at 2.5 years. The results of the present study suggest that direct composite restorations bonded to the worn anterior mandibular dentition to have an approximate survival of 85% at the 7-year follow-up. Approximately 53% of patients experienced survival of all of their restorations. Pre-operative circumferential preparation did not influence restoration survival, patient satisfaction or other clinical variables (restoration staining, marginal discolouration, shade match, surface roughness and marginal adaptation). The time taken to initially build-up the restorations was shown to be statistically significant with a longer procedural time meaning less chance of the restoration being present at 7 years. This treatment modality exhibited no biological complications for the teeth, supporting periodontium or TMJ apparatus. The placement of these restorations provided an improvement in the aesthetics of the teeth, a reduction in the concern over the longevity of the worn lower anterior teeth, and improvements with regard to sensitivity experienced with hot or cold foods or drinks. Marginal breakdown was the most frequently recorded clinical complication. Thus, for the majority of patients, the restorations offered a high degree of patient satisfaction and required an acceptable level of maintenance in the 7-year follow-up period.

Effects of radiotherapy to the jaws. I: The scale of the problem.

Cancer care has become one of the main targets of the National Health Service in England and with cancer patients surviving longer, it is likely that head and neck cancer patients will make up a large proportion of patients seen within secondary care settings in the future. The management of these patients can be very difficult for a number of reasons. Part one of this paper attempts to highlight the major oral health problems encountered by these patients during and after their cancer treatment and supported by the current literature. Part two of this series will address the dental management of head and neck oncology patients undergoing radiotherapy with particular attention of possible improvement to current management strategies for these patients.

Effects of radiotherapy to the jaws. 2: Potential solutions.

Dental maintenance and rehabilitation of head and neck cancer care is becoming more important as the outcome of cancer treatment improves. The management of these patients can be very difficult for a number of reasons as discussed in part one of this two-part series. This second part attempts to suggest possible solutions for the management of the major oral health problems encountered by these patients during and after their cancer treatment.

Metatarsal extension osteotomy without plantar aponeurosis release in cavus feet. The effect on claw toe deformity a radiographic assessment.

BACKGROUND: This study reviewed patients undergoing correction of cavus foot deformity by metatarsal extension osteotomy with preservation of the plantar aponeurosis, and assessed the correction achieved of the claw deformity of the toe by radiographic assessment. METHOD: 15 patients (18 feet) were reviewed clinically and radiographically. All feet required extension osteotomy of the first metatarsal and four patients (5 feet) had extension osteotomy of the first to fourth metatarsals. Hallux extension angle in relation to the 1st metatarsal and in relation to the ground was measured in all feet to estimate the degree of clawing of the hallux. RESULTS: 13 patients (15 feet) were satisfied with the outcome of their surgery and also the appearance of their foot. The mean radiographic change in the hallux extension angle in relation to the 1st metatarsal was 16°, and in relation to the ground was 7°. These changes were statistically significant. CONCLUSION: Our results indicate an improvement in the claw toe deformity and we recommend preservation of the plantar aponeurosis in corrective surgery for cavus foot.

Antimicrobial irrigants in endodontic therapy: root canal disinfection (part 1).

This paper highlights the importance of root canal disinfection. It discusses the different endodontic irrigants available and comments on how these can be used most effectively.

The evaluation of direct composite restorations for the worn mandibular anterior dentition - clinical performance and patient satisfaction.

This prospective split-mouth clinical trial evaluated the performance and patient satisfaction of 168 Herculite XRV direct composite restorations bonded to the worn anterior dentition of 18 patients with localized anterior tooth surface loss. One hundred and six of these restorations were placed on the mandibular anterior teeth. The restorations increased the anterior occlusal vertical dimension between 0.5 and 5 mm and the posterior occlusal contacts were restored after a mean duration of 6.2 months (range: 3-13 months) in 14 out of the 15 'Dahl' sub-group patients. The restorations were evaluated after 2.5 years of service by five examiners. Four patients and 23 mandibular restorations were lost to follow-up. Multiple clinical and restorative variables were assessed to determine their influence on restoration performance. Complete failure occurred in 6% of the restorations. Circumferential preparation and height of the restorative addition did not influence the performance of the restorations. A Visual Analogue Scale (VAS) was used to assess the patient's opinion regarding sensitivity, aesthetics, longevity and function of the worn mandibular anterior teeth. A statistically significant difference (95% CI) was found between the pre-operative and 1-month review VAS responses for aesthetics and longevity and this was maintained at the 2.5-year review. Direct composite restorations placed at an increased occlusal vertical dimension are a simple and time-efficient method of managing the worn mandibular anterior dentition. Patient's acceptance and adaptation to the technique is good and the results are accompanied with a high level of patient satisfaction that is maintained for the medium-term.

A life threatening event from poorly managed dental pain--a case report.

The history of a patient who suffered encephalopathy and coma is presented. A 25-year-old female consumed large quantities of cold water over several weeks, to control long-term dental pain. This eventually led to dilution hyponatraemia, followed by a seizure and encephalopathy. The patient made a good recovery after spending three days in neurological intensive care. Conventional endodontic therapy immediately resolved her symptoms following recovery from this life-threatening episode. Prior to her admission the patient had experienced difficulties in gaining access to effective emergency dental care. Her problems could have been avoided if appropriate management had been provided sooner. The dental profession should be aware of the potential life-threatening risk when continued water consumption is used to control the long-term pulpitic pain. Primary care agencies should ensure that information on local emergency dental services is well disseminated to the population. Dental surgeons should be able to manage acute dental pain.

Development and certification of the new SRM 695 trace elements in multi-nutrient fertilizer.

During the past seven years, several states within the US have enacted regulations that limit the amounts of selected non-nutritive elements in fertilizers. Internationally, several countries, including Japan, China, and Australia, and the European Union also limit the amount of selected elements in fertilizers. The elements of interest include As, Cd, Co, Cr, Cu, Hg, Mo, Ni, Pb, Se, and Zn. Fertilizer manufacturers and state regulatory authorities, faced with meeting and verifying these limits, need to develop analytical methods for determination of the elements of concern and to validate results obtained using these methods. Until now, there were no certified reference materials available with certified mass fraction values for all elements of interest in a blended, multi-nutrient fertilizer matrix. A new standard reference material (SRM) 695 trace elements in multi-nutrient fertilizer, has been developed to help meet these needs. SRM 695 has recently been issued with certified mass fraction values for seventeen elements, reference values for an additional five elements, and information values for two elements. The certificate of analysis includes an addendum listing percentage recovery for eight of these elements, determined using an acid-extraction inductively-coupled plasma optical-emission spectrometry (ICP-OES) method recently developed and tested by members of the Association of American Plant Food Control Officials.