Online assessment platforms: What is on offer?

AIMS: Web-based digital assessment platforms offer several benefits for educational providers. The aims of this study were to evaluate digital assessment platforms suitable for design, delivery and quality assurance of assessments in dental education to facilitate informed choices by educational providers. METHODS: The study was based on an online cross-sectional survey. A questionnaire was designed to include relevant details of providers, types of assessments offered, post-assessment psychometrics, remote proctoring, integration with digital learning platforms faculty training, and indicative costs of services. Following a google search, 25 potential providers of digital assessment software were identified and contacted by email. RESULTS: Ten companies responded to the questionnaire. All providers, except one, reported extensive experience in delivering high-stake assessments for programs in dentistry, medicine and allied health professions. All companies confirmed availability of a wide variety of assessment formats and also offer remote proctoring either directly or through third parties. Indicative costs of different assessment platforms were also provided. CONCLUSION: This paper underscores the need for dental institutions to make informed decisions when choosing the most appropriate digital assessment platforms to suit their educational needs. It also provides a snapshot of services offered by commercial providers of assessment platforms. The Association for Dental Education in Europe can serve as a central hub to guide dental institutions on making informed choices for suitable assessment platforms to address their needs.

INTRA-CANAL ANTIBIOTIC PASTES MAY PROMOTE THICKER DENTIN WALLS AND CALCIUM HYDROXIDE MAY PROMOTE MORE APICAL CLOSURE.

ARTICLE TITLE AND BIBLIOGRAPHIC INFORMATION: Báez, Viviana; Corcos, Lorena; Morgillo, Florencia; Imperatrice, Lorena; Gualtieri, Ariel Félix (2022). Meta-analysis of regenerative endodontics outcomes with antibiotics pastes and calcium hydroxide. The apex of the iceberg. J Oral Biol Craniofac Res 12(1): 90-98. SOURCE OF FUNDING: Non-funded study TYPE OF STUDY/DESIGN: Systematic review and meta-analysis.

Present status and future directions: Surgical extrusion, intentional replantation and tooth autotransplantation.

Surgical extrusion, intentional replantation and tooth autotransplantation procedures are important treatment options that clinicians may consider performing in their day-to-day clinical practice. Despite compromised teeth are generally considered for extraction, clinicians must be aware that these cases could be suitable for management by these alternative predictable treatment options. Surgical extrusion, intentional replantation or tooth autotransplantation have similar treatment protocols which includes atraumatic tooth extraction, visualisation of the root portion and replantation. Surgical extrusion is defined as the 'procedure in which the remaining tooth structure is repositioned at a more coronal/supragingival position in the same socket in which the tooth was located originally'. Intentional replantation is defined as the 'deliberate extraction of a tooth and after evaluation of root surfaces, endodontic manipulation and repair, placement of the tooth back into its original position'. Tooth autotransplantation is defined as the 'transplantation of an unerupted or erupted tooth in the same individual, from one site to another extraction site or a new surgically prepared socket'. The same team previously published a narrative review (International Endodontic Journal. 2020, 53, 1636) and European Society of Endodontology position statement (International Endodontic Journal. 2020, 54, 655) on this topic in International Endodontic Journal. The aim of the current updated review was to provide the reader a complete overview and background on these procedures, to established clear clinical protocols and step-by-step for technically perform these therapies in their clinical practice and to establish future directions on the topics. The clinicians must periodically update their knowledge about these three procedures to achieve success.

An Update on the Dental Management of Children with Haemophilia.

Children with haemophilia present a bleeding risk and a challenge for dentists. Guidelines on the dental management of haemophilia patients are largely based on expert consensus. Many existing guidelines also provide generic guidance mainly for adult patients, which have been adapted for children. However, children have unique needs that require additional considerations. With limited evidence available, it is important that dentists have an understanding of the principles of both medical and dental management and have a close collaboration with the haematologist at all times. Therefore, this paper provides some key principles related to various aspects of dental management of children with haemophilia. Furthermore, there has been a recent update to the World Federation of Haemophilia (WFH) Guidelines for the Management of Haemophilia,1 with references to novel medical therapies for haemophilia. Hence, this paper also aims to inform dentists with the standard and newer medical therapies for haemophilia, including a specific focus on the novel agent Emicizumab and the associated dental considerations.

A Diagnostic Accuracy Study of Laser Doppler Flowmetry for the Assessment of Pulpal Status in Children's Permanent Incisor Teeth.

INTRODUCTION: The aim of this study was to assess whether laser Doppler flowmetry is more accurate than the conventional pulp sensibility tests (electric pulp test and ethyl chloride) in assessing the pulpal status of permanent anterior teeth in children and to identify the laser Doppler flowmetry's Flux cut-off threshold. METHODS: A cross-sectional diagnostic accuracy study with randomization was performed and included 74 participants (8- to 16-year-old children). Participants had 1 maxillary central or lateral incisor with either a completed root canal treatment or an extirpated pulp and a contralateral tooth with vital pulp. Outcome measures included the sensitivity, specificity, and predictive values as well as the repeatability of all tests. RESULTS: A significant difference between the Flux values for teeth with vital and non-vital pulps was found. The cut-off ratio for laser Doppler flowmetry was 0.6, yielding a sensitivity of 53% and a specificity of 33%, which were lower than the values of the electric pulp test (sensitivity = 83.8%-94.6% and specificity = 89.2%-97.6%) and ethyl chloride (sensitivity = 81.1%-91.9% and specificity = 73%-81.1%). The repeatability of laser Doppler flowmetry, electric pulp testing, and ethyl chloride were 0.85, 0.86, and 0.81, respectively. CONCLUSIONS: Laser Doppler flowmetry was unable to differentiate between teeth with vital and non-vital pulps. The results of this study showed that there was a high probability for false results. Further development of laser Doppler flowmetry in assessing pulpal blood flow would be required before it could be recommended for clinical use, especially in children.

The diagnostic accuracy of laser Doppler flowmetry in assessing pulp blood flow in permanent teeth: A systematic review.

BACKGROUND/AIM: Pulp necrosis is a frequent complication following dental trauma. The diagnosis of the state of the dental pulp can be challenging as most commonly used diagnostic tools are subjective and rely on a response from the patient, potentially making their use unreliable, especially in the child population. The aim of the study was to systematically review the evidence on the use of laser Doppler flowmetry in the assessment of the pulp status of permanent teeth compared to other sensibility and/or vitality tests. METHODS: A systematic literature search, using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, www.clinicaltrials.gov and www.controlled-trials.com, in addition to citation and manual reference list searches, was conducted up to 15th January 2018. A risk of bias assessment was performed using the quality assessment for diagnostic accuracy studies tool (QUADAS-2) with all steps performed independently by two reviewers. RESULTS: Four studies with a high risk of bias were included in the final analysis. Laser Doppler flowmetry was reported to be more accurate in differentiating between teeth with normal pulps and pulp necrosis with a sensitivity of (81.8%-100%) and specificity of 100% in comparison to other vitality tests such as pulp oximetry (sensitivity = 81.3%, specificity = 94.9%) and sensibility tests such as electric pulp testing (sensitivity = 63.3%-91.5%, specificity = 88%-100%). CONCLUSION: Despite the higher reported sensitivity and specificity of laser Doppler flowmetry in assessing pulp blood flow, these data are based on studies with a high level of bias and serious shortfalls in study designs. More research is needed to study the effect of different laser Doppler flowmetry's parameters on its diagnostic accuracy and the true cut-off ratios over which a tooth could be diagnosed as having a normal pulp.

Anaesthetic efficacy of 4% articaine and 2% lidocaine for extraction and pulpotomy of mandibular primary molars: an equivalence parallel prospective randomized controlled trial.

AIM: To compare the anaesthetic efficacy for pain and behaviour during treatment with mandibular infiltration using 4% articaine (BI) with inferior dental nerve clock (IDNB) using 2% lidocaine for extraction or pulp therapy in mandibular primary molars. DESIGN: This was equivalence parallel prospective RCT. A total of 98 children aged 5-9 years old were randomly assigned into two groups: BI supplemented by buccal intrapapillary infiltration with 4% articaine; IDNB with 2% lidocaine supplemented with long buccal infiltration. Behaviour during the injection and treatment procedures was assessed using Wong-Baker Facial Rating Scale (W-BFRS), Visual Analogue Scale (VAS), and Frankl Behaviour Rating Scale (FBRS). RESULTS: During the injection phase, the absolute differences in success rates between the two techniques were 0.06 (95% CI: -0.11 to 0.23) for VAS and -0.08 (95% CI: -0.19 to 0.03) for the behaviour of the child (FBRS). FBRS results showed the equivalence of the two, whereas the VAS results showed nonequivalence with the 95% confidence intervals slightly exceeding the equivalence margin (±0.20). W-BFRS success rates were 63.3% for both. During the treatment, VAS results showed similar success rates, demonstrating equivalence between the two as did the results for FBRS. CONCLUSION: The results suggested equivalence in success rates for both anaesthetic techniques during treatment.

Effect of fluoride sustained slow-releasing device on fluoride, phosphate and calcium levels in plaque biofilms over time measured using ion chromatography.

OBJECTIVES: To determine whether there are any differences in fluoride (F), calcium (Ca) or phosphate (PO(4)) concentrations in natural plaque biofilms between the upper right and left quadrants using a fluoride sustained slow-releasing device (FSSRD) placed in the upper right quadrant after 7 and 21 days. To report and validate a new methodology in measuring very low concentrations of F in dental plaque and saliva using ion chromatography. METHODS: Twenty-one participants were divided into two groups with 11 participants in group one and 10 in group two. Each participant had a FSSRD attached to the upper right second permanent molar and two plaque generating devices (PGDs) attached to the upper right and left first permanent molars. The PGDs were recovered after 7 days in group one and 21 days in group two. RESULTS: At both 7 and 21 days (right, left), F (1.081±1.517 ppm, 0.736±0.840 ppm) and (0.459±0.888 ppm, 0.203±0.139 ppm), PO(4) (1053±533 ppm, 654±246 ppm) and (865±1099 ppm, 474±304 ppm) and Ca (136±132 ppm, 74±36 ppm) and (130±109 ppm, 77±24 ppm), were higher in the quadrant containing the FSSRD but not significantly so (p>0.05). Fluoride and PO(4) fell in both quadrants between 7 and 21 days, though not significantly. CONCLUSIONS: Intriguingly while not statistically significant, 21 day plaque contained less fluoride than those investigated after 7 days. While the data was not statistically significant, it seems possible that F, Ca and PO(4) accumulated around the device to a limited extent but were washed away fairly quickly and distributed around the oral cavity. CLINICAL IMPORTANCE: The FSSRD was found to reduce dmfs/DMFS by 76% and raise salivary F levels by ∼10 folds. This device is very helpful in reducing dental decay where compliance is impaired such as in patients with special needs. This study further investigates the anti-cariogenic effect of this device.

Periodontal healing following avulsion and replantation of teeth: a multi-centre randomized controlled trial to compare two root canal medicaments.

BACKGROUND: Non-setting calcium hydroxide (Ultracal XS(®) ) is recommended by the International Association of Dental Traumatology as the initial medicament following avulsion and replantation for mature teeth. There is experimental evidence to suggest Ledermix(®) , placed as an alternative inter-visit dressing may improve periodontal healing. AIM: This study investigated, using a multi-centre randomized controlled trial, the effect of two root canal medicaments, Ledermix(®) and Ultracal XS(®) , on periodontal healing of avulsed and replanted teeth. MATERIAL AND METHODS: Children were recruited if they fulfilled all inclusion criteria. Treatment followed a standardized protocol. Assessment of periodontal healing or ankylosis was made clinically and radiographically by an experienced, 'blinded', clinician at 12months. RESULTS: Over 200 patients were assessed for eligibility at five centres. Twenty-nine patients were eligible for inclusion. Final analysis involved 22 patients with 27 teeth. Ankylosis was detected in four of the 12 teeth in the Ledermix(®) group and nine of 15 in the Ultracal XS(®) group. No significant difference between medicaments was found in the proportion of teeth or patients showing periodontal healing. DISCUSSION: There was no significant difference in periodontal healing between the two medicaments at either a tooth or patient level. The numbers recruited fell short of an estimated power calculation. For patients meeting the inclusion criteria and completing the trial, periodontal healing was seen in 52% of teeth at the 12-month assessment between both groups. The only factor found to significantly influence the periodontal outcome was dry time.

Discoloration of teeth after avulsion and replantation: results from a multicenter randomized controlled trial.

INTRODUCTION: There is evidence to suggest that Ledermix, placed as an intervisit root canal dressing, might improve periodontal healing after replantation of avulsed teeth. As a part of a multicenter randomized controlled trial, we aimed to compare the effect of 2 root canal medicaments, Ledermix and Ultracal XS, on the discoloration of replanted teeth. METHODS: Discoloration was investigated by using 3 methods: patient satisfaction with the color of replanted teeth, clinical photographs taken at baseline and 12-month reviews, and estimation of color change by using CIELAB scores for baseline and 12-month photographs. RESULTS: Twenty-two patients (27 teeth) were recruited. Ten patients (12 teeth) were randomized to the Ledermix group and 12 patients (15 teeth) to the Ultracal XS group. At 12 months, 8 patients were concerned with the discoloration of their teeth. Seven came from the Ledermix group and 1 from the Ultracal XS group. This difference was significant (Fisher exact test, P = .009). Standardized photographs were taken for the patients recruited at one center only (17 patients). There was significant discoloration of teeth from baseline with Ledermix, causing a darkening and gray-brown discoloration (mean change from baseline to 12 months, L∗ = -5.1, a∗ = 0.3, b∗ = -1.2, and ΔE = 8.1) and Ultracal XS, causing a yellowing and lightening of teeth (L∗ = 1.9, a∗ = 0.3, b∗ = 3.3, and ΔE = 5.4). There was a significant difference for the L∗ and b∗ variables (independent t test) between the 2 groups. CONCLUSIONS: Both root canal medicaments cause discoloration, with Ledermix proving less acceptable to patients.

Interventions for treating traumatized necrotic immature permanent anterior teeth: inducing a calcific barrier & root strengthening.

BACKGROUND: Apical barrier formation and root strengthening procedures have been extensively described in the literature. This systematic review attempts to establish where the effects of interventions using multi-visit apexification, single visit apical plug techniques and root strengthening procedures are consistent and where they may vary significantly. OBJECTIVES: To evaluate the relative effectiveness of apexification and apical plug techniques as well as root strengthening procedures for treating traumatized necrotic immature permanent anterior teeth through a systematic review of randomized controlled trials. Reported immediate and/or long-term adverse events and effects of the materials and techniques are also evaluated. SEARCH STRATEGY & SELECTION CRITERIA: Structured electronic and hand search was performed with no restriction on the language of publication. Only randomized controlled trials comparing different apical barrier formation techniques and root strengthening procedures in traumatized necrotic immature anterior teeth were assessed. RESULTS: Two hundred studies were identified but only two were suitable for inclusion. Included studies investigated multi-visit apexification techniques using calcium hydroxide and tricalcium phosphate. There were no eligible studies investigating root strengthening procedures or any other intervention for apical barrier formation in necrotic immature anterior teeth. No reliable information was available on long-term adverse effects of the reported interventions or cost implications. CONCLUSIONS: Based on two included studies, there is weak evidence supporting the use of either calcium hydroxide or tricalcium phosphate for apical barrier formation in necrotic immature anterior teeth employing multi-visit apexification techniques. The evidence is insufficient to provide guidelines for practice. There was no reliable evidence on adverse events or long-term effects after the use of calcium hydroxide or tricalcium phosphate justifying caution in their use in apical barrier formation techniques.

Dental trauma: part 2. Managing poor prognosis anterior teeth--treatment options for the subsequent space in a growing patient.

Part 1 concentrated on implications of dental trauma especially prior to and during orthodontic treatment. This paper examines the literature supporting various treatment options for poor prognosis anterior teeth and subsequent space generated when these teeth are lost. The role of an interdisciplinary team in managing this clinical situation is essential to obtain optimal results and an orthodontist is an essential member. Although some treatment options are not provided by orthodontists it is important that they have some knowledge of these and the latest research that support their use. Other techniques lie very much within the orthodontic remit. Treatment options can be split into maintaining the failing tooth or extraction and restoration of the edentulous gap. This paper reviews various treatment options including periodontal regeneration, surgical repositioning and distraction osteogenesis, composite build up to incisal levels and decoronation when maintaining a failing tooth. When extraction and restoration of edentulous gap is required the following treatment modalities are discussed: extraction technique to retain bone quantity, orthodontic space closure and opening (site development), autotransplantation, partial denture, resin bonded bridge and implants. All these options should be considered and available to an interdisciplinary team to ensure optimal care of children with anterior teeth of poor prognosis.

Dental trauma: an overview of its influence on the management of orthodontic treatment. Part 1.

This is the first of two papers discussing the implications of dental trauma for patients requiring orthodontic treatment. This paper will focus on the factors the orthodontic specialist should consider when contemplating movement of traumatized teeth. The prevalence of dental trauma and the recognition and prevention of traumatic injuries are discussed. The evidence available in the literature relating to orthodontic tooth movement in vital and endodontically treated traumatized teeth is explored. The interdisciplinary management of root fractured and intruded teeth receive special attention. The second paper will look at the role of the specialist team in the management of failing anterior teeth and will outline possible treatment options for children and adolescents encountering such situations. Avulsion injuries and tooth transplantation are considered in particular detail.

A clinical evaluation of mineral trioxide aggregate for root-end closure of non-vital immature permanent incisors in children-a pilot study.

The aim of this pilot study was to evaluate the clinical efficacy of mineral trioxide aggregate (MTA) as an apexification material when used in non-vital immature permanent incisors in children. Fifteen children with a mean age of 11.7 years and 17 non-vital permanent incisors were ajudged suitable for inclusion. Standard endodontic procedures were followed and an apical plug of 3-4 mm was created by using MTA after a calcium hydroxide intracanal dressing had been applied for at least 1 week. Final obturation was completed by using thermoplastisized Gutta-Percha (Obtura II) at least 1 week following MTA placement. Subjects were reviewed clinically and radiographically at 3-month intervals. Mean follow-up time for MTA was 12.53 months (+/-2.94 SD). Of the total of 17 teeth treated, MTA placement was considered to be adequate in 13 teeth. The procedure showed clinical success in 94.1% of the cases, radiographic success was found to be 76.5% and in further three cases (17.6%) the outcome was considered to be uncertain. This is one of the very few studies that have reported the out coming of MTA as an apexification material in children with non-vital teeth and incomplete root development. However, larger clinical studies are required to evaluate the long-term success of this procedure.

The role for 'reminders' in dental traumatology: 2. The effectiveness of a reminder stamp compared with the current clinical practice for documenting the diagnostic working length.

The aim of this study was to establish if a predesigned prompt in the form of a reminder stamp placed in a patient's dental records is more effective for recording the essential details of a diagnostic working length compared to the current practice without any specific prompts. Following a pilot study of current practice, a stamp was introduced. Twelve months following the introduction of the stamp, 198 patient records were examined, where endodontic treatment had been carried out mainly for traumatic injuries. The following parameters were specifically investigated whether a radiograph had been taken to establish working length and was it available for examination, whether the working length was recorded in the notes and whether a reference point for the measurements was given. The working length was conventionally recorded by 127 notes, whereas 71 used the stamp. A working length radiograph was taken and a working length recorded for 95% of the cases where no stamp had been used, compared to 100% of the stamp group. Where no stamp had been used only 83% of working length radiographs were available compared to 100% of the stamp group. Interestingly, a reference point from where the working length had been measured was only recorded in 5% of the cases where the stamp had not been used compared to 94% using the predesigned stamp. This result was statistically significant using a chi-squared test (P < 0.001). The stamp was generally more effective than the conventional method of recording the working length for endodontics.

The role for 'reminders' in dental traumatology: 1. Current practices in the UK and Ireland.

The aim of this study was to investigate the current method for recording trauma in UK dental hospitals. A standard questionnaire was sent out to all 19 UK and Irish dental hospitals to investigate how trauma was recorded both at initial presentation and at review appointments. Where a standard form was used, a copy was requested. Each form was analysed to assess what information was being recorded and whether prompts were used. For the initial presentation of trauma, nine institutions had a standard trauma form, one used a standard form for avulsions only, seven had no form and two did not respond. For subsequent follow-up visits of trauma cases, six hospitals had a standard form, one used a standard from for avulsions only, 10 had no form and two did not respond. There was considerable variation in the questions that were asked at initial presentation of trauma cases and follow-up reviews in dento-alveolar trauma. Without consistent recording, there is little chance that multi-centred prospective clinical trials can take place in the field of dental trauma.

The role for 'reminders' in dental traumatology: 3. The minimum data set that should be recorded for each type of dento-alveolar trauma - a review of existing evidence.

The aim of this study was to establish the prognostic factors recorded at the time of diagnosis or initial treatment that affect pulp and periodontal healing and tooth survival. A search strategy and quality assessment method was established to review the literature. The significant factors identified are listed for each type of dento-alveolar injury. These factors identified are the gold standard against which quality assessments of dento-alveolar trauma records can be compared and all new computer or paper-based methods for recording any type of dento-alveolar trauma should aim to record this minimum information.

The role for 'reminders' in dental traumatology: 4. The use of a computer database for recording dento-alveolar trauma in comparison to unstructured and structured paper-based methods.

The aims of this study were to investigate the effectiveness of a computer database (CD) developed for this study, a plain paper unstructured history (USH) and structured histories (SH) for the recording of important prognostic factors for simulated dento-alveolar trauma. Twelve vocational trainees, seven postgraduates in paediatric dentistry and 24 general dental practioners were randomly assigned to using USH, SH or CD. Each dentist visited a series of simulated trauma cases (with models, photos, radiographs and actors) and was asked to record important prognostic factors for each injury and make a diagnosis. There were a total of 243 dentist contacts with the trauma stations. The average percentage of important prognostic factors recorded per station was: USH 53%, SH 75.3% and CD 58.6%. SH was significantly better than the other two methods (P < 0.001, anova). Interestingly, those general dental practitioners (GDPs) who qualified prior to 1990 were significantly poorer at recording important prognostic information using CD. This effect was not obvious when using USH and SH. It was also seen that USH and SH were significantly better at helping clinicians reach a correct diagnosis as compared with CD (P < 0.001, chi-squared). A paper-based SH was the most effective method for collecting essential prognostic information for simulated trauma cases used in this study. At present, the introduction of our CD for recording of trauma is not justified without significant modification.

The effect of cocoa polyphenols on the growth, metabolism, and biofilm formation by Streptococcus mutans and Streptococcus sanguinis.

The aim of this study was to determine if cocoa polyphenols could interfere with biofilm formation by Streptococcus mutans or Streptococcus sanguinis, and reduce acid production from sucrose by S. mutans. The antimicrobial activity of cocoa polyphenols was assessed against cariogenic (S. mutans) and health-associated (S. sanguinis) species by minimum inhibitory concentration assays. Cocoa polyphenol dimer, tetramer, and pentamer inhibited the growth of S. sanguinis, whereas the growth of S. mutans was unaffected. However, pretreatment of surfaces with cocoa polyphenol pentamer (35 microM) reduced biofilm formation by S. mutans at 4 and 24 h, whereas the effects on S. sanguinis were less consistent. In contrast, brief exposure of preformed biofilms to pentamer either had no significant effect or resulted in increased counts of S. mutans under certain conditions. Cocoa polyphenol pentamer (500 microM) significantly reduced the terminal pH, and inhibited the rate of acid production by S. mutans at pH 7.0. In conclusion, cocoa polyphenols can reduce biofilm formation by S. mutans and S. sanguinis, and inhibit acid production by S. mutans.

A multicentre investigation into the role of structured histories for patients with tooth avulsion at their initial visit to a dental hospital.

A paper structured history (SH) is a sheet, which prompts or reminds the clinician to ask various important questions. The aim of this study was to examine avulsion cases with respect to the quality of clinical records. Hospitals studied used either a paper SH or had no specific structure in their recording of avulsion details, e.g. unstructured histories (USH). The most important prognostic items that should be recorded for avulsion cases at their first visit were identified by reviewing the literature. Clinical case records meeting strict inclusion criteria were retrospectively analyzed against 10 important prognostic items. Forty-seven patient records were identified in the SH group compared to 43 patient records in the USH group. Using chi-square and Fisher's exact tests, the SH group were significantly better at recording the following: accident details (P < 0.001), loss of consciousness (P < 0.001), other teeth or tooth injuries (P < 0.05), extra-alveolar mediums (P < 0.01), total extra-alveolar time (P < 0.001), antibiotics given at time of injury (P < 0.05) and apical maturity (P < 0.001). In all the dental hospitals selected, two-thirds of the case records were completed by junior dentists not in specialist training and the improvement in history when using an SH form was most pronounced in these groups. It is concluded, therefore, that an SH should be taken for cases ofavulsion as it was significantly better at collecting essential prognostic information.