Assessing the application of knowledge in clinical problem-solving: The structured professional reasoning exercise.

INTRODUCTION: Clinical reasoning is a fundamental and core clinical competence of healthcare professionals. The study aimed to investigate the utility of the Structured Professional Reasoning Exercise (SPRE), a new competence assessment method designed to measure dental students' clinical reasoning in simulated scenarios, covering the clinical areas of Oral Disease, Primary Dental Care and Restorative Dentistry, Child Dental Health and Dental Practice and Clinical Governance. MATERIALS AND METHODS: A total of 313 year-5 students sat for the assessment. Students spent 45 minutes assimilating the scenarios, before rotating through four pairs of 39 trained examiners who each independently assessed a single scenario over a ten-minute period, using a structured marking sheet. After the assessment, all students and examiners were invited to complete an anonymous perception questionnaire of the exercise. These questionnaires and the examination scores were statistically analysed. RESULTS AND DISCUSSION: Oral Disease showed the lowest scores; Dental Practice and Governance the highest. The overall Intraclass Correlation Coefficient (ICC) was 0.770, whilst examiner training helped to increase the ICC from 0.716 in 2013 to 0.835 in 2014. Exploratory factor analysis revealed one major factor with an eigenvalue of 2.75 (68.8% of total variance). The Generalizability coefficient was consistent at 0.806. A total of 295 students and 32 examiners completed the perception questionnaire. Students' lowest examination perceptions were an "Unpleasant" and "Unenjoyable" experience, whilst the highest were "Interesting", "Valuable" and "Important". The majority of students and examiners reported the assessment as acceptable, fair and valid. CONCLUSION: The SPRE offers a reliable, valid and acceptable assessment method, provided it comprises at least four scenarios with two independently marking and trained assessors. 3.

Outreach clinical dental education: the Portsmouth experience - a 4-year follow-up study.

BACKGROUND: The Portsmouth Dental Academy (UPDA) was opened in September 2010 and was a development from the highly successful School of Professionals Complementary to Dentistry (2004-2010). The aim of the Academy was to provide integrated team education for all dental professionals in a primary care setting. The dental students are on outreach from King's College London, and the dental care professional students are registered at the University of Portsmouth. OBJECTIVES: To evaluate the dental students response to the residential outreach educational experience at the UPDA. METHODS: A 49-item questionnaire divided into nine domains that provided both qualitative data and quantitative data were administered at the end of the longitudinal 10-week placement, to four successive cohorts of students in 2010-2014. RESULTS: A 95% return rate was achieved. Students valued highly the quality of the clinical teaching. Through their experience, they felt they understood fully the role of the dentist in care planning in primary care and felt well prepared for dental foundation training. This educational success is unpinned with successful maintenance factors including a well-organised induction period and giving the students a sense of belongingness, empowerment and autonomy for their personal development as new graduates. CONCLUSION: Within the limitations of the questionnaire study over the 4-year period, the students were very positive about all the aspects of this residential outreach education at the UPDA but particularly valued the immersion in clinical dentistry and the bridging from dental school to their dental foundation training.

The impact of integrated team care taught using a live NHS contract on the educational experience of final year dental students.

OBJECTIVE: To investigate the responses of the dental student body in the first three years of outreach education (2010-13) at the University of Portsmouth Dental Academy in the areas of integrated team work and use of a current NHS contact. METHODS: Use of a questionnaire to allow both quantitative and qualitative data to be obtained, administered to the three cohorts of students at the end of their longitudinal attendance at the Academy in their final year of education at King's College London Dental Institute. RESULTS: Data were obtained from 227 students which represented a 95% return rate. Sixty-four percent of students strongly agreed with both statements: 'I am confident with working with a dental nurse' and 'I now understand properly the scope of practice of dental hygiene-therapists'. Sixty-seven percent strongly agreed with the statement 'I have had useful experience of working in NHS primary care during the final year'. Eighty percent either strongly agreed or agreed with the statement 'My experience of real Units of Dental Activity and Key Performance Indicators has encouraged me to positively consider NHS high street dentistry as a career option'. CONCLUSIONS: Within the limitations of this study the dental students reported having gained useful experience of working in integrated team care dentistry. They expressed strong support for the education that is being delivered in an outreach environment and, most importantly, the student body was looking forward to entering general dental practice in the UK.

Levels of agreement between student and staff assessments of clinical skills in performing cavity preparation in artificial teeth.

OBJECTIVE: To determine the level of agreement between staff and students' assessment of clinical skills in performing tasks related to cavity preparation on a traditional dental manikin. METHODS: Two studies were conducted with two successive student cohorts: Study 1-138 year 1 BDS students in a 2009/10 cohort and Study 2-135 students in a 2010/11 cohort. Staff members and students rated the students' performance in preparing a cavity on a traditional dental manikin using artificial teeth: hand-held (Study 1) and located in a lower jaw (Study 2). A 5-item criterion-related scoring rubric was developed. The rubric assessed students' abilities to hold the instrument correctly, determine the angle of entry to the tooth, remove the caries, conserve healthy tissues and avoid pulp exposure. RESULTS: Agreement between the students' self-assessment and the staff's assessment was high for three of the five criteria (i.e. removal of artificial caries on the cavity wall, removal of artificial caries from the cavity floor and avoidance of pulp exposure). Levels of agreement for the remaining two criteria were moderate. A change in task difficulty affected the levels of agreement between staff and students, such that the more difficult the task, the greater the discrepancy in ratings. CONCLUSIONS: Students tend to overrate the quality of their performance when compared with staff ratings. Task difficulty has an impact on levels of agreement.

Three-year clinical evaluation of two ceramic crown systems: a preliminary study.

STATEMENT OF PROBLEM: The clinical performance and failure mechanisms of recently introduced ceramic crown systems used to restore posterior teeth have not been adequately examined. PURPOSE: The purpose of this prospective clinical study was to evaluate and compare the clinical performance of 2 new ceramic crown systems with that of metal ceramic crowns using modified United States Public Health Services (USPHS) criteria. MATERIAL AND METHODS: Ninety posterior teeth requiring crown restorations in 48 patients were randomized into 3 equal groups (n=30) for which different crown systems were used: an experimental hot-pressed glass ceramic based on a modified lithium disilicate ceramic (IPS e.max Press), an alumina-coping-based ceramic (Procera AllCeram), and a metal ceramic (Simidur S 2 veneered with IPS Classic Porcelain). The crowns were assessed over 3 years using the modified USPHS criteria. Crowns that developed visible cracks were sectioned and removed, and the surfaces were analyzed using a scanning electron microscope (SEM). The data were analyzed using the Kruskal-Wallis nonparametric statistical test, followed by the Mann-Whitney test with Bonferroni correction (alpha=.05). RESULTS: USPHS evaluation showed that the IPS e.max Press and metal ceramic crowns experienced fewer clinical changes than Procera AllCeram. Visible roughness, wear, and deformity were noticed in occlusal contact areas of Procera AllCeram crowns. SEM images showed well defined wear facets in both ceramic crown systems. Kruskal-Wallis tests showed a significant difference (P<.05) in Alpha scores among the 3 crown systems. Mann-Whitney tests showed significant differences among groups. CONCLUSIONS: IPS e.max Press crowns demonstrated clinical behavior comparable to Procera AllCeram and metal ceramic crowns, but the wear resistance of this crown type was superior to the Procera AllCeram crowns, according to modified USPHS criteria.

Treatment of dentin with polyacrylic acid--a retrospective observational study of the effect upon the durability of glass ionomer restorations.

This paper reports on the results of a material specific, retrospective observational study. It sought to determine the consequence of pretreatment of cavity margins with the conventional glass polyalkenoate Chemfil II prior to restoration with Tooth Cleanser on restoration durability. All restorations were placed and varnished by senior dental students under the supervision of a staff member. Manufacturer recommendations were followed. Data on each restoration was collected and entered into a relational computer database. Data included details of cavity morphology and the use or non-use of Tooth Cleanser. Six years following the study start a manual search of all records was carried out to determine, for those patients continuing to attend the Dental Hospital, the number of failed and surviving restorations. This yielded a dataset of 149 restorations, of which 41 had been placed with the aid of Tooth Cleanser and 108 without. The number of failed restorations was 20 and 62, respectively. Survival analysis by the Kaplan-Meier method revealed median survival times of 2,094 days, when Tooth Cleanser was used and 1,748 days when not. Although 80% survival times of 1111.0 (SE = 6.3) (With Tooth Cleanser) and 285.0 (SE = 3.8) (Without Tooth Cleanser) days were observed, together with a Hazard Ratio of 1.49 (95% Confidence Intervals 0.92 & 2.31), a Logrank test revealed no statistically significant difference between the survival curves (p = 0.12). It was concluded that although there was a trend for the application of Tooth Cleanser to improve the chances of obtaining a dependable restoration, this effect was not statistically significant.

Release of fluoride from glass polyalkenoate (ionomer) cement subjected to radiant heat.

OBJECTIVES: This study was designed to examine the effect of the application of radiant heat on the fluoride release from the surface of a glass polyalkenoate cement. METHODS: The radiant heat was applied at different intensities and for different time intervals using a high-intensity fibreoptic quartz halogen light source. A standard technique was used to measure the amount of fluoride released from one surface of a cement specimen into deionized water. Fluoride release was measured for a time period of over 2 years. RESULTS: Results showed that fluoride was still being released 2 years after placement. The application of radiant heat did not have a statistically significant effect on the release of fluoride from the surface of this material. CONCLUSIONS: There appeared to be a trend suggesting that the greater the amount of heat applied, the less fluoride was released from the surface of the cement. A considerable inter- and intrabatch variation was noted in the amount of fluoride released from the cement.

Effect of radiant heat on the surface hardness of glass polyalkenoate (ionomer) cement.

The use of heat to improve mechanical properties of materials is a widely accepted phenomenon. It has been studied in dentistry with a view to improving the properties of resin composite. Dental cements may benefit by the application of heat, in particular with regard to their early surface properties. This study was carried out to examine the effect of the application of radiant heat to the surface hardness of one type of glass polyalkenoate cement. It was found that raising the temperature of the surface of the cement to a maximum of 60 degrees C significantly improved the early surface hardness of the material. The application of a high level of heat also improved the surface hardness of the cement after 24 h compared to cement which had not been heat treated. The use of heat would appear to accelerate the matrix-forming reaction of the material and although further work is necessary this technique may have clinical application.

The use of intermediary resins when bonding glass polyalkenoate (ionomer) cement to composite resin.

This study was designed to examine the effects of three different types of glass polyalkenoate lining cement combined with three different types of bonding resin and varying surface treatments on the seal between the lining cement and the composite resin as used in the so called 'laminate' technique. The seal was assessed using a radioisotope and autoradiographic technique. Results showed that all the cements behaved in a manner specific to them. The seal of all systems examined could be improved, or at least, not compromised, by modification of the surface of the cement prior to attachment of the resin. Only one type of intermediate resin gave a reliable seal when applied to an unmodified surface of any of the cements under investigation. It is concluded that all the glass polyalkenoate cements tested behave differently when used beneath composite resin. Recommendations about the laminate restoration technique must be related to the specific combinations of materials used.

A comparison of the shear bond strengths to a resin composite of two conventional and two resin-modified glass polyalkenoate (ionomer) cements.

The inability of resin composite to bond directly to dentine has compromised the clinical success of this restorative material. This problem may be overcome by the so-called laminate technique in which glass polyalkenoate cement is placed upon dentine and then covered with a resin composite. The cement both adheres to dentine and affords micromechanical attachment to the composite. The introduction of the resin-modified glass polyalkenoate cements (RMCs) offers the potential for chemical union between cement and composite. This investigation examined the shear bond strengths of P-50 resin composite to four glass polyalkenoate lining materials, with and without the application of an intermediate bonding agent (Scotchbond 2). Two of the cements were RMCs (Vitrebond, XR-Ionomer) and the others were conventional base materials (Baseline, Ketac-Bond). The bond between P-50 and Vitrebond with or without Scotchbond 2 was significantly (P < 0.01) stronger and more consistent (P < 0.05) than that observed for all other materials. The treatment of the conventional materials and XR-Ionomer with Scotchbond 2 significantly (P < 0.01) improved the bond strengths to P-50. It is concluded that Vitrebond formed the most favourable cement-resin composite bond and that the other materials studied should be used in conjunction with an effective intermediate bonding agent, such as Scotchbond 2.

Surface pH of resin-modified glass polyalkenoate (ionomer) cements.

The recently developed group of materials known as light-activated, or resin-modified, glass polyalkenoate (ionomer) cements have been produced in response to clinical demands for a command set cavity base material. This study monitored the surface pH of three commercially available resin-modified glass ionomer cements over a 60-min period following either mixing alone or mixing followed by a 30-s exposure to a curing lamp. The results indicate that each material behaves in a unique manner. For all materials and conditions the pH reached after a 60-min period was significantly (P < 0.001) higher than the initial value. Light curing the materials significantly increased (P < 0.01) the surface pH of two of the materials (Baseline VLC and Vitrebond) as compared to the same materials in the uncured state. In the case of XR-Ionomer, however, no significant (P > 0.05) effect of light curing upon the surface pH was apparent. The precise clinical consequences of a low surface pH are unclear but may be an aetiological factor in postoperative pulpal sensitivity. It is therefore recommended that a sublining of a proprietary calcium hydroxide lining material should be placed routinely beneath these materials and every effort made to ensure effective light curing.

The surface pH of glass ionomer cavity lining agents.

It is considered that acid release from the surface of glass ionomer (polyalkenoate) cements may be associated with early pulpal sensitivity following the use of these materials. This study was carried out to examine the surface pH of different types of glass ionomer lining cements using a flat-ended pH electrode. It was found that the surface pH remains low for this group of materials during the first hour of setting. Different types of glass ionomer lining cement were also shown to behave differently when considering acid release from the surface. Conclusions regarding the behaviour of glass ionomers should only be made with reference to the specific material tested.

An investigation of possible iatrogenic damage caused by metal rubber dam clamps.

Rubber dam may be held in place over a tooth by metal clamps. It has been shown that a mismatch of contact between the clamp gripping edge and the tooth surface may be reduced to a point contact, thereby concentrating the gripping force generated by the bow of the clamp. Experiments were conducted to measure the force. Clinically realistic loading of the tooth surface by sections of the gripping edge of clamps was carried out using special apparatus. Examination by scanning electron microscopy showed that iatrogenic damage to the tooth could occur. Therefore a plea is made for clamps to be redesigned to reduce any harm.