Observer agreement in the grading of oral epithelial dysplasia.

OBJECTIVES: To determine the extent of observer agreement in diagnosis of oral epithelial dysplasia (OED). Published studies of OED examiner agreement report relatively low agreement levels; however, these studies were limited by the methodologies employed. METHODS: For this study, 64 slides were each independently examined twice by three oral pathologists. Consistency was assessed by determining intra- and interexaminer agreement. Conformity was assessed by using the modal diagnosis as a gold standard. RESULTS: The group showed moderate interobserver agreement when grading the presence or absence of OED with a group-simple kappa (Ks) of 0.51 (95% CI = 0.42-0.61), and substantial agreement when using a 5-point ordinal scale with a group-weighted kappa (Kw) of 0.74 (95% CI = 0.64-0.85). The group showed fair to substantial intraexaminer agreement when assessing the presence or absence of OED, with Ks ranging from 0.22 to 0.78, and showing almost a perfect agreement using a 5-point ordinal scale, with Kw ranging from 0.82-0.96. Conformity with the comparison standard modal diagnosis was almost perfect, with pairwise Kw ranging from 0.81 to 0.92. CONCLUSION: Overall, there was substantial intra- and interobserver consistency and almost perfect conformity in the grading of OED. Appropriate statistical methods are necessary to determine the degree of observer agreement.

Should the use of smoking cessation products be promoted by dental offices? An evidence-based report.

To address the issue of whether dentists should promote the use of smoking cessation products, an evidence-based methodology was applied to find answers to 3 questions: Does tobacco use affect periodontal health? Are dentists effective cessation counsellors? Do smoking cessation products improve the effectiveness of cessation interventions? MEDLINE and manual searches uncovered relevant evidence to use in developing evidence-based recommendations. There is fair evidence that tobacco use is a major factor in the progression and treatment outcome of adult periodontitis and that quitting tobacco use is beneficial to periodontal health. There is good evidence to recommend that oral health professionals provide cessation counselling. There is good evidence to recommend the use of smoking cessation adjuncts. In view of the strong supporting evidence, dental offices should incorporate systematic smoking cessation services into routine patient care and should promote the use of proven cessation products by patients who are attempting to quit.

Fluorosis risk in grade 2 students residing in a rural area with widely varying natural fluoride.

OBJECTIVES: This pilot study was performed to determine the prevalence of dental fluorosis and the association between fluorosis and a number of risk factors in a group of second grade students in a rural, non-fluoridated area of Ontario, Canada. METHODS: Of 1739 students screened during routine health surveillance, 1367 had erupted maxillary central incisors. Fluorosis was scored on these children using the Tooth Surface Index of Fluorosis (TSIF). A fluoride exposure questionnaire and water sample vial was sent home from school with each child. RESULTS: Valid responses were obtained for 752 children (55%). The prevalence of fluorosis in respondents was 23.3%, with 4.9% scoring TSIF of 2 or more. In bivariate analysis, several variables were significantly associated with the prevalence and/or severity of fluorosis. These included: water fluoride concentration, breast-feeding duration, professionally applied topical fluoride, fluoride supplement use, bottle-feeding, fluoridated mouthwash use, and early parental toothbrushing with toothpaste. In logistic regression analysis limited to children living at the current residence for 4 years or more, only four variables had significant independent effects. These were water fluoride concentration, breast-feeding duration, fluoride supplement use, and fluoridated mouthwash use. CONCLUSIONS: These findings indicate that fluorosis is an important concern in non-fluoridated areas. Fluoride supplements should not be recommended unless an independent home water test is performed. Breast-feeding for 6 months or more may protect children from developing dental fluorosis in the permanent incisors.

Quality assurance in the dental profession.

The dental profession has traditionally attempted to ensure quality and to guarantee high educational standards by restricting licensure. Recently, many factors have increased public and government interest in the quality of care provided by health professionals. A framework for understanding quality assurance is presented. This framework incorporates with Donabedian's dimensions of structure, process and outcome the additional dimensions of system capacity and community. All dimensions of quality are assessed by comparison with an accepted standard. Quality assurance can be considered as occurring at a system level, a managerial level, and a practice level. All quality assurance activities work to fulfil society's requirements to maintain self-governing professional status.

An update of mechanical oral hygiene practices: evidence-based recommendations for disease prevention.

PURPOSE: This review updates the mechanical oral hygiene practices discussed at a 1986 State-of-the-Science Workshop. METHODS: The 1984-1995 MEDLINE database was searched and appropriate studies that used disease outcome measurements were located and selected. Recommendations were made based on the levels of evidence concept. RECOMMENDATIONS: 1) There is good evidence to recommend: toothbrushing twice daily with fluoridated toothpaste; using oscillating-rotating or counter-rotational-action electric toothbrushes; flossing for adults; personal supragingival irrigation as an adjunct to toothbrushing; and scaling of disease active sites for the treatment of periodontal diseases. 2) There is moderate evidence to recommend: using any soft-bristled manual toothbrush; using wooden interdental cleaners; scaling of disease active sites every three to four months for patients with histories of moderate/severe periodontitis; scaling of disease active sites at intervals of > or = 6 months for most patients, based on patient need; and removal of restoration overhangs. 3) There is moderate evidence to not recommend: use of vibrating, rotating or sonic action electric toothbrushes; using foam brushes; flossing for children; using interdental brushes; gingival massage; and tongue brushing or scraping. 4) There is good evidence to not recommend: subgingival scaling for patients with no signs of active disease; and polishing for disease prevention. CONCLUSIONS: Consistent with the 1986 workshop report, the 1996 recommendations emphasize the importance of personal oral hygiene and the provision of professional treatment when personal care fails to prevent disease.

Guidelines on the use of space maintainers following premature loss of primary teeth.

OBJECTIVE: To formulate evidence-based guidelines on the appropriate use of space maintaining appliances to prevent or reduce the severity of malocclusion in the permanent dentition following the premature loss of primary teeth. OPTIONS: Placement of lingual arch, palatal arch, band-loop, crown-loop, and intra-alveolar space maintainers. OUTCOMES: Reduced prevalence or severity of space loss in the primary or mixed dentition, reduced prevalence or severity of malocclusion in the permanent dentition measured as significant changes in: crowding, ectopic eruption, impacted teeth, Angle's class II or III occlusion, crossbite, deep overbite, deep overjet, or midline shift. EVIDENCE: Articles published from 1966 to 1996, located though Medline searches. Only clinical trials, cohort studies, case-control studies, or large case series were considered. VALUES: Relevant clinical findings were evaluated and categorized using evidence-based methods and values established by the Canadian Task Force on the Periodic Health Examination. A recommendation was developed for the use of space maintainers. BENEFITS, HARMS AND COSTS: The potential benefits of using space maintaining appliances include reduced prevalence or severity of: crowding, ectopic eruption, tooth impaction, crossbite, excessive overbite and overjet, and poor molar relationship. Other advantages include the potential for considerable cost savings by reducing the need for future orthodontic treatment. The potential disadvantages of using space maintaining appliances include soft tissue impingement, interference with eruption of adjacent teeth, pain, plaque accumulation, caries, and broken, dislodged or lost appliances. RECOMMENDATIONS: There is poor evidence to recommend for or against the use of space maintainers to prevent or reduce the severity of malocclusion in the permanent dentition (see Table 1, Recommendation C) Decisions regarding the use of space maintainers must therefore be guided by factors other than scientific evidence.

Three-year coronal caries incidence in older Canadian adults.

This paper describes the incidence of coronal caries in a sample of older adults. A 3-year follow-up study was conducted of 493 community-dwelling adults aged 50 years and over in Ontario, Canada. The incidence of coronal caries was 57.0%, and the mean net DFS increment was 1.9 surfaces. In bivariate analysis, several variables were significantly associated with incidence and/or mean DFS increment. These included: age, marital status, baseline coronal DFS, number of teeth at baseline, mean periodontal attachment loss of 4 mm or more, and wearing partial dentures. In logistic regression analysis only four factors had significant independent effects. These were level of education, marital status, mean periodontal attachment loss and number of teeth at baseline. The predictive ability of this model was fair: accuracy 65.7%, sensitivity 80.2%, and specificity 46.2%. When logistic analysis was repeated separately for two age groups, different predictors had significant independent effects, and sensitivity and specificity values differed substantially. These findings indicate predictive models for caries incidence should include both clinical and non-clinical variables because both types of variables may help to explain different aspects of coronal caries experience. Further research is required to identify other factors associated with coronal caries in older adults.