Exploring academic teachers perspectives regarding the impact of using medical simulation in dentistry pre- and post-COVID-19 pandemic: a qualitative study.

BACKGROUND: Medical simulation allows for the achievement of many educational goals and the continued education of some practical skills. The COVID-19 pandemic's restrictions have led to a major increase in dental education simulations. The aim of this study was to analyse the perspectives of academic teachers towards dental simulation, their concerns and evaluation of this teaching method, as well as their opinion on the use of medical simulation during the COVID-19 pandemic. METHOD: A focus study was conducted in a group of 5 academic teachers, comprising 10% of academic teachers of a Dental Faculty using simulation techniques. Prior to and during the COVID-19 pandemic, the interviewed teachers had expertise with medical simulation in dentistry education methods. A facilitator used pre-planned, open-ended questions about the use of simulation in dentistry also with regard to the COVID-19 pandemic period. The group discussion has been managed, monitored, and recorded. The data analysis model was based on Braun and Clarke's six phases of thematic analysis. Five thematic domains/fields were evaluated: (1) Simulation as a didactic method; (2) Simulation during COVID-19 pandemic; (3) General observations and expectations with regard to simulation; (4) Teachers in simulation; (5) Concerns in relation to simulation. Two researchers analysed the data. RESULTS: Based on interviewed teachers' perspective the simulation allows students to learn basic and complex skills providing the repeatability of the procedures performed. During Covid-19 the simulation methods undoubtedly filled the gap in the training of future dentists. However, interviewed teachers pointed out the high cost of the methods dictated by the need to prepare the simulation environment at a high level, in order to reflect the real clinical situation. CONCLUSIONS: The use of simulation methods requires adequate preparation of academic teachers, continuous education and updating of knowledge in the field of medical simulation. The COVID-19 pandemic significantly influenced the growth of dental education simulation techniques as well as staff knowledge of the usage of medical simulation.

Does the shape of the field-of-view influence the magnitude of artefacts from high-density materials in cone-beam computed tomography?

OBJECTIVE: To compare cylindrical and convex triangular field-of-views (FOVs) concerning the magnitude of artefacts from high-density materials in cone-beam CT (CBCT). METHODS AND MATERIALS: Cylinders of amalgam, chromium-cobalt, titanium, and zirconia were individually placed in the anterior and posterior regions of a polymethylmethacrylate phantom and scanned using cylindrical and convex triangular FOVs of the Veraview X800 CBCT device. Using the Image J software, 15 square regions of interest (ROIs) were placed in the axial reconstruction around the middle level of the cylinder and at distances of 0.5, 1.0, and 1.5 cm from the centre of the cylinder. Mean grey value and standard deviation of each ROI were averaged for each distance and subtracted from the values of a control ROI to calculate the magnitude of the artefacts by the grey value mean difference (GVMD) and grey value standard deviation (GVSD). Multiway analysis of variance with Tukey post-hoc test with a significance level of 5% evaluated the effect of the shape of the FOV, position inside the FOV, high-density material, and the distance of the artefact from the material. RESULTS: The convex triangular FOV increased the GVSD for all materials in the anterior and posterior regions at 0.5 cm compared to the cylindrical FOV (p < 0.0001). The convex triangular FOV showed greater GVMD for chromium-cobalt and zirconium in the anterior region and all materials in the posterior region at all distances (p < 0.0001). CONCLUSION: The FOV shape influences the magnitude of artefacts from high-density materials. The convex triangular FOV showed greater artefact magnitude with variability among the high-density materials, region in the FOV, and distance from the material.

A novel method of objectively detecting tooth ankylosis using cone-beam computed tomography: A laboratory study.

Purpose: The aim of this study was to objectively detect simulated tooth ankylosis using a novel method involving cone-beam computed tomography (CBCT). Materials and Methods: Tooth ankylosis was simulated in single-rooted human permanent teeth, and CBCT scans were acquired at different current levels (5, 6.3, and 8 mA) and voxel sizes (0.08, 0.125, and 0.2). In axial reconstructions, a line of interest was perpendicularly placed over the periodontal ligament space of 21 ankylosed and 21 non-ankylosed regions, and the CBCT grey values of all voxels along the line of interest were plotted against their corresponding X-coordinates through a line graph to generate a profile. The image contrast was increased by 30% and 60% and the profile assessment was repeated. The internal area of the resulting parabolas was obtained from all images and compared between ankylosed and non-ankylosed regions under different contrast enhancement conditions, voxel sizes, and mA levels using multi-way analysis of variance with the Tukey post hoc test (α=0.05). Results: The internal area of the parabolas of all non-ankylosed regions was significantly higher than that of the ankylosed regions (P<0.05). Contrast enhancement led to a significantly greater internal area of the parabolas of non-ankylosed regions (P<0.05). Overall, voxel size and mA did not significantly influence the internal area of the parabolas (P>0.05). Conclusion: The proposed novel method revealed a relevant degree of applicability in the detection of simulated tooth ankylosis; increased image contrast led to greater detectability.

Revisiting dynamic range and image enhancement ability of contemporary digital radiographic systems-part 2: a subjective assessment.

OBJECTIVE: To assess the subjective image quality of original and manually enhanced radiographs acquired at different X-ray exposure times and using different digital systems. METHODS: A total of 500 radiographs obtained under 10 exposure times, 5 digital systems, and 2 enhancement conditions were assessed by 5 observers, who were asked to categorize each radiograph into acceptable or unacceptable. A radiograph was considered to be acceptable when at least four out of five observers found it acceptable. Descriptive analysis was used to summarize the outcomes and compare the subjective image quality of original and manually enhanced digital radiographs among different X-ray exposure times and digital systems. RESULTS: Express had six exposure times producing acceptable original images within a range from 0.063 to 0.4 s, followed by Digora Toto, which had five within a range from 0.063 to 0.32 s, Digora Optime, which had four within a range from 0.063 to 0.2 s,and SnapShot and VistaScan, which had 2 (0.2 and 0.32 s) and 1 (0.63 s), respectively. Image enhancement turned unacceptable images into acceptable ones in four digital systems: SnapShot at three exposure times, Digora Toto at two exposure times, Express at one exposure time, and VistaScan at four exposure times. CONCLUSION: Image enhancement based on brightness and/or contrast adjustments may be necessary to reveal the useful dynamic range of some digital radiographic systems and PSP-based systems may not necessarily have a wider range than sensor-based systems.

Is the efficacy of cone beam computed tomography in the diagnosis of tooth ankylosis influenced by dose reduction protocols?

OBJECTIVE: To evaluate the diagnostic efficacy of cone beam computed tomography (CBCT) examinations acquired with varying dose protocols in the diagnosis of simulated tooth ankylosis (TA). STUDY DESIGN: Tooth ankylosis was simulated in 15 of 30 teeth, and CBCT examinations were acquired at 3 mA levels (8, 6.3, and 5) and 3 voxel sizes (0.08, 0.125, and 0.2 mm). Four radiologists independently assessed the presence of TA using a 5-point scale. Sensitivity, specificity, and area under the curve (AUC) obtained through receiver operating characteristic analysis were compared among mA levels and voxel sizes using two-way analysis of variance (α = 0.05). Intra- and interexaminer reliability levels were assessed with the weighted kappa examination. RESULTS: Sensitivity was low (0.32-0.49), and specificity was reasonably high (0.71-0.83). Mean values of AUC were low, ranging between 0.54 and 0.67, which reveals poor overall discrimination between health and disease. The detection of TA was not significantly influenced by mA level or voxel size (P > .05). Intra- and interexaminer agreements ranged from slight to moderate (0.160-0.535) and from fair to substantial (0.236-0.697), respectively. CONCLUSIONS: Despite the limited efficacy of CBCT for TA detection, when indicated as a complementary examination, mA reduction should be considered for dose optimization purposes.

Influence of kilovoltage-peak and the metal artifact reduction tool in cone-beam computed tomography on the detection of bone defects around titanium-zirconia and zirconia implants.

Purpose: The aim of this study was to assess the influence of kilovoltage-peak (kVp) and the metal artifact reduction (MAR) tool on the detection of buccal and lingual peri-implant dehiscence in the presence of titanium-zirconia (Ti-Zr) and zirconia (Zr) implants in cone-beam computed tomography (CBCT) images. Materials and Methods: Twenty implant sites were created in the posterior region of human mandibles, including control sites (without dehiscence) and experimental sites (with dehiscence). Individually, a Ti-Zr or Zr implant was placed in each implant site. CBCT scans were performed using a Picasso Trio device, with variation in the kVp setting (70 or 90 kVp) and whether the MAR tool was used. Three oral radiologists scored the detection of dehiscence using a 5-point scale. The area under the receiver operating characteristic (ROC) curve, sensitivity, and specificity were calculated and compared by multi-way analysis of variance (α=0.05). Results: The kVp, cortical plate involved (buccal or lingual cortices), and MAR did not influence any diagnostic values (P>0.05). The material of the implant did not influence the ROC curve values (P>0.05). In contrast, the sensitivity and specificity were statistically significantly influenced by the implant material (P<0.05) with Zr implants showing higher sensitivity values and lower specificity values than Ti-Zr implants. Conclusion: The detection of peri-implant dehiscence was not influenced by kVp, use of the MAR tool, or the cortical plate. Greater sensitivity and lower specificity were shown for the detection of peri-implant dehiscence in the presence of a Zr implant.

Mapping of a multilayer panoramic radiography device.

OBJECTIVE: To map the shape, location, and thickness of the focal trough of a panoramic radiography device with a multilayer imaging program. METHODS: An acrylic plate (148 × 148 × 3 mm) containing 1156 holes distributed in a matrix of 34 × 34 rows was placed in the OP300 Maxio at the levels of the maxilla and mandible. 20 metal spheres (3.5 mm in diameter) were placed on the holes of the plate under 15 different arrangements and panoramic images were acquired for each arrangement at 66 kV, 8 mA, and an exposure time of 16 s. The resulting panoramic radiographs from the five image layers were exported, the horizontal and vertical dimensions of the metal spheres were measured in all images using the Image J software, and the magnification and distortion rates of the spheres were calculated. All metal spheres presenting a magnification rate lower than 30% in both vertical and horizontal dimensions and a distortion rate lower than 10% were considered to map the focal troughs of each of the five image layers. RESULTS: All panoramic image layers had a curved shape ranging from 39° to 51° for both dental arches and varied in position and thickness. The anterior region of maxilla was anteriorly displaced when compared to the anterior region of the mandible for all layers. Image layers are thicker at the level of the mandible than those at the level of the maxilla; also, inner layers were thinner and outer layers were thicker. CONCLUSION: All image layers in the studied panoramic radiography device had a curved shape and varied in position and thickness. The anterior region of maxilla was anteriorly displaced when compared to that of the mandible for all layers.

Revisiting dynamic range and image enhancement ability of contemporary digital radiographic systems.

OBJECTIVES: To assess the dynamic range and enhancement ability of radiographs acquired with contemporary digital systems. METHODS: Five repeated periapical radiographs of human mandibles with an aluminium step-wedge were acquired using two sensor-based and three photostimulable phosphor plate-based systems and an X-ray unit at ten exposure times 0.020, 0.032, 0.063, 0.080, 0.100, 0.200, 0.320, 0.400, 0.500, and 0.630 s. All images had their brightness and contrast enhanced by two experienced oral and maxillofacial radiologists in consensus and were exported as both the original and enhanced file formats. Mean grey values were obtained from the aluminium steps and tabulated with their corresponding thicknesses for each exposure time, digital radiographic system, and file format. Images with saturated steps were excluded and the mean grey values from the remaining images were averaged to assess image brightness and the angular coefficient of the linear trendlines was generated from the relationship between mean grey values and their corresponding aluminium thicknesses to assess image contrast. Brightness and contrast values were compared using two-way ANOVA with post-hoc Tukey (α = 0.05). RESULTS: Photostimulable phosphor plate-based digital radiographic systems had a broader dynamic range. Longer exposure times produced original images with lower brightness and variable contrast (p < 0.05). Subjective enhancement significantly increased or reduced brightness and/or contrast in some systems (p < 0.05). CONCLUSIONS: Contemporary digital radiographic systems present different dynamic ranges and exposure-related brightness and contrast. Image enhancement may be a valuable tool at slightly suboptimal exposure times.

Comparison of distance of upper central incisor root and incisive canal in different sagittal and vertical skeletal patterns and sex: A retrospective CBCT study.

INTRODUCTION: To evaluate the influence of sagittal and vertical skeletal patterns (skeletal classes and facial profiles), and sex on the distance between upper central incisors roots and incisive canal. MATERIAL AND METHODS: Cone-beam computed tomography exams of 172 patients were classified into skeletal classes I, II, and III and according to the facial profile into mesofacial, brachyfacial, and dolichofacial. In sagittal reconstructions, linear measurements were done between central incisors roots and incisive canal at three levels: incisive foramen opening, intermediate region, and the region close to the apex of upper central incisors. In axial reconstructions, measurements of incisive canal width and distance between the roots were obtained. Analysis of Variance (three-way ANOVA) was used to evaluate measurement differences in relation to skeletal classes, facial profiles, and sex. RESULTS: The distance between upper central incisors roots and incisive canal anterior region was little influenced by sagittal and vertical skeletal patterns and sex. Men had significantly greater incisive canal (mean=2.85mm; SD=1.18) width compared to women (mean=2.40mm; SD=1.04), regardless of skeletal class and facial profile (P<0.05). In general, inter-root distance between medial points of central incisors roots and incisive canal opening was greater in the region close to upper central incisors apex (mean=3.84mm; SD=1.44) than in incisive foramen opening (2.44mm; SD=1.04), (P<0.05). CONCLUSIONS: The distance between upper central incisors roots and incisive canal is little influenced by sagittal and vertical skeletal patterns and sex.

Does dose optimisation in digital panoramic radiography affect diagnostic performance?

OBJECTIVES: To compare the overall diagnostic performance of digital panoramic radiographs obtained with low-dose protocols and to estimate the absorbed dose in the head and neck. MATERIALS AND METHODS: Forty-eight panoramic radiographs were obtained from eight imaging phantoms using six exposure protocols of progressively lower tube voltages (kVp) and currents (mA), as follows: (1) 70 kVp and 12.5 mA, (2) 66 kVp and 10 mA, (3) 66 kVp and 8 mA, (4) 66 kVp and 5 mA, (5) 66 kVp and 4 mA and (6) 66 kVp and 3.2 mA. Five oral radiologists independently evaluated the images and reported all detectable radiographic findings. Intra-examiner reproducibility was assessed by re-evaluation of 25% of the images. The data were analysed using the McNemar and weighted Kappa tests. Absorbed doses of the six protocols were obtained from thermoluminescent dosimeters placed inside a Rando phantom and compared using one-way ANOVA with post hoc Tukey (α = 0.05). RESULTS: The overall diagnostic performance of panoramic radiographs obtained with low-dose protocols did not differ from that of panoramic radiographs obtained with the highest dose (p > 0.05). Moreover, substantial agreement was observed between all protocols. Protocol 1 resulted in the highest absorbed dose and protocols 4, 5 and 6 in the lowest absorbed doses, with the difference being significant (p ≤ 0.05). CONCLUSION: Although digital panoramic radiography is considered a relatively low-dose examination, the radiation dose can be further reduced without negatively affecting its overall diagnostic performance. CLINICAL RELEVANCE: Considering the risks associated with X-rays, digital panoramic radiographs can be obtained at even lower exposure levels.

Influence of windowing and metal artefact reduction algorithms on the volumetric dimensions of five different high-density materials: a cone-beam CT study.

OBJECTIVE: To assess the influence of windowing and metal artefact reduction (MAR) algorithms on the volumetric dimensions of high-density materials using two CBCT systems. METHODS: Four cylinders of amalgam, cobalt-chromium, gutta-percha, titanium and zirconium, were manufactured and their physical volumes (PV) were measured. A polymethyl methacrylate phantom containing the cylinders was submitted to CBCT acquisitions with Picasso Trio and OP300 units with their MAR enabled and disabled. The tomographic volume (TV) of all the cylinders was obtained by semi-automatic segmentation using two windowing adjustments: W1-large window width and upper window level; W2-narrow window width and low window level. Volumetric distortion was expressed as the difference between TV and PV. Statistics comprised intraclass correlation coefficient (ICC) and analysis of variance (ANOVA) for repeated measures with Tukey post hoc test (α = 5%). RESULTS: The ICC values ​​indicated excellent reproducibility of TV. Gutta-percha and titanium resulted in the smallest volumetric distortion. Using W1 provided less volumetric distortion for almost all experimental conditions (p < 0.05). Activating MAR algorithm of Picasso Trio underestimated gutta-percha and titanium TV (p < 0.05) and was inefficient in significantly reducing the volumetric distortion of the other materials (p > 0.05). Disabling MAR algorithm of OP300 resulted in smaller volumetric distortion for almost all experimental conditions (p < 0.05). CONCLUSIONS: The TV of gutta-percha and titanium were closer to the PV. In general, the MAR algorithms of both systems were inefficient in significantly reducing the volumetric distortion of high-density materials. We encourage the use of large window width and upper window level to evaluate high-density materials.

Assessment of dentists' behaviour on the use of patients' images.

BACKGROUND: Photographs and radiographs are indispensable resources for dental education, research and dissemination of clinical cases in scientific journals. The objective of this study was to evaluate the behaviour of dentists on the use of patients' images. MATERIAL AND METHODS: Fifty-two dentists were interviewed using a semi-structured script containing open-ended questions on the use of patients' images. The answers were analysed using a qualitative-quantitative method of the discourse of the collective subject, and the distribution of the absolute and relative frequency of the answers was presented according to the central ideas obtained from the discourses. RESULTS: The following central ideas on the use of patients' images were identified: (a) purpose: didactic and/or academic; (b) informed consent: verbal or absent when the patient cannot be identified; (c) discussion groups on social media contribute to learning; (d) most dentists would not appreciate and sue the author if they had their own photographs/imaging examinations posted on social media; 5. most dentists received some information on ethical regulations during dental school and state that images can be used with patient authorisation, without identification and for didactic/academic purposes. CONCLUSION: Dentists consider the use of patients' images for didactic and scientific purposes beneficial, request informed consent to share mainly images that reveal the identity and would not appreciate if their personal images were shared without consent.

Evaluation of metal artefacts for two CBCT devices with a new dental arch phantom.

OBJECTIVES: To create a new phantom design to evaluate the real impact of artefacts caused by titanium on bone structures in cone beam CT images considering different positions and quantity of metals in the dental arch, with and without metal artefact reduction (MAR). METHODS: A three cylindrical polymethyl methacrylate (PMMA) plate phantom was designed containing eight perforations arranged to simulate the lower dental arch in the intermediate plate. Three titanium cylinders were positioned in different locations and quantities to test different clinical conditions and to quantify the impact of the metal artefact around five bone cylinders. Scans were carried out in seven different protocols (Control, A-F) in two cone beam CT devices (OP300 Maxio and Picasso Trio). Eight regions of interest around each cortical and trabecular bone were used to measure the grey value standard deviation corresponding the artefact expression in the Image J software. Both the artefact expression and the MAR effect were assessed using the Wilcoxon, Friedman (Dunn) and Kruskal-Wallis tests (significance level of 5%). RESULTS: For both devices, MAR was statistically efficient only for the protocols E, and F. Protocol F (three metals on the adjacent area of the analysis region) showed higher artefact expression when compared to the others. CONCLUSION: In conclusion, the new phantom design allowed the quantification of the metal artefact expression caused by titanium. The metal artefact expression is higher when more metal objects are positioned in the adjacent bone structures. MAR may not be effective to reduce artefact expression on the adjacencies of those objects for the devices studied.

Morphological Evaluation of the Nasopalatine Canal in Patients With Different Facial Profiles and Ages.

PURPOSE: To evaluate the influence of facial profile and age on the morphology of the nasopalatine canal. MATERIALS AND METHODS: One hundred thirty-two cone-beam computed tomograms were classified according to facial profile-mesofacial, brachyfacial, and dolichofacial-and divided into the following age groups: 21 to 30, 31 to 40, 41 to 50, and 51 to 60 years. Measurements were obtained for openings of the incisive and nasopalatine foramina, alveolar bone thickness, and the full length, most constricted region, and volume of the nasopalatine canal. Intra- and inter-examiner agreements were calculated using the intraclass correlation coefficient. After exploratory and descriptive analysis, data were subjected to 2-way analysis of variance and Tukey test for comparisons between facial profiles and age groups. The significance level was 5% (α = 0.05). RESULTS: Intra- and inter-examiner reproducibilities were excellent for all measurements. Patients older than 50 years presented a significantly larger nasopalatine canal than patients 21 to 30 years old for all facial profiles (P ≤ .05). Linear measurements obtained from the nasopalatine canal showed no significant difference between facial profiles and age groups (P > .05). CONCLUSIONS: The nasopalatine canal was not influenced by facial profile but did exhibit an increased volume with aging, particularly after 50 years of age.

A retrospective cephalometric study on upper airway spaces in different facial types.

BACKGROUND: Craniofacial growth pattern has been correlated with variations in size of the upper airway spaces. The objective of this study was to evaluate the nasopharyngeal, oropharyngeal, and hypopharyngeal airway spaces variations according to the craniofacial growth pattern, by comparing brachyfacial, mesofacial, and dolichofacial in Angle Class I individuals. METHODS: To measure the spaces, 45 lateral teleradiographs were used and divided into 3 groups per the craniofacial growth pattern, determined by the Tweed cephalometry angular measurements: FMA and Y-axis. To evaluate the airways, sleep apnea cephalometry was used, containing 28 points that compose 14 factors. Three groups were compared relative to each of the 14 sleep apnea cephalometry measurements. Adherence test to the normal curve was performed. For the non-normally distributed data-measurement of the inferior pharyngeal space-the Kruskal-Wallis test was used for comparison between the groups. For the remaining data, the distribution was normal and ANOVA test was used. RESULTS: Statistically significant difference was verified among the groups for the measurement of the median posterior-palatal space, with the difference being pointed out by the post hoc test between the brachyfacial and dolichofacial groups. For the other measurements, there was no statistically significant difference. CONCLUSIONS: It could be concluded that there was difference in the median posterior-palatal space measurement, in the oropharynx region, which was reduced for individuals with a dolichofacial pattern.