Oral Medicine for undergraduate dental students in the United Kingdom and Ireland-A curriculum.

INTRODUCTION: Oral Medicine focuses on care for patients with chronic, recurrent and medically related disorders of the orofacial region that are distinct from diseases of the periodontal and tooth tissues, with an emphasis on non-surgical management. At present, there are no shared outcomes for Oral Medicine to define the standards to be achieved before new graduates become registered dentists engaged with ongoing professional development. CURRICULUM: We present a consensus undergraduate curriculum in Oral Medicine agreed by representatives from 18 Dental Schools in the United Kingdom and Republic of Ireland. The scope of Oral Medicine practice includes conditions involving the oral mucosa, salivary glands, neurological system or musculoskeletal tissues that are not directly attributable to dental (tooth and periodontium) pathology. Account is taken of the priorities for practice and learning opportunities needed to support development of relevance to independent clinical practice. The outcomes triangulate with the requirements set out by the respective regulatory bodies in the UK and Republic of Ireland prior to first registration and are consistent with the framework for European undergraduate dental education and greater harmonisation of dental education. CONCLUSIONS: This curriculum will act as a foundation for an increasingly shared approach between centres with respect to the outcomes to be achieved in Oral Medicine. The curriculum may also be of interest to others, such as those responsible for the training of dental hygienists and dental therapists. It provides a platform for future collective developments with the overarching goal of raising the quality of patient care.

Patient-reported outcome measures in burning mouth syndrome - a review of the literature.

Oral Diseases (2013) 19, 230-235 This review aims to investigate the patient-reported outcomes currently used in the burning mouth syndrome literature and to explore whether any standardisation of such measures has taken place. Electronic databases were searched for all types of burning mouth syndrome studies using patient-reported outcome measures. Studies were selected by predefined inclusion criteria. Copies of the papers obtained were thoroughly reviewed. A study-specific data extraction form was used, allowing papers to be reviewed in a standardised manner. The initial literature search yielded a total of 173 citations, 43 of which were deemed suitable for inclusion in this study. Symptom severity and symptomatic relief were reported as a patient-reported outcome measure in 40 of the studies and quantified most commonly using a visual analogue scale. Quality of life was reported in 13 studies included in this review. Depression and/or anxiety was reported in 14 of the studies. As is evident from the variety of questionnaires and instruments used in the evaluation of the impact of burning mouth syndrome on patients' lives, no standardisation of patient outcomes has yet been achieved.

Transmission dynamics of hepatitis E virus in pigs: estimation from field data and effect of vaccination.

Hepatitis E is a viral disease that causes serious concerns for public health. Hepatitis E virus (HEV) genotype 3 is endemic in commercial pig farms worldwide that act as a reservoir. Pig-to-human transmission may occur when infectious animals enter the food chain at slaughter, through consumption of contaminated meat, direct exposure or use of by-products. To reduce the fraction of infectious animals at slaughter age and thus the risk for public health, it is important to understand the transmission dynamics of HEV in pig populations. In this study, we estimate the transmission rate parameter and mean infectious period of HEV in pigs from field data, using a Bayesian analysis. The data were collected in ten commercial pig herds that are each divided into three different age groups. Two transmission models were compared, assuming that animals are infected either locally by their group mates or globally by any infectious animal regardless of its group. For local and global transmission, the transmission rate parameters were 0.11 (posterior median with 95% credible interval: 0.092-0.14 day(-1)) and 0.16 (0.082-0.29 day(-1)), the mean infectious periods were 24 (18-33) days and 27 (20-39) days and the reproduction numbers were 2.7 (2.2-3.6) and 4.3 (2.8-6.9). Based on these results, global transmission is considered to be the more conservative model. Three effects of vaccination were explored separately. When vaccination is not sufficient to eliminate the virus, a shorter mean infectious period decreases the fraction of infectious animals at slaughter age, whereas a reduced transmission rate parameter adversely increases it. With a reduced susceptibility, vaccination of animals at a later age can be a better strategy than early vaccination. These effects should be taken into account in vaccine development.

Further reliability and responsiveness of the Chronic Oral Mucosal Diseases Questionnaire.

OBJECTIVE: To test the reliability and responsiveness of the Chronic Oral Mucosal Diseases Questionnaire (COMDQ), in measuring the quality of life (QofL) in patients with chronic oral mucosal conditions. METHODS: A random sample of 160 patients with the following chronic oral mucosal conditions, recurrent aphthous stomatitis, oral lichen planus, the more common vesiculobullous conditions (mucous membrane pemphigoid and pemphigus vulgaris) and orofacial granulomatosis received a copy of the COMDQ. A subset of 100 patients received the questionnaire on two further occasions, 2 weeks and 3 months later. Statistical tests were carried out to evaluate the test-retest reliability and responsiveness of this instrument. RESULTS: This study has demonstrated that the COMDQ has good test-retest reliability with an intraclass correlation coefficient of 0.81 and is responsive to changes in the patients' overall conditions. CONCLUSION: In conclusion, this study has further demonstrated the reliability and responsiveness of the COMDQ in assessing QofL in patients with chronic oral mucosal diseases.

Characteristics of patients with orofacial granulomatosis.

OBJECTIVES: Orofacial granulomatosis has mostly been described in reports of very small numbers of cases. Few large case groups have been described. The aim of this study was to describe the demographics, symptoms, clinical features and laboratory findings in a large cohort of cases. SUBJECTS AND METHODS: Clinical and laboratory data for 119 cases of orofacial granulomatosis who attended oral medicine clinics in Dublin, Ireland, were examined for demographic characteristics at the time of first presentation. The male/female ratio was approximately 1:1, with a median age (and range) of 28 (5-84) years. RESULTS: Symptoms had been present for a median duration of 12 weeks. A food association was suspected by 30% of patients. The predominant complaint was lip swelling (77%) with only 15% reporting facial swelling, while 8% complained of both. Almost all patients had clinical evidence of lip or facial swelling (95%). Other common extra-oral manifestations were lip fissuring (30%), angular cheilitis (28%) and perioral erythema (28%). Common intra-oral manifestations were cobblestoning of the buccal mucosa (63%), ulcers (36%), granulomatous gingivitis (33%), mucosal tags (29%) and fissured tongue (17%). Over half of the biopsies (56%) performed were reported as typical of orofacial granulomatosis. CONCLUSION: This is one of the largest cohorts of orofacial granulomatosis patients to have been described in detail.

Clinical medical sciences for undergraduate dental students in the United Kingdom and Ireland - a curriculum.

The technical aspects of dentistry need to be practised with insight into the spectrum of human diseases and illnesses and how these impact upon individuals and society. Application of this insight is critical to decision-making related to the planning and delivery of safe and appropriate patient-centred healthcare tailored to the needs of the individual. Provision for the necessary training is included in undergraduate programmes, but in the United Kingdom and Ireland there is considerable variation between centres without common outcomes. In 2009 representatives from 17 undergraduate dental schools in the United Kingdom and Ireland agreed to move towards a common, shared approach to meet their own immediate needs and that might also be of value to others in keeping with the Bologna Process. To provide a clear identity the term 'Clinical Medical Sciences in Dentistry' was agreed in preference to other names such as 'Human Disease' or 'Medicine and Surgery'. The group was challenged to define consensus outcomes. Contemporary dental education documents informed, but did not drive the process. The consensus curriculum for undergraduate Clinical Medical Sciences in Dentistry teaching agreed by the participating centres is reported. Many of the issues are generic and it includes elements that are likely to be applicable to others. This document will act as a focus for a more unified approach to the outcomes required by graduates of the participating centres and act as a catalyst for future developments that ultimately aim to enhance the quality of patient care.

Correlations between MRI white matter lesion location and executive function and episodic memory.

OBJECTIVES: MRI white matter hyperintensity (WMH) volume is associated with cognitive impairment. We hypothesized that specific loci of WMH would correlate with cognition even after accounting for total WMH volume. METHODS: Subjects were identified from a prospective community-based study: 40 had normal cognition, 94 had mild impairment (defined here as a Clinical Dementia Rating [CDR] score of 0.5 without dementia), and 11 had mild Alzheimer's dementia. Factor analysis of a 22-item neuropsychological battery yielded 4 factors (episodic memory, executive function, spatial skills, and general knowledge). MRI WMH segmentation and analysis was performed using FreeSurfer software. RESULTS: Higher WMH volume was independently associated with lower executive function and episodic memory factor scores. Voxel-based general linear models showed loci where WMH was strongly inversely associated with specific cognitive factor scores (p < 0.001), controlling for age, education, sex, APOE genotype, and total WMH volume. For episodic memory, clusters were observed in bilateral temporal-occipital and right parietal periventricular white matter, and the left anterior limb of the internal capsule. For executive function, clusters were observed in bilateral inferior frontal white matter, bilateral temporal-occipital and right parietal periventricular white matter, and the anterior limb of the internal capsule bilaterally. CONCLUSIONS: Specific WMH loci are closely associated with executive function and episodic memory, independent of total WMH volume. The anatomic locations suggest that WMH may cause cognitive impairment by affecting connections between cortex and subcortical structures, including the thalamus and striatum, or connections between the occipital lobe and frontal or parietal lobes.

Retrospective evaluation of the referral pattern to an oral medicine unit in Ireland.

OBJECTIVES: The aims of this study were firstly to examine patient demographics, lesion types and referral sources to Cork University Dental School and Hospital (CUDSH) for oral medicine services and secondly, to indicate factors that could improve the efficiency of the service provided. METHODS: A retrospective analysis of the clinical records for all new patients, both public and private, seen in the CUDSH oral medicine unit (n = 412) in the calendar year 2007 was undertaken. For each patient the following parameters were recorded: age, gender, residence, referral source and the reason for referral including site of lesion. RESULTS: The majority of patients were females and the majority of referrals came from general dental practitioners. The most common reason for referral was due to concern about white lesions. Raised soft tissue lesions including epuli and mucocoeles were second and ulceration, including recurrent aphthous and traumatic ulceration, was the third most common reason for referral. CONCLUSIONS: To our knowledge this is the first study to investigate factors influencing referrals to oral medicine clinics in Ireland. Based on the results presented there appears to be a considerable demand for an oral medicine service dealing with oral lesions and conditions which other practitioners consider to be outside the scope of their practice. Studies of this nature should prove to be valuable in maximising hospital resources at a time when economic factors are leading to increased financial pressure in health care funding.

Impact of chronic oral mucosal disease on daily life: preliminary observations from a qualitative study.

OBJECTIVE: To explore the experience of daily life of persons with chronic oral mucosal conditions. METHODS: Purposive sampling was used to recruit patients from the Oral Medicine Unit of Cork University Dental School and Hospital. An experienced independent facilitator convened the focus groups and conducted individual interviews in a non clinical setting. Focus groups were mixed with regard to gender, age, chronic oral mucosal condition, time since diagnosis and severity. A total of 24 patients took part, including patients with oral lichen planus, mucous membrane pemphigoid, pemphigus vulgaris, recurrent aphthous stomatitis and orofacial granulomatosis. RESULTS: Analysis of the interviews revealed that patient views could be divided into the following themes - biopsychosocial issues, treatment limitations and side effects, unpredictability of the conditions and the potential for malignant transformation and issues for the healthcare professionals. CONCLUSION: Chronic oral mucosal conditions impact upon the experience of daily life of patients in a variety of areas from physical health and functioning, to concerns about their future. The role of the oral medicine practitioner in treating patients with chronic oral mucosal diseases extends beyond active management and symptomatic relief to the management of all aspects of these conditions that impact upon their daily lives.

Burning mouth syndrome and oral health-related quality of life: is there a change over time?

BACKGROUND: The symptoms associated with burning mouth syndrome can be quite varied and can interfere with the every day lives of patients. Management of the condition can be challenging for clinicians. AIMS: To determine the oral health-related quality of life (OHRQOL) implications of BMS on patients over a period of time whilst undergoing treatment and to evaluate whether treatment interventions had a positive effect on OHRQOL. MATERIALS AND METHODS: Thirty-two individuals (26 females, 6 males, mean age 61 years, range 38-83 years) were enrolled in this study. Individuals were interviewed using Short-Form McGill Pain Questionnaire (SFMPQ), Visual Analogue Scale (VAS), the Hospital Anxiety and Depression Scale (HADS) and the Oral Health Impact Profile (OHIP-14), at weeks 0, 8 and 16. RESULTS: Scores from all outcome measures used decreased over the 16 weeks of the study. Statistically significant differences were found between time points for VAS pain scores (P < 0.001), HADS depression scores (P = 0.029), SFMPQ sensory pain scores (P < 0.01) and total scores for OHIP-14 (P < 0.05). CONCLUSION: Burning mouth syndrome has a negative impact on OHRQOL; however, individually tailored management of the condition can result in an improvement in patient-reported outcome measures including quality of life.

The use of quality of life measures in oral medicine: a review of the literature.

OBJECTIVES: To explore the use of patient reported quality of life measures in oral medicine, to highlight the importance of use of these measures in oral medicine practice and to provide guidance for the selection of such measures in the future. METHODS: A detailed literature review was undertaken to investigate the use of quality of life measures in oral medicine. The databases searched were MEDLINE (through PubMed), EMBASE, CINDHL, Web of Science Citation Index and the Cochrane Database of Systematic Reviews and randomised controlled trials. RESULTS: The initial literature search yielded a total of 5310 citations; however, only 63 of these fulfilled the inclusion criteria. Twenty-two articles were regarding oral mucosal conditions, 14 related to orofacial pain disorders and 27 were regarding salivary gland-related conditions. CONCLUSIONS: The evaluation of quality of life in oral medicine has a broad applicability, providing information in treatment-based studies and population-based studies. A predominance of generic and oral health specific quality of life measures are being used to a limited extent in oral medicine practice. A scarcity of reports of the development, validation or use of disease specific measures is evident.

Dental patients' use of the Internet.

AIMS AND OBJECTIVES: To determine the use of the Internet by patients attending a range of dental clinics to search for information regarding dental procedures, and also to investigate their interest in online dental consultations and 'dental tourism'. METHODS: A questionnaire was designed and randomly distributed to 520 patients attending the restorative dentistry, dental surgery and oral medicine clinics of Cork University Dental School and Hospital. RESULTS: Of the 520 questionnaires distributed, 500 were completed leading to a response rate of 96.2%. The majority of patients were familiar with using the Internet on a daily basis, with only 163 (32.6%) patients not using the Internet in their everyday lives. One hundred and seventy-seven (34.5%) patients either researched their presenting dental/oral condition or had a family or friend research their condition on their behalf. One hundred and eighty-five (37%) patients would consult with a dental practitioner online regarding an oral problem and a similar number (n=186) of patients surveyed would consider using the Internet to plan trips abroad for dental treatment. CONCLUSION: Practitioner-led direction for patients regarding quality information sources online is important. With the increased interest in travelling abroad for dental treatment, guidance for patients and practitioners regarding the legal and ethical issues pertaining to dental tourism is critical.

NICE guideline on antibiotic prophylaxis against infective endocarditis: attitudes to the guideline and implications for dental practice in Ireland.

AIMS AND OBJECTIVES: To investigate attitudes of Irish dental practitioners, cardiologists and patients with cardiac lesions to the new NICE guideline for antibiotic prophylaxis against infective endocarditis and to determine the implications of this guideline for dental practice in Ireland. METHODS: Individually tailored anonymous postal questionnaires were sent to 500 dental practitioners, 54 cardiologists and 50 patients with a history of antibiotic prophylaxis usage before dental treatment. RESULTS: Two hundred and ninety questionnaires were returned from dental practitioners (a response rate of 58%), 20 questionnaires were returned from cardiologists (a response rate of 37%) and 34 questionnaires were returned from patients (a response rate of 68%). Two thirds of patients surveyed would be concerned about the possible cessation of antibiotic prophylaxis before dental treatment and would require either verbal or written confirmation from a cardiologist. Among the dental practitioners surveyed a significant majority were not willing to implement the NICE guideline without further information from the patient general medical practitioner, cardiologist or an official Irish body. CONCLUSION: To enable patient re-education regarding antibiotic prophylaxis, dental practitioners must keep abreast of changes to current guidelines and understand the rationale driving these changes. Difficulties arise for dental practitioners when there is no national statutory body endorsing such guidelines, particularly now that the guidelines in relation to antibiotic prophylaxis in dentistry are so different.

Excretion of hepatitis E virus by pigs of different ages and its presence in slurry stores in the United Kingdom.

Five faecal samples were collected from four different stages of production at each of 10 pig farms in the Yorkshire Humberside area of the UK, and samples of slurry were collected from nine of the farms. All the samples were tested for hepatitis E virus (HEV) RNA by a nested reverse transcriptase PCR. At least one sample from the pigs on each of the farms tested positive for hev; its prevalence in the 10 herds varied from 5 per cent to 35 per cent and its mean prevalence was 21.5 per cent. The mean prevalence in pigs aged three to five weeks was 26.0 per cent, in pigs aged 10 to 12 weeks 44.0 per cent, in pigs aged 22 to 24 weeks 8.9 per cent, and in adult dry sows 6.0 per cent. Two of the nine slurry lagoons tested positive for HEV RNA. Phylogenetic analysis of the sequence data indicated that the strains of the virus were of genotype 3 and closely related to strains detected in other pigs and in human beings in the UK.

Attitudes of Irish dental, dental hygiene and dental nursing students and newly qualified practitioners to tobacco use cessation: a national survey.

BACKGROUND: Ireland has some of the strictest smoking regulations in the world. Little is known of the attitudes of student Irish dental healthcare workers towards tobacco control and tobacco use cessation. This study aimed at determining the knowledge and attitudes of these students towards the deleterious effects of tobacco in the mouth and towards tobacco use cessation in dental practice. METHOD: A questionnaire survey was distributed to 654 students (including newly qualified) on dentistry, dental hygiene and dental nursing programmes in Irish dental schools. Information sought included college, course, year of study, sex, age, nationality, smoking status, knowledge of effects of tobacco in the mouth and attitudes towards tobacco use cessation in dental practice and towards the Irish smoking bans. MAIN FINDINGS: There was a 90% response rate. In all, 12% of dental students, 25% of dental hygiene students and 31% of dental nursing students were current smokers. Newly qualified dental hygienists were as knowledgeable about tobacco effects in the mouth as newly qualified dentists. Overall, the majority in each student category believed that all three groups could be effective tobacco counsellors and should provide tobacco use cessation counselling to patients, although less than half of evening course dental nursing students felt that dental nurses could be effective counsellors or should provide counselling. There was overwhelming support for the Irish smoking ban. Only a minority of dental students and dental nursing students had received instruction in tobacco use cessation counselling. CONCLUSIONS: There are strong positive attitudes to tobacco use cessation counselling in dental practice among these young dental healthcare students. This is true even amongst those who have not received specific instruction in tobacco use cessation counselling.

Clinical management of oral lichen planus.

Oral lichen planus is a relatively common chronic disease of the mucous membranes which may have more transient cutaneous manifestations. It has a number of well-recognized clinical signs and a wide range of symptoms from none through mild discomfort to severe debilitating intra-oral erosions and ulceration. It often does not respond to treatment and, in a small proportion of cases, undergoes malignant transformation to squamous cell carcinoma. Although there is an array of treatments, they are palliative rather than curative. Corticosteroids in various forms remain the mainstay of treatment but newer immunomodulatory agents have an increasing role. In this paper, we review current thinking about the management of oral lichen planus and summarize a recent European consensus protocol.