A predictive model for alternative admission to dental education.

AIM: To compare academic progress and performance of students admitted through two admission systems and to analyse the predictive power of different components in an alternative admission. SAMPLE AND METHODS: The subjects were students admitted to the dental programme at Malmö University, Sweden. The grade admission group was admitted on grades from secondary school (n = 126) and the alternative admission group via an alternative admission procedure (n = 157). The alternative admission procedure consisted of the following components: problem-solving matrices, spatial capacity tested with folding and tin models, manual dexterity, capacity for empathy and interview. Comparisons were made for academic progress (dropouts from the programme and study rate) and academic performance (examinations failed and outcomes of a comprehensive clinical examination). Spearman correlation was calculated for each component of the alternative admission procedure and academic progress as well as academic performance. Multivariate analyses were also carried out. RESULTS: Compared to the grade admission group, the alternative admission group presented lower rate of dropouts (3% vs. 20%, P < 0.001) and a larger proportion graduated within the expected time (88% vs. 60%, P < 0.01). There was no difference between the groups concerning academic performance. Capacity of empathy was correlated with study rate and outcomes of the clinical examination. The matrices predicted low proportion failed examinations and high students' self-assessments in the clinical examination. Predictive power of folding was limited and so was that of the interview. Manual dexterity was not correlated with academic progress or performance. CONCLUSIONS: Results support further development of admission selection criteria, particularly emphatic capacity that predicts important student academic achievements.

Treatment with an oral direct thrombin inhibitor decreases platelet activity but increases markers of inflammation in patients with myocardial infarction.

BACKGROUND: Thrombin has a role not only in the coagulation process but also in inflammatory responses. Oral direct thrombin inhibitors (DTIs) are currently being evaluated in patients with thromboembolic diseases. OBJECTIVE: To investigate whether an oral DTI affects markers for platelet and inflammatory activity after myocardial infarction (MI). METHODS: A total of 518 patients with MI were randomly assigned to ximelagatran treatment (four different dose groups) in combination with aspirin, or aspirin alone for 6 months. The levels of soluble (s) P-selectin, soluble tissue factor, C-reactive protein (CRP), interleukin (IL)-10 and IL-18 were analysed in serial blood samples. RESULTS: sP-selectin concentration increased after 1 week and persisted at an elevated level for 6 months in all study groups (P < 0.001). In the two highest ximelagatran dose groups, there was a reduced increase in sP-selectin compared to treatment with lower doses of ximelagatran and aspirin alone (P = 0.01 and P = 0.002, respectively). IL-18 levels did not change in the aspirin alone treatment group. By contrast, there was an elevation in IL-18 level in the lower and higher ximelagatran dose groups after 6 months (P = 0.006 and P < 0.001, respectively). Ximelagatran increased IL-10 levels (P = 0.002) and reduced the decrease in CRP levels after 6 months compared to treatment with aspirin alone (P = 0.002). CONCLUSION: A persistent elevation of platelet activity is found in patients with a recent MI after the cessation of acute antithrombotic treatment, and the addition of an oral DTI at higher doses decreases the activity. By contrast, long-term treatment with a DTI increases the levels of several markers of inflammation. Further studies with prolonged exposure of oral DTIs are needed for evaluation of the effect on inflammatory processes and to determine whether these agents influence clinical outcomes.

Curriculum structure, content, learning and assessment in European undergraduate dental education - update 2010.

This paper presents an updated statement on behalf of the Association for Dental Education in Europe (ADEE) in relation to proposals for undergraduate Curriculum Structure, Content, Learning, Assessment and Student / Staff Exchange for dental education in Europe. A task force was constituted to consider these issues and the two previous, related publications produced by the Association (Plasschaert et al 2006 and 2007) were revised. The broad European dental community was circulated and contributed to the revisions. The paper was approved at the General Assembly of ADEE, held in Amsterdam in August 2010 and will be updated again in 2015.

Non-vitamin K antagonist oral anticoagulants (NOACs) for thromboembolic prevention, are they safe in congenital heart disease? Results of a worldwide study.

BACKGROUND: Current guidelines consider vitamin K antagonists (VKA) the oral anticoagulant agents of choice in adults with atrial arrhythmias (AA) and moderate or complex forms of congenital heart disease, significant valvular lesions, or bioprosthetic valves, pending safety data on non-VKA oral anticoagulants (NOACs). Therefore, the international NOTE registry was initiated to assess safety, change in adherence and quality of life (QoL) associated with NOACs in adults with congenital heart disease (ACHD). METHODS: An international multicenter prospective study of NOACs in ACHD was established. Follow-up occurred at 6 months and yearly thereafter. Primary endpoints were thromboembolism and major bleeding. Secondary endpoints included minor bleeding, change in therapy adherence (≥80% medication refill rate, ≥6 out of 8 on Morisky-8 questionnaire) and QoL (SF-36 questionnaire). RESULTS: In total, 530 ACHD patients (mean age 47 SD 15 years; 55% male) with predominantly moderate or complex defects (85%), significant valvular lesions (46%) and/or bioprosthetic valves (11%) using NOACs (rivaroxaban 43%; apixaban 39%; dabigatran 12%; edoxaban 7%) were enrolled. The most common indication was AA (91%). Over a median follow-up of 1.0 [IQR 0.0-2.0] year, thromboembolic event rate was 1.0% [95%CI 0.4-2.0] (n = 6) per year, with 1.1% [95%CI 0.5-2.2] (n = 7) annualized rate of major bleeding and 6.3% [95%CI 4.5-8.5] (n = 37) annualized rate of minor bleeding. Adherence was sufficient during 2 years follow-up in 80-93% of patients. At 1-year follow-up, among the subset of previous VKA-users who completed the survey (n = 33), QoL improved in 6 out of 8 domains (p ≪ 0.05). CONCLUSIONS: Initial results from our worldwide prospective study suggest that NOACs are safe and may be effective for thromboembolic prevention in adults with heterogeneous forms of congenital heart disease.

Long-term treatment with ximelagatran, an oral direct thrombin inhibitor, persistently reduces the coagulation activity after a myocardial infarction.

BACKGROUND: In the ESTEEM study, patients with a recent myocardial infarction were treated with aspirin and randomized to one of four doses (24-60 mg b.i.d) of the oral direct thrombin inhibitor ximelagatran or placebo for 6 months. Ximelagatran and aspirin reduced the risk of recurrent ischemic events compared with aspirin alone. In the present substudy we evaluated the different doses of ximelagatran on pharmacokinetics as measured by plasma concentration of the active compound melagatran and activated partial thromboplastin time (APTT) and pharmacodynamics as related by markers for coagulation activity, prothrombin fragment 1 + 2 (F1 + 2) and D-dimer. METHODS AND RESULTS: Plasma samples from 518 patients were collected before, during and after the treatment period. There was a linear dose-concentration relation at peak and trough and a linear relation between concentration and APTT (P < 0.001). F1 + 2 and D-dimer were decreased by 25% and 52% at 1 week (P < 0.001) in the ximelagatran groups compared with the placebo group and the reductions were maintained during the 6 months treatment. There were no differences detected in F1 + 2 or D-dimer levels between the different ximelagatran dosages. There was no correlation between the melagatran concentration and the change in F1 + 2 and D-dimer levels. After cessation of ximelagatran F1 + 2 and D-dimer levels returned to the initial levels. CONCLUSION: The dose of ximelagatran and APTT are linearly related to the plasma concentration of melagatran. Ximelagatran induces a sustained and stable reduction of thrombin generation and fibrin turnover without any relation to dose above 24 mg b.i.d. These properties indicate that long-term treatment with a low dose of ximelagatran may provide valuable depression of coagulation activity in aspirin treated post myocardial infarction patients.

Endochondral bone formation in toothless (osteopetrotic) rats: failures of chondrocyte patterning and type X collagen expression.

The pacemaker of endochondral bone growth is cell division and hypertrophy of chondrocytes. The developmental stages of chondrocytes, characterized by the expression of collagen types II and X, are arranged in arrays across the growth zone. Mutations in collagen II and X genes as well as the absence of their gene products lead to different, altered patterns of chondrocyte stages which remain aligned across the growth plate (GP). Here we analyze GP of rats bearing the mutation toothless (tl) which, apart from bone defects, develop a progressive, severe chondrodystrophy during postnatal weeks 3 to 6. Mutant GP exhibited disorganized, non-aligned chondrocytes and mineralized metaphyseal bone but without cartilage mineralization or cartilaginous extensions into the metaphysis. Expression of mRNA coding for collagen types II (Col II) and X (Col X) was examined in the tibial GP by in situ hybridization. Mutant rats at 2 weeks exhibited Col II RNA expression and some hypertrophied chondrocytes (HC) but no Col X RNA was detected. By 3rd week, HC had largely disappeared from the central part of the mutant GP and Col II RNA expression was present but weak and in 2 separate bands. Peripherally the GP contained HC but without Col X RNA expression. This abnormal pattern was exacerbated by the fourth week. Bone mineralized but cartilage in the GP did not. These data suggest that the tl mutation involves a regulatory function for chondrocyte maturation, including Col X RNA synthesis and mineralization, and that the GP abnormalities are related to the Col X deficiency. The differences in patterning in the tl rat GP compared to direct Col X mutations may be explained by compensatory effects.

Expression of amelogenin mRNA sequences during development of rat molars.

The expression of amelogenin mRNA in growing rat molars was studied. Northern blotting and the analysis of cDNA isolates revealed two predoninant variants. One group of cDNA inserts contained sequences of a long mRNA version and the other group contained mRNA sequences of the shorter leucin-rich amelogenin polypeptide (LRAP). The LRAP group was deficient in an internal stretch which coded for a peptide with a high potential for beta turns. Northern blot experiments showed that most amelogenin RNA in rat teeth was represented by two bands of 1.1 and 0.8 kb. Two oligonucleotide probes were designed that were specific for the long version and for the LRAP variant. The probes were used for in situ hybridization experiments on sections of developing maxillar teeth of rats between day 2 and day 15 after birth. Both RNA species were accumulated concomitantly and exclusively in cells of the inner enamel epithelium. Expression was first observed at the mesial cusp sides and finally involved the whole ameloblast layer except for the cells adjacent to the enamel-free region at the tip of the cusps. The early amelogenin RNA expression occurred adjacent to the initial deposition of the dentin matrix. Low amounts of amelogenin RNA persisted after the differentiation of ameloblasts into the maturative stage. The sequence of events was similar in all three molars.

Collagen mRNA expression during tissue development: the temporospacial order coordinates bone morphogenesis with collagen fiber formation.

Bone formation of the maxilla and premaxilla of rats was studied by in situ hybridization, using probes for fibrillar collagen mRNAs. Chondroblasts, osteoblasts, fibroblasts and peripheral bone cells differed in their expression patterns. Prospective nasal chondroblasts expressed collagen alpha1(II) and alpha1(XI) RNA from day 15 post coitum. Bone formation in the adjacent maxilla and premaxilla started around day 17: groups of osteoblasts, representing ossification centers, expressed collagen alpha1(I) RNA strongly, and alpha1(V), alpha2(V) and alpha1(XI) RNA weakly, but they were deficient in collagen alpha1(III) RNA. As the centers expanded, osteoblasts in the resulting bone domains expressed collagen alpha1(I) RNA in abundance, whereas collagen alpha1(III) RNA was absent. Bone domains were surrounded by fibroblasts containing collagens alpha1(I), alpha1(III) and alpha2(V) RNA. Widely separated fibroblasts underwent condensation into densely packed periosteum and sutural soft tissues. Cells at the periphery of fast-growing bone domains also displayed, apart from collagen alpha1(I) RNA, collagens alpha2(V) and alpha1(XI) RNA. Given the continuous recruitment of cells from the periosteum, peripheral bone cells represent differentiating osteoblasts synthetizing collagens alpha2(V) and alpha1 (XI) RNA transiently. Thus, gene expression during osteoblast differentiation reflects synthesis of fiber components during bone growth, since collagen V is located in the center of fibers consisting primarily of collagen I.

Expression of collagen alpha1(I) mRNA variants during tooth and bone formation in the rat.

Collagen alpha1(I) mRNA is composed of two variants of 5 and 6 kb, differing in the length of the 3' untranslated region. In this work, the nucleotide sequences of the two rat mRNA variants were compared, and their expression pattern in cells forming bone, dentin, and cementum were analyzed. The sequences were determined from cDNA inserts of tooth and bone libraries plus directly from PCR fragments, obtained from bone. A total of 5721 bases of the rat collagen alpha1(I) sequence from cDNA of tooth and bone was determined. All sequences of the short variant were represented in the long variant. Only the alternatively poly-A additions gave rise to the variants in hard tissue. Two oligonucleotides were chosen as probes, one of which recognized, on Northern blots, the two bands of 5 and 6 kb, and the other the 6-kb variant only. The oligonucleotides were used in in situ hybridization experiments, for study of the distribution of the variants in different extracellular matrix-forming cells. Osteoblasts, odontoblasts, and cementum-associated cells were closely examined in sections from rat maxillae from 2 to 25 days of age. A similar or identical pattern of mRNA expression was observed with both oligonucleotides, indicating that the two mRNA variants were co-expressed in all cases.

Biochemical and physiological considerations for modeling biofilms in the oral cavity: a review.

This review describes some of the biochemical and physiological factors that should be considered in designing in vitro models of the oral cavity. The significance of the non-Newtonian properties and internal structures of saliva are reported as well as the ability of saliva to form biological films on all types of solid surfaces. The presence of compositional biochemical variations between absorbed salivary films is discussed for solid surfaces having different surface chemistries. The significance of the presence of small amounts of organic material in enamel and dentin is also stressed. Finally, by selecting other, more easily available secretional products than saliva, more relevant model systems for materials testing in vitro may be established than if only simple aqueous salt solutions are used.

On salivary film formation and bacterial retention to solids. A methodological and experimental in vitro study.

A parallel-plate flow cell system was developed to assess individual and combined parameters relevant to oral microbial retention. In this system, internal reflection germanium prisms represented oral solid surfaces including tooth surfaces. The system used, allowed adsorbed protein films to be analyzed in situ by multiple non-destructive surface analytical techniques, without provoking surface associated biofilms. Using a range of biochemical and biophysical techniques, germanium prisms of medium critical surface tension were noted to accurately model film formation at tooth-saliva interfaces. A range of clinically relevant temperatures (22 and 37 degrees C), rinse shear rates (1 and 32 ml/min) and critical surface tensions (high, medium and low) were systematically tested in the flow-cell system for their influence, if any, on salivary microbial retention from whole human saliva. Comparisons of the interfacial organization of adsorbed material were made between human parotid (HPS) and submandibular-sublingual (HSMSL) salivas. The influence of these salivary secretions was also tested on the retention capacities of Streptococcus sanguis and Streptococcus salivarius. Microbial retention was found to be significantly dependent on initial critical surface tensions and rinse flow rates, but not to be affected by tested temperatures. When compared to prisms of low and high critical surface tension, medium critical surface tension prisms retained the highest numbers of microorganisms. No statistically verified morphological selectivity was observed in the retained microbial populations. When the interfacial organizations of HPS and HSMSL were evaluated at low- and medium energy surfaces in the absence and presence the streptococci, comparatively thinner and denser films with pronounced bacterial retention was noted for HPS on prisms of low critical surface tension. In the presence of saliva or salivary fractions, no difference in retention capacities was observed between the tested bacterial strains. The data suggest that in the presence of saliva, physico-chemical and mechanical factors have a major influence on the short term microbial retention to solid surfaces. The amount of salivary proteins being initially retained to a material also seems to be more directly related to the critical surface tension quality of the solid than to the type of bacterial strain present in suspension. The empirical critical surface tension of a material is thus a useful predictor of both microbial retention capacities and primary interactions between saliva and solid surfaces.

D-dimer and risk of thromboembolic and bleeding events in patients with atrial fibrillation--observations from the ARISTOTLE trial.

BACKGROUND: D-dimer is related to adverse outcomes in arterial and venous thromboembolic diseases. OBJECTIVES: To evaluate the predictive value of D-dimer level for stroke, other cardiovascular events, and bleeds, in patients with atrial fibrillation (AF) treated with oral anticoagulation with apixaban or warfarin; and to evaluate the relationship between the D-dimer levels at baseline and the treatment effect of apixaban vs. warfarin. METHODS: In the ARISTOTLE trial, 18 201 patients with AF were randomized to apixaban or warfarin. D-dimer was analyzed in 14 878 patients at randomization. The cohort was separated into two groups; not receiving vitamin K antagonist (VKA) treatment and receiving VKA treatment at randomization. RESULTS: Higher D-dimer levels were associated with increased frequencies of stroke or systemic embolism (hazard ratio [HR] [Q4 vs. Q1] 1.72, 95% confidence interval [CI] 1.14-2.59, P = 0.003), death (HR [Q4 vs. Q1] 4.04, 95% CI 3.06-5.33) and major bleeding (HR [Q4 vs. Q1] 2.47, 95% CI 1.77-3.45, P < 0.0001) in the no-VKA group. Similar results were obtained in the on-VKA group. Adding D-dimer level to the CHADS2 score improved the C-index from 0.646 to 0.655 for stroke or systemic embolism, and from 0.598 to 0.662 for death, in the no-VKA group. D-dimer level improved the HAS-BLED score for prediction of major bleeds, with an increase in the C-index from 0.610 to 0.641. There were no significant interactions between efficacy and safety of study treatment and D-dimer level. CONCLUSION: In anticoagulated patients with AF, the level of D-dimer is related to the risk of stroke, death, and bleeding, and adds to the predictive value of clinical risk scores. The benefits of apixaban were consistent, regardless of the baseline D-dimer level.

Tissue factor and IL8 production by P-selectin-dependent platelet-monocyte aggregates in whole blood involves phosphorylation of Lyn and is inhibited by IL10.

BACKGROUND: P-selectin and CD40L expressed by activated platelets induce tissue factor (TF) and inflammatory cytokines in monocytes, but little is known of the cellular signaling pathways involved. The anti-inflammatory cytokine IL10 reduces atherosclerotic plaque formation. OBJECTIVES: To evaluate the importance of P-selectin upon platelet-monocyte aggregate (PMA) formation in thrombin receptor activator peptide (TRAP) stimulated whole blood, the P-selectin-P-selectin glycoprotein ligand (PSGL)-1-induced cellular signaling pathway, and the effects of IL10 on these functions. METHODS: TF, IL8, and monocyte chemotactic protein-1 (MCP-1) production, PMAs and phosphorylation of Lyn were analyzed in whole blood, purified monocytes, and vitamin D(3)-differentiated U-937 cells stimulated with TRAP or P-selectin with or without IL10. Anti-P-selectin or anti-CD40L antibodies (Abs), Src-kinases inhibitors, SU6656 or PP2, were added in some experiments. RESULTS: TRAP and P-selectin increased TF, IL8, and MCP-1 mRNA in whole blood and purified monocytes. Anti-P-selectin Ab reduced TRAP-induced PMA formation by 80 +/- 2% (P = 0.001) and production of TF (P = 0.04) and IL8 (P = 0.01). IL10 and SU6656 had no effect on PMA formation, although both significantly reduced TF (P = 0.002 and P = 0.02) and IL8 (P = 0.009 and P = 0.001) mRNA upon TRAP and P-selectin stimulation. Induced Lyn phosphorylation in monocytes was diminished by SU6656 (P = 0.02), anti-P-selectin Ab (P = 0.02), and IL10 (P = 0.03) upon TRAP or P-selectin stimulation. These results were confirmed in the vitamin D(3)-differentiated U-937 cells. CONCLUSIONS: The formation of PMAs in whole blood was P-selectin-dependent in the long term. P-selectin-PSGL-1-induced TF and IL8 expression through Lyn phosphorylation, and part of the inhibitory effect of IL10 depends on reduced phosphorylation.

Evaluation of student and faculty perceptions of the PBL curriculum at two dental schools from a student perspective: a cross-sectional survey.

Problem-based learning (PBL) research has primarily highlighted issues related to medical education and less evaluation has been reported from the field of dental education. Furthermore, literature reports tend to focus mainly on PBL from a pedagogic and curriculum constructional view and up to this date, studies from a student perspective are lacking. The aim of this study was to approach the evaluation of student and staff perceptions of PBL curricula from a student perspective at two separate schools: the Faculty of Odontology at the University of Malmö, Sweden and the dental school of the University of Southern California, School of Dentistry (USCSD), Los Angeles, CA, USA. The study was initiated and conducted by two of the authors, at the time senior students at the Faculty of Odontology in Malmö, Sweden. The study was comprised of a literature search, a 2 week field trip to USCSD, USA, survey distribution to students and faculty in both schools, analysis of the data and a written report for oral defence. The results from the survey were intended to provide feedback on student and faculty perceptions regarding the PBL curriculum. The results indicate a general student and faculty satisfaction with the PBL curriculum. Perhaps, surprisingly their perceptions did not differ significantly despite differences in geography, culture and implementation of PBL pedagogy.

Expression of HMGB1 during tooth development.

High mobility group box 1 (HMGB1) is a nuclear and cytosolic protein that can act as a transcription factor, a growth factor, or a cytokine. To elucidate a possible role for HMGB1 in tooth development, we have studied the expression of HMGB1 and its receptor RAGE (receptor for advanced glycation end-products) during the late fetal and early postnatal period of rat by using light- and electron-microscopic immunohistochemistry. Low HMGB1 protein expression was observed during fetal and newborn stages of tooth development. However, from postnatal day 5 (P5) onward, a marked increase occurred in the levels of the protein in most dental cell types. Expression was particularly high in ameloblasts and odontoblasts at regions of ongoing mineralization. Although most HMGB1 immunoreactivity was confined to cell nuclei, it was also present in odontoblast cytoplasm. At P5, ameloblasts and odontoblasts also showed RAGE immunoreactivity, and reverse transcription-polymerase chain reaction demonstrated both HMGB1 and RAGE mRNA in human dental pulp cells in vitro. Immunoblots performed on extracts from bovine dentin demonstrated a principal band at approximately 27 kDa, indicating that HMGB1 participates in tooth mineralization. The expression of both ligand and receptor suggests an autocrine/paracrine HMGB1 signalling axis in odontoblasts.

Rat enamel contains RP59: a new context for a protein from osteogenic and haematopoietic precursor cells.

We have recently identified a protein, RP59, in bone marrow cells and young osteoblasts, in cells involved in bone repair and in young erythroblasts and megakaryocytes. Here, we report immunohistochemical data at the light- and electron-microscope level indicating that RP59 is also present in newly secreted tooth enamel of the rat and in ameloblasts, the formative cells. In enamel matrix, RP59 was located proximal to secretory ameloblasts only, i.e. in newly secreted material. Distal enamel and enamel in association with maturation stage ameloblasts were unlabelled. Secretory ameloblasts contained RP59 in the matrix-proximal region including Tomes' processes, post-secretory ameloblasts in the cell-matrix interface. Western blotting of proteins from tooth germs identified RP59 as a band at 90 kD, co-migrating with RP59 from bone marrow and spleen. Antisera versus a chemically synthesised RP59 peptide and versus a bacteria-synthesised protein fragment reacted in the same manner. In situ hybridisation of tooth tissue revealed RP59 RNA specifically in ameloblasts. The reverse transcription/polymerase chain reaction method identified tooth RNA coding for RP59. Sequence analysis indicated that RP59 RNA from tooth and marrow had the same sequence. An internal sequence motif was found in rat RP59 resembling a signal implicated in secretion of the chicken "engrailed" gene product. The findings indicate that RP59 is a genuine product of ameloblasts and that it is secreted in the course of enamel formation together with other matrix components.

Retention of streptococci to defined solid surfaces in the presence of saliva secretions.

The initial surface retention of Streptococcus sanguis (G9B and ATCC 10556) and Streptococcus salivarius (ATCC 9758 and ATCC 13419) was examined using a well defined flow cell system. The microorganisms, known to be recovered from hard vs. soft tissue surfaces, respectively, were suspended in either Ringer solution, human parotid saliva (HPS), human submandibular and sublingual saliva (HSMSL), or mixed saliva. Microbial retention was evaluated on germanium prisms of low (20-25 mNm-1) and medium (30-35 mNm-1) critical surface tensions following distilled water rinse at 1 ml/min for 15 min. When suspended in only Ringer solution, the tested microorganisms showed patterns of generally high retention, that reflected the influence of both bacterial and substratum surface properties. However, in the saliva suspensions an overall reduction of retention was found with preferential retention to surfaces of medium critical surface tension for all bacteria. When comparing HPS and HSMSL as the suspending medium, a statistically significant observation was that smaller numbers of retained bacteria were recorded in the presence of HSMSL. The most frequently observed relationship between the tested salivas and numbers of retained cells was HSMSL less than MIXED less than HPS.

Role of temperature and shear forces on microbial detachment.

A flow cell system was used to assess the effects of shear stress and temperature on adhesion and retention of oral microorganisms from unstimulated whole human saliva. The saliva passed between two parallel mounted test plates, prepared and calibrated to present a surface energetic state similar to that of natural teeth and most restorative materials. The initial attachment of microorganisms occurred at a constant flow rate of 1 ml/min. Microbiota and biofilm material associated with the surface after 15 min of exposure were then challenged by introducing a cell-free rinsing fluid at increased flow rates. The remaining population was counted in a reflected light microscope and correlated to the calculated shear stress for each experiment. A reduction of 70-80% of attached microorganisms was seen after a 30-fold increase of the detaching force. No statistically significant differences could be detected in the proportions of initially attached or the remaining cocci and rods. The experiments were conducted at two temperature levels, both within a physiologic range representative of the oral environment. Temperature did not significantly affect the total numbers of attached or retained microorganisms, within the range of 22-37 degrees C. These findings demonstrate that non-specific attachment and detachment processes are important in the initial stage of microbial adhesion. Although biologically specific adhesive interactions were not addressed in this study, the data suggest that these may occur only after a minimum contact time of non-specifically surface associated cells.

Clinical guidelines and self-assessment in dental education.

This paper describes an educational programme where clinical guidelines are used in dental education and assesses the value of these guidelines as perceived by undergraduate students. It presents a comparison of students' own assessments of their performance with those of their instructors, according to such guidelines. The educational programme at the Faculty of Odontology, Lund University, is described through 3 main principles: problem-based learning, adoption of a holistic attitude to patient care and the promotion of oral health. The dental curriculum occupies 5 years comprising 10 semesters. 41, 5th semester students (16 male and 25 female) participated in the study. Students were introduced to guidelines in group discussions at the beginning of the semester. At the completion of a patient's planned course of treatment, the outcome was formally assessed both by students and clinical instructors. Performance was scored in various categories as "excellent", "acceptable" or "unacceptable" according to the standards defined. A total of 1373 scores were made by both students and instructors. 88% cent of students used the guidelines often or almost always and found them useful. Overall, no students received an "unacceptable" score and 40% of students achieved a score of "excellent". Female students tended towards a higher score, but this was not significant. Instructors' and students' scores agreed in almost 90% of instances. Students under-scored their performance more frequently than they over-scored it. It appears that the use of clinical guidelines may encourage an increased awareness of the decision-making processes involved in clinical practice, but it must be acknowledged that these guidelines are complex both in derivation and application.