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1.  Transcutaneous electrical nerve stimulation therapy: An adjuvant pain controlling modality in TMD patients — A clinical study 
Dental Research Journal  2014;11(6):676-679.
Background:
The use of transcutaneous electrical nerve stimulation (TENS) in dentistry was first described in 1967, by Shane and Kessler, but it has yet to gain widespread acceptance in dentistry. A study was undertaken to evaluate the effectiveness of TENS therapy as an adjuvant modality and to compare it with the conventional medication in controlling pain in temporomandibular disorder (TMD) patients.
Materials and Methods:
The study was carried out in the Department of Oral Medicine and Radiology, Yenepoya Dental College and Hospital, Mangalore. A total of 40 patients with the clinical symptom of pain associated with TMDs were randomly divided into two groups. Group A (control) patients were treated with medication (analgesics and muscle relaxants) alone, while group B patients were treated with TENS therapy in combination with medication. The intensity of the pain was assessed using the Visual Analog Scale (VAS). The results were analyzed with the student's ‘t’ test. A P-value < 0.05 was considered as significant.
Results:
A significant improvement was observed in both the TENS and the control group in terms of pain control. On comparative analysis, adjuvant TENS therapy was found to be more effective than medication alone, in controlling pain. (P value = 0.019).
Conclusion:
The observed data suggest that TENS therapy can be used as an adjuvant modality in the management of pain associated with TMDs. This study justifies the use of TENS therapy in the management of TMD.
PMCID: PMC4275636  PMID: 25540662
Temporomandibular disorder; temporomandibular joint; transcutaneous electrical nerve stimulation
2.  Dentistry – a professional contained career in healthcare. A qualitative study of Vocational Dental Practitioners' professional expectations 
BMC Oral Health  2007;7:16.
Background
New graduates in the UK presently spend one year in training as Vocational Dental Practitioners (VDPs) in preparation for primary dental care. There is a growing recognition that the emerging workforce has very different professional expectations to those of earlier generations, with implications for the profession, patients and the performance of health systems. The objectives of this study were to investigate why VDPs' in England and Wales perceive they chose dentistry as a professional career; how they perceive their vision has changed and the implications for their professional career plans, both short- and longterm.
Methods
Purposive sampling of schemes was undertaken to include urban, rural and metropolitan schemes, schemes in areas with and without dental schools and geographic coverage across England and Wales. All VDPs in these schemes were initiated to participate in this qualitative study using focus groups. A topic guide was utilised to standardise data collection. Informants' views were recorded on tape and in field notes. Data were transcribed and analysed using Framework Methodology.
Results
A total of 99 VDPs participated in the 10 focus groups. Their choice of dentistry as a professional career was motivated by multiple categories of influence: 'academic', 'healthcare', 'lifestyle', the influence of 'family', 'friends', 'careers advice' and 'work experience'. Consideration of the features of the 'professional job' appears to have been key to their choice of dentistry and the 'active rejection of medicine' as an alternative career.
Entry into the profession was proving a challenging process for some but not all VDPs. Informants perceived that their vision had been moderated as a result of 'personal student debt', 'national workforce initiatives', 'limitations on clinical practice' and the 'cost of additional training'.
Short term goals focused around 'recovery from the past' and 'preparation for the future'. Longterm goals covered the spectrum of opportunities within dentistry. Factors influencing VDPs longterm career plans fell into six main categories: professional, personal, financial, political, social and cultural.
Conclusion
VDPs chose dentistry because they perceived that it provides a financially lucrative, contained career in healthcare, with professional status, job security and the opportunity to work flexibly. They perceive that their vision is challenged by changes affecting education and the healthcare system. Longterm professional expectations were closely linked with their personal lives and support a vision of a favourable work/life balance.
doi:10.1186/1472-6831-7-16
PMCID: PMC2200640  PMID: 18005452
3.  Dental anxiety: a comparison of students of dentistry, biology, and psychology 
Introduction
Dental anxiety is an important challenge for many patients and clinicians. It is thus of importance to know more about dental students’ own experiences with dental anxiety and their understanding of dental anxiety. The aim was to investigate differences in dental anxiety levels between dental students, psychology students, and biology students at a Norwegian university.
Materials and methods
A total of 510 students of dentistry, psychology, and biology at the University of Tromsø received a questionnaire consisting of the Modified Dental Anxiety Scale, demographic questions, and questions relating to their last visit to the dentist/dental hygienist; 169 students gave complete responses. Nonparametric tests were used to investigate differences between the student groups.
Results
The respondents were 78% female and 22% male; their mean age was 24 years. The dental students showed a significantly lower degree of dental anxiety than the psychology (P<0.001) and biology students (P<0.001). A significant decrease in dental anxiety levels was found between novice and experienced dentistry students (P<0.001).
Discussion
The dental students had less dental anxiety compared to psychology students and biology students. Experienced dental students also had less dental anxiety than novice dental students. This could indicate that the dentistry program structure at the university may influence dental anxiety levels.
Conclusion
Dental anxiety seemed to be less frequent in dentistry students compared to students of biology or clinical psychology. The practice-oriented dentistry education at the university might contribute to the differences in anxiety levels between new and experienced dentistry students.
doi:10.2147/JMDH.S69178
PMCID: PMC4181736  PMID: 25285013
dentistry; Modified Dental Anxiety Scale; practice; training; education; questionnaire-study
4.  An Objective Evaluation of Clinical Signs Used to Assess Sedation with Intravenous Diazepam 
Anesthesia Progress  1980;27(1):18-20.
In the majority of dental schools there are insufficient numbers of clinical patients for all students to receive optimal experience in intravenous sedation. This investigation was carried out to assess whether the signs and symptoms for intravenous sedation taught to the undergraduates were sufficiently objective to ensure that this clinical deficiency was not detrimental to competency of the graduating student. The signs of ptosis, altered speech and blurred vision were used by both experienced dentists and novice students to assess the level of intravenous sedation. Blurred vision was found to be unreliable while altered speech was more accurate than ptosis. The more experienced the operator the earlier the signs were observed.
The “Guidelines for the Teaching of Pain and Anxiety Control in Dentistry” were initially formulated by the American Dental Association in 1971 and revised in 19781 while similar guidelines were accepted by the House of Delegates of the Association of the Canadian Faculties of Dentistry in 19752 Both of these documents outlined the course of instructions necessary for the teaching of all modalities of pain and apprehension control at the undergraduate, postgraduate and continuing education level. Implementation of these guidelines at the undergraduate level has proven to be particularly difficult in the area of intravenous sedation because of the lack of suitable patients. This has resulted in many students graduating, having had little practical experience in sedating a patient with an intravenous drug. It is the hope of educators in this field that lectures, seminars, and demonstrations given to dental students are sufficient to overcome this deficiency.
Since the most critical clinical aspect of intravenous sedation is titrating the amount of drug required without overdosing or underdosing the patient, it was decided to investigate this ability in students with no clinical experience with intravenous diazepam. Although many drugs and techniques are advocated3,4,5 it was decided to limit the study to intravenous diazepam as it may be used alone and has a high therapeutic index.
With the introduction of diazepam to clinical practice the symptomatology of the drug was established and described by clinicians.6,7 Objective methods of measuring recovery from diazepam have been described by several authors8,9,10 but the signs and symptoms used to assess the initial level of sedation have been subjective. This can be attributed to the fact that sedation is an ill-defined clinical effect and can, therefore, only be calibrated by individual arbitary signs. The most frequently used signs for intravenous diazepam sedation are ptosis, also referred to as “the Verrill sign,”11 altered speech and blurred vision.7 This investigation was designed to test the reliability of these signs and to examine the variability of observations between clinicians and students.
PMCID: PMC2515966  PMID: 6933870
5.  Assessment of quality of prescription by dental students 
Journal of Applied Oral Science  2014;22(3):204-208.
Objective
The main objective of this study was to evaluate changes in prescribing pattern of Dentistry students throughout academic course.
Methods
A case of non-complicated dental extraction was presented to all students that had completed their pharmacology coursework (from 4th semester to the last semester). The students were grouped according to year of study and were asked to prescribe paracetamol for pain control. A maximal score of 5 points was calculated from three subscores for identification of professional and patient (1.0 point), drug concentration, dosage, and quantity (1.5 points); and drug information, instructions, and warnings (2.5 points). The data were expressed as medians [95% confidence intervals (CIs)] and were compared using the Kruskal-Wallis test followed by Dunn's post hoc test. A p<0.05 value was considered statistically significant. A total of 92 students participated the study (2nd year, N=12; 3rd year, N=32; 4th year, N=28; 5th year, N=20).
Results
The quality of prescription showed improvement between 2nd-year students [2.0 (1.5-2.5)] and 4th-year students [3.2 (2.9-3.5), p<0.05]; 4th- and 5th-year students [3.6 (3.5-3.8)] performed similarly. Lack of information about pharmacological treatment, side effects, and administration route were the major deficiencies observed.
Conclusion
Although Dentistry students present a general improvement in their prescribing performance, deficiencies remain even in advanced students. The data suggest that the teaching of good prescription practices should extend throughout the later phases of preprofessional dental education.
doi:10.1590/1678-775720130568
PMCID: PMC4072271  PMID: 25025561
Teaching; Drug prescriptions; Dentistry
6.  Anesthetic technique for inferior alveolar nerve block: a new approach 
Background
Effective pain control in Dentistry may be achieved by local anesthetic techniques. The success of the anesthetic technique in mandibular structures depends on the proximity of the needle tip to the mandibular foramen at the moment of anesthetic injection into the pterygomandibular region. Two techniques are available to reach the inferior alveolar nerve where it enters the mandibular canal, namely indirect and direct; these techniques differ in the number of movements required. Data demonstrate that the indirect technique is considered ineffective in 15% of cases and the direct technique in 1329% of cases.
Objective
Objective: The aim of this study was to describe an alternative technique for inferior alveolar nerve block using several anatomical points for reference, simplifying the procedure and enabling greater success and a more rapid learning curve.
Materials and Methods
A total of 193 mandibles (146 with permanent dentition and 47 with primary dentition) from dry skulls were used to establish a relationship between the teeth and the mandibular foramen. By using two wires, the first passing through the mesiobuccal groove and middle point of the mesial slope of the distolingual cusp of the primary second molar or permanent first molar (right side), and the second following the oclusal plane (left side), a line can be achieved whose projection coincides with the left mandibular foramen.
Results
The obtained data showed correlation in 82.88% of cases using the permanent first molar, and in 93.62% of cases using the primary second molar.
Conclusion
This method is potentially effective for inferior alveolar nerve block, especially in Pediatric Dentistry.
doi:10.1590/S1678-77572011000100004
PMCID: PMC4245857  PMID: 21437463
Anesthesia, dental; Nerve block; Inferior alveolar nerve
7.  Drugs Used for Parenteral Sedation in Dental Practice 
Anesthesia Progress  1988;35(5):199-205.
The relative efficacy and safety of drugs and combinations used clinically in dentistry as premedicants to alleviate patient apprehension are largely unsubstantiated. To evaluate the efficacy and safety of agents used for parenteral sedation through controlled clinical trials, it is first necessary to identify which drugs, doses, and routes of administration are actually used in practice. A survey instrument was developed to characterize the drugs used clinically for anesthesia and sedation by dentists with advanced training in pain control. A random sample of 500 dentists who frequently use anesthesia and sedation in practice was selected from the Fellows of the American Dental Society of Anesthesiology. The first mailing was followed by a second mailing to nonrespondents after 30 days. The respondents report a variety of parenteral sedation techniques in combination with local anesthesia (the response categories are not mutually exclusive): nitrous oxide (64%), intravenous conscious sedation (59%), intravenous “deep” sedation (47%), and outpatient general anesthesia (27%). Drugs most commonly reported for intravenous sedation include diazepam, methohexital, midazolam, and combinations of these drugs with narcotics. A total of 82 distinct drugs and combinations was reported for intravenous sedation and anesthesia. Oral premedication and intramuscular sedation are rarely used by this group. Most general anesthesia reported is done on an outpatient basis in private practice. These results indicate that a wide variety of drugs is employed for parenteral sedation in dental practice, but the most common practice among dentists with advanced training in anesthesia is local anesthesia supplemented with intravenous sedation consisting of a benzodiazepine and an opioid or a barbiturate.
PMCID: PMC2167868  PMID: 3250279
8.  Characterization of the "deqi" response in acupuncture 
Background
Acupuncture stimulation elicits deqi, a composite of unique sensations that is essential for clinical efficacy according to traditional Chinese medicine (TCM). There is lack of adequate experimental data to indicate what sensations comprise deqi, their prevalence and intensity, their relationship to acupoints, how they compare with conventional somatosensory or noxious response. The objective of this study is to provide scientific evidence on these issues and to characterize the nature of the deqi phenomenon in terms of the prevalence of sensations as well as the uniqueness of the sensations underlying the deqi experience.
Methods
Manual acupuncture was performed at LI4, ST36 and LV3 on the extremities in randomized order during fMRI in 42 acupuncture naïve healthy adult volunteers. Non-invasive tactile stimulation was delivered to the acupoints by gentle tapping with a von Frey monofilament prior to acupuncture to serve as a sensory control. At the end of each procedure, the subject was asked if each of the sensations listed in a questionnaire or any other sensations occurred during stimulation, and if present to rate its intensity on a numerical scale of 1–10. Statistical analysis including paired t-test, analysis of variance, Spearman's correlation and Fisher's exact test were performed to compare responses between acupuncture and sensory stimulation.
Results
The deqi response was elicited in 71% of the acupuncture procedures compared with 24% for tactile stimulation when thresholded at a minimum total score of 3 for all the sensations. The frequency and intensity of individual sensations were significantly higher in acupuncture. Among the sensations typically associated with deqi, aching, soreness and pressure were most common, followed by tingling, numbness, dull pain, heaviness, warmth, fullness and coolness. Sharp pain of brief duration that occurred in occasional subjects was regarded as inadvertent noxious stimulation. The most significant differences in the deqi sensations between acupuncture and tactile stimulation control were observed with aching, soreness, pressure and dull pain. Consistent with its prominent role in TCM, LI4 showed the most prominent response, the largest number of sensations as well as the most marked difference in the frequency and intensity of aching, soreness and dull pain between acupuncture and tactile stimulation control. Interestingly, the dull pain generally preceded or occurred in the absence of sharp pain in contrast to reports in the pain literature. An approach to summarize a sensation profile, called the deqi composite, is proposed and applied to explain differences in deqi among acupoints.
Conclusion
The complex pattern of sensations in the deqi response suggests involvement of a wide spectrum of myelinated and unmyelinated nerve fibers, particularly the slower conducting fibers in the tendinomuscular layers. The study provides scientific data on the characteristics of the 'deqi' response in acupuncture and its association with distinct nerve fibers. The findings are clinically relevant and consistent with modern concepts in neurophysiology. They can provide a foundation for future studies on the deqi phenomenon.
doi:10.1186/1472-6882-7-33
PMCID: PMC2200650  PMID: 17973984
9.  Compliance with infection control practices in an university hospital dental clinic 
Aim: Compliance with infection control practices is the key to quality care and excellence in dentistry. Infection control remains one of the most cost-beneficial interventions available. However, implementing control procedures requires full compliance of the whole dental team. The aim of our study was to measure the compliance in daily clinical practice.
Methods: The compliance with infection control practices in dentistry by dental health care personnel (DHCP) in a German university dental clinic was observed during clinical work. In addition, a survey was conducted to assess the individual knowledge about infection control procedures. Contamination of the workplace during invasive dental procedures was tested, as well.
Results: A total of 58 invasive dental treatments implying close contacts between HCWs and patients were scrutinized. All HCWs (100%) wore gloves during dental work, but in some cases (female dentists: 14.3%; dental assistants: 28.6%) gloves were neither changed nor hands were disinfected between different activities or patient contacts (female dentists: 68.6%; male dentists: 60.9%; dental assistants: 93%). Only 31.4% of female and 39.1% of male dentists carried out adequate hygienic hand disinfection after removing gloves. Male dentists wore significantly more often (100%) protective eyewear compared to 77.1% of female dentists (p<0.05). In addition, most of female dentists (62.9%) and dental assistants (80.7%) wore jewelry during dental procedures.
Conclusion: Despite the knowledge of distinct hygiene procedures only a small percentage of dental staff performs hygiene practices according to recommended guidelines. Strict audit is clearly needed in the dental setting to ensure compliance with infection control guidelines to prevent transmission of pathogens. Our results provide insights for the development of a targeted education and training strategy to enhance compliance of dental staff especially of dental assistants with infection control procedures.
doi:10.3205/dgkh000238
PMCID: PMC4184038  PMID: 25285262
infection control; guidelines; environmental contamination; compliance
10.  Knowledge of drug prescription in dentistry students 
Background
Students in schools of dentistry attend to patients with illnesses, and often prescribe medication. Because students are still learning, they are influenced by a variety of factors: the different teaching approaches of the professors at the clinics and in the pharmacology course, fellow students, and even the information provided by the pharmaceutical industry.
Objectives
The aim of this pilot study was to assess the prescription knowledge and common mistakes in fourth-year students at the School of Dentistry at the Universidad Nacional Autónoma de México.
Methods
In March 2010, a survey was conducted among 66 fourth-year students at the School of Dentistry, applying a previously validated questionnaire consisting of six open-ended questions The following factors were assessed: the most frequent illness requiring dental prescription; the most prescribed nonsteroidal anti-inflammatory drugs and antibiotics; the most frequent errors; sources of information used for prescribing drugs; and whether the students knew and followed the World Health Organization Guide to Good Prescribing.
Results
The most frequent response for each question was considered the most significant. The most common reason for prescribing medication was infection (n = 37, 56%), followed by pain (n = 24, 38%); the most used painkillers were ibuprofen and acetaminophen at equal levels (n = 25, 37.8%), followed by ketorolac (n = 7, 10.6%), naproxen (n = 6, 9.1%), diclofenac (n = 2, 3%), and aspirin (n = 1, 1.5%); the most widely prescribed antibiotics were amoxicillin (n = 52, 78.9%), ampicillin (n = 7, 10.6%), and penicillin V and clindamycin (n = 3, 4.5%). The most frequent errors reported by students were: lack of knowledge about drug posology (n = 49, 74.2%), improperly filled prescriptions (n = 7, 10.7%), not knowing the brand names and uncertainty about the correct drug indicated for each case (n = 3, 4.54%), not knowing the duration of treatment (n = 2, 3%), not asking the patient about possible allergies, and not giving prescriptions (n = 1, 1.5%). The sources of information used by students for prescribing drugs included the professors at the clinics (n = 49, 74.2%), the pharmacology course (n = 7, 10.7%), medical dictionary consultation (n = 15, 22.72%), classmate support (n = 3, 4.54%), and information provided by medical representatives from pharmaceutical companies (n = 1, 1.5%). Finally, only 20 students (30.3%) followed the WHO Guide to Good Prescribing, 40 students acknowledged not following it (60.6%), and six students (9.1%) had no knowledge of it.
Conclusion
The knowledge of pharmacology among fourth-year students in the School of Dentistry has gaps that could affect patient safety. More studies are needed to determine whether this issue affects the quality of patient care and the effectiveness and safety of treatments. Since prescribing accurately is extremely important, it is necessary to develop therapeutic guidelines, and to provide pharmacological therapy courses. The implementation of educational programs, including the WHO Guide to Good Prescribing and Patient Safety Curriculum Guide, would be beneficial in helping students develop prescribing skills.
doi:10.2147/DHPS.S30984
PMCID: PMC3396048  PMID: 22807647
prescription; dentistry prescription; most used NSAIDs by dentists; most used antibiotics; dentist prescribing errors; sources of information for prescribing; WHO Guide to Good Prescribing
11.  Cross-sectional survey: smoking among medical, pharmacy, dental and nursing students, University of Health Sciences, Lao PDR 
BMJ Open  2013;3(8):e003042.
Objectives
To investigate the prevalence of and attitudes to smoking among third year medical, pharmacy, dentistry and nursing students in Lao People’s Democratic Republic (PDR).
Design
A cross-sectional survey conducted among third year university level, health professional students. The survey used a self-administered questionnaire which was originally developed by WHO, and modified to suit the setting.
Setting
The setting was the University of Health Sciences in Vientiane, the capital of Lao PDR. Participants were recruited from the Faculties of Medicine, Pharmacy, Dentistry and Nursing. At the time of the survey, 521 third year students were enrolled.
Primary and secondary outcome measures
The primary outcome measure was prevalence of current cigarette smoking and other tobacco use. Smoking status was categorised as: current smoker, ex-smoker and non-smoker with current smokers defined as those who had smoked cigarettes or used other tobacco on one or more days during the previous 30 days.
Results
In total, 506 respondents completed the questionnaire, giving a response rate of 97.1% to 98.5% across the different faculties. Overall smoking prevalence was 5.07% (95% CI 3.2% to 7.1%), which is lower than previously reported national prevalence rates. Women reported smoking less than men did (OR=0.56, 95% CI=0.013 to 0.242; p=0.003). The majority of students supported tobacco control measures. The number of people who reported receiving formal training in tobacco cessation counselling ranged from 10.9% (95% CI 5.3% to 19.1%) among nursing students to 51.1% (95% CI 40.4% to 61.7%) among medical students.
Conclusions
Smoking prevalence among this cohort was relatively low. Students were supportive of tobacco control policies. Further research is needed to understand what is working in this context, in order to apply lessons learnt in similar settings. In the meantime, health professional students should be provided health education to discourage tobacco use. Information on tobacco control policies needs to be more widely disseminated.
doi:10.1136/bmjopen-2013-003042
PMCID: PMC3758981  PMID: 23996817
EPIDEMIOLOGY; PUBLIC HEALTH; SOCIAL MEDICINE
12.  Integration of an Objective Structured Clinical Examination (OSCE) into the Dental Preliminary Exams 
Introduction: In the pre-clinical phase of the study of dentistry at the University of Greifswald, the course “Early Patient Contact (EPC)” is conducted within the framework of Community Medicine/Dentistry. The course is based on three pillars: the patient visiting program, special problem-oriented seminars, and communication training for doctors. The essential goal consists of providing students with real patient contact right at the beginning of their study of dentistry, thus making the study of dentistry patient-based very early on. Students are trained in taking comprehensive anamneses and recording clinical findings.
Methods: Within the framework of the dental preliminary exams, the course is evaluated using an OSCE on a standardized patient. Furthermore, the added value of an additional training unit (conducting anamnesis and clinical examination) in preparation for the OSCE was evaluated. The exam results of a group without training (control group) were compared with those of a group with training (intervention group).
Results: The intervention group performed significantly better than the control on the following items: the total number of points achieved on the OSCE early patient contact, and in the most important points of the anamnesis and clinical examination. In addition, the intervention group tended to score higher in terms of the item “oral health status”.
Conclusion: The present study showed a positive effect of an additional training unit on students’ performance in the OSCE. Taking the limitations of the study and the results of a literature review into account, we recommend conducting such training as preparation for the OSCE.
doi:10.3205/zma000779
PMCID: PMC3296098  PMID: 22403594
Community Dentistry; educational measurement; predental examination; OSCE
13.  Titanium in Dentistry: Historical Development, State of the Art and Future Perspectives 
Titanium is a metallic element known by several attractive characteristics, such as biocompatibility, excellent corrosion resistance and high mechanical resistance. It is widely used in Dentistry, with high success rates, providing a favorable biological response when in contact with live tissues. Therefore, the objective of this study was to describe the different uses of titanium in Dentistry, reviewing its historical development and discoursing about its state of art and future perspective of its utilization. A search in the MEDLINE/PubMed database was performed using the terms ‘titanium’, ‘dentistry’ and ‘implants’. The title and abstract of articles were read, and after this first screening 20 articles were selected and their full-texts were downloaded. Additional text books and manual search of reference lists within selected articles were included. Correlated literature showed that titanium is the most used metal in Implantology for manufacturing osseointegrated implants and their systems, with a totally consolidated utilization. Moreover, titanium can be also employed in prosthodontics to obtain frameworks. However, problems related to its machining, casting, welding and ceramic application for dental prosthesis are still limiting its use. In Endodontics, titanium has been used in association to nickel for manufacturing rotatory instruments, providing a higher resistance to deformation. However, although the different possibilities of using titanium in modern Dentistry, its use for prostheses frameworks still needs technological improvements in order to surpass its limitations.
doi:10.1007/s13191-012-0190-1
PMCID: PMC3634937  PMID: 24431713
Titanium; Dental materials; Prosthesis
14.  A Blueprint of Pain Curriculum across Prelicensure Health Sciences Programs: One NIH Pain Consortium Center of Excellence in Pain Education (CoEPE) Experience 
To improve U.S. pain education and promote inter-institutional and inter-professional collaborations, the NIH Pain Consortium has funded 12 sites to develop Centers of Excellence in Pain Education (CoEPE). Each site was given the tasks of development, evaluation, integration, and promotion of pain management curriculum resources, including case studies that will be shared nationally. Collaborations among schools of medicine, dentistry, nursing, pharmacy, and others were encouraged. The John D. Loeser CoEPE is unique in that it represents extensive regionalization of health science education, in this case in the region covering the states of Washington, Wyoming, Alaska, Montana, and Idaho (WWAMI). This paper describes a blueprint of pain content and teaching methods across the University of Washington’s six health sciences schools and provides recommendations for improvement in pain education at the prelicensure level. The Schools of Dentistry and Physician Assistant provide the highest percentage of total required curriculum hours devoted to pain compared with the Schools of Medicine, Nursing, Pharmacy, and Social Work. The findings confirm paucity of pain content in health sciences curricula, missing International Association for the Study of Pain (IASP) curriculum topics, and limited use of innovative teaching methods such as problem-based and team-based learning.
doi:10.1016/j.jpain.2013.07.006
PMCID: PMC3855868  PMID: 24094694
pain education; curriculum; health sciences; prelicensure; teaching methods; WWAMI
15.  Management of children with autism spectrum disorder in the dental setting: Concerns, behavioural approaches and recommendations 
Objectives: This article reviews the present literature on the issues encountered while coping with children with autistic spectrum disorder from the dental perspective. The autistic patient profile and external factors affecting the oral health status of this patient population are discussed upon the existing body of evidence. Material and Methods: The MEDLINE database was searched using the terms ‘Autistic Disorder’, ‘Behaviour Control/methods’, ‘Child’, ‘Dental care for disabled’, ‘Education’, ‘Oral Health’, and ‘Pediatric Dentistry’ to locate related articles published up to January 2013. Results: Most of the relevant studies indicate poor oral hygiene whereas they are inconclusive regarding the caries incidence in autistic individuals. Undergraduate dental education appears to determine the competence of dental professionals to treat developmentally disabled children and account partly for compromised access to dental care. Dental management of an autistic child requires in-depth understanding of the background of the autism and available behavioural guidance theories. The dental professional should be flexible to modify the treatment approach according to the individual patient needs.
Key words:Autism spectrum disorder, dental management, children.
doi:10.4317/medoral.19084
PMCID: PMC3854078  PMID: 23986012
16.  Syringe micro vibrator (SMV) a new device being introduced in dentistry to alleviate pain and anxiety of intraoral injections, and a comparative study with a similar device 
Background
Neurologically, it is proven that stimulation of larger diameter fibers - e.g. using appropriate coldness, warmth, rubbing, pressure or vibration- can close the neural "gate" so that the central perception of itch and pain is reduced. This fact is based upon "Gate-control" theory of Melzack and Wall.
Presentation of the hypothesis
Syringe Micro Vibrator is a new design being introduced for the first time in the field of Dentistry. This device is a promising breakthrough in pain and anxiety management and may deliver solution for clinicians plagued with patient pain phobia. It has an off-set rotating micro vibration creator with ultra high frequency and ultra low altitude that can be easily placed on any standard dental syringe and some disposable syringes. This device was registered as an invention in dentistry and received Iran National Patent number of 63765.
Testing the hypothesis
By creating micro vibration, this device would be effective in reducing the pain and anxiety confronted with most types of intraoral injections as palatal, mandibular block, intraligamental and local infiltration. From the aspect of the patient pain management, this device contributes both physiologically (based on Gate Control Theory of pain) and psychologically (based on the device function as will be explained by dentist to the patient as a modern pain reducing technology). From the aspect of clinician, SMV motor provides vibrations with ultra high frequency to alleviate pain, but since it has ultra low vibration altitude, it has no adverse effect on the clinician dexterity and accuracy during injection and it does not interfere with pin point localization of injection site.
Implications of the hypothesis
Upon mounting on a conventional dental anesthesia injection syringe, SMV is switched on and the clinician then uses normal injection technique to administer the anesthetic. This device is not only a useful accessory device for ordinary patients, but also more useful for pediatric patients and those who have a phobia of intraoral injection or pain.
doi:10.1186/1750-1164-5-1
PMCID: PMC3025000  PMID: 21211061
17.  Anesthetic Cartridge System Under Evaluation 
Anesthesia Progress  1981;28(1):5-10.
The problem of glass breakage in the local anesthetic cartridge system was evaluated under laboratory conditions with a mechanical testing machine. The anticipated breakage of the glass did not occur with any frequency, as the rubber stopper produced more uniform failures of the system. The glass cartridge appeared to be quite reliable and resistant to breakage.
Local anesthetics have been used for many years to provide patients temporary freedom from pain. Local anesthetic solutions are in wide use in both dentistry and medicine and are the most frequently used drugs in dentistry. Various estimates place the number of injections at approximately one half million daily or 125 million injections per year.
These drugs and the armamentarium necessary to administer them have proven to be safe and reliable. Only rarely are there reports of sensitivity to the anesthetic solution or breakage of needles.. Sterility of the solutions has not been a problem as they are carefully processed and evaluated at the factory. Although there are sporadic reports of loss of sterility, this has been attributed to the reuse of the anesthetic cartridges on more than one patient. Monheim states “The success of the cartridge system in dentistry has been due to the sincerity, honesty, and high standards of the manufacturers in giving the profession a near-perfect product.” However, on occassion a glass cartridge will break or shatter when inserting the harpoon into the rubber stopper or even during injection. Cooley et al reported on eye injuries occurring in the dental office, one of which was due to glass from a local anesthetic cartridge that exploded and propelled particles into the patient's eye. Forrest evaluated syringes, needles, and cartridges and reported that one brand (made in Britain) fractured more often than any other, but that the fracture rate was too low to be of any consequence.
It is apparent that glass cartridges will fracture or burst from time to time. This study evaluates the cartridge system with carefully controlled laboratory procedures. The cartridges were tested under various pressures and conditions in an attempt to determine the causes of failure and when such failure may be anticipated.
Images
PMCID: PMC2235753  PMID: 6939350
18.  Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal 
BMC Oral Health  2013;13:20.
Background
Chepang communities are one of the most deprived ethnic communities in Nepal. According to the National Pathfinder Survey, dental caries is a highly prevalent childhood disease in Nepal. There is no data concerning the prevalence of caries along with knowledge, attitude and oral hygiene practices among Chepang schoolchildren. The objectives of this study were to 1) record the prevalence of dental caries 2) report experience of dental pain 3) evaluate knowledge, attitude and preventive practices on oral health of primary Chepang schoolchildren.
Method
A cross sectional epidemiological study was conducted in 5 government Primary schools of remote Chandibhanjyang Village Development Committee (VDC) in Chitwan district. Ethical approval was taken from the Institutional Review Board within the Research Department of the Institute of Medicine (IOM) Tribhuvan University. Consent was obtained from parents for conducting clinical examination and administrating questionnaire. Permission was taken from the school principal in all schools. Data was collected using a pretested questionnaire on 131 schoolchildren aged 8-16-year- olds attending Grade 3–5. Clinical examination was conducted on 361 school children aged 5–16 –year-olds attending grade 1–5. Criteria set by the World Health Organization (1997) was used for caries diagnosis. The questionnaires, originally constructed in English and translated into Nepali were administered to the schoolchildren by the researchers. SPSS 11software was used for data analysis.
Results
Caries prevalence for 5–6 –year-old was above the goals recommended by WHO and Federation of Dentistry international (FDI) of less than 50% caries free children. Caries prevalence in 5-6-year-olds was 52% and 12-13-year-olds was 41%. The mean dmft/DMFT score of 5–6 –year-olds and 12 -13-year -olds was 1.59, 0.31 and 0.52, 0.84 respectively. The DMFT scores increased with age and the d/D component constituted almost the entire dmft/DMFT index. About 31% of 8-16-year-olds school children who participated in the survey reported having suffered from oral pain. Further, the need for treatment of decayed teeth was reported at 100%. About 76% children perceived teeth as an important component of general health and 75% reported it was required to eat. A total 93% children never visited a dentist or a health care service. Out of 56% children reporting cleaning their teeth daily, only 24% reported brushing their teeth twice daily. About 86% of the children reported using toothbrush and toothpaste to clean their teeth. Although 61% children reported to have received oral health education, 82% children did not know about fluoride and its benefit on dental health. About 50% children reported bacteria as the main cause of tooth decay and 23% as not brushing teeth for gingivitis. Frequency of sugar exposure was low; 75% of children reported eating sugar rich food once daily.
Conclusions
Caries prevalence of 5–6 –year- old Chepang school children is above the recommended target set by FDI/WHO. The study reported 31% schoolchildren aged 8-16-year old suffered oral pain and decayed component constituted almost the entire dmft/DMFT index. The brushing habit was reportedly low with only 24% of the children brushing twice daily. A nationwide scientifically proven, cost effective school based interventions is needed for prevention and control of caries in schoolchildren in Nepal.
doi:10.1186/1472-6831-13-20
PMCID: PMC3655880  PMID: 23672487
Dental caries; School children; Oral hygiene
19.  Behavioural aspects of patients with Autism Spectrum Disorders (ASD) that affect their dental management 
Dental treatment in patients with Autism Spectrum Disorders (ASD) can be complicated due to the presence of behavioral alterations. In this group, there are no specific behavioral profiles that allow dentist to anticipate the attitude that a patient will show during a visit. Thus, behavioral attitudes have been described that vary from total permissiveness and collaboration during even bloody procedures, to the absolute impossibility in conducting a simple oral examination. There is no effective behavioral management technique for all ASD patients. Prior information, such as the type of ASD or the presence of certain concurrent pathologies can help predict the patient’s likely behavior. Therefore, gathering all the information in a preliminary interview with the parents/guardians of the patient is recommended. Knowing these factors will allow individualized behavioral management strategies to be designed and facilitates the planning of dental treatment.
Key words:Dentistry, autism, ASD, behavior management.
doi:10.4317/medoral.19566
PMCID: PMC4192569  PMID: 24608219
20.  Contamination of a Dental Unit Water Line System by Legionella Pneumophila in the Mashhad School of Dentistry in 2009 
Background
Dental unit waterline system is considered potential source for contamination with Legionella species. The aim of this study was to determine if contamination of a dental unit water line system by Legionella pneumophila serogroup1 in the Mashhad School of Dentistry occurred in 2009.
Methods
A total of 52 dental units were selected from all clinical departments of the Mashhad School of Dentistry. Samples of water were collected from outlets of water/air spray, high-speed dental hand pieces and water cup fillers. Samples were tested via the ELISA method.
Results
At the beginning of the work day, a total of 36.1 percent of dental units were contaminated by Legionella pneumophila serogroup 1.
Conclusion
Infection control of the dental unit water line system regarding legionella in the Mashhad School of Dentistry is a challenge and engineering controls should be used in contaminated clinics.
PMCID: PMC3420029  PMID: 22924117
Legionella; Dental unit water line system; Contamination; Iran
21.  Evaluating an audit and feedback intervention for reducing antibiotic prescribing behaviour in general dental practice (the RAPiD trial): a partial factorial cluster randomised trial protocol 
Background
Antibiotic prescribing in dentistry accounts for 9% of total antibiotic prescriptions in Scottish primary care. The Scottish Dental Clinical Effectiveness Programme (SDCEP) published guidance in April 2008 (2nd edition, August 2011) for Drug Prescribing in Dentistry, which aims to assist dentists to make evidence-based antibiotic prescribing decisions. However, wide variation in prescribing persists and the overall use of antibiotics is increasing.
Methods
RAPiD is a 12-month partial factorial cluster randomised trial conducted in NHS General Dental Practices across Scotland. Its aim is to compare the effectiveness of individualised audit and feedback (A&F) strategies for the translation into practice of SDCEP recommendations on antibiotic prescribing. The trial uses routinely collected electronic healthcare data in five aspects of its design in order to: identify the study population; apply eligibility criteria; carry out stratified randomisation; generate the trial intervention; analyse trial outcomes.
Eligibility was determined on contract status and a minimum level of recent NHS treatment provision. All eligible dental practices in Scotland were simultaneously randomised at baseline either to current audit practice or to an intervention group. Randomisation was stratified by single-handed/multi-handed practices. General dental practitioners (GDPs) working at intervention practices will receive individualised graphical representations of their antibiotic prescribing rate from the previous 14 months at baseline and an update at six months. GDPs could not be blinded to their practice allocation. Intervention practices were further randomised using a factorial design to receive feedback with or without: a health board comparator; a supplementary text-based intervention; additional feedback at nine months. The primary outcome is the total antibiotic prescribing rate per 100 courses of treatment over the year following delivery of the baseline intervention.
A concurrent qualitative process evaluation will apply theory-based approaches using the Consolidated Framework for Implementation Research to explore the acceptability of the interventions and the Theoretical Domains Framework to identify barriers and enablers to evidence-based antibiotic prescribing behaviour by GDPs.
Discussion
RAPiD will provide a robust evaluation of A&F in dentistry in Scotland. It also demonstrates that linked administrative datasets have the potential to be used efficiently and effectively across all stages of an randomised controlled trial.
Trial registration
Current Controlled Trials ISRCTN49204710
doi:10.1186/1748-5908-9-50
PMCID: PMC4108126  PMID: 24758164
Prescribing; Antibiotics; Dental
22.  Predictive, preventive, personalised and participatory periodontology: ‘the 5Ps age’ has already started 
The EPMA Journal  2013;4(1):16.
An impressive progress in dentistry has been recorded in the last decades. In order to reconsider guidelines in dentistry, it is required to introduce new concepts of personalised patient treatments: the wave of predictive, preventive and personalised medicine is rapidly incoming in dentistry. Worldwide dentists have to make a big cultural effort in changing the actual ‘reactive’ therapeutic point of view, belonging to the last century, into a futuristic ‘predictive’ one. The first cause of tooth loss in industrialised world is periodontitis, a Gram-negative anaerobic infection whose pathogenesis is genetically determined and characterised by complex immune reactions. Chairside diagnostic tests based on saliva, gingival crevicular fluid and cell sampling are going to be routinely used by periodontists for a new approach to the diagnosis, monitoring, prognosis and management of periodontal patients. The futuristic ‘5Ps’ (predictive, preventive, personalised and participatory periodontology) focuses on early integrated diagnosis (genetic, microbiology, host-derived biomarker detection) and on the active role of the patient in which networked patients will shift from being mere passengers to responsible drivers of their health. In this paper, we intend to propose five diagnostic levels (high-tech diagnostic tools, genetic susceptibility, bacterial infection, host response factors and tissue breakdown-derived products) to be evaluated with the intention to obtain a clear picture of the vulnerability of a single individual to periodontitis in order to organise patient stratification in different categories of risk. Lab-on-a-chip (LOC) technology may soon become an important part of efforts to improve worldwide periodontal health in developed nations as well as in the underserved communities, resource-poor areas and poor countries. The use of LOC devices for periodontal inspection will allow patients to be screened for periodontal diseases in settings other than the periodontist practice, such as at general practitioners, general dentists or dental hygienists. Personalised therapy tailored with respect to the particular medical reality of the specific stratified patient will be the ultimate target to be realised by the 5Ps approach. A long distance has to be covered to reach the above targets, but the pathway has already been clearly outlined.
doi:10.1186/1878-5085-4-16
PMCID: PMC3703280  PMID: 23763842
Predictive periodontology; Preventive periodontology; Personalised periodontology; Participatory periodontology; Lab-on-a-chip; Gas chromatographs; Cone beam computed tomography; Host-derived diagnostic markers; Saliva; Gingival crevicular fluid
23.  Are clinicians being prepared to care for abused women? A survey of health professional education in Ontario, Canada 
Background
The current project undertook a province-wide survey and environmental scan of educational opportunities available to future health care providers on the topic of intimate partner violence (IPV) against women.
Methods
A team of experts identified university and college programs in Ontario, Canada as potential providers of IPV education to students in health care professions at the undergraduate and post-graduate levels. A telephone survey with contacts representing these programs was conducted between October 2005 and March 2006. The survey asked whether IPV-specific education was provided to learners, and if so, how and by whom.
Results
In total, 222 eligible programs in dentistry, medicine, nursing and other allied health professions were surveyed, and 95% (212/222) of programs responded. Of these, 57% reported offering some form of IPV-specific education, with undergraduate nursing (83%) and allied health (82%) programs having the highest rates. Fewer than half of undergraduate medical (43%) and dentistry (46%) programs offered IPV content. Postgraduate programs ranged from no IPV content provision (dentistry) to 41% offering content (nursing).
Conclusion
Significant variability exists across program areas regarding the methods for IPV education, its delivery and evaluation. The results of this project highlight that expectations for an active and consistent response by health care professionals to women experiencing the effects of violence may not match the realities of professional preparation.
doi:10.1186/1472-6920-9-34
PMCID: PMC2709616  PMID: 19575776
24.  Teaching the placement of posterior resin-based composite restorations in Spanish dental schools 
Objectives: In an area of esthetic dentistry such as posterior composites, in which new materials and techniques are being devolved continuously, it is important to confirm that dental students have a clear understanding of the basic principles of clinical application of this knowledge. Considering that the preparation of dental graduates in Spain may be of interest to competent dental authorities and employers with whom they can work worldwide, this study investigated the teaching of posterior composite restorations in Spanish dental schools. Study design: In late 2009⁄ early 2010, a questionnaire seeking information on the teaching of posterior composites was emailed to the professor responsible for teaching operative dentistry in each of the fifteen dental schools having complete undergraduate dental degree programs in Spain. Results: The response rate was 100%. Most investigated topics did not show noteworthy differences depending on whether the schools were public or private. Variations were found among Spanish dental schools in both the amount and content of the teaching programs concerning posterior composite restorations. Differences were recorded in the teaching of cavity design, contraindications to composite placement, indications for liners and bases, matrix and wedging techniques, composite and bonding systems, light curing and finishing procedures for composite restorations. More consistency was observed in teaching methods of moisture-control, indirect composites and amalgam bonding. Conclusions: As recommended in previously surveyed countries, efforts must be made to promote harmonization of dental curricula to make it easier for graduates to work elsewhere, and to ensure they meet the needs of their patients on entering independent practice.
Key words:Aesthetic dentistry, composite restoration, dental education, teaching program, undergraduate dental student.
doi:10.4317/medoral.17656
PMCID: PMC3476032  PMID: 22322491
25.  A Novel Tool for the Assessment of Pain: Validation in Low Back Pain 
PLoS Medicine  2009;6(4):e1000047.
Joachim Scholz and colleagues develop and validate an assessment tool that distinguishes between radicular and axial low back pain.
Background
Adequate pain assessment is critical for evaluating the efficacy of analgesic treatment in clinical practice and during the development of new therapies. Yet the currently used scores of global pain intensity fail to reflect the diversity of pain manifestations and the complexity of underlying biological mechanisms. We have developed a tool for a standardized assessment of pain-related symptoms and signs that differentiates pain phenotypes independent of etiology.
Methods and Findings
Using a structured interview (16 questions) and a standardized bedside examination (23 tests), we prospectively assessed symptoms and signs in 130 patients with peripheral neuropathic pain caused by diabetic polyneuropathy, postherpetic neuralgia, or radicular low back pain (LBP), and in 57 patients with non-neuropathic (axial) LBP. A hierarchical cluster analysis revealed distinct association patterns of symptoms and signs (pain subtypes) that characterized six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain. Using a classification tree analysis, we identified the most discriminatory assessment items for the identification of pain subtypes. We combined these six interview questions and ten physical tests in a pain assessment tool that we named Standardized Evaluation of Pain (StEP). We validated StEP for the distinction between radicular and axial LBP in an independent group of 137 patients. StEP identified patients with radicular pain with high sensitivity (92%; 95% confidence interval [CI] 83%–97%) and specificity (97%; 95% CI 89%–100%). The diagnostic accuracy of StEP exceeded that of a dedicated screening tool for neuropathic pain and spinal magnetic resonance imaging. In addition, we were able to reproduce subtypes of radicular and axial LBP, underscoring the utility of StEP for discerning distinct constellations of symptoms and signs.
Conclusions
We present a novel method of identifying pain subtypes that we believe reflect underlying pain mechanisms. We demonstrate that this new approach to pain assessment helps separate radicular from axial back pain. Beyond diagnostic utility, a standardized differentiation of pain subtypes that is independent of disease etiology may offer a unique opportunity to improve targeted analgesic treatment.
Editors' Summary
Background
Pain, although unpleasant, is essential for survival. Whenever the body is damaged, nerve cells detecting the injury send an electrical message via the spinal cord to the brain and, as a result, action is taken to prevent further damage. Usually pain is short-lived, but sometimes it continues for weeks, months, or years. Long-lasting (chronic) pain can be caused by an ongoing, often inflammatory condition (for example, arthritis) or by damage to the nervous system itself—experts call this “neuropathic” pain. Damage to the brain or spinal cord causes central neuropathic pain; damage to the nerves that convey information from distant parts of the body to the spinal cord causes peripheral neuropathic pain. One example of peripheral neuropathic pain is “radicular” low back pain (also called sciatica). This is pain that radiates from the back into the legs. By contrast, axial back pain (the most common type of low back pain) is confined to the lower back and is non-neuropathic.
Why Was This Study Done?
Chronic pain is very common—nearly 10% of American adults have frequent back pain, for example—and there are many treatments for it, including rest, regulated exercise (physical therapy), pain-killing drugs (analgesics), and surgery. However, the best treatment for any individual depends on the exact nature of their pain, so it is important to assess their pain carefully before starting treatment. This is usually done by scoring overall pain intensity, but this assessment does not reflect the characteristics of the pain (for example, whether it occurs spontaneously or in response to external stimuli) or the complex biological processes involved in pain generation. An assessment designed to take such factors into account might improve treatment outcomes and could be useful in the development of new therapies. In this study, the researchers develop and test a new, standardized tool for the assessment of chronic pain that, by examining many symptoms and signs, aims to distinguish between pain subtypes.
What Did the Researchers Do and Find?
One hundred thirty patients with several types of peripheral neuropathic pain and 57 patients with non-neuropathic (axial) low back pain completed a structured interview of 16 questions and a standardized bedside examination of 23 tests. Patients were asked, for example, to choose words that described their pain from a list provided by the researchers and to grade the intensity of particular aspects of their pain from zero (no pain) to ten (the maximum imaginable pain). Bedside tests included measurements of responses to light touch, pinprick, and vibration—chronic pain often alters responses to harmless stimuli. Using “hierarchical cluster analysis,” the researchers identified six subgroups of patients with neuropathic pain and two subgroups of patients with non-neuropathic pain based on the patterns of symptoms and signs revealed by the interviews and physical tests. They then used “classification tree analysis” to identify the six questions and ten physical tests that discriminated best between pain subtypes and combined these items into a tool for a Standardized Evaluation of Pain (StEP). Finally, the researchers asked whether StEP, which took 10–15 minutes, could identify patients with radicular back pain and discriminate them from those with axial back pain in an independent group of 137 patients with chronic low back pain. StEP, they report, accurately diagnosed these two conditions and was well accepted by the patients.
What Do These Findings Mean?
These findings indicate that a standardized assessment of pain-related signs and symptoms can provide a simple, quick diagnostic procedure that distinguishes between radicular (neuropathic) and axial (non-neuropathic) low back pain. This distinction is crucial because these types of back pain are best treated in different ways. In addition, the findings suggest that it might be possible to identify additional pain subtypes using StEP. Because these subtypes may represent conditions in which different pain mechanisms are acting, classifying patients in this way might eventually enable physicians to tailor treatments for chronic pain to the specific needs of individual patients rather than, as at present, largely guessing which of the available treatments is likely to work best.
Additional Information
Please access these Web sites via the online version of this summary at http://dx.doi.org/10.1371/journal.pmed.1000047.
This study is further discussed in a PLoS Medicine Perspective by Giorgio Cruccu and and Andrea Truini
The US National Institute of Neurological Disorders and Stroke provides a primer on pain in English and Spanish
In its 2006 report on the health status of the US, the National Center for Health Statistics provides a special feature on the epidemiology of pain, including back pain
The Pain Treatment Topics Web site is a resource, sponsored partly by associations and manufacturers, that provides information on all aspects of pain and its treatment for health care professionals and their patients
Medline Plus provides a brief description of pain and of back pain and links to further information on both topics (in English and Spanish)
The MedlinePlus Medical Encyclopedia also has a page on low back pain (in English and Spanish)
doi:10.1371/journal.pmed.1000047
PMCID: PMC2661253  PMID: 19360087

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