High quality clinical studies.
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Journalism, Dental↗
Biomedical subjects
S Richmond
Publications and source records attributed to S Richmond.
Patient presentation at medical practices with dental problems: an analysis of the 1996 General Practice Morbidity Database for Wales.
OBJECTIVE: To describe the characteristics of attendances and patients who present to family medical practitioners with oral or dental problems. DESIGN: Secondary analysis of standard consultation data. SETTING: 30 family medical practices in the General Practice Morbidity Database for Wales. SUBJECTS: All patients who presented at the practices with an oral or dental complaint during 1996. RESULTS: Of the 1,650,882 patient attendances at the 30 medical practices in the study year, 4,891 (0.3%) were for oral/dental problems. The frequency of these attendances varied considerably between practices (ranging from 0.02 to 0.67% of all attendances); 44.2% of the attendances included tooth-related problems, and 42.3% were for diseases of soft tissue, salivary glands or the tongue. On average patients with dental problems attended their doctor twice as frequently as other patients. The majority (75%) of oral/dental attendances were related solely to these problems. Patients with tooth-related dental problems were three times more likely to seek treatment at weekends than patients attending for other reasons. CONCLUSIONS: The rate of attendance for oral/dental problems varies substantially between practices, but is generally low. The higher rate of attendance for tooth-related problems at weekends suggests that some of the attendances for oral problems might be related to a perceived or actual lack of dental services at these times.
Adolescent↗
Surfactant-deficient respiratory distress after elective delivery at 'term'.
Babies of 37-41 wk gestation are, by international convention, said to be born at 'term', but some still develop respiratory distress. It is not clear how mature a baby has to be to be free of risk of primary surfactant deficiency. An area-based retrospective study of all the 179,701 babies of 34 or more weeks' gestation born alive in a defined area of the north of England in 1988-92 identified 149 babies with features of respiratory distress typical of surfactant deficiency severe enough to be managed with ventilatory support and with no evidence of aspiration or intrapartum infection. Gestation was carefully cross-validated against antenatal information, including at least one ultrasound assessment in the first half of pregnancy. Thirty-six of these babies were born at or after 37 wk gestation. Only 4 of the 35 delivered at 37-38 wk went into spontaneous labour. Seven became ill enough to be candidates for ECMO and two died. A review of all neonatal deaths in the study area between 1981 and 1995 identified four similar deaths in 1981-87 and two in 1993-95. Babies who are not premature, using the internationally agreed definition, can show signs of potentially lethal pulmonary immaturity at birth, especially if subjected to pre-labour Caesarean delivery. Those born at 37-38 wk are 120 times more likely to receive ventilatory support for surfactant deficiency than those born at 39-41 wk. Elective delivery should only be undertaken before 39 wk gestation for good medical reasons.
Cesarean Section↗
Presentation of congenital heart disease in infancy: implications for routine examination.
AIM: To investigate the performance of routine neonatal and 6 week examinations for detecting congenital heart disease. METHODS: A retrospective review of findings on clinical examination was conducted of a cohort of live born infants with congenital heart disease in one health region in 1987-94. RESULTS: Of 1590 babies with congenital heart disease, 523 (33%) presented before neonatal examination because of symptoms or non-cardiac abnormalities. 1061 underwent routine neonatal examination which was abnormal in 476 (45%), but only 170 were referred directly for diagnosis. Of 876 discharged with no diagnosis, 306 presented or died undiagnosed before 6 weeks. At 6 weeks 252 of 569 babies underwent a second routine examination which was abnormal in 164 (65%). CONCLUSIONS: Routine neonatal examination fails to detect more than half of babies with heart disease; examination at 6 weeks misses one third. A normal examination does not exclude heart disease. Babies with murmurs at neonatal or 6 week examinations should be referred for early paediatric cardiological evaluation which will result either in a definitive diagnosis of congenital heart disease or in authoritative reassurance of normal cardiac anatomy and function.
Down Syndrome↗
What type of filling? Best practice in dental restorations.
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Cost-Benefit Analysis↗
ICAM-1 and CD11b inhibition worsen outcome in rats with E. coli pneumonia.
We investigated whether inhibiting an endothelial adhesion molecule [intracellular adhesion molecule 1 (ICAM-1)] would alter outcome and lung injury in a similar fashion to inhibition of a leukocyte adhesion molecule (integrin CD11b) in a rat model of gram-negative pneumonia. Inhibition of ICAM-1 with monoclonal antibody (MAb) 1A29 (1 mg/kg sc or 0.2 or 2 mg/kg iv, q 12 h x 3) or of CD11b with MAb 1B6 (1 mg/kg sc, q 12 h x 3) were compared against similarly administered placebo proteins in rats challenged with intrabronchial Escherichia coli. After challenge, all animals were treated with antibiotics. ICAM-1 MAb (6 mg/kg, iv, total dose) increased mortality vs. control (P = 0.03). CD11b MAb (3 mg/kg, sc, total dose) did not significantly (P = 0.16) increase mortality rates, but this was not in a range of probability to exclude a harmful effect. All other doses of MAb had no significant effect on survival rates. ICAM-1 and CD11b MAbs had significantly different effects on the time course of lung injury, circulating white cells and lymphocytes, and lung lavage white cells and neutrophils (P = 0.04-0.003). CD11b MAb decreased, whereas ICAM-1 MAb increased these measures compared with control from 6 to 12 h after E. coli. However, from 144 to 168 h after E. coli both MAbs increased these measures compared with control rats but to a greater level with CD11b MAb. Thus both ICAM-1 and CD11b appear to be necessary for survival during E. coli pneumonia. Although these adhesion molecules may participate differently in early lung injury, with CD11b increasing and ICAM-1 decreasing inflammation and injury, both are important for the resolution of later injury. During gram-negative pneumonia the protective roles of ICAM-1 and CD11b may make their therapeutic inhibition difficult.
Animals↗
International comparisons of professional assessments in orthodontics: Part 1--Treatment need.
An international survey has been undertaken to assess variation in professional assessment of orthodontic treatment need. Ninety-seven orthodontists from nine countries examined a standard sample of 240 dental study casts to judge the need for orthodontic treatment in terms of dental health, dental esthetics, and deviation from normal. Participants also indicated their assessment of treatment complexity and whether they would recommend treatment. Practitioners' subjective assessments were found to be only moderately reliable overall. Of the cases examined, 76% [corrected] obtained a consensus of 80% or greater on the need for treatment. Logistic regression equations were derived to explain the observed variation in treatment decisions. It was found that occlusal traits from the dental casts were highly predictive of the treatment decision, and that the practitioners' country of origin and payment methods are important influences on prescribing behavior. The treatment decisions were predicted with an accuracy of 84% by using occlusal score values for the dental esthetics, the degree of upper arch crowding, the presence of crossbite, the anterior overbite, and the buccal segment sagittal relationship. It is suggested that these traits may form the basis for an internationally validated index of treatment need for use in clinical audit and orthodontic research.
Adult↗
International comparisons of professional assessments in orthodontics: Part 2--treatment outcome.
The opinion of 97 orthodontists in 9 countries has been surveyed with respect to the judgment of treatment outcome. Ninety-eight pretreatment and posttreatment study casts were examined by each orthodontist who gave a judgment of the degree of improvement and whether they thought the result was acceptable. It was found that there was at least 80% agreement on the acceptability of the outcome for only 45.5% of the sample. Logistic regression was used to identify predictive indicators for the judgment of acceptance. It was found that the posttreatment scores for dental esthetics, crossbite, buccal segment sagittal relation, lower arch crowding, centerline, and left and right buccal segment vertical relationship were most important predictor variables. These six traits correctly assigned the decision with 70% accuracy. The judgment of outcome did not seem to take account of the treatment complexity as judged by the practitioners. It was also found that judgments are significantly affected by the country and payment methods, practice environment, and experience of the practitioner. The occlusal traits identified can be usefully incorporated into a index for assessing both treatment need and outcome, and may serve the purposes for audit and research in orthodontics.
Attitude of Health Personnel↗
Assessing incisor inclination: a non-invasive technique.
A method of recording incisor inclination is described using the Tooth inclination Protractor (TIP). This instrument was used to record incisor inclination on dental casts. The scores were related to traditionally determined inclinations for the upper incisor to maxillary plane and the lower incisor to mandibular plane from the lateral cephalometric radiograph. The TIP scores were closely related to the upper incisor to maxillary plane angle and lower incisor to mandibular plane angle. There was a systematic bias between the TIP and radiographically determined assessments. The TIP under-scored the lateral cephalometrically determined maxillary incisor inclination by 10.46 degrees and consistently over-scored the lower mandibular incisor angulation by 2.57 degrees. The TIP is a reliable and valid measure for assessing left and right maxillary and mandibular crown inclinations, and may also be used to record changes of incisor inclination during treatment.
Bias↗
A critical assessment of high-earning orthodontists in the General Dental Services of England and Wales (1990-1991)
Cases from the Dental Practice Board's 2 per cent random sample of completed cases which had been treated by orthodontic practitioners with high gross earnings, were compared to all the cases within the sample from other practitioners. They were assessed using the PAR index and IOTN. High earning orthodontists treated slightly more cases with lower objective need for treatment, but treated no more cases 'Unnecessarily' than other practitioners. They used more fixed appliances, and had marginally better levels of residual need for treatment at finish, although this was at least partially explained by lower levels at start. Generally, their standards were not substantially different to other practitioners. Appliance type had a marked effect on outcome, as did levels of malocclusion and need for treatment at start. Both groups of practitioners performed similarly (better) with dual arch fixed appliances: however, overall standards could only be described as mediocre. There is no justification to single out high earning orthodontists for special scrutiny. However, it may be beneficial if the system of remuneration in the General Dental Services could be modified to give more positive incentive to quality, rather than simply quantity of treatments.
Analysis of Variance↗
In pursuit of improvement before excellence.
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Attitude of Health Personnel↗
Cardiopulmonary effects of inhaled nitric oxide in normal dogs and during E. coli pneumonia and sepsis.
We investigated the effect of inhaled nitric oxide (NO) at increasing fractional inspired O2 concentrations (FIO2) on hemodynamic and pulmonary function during Escherichia coli pneumonia. Thirty-eight conscious, spontaneously breathing, tracheotomized 2-yr-old beagles had intrabronchial inoculation with either 0.75 or 1.5 x 10(10) colony-forming units/kg of E. coli 0111:B4 (infected) or 0.9% saline (noninfected) in one or four pulmonary lobes. We found that neither the severity nor distribution (lobar vs. diffuse) of bacterial pneumonia altered the effects of NO. However, in infected animals, with increasing FIO2 (0.08, 0.21, 0.50, and 0.85), NO (80 parts/million) progressively increased arterial PO2 [-0.3 +/- 0.6, 3 +/- 1, 13 +/- 4, 10 +/- 9 (mean +/- SE) Torr, respectively] and decreased the mean arterial-alveolar O2 gradient (0.5 +/- 0.3, 4 +/- 2, -8 +/- 7, -10 +/- 9 Torr, respectively). In contrast, in noninfected animals, the effect of NO was significantly different and opposite; NO progressively decreased mean PO2 with increasing FIO2 (2 +/- 1, -5 +/- 3, -2 +/- 3, and -12 +/- 5 Torr, respectively; P < 0.05 compared with infected animals) and increased mean arterial-alveolar O2 gradient (0.3 +/- 0.04, 2 +/- 2, 1 +/- 3, 11 +/- 5 Torr; P < 0.05 compared with infected animals). In normal and infected animals alike, only at FIO2 < or = 0.21 did NO significantly lower mean pulmonary artery pressure, pulmonary artery occlusion pressure, and pulmonary vascular resistance index (all P < 0.01). However, inhaled NO had no significant effect on increases in mean pulmonary artery pressure associated with bacterial pneumonia. Thus, during bacterial pneumonia, inhaled NO had only modest effects on oxygenation dependent on high FIO2 and did not affect sepsis-induced pulmonary hypertension. These data do not support a role for inhaled NO in bacterial pneumonia. Further studies are necessary to determine whether, in combination with ventilatory support, NO may have more pronounced effects.
Administration, Inhalation↗
The professional perception of orthodontic treatment complexity.
OBJECTIVE: To assess the current professional concept of orthodontic treatment complexity. DESIGN: Cross sectional survey of practitioners' views towards recently completed orthodontic treatments. SETTING: Specialist and non-specialist practitioners in General Dental Services in North Western and Mersey regions. The sampling was carried out between 1993-95. SUBJECTS AND METHODS: All practitioners undertaking orthodontic treatments in the GDS in the North Western and Mersey regions were invited to participate. Practitioners submitted consecutively started cases for scrutiny by analysis of study models and pre-treatment and post-treatment questionnaires. 280 cases were collected. Data were analysed using multiple linear regression. MAIN OUTCOME MEASURES: The occlusal changes were assessed using the Index of Orthodontic Treatment Need and the Peer Assessment Rating. Self administered questionnaires employed 5-point Likert type scales to record practitioners' and patients' opinions. RESULTS: It appears that the concept of complexity is related to the occlusal changes which occur during orthodontic treatment. Attempts to define treatment complexity identifies factors which are of questionable validity and could be easily manipulated in practice setting. CONCLUSIONS: The present concepts of treatment complexity appear to be somewhat flawed. There is no occlusal index of complexity which is particularly satisfactory but as a crude interim measure 3 grades of complexity are proposed based on the PAR index.
Adolescent↗
A critical appraisal of measurement of the soft tissue outline using photographs and video.
Radiographs are essential in the planning and assessment of treatment, as well as the study of growth patterns, but before subjecting a child to X-rays, the clinician must ensure that it is justifiable on clinical grounds. The use of cephalometric radiography, particularly in the young patient with a cleft of the lip and/or palate, has been questioned. The aim of this project was to investigate the validity and reproducibility of using a photograph or video image, compared with a radiograph, for measurement of the soft tissue profile of the face. A radiographic phantom head was used, which consisted of a dry bone skull encased in a soft tissue substitute. The method involved comparing direct measurement of the head in a Reflex Metrograph with the results of computerized digitizing of a cephalometric radiograph, digitizing a video image from a computer screen and measurement of a photograph. It was found that digitizing of the soft tissue outline of a radiographic phantom head from a video image was neither a valid, nor a reproducible method of replacing cephalometric radiographs in the measurement of the soft tissue profile of the face. A photograph may be a clinically acceptable alternative, but errors from this method are likely to be larger than those due to digitization of a radiograph.
Analysis of Variance↗
The design and analysis of reliability studies for the use of epidemiological and audit indices in orthodontics.
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Bias↗
Factors affecting the outcome of orthodontic treatment within the general dental service.
Previous studies have suggested large differences in the outcome of orthodontic treatment as measured by the PAR index in two adjacent regions of England. The aim of this prospective study was to identify any factors contributing to the mean PAR score reduction in the North Western region and the Mersey region. Forty-one practitioners submitted 375 sets of start models and 250 end of treatment models. The study ran for 36 months. There were no significant differences detected in the type of malocclusion treated or in outcome of treatment between the two regions with respect to the PAR and IOTN indices. This study did, however, clearly demonstrate that qualified orthodontic practitioners were achieving significantly better results with fixed appliances that practitioners with no orthodontic qualification who used fixed appliances.
Adolescent↗
Variations in the depth of preparations for porcelain laminate veneers.
The reflex metrograph was used to measure preparation depth for a sample (21) of preparations for porcelain laminate veneers obtained from a large commercial laboratory. Eight (38%) of the teeth investigated were found to be unprepared with 13 (62%) teeth prepared to varying degrees. Five (24%) of the teeth were over prepared with the depth of two preparations exceeding 1.0 mm. There was little evidence that widely advocated guidelines for the preparation of teeth for porcelain laminate veneers had been used. The effect of dentine exposure on the clinical longevity of porcelain laminate veneers remains to be investigated.
Dental Casting Technique↗
A computerised method of monitoring and assessing undergraduate clinical activity.
This article describes the development and use of an electronic data acquisition system for monitoring and assessing the clinical activity of undergraduate dental students. The advantages of such a system over a paper-based one is that it can generate reports quickly and easily, showing the variety of clinical experience gained by the undergraduates and an assessment of the level of skill displayed. It also relieves academic staff of the tedious, repetitive task of collecting and collating data by hand.
Clinical Competence↗