Justification for the minor oral surgery outcome scale.
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Financing, Personal↗
Biomedical subjects
M R Brickley
Publications and source records attributed to M R Brickley.
Response to a letter from Agram et al. Br J Oral Maxillofac Surg 1999; 37: 509.
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Anesthesia, Dental↗
A controlled trial of three referral methods for patients with third molars.
AIM: To evaluate the accuracy, sensitivity and specificity of three primary to secondary care referral strategies. METHOD: Thirty two primary care dental practitioners (GDPs) were randomly allocated one of three referral strategies: current practice (control strategy); a neural network embedded within a computer program and a paper-based clinical algorithm. One hundred and seven patients were assessed for lower third molar treatment: 47, 30 and 30 in each group, respectively. Clinical details were assessed by a panel of experts against a gold standard for third molar removal (the National Institutes of Health criteria). The accuracy, sensitivity, specificity, positive and negative predictive values were calculated for each strategy. RESULTS: The referral decisions made by the GDPs in the control group displayed greater accuracy and sensitivity but poorer specificity (0.83; 0.97; 0.22) compared with the neural network (0.67; 0.56; 0.79) and clinical algorithm (0.73; 0.56; 0.93). CONCLUSIONS: It was concluded that incorporation of the clinical algorithm into primary care was the most appropriate option. The computer neural network performed less well than either current practice or the clinical algorithm.
Adolescent↗
Perceived risk of future pathology associated with pathology-free third molars: a comparison of oral and maxillofacial surgeons and family dentists.
OBJECTIVE: To examine and compare practitioners' judgements of risk of future pathology associated with pathology-free disease asymptomatic third molars. SUBJECTS: 10 oral and maxillofacial surgeons and 18 family dentists (90% male) with experience ranging from 5-28 years. METHOD: Participants were presented with periapical radiographs of 36 asymptomatic, disease-free mandibular third molars and were informed of the age and sex of the patients and the degree of eruption of the third molars. Participants were asked to assess likelihood of future pathology in general, and more specifically, likelihood of root resorption, pericoronitis, periodontitis, cystic change and neoplasia if the third molar was left in situ. RESULTS: There was significant variation between the 28 raters but not between the two groups. Excepting assessment of future cystic change, there was no evidence that oral and maxillofacial surgeons and family dentists rated the 36 cases in consistently different ways. CONCLUSIONS: Practitioners varied very considerably in their judgment of the risks of pathology associated with asymptomatic disease-free third molars. Specialisation, did not account for this variation.
Adult↗
The minor oral surgery outcome scale: a multi-attribute patient-derived outcome measure.
PURPOSE: The purpose of this study was to produce a clinically useful, patient-derived, minor oral surgery outcome scale. PATIENTS AND METHODS: Seventy-seven consecutive patients scheduled for minor oral surgery were interviewed using semistructured interview techniques to identify those areas of life (domains) that patients believed will be affected by minor oral surgery. These interviews were analyzed by a multidisciplinary panel and a scale based on 5 domains, each with 4 outcome statements was constructed. The domains and outcome statements were weighted in terms of importance by a further consecutive sample of 100 patients using resource allocation and visual analog tasks. An additive mathematical formula was applied to the mean weights for each domain and outcome states to produce the final weighted scale. RESULTS: Five domains were identified from the interviews and weighted according to their order of importance (0 to 100 scale; 0 = least important). These were general health and well-being (24.6); impact on home/social life (20.8); health and comfort of the mouth, teeth, and gums (20.0); appearance (18.8); and impact on job/studies (15.8). CONCLUSION: A clinically applicable, multi-attribute outcome scale has been produced that takes into account all determinants of health outcome as perceived by the patient in the context of minor oral surgery. It is completed by selecting a weighted statement from each domain, the sum of which constitutes the patient's health state utility score. The scale has potentially extensive application to both clinical care and research.
Adolescent↗
The cost, effectiveness and cost effectiveness of removal and retention of asymptomatic, disease free third molars.
PURPOSE OF INVESTIGATION: The study was undertaken to identify the least costly, most effective and most cost-effective management strategy for asymptomatic, disease free mandibular third molars. METHODS AND PATIENTS: A decision tree model of the outcomes of mandibular third molar retention and removal was constructed. Probability data for possible outcomes were obtained from a comprehensive literature review and entered into the decision tree. The cost to the NHS in treating each outcome was calculated. 100 patients attending the oral surgery clinics, University of Wales Dental Hospital rated the effect of each outcome on their own life. The cost and effectiveness data for each outcome were entered into the decision tree and the analyses were conducted by 'folding back' the decision tree based on the probabilities. MAIN FINDINGS: Mandibular third molar retention was less costly (170 Pounds), more effective (69.5 effectiveness units on a 100 point scale) and more cost-effective (2.43 Pounds per unit of effectiveness) than removal (226 Pounds, 63.3 and 3.57 Pounds respectively). These findings were sensitive to changes in the probability of pericoronitis, periodontal disease and caries. PRINCIPAL CONCLUSIONS: Mandibular third molar retention is less costly to the NHS, more effective for the patient and more cost-effective to both parties than removal. However, should the likelihood of developing pericoronitis, periodontal disease and caries increase substantially then removal becomes the more cost-effective strategy.
Cost-Benefit Analysis↗
Factors influencing nerve damage during lower third molar surgery.
OBJECTIVE: To investigate relationships between pathology, eruption status, age, anaesthetic modality and nerve damage during lower third molar surgery. DESIGN: Single centre prospective study. SETTING: Oral surgery out-patient clinics. SUBJECTS: 367 patients unselected for age, gender or social class, scheduled for lower third molar removal. At 1 week, any evidence of iatrogenic nerve damage was recorded. Patients with altered lingual and/or labial sensation were followed up for 6 months. RESULTS: 718 lower third molars were removed from 250 males and 117 females. 96 removals (13.4%) were associated with altered lingual, labial or buccal sensation. There were no significant associations between nerve damage and eruption status, age and pre-operative pathology. There was a highly significant difference in the incidence of nerve damage between LA removal (3%) and GA removal (18%) (chi-squared = 17.18; f = 2; P < 0.01) but no significant associations between surgical difficulty and nerve damage within each of the two groups. CONCLUSIONS: Lingual and inferior alveolar nerve damage was five times more frequent when lower third molars were removed under general anaesthesia rather than local anaesthesia. This could not be explained in terms of surgical difficulty, pre-operative pathology, age or anatomical position.
Adolescent↗
Impact of third molar removal on demands for postoperative care and job disruption: does anaesthetic choice make a difference?
A prospective cohort study was undertaken to investigate the influences of anaesthetic modality and surgical difficulty on social reintegration and demands on health services after third molar removal. The study was undertaken at the Oral and Maxillofacial Surgery Department, Cardiff Dental Hospital. Of 444 patients, 266 (60%) had their third molars removed. The main outcome measures included anaesthetic modality, surgical difficulty (WHARFE scores), utilisation of health services, effects on work, school and home life. In all, 101 (40%) patients were treated under local anaesthesia (LA) +/- intravenous (i.v.) sedation and 165 (60%) under general anaesthesia (GA); 81 (49%) as inpatients and 84 (51%) as day cases. Of these patients, 38 (14%) returned to the hospital and 74 (28%) utilised primary care services postoperatively in addition to a standard review appointment. Patients treated under GA made more demands on primary care services (chi 2 = 6.41, df = 2, P < 0.05) and took more time away from work (P < 0.05). Patients underestimated the time they needed to recover. There was similar disruption to job, college and home life. There were no links between disruption and particular anaesthetic modalities and surgical difficulty. Surgery under GA was linked to increased postoperative demands on primary care, but not secondary care, and to longer job disruption. This could not fully be attributed to surgical difficulty.
Adolescent↗
A study of the validity of a simulation of third molar eruption based on Markov modelling.
PURPOSE OF INVESTIGATION: The study was undertaken to examine the extent to which a model based on a Markov modelling process would simulate the eruption of lower third molars. BASIC PROCEDURE: A Markov process model was developed to model eruption of lower third molars using a 1-year time increment based on simulated eruption data relating to 100 lower third molars. This model was tested using a Monte Carlo simulation and compared with eruption patterns of 973 actual lower third molars. Statistical analysis of the differences between the simulated and actual groups was undertaken. MAIN FINDINGS: There were no differences between the simulated and actual data other than for the subgroup aged 30-34 where the simulation overestimated the probability of parteruption and underestimated the probability of uneruption and full eruption. PRINCIPAL CONCLUSIONS: This methodology produced an accurate model that may be of use in service planning.
Adolescent↗
Intra-observer reliability regarding removal of asymptomatic third molars.
OBJECTIVE: To investigate reliability of practitioners' removal decisions and judgements of risk of pathology associated with asymptomatic third molars. SUBJECTS: 10 oral surgeons and 18 family dentists from South Wales with experience ranging from 5 to 28 years. METHOD: Participants were presented with periapical radiographs of 36 asymptomatic, mandibular third molars and were informed of the age and sex of the patients and the degree of eruption of the third molars. Participants were asked to assess, using visual analogue scales, the likelihood of future pathology if the third molars were left in situ and to indicate if they should be removed or not. To assess intra-observer reliability, the 36 cases were duplicated and presented to the participants on a different occasion, a month later. The same questions were asked as on the first occasion. RESULTS: Significant correlations (Pearsons correlation coefficients) were found between initial and repeat assessments of all measures but there was little agreement about the need for removal (Kappa values: 0.54 for oral surgeons and 0.41 for the family dentists). For every item studied, changes in position on the visual analogue scale of two-thirds or more of the total length occurred from the first to the second assessment. CONCLUSION: Treatment decisions about whether or not to remove asymptomatic third molars were not made on a rational basis. Since similar conclusions were recorded in a previous Swedish study, it is inferred that until further high quality evidence of disease prediction is published, decisions to remove third molars prophylactically cannot be made reliably.
Adult↗
A comparison of the ability of experts and non-experts to differentiate between adult and child human bite marks using receiver operating characteristic (ROC) analysis.
Fifty colour prints of human bite marks were sent to 109 observers who were asked to decide using a six point rating scale, whether the marks had been produced by the teeth of an adult or a child. The observers consisted of accredited senior forensic dentists, accredited junior forensic dentists, general dental practitioners, final year dental students, police officers and social workers. The results were compared against a "gold standard" which was the actual verdict from the case. Comparison of the results between the groups of observers and the standard was made using Receiver Operating Characteristics (ROC) methodology. The best decisions were made by senior/junior experts or final year dental students. General dental practitioners and police officers were least able to differentiate correctly between adult and child bite marks. The effect of training is important and its effects need to be assessed in more detail in future studies.
Adult↗
Choice of anaesthetic and healthcare facility for third molar surgery.
A prospective investigation was carried out to find out which factors affected the choice of anaesthetic for 444 consecutive patients (153 male, 291 female, age range 15-85) listed for extraction of third molars. Two hundred and seventy-two were listed for treatment under general anaesthesia, 120 (44%) as inpatients and 152 (60%) as day cases. The remaining 144 (32%) patients were to be treated under local anaesthesia and 28 (6%) with additional intravenous sedation. Logistic regression analysis showed that difficulty of surgery, patients' anxiety, patients' preferences, medical history, and number of teeth to be removed were important predictors of choice of anaesthetic. From an anaesthetist's perspective, many more patients should have been treated under local anaesthesia with intravenous sedation and fewer should have been listed for inpatient extraction under general anaesthesia.
Adolescent↗
Neural networks: a new technique for development of decision support systems in dentistry.
OBJECTIVES: To outline the key concepts of neural network based systems and to evaluate the potential applications of such systems in dentistry. DATA SOURCES: Published work on neural networks. CONCLUSIONS: Neural networks may initially seem complex and computer intensive, but actually integrate well with a clinical environment. Neural network expert systems may be trained with only clinical data and as such can be used where 'rule based' decision making is not possible. This is the case in many clinical situations. Neural networks may therefore become important decision making tools within dentistry and have applications both in improving clinical care and in maximizing the cost benefit of care.
Algorithms↗
Perceptions of women on the impact of menorrhagia on their health using multi-attribute utility assessment.
OBJECTIVE: To assess patient preferences regarding the treatment of menorrhagia using the multi-attribute utility methodologies, to produce a clinically applicable scale, and to assess health outcomes following treatment of menorrhagia. METHODS: Women referred to the gynaecology department for the treatment of menorrhagia were interviewed regarding the effects of menorrhagia on different aspects of their life. Their concerns were categorised into main components of health (domains). The relative importance of each domain was rated by the women using importance points which were distributed to represent the perceived importance of each domain. A series of statements (intra-domain statements) was developed for each domain, which described various possible conditions of that component of health. These were also rated using a one metre visual analogue scale with numerical anchor points at zero (worst) and 100 (best). RESULTS: The components of health considered most important were, in order of impact, family life, followed by physical health, work life, psychological health, practical difficulties and social life. The scores for the intra-domain statements were combined into a scale to allow the calculation of a final health state utility for a particular outcome based upon the statements the patient chooses within each domain. DISCUSSION: In planning treatment for menorrhagia clinicians can assess a woman's current perception of their health, using a simple to administer clinical scale.
Adult↗
Automatic identification of dental appliances.
AIM: To develop a reliable, machine-readable coding system for dental appliances. METHODS: Incorporation of two-dimensional bar codes and matrix codes into a range of dental appliances using printed thermal substrates and laser-etched ceramic discs. RESULTS: Problems including reaction of thermal substrates with methyl methacrylate monomer, loss of code clarity, limited areas available for bar codes, difficulty in scanning opaque pigmented acrylic resin and palatal and lingual surfaces were overcome using 4 mm2 data matrix codes etched onto ceramic discs. CONCLUSIONS: Reliable automatic identification of dental appliances was achieved using laser-etched matrix codes. Further development is necessary in relation to optimisation of code size, encryption, scanners and maintenance of code readability over time.
Dental Equipment↗
Comparisons of the abilities of a neural network and three consultant oral surgeons to make decisions about third molar removal.
AIM: To compare the performance of a computer based decision support system (a neural network) and consultant oral and maxillofacial surgeons in making decisions about the need to remove lower third molars. DESIGN AND SETTING: Receiver operating characteristic (ROC) analysis at a hospital department of oral and maxillofacial surgery. SUBJECTS AND METHODS: Three consultant oral and maxillofacial surgeons indicated on a six-point rating scale how certain they were that each of 50 documented lower third molars required removal. Similar data were obtained from the neural network following appropriate coding of the clinical information. These data were compared with gold standard treatment decisions for each tooth based on National Institutes of Health Concensus criteria using ROC analysis. MAIN OUTCOME MEASURES: The area beneath each operator ROC curve (varying between zero and one with greater areas indicating better performance). RESULTS: The network performed as well a two consultants (P = 0.12/0.18, NS) and significantly better than the third (z = 526, P < 0.01). CONCLUSIONS: This work suggests that this computer based neural network could play a useful role in supporting dental practitioners making third molar referral decisions.
Adult↗
Multiattribute utility assessment of outcomes of treatment for head and neck cancer.
Good clinical practice is dependent on continuous audit. Most audits of head and neck cancer treatment planning have been subjective, with only 5-year survival rates being considered objectively. Improvements in clinical care require not only measurable goals that relate to patients' perspectives, but also a means of assessing to what extent those goals have been met. In this context, 5-year survival rates are too crude to be useful, although they remain important for other reasons. Because a simple clinical objective measure of outcome applicable to head and neck cancer is not available, multiattribute assessment techniques were used to develop a clinically based scale for outcomes following treatment for head and neck cancer, with domains centred on social function, pain, physical appearance, eating and speech problems, nausea, donor site problems and shoulder function. Domains were weighted relative to each other; pain (mean weight 85) and social function (89) were considered most important followed by physical appearance (76), eating (76) and speech problems (74) A series of graded statements was constructed within each domain and scaled relative to each other. These components were also combined into an overall scale that will enable objective outcome assessment in this important area of medical care.
Head and Neck Neoplasms↗
Treatment strategies for lower third molars following orthodontic care.
To examine the extent to which orthodontists consider it appropriate to refer post-orthodontic patients for lower third molar treatment. The subjects were 10 orthodontists from hospital, specialist practice and community setting. Participants were presented with 15 case histories of orthodontic patients (including full records) and asked to state whether they would have referred the case to an oral surgeon for management of their third molars. Data were analysed using multi-kappa measure. Two-hundred-and-sixty-two decisions of 300 (88%) were not to refer cases for third molar management. Little consensus was seen between orthodontists on which post-orthodontic cases referral (kappa = 0.14). Some clinicians referred cases much more frequently than others (Kruskall-Wallis = 46.84, P < 0.001) and some clinicians referred much more frequently (Kruskall-Wallis = 85.57, P < 0.001). This group of orthodontists did not refer post-orthodontic cases for third molar management and little consensus was observed regarding which cases did warrant removal.
Adolescent↗