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Objective: To investigate variations in preparations for porcelain laminate veneers (PLVs) in general dental practice., Design: Laboratory-based retrospective analysis of dies for PLVs., Setting: General dental practice in England and Wales (1994)., Methods: A sample (95 cases) of laboratory models from general dental practice featuring preparations for PLVs was randomly selected from a full service commercial dental laboratory. Aspects of the preparations were quantified and compared with accepted preparation criteria distilled from a review of the literature., Results: The teeth found to be most frequently prepared for PLVs were maxillary incisors (48%). The majority of cases investigated were for one veneer only (56%). The margins of the preparations were variably positioned with more than half of the preparations (55%) having no clear margin. In accordance with current guidelines the incisal edge tended to have been reduced during preparation (47%). In contrast, most teeth were underprepared with an average depth of preparation of 0.16 mm (SD 0.60 mm, 95% CI-0.1, 0.42)., Conclusions: There was little evidence that established guidelines for the preparation of teeth for PLVs had been applied in full.

Objective: To evaluate the pilot peer review scheme for general dental practitioners, working in the general dental services in England., Design: A retrospective analysis of a 50% random sample of end of project résumés., Setting: The scheme was piloted from August 1991 to April 1996. At the end of each project a résumé was completed., Methods: The random sample of résumés was subjected to content analysis by three reviewers who had previously undergone consistency training., Main Outcome Measures: The range of topics reviewed, the choice of single or multiple topics, the direct relevance of projects to patient care and the comments of the scheme's participants., Results: 332 résumés were analysed, 89% included positive comments. Overall 42% of projects reviewed single topics, with participants in 4 out of 13 regions favouring this approach. 61% of topics related directly to patient care., Conclusions: The pilot peer review scheme was enthusiastically welcomed by the participants and achieved its objectives of encouraging initiatives to improve patient services and testing different types of peer review.

The aim of this study was to assess the involvement of general dental practitioners in Yorkshire in clinical audit activity and in postgraduate dental education and to compare the results with those of a previous survey undertaken in 1989. There is a need to find ways of encouraging all general dental practitioners to become actively involved in continuing professional development and in improving the quality of general dental practice through the use of clinical audit.

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.

In this study, patient opinion on oral rehabilitation by means of Brånemark implants was investigated. All patients were referred to a periodontal clinic for implant installation and treated by one and the same operator. Prosthetic restorations were performed by dentists, who had no previous experience with prostheses on implants, but had completed a postgraduate training course. Patient opinion was obtained through questionnaires, pertaining to satisfaction and oral function. A comparison was made between pre-implant situation, short-term (< 4 months) and long-term functioning (3 years) with the implant-restorative rehabilitation. In total, 61 patients participated in the study; 23 received a full lower arch bridge and 18 a full upper arch bridge, while 20 patients got partial bridges. Of 298 installed implants, 7 failed at abutment connection (2.3%) and 1 during the 3-year follow-up interval (0.3%). The study results indicated that a great majority of patients were very satisfied with the treatment. Comfort with eating, aesthetics, phonetics and overall satisfaction improved significantly and nearly all patients said that they would undergo the treatment again or recommend it to others. Patients experienced their implants as "natural" teeth. The conclusion is that rehabilitation ad modum Brånemark, even in the hands of non-specialized dentists, can be of high quality, improving oral function and satisfying the needs and demands of patients.

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.

General practice audit is essential in the process of developing an evidence-based approach to dental care. The CHAID (CHi-Squared Automatic Interaction Detector) statistical software package is both practical and user-friendly for many simple applications. The types of questions asked in general practice audit projects will frequently be suitable for analysis using this technique. This may include the identification of patients who are likely to fail appointments and place an additional financial burden on the practice. This paper illustrates the potential value of CHAID to general dental practitioners (GDPs) by using examples of commonly cited dental audit topics. This paper aims to illustrate how a simple statistical package (SPSS CHAID) may be of use for both audit and practice management activities.

Clinical audit is widely recognised as the systematic and critical analysis of the quality of clinical care, including treatment regimes, the associated use of resources, and the resulting outcome and quality of life for the patient. The prescribing of antibiotics in general dental practice is an area 'wide open' for audit analysis since the profession must clearly accept its responsibility to use antibiotics sensibly; however, the definition of 'sensibly' is likely to vary from practitioner to practitioner. This audit reviews the need for antibiotic prescribing in general dental practice over two consecutive four-month periods. A consensus was achieved on the rationale for antibiotic prescribing and the number of prescriptions fell by 50% as a result.

Objective: The purpose of this study was to assess aspects of the quality of care provided by dental hygienists in a California demonstration project in which hygienists treated patients independent of dentists' supervision., Methods: The structure and process of care were evaluated in nine independent practices using site visits and reviews of 25 records at each practice. The findings were compared to evaluations of six general dentist practices reviewed for a government agency and insurance company during the same time period. Patient satisfaction was assessed by a questionnaire., Results: The structural aspects of the unsupervised hygienist practices were generally acceptable and surpassed the dentist practices in most areas, including infection control. For process, the hygienist practices had high percentages of acceptable care and were significantly better than the dentist practices in several areas, including follow-up to medical findings, updating the medical history at recall, and documenting the evaluation of the periodontal status and soft tissues. Ninety-eight percent of patients expressed satisfaction with their care in hygienist practices., Conclusion: Under the circumstances of the demonstration project and the methods used to assess the quality of care, the study showed that independent dental hygienist practice did not increase the risk to the health and safety of the public.

Objective: To examine the relationships between price of services, quality of care, and patient time costs in private practices of general dentists., Data Source/study Setting: In October 1992, a 3.7 percent sample of eligible general dentists in part-time or full-time private practice in 1991 was randomly drawn from a sampling frame tailored from data gathered by the 1991-1992 American Dental Association Distribution of Dentists census of all United States dentists., Data Collection: A mail survey was used to collect data on dentist demographic characteristics, dental practice characteristics practice finances, and insurance. The survey was completed and returned by 3,048 general dentists (77 percent response rate). Local area population characteristics were obtained from secondary sources., Study Design: Two-stage least squares regression was used to evaluate the structural relationships between price of services, quality of care, and time costs to patients. Structural equations were estimated for four different quality of care measures and two time costs., Principal Findings: Price of services and quality of care were significantly related to each other. Higher quality of care was associated with higher price of services and, reciprocally, higher price of services was associated with higher quality of care. Shorter waits for a new patient appointment were associated with higher prices. Higher price of services, lower quality of care, and longer waits for a new patient appointment were related to shorter in-office waiting time., Conclusions: The implication of these findings is that if price of services is constrained, then the quality of care provided by the dentist may also be reduced.

Aim: To ascertain the views of dental consultants on the relative importance of a range of topics relevant to specialist referral., Subjects: 200 randomly selected dental consultants working in the UK in 1995., Main Outcome Measures: Data items which referral letters should contain; standard of referral letters; appropriate reasons for referral; how referrals could be improved; should restrictions be placed on specialist referrals., Results: 161 replies were received. Overall there was only slight variation between specialities with regard to data items, appropriateness of referral and standard of referral letter. The perceived standard of referral letters was adequate or better on 76% of occasions; 21% were deemed to be of a poor standard; 2% were described as appalling., Conclusions: A Section 63 course on how to refer competently could be of benefit. Consultants were generally not in favour of restricting referrals to them.

After consulting a large community of interested parties, the National Dental Examining Board of Canada (NDEB) and the provincial licensing authorities recently made significant changes to the certification process for dentists in Canada. This paper provides a chronology of the evolution of national certification and a summary of the present certification processes for graduates of both accredited and non-accredited programs.

ORATEL (a telematic system for quality assurance indicators in oral health care) is a three-year project with the ultimate objective of improving the quality of oral health care through the use of appropriate computerised information systems. These tools are designed to promote quality assurance and quality of care development in oral health care by using common quality indicators/standards. ORATEL has developed three prototypes of computerised information systems: an interactive multimedia teach software on quality assurance in oral health care, ORATEL-TEACH; a proactive quality assurance support tool for real time use at the dental unit, ORATEL-PROACT; and an integrated set of modules for monitoring and self assessment at the clinical level and for the computerised reporting of aggregated data for evaluation at higher levels, ORATEL-REVAL. The initial experiences of using these tools was assessed during 1993 in general dental practice locations in Liverpool and clinics in for other European countries. Overall, the dentists were positive about the potential usefulness of the ORATEL tools but further improvements were considered necessary. Finding has been approved by the European Commission for further development under a new project called ORQUEST.

The aim of this paper was to assess the health gain in orthodontics achieved by practitioners in the General Dental Service (GDS) and Hospital Dental Service (HDS) and the relative probabilities in achieving health gain in relation to the presenting occlusal trait. In a sample of 1225 patients in the GDS in England and Wales and 1365 cases in the HDS different levels of health gain were found. Occlusal traits are most likely to be treated more successfully in the HDS. Seven out of every ten patients in the HDS were likely to achieve health gain as opposed to four out of every ten patients in the GDS.

Many GDPs still look upon clinical audit with some scepticism, but there are clear benefits to be gained by GDPs from using audit within general practice. This article draws on the authors' own experience of the benefits that were gained by practitioners during a clinical audit session, as part of vocational training.

There have been many calls recently for a more 'evidence based' approach to clinical dentistry. This article argues the need for a similar approach to be adopted by the private dental schemes when setting criteria for practice inspection. The author recognises the laudable attempt to revise the 'quality' of dental practice but questions whether the methods adopted to date are justifiable.

This study investigated treatment times and treatment standards produced by 10 specialist orthodontic practitioners working in the General Dental Service (GDS) in England. Twenty cases from each practitioner, consecutively completed with two-arch fixed appliance therapy, were selected and assessed to evaluate treatment times and treatment standards. Observer-generated timings were recorded to provide values for the time taken by these practitioners to perform the various component activities associated with fixed appliance orthodontic therapy. These timings were then pooled to produce an 'average' value for each procedure. Treatment time was assessed retrospectively by applying these average times to the appropriate appointments, as documented on the patient's record card. The treatment duration, number of visits, appliance type and extraction regime were also recorded. Treatment standards were assessed by applying the weighted Peer Assessment Rating Index (PAR Index) to pre- and post-treatment study casts. Relationships between each of these variables were investigated using multiple regression analysis. No relationship was found between treatment time and PAR score change. Predictors of treatment time were the number of visits, and more interestingly, the use of extra-oral forces. However, no useful predictors of the treatment standard were found. On the basis of this sample, it appears that when specialist orthodontic practitioners in the GDS provide two-arch fixed appliance therapy: treatment is completed, on average, in 3-5 hours of chairside time, in 20 visits, spread over 22 months; they provide a high standard of treatment, as assessed by the PAR Index, to a caseload of patients in need to treatment.

A sample of 172 orthodontic patients treated by 10 general dental practitioners in their practices was assessed in terms of treatment need and standard of treatment provided. The practitioners had been clinical assistants, for a minimum of 2 years, at a District General Hospital before starting any of the cases. Prior to treatment 70% of the cases had a 'clear need' for treatment on dental health grounds and 73% of the cases had a 'moderate' or 'great need' for treatment on aesthetic grounds. Using the Peer Assessment Rating nomogram to assess the treatment standard, 83% of patients could be classed as 'improved' or 'greatly improved' with treatment but 17% were 'worse or no different'. The standard of treatment produced by fixed appliances was found to be superior to that produced by removable appliances alone. When removable appliances were used the best results were obtained when consultant advice was given. The results for the clinical assistant sample are compared with the results for the GDS sample published in 1993. Ways of further improving the treatment standards produced by the general dental practitioners are considered.

Objectives: The impact of any effort aimed at improving diagnostic accuracy by improving clinical decision making in diagnostic radiology will be limited by the ability of the clinician to correctly recognize the presence of abnormalities on radiographs. We carried out a study designed to examine whether dentists are able to correctly identify various kinds of periapical bone lesions visible on intraoral radiographs and diagnose their pathologic nature., Study Design: General dental practitioners (n = 98) assessed 32 radiographs that showed either normal bone (10) or one abnormality (22) in the periapical bone. The "gold standard" for pathosis was histopathologic analysis. The dentists were asked to judge for the presence of an abnormality and to decide whether an active pathologic process was present., Results: On average dentists identified 81% of all visible abnormalities correctly. Subsequently, they diagnosed 59% of all the pathologic cases correctly. Dentists, however, incorrectly identified 55% lesions on radiographs when experts had stated that no abnormality was visible., Conclusion: There is room for improvement of diagnostic accuracy of bony pathology.

An investigation and survey explored the effect of the display of dental undergraduates clinical performance by a process termed silent monitoring. The study measured the effect of silent monitoring on the quality of patients' treatment and the frequency of non-attendance at appointments for patients arranged by undergraduates. A cross-sectional study also estimated the impact of silent monitoring on undergraduates' clinic time use. Both enquiries revealed that silent monitoring motivated students. It significantly increased the number of patients treated and reduced the non-attendance of appointments. However, there was an increase in the incidence of patients informing undergraduates that they could not attend appointments. This phenomenon allowed the rescheduling of appointments and better use of clinic time. Silent monitoring increased the time undergraduates spent preparing for the patients' treatment. it also improved the patients punctuality. Evaluation of the procedure by questionnaires showed approval of the method, although some undergraduates felt that aspects of their assessment were unfair. A survey revealed that other United Kingdom dental schools do not use silent monitoring. If they adopted such a method, it could have similar positive influences on their undergraduates' management of clinical practice and improve the quality for dental practice.

The aim of this study was to assess the impact of two quality control measures upon the quality of periapical radiographs in general dental practices. Five general dental practitioners took part in the study. Periapical radiographic quality was assessed before and after the introduction of film holders and quality control measures for processing. Prior to the introduction of the quality control measures, 49% of radiographs were assessed as being 'unacceptable', 49% exhibited faults but were 'acceptable' for diagnostic purposes, while only 2% of radiographs were 'excellent' being entirely free of faults. After the introduction of film holders and processing quality control procedures 39% were 'unacceptable' (P < 0.05), 56% were 'acceptable' and 5% of radiographs were classified as 'excellent'. It is concluded that current recommendations to dentists to use film holders and to carry out processing quality control are justified in terms of an improvement in the diagnostic quality of radiographs. However, improvements in undergraduate and continuing education for all members of the dental team, with emphasis on practical 'hands-on' instruction, may improve the effectiveness of these recommendations.

This study had three aims. The first was to examine the influence of legislative and educational factors on facilities and equipment in dental practices, the second to find out if these and practice size affected standards and the third to assess the degree to which technique and other faults not connected with processing accounted for inadequate diagnostic quality in intra-oral radiography. Dentists from 62 practices returned questionnaires about the sizes of their practices, facilities and equipment for radiography and relevant updating, training and education of their staff. The quality of 305 radiographs taken in a sample of 11 practices was assessed. Ten examples of good radiographic practice were used to evaluate standards in the general practices. The 'good practice score' ranged from 2 (two practices) to 10 (one practice) with a mean of 6.2. Practices whose principals had engaged in the recommended educational activities scored more highly than those that had not (P < 0.05), and the mean scores in practices of two or more dentists were higher than in single-handed (P < 0.05). Of the 305 radiographs, the dentists, without the use of criteria to assess them, rejected 13.8%; with criteria they rejected 39.3% (P < 0.05). The researcher rejected 63.9% (P < 0.05). All films were processed under controlled conditions and it is likely that reject rates would have been higher under normal processing conditions. It is concluded that the use of criteria to assess radiographs and acceptance of postgraduate opportunities, particularly by single-handed practitioners, would improve the conduct of radiography. Further improvements might be gained by orienting updating courses and materials towards behavioural change.

There is increasing demand for PGD positions. New and innovative models for accrediting these programs will be necessary if the number of positions is to grow to meet the anticipated need. The current accreditation system is the result of a historical and political evolution and now does not reflect the increasing diversity among PGD programs. Ad hoc attempts to respond to changing workforce pressures led to difficulties for program directors in meeting accreditation requirements and confusion among applicants to these programs. At the same time, there is a growing trend to describe educational endeavors using a competency-based model, emphasizing the outcome rather than the structure or process of the educational experience.

A postal questionnaire regarding potential and official patient complaints was sent to all dentists on the Family Health Service Authority list of four health districts in Greater Manchester. From an eligible sample of 335 dentists, 306 responses were received (91%), 289 of them from general dental practitioners (GDPs). One hundred of the GDPs (35%) had reported at least one potential complaint to their defence organisation in the past 5 years (1989-1993) and 10 GDPs had reported three or more complaints. The majority of complaints were in the field of restorative dentistry (57%) with complaints about oral surgery accounting for another 20%. Dentists who worked longer hours contacted their defence organisation more often regarding potential complaints. Thirty-two dentists reported that their most recent potential complaint had resulted in an official complaint being filed against them. There was a significant relationship between the prevalence of official complaints and the dentists' reported level of unsatisfactory patient visits.

Clinical audit focuses on self--and, more importantly, peer assessments of the performance of practitioners and the service they provide to patients. Some practitioners may feel threatened by audit; however, when conducted as intended and viewed as a form of education, it may become recognised as an integral, cost-effective element of everyday clinical practice. This article highlights ways in which practitioners may increasingly appreciate the need to understand and apply clinical audit processes in their practice environments.

A great number of dentists recognise the conflict between running a viable business and providing dental care to the same level they had been taught as students. This Personal View recounts the experiences of one general dental practitioner, but the feelings expressed have a universality that many will recognise.

A number of studies have shown a low standard of radiographic image quality in general dental practices. Image quality was evaluated on 1094 radiographs from 100 consecutive cases submitted to a dental insurance office for approval of planned prosthodontic treatment. It was found that only 404 radiographs were without any type of error and that 690 radiographs had a total of 959 errors. The most common errors were projection and film density errors. The number of submitted radiographs ranged from one to 40. Nearly every fourth tooth proposed for treatment was not properly documented. The results also showed that 43 of 100 cases did not meet the criteria for acceptance for assessment of the proposed prosthodontic treatment. This means that they were incompletely documented radiographically so that the treatment plan could not be evaluated. This study suggests that new or additional radiographic documentation ought to be requested frequently before approval of proposed treatment plans.

In September of 1991, all postgraduate general dentistry (PGD) program directors (Advanced Education in General Dentistry [AEGD] and General Practice Residency [GPR] directors [n = 325]) were surveyed to ascertain their opinions of the ideal goals and objectives of PGD programs. The response rate was 81.5 percent (n = 265). The directors rated the relative importance of various PGD program goals and objectives. The average of all the items rated was 3.4 on a scale ranging from 1 = unimportant to 4 = very important. The respondents identified several clinical and didactic subject areas that they considered very important including; infection control, CPR, dental and medical emergencies, diagnosing dentoalveolar trauma, diagnosing oral pathology, and assessment and treatment of patients with medical conditions. They also identified several training areas which were beyond the scope of a PGD program, e.g., research techniques, pediatric sedation, and selected advanced clinical procedures in dentistry (implantology and orthodontics) which require a long time to complete. In general, there was substantial agreement among the directors of different program types and sites as to the relative importance of various program goals. The largest differences were found among directors of programs from different sites, e.g., hospitals versus dental schools as opposed to directors from different program types, e.g., GPR versus AEGD. There is now a need to determine the relationship of these identified idealized goals and differences to program outcomes for the graduates of PGDs.

Prior to 1987, dental practitioners in England and Wales intending to carry out all but the simplest orthodontic treatment within the National Health Service, were required to submit pretreatment study models, details of the orthodontic assessment and the proposed treatment plan to the Dental Estimates Board prior to starting treatment. Models taken at the end of treatment were required by the Board to enable payment to be made. In this pilot study, the acceptability of orthodontic treatment plans used by practitioners working in the General Dental Services was assessed by eight hospital consultants, using information about 40 cases submitted to the Dental Estimates Board in 1987/88. All consultants considered a high proportion of plans to be unacceptable, but agreement between the consultants was variable and some agreed with one another on very few plans. A single scorer used the weighted PAR (Peer Assessment Rating) index to assess the degree of departure from normal occlusion of both pre- and post-treatment models. Using accepted standards, only nine cases were greatly improved (PAR reduction > 70%) and the mean percentage reduction in PAR score was low. Consultant opinion on the appropriateness of treatment planning was not related to the outcome of orthodontic treatment.

Dentists, while recognising the need to be more marketing orientated, still have some way to go to improve the perception of themselves and their services in the eyes of the public. Nigel Coates and John Willans suggest some ways to address the barriers to visiting dentists.