Cork University Dental School and Hospital - Doctoral Theses

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The utility of survey and administrative data to generate information for research and outcomes-based oral health services development
(University College Cork, 2013) Guiney, Helena; Whelton, Helen; Woods, Noel
The aim of this research, which focused on the Irish adult population, was to generate information for policymakers by applying statistical analyses and current technologies to oral health administrative and survey databases. Objectives included identifying socio-demographic influences on oral health and utilisation of dental services, comparing epidemiologically-estimated dental treatment need with treatment provided, and investigating the potential of a dental administrative database to provide information on utilisation of services and the volume and types of treatment provided over time. Information was extracted from the claims databases for the Dental Treatment Benefit Scheme (DTBS) for employed adults and the Dental Treatment Services Scheme (DTSS) for less-well-off adults, the National Surveys of Adult Oral Health, and the 2007 Survey of Lifestyle Attitudes and Nutrition in Ireland. Factors associated with utilisation and retention of natural teeth were analysed using count data models and logistic regression. The chi-square test and the student’s t-test were used to compare epidemiologically-estimated need in a representative sample of adults with treatment provided. Differences were found in dental care utilisation and tooth retention by Socio-Economic Status. An analysis of the five-year utilisation behaviour of a 2003 cohort of DTBS dental attendees revealed that age and being female were positively associated with visiting annually and number of treatments. Number of adults using the DTBS increased, and mean number of treatments per patient decreased, between 1997 and 2008. As a percentage of overall treatments, restorations, dentures, and extractions decreased, while prophylaxis increased. Differences were found between epidemiologically-estimated treatment need and treatment provided for those using the DTBS and DTSS. This research confirms the utility of survey and administrative data to generate knowledge for policymakers. Public administrative databases have not been designed for research purposes, but they have the potential to provide a wealth of knowledge on treatments provided and utilisation patterns.
The use of atraumatic restorative treatment in elderly patients: a randomised controlled clinical trial
(University College Cork, 2013) da Mata, Cristiane; O'Mahony, Denis; Allen, P. Finbarr; Health Research Board
Objectives: to assess elderly patients’ dental status and dental habits and compare the survival rates, impact on patients’ quality of life and cost-effectiveness of Atraumatic Restorative Treatment (ART) and a conventional treatment (CT) to restore carious lesions in an elderly population. Methods: In this randomised clinical trial, 99 independently living adults (65-90 yrs) with carious lesions were randomly allocated to receive either ART or CT. Details of restored, missing and carious teeth were recorded and patients answered some questions about their oral hygiene and dental attendance habits. Direct and indirect costs were measured based on treatment time, materials and labour. Effectiveness was measured using restoration survival percentage after one year. The survival of restorations was assessed 6 months and one year after restoration placement by an independent examiner. Oralhealth related quality of life (OHRQoL) was assessed using the OHIP-14 at baseline and 2 months after treatment together with a global transition statement. Results: The patient sample comprised 46 (46.46%) male and 53 (53.54) female participants at baseline, with a mean age of 73.18 (SD=6.76). The mean DMFT of the entire sample was 27.10. Ninety patients and 268 restorations could be assessed after one year, 127 ART (46 patients) and 141 conventional restorations (44 patients). 93.7% and 97.2% of the restorations placed were considered successful in the ART and CT groups, respectively. The OHIP scores did not change dramatically 2 months after treatment, in either group. The global transition scale showed an improvement in overall oral health after treatment for the majority of patients. The ART were more cost-effective compared to the CT restorations. Conclusions: ART presented survival rates similar to CT after 1 year and was a more cost-effective alternative to treat the elderly.
Tooth wear in Irish teenagers: a laboratory and epidemiological study
(University College Cork, 2015) Harding, Máiréad; Whelton, Helen; Sheehan, David; GSK Consumer Healthcare (UK); Health Research Board
Aim: To investigate the characteristics, development and determinants of toothwear among Irish schoolchildren. Methods: A cross-sectional (examination at 16-years-old) and longitudinal (examinations at 5-,12-,14-years) study were conducted. Two indices were used to measure toothwear, children/parents completed a demographic profile and questionnaire on oral hygiene and dietary practices, health, and lifestyle in both studies. Saliva was collected from consenting 16-year-olds. The explanatory variables for the cross-sectional and longitudinal study were derived from children/parents responses. Differences in salivary profiles were determined for subsets; the protein concentration was determined with Bradford protein assay and protein carbonyl concentration (a protein oxidation marker) was determined spectrophotometrically. Gel-electrophoresis and mass spectrometry determined proteins and ion chromatography inorganic ions. Statistical significance was accepted at p<0.05. Results: At 16-years-old the prevalence of toothwear with dentine visible was 44%. No difference in salivary flow rates existed. In unstimulated saliva a higher mean, protein carbonyl (p<0.0001) and total calcium concentration (p<0.002) existed for the group with moderate toothwear. In stimulated saliva the moderate toothwear group had a lower mean protein concentration(p<0.0001). The 2-DE protein spots prepared for a sub-group differed between those with toothwear and without. Mass spectrometry, identified one of the different proteins as IgA. For 16-year-olds, the self-reported factors indicated that brushing after breakfast was associated with lower toothwear scores(p<0.03). Nail-biting, being asthmatic or reporting a dry mouth were associated with higher toothwear scores(all p<0.05). Eating an apple daily or less was associated with less toothwear(p<0.002). In the longitudinal study toothwear into dentine at age five or 12-years was associated with more toothwear at age 14(all p<0.05). Discussion: The results illustrate the multifactorial aetiology of toothwear. The biochemical and physical correlates of saliva with toothwear requires further research. Conclusion: The impact of previous toothwear, salivary, dietary and personal factors on toothwear in the early permanent dentition is demonstrated.
Three-dimensional outcomes of twin-block appliance treatment and the influence of the postured wax bite
(University College Cork, 2015) Salloum, Erfan; Millett, Declan; Allen, P. Finbarr
Aims 1 To identify the 3D soft tissue volumetric and linear landmark changes following treatment with the Twin-Block Appliance TBA. 2 To estimate the TBA treatment outcome on the soft tissue facial profile volumetric and linear landmark changes from the Postured Wax Bite (PWB). 3 To identify if there is any association between certain soft tissue landmark variables and successful treatment outcome of the TBA as measured by the reduction in overjet. 4 To assess the effects of TBA treatment on facial expressions. Materials and Methods Forty-seven Caucasian subjects with Class II division 1 were recruited. 3D images captured of each subject, pre-treatment (T1), with the PWB (T2) and at the end of treatment (T3). Soft tissue volumetric and linear changes as well as the correlation between facial parameters and successful treatment were calculated. Results The mean soft tissue volumetric change from T1 to T3 was 22.24 ± 16.73 cm³. Soft tissue profile linear changes from T1-T3 for lower facial landmarks were 4-5 mm. From T1-T3, the mean soft tissue volumetric change of the total sample was 60% of the change produced by the PWB (T1 to T2). Correlations were weak for all 3D facial parameters and successful overjet reduction. Facial expression changes were only significant for the lower landmarks. Conclusions 1 TBA treatment, in growing subjects, increased the lower facial soft tissue volume and caused forward movement of the lower soft tissue facial profile landmarks.2 The PWB can be used to estimate the treatment outcome of the TBA on soft tissue profile changes.3 No association was found between soft tissue landmark variables and successful overjet reduction.4 TBA treatment had no effect on the upper facial landmarks for each facial expression but it changed the lower facial expressions significantly except for maximal smile in males.
Adult orthodontics: internet information and a national survey
(University College Cork, 2015) McMorrow, Siobhán; Millett, Declan; Harding, Mairead
Aims: 1. To investigate the reliability and readability of information on the Internet on adult orthodontics. 2. To evaluate the profile and treatment of adults by specialist orthodontists in the Republic of Ireland (ROI). Materials and methods: 1. An Internet search was conducted in May 2015 using three search engines (Google, Yahoo and Bing), with two search terms (“adult orthodontics” and “adult braces”). The first 50 websites from each engine were screened and exclusion criteria applied. Included websites were then assessed for reliability using the JAMA benchmarks, the DISCERN and LIDA tools and the presence of the HON seal. Readability was assessed using the FRES. 2. A pilot-tested questionnaire about adult orthodontics was distributed to 122 eligible specialist orthodontists in the ROI. Questions addressed general and treatment information about adult orthodontic patients, methods of information provision and respondent demographics. Results: 1. Thirteen websites met the inclusion criteria. Three websites contained all JAMA benchmarks and one displayed the HON Seal. The mean overall score for DISCERN was 3.9/5 and the mean total LIDA score was 115/120. The average FRES score was 63.1. 2. The questionnaire yielded a response rate of 83%. The typical demographic profile of adult orthodontic patients was professional females between 25-35 years. The most common incisor relationship and skeletal base was Class II, division 1 (51%) and Class II (61%) respectively. Aesthetic upper brackets and metal lower brackets were the most frequently used appliances. Only 30% of orthodontists advise their adult patients to find extra information on the Internet. Conclusions: 1. The reliability and readability of information on the Internet on adult orthodontics is of moderate quality. 2. The provision of adult orthodontic treatment is common among specialist orthodontists in the Republic of Ireland.
Accuracy of computer-aided design/computer-assisted manufacture (CAD/CAM) fabricated dental restorations: a comparative study
(University College Cork, 2015) Nasruddin, Mohd Faiz; Burke, Francis M.; Ray, Noel J.; Theocharopoulos, Antonios; Universiti Teknologi MARA, Malaysia
Introduction: Computer-Aided-Design (CAD) and Computer-Aided-Manufacture (CAM) has been developed to fabricate fixed dental restorations accurately, faster and improve cost effectiveness of manufacture when compared to the conventional method. Two main methods exist in dental CAD/CAM technology: the subtractive and additive methods. While fitting accuracy of both methods has been explored, no study yet has compared the fabricated restoration (CAM output) to its CAD in terms of accuracy. The aim of this present study was to compare the output of various dental CAM routes to a sole initial CAD and establish the accuracy of fabrication. The internal fit of the various CAM routes were also investigated. The null hypotheses tested were: 1) no significant differences observed between the CAM output to the CAD and 2) no significant differences observed between the various CAM routes. Methods: An aluminium master model of a standard premolar preparation was scanned with a contact dental scanner (Incise, Renishaw, UK). A single CAD was created on the scanned master model (InciseCAD software, V2.5.0.140, UK). Twenty copings were then fabricated by sending the single CAD to a multitude of CAM routes. The copings were grouped (n=5) as: Laser sintered CoCrMo (LS), 5-axis milled CoCrMo (MCoCrMo), 3-axis milled zirconia (ZAx3) and 4-axis milled zirconia (ZAx4). All copings were micro-CT scanned (Phoenix X-Ray, Nanotom-S, Germany, power: 155kV, current: 60µA, 3600 projections) to produce 3-Dimensional (3D) models. A novel methodology was created to superimpose the micro-CT scans with the CAD (GOM Inspect software, V7.5SR2, Germany) to indicate inaccuracies in manufacturing. The accuracy in terms of coping volume was explored. The distances from the surfaces of the micro-CT 3D models to the surfaces of the CAD model (CAD Deviation) were investigated after creating surface colour deviation maps. Localised digital sections of the deviations (Occlusal, Axial and Cervical) and selected focussed areas were then quantitatively measured using software (GOM Inspect software, Germany). A novel methodology was also explored to digitally align (Rhino software, V5, USA) the micro-CT scans with the master model to investigate internal fit. Fifty digital cross sections of the aligned scans were created. Point-to-point distances were measured at 5 levels at each cross section. The five levels were: Vertical Marginal Fit (VF), Absolute Marginal Fit (AM), Axio-margin Fit (AMF), Axial Fit (AF) and Occlusal Fit (OF). Results: The results of the volume measurement were summarised as: VM-CoCrMo (62.8mm3 ) > VZax3 (59.4mm3 ) > VCAD (57mm3 ) > VZax4 (56.1mm3 ) > VLS (52.5mm3 ) and were all significantly different (p presented as areas with different colour. No significant differences were observed at the internal aspect of the cervical aspect between all groups of copings. Significant differences (p< M-CoCrMo Internal Occlusal, Internal Axial and External Axial 2 ZAx3 > ZAx4 External Occlusal, External Cervical 3 ZAx3 < ZAx4 Internal Occlusal 4 M-CoCrMo > ZAx4 Internal Occlusal and Internal Axial The mean values of AMF and AF were significantly (p M-CoCrMo and CAD > ZAx4. Only VF of M-CoCrMo was comparable with the CAD Internal Fit. All VF and AM values were within the clinically acceptable fit (120µm). Conclusion: The investigated CAM methods reproduced the CAD accurately at the internal cervical aspect of the copings. However, localised deviations at axial and occlusal aspects of the copings may suggest the need for modifications in these areas prior to fitting and veneering with porcelain. The CAM groups evaluated also showed different levels of Internal Fit thus rejecting the null hypotheses. The novel non-destructive methodologies for CAD/CAM accuracy and internal fit testing presented in this thesis may be a useful evaluation tool for similar applications.
Dentofacial parameters associated with the unilateral palatally impacted canine
(University College Cork, 2015) Koshak, Lamis; Millett, Declan; Allen, P. Finbarr
Aims To investigate the relationship between unilateral PIC and specific dentofacial parameters. Materials and methods A sample of 216 subjects, with 108 subjects in the retrospective and prospective samples respectively. Dental parameters: The following dental parameters were assessed: Inter-canine and intermolar width; palatal depth and palatal area; anterior Bolton tooth-size discrepancy (TSD); maxillary arch shape and ratio and maxillary central and lateral incisor shape and ratio. Facial parameters: Three-dimensional (3D) images were taken for subjects in the prospective sample only, and were used to assess the following facial parameters: Face shape; face ratio and 3D distances and angles. Results Dental parameters: Inter-canine width was significantly smaller in the test group compared to the control group in the retrospective (p= 0.0002) and prospective (p= 0.0018) samples respectively. Anterior Bolton TSD was significantly higher in the prospective test group compared to controls (p= 0.0070). Arch ratio was significantly smaller in the test group than the control group for the retrospective sample (p= 0.0029), whereas no significant difference was recorded in the prospective sample (p= 0.1017). Arch shape distribution was significantly different in the retrospective sample (p= 0.009). Tooth shape distribution was significantly different for the maxillary right central incisor in the retrospective sample (p= 0.030). Tooth ratio showed no significant difference for both samples. Facial parameters: Basal width was significantly smaller in the test compared to the control group (p= 0.0001). No significant difference was found in all other 3D distances and angles measured. Conclusion Inter-canine width was significantly smaller in unilateral PIC subjects compared to controls. Anterior Bolton TSD was significantly higher in prospective unilateral PIC compared to controls. Maxillary arch ratio was significantly smaller in retrospective subjects. Square/tapered tooth shape was significantly more common in the retrospective group. Basal width was significantly smaller in subjects with unilateral PIC than controls.
Comparison between local anaesthetic agents, lidocaine and bupivacaine, in patients undergoing third molar extraction in terms of patient satisfaction.
(University College Cork, 2016) McCarthy, Caroline; Sleeman, Duncan
AIMS: (1) To determine if anaesthetic agent bupivacaine, has a prolonged effect on the period of acute postoperative pain when compared to lidocaine, a shorter acting agent. (2) To determine patient’s post-operative satisfaction and preference with regard to anaesthetic choice. METHODS: This double blind, randomised, interventional clinical trial included 85 patients. All patients had bilateral impacted lower third molars of removed under general anaesthetic. All patients received 0.5% plain bupivacaine on one randomly allocated side, with 2% lidocaine (with adrenaline) administered on the opposite side. Pain was measured using visual analogue scales at 0, 30, 60 minutes and 3, 4, 6 and 8 hours post-surgery. Pain was analysed for 1 week following surgery. Psychological evaluations and patient reported outcomes, including patient satisfaction were evaluated. RESULTS: A significant difference in pain (P=0.001) was seen during the 3-8 hour post-operative period. The upper limit of the 95% confidence interval was 10.0 or above at 3hours and 4 hours post-surgery. Two-thirds of patients preferred bupivacaine. CONCLUSION: Longer lasting anaesthetics such as bupivacaine offer a longer period of analgesia, and improve overall patient satisfaction.
Epidemiology, risk assessment, and treatment of root caries in older adults
(University College Cork, 2017) Hayes, Anne Martina; Allen, P. Finbarr; Burke, Francis M.; Health Research Board
Objectives This research had four objectives; 1 To assess the prevalence of, and risk indicators associated with, root caries in a cohort of independently living older adults. 2 To determine the root caries incidence over a two-year period in a cohort of independently living older adults and identify associated risk factors. 3 To evaluate the Cariogram as a risk assessment tool for the prediction of root caries in an older adult population. 4 To clinically evaluate a calcium silicate cement (Biodentine™, Septodont, Saint Maur de Fosses, France) in the restoration of root caries lesions in older adults and to compare it to the clinical performance of a high viscosity glass ionomer cement (Fuji IX GP® Extra, GC Corporation, Tokyo, Japan) and a resin modified glass ionomer cement (Fuji II LC®, GC Corporation, Tokyo, Japan). Methods Three hundred and thirty four participants were recruited in this prospective cohort study. Each subject underwent an oral examination, performed by a single calibrated examiner, to determine the root caries index and other clinical variables (DMFT, BPE, plaque index). Stimulated saliva samples were collected to determine salivary variables at baseline. Questionnaires were used to collect data on oral hygiene habits, diet, smoking and alcohol habits and education level. The participants were recalled after 12 and 24 months for a repeat clinical examination. Data was entered into the Cariogram computer model to generate a risk assessment score. A nested randomised clinical trial recruited eighty-five participants. Each participant received at least two root surface restorations; one lesion was allocated to receive Biodentine™ and the other was allocated either Fuji IX GP Extra or Fuji II LC. One dentist placed all restorations. 303 were randomized with 151 lesions allocated to receive Biodentine™, 77 to Fuji IX GP® Extra and 77 to Fuji II LC®. Patients were reviewed by a calibrated dentist who was not involved in restoration placement and who was blinded to material allocation. Restorations were assessed according to a modified USPHS criterion. Results A total of 334 older dentate adults with a mean age of 69.1 years were examined at baseline. Of these, 53.3% had at least one filled or decayed root surface. The median root caries index was 3.13 (IQR 0.00, 13.92). 280 participants were examined at two-year follow up. One quarter (n=70) of participants had developed at least one new root caries lesion in this period. The mean root caries increment was 0.70 surfaces (Q3 0.75). The baseline variables xerostomia, coronal caries experience (≥2 teeth affected), root caries index (≥14) and number of exposed root surfaces (≥37) and low final education level were associated with new root caries development over a two-year period. New caries was observed in 55.6% of those categorised by the Cariogram in the highest risk group compared to 3.8% in the lowest risk group. The area under the ROC curve was 0.77 (95% CI 0.70-0.83) indicating a fair performance in predicting root caries. Restorations placed as part of the randomised clinical trial were assessed after one year. Restorations were clinically acceptable in 47.2% of the Biodentine™ group, 83.8% of the Fuji IX GP® Extra group and 84.9% of the Fuji II LC® group respectively. There was a significantly lower success rate in the Biodentine™ group compared to that of the other two materials Conclusions The prevalence and incidence of root caries was high in this cohort. The factors associated with new root caries development in this study should be examined in future studies. Within the limitations of this study, the Cariogram was clinically useful in identifying individuals with a high risk of developing root caries. Biodentine™ cannot be recommended for the operative management of root caries. High viscosity glass ionomer cement and resin-modified glass ionomer cement continue to be the best available option for the restoration of root caries.
The oral microbiota of Irish children in health and disease: a longitudinal and cross sectional study
(University College Cork, 2017) Hurley, Eimear; O'Toole, Paul W.; Whelton, Helen; Kinirons, Martin; Health Research Board
The oral cavity harbours a very rich and diverse microbial community. In the last decade, the oral microbiota of children and adults has been studied in detail using continuously developing DNA sequencing methods. In particular focusing on the oral microbiome changes in the presence of diseases such as dental caries, periodontal disease and the relationship of the oral microbiome with oral health and disease states. The overall aim of these studies was to unravel the complexity of the oral ecosystem and the driving forces behind the imbalance of this ecosystem which leads to increased risk of disease and poor oral health. The oral microbiota of the edentulous neonate and infant is poorly characterised particularly the dynamics of the oral microbial changes of the neonate as it grows from birth to an older age. This is important as it would give researchers that study the oral health of children a better understanding of the foundation of the oral microbiome. An important addition would also be to explore the influence feeding modality (breast or formula), introduction of solid foods, eruption of teeth, antibiotic intake, fluoridation intake and oral hygiene habits all have on the infant oral microbiota. Gaining a better understanding of the dynamics and maturation of the oral microbiome of neonates from birth is important to identify any microbial factors which increase the risk of dental diseases in these children. In this ORALMET study, we recorded the oral microbial changes from birth to 2 years of age of infants (n=382) (year 3 data is not included in this thesis) born via C-section or Vaginal delivery. Factors included in our analysis of the oral microbiota of these infants included breast feeding duration and the influence of the maternal microbiota (saliva/skin or vaginal microbiota). We observed that breast feeding duration does not have an effect on the oral microbiota of infants, and birth mode has an effect on the oral microbiota of infants up to 4 weeks of age only, but not beyond that. The oral microbiota changes in composition are most apparent from 6 months of age to 2 years of age, with less microbial changes within the oral cavity from birth to 8 weeks of age. The oral microbiota composition is continually changing and developing up to 1 year of age and at 2 years of age, illustrating continuous maturation, with no evidence of stability by 2 years of age. The second part of the ORALMET study (cross-sectional study) compared the oral microbiota of children between 3-5 years with SECC (n=68) and without caries (n=70). We observed distinct microbiota differences in the caries microbiota of children with active ECC, and the presence of species in the salivary microbiota of children with active caries, but not in the salivary microbiota of children without caries. ORALMET is the first in depth longitudinal study of the oral microbiome from birth of the infant, together with the influence of the maternal microbiota and also the first microbiota study of Irish children with and without caries. Together these studies provide us with information of the infant oral microbiome and a better understanding of the microbial dynamics within the oral cavity of neonates, infants and children.
A randomised controlled trial to determine if the addition of capnography to standard monitoring results in a decreased incidence of hypoxaemia during conscious sedation for oral surgery
(University College Cork, 2017) Brady, Paul; O'Halloran, Ken D.; McCreary, Christine; Health Research Board
Background: Data from procedural sedation suggest that capnography is a more sensitive measure of ventilation than standard modalities and detects respiratory depression before hypoxaemia occurs. However, the generalisability of published research is problematic. To date, there has been no dentistry-specific published data supporting the use of monitoring with capnography for dental sedation. Our aim was to determine if adding capnography to standard monitoring during conscious sedation with Midazolam in a dental setting would decrease the incidence of hypoxaemia. Methods: A randomised controlled trial was conducted in which all patients (ASA I & II with BMI < 35 kg/m2) received standard monitoring and capnography, but were randomised to whether staff could view the capnography (intervention) or were blinded to it (control). The primary outcome was the incidence of hypoxaemia defined as a fall in oxygen saturation (SpO2) ≤ 94%. Results: 190 patients, mean age 31.3 years (range 14–62 years) were enrolled. There were 93 patients in the capnography group and 97 in the control group. The mean cumulative dose of Midazolam titrated was 6.94 mg (SD 2.31, range 3–20 mg). Six (3%) patients, three in each group, required temporary supplemental oxygen. There was no statistically significant difference between the capnography and control groups for the incidence of hypoxaemia: 34.4% vs 39.2% (p=0.5149, OR=0.78, 95% CI: 0.38–1.63). Conclusions: We were unable to confirm an additive role for capnography to prevent hypoxaemia during conscious sedation with Midazolam in a dental setting for patients not routinely administered supplemental oxygen. Clinical trial registration: ClinicalTrials.gov NCT01949012.
Psychosocial and physiological assessments of orthognathic patients
(University College Cork, 2018) Paul Cheruvathur, Raphy; Millett, Declan; Health Service Executive, Ireland
Aims: The primary aim was to compare, in the RoI, generic oral health-related quality of life (OHIP14), condition-specific quality of life (OQLQ), the fear of negative evaluation (BFNES) and self-reported BMI of patients seeking surgical-orthodontic correction of their malocclusion versus those of the general population. A secondary aim was to assess the IOFTN in the orthognathic cohort and to investigate any correlation between the functional domain of OQLQ and IOFTN. Materials and Methods: Orthognathic patients prior to commencing pre-surgical orthodontics from five regional HSE orthodontic units within the RoI and randomly selected age-matched subjects from the general population were invited to complete a telephone interview. Participants were asked questions regarding general characteristics and then asked to respond to the validated questionnaires OHIP-14, OQLQ, and BFNES. IOFTN grades of the orthognathic sample were also assessed. Results: Eighty orthognathic patients (39 males; 41 females) with an overall mean age of 17.5 (SD 1.6) years and 213 subjects from the general population (95 males; 118 females) with an overall mean age of 17.8 (SD 1.5) years completed a telephone interview. Orthognathic patients had significantly higher mean scores for OHIP-14, OQLQ and S-BFNES than the general population (p < 0.001). The mean score of OHIP-14 for the orthognathic patients and the general population were 14 (SD 8.6) and 5 (SD 5.9) respectively. Corresponding group scores for OQLQ were 40.9 (SD 19.3) and 19.9 (SD 14.9), and for S-BFNES were 23.2 (SD 7.2) and 18.8 (SD 8.1). Females had higher overall OQLQ and S-BFNES scores than males in both groups (p < 0.0001). There was no significant difference in the distribution of self-reported BMI categories between the groups (p = 0.8931). More than 90 per cent of the orthognathic sample were in IOFTN grade 4 and grade 5 showing ‘great’ and ‘very great’ functional need for surgery respectively. No association was found between the functional domain of OQLQ and IOFTN categories (p=0.5530). Conclusion: Orthognathic patients reported significantly poorer oral-health related and condition-specific quality of life as well as higher levels of social anxiety than the general population. Females in both groups had higher scores than males for OQLQ and S-BFNES. There was no correlation between the functional domain of OQLQ and IOFTN.
Survival and quality of life for Sudanese oral cancer patients
(University College Cork, 2018) El Sheikh, Mariam; O'Sullivan, Eleanor; Suleiman, A.M.
Background: Cancer is a growing problem in Sudan. Despite being among the top ten cancers in the country, little attention has been paid to oral cancer by policy makers. There is no national screening program, no national registry, and a paucity of well-designed studies, deficiency in medical facilities, together with the lack of awareness among both the public and health professionals. Thus, updated information on the epidemiology and pattern of oral cancer is needed to draw the attention of the local authorities and improve intervention. The majority of oral cancer cases are diagnosed at advanced stages mainly due to lack of awareness and poverty, leading to high rates of morbidity and mortality. Aim: The principle objective of this project was to provide baseline data on survival rates and quality of life for Sudanese oral cancer patients. The Methods: This research is based on two studies. The first was a retrospective study from 2007-2012 in which the medical records of 940 eligible patients obtained from the archives of Khartoum Teaching Dental Hospital were reviewed. The second study was a longitudinal prospective study from January 2013 to December 2015, in which 360 eligible patients were enrolled. The Functional Assessment of Cancer Therapy – Head and Neck Cancer Questionnaire was translated to Arabic, and a pilot study was conducted to assess feasibility and reliability of the FACT Head and Neck scale. Out of the 360 patients, 130 patients agreed to participate in the QOL study. Survival was calculated using Kaplan – Meier method. Analysis of Variance (ANOVA) was used to compare summary and subscale mean scores. The correlations between the variables (socio-demographic and clinical variables) and the FACT summary scales were analysed with general linear modelling (GLM) using multivariate analysis of variance (MANOVA). Results of the retrospective study: The overall male to female ratio of oral cancer patients was 1.8 to 1 (567 males and 373 females) and the mean age was 56.5 years. On average, patients presented to the hospital seeking treatment 8.5±12.7SD months following the onset of symptoms (range 0.5 to 120 months). Over 50% of patients exhibited considerable delay in presentation, with 29.3% waiting more than 6 months. In 72.9% of the delayed cases, the cause of delay was reported to be patient related. The vast majority (67.1%) presented with stage IV, and two-thirds of patients (63.2%) had evidence of nodal disease on presentation. Among the study sample, 43.6% used tobacco, mainly the local smokeless toombak, especially among males. Over half the patients presented with large lesions extending beyond a specific sub-site. The most common sites were gum (17.2%) and tongue (11.3%). Squamous Cell Carcinoma was the dominant histological type (78.5%). The overall 1, 2, 3 and 5-year overall survival rates were 51%, 39.9%, 36.7% and 34% (CI 30.4-37.7%), respectively. Age was found to be an independent predictor for survival (p=0.001), while histological diagnosis, tumour size (early vs. advanced cancer) and nodal involvement (N0 versus N+ ) were found to be the most important independent prognostic factors (p=0.0001). Results of the prospective study: The FACT-H&N questionnaire exhibited high reliability and demonstrated high internal consistency. Patients with advanced disease stages exhibited significantly lower HRQOL. Likewise, patients who received combined chemotherapy and radiotherapy displayed significantly worse QOL scores; patients who were treated surgically reported better scores. The only exception was the emotional well-being domain. In terms of the prospective changes in QOL, the scores at diagnosis showed mild to moderate impairment. However, one month later there was a rapid deterioration. At 3 months and 12 months the QOL scores showed an improvement with the highest HRQOL scores noted at one year. For the social well-being subscale, the mean HRQOL scores showed a clear trend of increasing from baseline to the subsequent points. Conclusion: This study showed that the majority of patients seek treatment in advanced stages of disease, which impacts negatively on prognosis and decreases overall QOL. The QOL generally improved over time with the highest scores reported in those treated surgically. Thus, more public health efforts are needed for education, prevention and early detection of cases. The findings of this research may contribute to a better understanding of the impact of oral cancer in Sudan.
The immediate effects of aligners and aesthetic fixed appliances on smiling and perceptions in young adults
(University College Cork, 2018) Clune, Jacqueline; Millett, Declan
AIMS • To evaluate, in young adults, the immediate effect of clear aligners (CAs) and aesthetic fixed appliances (AFAs) on the magnitude of rest to natural and rest to maximal smile • To evaluate, in young adults, the immediate effect of CAs and AFAs on intra-session reproducibility of rest to natural and rest to maximal smile • To evaluate, in young adults, the immediate perception of CAs and AFAs MATERIALS AND METHODS Forty Caucasian subjects (20 females, 20 males), aged between 18 and 25 years, with a Class I incisor relationship and no history of orthodontic treatment were recruited. 3D stereophotogrammetric images were captured of each subject without appliances and separately, in random order with either CAs or AFAs (Session 1), at rest, natural and maximum smile (Capture A). Following a rest period of 15 minutes, the images were retaken both without and with appliances (Capture B) to assess intra-session reproducibility. Four weeks later (Session 2), the same protocol was adopted as per Session 1, except that subjects who had been randomised to the CAs were allocated to the AFAs and vice versa. All images had 26 landmarks placed by 1 operator. The landmarking identification error was calculated by re-landmarking 10 percent of the original sample one month after initial images were landmarked and determining the difference in landmark placement. The mean magnitude of movement and reproducibility with each expression, rest to natural and rest to maximal smile, were compared and analysed across both genders. Four weeks after Session 2, a questionnaire was issued via email to all subjects to evaluate the immediate perception of CAs and AFAs. RESULTS The landmark identification error was 0.50 +/- 0.08 mm. For rest to natural smile, there was no significant difference in magnitude of movement with and without CAs (p = 0.6964). In contrast, for rest to maximal smile, the magnitude of movement differed significantly with and without CAs (p = 0.0001), with significantly greater movement recorded with the latter. For rest to natural and rest to maximal smile, there was a significant difference in magnitude of movement with and without AFAs (p = 0.0024 and p = 0.0002 respectively). Significantly greater mean movement occurred with AFAs, than with CAs, for both expressions. The mean magnitude for each smile was greater in males than in females (p = 0.0109). The order of randomisation of appliances made no difference to the mean magnitude of movement from rest to natural and rest to maximal smile (p = 0.0939). Without appliances, there was no significant difference in intra-session reproducibility of the magnitude of rest to natural and rest to maximal smile (p = 0.3601) but significant differences existed in intra-session reproducibility of the mean magnitude of each expression with appliances (p = 0.0290). Although statistically significant differences were recorded between appliances in magnitude and intra-session reproducibility for both expressions, these are unlikely to be of any clinical significance. Seventy-six percent of subjects preferred CAs to AFAs as they were deemed to be more discrete (43 percent) and more comfortable (33 percent). All subjects indicated the appearance of CAs was good or very good. Ninety percent of subjects indicated that they were likely or very likely to recommend CAs. CONCLUSIONS • Except for rest to natural smile with CAs, both appliances had an immediate and significant impact on the mean magnitude of movement for both expressions • CAs and AFAs had a significant immediate effect on intra-session reproducibility of rest to natural and rest to maximal smile • Young adults’ immediate perception was preference for CAs as they were reckoned to be more discrete and comfortable.
Endodontic access in all-ceramic dental restorative crown materials
(University College Cork, 2018) Gorman, Catherine M.; Burke, Francis M.; Ray, Noel J.
A diagnosis of irreversible pulpitis can occur after a crown has been permanently cemented. This necessitates the need for endodontic treatment, often with the crown in situ. Increasing trends indicate that all-ceramic crowns are provided as the preferred restorative option to metal-ceramic crowns. This is because modern all-ceramic restorations can now provide excellent aesthetic solutions combined with high mechanical strength properties, compared with earlier, weaker ceramic materials. It is a considerable operative challenge for the dental practitioner to prepare an endodontic access cavity in vivo, due to the high mechanical properties of modern dental ceramic materials. The inherent nature of ceramic materials is that they are brittle, sensitive to damage and moisture, with failure occurring in an unpredictable manner. The difficulties in performing endodontic treatment in all-ceramic crowns and subsequently repairing the access cavity is relatively unexplored in the dental literature, more research is needed to inform clinical practice in this area. A systematic review of the literature aimed to identify influential treatment factors of endodontically accessed and repaired all-ceramic crowns and report the evidence of damage around the endodontic access cavity as a result of preparing the cavity in an all-ceramic crown. Eight studies were selected to address the aims. The inadequate volume of literature was highlighted with, the earliest relevant publication identified in 1962 and since the last electronic search (2016) only 26 additional references were identified in the subject area. Potentially noteworthy strength controlling factors were identified to be related to the crown material, its baseline strength, the grit size of the diamond bur used to create the access cavity, the ratio of access cavity to crown dimension, the cement used to lute the crown and the presence of radial cracks after access cavity preparation. The effect of two variables, namely, cavity dimension and modulus of elasticity of the resin composite repair material on the equibiaxial flexural strength of lithium disilicate glass-ceramic (IPS e.max® Press, Ivoclar Vivadent) material was investigated. Disc specimens with representative access cavities were used as a model system to examine these variables. Within the study limitations, the results indicate that cavity size and not the repair material, influence the equibiaxial flexural strength. The shear bond strength of the resin composite material used to repair the access cavity in a lithium disilicate glass-ceramic was determined to be comparable to those values as found in the literature (see Appendices). Model mandibular first molar crowns were fabricated from lithium disilicate glass-ceramic to examine the impact of cavity size on failure load. The failure load for the intact crowns and crowns with a rhomboidal (based on the presence of three-canals) or rectangular (based on the presence of four-canals) endodontic access cavity, with and without a resin composite repair were measured and analysed statistically. Within the limitations, the results show that a rectangular access cavity significantly reduces the failure load which was then restored to the original values upon repair with resin composite. The preparation of a rhomboidal access cavity did not reduce the failure load compared with the intact crown. The novel use of Finite Element Analysis (FEA) was successfully demonstrated in this subject area. Solid geometric models of lithium disilicate glass-ceramics (LDGC) crowns with three endodontic access options repaired with a resin composite (Tetric EvoCeram®, Ivoclar Vivadent) were modelled. The models were subsequently subjected to clinically relevant loads and a stress analysis was performed using FEA. This work showed that high curvature access cavity designs produced the highest stress scenario and therefore should be avoided. In an attempt to compliment the in vitro study computer models of LDGC discs were modelled using Finite Element (FE). The models were successfully validated, similar variables were modelled and concentric ring loading conditions were applied as per the in vitro study. It was determined that the size and not the stiffness of the repair material was more critical to the strength of LDGC discs. In conclusion, this study has addressed some of the aspects of problems encountered when endodontic access cavities are prepared in all-ceramic dental crowns, however it is an area where substantial literature is lacking and therefore further research is warranted.
Personal experiences and social perception of a modified twin block appliance
(University College Cork, 2018) Bowe, John C.; Millett, Declan
Aims • To evaluate patient experiences over the first 6 months of Modified Twin Block Appliance (MTBA) treatment for the correction of Class II division 1 malocclusion. • To investigate whether social judgements are made by peers of patients with Class II division 1 malocclusion with and without an MTBA. Materials and methods • Following ethical approval, 50 children, with Class II division 1 malocclusion (overjet greater than 7 mm) were recruited. Treatment was undertaken with an MTBA and the children were followed up for 6 months. Two validated questionnaires were completed at prescribed time-points. One questionnaire recorded pain and discomfort scores; the second questionnaire, the Child Perception Questionnaire (CPQ), assessed the impact treatment with an MTBA had on the child’s OHRQoL. Statistical analysis was performed using SAS (Version 9.4) • Following ethical approval, a cross-sectional questionnaire study was conducted on 461 children from 30 randomly selected primary schools in Cork City and County. Each child was randomly assigned one full face smiling photograph of a boy or girl, with or without an MTBA in situ. Children were asked to make judgements concerning the subject’s social competence (SC), psychosocial adjustment (PA) and intellectual ability (IA). Four point Likert scales were used to record their opinions. Statistical analyses were performed using SAS (Version 9.4) Results • After fitting an MTBA, mean pain scores peaked in the incisors in the first 2 days, lip and soft tissue pain peaked on day 2, with the former greater than the latter. Discomfort in the jaws peaked on day 1. Over a 6 month period, the mean levels of pain and discomfort reported after fitting of an MTBA were mild. The frequency of headaches was lower after 6 months of MTBA treatment than before fitting the MTBA. • The mean CPQ scores were highest at the 6 week time-point (p=0.0155) in the OS, FL, SWB domains. Patients who reported wearing the MTBA full time (p=0.0070) or full time except while eating (p=0.0288) had lower CPQ scores than those with poor compliance. The larger the pre-treatment overjet, the greater the CPQ scores in the EWB and SWB domains (p=0.0258 and p=0.0458) respectively. • There was no significant difference between social competence (SC) (p=0.2614), psychosocial ability (PA) (p=0.6890), and intellectual ability (IA) (p=0.2564) for the presence or absence of an MTBA. For SC, 11 year old children gave a more positive rating than 12 year old children when the child in the photograph was male. For PA and IA, females tended to give more positive ratings than males, particularly when the child in the photograph was male. Conclusions • After fitting an MTBA, peak dental and soft tissue pain was experienced on day 1 and day 2 respectively. • Peak discomfort in the teeth and jaws occurred on the evening of fit and decreased after day 1. In general over the first 6 months after fitting an MTBA mean pain and discomfort levels in the teeth, soft tissues and jaws were mild. • MTBA wear had its greatest impact on OHRQoL at 6 weeks and those with good compliance had overall better OHRQoL than those with poor compliance. • Social perceptions of children do not differ in the presence or absence of an MTBA.
Magnitude and reproducibility of smiling in 12-year-old Caucasian children in the Republic of Ireland: a comparison of Class I and Class II malocclusions
(University College Cork, 2018) Ennis, Ciara Gabrielle; Millett, Declan
Aims:• To determine if malocclusion (Class I, Class II division 1 and Class II division 2) influences the magnitude, the immediate intra-session and the short-term inter-session reproducibility of the rest position to posed smile and the rest position to maximal smile. • To determine if gender influences the magnitude, the immediate intra-session and the short-term inter-session reproducibility of the rest position to posed smile and the rest position to maximal smile. Materials and Methods: One hundred and ten Caucasian volunteers (55 males; 55 females) aged 12 years, with no previous history of orthodontic treatment, identifiable syndrome or facial asymmetry, were recruited. Three malocclusion categories were assessed: Class I (20 males, 20 females), Class II division 1 (20 males; 20 females) and Class II division 2 (15 males; 15 females). Three-dimensional (3D) images of three facial expressions (rest position, posed smile and maximal smile) of each subject were captured using the Di3D system. These images were repeated 15 minutes later to assess immediate intra-session reproducibility and two weeks later to assess short-term inter-session reproducibility. Twenty-six landmarks were digitally placed on all the images. Landmark identification error was assessed by re-landmarking 10 percent of the images, one month after initial landmarking. The magnitude of movement from rest to posed smile and from rest to maximal smile averaged over all the landmarks was calculated for each session. Results: The magnitude of mean movement averaged over all the landmarks differed significantly between rest to posed smile and rest to maximal smile (p < 0.0001). This difference was found in both genders (p = 0.0012) but was greater in males than in females (p <0.0001). Immediate intra-session reproducibility (p=0.1677) was high for both rest to posed smile and rest to maximal smile. A statistically significant difference (p <0.0001) of 0.27mm in short-term inter-session reproducibility was found for both rest to posed smile and rest to maximal smile. This was, however, clinically insignificant. Malocclusion had no effect on magnitude of either smile (p = 0.8138) or immediate intra-session reproducibility (p = 0.3878) or short-term inter-session reproducibility (p=0.3396). Similar results were found when the 10 lower-face landmarks were assessed independently. Conclusion Rest to posed smile and rest to maximal smile differed in terms of magnitude of movement for both genders with males displaying a greater difference. The rest to posed smile and rest to maximal smile demonstrated immediate intra-session and short-term inter-session reproducibility in males and females. Malocclusion had no effect on the magnitude or reproducibility of smiling.
Personalised dental education for caries risk reduction in an adult population in the Republic of Ireland
(University College Cork, 2018) Nishi, Makiko; Allen, P. Finbarr; Whelton, Helen; Harding, Mairead; International Association for Dental Research; Unilever
Overall aim: To investigate the impact on caries risk reduction of a personalised dental education approach based on individual caries risk assessment using mobile-phone short text messages in an economically disadvantaged adult population in the Republic of Ireland. Methods: Two studies were conducted: a cross-sectional study with patients recruited through a non-profit organisation in Japan using questionnaires, and a 2-arm parallel-group, single-blinded, randomised controlled study with medical-card holders recruited in Ireland; caries risk was assessed using the Cariogram and participants responded to a survey questionnaire. Results: A higher proportion of Irish participants (n = 159) identified “Not visiting the dentist for check-up and cleaning” (odds ratio (OR) 2.655; 99% confidence interval (CI) 1.550, 4.547) and “Not using fluoride” (OR 1.714; 99% CI 1.049, 2.802) than did Japanese participants (n =482) as caries risk factors. There was an association between assessed caries risk (Chance-AC) and self-perceived caries risk in the four risk groups (n = 165). Approximately two-thirds of participants in the high-risk groups did not consider themselves as being more prone to dental decay than the average person. Caries risk profiles among participants (n = 167) were clustered into five groups. As a result of protocol violations, 84% of the 111 participants (56: personalised group; 55: non-personalised group) were not sent their assigned number and combination of text messages. Intent-to-treat analysis did not show a personalised intervention effect in Chance-AC. Of the secondary outcome measures, the stimulated saliva amount factor showed a personalised intervention effect, P = 0.036 (OR 0.3; 95% CI 0.1, 0.9). Conclusions: This thesis could not reach a definitive conclusion as to whether a personalised mHealth approach was more effective than a non-personalised mHealth approach, the exception being for the saliva amount parameter. It is worth further exploring the potential of mobile-devices for personalised caries risk reduction.
Innovative strategies for teaching anatomy to dental students
(University College Cork, 2018) Lone, Mutahira; Downer, Eric J.; McKenna, Joseph P.; Toulouse, André; Cryan, John F.; University College Cork
Anatomy education is an integral component of the undergraduate and postgraduate dental curriculum. A detailed understanding of anatomy is a pre-requisite before examination, diagnosis and clinical treatment of patients in all aspects of the healthcare systems. Anatomy teaching is undergoing pioneering changes. Traditional Vesalius’ dissection-based teaching has evolved to include didactic lectures and nowadays incorporates digital teaching, e-learning and a wide range of 3D images and models. Furthermore, the current generation of dental students are using devices like smartphones and laptops for educational purposes. The focus of this PhD was to assess the efficacy of innovative teaching aids for teaching anatomy to dental students. We hypothesized that innovative tools are effective in enhancing students learning experience and improving academic performance. Firstly, a cranial nerve animation was developed and results show an increase in student’s knowledge of the topic after watching the animation (Chapter 2). The teaching of clinical skills was assessed using a soft-preserved cadaver (Chapter 3) which showed promising results. Furthermore, to aid in teaching tooth morphology a 3D quiz application was developed (Chapter 5) and results show that it was effective in teaching tooth morphology to dental students. Additionally, a survey was also undertaken to assess the staff involved in teaching tooth morphology to dental students in the UK and Ireland and the teaching aids employed for teaching and examination of tooth morphology (Chapter 4). Students’ feedback and perceptions were also gathered at the end of each study. The results show that innovative teaching aids can supplement the traditional teaching methods. Furthermore, students benefitted from using the innovative teaching aids and reported it as a positive learning experience. Hence, accepting the above stated alternate hypothesis that innovative tools were effective in enhancing students learning experience and improved their academic performance. In summary, the principles of anatomy are best taught through traditional teaching methods which are reinforced by the various innovative supplemental teaching aids available. A blended teaching model has been recommended with traditional methods complimented by innovative pedagogies. The introduction of these innovative technologies is vital in providing educational support to students and are successful when delivered alongside taught lectures and the use of the traditional teaching methods.
Exploring patients' experience of dental implant surgery with or without intravenous conscious sedation: a qualitative study
(University College Cork, 2021) O'Dwyer, Sinead; Ni Riordain, Richeal
Aim: Little qualitative evidence is available regarding the patients’ experience of dental implant surgery and the influence of intravenous conscious sedation (IVCS) on the implant experience. The aim of this qualitative study was to explore patients’ experience of dental implant surgery with or without IVCS, with specific consideration given to understanding the patients’ preferences, motivations, needs and values. Methods: Purposive sampling was used to recruit patients from the Dental Surgery Unit of Cork University Dental School and Hospital. A trained facilitator convened the individual in-depth semi-structured interviews over the telephone 7 days’ post-surgery. Interviews were audio-recorded with a Dictaphone, manually transcribed and imported into a qualitative software tool (Nvivo). The data were then analysed using a thematic framework. Results: Eighteen semi-structured telephone interviews were conducted; 8 patients had dental implants placed under IVCS, while 10 had dental implants placed with local anaesthetic (LA) only. Thematic analysis revealed that emergent themes fitted appropriately with 3 different time points along the dental implant surgical journey (Pre-operative, Intra-operative and Post-operative experiences). Data and analysis were categorized, therefore, to follow the patients experience in chronological order. This facilitated narration of the patients accounts of the experience in an explicit way. Preoperative themes that emerged included the impact of tooth lost, motivations for seeking dental implants and dental anxiety. Intraoperative themes included confidence in the operating surgeon, local anaesthetic injections, the dental implant drill and being sedated. While post-operative themes that emerged were pain, postoperative instructions and follow up. Conclusions: This research offers clinicians deeper understandings of the patients’ experience of dental implant surgery, their preferences, motivations, needs and values, as well as the adjunctive effects of IVCS. Moreover, this research offers ways to improve clinical communications based on the patients’ views and suggestions and ultimately enhancing the quality of patient care.

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