This research aims to assess the test-retest reliability, the face, content and known groups vali... more This research aims to assess the test-retest reliability, the face, content and known groups validity, and responsiveness to change, of OHIP-TMDs, a 22-item TMDs-specific version of the Oral Health Impact Profile (OHIP). Test-retest reliability - A group of patients with TMDs (n = 20) was administered OHIP-TMDs twice before initial consultation with a 2-week interval. Face and content validity - Content validity index assessments were undertaken with professionals and patients. Known groups validity - Participants (n = 76) with confirmed Axis 1 RDC/TMD diagnoses completed OHIP-TMDs prior to TMDs treatment. Their responses were compared, using inferential statistics, with those of age- and gender-matched controls. Responsiveness to change - Using the same 76 participants, a comparison was made of OHIP-TMDs with OHIP-49 (order of administration randomized) both at baseline and 3 months after starting treatment. OHIP-TMDs showed good test-retest reliability ICC [2,1] 0.805 (95% CI: 0.565, 0.918); good face and content validity; significant differences (P < 0.001) between controls and participants demonstrating known groups validity. Its responsiveness to change was similar to OHIP-49. OHIP-TMDs is an appropriate biopsychosocial, patient-centred, outcome measure for assessing QOL in patients with TMDs. It is less than half the length of OHIP-49 and contains proportionately more items relevant to TMDs.
Fifty-three subjects each had a single Michigan splint constructed of either heat-cured or autopo... more Fifty-three subjects each had a single Michigan splint constructed of either heat-cured or autopolymerized polymethylmethacrylate. The choice of material was decided randomly. A blind assessment for fit and retention was used on a three-point scale. Fit and retention were apparently unaffected by the material used. Thirteen percent of splints were unsatisfactory for clinical use (poor fit or retention) and this was also independent of material. A small number of splints contained structural faults (voids, porosity, or cracks) that may shorten the clinical life of these restorations; 9 of 12 such faults occurred in the autopolymerized group. Previous research has shown that conventional heat-cured polymethyl-methacrylate has superior properties compared with autopolymerized resin. In the absence of differences in accuracy of fit or retention, a heat-cured material is therefore advised where splints are intended for long-term clinical use.
The accuracy of two different techniques for locating casts in the intercuspal position (ICP) in ... more The accuracy of two different techniques for locating casts in the intercuspal position (ICP) in a semi-adjustable articulator was assessed. The techniques for establishing the ICP were a polyether interdental registration, or location of the casts in a position of maximum interdigitation using tactile and visual methods. Fifty-three sets of study models were used in this investigation. Each set of study models was mounted on two occasions, once with each of the two techniques. The models were divided into two groups at random, and mounting and assessment procedures were performed using a single blind crossover design. The quality of the contacts between the mounted casts was compared with the results of an occlusal examination of the same subjects. Hand articulation of the casts prior to mounting the lower cast against the upper cast was a more accurate means of locating the ICP than the use of a low-viscosity polyether interdental registration material, unless there were difficulties in establishing the ICP by visual and tactile methods.
Temporomandibular disorders (TMDs) are a common group of chronic illnesses. There is evidence tha... more Temporomandibular disorders (TMDs) are a common group of chronic illnesses. There is evidence that health professionals find them difficult to diagnose and manage. A consequence of this difficulty in diagnosis might be that sufferers of TMDs have an experience of illness comparable with other chronic illnesses. To explore the sufferers' experience of TMDs, we conducted a qualitative study with a purposive maximum variation sample of secondary care TMD patients. Semi-structured interviews were conducted with the sample and were recorded and transcribed verbatim. Data collection and analysis continued until data saturation (n = 19). For analysis, we broadly followed the constant comparative method and used frameworks to organize the data. The key finding was that a lack of diagnosis caused uncertainty over the nature of the cause of the sufferer's complaint. This uncertainty reportedly caused negative impacts on sufferers' daily lives. Clearly, diagnosis of TMDs needs to be encouraged at the first point of contact.
As one of the most demanding tasks facing the restorative dentist, planning and executing an occl... more As one of the most demanding tasks facing the restorative dentist, planning and executing an occlusal rehabilitation should not be undertaken lightly. The stakes are high and failure is costly. Treatment planning decisions should be undertaken on the basis of scientific evidence, where this is available, or on the basis of documented experience where it is not. This review article identifies the major biological and clinical considerations used when planning an occlusal rehabilitation. These include the indications for reorganising the occlusion, the choice of condylar position and occlusal scheme, the implications of and indications for increasing the vertical dimension, replacing missing teeth and the choice of materials. Finally, the literature surrounding the controversial issue of occlusal rehabilitation as a means to treat temporo-mandibular disorders is also reviewed.
The aim of this study was to generate a putative patient-based outcome measure specifically for T... more The aim of this study was to generate a putative patient-based outcome measure specifically for Temporomandibular Disorders (TMDs) using a mixed-method approach. A combined quantitative-qualitative methodology was used to identify the most relevant items in the Oral Health Impact Profile (OHIP-49) for TMDs. The quantitative study involved 110 patients with TMDs diagnosed using the Research Diagnostic Criteria for TMDs (RDC/TMD) and 110 age- and sex-matched controls. All subjects completed the OHIP-49. The qualitative study involved semi-structured interviews with a separate sample of patients with TMDs (n = 29). The two resultant data sets were analysed blinded and separately. Each data set used predetermined rules to select candidate items for the putative OHIP for TMDs. The two sets of selected items were then compared using a priori rules to make a final item selection for OHIP TMDs. Eighteen pre-existing items were selected through the quantitative process and fourteen by the qu...
Temporomandibular disorders (TMDs) are a common group of chronic disorders (illnesses) that healt... more Temporomandibular disorders (TMDs) are a common group of chronic disorders (illnesses) that health care providers can find difficult to diagnose and explain. Similar difficulties in the diagnosis of other chronic conditions have been shown to have a negative impact on health. An understanding of TMD patients' experiences and journey through care could indicate time points and strategies to help patients.
Materials selection is the second in the series on crowns and other extra-coronal restorations. S... more Materials selection is the second in the series on crowns and other extra-coronal restorations. Some of us are less than inspired by dental materials science. Nevertheless, many of the things that concern us clinically with crowns and their alternatives are based on material properties. We worry about the strength of the restoration, how well it fits and its aesthetics. We also worry about wear, occlusal control and biocompatibility. Not least of our concerns are dental laboratory charges, which inevitably have to be passed on to the patient.
Objective To gain a deeper understanding of the range of infl uences on the full range of dental ... more Objective To gain a deeper understanding of the range of infl uences on the full range of dental professionals who provide treatment for temporomandibular disorders (TMD). Design Qualitative semi-structured interviews. Setting Primary and secondary care in the North and South of the United Kingdom. Sample and method A criterion-based purposive sample was taken of dental practitioners, comprising primary and secondary care practitioners. In-depth interviews were conducted and data collection and analysis occurred concurrently until data saturation was achieved. Data and discussion There was a reported lack of adequate remuneration for provision of treatment for TMD within primary care. This alongside the primary care practitioners' reported uncertainty in diagnosis of TMD appeared to lead to a propensity for referral to secondary care. Practitioners recognised a poor and scanty evidence base on which to base their care, and this allowed for idiosyncratic practice. Often the outcome measure for treatment was a subjective questioning of the patient focussing mainly on relief of pain. Conclusion There is a need for better quality evidence on which to base TMD treatment, more continuing professional development and improvement in contracting arrangements to enable primary practitioners to feel confi dent in managing TMD.
A pleasing dental appearance is the subjective appreciation of the shade, shape and arrangement o... more A pleasing dental appearance is the subjective appreciation of the shade, shape and arrangement of the teeth and their relationship to the gingiva, lips and facial features. Achieving such a pleasing appearance in our patients is not always easy but is critical, not least because our work is effectively on display and this has implications for patients' perceptions of our practice. To be successful, thorough assessment, careful planning and precise clinical execution is required. Every bit as important though, is good communication, both with the dental laboratory and particularly with the patient. In few areas of dentistry can effective communication be as critical as it is here.
This series of articles is aimed at anybody who places crowns and other extra-coronal restoration... more This series of articles is aimed at anybody who places crowns and other extra-coronal restorations (ie veneers and shims) on individual teeth. We hope that everyone from experienced practitioners to undergraduate students may find something of value. Whoever reads them, we would ask to do so with an open mind. We have tried not to be dogmatic, and the techniques and materials described are not the only ones available, but are the ones which accord with the principles we describe.
Having successfully negotiated the planning, preparation, impression and prescription of your cro... more Having successfully negotiated the planning, preparation, impression and prescription of your crown, the cementation stage represents the culmination of all your efforts. This stage is not difficult, but a successful outcome needs as much care as the preceding stages. Once a restoration is cemented there is no scope for modification or repeat. You have to get it right first time. Decemented crowns often have thick layers of residual cement suggesting problems with either initial seating or cement handling. When the fate of restorations costing hundreds of pounds depends on correct proportioning of cements and the quality of the mix, the value of a well-trained and experienced dental nurse is easy to see. Both dentist and nurse need a working knowledge of the materials they are handling.
Considerations when planning treatment is the third in the series of crowns and other extra-coron... more Considerations when planning treatment is the third in the series of crowns and other extra-coronal restorations. Articles or chapters on treatment planning in restorative dentistry can make pretty dry reading, often built around a list of factors that might influence your decision-making. In truth though, planning and placing crowns or other extra-coronal restorations cannot be distilled into a series of lists. The decision-making involved requires experience, subtle understanding and a flexible approach, none of which come easily.
Preparations for full veneer crowns is the eighth in the series on crowns and other extra-coronal... more Preparations for full veneer crowns is the eighth in the series on crowns and other extra-coronal restorations. Whilst handpiece skills are important, many other factors combine to ensure provision of a satisfactory full veneer crown (also termed 'full coverage crown'). Our aim in writing this article is to consider the principles which influence crown preparation, seasoned with clinical advice our undergraduate and postgraduate students have found useful.
Porcelain veneers are resin-bonded to the underlying tooth and provide a conservative method of i... more Porcelain veneers are resin-bonded to the underlying tooth and provide a conservative method of improving appearance or modifying contour, without resorting to a full coverage crown. The porcelain laminate veneer is now a frequently prescribed restoration for anterior teeth. The sums spent by the Dental Practice Board on this type of treatment increased from quarter of a million pounds in 1988/89 to over seven million in 1994/95, 1 representing some 113,582 treatments. Since that time the number has stabilised at over 100,000 veneers prescribed each year. 2 The objective of this paper is to give a practical guide on providing these restorations.
To test a measurement model based on clinicians' assessments of patient data that allows simp... more To test a measurement model based on clinicians' assessments of patient data that allows simple and confident clinical validation of any statistical or numerical technique designed to separate patients improving with treatment from those who are not, particularly for pain that shows large daily variation. Diaries using daily visual analog scales (VAS) of pain intensity were obtained from 39 patients treated for chronic temporomandibular disorders. Three experienced clinicians visually assessed 39 VAS/time graphs. Criteria indicating improvement (general trend, height and apparent frequency of graph spikes) evolved over 3 assessments. The third assessment defined improvers visually. Numeric analyses considered the difference between first and last months of treatment for mean, area under the curve (AUC), and maximum VAS scores. Thresholds of 40%, 50%, or 60% pain reduction defined improvement numerically. Aggregate sensitivity and specificity was compared with visual definition t...
This research aims to assess the test-retest reliability, the face, content and known groups vali... more This research aims to assess the test-retest reliability, the face, content and known groups validity, and responsiveness to change, of OHIP-TMDs, a 22-item TMDs-specific version of the Oral Health Impact Profile (OHIP). Test-retest reliability - A group of patients with TMDs (n = 20) was administered OHIP-TMDs twice before initial consultation with a 2-week interval. Face and content validity - Content validity index assessments were undertaken with professionals and patients. Known groups validity - Participants (n = 76) with confirmed Axis 1 RDC/TMD diagnoses completed OHIP-TMDs prior to TMDs treatment. Their responses were compared, using inferential statistics, with those of age- and gender-matched controls. Responsiveness to change - Using the same 76 participants, a comparison was made of OHIP-TMDs with OHIP-49 (order of administration randomized) both at baseline and 3 months after starting treatment. OHIP-TMDs showed good test-retest reliability ICC [2,1] 0.805 (95% CI: 0.565, 0.918); good face and content validity; significant differences (P < 0.001) between controls and participants demonstrating known groups validity. Its responsiveness to change was similar to OHIP-49. OHIP-TMDs is an appropriate biopsychosocial, patient-centred, outcome measure for assessing QOL in patients with TMDs. It is less than half the length of OHIP-49 and contains proportionately more items relevant to TMDs.
Fifty-three subjects each had a single Michigan splint constructed of either heat-cured or autopo... more Fifty-three subjects each had a single Michigan splint constructed of either heat-cured or autopolymerized polymethylmethacrylate. The choice of material was decided randomly. A blind assessment for fit and retention was used on a three-point scale. Fit and retention were apparently unaffected by the material used. Thirteen percent of splints were unsatisfactory for clinical use (poor fit or retention) and this was also independent of material. A small number of splints contained structural faults (voids, porosity, or cracks) that may shorten the clinical life of these restorations; 9 of 12 such faults occurred in the autopolymerized group. Previous research has shown that conventional heat-cured polymethyl-methacrylate has superior properties compared with autopolymerized resin. In the absence of differences in accuracy of fit or retention, a heat-cured material is therefore advised where splints are intended for long-term clinical use.
The accuracy of two different techniques for locating casts in the intercuspal position (ICP) in ... more The accuracy of two different techniques for locating casts in the intercuspal position (ICP) in a semi-adjustable articulator was assessed. The techniques for establishing the ICP were a polyether interdental registration, or location of the casts in a position of maximum interdigitation using tactile and visual methods. Fifty-three sets of study models were used in this investigation. Each set of study models was mounted on two occasions, once with each of the two techniques. The models were divided into two groups at random, and mounting and assessment procedures were performed using a single blind crossover design. The quality of the contacts between the mounted casts was compared with the results of an occlusal examination of the same subjects. Hand articulation of the casts prior to mounting the lower cast against the upper cast was a more accurate means of locating the ICP than the use of a low-viscosity polyether interdental registration material, unless there were difficulties in establishing the ICP by visual and tactile methods.
Temporomandibular disorders (TMDs) are a common group of chronic illnesses. There is evidence tha... more Temporomandibular disorders (TMDs) are a common group of chronic illnesses. There is evidence that health professionals find them difficult to diagnose and manage. A consequence of this difficulty in diagnosis might be that sufferers of TMDs have an experience of illness comparable with other chronic illnesses. To explore the sufferers' experience of TMDs, we conducted a qualitative study with a purposive maximum variation sample of secondary care TMD patients. Semi-structured interviews were conducted with the sample and were recorded and transcribed verbatim. Data collection and analysis continued until data saturation (n = 19). For analysis, we broadly followed the constant comparative method and used frameworks to organize the data. The key finding was that a lack of diagnosis caused uncertainty over the nature of the cause of the sufferer's complaint. This uncertainty reportedly caused negative impacts on sufferers' daily lives. Clearly, diagnosis of TMDs needs to be encouraged at the first point of contact.
As one of the most demanding tasks facing the restorative dentist, planning and executing an occl... more As one of the most demanding tasks facing the restorative dentist, planning and executing an occlusal rehabilitation should not be undertaken lightly. The stakes are high and failure is costly. Treatment planning decisions should be undertaken on the basis of scientific evidence, where this is available, or on the basis of documented experience where it is not. This review article identifies the major biological and clinical considerations used when planning an occlusal rehabilitation. These include the indications for reorganising the occlusion, the choice of condylar position and occlusal scheme, the implications of and indications for increasing the vertical dimension, replacing missing teeth and the choice of materials. Finally, the literature surrounding the controversial issue of occlusal rehabilitation as a means to treat temporo-mandibular disorders is also reviewed.
The aim of this study was to generate a putative patient-based outcome measure specifically for T... more The aim of this study was to generate a putative patient-based outcome measure specifically for Temporomandibular Disorders (TMDs) using a mixed-method approach. A combined quantitative-qualitative methodology was used to identify the most relevant items in the Oral Health Impact Profile (OHIP-49) for TMDs. The quantitative study involved 110 patients with TMDs diagnosed using the Research Diagnostic Criteria for TMDs (RDC/TMD) and 110 age- and sex-matched controls. All subjects completed the OHIP-49. The qualitative study involved semi-structured interviews with a separate sample of patients with TMDs (n = 29). The two resultant data sets were analysed blinded and separately. Each data set used predetermined rules to select candidate items for the putative OHIP for TMDs. The two sets of selected items were then compared using a priori rules to make a final item selection for OHIP TMDs. Eighteen pre-existing items were selected through the quantitative process and fourteen by the qu...
Temporomandibular disorders (TMDs) are a common group of chronic disorders (illnesses) that healt... more Temporomandibular disorders (TMDs) are a common group of chronic disorders (illnesses) that health care providers can find difficult to diagnose and explain. Similar difficulties in the diagnosis of other chronic conditions have been shown to have a negative impact on health. An understanding of TMD patients' experiences and journey through care could indicate time points and strategies to help patients.
Materials selection is the second in the series on crowns and other extra-coronal restorations. S... more Materials selection is the second in the series on crowns and other extra-coronal restorations. Some of us are less than inspired by dental materials science. Nevertheless, many of the things that concern us clinically with crowns and their alternatives are based on material properties. We worry about the strength of the restoration, how well it fits and its aesthetics. We also worry about wear, occlusal control and biocompatibility. Not least of our concerns are dental laboratory charges, which inevitably have to be passed on to the patient.
Objective To gain a deeper understanding of the range of infl uences on the full range of dental ... more Objective To gain a deeper understanding of the range of infl uences on the full range of dental professionals who provide treatment for temporomandibular disorders (TMD). Design Qualitative semi-structured interviews. Setting Primary and secondary care in the North and South of the United Kingdom. Sample and method A criterion-based purposive sample was taken of dental practitioners, comprising primary and secondary care practitioners. In-depth interviews were conducted and data collection and analysis occurred concurrently until data saturation was achieved. Data and discussion There was a reported lack of adequate remuneration for provision of treatment for TMD within primary care. This alongside the primary care practitioners' reported uncertainty in diagnosis of TMD appeared to lead to a propensity for referral to secondary care. Practitioners recognised a poor and scanty evidence base on which to base their care, and this allowed for idiosyncratic practice. Often the outcome measure for treatment was a subjective questioning of the patient focussing mainly on relief of pain. Conclusion There is a need for better quality evidence on which to base TMD treatment, more continuing professional development and improvement in contracting arrangements to enable primary practitioners to feel confi dent in managing TMD.
A pleasing dental appearance is the subjective appreciation of the shade, shape and arrangement o... more A pleasing dental appearance is the subjective appreciation of the shade, shape and arrangement of the teeth and their relationship to the gingiva, lips and facial features. Achieving such a pleasing appearance in our patients is not always easy but is critical, not least because our work is effectively on display and this has implications for patients' perceptions of our practice. To be successful, thorough assessment, careful planning and precise clinical execution is required. Every bit as important though, is good communication, both with the dental laboratory and particularly with the patient. In few areas of dentistry can effective communication be as critical as it is here.
This series of articles is aimed at anybody who places crowns and other extra-coronal restoration... more This series of articles is aimed at anybody who places crowns and other extra-coronal restorations (ie veneers and shims) on individual teeth. We hope that everyone from experienced practitioners to undergraduate students may find something of value. Whoever reads them, we would ask to do so with an open mind. We have tried not to be dogmatic, and the techniques and materials described are not the only ones available, but are the ones which accord with the principles we describe.
Having successfully negotiated the planning, preparation, impression and prescription of your cro... more Having successfully negotiated the planning, preparation, impression and prescription of your crown, the cementation stage represents the culmination of all your efforts. This stage is not difficult, but a successful outcome needs as much care as the preceding stages. Once a restoration is cemented there is no scope for modification or repeat. You have to get it right first time. Decemented crowns often have thick layers of residual cement suggesting problems with either initial seating or cement handling. When the fate of restorations costing hundreds of pounds depends on correct proportioning of cements and the quality of the mix, the value of a well-trained and experienced dental nurse is easy to see. Both dentist and nurse need a working knowledge of the materials they are handling.
Considerations when planning treatment is the third in the series of crowns and other extra-coron... more Considerations when planning treatment is the third in the series of crowns and other extra-coronal restorations. Articles or chapters on treatment planning in restorative dentistry can make pretty dry reading, often built around a list of factors that might influence your decision-making. In truth though, planning and placing crowns or other extra-coronal restorations cannot be distilled into a series of lists. The decision-making involved requires experience, subtle understanding and a flexible approach, none of which come easily.
Preparations for full veneer crowns is the eighth in the series on crowns and other extra-coronal... more Preparations for full veneer crowns is the eighth in the series on crowns and other extra-coronal restorations. Whilst handpiece skills are important, many other factors combine to ensure provision of a satisfactory full veneer crown (also termed 'full coverage crown'). Our aim in writing this article is to consider the principles which influence crown preparation, seasoned with clinical advice our undergraduate and postgraduate students have found useful.
Porcelain veneers are resin-bonded to the underlying tooth and provide a conservative method of i... more Porcelain veneers are resin-bonded to the underlying tooth and provide a conservative method of improving appearance or modifying contour, without resorting to a full coverage crown. The porcelain laminate veneer is now a frequently prescribed restoration for anterior teeth. The sums spent by the Dental Practice Board on this type of treatment increased from quarter of a million pounds in 1988/89 to over seven million in 1994/95, 1 representing some 113,582 treatments. Since that time the number has stabilised at over 100,000 veneers prescribed each year. 2 The objective of this paper is to give a practical guide on providing these restorations.
To test a measurement model based on clinicians' assessments of patient data that allows simp... more To test a measurement model based on clinicians' assessments of patient data that allows simple and confident clinical validation of any statistical or numerical technique designed to separate patients improving with treatment from those who are not, particularly for pain that shows large daily variation. Diaries using daily visual analog scales (VAS) of pain intensity were obtained from 39 patients treated for chronic temporomandibular disorders. Three experienced clinicians visually assessed 39 VAS/time graphs. Criteria indicating improvement (general trend, height and apparent frequency of graph spikes) evolved over 3 assessments. The third assessment defined improvers visually. Numeric analyses considered the difference between first and last months of treatment for mean, area under the curve (AUC), and maximum VAS scores. Thresholds of 40%, 50%, or 60% pain reduction defined improvement numerically. Aggregate sensitivity and specificity was compared with visual definition t...
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Papers by J. Steele