Routine oral examination: Clinical vignettes, a promising tool for continuing professional development?

Routine oral examination: Clinical vignettes, a promising toolfor continuing professional development?

Theodorus G. Mettes a,*, Wil J.M. van der Sanden a, Leontien van Eeten-Kruiskamp a,Jan Mulder a, Michel Wensing b, Richard P.T.M. Grol b, Alphons J.M. Plasschaert a

aRadboud University Nijmegen Medical Centre, College of Oral Sciences, Department of Preventive and Operative Dentistry,

Nijmegen, The NetherlandsbRadboud University Nijmegen Medical Centre, Scientific Institute for Quality of Health Care, Nijmegen, The Netherlands

j o u r n a l o f d e n t i s t r y 3 8 ( 2 0 1 0 ) 3 7 7 – 3 8 6

a r t i c l e i n f o

Article history:

Received 7 August 2009

Received in revised form

23 December 2009

Accepted 9 January 2010

Keywords:

Routine oral examination

Risk assessment

Decision support systems

Knowledge translation

Quality of oral care

CPD

a b s t r a c t

Objectives: To develop content for an educational system for dental professionals to be used

for patient-tailored evidence-based decisions regarding routine oral examinations (ROEs)

and to test the model as a tool in dental education.

Methods: Initially, an electronic database was developed comprising conclusive data of a

structured literature search and 27 ROE clinical cases which were selected on predefined

criteria. A RAND-modified Delphi procedure was successfully conducted with 31 multidis-

ciplinary dental experts. Twenty-one selected risk factors for oral disease were assessed for

feasibility and subsequently modelled into 19 risk based clinical vignettes, each represent-

ing a specific group of ROE-patients. Each vignette comprised all relevant clinical and non-

clinical data. Expert judgements were collected including ROE-content, risk level, bitewing

frequency and recall interval. Feedback regarding evidence was provided for each of the

topics. A pilot with 35 experienced General Dental Practitioners (GDPs) was conducted to

assess the reliability of the model for continuing professional development (CPD). Decisions

made on content screening items, bitewing frequencies and recall interval were compared

with expert opinions.

Results: A comprehensive set of clinical vignettes was developed. Expert consensus was

reached with regard to risk factors to be applied, content of ROE-items, bitewing frequency

and recall interval. Differences between GDPs and experts were found especially concerning

recall length in low-risk patient groups.

Conclusions: Clinical vignettes provide a promising educational instrument for CPD to

improve clinical performance. Further research is needed to test the reliability of these

set of 19 vignettes.

# 2010 Elsevier Ltd. All rights reserved.

avai lab le at www.sc iencedi rect .com

journal homepage: www.intl.elsevierhealth.com/journals/jden

1. Introduction

The prevalence of dental caries and periodontaldisease shows a

skewed distribution in Western societies.1,2 Recently, a more

* Corresponding author at: Radboud University Nijmegen Medical CentPhilips van Leydenlaan 25, P.O. Box 9101, 6500 HB Nijmegen, The Net

E-mail address: [email protected] (T.G. Mettes).

0300-5712/$ – see front matter # 2010 Elsevier Ltd. All rights reserveddoi:10.1016/j.jdent.2010.01.004

patient-tailored risk strategy in dental practice has been

advocated.3,4 The aim of this approach is to discriminate

between high- and low-risk individuals by assessing risk and by

predicting future disease onset and progression.5,6 Evidence-

re, College of Oral Sciences, Preventive and Restorative Dentistry,herlands. Tel.: +31 24 36 16 410; fax: +31 24 35 40 265.

.

mailto:[email protected]

http://dx.doi.org/10.1016/j.jdent.2010.01.004


based routine oral examination (ROE) is also directly related

to the planning of appropriate preventive interventions

influencing the provision of oral care and reducing the burden

of restorative treatment.7 Unfortunately, a paucity of random-

ised studies exists on patient-tailored recall intervals.3–8

Little is known regarding the appropriate content and

frequency of ROEs conducted in patients at different oral risk

levels. General dental practitioners (GDPs) still assign

standardised recall periods for all regular attendees.9,10

Fuelled by quality of care aspects, GDPs are being confronted

with new patient-tailored surveillance approaches. They

have not been trained to screen systematically high- and low-

risk patients.

Based on the available evidence, the most consistent

clinical caries predictor at an individual level is previous caries

experience i.e. clinical evidence of previous disease.5,6 This

‘clinical evidence’ seems to be a feasible instrument for GDPs

for risk-based decisions in daily practice.

Despite the variation within the dental profession regard-

ing clinical judgement,11–15 best evidence regarding clinical

screening abilities of the GDPs is still the ability to combine

risk factors, based on characteristics of patients and clinical

and socio-demographic information. This ability is as good as,

or better than, any other method of predicting caries risk.5,16

Box 1. Definitions of ROE clinical case, clinical vignette and ris

caries and periodontal disease.

ROE clinical case Represents a clinical case (patient

characteristics (personal, patient

of regular attendees (individuals).

Clinical vignette A vignette represents a specific p

and non-clinical patient characte

described with experts’ opinions

bitewing radiographs and the ass

Risk profile A risk profile is a predefined level

risk factors.

Pred

Dental caries

High Presence of (recurrent) active carious

lesions, and increment of �2 new,

progressing or filled lesions a year

or �1 new lesion a year in

subsequent years.

Risk factors may not totally be changed

or may partially be unknown.

Elevated Presence of active carious lesions, or

increment of 1 new, progressing or

filled lesions after a period of reduced

or low-risk.

Risk factors can potentially be changed.

Reduced Previous disease experience, no

active lesions or restorations due to

caries in preceding 2 years or more.

Risk factor surveillance.

Low No caries experience.


Structured disease prediction, based on clinically recorded

disease progression and enhanced risk assessment skills,

could lead towards a more patient-tailored strategy.

An educational system focussing on clinical and scientific

evidence, by providing specific standardised risk groups of

clinical patient characteristics (clinical vignettes), could

provide guidance and training for the screening of ROE-

patients.

Furthermore, it could offer a quality assessment tool for

clinical performance. Therefore, a representative set of risk-

based clinical vignettes (Box 1) was designed. Stored in an

electronic database, i.e. Content Management System (CMS),

these clinical vignettes could be used as a clinical decision

support system17 for under and postgraduate purposes.

Clinical vignettes have been found to be a reliable instrument

to assess and guide clinical decision-making18–21 in case

evidence showed to be inconclusive.

The aim of the study was twofold:

1. To describe the structured procedure of developing a

representative set of risk-based clinical vignettes.

2. To test the realiabilty of the set of vignettes as an

educational tool to be used for continuing professional

development (CPD).

k profile as well as predefined vignette risk levels for dental

Definitions

) with extensive description of clinical and non-clinical patient

history, clinical examination and additional examination data)

atient age group, whose risk factors for oral disease and clinical

ristics are for the greater part similar. Per vignette a risk profile is

for the type and number of screening items, the frequency of

igned recall interval.

of risk for oral diseases as a result of exposure to certain

efined risk levels

Periodontal disease

Presence of (recurrent) active and progressing

periodontal lesions (bleeding on probing, generalised

attachment, vertical bone loss, root furcation defects,

multiple pockets >5 mm).

Risk factors may not totally be changed or may partially be unknown.

Presence of maximum 2 localised active periodontal lesions

(bleeding on probing, no vertical bone loss, minor attachment

loss with shallow pockets 4–5 mm).

Risk factors can potentially be changed.

Previous disease experience, no active periodontal lesions,

no disease progression in preceding 2 years or more.


No periodontal disease experience.


j o u r n a l o f d e n t i s t r y 3 8 ( 2 0 1 0 ) 3 7 7 – 3 8 6 379

2. Materials and methods

In order to compose content elements for the database,

representative ROE-patients from clinical practice were

selected and a literature search was conducted covering all

relevant risk aspects of ROEs to provide a scientific evidence

base. A structured RAND-modified Delphi consensus proce-

dure was conducted with two expert groups to develop a set of

risk-based clinical vignettes (Fig. 1).

2.1. Database content

A web-based content management system (CMS) was con-

structed containing clinical and non-clinical data and scien-

tific evidence.

Fig. 1 – Development procedure risk-based clinical vignettes co

examination, BW = bitewing radiographs, GDP = general dental

(patient) with extensive description of clinical and non-clinical

specific patients’ age group, whose risk factors for oral disease

greater part similar.

At the start of the procedure, 6 experienced dentists (>10-

year inpractice)were invited to take part ina clinicalcasetry out

to test its feasibility. They were provided with a sample ROE-

case which was accompanied with online manual instructions

and individual feedback. The dentists were able to receive

assistance on the case either by email or telephone. The

outcome was that these 6 experienced dentists were confident

with the presentation of the clinical and non-clinical data of the

cases and with the content and composition of the provided

data. Additional advice was given about a more compact

description of clinical and non-clinical data to prevent

unnecessaryand time-consumingexploration ofdatabasedata.

At the end of the consensus procedure a pilot will be

conducted with experienced peer groups of GDPs to test the

reliability of the set of vignettes.

ncerning routine oral examination; ROE = routine oral

practitioner. *ROE clinical case: represents a clinical case

patient characteristics. **Clinical vignette: represents a

and clinical and non-clinical characteristics are for the

Table 1 – Set of 21 risk factors/indicators and selectedrisk factors for clinical vignettes as a result of a RAND-modified Delphi procedure for each age group (�).

Selected risk factors/indicators

Based on literature search Selected in vignettes

�18-year >18-year

Dental plaquea � �Oral hygiene � �Gingival bleeding � �Caries primary dentition � �Number of new carious lesions � �Number of restorations � �Fissure morphology

Root surface exposure �Crowding anterior teeth

Pockets/attachment loss �Tooth loss (missing teeth)

Motivation/oral health compliance � �Fluoride intake � �Smoking habits �Dietary habits � �Education/income (parents) �

Saliva �Systemic disease �Genetic factors

Medications �Type bacterial flora �

Total (n) 10 16

a Bold typeface: selected risk factors.


2.2. Scientific evidence

A literature search was conducted to identify evidence on

relevant domains of ROEs. The selection of scientific

evidence was based on research towards primary studies,

systematic reviews and relevant evidence-based clinical

practice guidelines (CPGs). Topics concerned were: the

effectiveness of ROEs, risk management of dental caries,

periodontal disease, oral cancer, dental wear and third

molars. In addition the following topics were addressed:

evidence on oral health promotion; on the prescription and

frequency of (bitewing) radiographs; recall interval assign-

ment and patient preferences towards ROEs. A description

of the combined search terms used (text words and MESH-

terms) is available from the authors. Additional to these

data relevant textbooks were used.22,23 Databases used

were: Medline, PubMed, Cochrane Library and Cochrane

Oral Health Group specialised trial register. The search

period comprised 1980–2007. The studies retrieved from the

literature search were critically appraised and conclusions

were summarised. All retrieved citations and abstracts were

assessed by two researchers (ThM, WS) independently,

using predetermined inclusion criteria. Disagreements were

resolved by discussion. Orthodontic treatment need studies

were excluded from this literature search. As a result of the

narrowed search, two recently rigorously conducted sys-

tematic reviews (2003, 2005) and a NICE CPG (2004) were

located. The latter comprised an updated, extensive search

strategy of the 2003 systematic review on effectiveness,

providing extensive actual research information. Both

systematic reviews and the NICE CPG provided extensive

up to date literature references.

2.3. Clinical evidence

The 27 ROE-cases for different age categories (�18-year and

>18-year) were selected considering disease prevalence and

four predefined risk levels for dental caries and periodontal

disease (Box 1). The rationale for applying four risk levels

was based on the best available clinical predictor for future

oral disease, being ‘past disease experience’,5 and related to

risk factor exposure and the number of new or progressing

lesions in time. All clinical cases to be assessed, comprised

the most relevant clinical and non-clinical features and

characteristics in detailed description and good quality

images of the oral cavity. All potential risk factors related to

the above-mentioned oral diseases for different age

groups24 were selected from textbooks and electronic

databases (Table 1).

3. E-modified RAND/Delphi consensusprocedure

3.1. Procedure

A validated modified e-RAND-modified Delphi consensus

procedure was conducted to eventually construct clinical

vignettes using the 27 selected clinical ROE-cases (Fig. 1). This

consensus procedure has been extensively validated and is

especially useful when the available scientific literature does

not provide sufficient indications for rating the appropriate-

ness of medical or dental procedures.25–33

Sixty experts were initially invited to participate in the

multidisciplinary RAND-modified Delphi procedure repre-

senting GDPs, researchers, educators and dentists graduated

in special fields (i.e. paediatrics, periodontology, gerodontol-

ogy). Participants were allocated to 2 expert groups, to obtain

appropriate strata of different age, expertise and place of

residence in each group.

3.2. From clinical cases to clinical vignettes

Both expert groups were first invited to assess independently

for each ROE-clinical case the impact of 21 risk factors/

indicators on disease onset and progression. Additional

specific clinical or non-clinical background information was

available by using a pop-up scroll menu containing ‘personal

and patient data’ (Fig. 2). The impact of each risk factor had to

be assessed on a nine-point ordinal scale (1 = not important/

applicable � 9 very important/applicable). Finally, a recall

interval had to be assigned for each clinical case. After

completing 27 clinical cases, individual scores were collected.

Subsequently, each expert received feedback to evaluate the

‘individual risk factor-score’ and ‘recall interval-score’ to the

median score of the expert group, so enabling to adjust

previous individual judgement. The consensus results were

analysed by the research group to transfer clinical cases in a

Fig. 2 – Screen dump, example of web page with clinical

case risk factor identification schedule (Round I).

Box 2. Consecutive oral health review steps determining

the process of ROE-risk management.

I Retrospective analysis of previous risk level as

documented in patient record

II Oral health assessment to identify risk factors/

indicators and protective factors

III Assessment of the impact of potential risk factors on

disease history and actual oral condition

IV Timing bitewing radiographs and preventive

intervention(s)

V Classification of the actual risk level in patient

record

VI Decision on patient-tailored recall interval


smaller number of clinical vignettes, considering a balanced

exposure of all relevant risk related aspects.

A clinical vignette represents a specific patient age group,

whose risk factors for oral disease as well as clinical and non-

clinical patient characteristics are similar (Box 1). Clinical and

non-clinical characteristics comprised age category, patient

history, attendance patterns, fluoride intake, dietary habits,

extensive clinical information and oral health compliance.

The presentation of each vignette was standardised (Fig. 3). By

using consecutive oral health review steps for risk manage-

ment (Box 2), each expert had to classify the risk level (high,

elevated, reduced, low) for dental caries and periodontal

disease, to prescribe an appropriate frequency for bitewing

radiographs (in mths) and to assign a preferred recall interval

(in mths).

Additionally, the number of oral health screening items to

perform per vignette had to be selected out of a consensus-

based list of 19 ROE-items (Table 2). Per expert group, ROE-

items selected by 9 or more experts (out of 15) were

determined as applicable. If selected by 6–9 experts, they

were scheduled for further discussion and if selected by less

than 6 experts, ROE-items were excluded. Scores for ROE-

items, bitewing frequencies and recall intervals (in mths) were

tabulated per vignette and provide with median scores by the

reseachers in order to provide feedback.

Two weeks before the consensusmeeting, a questionnaire

had to be filled out for each vignette regarding appropriate

ROE-content (type and number of items), bite wing frequency

and recall interval. Experts received anonymously coded

individual scores and median scores by mail as well as a

hard copy presentation of each vignette.

Finally, a consensus meeting (5 h) was planned for each

group. The aim was to discuss the variation in final

judgements and to reach consensus for each vignette. Both

meetings were tape-recorded and observed by two research

group members (TM, LvE) using a checklist.28 A professional

independent chairman (dental professional) and a secretary

were provided.

4. Pilot experiment

To test the feasibility and reliability of the final set of clinical

vignettes, involvement of independent peer groups (peer

review) was planned resulting in a pilot experiment. A

newsletter on the website of the Dutch Dental Association

(NMT) invited peer groups to participate, to test the model for

educational purposes as well as for CPD. A dental peer group

consists of 7–9 GDPs, who attend monthly sessions scheduled

for practice related topics as part of a quality assurance

program. Members have to work in general dental practice for

at least 3 days a week and should have been practicing for at

least 5 years. The expert opinions, including the recommen-

dations concerning content items, risk level, bitewing fre-

quency and recall assignment per vignette were used as a

reference standard.

4.1. Statistical analysis

Measurements of agreement in identifying risk factors were

applied by means of group Kappa scores. To test differences in

judgement between experts at the end of the consensus

Fig. 3 – Screen dump example of risk-based clinical vignette (oral cavity photographs, dental status chart, bar graphs on

plaque and bleeding indices and Dutch periodontal score index (DPSI)) applied in the content management system.


procedure for bitewing frequency and recall interval, a two-

way ANOVA was performed with clinical vignette and

observer as independent variables. To test the influence of

specific risk factors on the assigned recall interval, a one-way

ANOVA was conducted. Regression analysis was used to

evaluate the impact of individual risk factors on recall length.

The level of significance was set at Alpha is 0.05. Sign Rank

tests were conducted to evaluate percentages of agreement

with expert opinions concerning prescription of bitewing

radiographs and recall intervals.

5. Results

5.1. Literature search

Two systematic reviews3,8 and one recent CPG4 were identi-

fied concerning recall intervals and the context of ROEs. Based

on the available search strategies and with additional

searches for bitewing radiography prescription, eventually

146 studies were selected for the evidence base. Overall, a

paucity of good quality research data on effectiveness and

risk management aspects of ROEs was found. Insufficient

evidence exists either to support or reject the practice of

stimulating patients to visit the dentist every 6 months for

ROE. The best available oral disease clinical predictor

applicable in general practice is previous disease experience.

Individual differences in caries progression rates on proximal

surfaces prevent precise timing of bite wing radiographs.

Systematic prophylactic removal of asymptomatic impacted

third molars is not based on reliable evidence. Risk-based

screening for early detection of oral cancer may reduce

morbidity and increase survival rates. Individual oral health

education and advice showed to be beneficial to individual

patients in clinical practice in reducing plaque levels in the

short-term.

Table 2 – Numbers and type ROE screening items toperform as a result of RAND modified Delphi consensusprocedure conducted with expert groups for both agecategories.

ROE-examination items �18-year >18-year

Patient history

Problems, complaints, discomforta � �Quality of life aspects (esthetical,

functional)

� �

Update patient history (medical,

social, oral)

� �

Update dental diagram � �

Analysis dietary habitsb � �

Clinical examination

Oral mucosa and oropharynx

abnormalities

� �

Oral health compliance

(plaque and bleeding)

� �

Detection and assessment

dental caries

� �

Screening periodontal disease � �Restorations (past caries

experience, quality)

� �

Hard tissue wear (dental

erosion, attrition)

� �

Growth and development � –

Face, head and neck � �

Patient communication and feed back � �Periodontal pockets and

attachment loss

� �

Pathologic oral habits � �Occlusion and articulation (functional

abnormalities)

� �

Screening third molar development � �Saliva quality � �

Additional examination

Dental radiographs � �

a Bold typeface: items to perform standardised.b Normal type face: items to perform optional.

Fig. 4 – Percentages agreement for bite wing frequency

prescription (in months) between experts and 35 GDPs in 8

clinical vignettes for risk levels HR: high, ER: elevated, RR:

reduced and LR: low.

Fig. 5 – Percentages agreement for recall interval

assignment (in months) between experts and 35 GDPs in 8

clinical vignettes for risk levels HR: high, ER: elevated, RR:

reduced and LR: low.


5.2. Expertgroups

A total of 31 experts participated, of whom 15 were allocated to

age category ‘�18-year’ and 16-age category ‘>18-year’.

5.3. From clinical cases to representative risk-basedvignettes

The overall mutual agreement in identifying risk factors for

both expert groups (round I) was moderate to good (group

Kappa �18-year: 0.72; >18-year: 0.65). The variation between

experts in assigning recall intervals (in months) was substan-

tial. In high-risk ROE clinical cases the standard deviation in

recall interval was smaller compared to low-risk cases,

suggesting that quality improvement in the latter group in

dental practice is needed.

Out of the list of 21 risk factors 10 were used for modelling

vignettes in children and adolescents, whereas 16 risk factors

were applicable for adults (Table 2). Consensus was reached for

each vignette concerning the content, bite wing frequency and

recall interval. Both expert groups showed mutual agreement

on ROE-items that had to be performed each time as well as

additional items that should be performed in individuals which

risk level was found to be high (Table 2). Recurrent and

systematic patient data recording were highlighted by experts

as predominant professional performance.

A comprehensive set of 19 clinical vignettes to be used for

CPD emerged. Both expert groups concluded unanimously

that the set of 19 was representative for ROE-attendees in

dental practice.

In order to validate the model, an ANOVA-analysis of the

influence of specific risk factors per vignette on recall length

scores showed that certain risk factors were strongly 1–1

correlated, preventing reliable effects (confounding). Negative

correlation coefficients were found both for specific risk

factors versus bite wing prescription and recall intervals,

suggesting that risk level and recall length were correlated.

5.4. Peer group pilot

Five peer groups comprising 35 GDPs assessed 8 selected

clinical vignettes. Variation in months within peer group

scores concerning bite wing prescription frequency and recall

interval was found to be very small. Bite wing prescription of

GDPs showed overall more agreement with expert opinions


compared to recall interval assignment. Significant differ-

ences (p < 0.05) in bite wing prescription (vignettes 1, 6) were

merely found in the high-risk vignettes showing lower

frequencies compared to expert opinions (Fig. 4). Concerning

recall interval agreement, the most significant differences

(p < 0.05) between GDPs and experts were found in the low-

risk vignettes (vignettes 2, 4, 8) (Fig. 5) in which GDPs assigned

considerably shorter intervals (in mths) compared to the

expert judgement.

6. Discussion

The main conclusion from this study is that clinical vignettes

regarding patient-tailored risk ROE-management, developed

by means of a validated procedure, provide a promising

educational tool for CPD. As shown in the pilot experiment,

experienced GDPs perform in general in accordance with

expert opinions, except for ROE-aspects most in need for

improvement in patient-tailored risk strategies, i.e. extending

recall periods in low-risk patients and increased bite wing

frequency prescription in high-risk patients. It is assumed that

when the CMS is useful for CPD, it can also play a significant

role in undergraduate dental training in Dental Schools.

As far as we know, risk-based clinical vignettes are seldom

used in dental education to enhance quality performance,

despite earlier research on patient management problems and

problem solving some decades ago.34 Clinical vignettes,

applied in a peer group educational setting and provided with

interactive feedback on individual as well as group perfor-

mances, may be potentially effective for implementing

strategies to improve clinical performance in daily practice.

Small group discussions on divergent assessments outcomes

of individual peer group members was reported to be a

powerful feature using the model.

In the absence of reliable evidence to precisely predict oral

disease onset in individuals, we used a clinical parameter to

guide GDPs decisions, i.e the number of new or progessing

lesions in time in combination with previous disease experi-

ence and risk factor assessment. This provided a practice-

based tool for risk classification, which eventually may lead

towards patient-tailored outcomes.

The rationale to implement four risk categories is build on

several assumptions; firstly, the skewed distribution of oral

diseases in The Netherlands. There exists a substantial group

of individuals, representing the low- and reduced risk

category. Secondly, the individual differences in lesion

incidence and lesion progression,1 resulting in a more prudent

diagnostic process to monitor slow progressing initial enamel

and dentinal lesions in order to enable a priori preventive

interventions (elevated and high-risk category). Using the

model in CPD, contemporary individual disease management

could promote a more evidence-based professional perfor-

mance (‘best practices’). The reliability has to be part of further

research conducted in general practice (practice-based re-

search) with substantial numbers of assessments by GDPs.

This set of 19 clinical vignettes provides a representative

set of prevalent combinations of oral disease in The Nether-

lands and might therefore be applicable in more industrialised

Western countries with low prevalence and a skewed

distribution of oral disease. Furthermore, this online model

could be also easily transformed into an educational tool

applicable in countries with divergent prevalence’s of oral

disease and attendance patterns. Due to this specific proce-

dure carried out, these set of vignettes could be used as part of

a national development and implementation procedure of a

ROE clinical practice guideline (CPG).

Advantages of working with online assessments are the

following: (1) less time consuming for individual patients and

professionals compared to assessments of standardised

patients; (2) the improving technical possibilities of electroni-

cally databases to visualise the clinical setting; (3) the ‘relative’

freedom of going online to participate; (4) the immediate

provision of feed back individually as well as to groups of peers

and last but not least: (5) the efficient data collection by

researchers with appropriate software for educational and

research purposes. Nevertheless, a substantial disadvantage

of the CMS is the lack of real life interaction between patient

and professional, making the assessment in a particular way

‘artificial’. This could probably be overcome by active

involvement and nationwide selection of multidisciplinary

experts to prevent under or overexposure of relevant clinical

characteristics.

We intended to statistically validate the model but failed to

do so due to the extensive number of variables within each

vignette and the strong correlation (1–1 confounding) between

specific risk factors. The total number of assessments made by

expert groups was too small to be reliable for statistical

analysis and prevented a straightforward regression analysis

with applied risk factors as dependent and assigned recall

periods as independent variables. Therefore the pilot experi-

ment was conducted to further analyse the use of the model by

experienced GDPs.

The first results highlighted the differences in scores

between experts and GDPs which were mainly caused by

the standardised way of decision-making by GDPs in every day

practice regarding BW-frequency (every 36 months) and recall

interval (6 months)35 underpinning the room for improvement

as visualised by the model. Further long-term studies are

needed to deliver more data on the reliability of this set of

clinical vignettes.

Furthermore, clincal vignettes may also serve as a tool for

measuring quality of clinical practice20 compared to (stan-

dardised) real life patients and chart abstraction.22 Applied in a

scientific context, an additional validation experiment could

help to sort out out in what way (reliability) this set of vignettes

measures risk-based oral screening and improves quality of

oral care, resulting in substantial cost-effectiveness of routine

oral screening. In order to measure the quality of the step wise

decision-making process, sophisticated software build into

the database could reveal data on the total numbers of clinical

and non-clinical items from which individual dentists make

use to underpin their decisions. Further research and

experiments are needed to optimize the CMS and to explore

how potential users are dealing with the information provided

in the CMS.

The results of this study give rise to conclude:

� Clincal vignettes based on evidence and practice-based

recommendations could support knowledge translation and


as a result enhance the quality of individual patient care

delivery (‘best practices’).

� Computer-assisted systems could support knowledge trans-

lation in providing self-assessment educational tools for

GDPs.

� Evidence-based routine oral examination in individuals

requires risk disease management skills tailored to content

items, bitewing radiograph prescription and recall assign-

ment.

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Routine oral examination: Clinical vignettes, a promising tool for continuing professional development?