Diagnosis under pressure

It is true to say that our judgement is not always at it’s best when we are stressed or under time pressure. In a recent paper (Plessas et al., 2019 ) a research team  placed 40 dentist under time pressure to assess a number of dental radiographs and compared it to the same groups results if they has as much time as they felt necessary.  Their conclusion was:

Time pressure negatively impacts one aspect of dentists’ diagnostic performance, namely sensitivity (increased diagnostic errors and omissions of pathology), which can potentially affect patient safety and the quality of care delivered.

Since this study was based about diagnostic test accuracy (DTA) I felt it might be interesting to express this result graphically, and the author was kind enough to provide me with the raw data from the research. The  data was extracted into  excel and then analysed using the statistical package ‘mada’ in R to  create a summary receiver operator characteristic (sROC).

The Results

The ellipse with circle surrounded by the solid line represents the summary estimate for diagnosis with time pressure (TP) and 95% confidence interval, and the ellipse with triangle surrounded by the dotted line represents the summary estimate for diagnosis with no time pressure (NTP).

Diagnostic test accuracy (sROC curve)Time pressure

Sensitivity = 0.551 (95%CI: 0.439 to 0.658)

False positive rate = 0.006 (95%CI: 0.004 to 0.01)

No time pressure

Sensitivity = 0.797 (95% CI: 0.692 to 0.873)

False positive rate = 0.009 (95%CI: 0.006 to 0.13)

Summary result

The difference between TP and NTP are statistically significant p=0.0007

In absolute terms there was a 24.6% reduction in correct diagnosis under TP.

In relative terms there was a 40% reduction in correct diagnosis under TP.

My conclusion

When under stress or significant time pressure there was a significant reduction in the clinician ability to diagnose pathology (from 80% to 55%) but a misdiagnosis of ‘normal’ was very low in both scenarios.

Acknowledgements

I would like to thank the authors for allowing me access to their data

Plessas, A., Nasser, M., Hanoch, Y., O’Brien, T., Bernardes Delgado, M. and Moles, D. (2019) ‘Impact of time pressure on dentists’ diagnostic performance’, Journal of Dentistry, 82, pp. 38–44. doi: 10.1016/j.jdent.2019.01.011.

How well do different treatments perform?

How successful are your treatment options

I have compiled a short list of risk relating to advanced dental treatment. Most marketing material relating to dentistry tends to only show success and how they will improve you health, well being and looks. What they don’t mention is the how long that treatment is going to last and the risk of it not working. It is extremely important that the patient can make an educated decision with their dentist as to the amount of risk they are prepared to accept before staring any advanced dental treatments

The figures are given in terms of Success

Implant placement (after 5 years)

Implant retained crown/bridge 96 in 100 at 5 years

Conventional crown and bridge

Back teeth 95 in 100 at 5 years

Front teeth 86 in100 at 5 years

Resin bonded bridge 87 in 100 at 5 years

Post retained 80 in 100 at 5 years

Treatment to resolve gum disease

Non surgical gum treatment 90 in 100 at 5 years

Surgical gum treatment 80 in 100 at 5 years

Root fillings

Root fill + crown (back tooth) 93 in 100 at 5 years

Root fill only (back teeth) 75 in 100 at 5 years

If you want to read further follow this link to Evidence Based Dentisty

http://www.nature.com/ebd/journal/v9/n1/pdf/6400565a.pdf

EAO Conference 2010

EAO 22nd Scientific Meeting Dublin

The European Association for Osseointegration meeting opened on Wednesday evening in Dublin, Ireland . The conference theme being ‘Preparing for the Future of Implant Dentistry’.

Famine Ship - Jeanie Johnston Dublin
Famine Ship – Jeanie Johnston Dublin

On the Thursday morning we started with a presentation about the importance of maintaining the bone supporting the teeth and gums after extraction. In a normal extraction we lose 50% of the supporting bone within 4 months. This volume of bone loss can make it difficult to restore the missing tooth later both functionally and aesthetically. Bone loss can however be reduced to about 20% with the immediate use of bone substitutes placed in the extraction socket at the time of extraction making speeding up healing and  future restoration of the space more predictable.

The afternoons title was ‘Treatment planning for success-how to get in right.’ and was presented by Dr Mark Pinsky a dentist who is also a commercial airline pilot. The theme revolved around the adoption of airline style checklists to reduce errors in surgery. As a side note we have been using these checklists in the practice for the past two years already and find them extremely useful as treatments and patients medical histories get more complex.

Exif_JPEG_PICTURE

Friday morning we discussed the increasing problem of infection round dental implants and whether it was an infection or just the body trying to reject the implant, the conclusion was that more research needed to be done into this area but both factors were to a degree responsable.

The afternoon covered treating patients with long-term loss of upper back teeth from a quite minimalist approach to major surgery for cancer patients.

By far the most interesting series of lectures was on saturday morning titled ‘Implants in the Aging population’. In a lot of Western countries there are more over 65 year olds than 5 year olds and we discussed the problem of how to manage dental health in the age group 80-100. In fact the population of 100 year olds will increased by 400% in the next 25 years. The biggest problems were dental health, retaining unhealthy teeth into old age and long-term chronic illness. Though this subject is not a political vote winner we do need to acknowledge its existence and positively take charge of the challenges it presents. One strategy was the use of a single implant to stabilise a lower denture which over 10 years has dramatically improved patients quality of life at a significantly reduced cost and level of intervention.I have always found the Saturday morning lectures to be the most thought-provoking and applicable to the real world of dental health.

Trinity College Library - Dublin
Trinity College Library – Dublin