Many undergraduate and postgraduate or even graduate dentists struggle when it comes to writing academic essays. In this section, we will cover all possible techniques on how to improve your academic writing and provide examples to get you going on the right track. Finally, we will provide examples to practice writing and compare your work with others who got high and low grades.
1- The first thing you want to do is scan the question and write down all the possible sections/headlines related to that topic. Here is a prime example that is used frequently by many dental schools, "A 65-year-old patient is presented to your clinic with facial swelling in his lower molar area. The patient has uncontrolled diabetes and hypertension. Discuss possible diagnosis and your management". A good essay for this topic should start with an introduction, followed by an assessment of the condition, possible radiographic techniques required and their role, histopathological findings, consent form, management of the case, and possible complications, long term follow up and quality of life and finally a solid conclusion. These are the standard headlines used in almost every essay but some essays may be unique and require additional sections.
2- Finding good resources. Even if you are unable to identify good headlines or if you're completely unfamiliar with the topic then finding one good resource can be a game-changer for you. 99% of professors dislike the use of books when writing essays, and for that, your best bet is to avoid including them as references. The reason being is that almost all books are outdated when it comes to guidelines, radiographic examination, and the latest management of the case. Therefore, finding new articles and most importantly systematic reviews and using them as references is a huge boost for your essay. As your supervisor is reading your essay, if he/she comes across a reference used that is 10 years ago, you're most likely to lose grades unless there are no other reviews made since then, and in that case, you may have to mention that in your writing.
3- Enhance your essay with a unique vocabulary. No one expects you to write like Shakespeare, but if you keep using the same words over and over again, you will surely lose out on some marks. The easiest thing to do is to use google search to find word synonym. If your topic is boring and you are forced to repeat some words then you might as well try to find alternative synonyms. This will keep the reader focused and not feel bored while reading your essay.
4- Adding pictures and tables. There has to be something unique on every page. Graphs, tables, pictures, and bar charts are excellent choices for academic writing in dentistry. Systematic reviews and meta-analysis often contain a bunch of those and it advised NOT to copy them directly but to use the data and create a better-looking table using other Softwares.
5- Do not copy and paste no matter what. Yes, they said it is okay to use the same sentences as long as you reference them correctly, but the truth is, nobody likes that. Avoid using the same words as the original writer.
6- Use references for everything. Writing essays is not about opinions, it's about evidence-based dentistry. No matter what system of referencing you decide to go with, you must reference everything in your essay. If you decide to bring your own pictures and data then you need to mention clearly in the references section that those pictures are copyrights of the author of this essay.
7- Avoid repeating references. A simple rule is that if you're asked to write 2500 words, then you need at least 25 references, if you're asked to write 4000 words then you need at least 40 references. Adding more references shows the reader that you have done a good amount of research before writing this essay.
Here is a real-time essay question handed to post-graduate students. You can test yourself by writing a small paragraph using the tips mentioned above and compare to an essay that scored distinction.
"A 67-year-old woman presents with exposed bone in the mandibular molar region, after a dental extraction 3 months ago. She suffers from osteoporosis and has infusions 6 monthly of denosumab. Discuss your assessment, diagnosis and management options for this patient"
The historical disease phosphorous necrosis resulted from exposure to white phosphorous which was ubiquitous in the 19th-century match industry (Vance 2007). The disfiguring condition produced lytic lesions of the skeleton with a particular affinity for the mandible (Treves 1882). Present-day medication-related osteonecrosis of the jaws (MRONJ) is analogous to this entity, exhibiting a similar destructive pattern (Hellstein and Marek 2005). It was recognised initially in 2003 when a correlation between an increase in osteonecrotic presentations and certain medications was noticed (Marx 2003). The condition has undergone a number of nomenclature changes from bisphosphonate-related osteonecrosis of the jaws (BRONJ), antiresorptive-related osteonecrosis of the jaws (ARONJ) to the present overarching term MRONJ (Neville et al. 2015).
MRONJ is defined in the American Association of Oral and Maxillofacial Surgeons (AAOMS) position paper as exposed bone or bone that can be probed through an intraoral or extra-oral fistula(e) in the maxillofacial region that has persisted for more than eight weeks (AAOMS 2014). The classification stipulates current or previous medication with an antiangiogenic or antiresorptive agent with no history of irradiation or metastatic disease to the jaws (AAOMS 2014).
The treatment planning of a disease state is a concatenate process involving assessment, diagnosis, therapy options and management (Mitchell 2006). A consultation commences with clinician introduction and verification of patient details including name, date of birth, and place of residence (Pedlar and Frame 2007). The assessment proceeds stepwise to record the patient’s presenting complaint, history of presenting complaint, current and past medical history, social history and dental history (Fonseca 2017). It is important to establish all current and previous patient medications in particular concomitant use of corticosteroids (SDCEP 2017). The type, method of administration and duration of medication usage is vital to risk categorization as currently recommended by the Scottish Dental Clinical Effectiveness Programme (SDCEP 2017). Prior to the patient’s extraction a risk profile should have been undertaken involving a thorough discussion with the patient and documentation of whether low or high risk grouping (SDCEP 2017). A synergistic relationship between the co-morbidities of diabetes and periodontal impairment in disease propagation has been suggested (Filleul et al. 2010). Similarly, mucosal trauma as a consequence of an ill-fitting denture is thought to expedite disease development (Leven and Preston 2016). Alcohol and tobacco are mooted as risk factors in causation (Filleul et al. 2010). Therefore, advice regarding limiting alcohol consumption, maintaining a high standard of oral hygiene and tobacco cessation is appropriate in those at risk of MRONJ (SDCEP 2017). In this instance the patient has an established bony exposure pathognomonic of MRONJ which corresponds to a high risk category (SDCEP 2017). An extra-oral examination is essential to identify bony anomalies and any fistulae indicative of disease activity (Otto et al. 2015) . Extra-gnathic occurrence of osteonecrosis has been described with case reports of otic and long bone involvement (Polizzotto at al. 2006) (Kim et al. 2015). Specific questioning of the patient and interaction with medical colleagues regarding other body lesions is prudent.
MRONJ displays a gamut of presentations and is frequently non-painful unless secondarily infected (Odell 2010). Cases preferentially affect the mandible with a marked predilection for the posterior region (Abu-Id et al. 2008). Clinical manifestations can include loosening of teeth, halitosis, suppuration, presence of a sinus tract with localised infection, encroachment of neurological structures and pathological erosion of the antral floor resulting in a communication (Saldanha et al. 2012) (Mast et al. 2012). Intractable disease can be characterised by facial disfigurement involving mandibular fracture and potentially life-threatening deep space abscesses of the head and neck (Mehanna and Goddard 2010). The extent of bony involvement is variable ranging from small exposed edges to large denuded, necrotic areas (Otto et al. 2015). There is a degree of idiosyncrasy associated with MRONJ as the size of a lesion does not necessarily correlate with the severity of underlying disease or pain experience (Otto et al. 2015). A careful summation of patient history and clinical findings is a prerequisite to disease staging and treatment plan formulation.
A number of staging systems exist in the dental literature including one proposed by Marx and another by the Italian Society of Maxillofacial Surgery – Italian Society of Oral Pathology and Medicine (SIMCF-SIPMO) (Rosella et al. 2016). The AAOMS classification (Table 1) is the most widely used (Shah et al. 2015).
Several authors have expressed criticism of AAOMS staging impugning it as restrictive and reactive (Mawardi and Woo 2015). Non-exposed bone can represent up to 23% of stage 3 cases following disease progression but is rated at the lower end of risk hierarchy (Schiodt et al. 2014). Bone exposure is a late indicator of diagnosis with a poor response to treatment (Devlin et al. 2018). A proactive classification and an early intervention protocol have been urged (Pautke 2015). The clinical presentation of MRONJ stages 1, 2 and 3 is pictured below (Figure 1).
Figure 1 MRONJ clinically*
Denosumab was granted European regulatory approval for the treatment of postmenopausal osteoporosis and the prevention of bone fracture in men following prostate cancer in May 2010 (EMA 2011). It received later sanction as a prophylactic agent in patients with bone metastases using a higher dosing regimen (EMA 2011). The drug is marketed under the tradenames Prolia® and Xgeva®. Prolia® is an anti-osteoporotic analogue which is administered by subcutaneous injection 60mg every 6 months with calcium and vitamin D supplementation advised (BNF 2018). Denosumab is a human immunoglobulin G₂ (IG₂) monoclonal antibody which inhibits the binding of nuclear factor-κB ligand (RANKL) to nuclear factor-κB (RANK) (Cummings et al. 2009). The selective inhibition of the RANKL-RANK complex hinders osteoclastic differentiation thereby, reducing bone turnover and resorption (Figure 2) (Green 2010). Consequently, there is an increase in bone mass and buttressing of cortical and trabecular bone (Miller 2009). The medication is not incorporated in bone with a half-life of 24.5 days (Neville et al. 2015). Serum concentrations of the drug are eliminated over a 4 to 5 month period (Miller 2009).
Prolia® is associated with an increase in nonfatal serious infections due to RANKL inhibition of activated T and B lymphocytes (Amgen 2017). An increase in the incidence of endocarditis is reported as well as de novo breast, reproductive and gastrointestinal system malignancy compared with placebo though a drug causative relationship is unproven (Amgen 2017).
An accurate anamnesis combined with clinical examination and special investigations are pivotal to diagnosis (Ruggiero et al. 2009). Various imaging modalities from panoramic radiographs, CBCT/CT to esoteric nuclear imaging techniques have been advocated (Probst et al. 2015). The radiographic features attributed to MRONJ are diffuse osteosclerosis, osteolysis, widened periodontal ligament, thickening of the lamina dura, and cortices (Guo et al. 2016). Atypical bone has a flocculent appearance on a radiograph (Hutchinson et al. 2010). No feature is predictive of future bone exposure meaning early diagnosis is not possible radiographically (Devlin et al. 2018). In established cases, radiographic imaging aids the identification of aberrant bone but is unable to delineate the border between healthy and atypical bone (Klingelhöffer et al. 2016). Good detectability of lytic lesions has been demonstrated with MRI with an increased identification rate using contrast-enhanced MRI (Stockmann et al. 2010) (Guggenberger et al. 2013). The technique is limited by its inability to define the extent of affected bone (Stockmann et al. 2010).
The aetiopathogenesis of MRONJ is unclear though several theories regarding disease initiation and propagation exist (Kyriakidou et al. 2016). The incidence of MRONJ in osteoporosis treated with Prolia® is 0.04% at 3 years, 0.06% at 5 years and 0.44% at 10 years (eMC 2017). There is a relationship between risk and duration of drug exposure (eMC 2017). The incidence associated with Prolia® is at the lower end of the spectrum compared with antiresorptive or antiangiogenic formulations in cancer cases (SDCEP 2017). MRONJ upholds the maxim that prevention is better than cure. A dental examination is recommended prior to commencement of drug treatment with completion of any remedial work and advice regarding good oral care (Amgen 2017). A review appointment following dental extraction is advised (SDCEP 2017). An established lesion is difficult to manage and frequently refractory to effective treatment (Pautke 2015). As the condition has a short history of recognition the mechanism of optimal care is controversial (Domah et al. 2018). In the absence of a gold standard, a heuristic approach to treatment has filled the vacuum (Matsuda et al. 2018). The variety of treatments span a broad church which largely conform to a conservative or surgical concept (Beth-Tasdogan et al. 2017). Proponents of a conservative technique aim to avoid pain and infection in established disease (Domah et al. 2018). The mainstay of this philosophy is local and systemic antibiotics, meticulous oral hygiene with adjunctive chlorhexidine, bony irrigation, analgesics and coverage of bone exposure (Migliorati et al. 2005). Penicillin is the first line antimicrobial (Ruggiero et al. 2014). In cases of allergic contraindication quinolones, metronidazole, clindamycin, doxycycline and erythromycin are proven alternatives (Ruggiero et al. 2014). These measures are associated with a variable success rate of between 23-53% (Hoff et al. 2008) (Van den Wyngaert et al. 2009).
The benefit of hyperbaric oxygen additional to conservative treatment is unsubstantiated (Beth- Tasdogan et al. 2017). There is disagreement regarding the parameter of clinical success following treatment whether it implies re-establishment of bony and soft tissue architecture or a holding position with no worsening of the condition (Badros et al. 2008). Surgical intervention has gained traction as conservative methods are viewed as passive rather than curative (Ristow et al. 2015). A success rate above 90% is reported (Ristow et al. 2015).
The current AAOMS recommendations which incorporate conservative and surgical elements are outlined below (Table 2). Critics of this strategy support surgical removal of necrotic bone below stage 3 and argue that the AAOMS guidelines promote palliation of the disease (Fliefel et al. 2015). The technical details of surgical flap design and reflection must be carefully planned. The incision line includes any mucosal dehiscence or fistula resulting in tension free mucoperiosteal coverage of the surgical field following osteotomy of the exposed, necrotic bone (Lorenzo et al. 2013). Altered marginal tissue containing the products of chronic infection is resected prior to flap closure (Lorenzo et al. 2013). The size of the osteotomy relies on the subjective judgement and experience of the surgeon (Khosla et al. 2007). Bone bleeding at the surgical site following provocation is not associated histologically with vital bone (Pautke et al. 2011). The evidence pertaining to autofluorescence-guided versus tetracycline fluorescence-guided sequestrectomy is equivocal (Beth- Tasdogan et al. 2017). A Cochrane Review concluded there was currently insufficient evidence to guide the clinician regarding optimal treatment (Rollason et al. 2016). The suspension of medication prior to active treatment is polemical (Kimmel 2007). Due to the shortened half-life of denosumab, a “drug holiday” has been advocated (Malan et al. 2012). A recent review article encourages an individualised approach, balancing the oral condition with patient need (Ramaglia et al. 2018). Every intervention is predicated on informed patient consent and absence of contraindicating comorbidities to operative management (Bayliss 2017). Crucial to informed consent is relay of surgical complications particularly, risks to anatomical and neurovascular structures (Fonseca 2017). An ASA determination is necessary prior to consideration of anaesthetic/sedative management (Pedlar and Frame 2007).
In the absence of a consensus several innovative treatments have emerged (Table 3). Further investigation is required to establish validity.
Dental rehabilitation is a contentious field (Leven and Preston 2016). Ideally, a mucosal supported prosthesis should avoid vulnerable areas and healing tissue (Hoefert et al. 2015). The provision of a dental implant, endodontic or periodontal interventions that necessitate exposure and manipulation of bone is comparable to the risk posed with tooth extraction (Ruggiero et al. 2014). Osteonecrosis is not confined to antiangiogenic and antiresorpitve drug classes. Case reports of methotrexate associated osteonecrotic jaw involvement have surfaced (Henien et al. 2017). Dental vigilance is paramount.
Operative care of the patient should not be considered in isolation. Forethought should be given to aftercare. Almost 12 million people in the UK are aged 65 or over with just one in seven suffering no long term health condition by age 80 (AgeUK 2017). Care of the elderly represents an enormous social and provision of service challenge (NHS 2013). Many elderly patients present with significant co-morbidities and polypharmacy which complicate treatment (Vogt-Ferrier 2011). The problem is compounded when operative care is necessary requiring a period of convalescence. Oral surgery impacts on quality of life and is disruptive of normal function (Gift and Redford 1992). Post-operative discomfort impacts on daily activities involving nutrition and oral hygiene (Saunders 1995). Patients with mobility and dexterity issues are vulnerable and at an increased risk of neglect following treatment with poorer surgical outcomes (Vogt-Ferrier 2011). The overall patient management involves interplay between patient values, medical fitness, adequate homecare, post-operative compliance ability and risk/benefit assessment (Fraccaro et al. 2015). Regular dental monitoring is essential (Rasaratnam et al. 2018).
MRONJ is a diverse entity and homogeneity regarding staging and treatment is lacking. A number of differing philosophies compete to establish influence however; many aspects of current treatment are arbitrary with a dearth of robust clinical evidence. The clinician should uphold the patient’s best interests and adopt a practical treatment regime. An interdisciplinary approach to management is vital involving general practitioner, specialist medical colleagues and auxiliary disciplines as required. With an ageing population, increasing life expectancy, and greater use of MRONJ associated drugs, clinicians will encounter disease more frequently. Diagnosis and treatment planning are dynamic and set to evolve as the disease is further understood. The clinician needs to adapt as guidelines change and foster an evidence based approach.
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