Factors related to decisions to extract or retain at-risk teeth

OBJECTIVES: Decisions to extract a tooth may be among the most critical in dentistry. The aim of this study was to prospectively investigate both clinical and nonclinical factors related to decisions to extract or retain teeth in private general dental practice. METHODS: A convenience sample of 196 Iowa dentists in private general dental practice reported on 549 cases where decisions were made to extract or retain teeth as they occurred in their practices during a one-month period in May 1997. Bivariate and multivariate analyses were used to identify factors that differentiated between cases where a tooth (or teeth) was extracted and cases where an at-risk tooth was retained. RESULTS: Of the 549 cases, 67 percent involved extraction, while the remainder involved alternatives to extraction. In comparing extraction cases to alternative treatment cases, we excluded 150 extraction cases because dentists reported that no alternative to extraction was available. Using Generalized Estimating Equations (GEE), we identified cost of treatment, presence of tooth mobility, poor prognosis of alternative treatment, and presence of gross caries as significant factors associated with extraction, while previous treatment of the tooth and concerns with patients' health were significantly associated with alternatives to extraction. CONCLUSIONS: For teeth at risk for extraction, cost, substantial periodontal disease, and several clinical factors were predictive of extraction.     

Diagnostic tools and measurements-impact on appropriate care

Abstract The diagnosis of primary coronal caries should be seen as a complex process, comprising both detection and measurement phases, which enables clinicians, researchers and epidemiologists to make informed decisions about the management and prognosis of the disease process. The different diagnostic thresholds employed for measurements of caries experience can be viewed as an iceberg, a metaphor which demonstrates the ambiguity of the term “caries free” and which can also represent the differing management options appropriate for the care of different types of active and inactive lesions: NAC (No Active Care), PCA (Preventive Care Advised) and OCA (Operative Care Advised). There are considerable methodological difficulties in drawing valid comparisons between studies using incompatible criteria and simulations. However, it is apparent that no caries diagnostic tool in current clinical use fulfils all of the ideal criteria for measurements needed to plan and monitor appropriate care. Systems providing reliable serial measurements with which to assess future caries risk and present caries activity are urgently required, as diagnostic tasks are becoming both more difficult and more important from the standpoint of long-term oral health. Existing diagnostic tools frequently rely on subjective judgements and provide only semi-quantitative measures insensitive to smaller lesions. In the future tools are needed which are objective, quantitative and which can provide acceptable compromises between sensitivity and specificity for a wide range of applications for individual patient care as well as for research and survey use. Key problem areas with existing tools include confusion in terminology and between caries assessments made by clinicians and epidemiologists as well as the lack of valid measurements relating to the activity of primary root caries and secondary caries. Deficiencies with current tools impact on the care of individuals by allowing false negative diagnoses of hidden occlusal dentine lesions and approximal cavities on the one hand, whilst generating some false positive diagnoses on sound surfaces leading to inappropriate decisions to restore on the other. At the population level, current conventional tools significantly underestimate overall caries experience. In future the adoption of more accurate and reliable methods would facilitate more effective preventive care and promote more appropriate restorative treatment decisions. Research in this area should focus for the next five years on diagnostic technologies which: 1) inform valid prospective caries risk assessments for different age groups, 2) can help to determine present caries activity and monitor lesion behaviour over time and 3) help identify methods which can implement existing and new research knowledge about diagnostic tools into clinical and research practice.     

The practice of dentistry by male and female dentists

Increasing numbers of women are entering the once male-dominated dental profession in Australia. Determining what differences exist in the practice of dentistry between male and female dentists has therefore become an important task. The purpose of the present study was to examine differences in practice between male and female dentists. Data were available from a weighted, stratified random sample of 730 dentists (486 male and 294 female dentists) in each State or Territory of Australia. Using discriminant analysis age, practice setting, number of other dentists in the practice, inputs to the practice of dentistry either hired, acquired or contributed, direct demand and community size were all found significant in separating male and female dentists. It was more difficult to separate younger male and female dentists, indicating some convergence between the sexes. However, some differences persisted. Possible reasons for the differences are discussed and some implications noted.     

Repair or replacement of defective restorations by dentists in The Dental Practice-Based Research Network

BackgroundThe authors aimed to determine whether dentists in practices belonging to The Dental Practice-Based Research Network (DPBRN) were more likely to repair or to replace a restoration that they diagnosed as defective; to quantify dentists' specific reasons for repairing or replacing restorations; and to test the hypothesis that certain dentist-, patient- and restoration-related variables are associated with the decision between repairing and replacing restorations.MethodsThis cross-sectional study had a consecutive patient and restoration recruitment design. Practitioner-investigators (P-Is) recorded data for consecutively seen restorations in permanent teeth that needed repair or replacement. The DPBRN is a consortium of dental practitioners and dental organizations in the United States and Scandinavia. The collected data included the primary reason for repair or replacement, tooth surface or surfaces involved, restorative materials used and patients' demographic information.ResultsP-Is collected data regarding 9,484 restorations from 7,502 patients in 197 practices. Seventy-five percent (7,073) of restorations were replaced and 25 percent (2,411) repaired. Secondary caries was the main reason (43 percent, n = 4,124) for treatment. Factors associated with a greater likelihood of repairing versus replacing restorations (P N/A .05) included having graduated from dental school more recently, practicing in a large group practice, being the dentist who placed the original restoration, patient's being of an older age, the original restorative material's being something other than amalgam, restoration of a molar and the original restoration's involving fewer tooth surfaces.ConclusionsDPBRN dentists were more likely to replace than to repair restorations. Secondary caries was the most common reason for repairing or replacing restorations. Certain dentist-, patient- and restoration-related variables were associated with the repair-or-replace decision.Clinical ImplicationsThe selection of minimally invasive treatment for an existing restoration is critical, as it may affect the longevity of the tooth.     

The relationship between working conditions and sick leave in Swedish dental hygienists

Abstract:  The purpose of this study was to examine the relationship between working conditions and sick leave in Swedish dental hygienists. Seventy-one percent of 577 randomly selected dental hygienists responded to a questionnaire. From those who responded ( n  = 411) a homogenous group of 252 was selected. They were assigned to four groups that exhibited either musculoskeletal disorders (MSD), low well-being (LWB), both low well-being and musculoskeletal disorders (BLM), or relative health (main group or M group). These groups were further divided according to number of sick days taken per year. Non-parametric statistics and logistic regressions were used for analyses. Those with MSD worked more clinical hours and treated more patients per day than the other groups. While the M group had fewer sick days, better work climates and decreased demands on work efficiency, increased sick leave within this group was related to greater staff numbers and less commitment to improving work processes. In the M group, role ambiguity and LWB were associated with absence of 1–3 days, compared with those who took no sick leave. Respondents in the LWB group, who perceived role ambiguity, were absent more than 7 days/year, compared with those who perceived role clarity. Management issues were the distinguishing factor for those who had severe health problems. In conclusion: role ambiguity is the predominant psychosocial factor associated with sick leave. Psychosocial management factors rather than physical work factors seem important for work and sick leave rates among dental hygienists.     

The use of administrative databases to assess oral health care

OBJECTIVE: We examined the potential for research using administrative databases containing dentists' claims to identify both the type of health services research questions addressed and the strength of the evidence that is achieved in such studies. METHODS: We searched Medline (1966 to March, 2003), retrieved additional reports from personal files, reviewed the literature cited in the relevant articles and conducted electronic searches on investigators' surnames. Information from relevant articles was abstracted into tables and the strength of the evidence for each was classified. RESULTS: Thirty-eight studies met our inclusion criteria. Researchers have used administrative databases of dental records to examine provider practices, the longevity or consequences of dental interventions, the prevalence of dental conditions, and patient factors that determined care, and to establish quality assurance criteria or standards of care. The strongest designs were prospective or case-control (Level II-2). CONCLUSION: Studies analyzing administrative databases have the advantage of size and economy but are subject to several threats to their validity and are seldom population-based. The strongest designs occurred with investigation of the longevity or consequences of care. Several studies demonstrated the benefit of linking the service data to patient or provider characteristics. The study of dentists' claims data appears under exploited, especially in the area of identifying and recommending changes in dental health care policies.     

Radiographic interpretation and treatment decisions among dental therapists and dentists in Western Australia

All dentists and dental therapists employed in the Community Dental Services in Western Australia were invited to participate in a questionnaire study to find out about their use of radiographs and opinions and knowledge about the diagnosis of approximal caries. Replies were received from 45 dentists (95.1%) and 207 dental therapists (84.0%). Most dentists would not restore a lesion before it appeared on radiograph to have reached the dentine, while therapists were more likely to consider a restoration for a lesion just in enamel. Sixty percent of all respondents thought that a cavity was present when the radiographic lesion was confined to enamel. Fifty-seven percent of dentists thought that an average lesion took at least 12 months to progress from outer enamel to dentine, while a majority of dental therapists thought this would take less than 12 months. Radiographs were not frequently taken by the participants. Operators' opinions about cavity formation were the most important predictor of choice of treatment. In general, these participant's responses were similar to those provided by Norwegian and Dutch respondents in similar surveys conducted 5-6 yr ago, but the present participants worked in an optimally fluoridated area and might therefore have been expected to have adopted more cautious criteria for restorative treatment. Differences between dentists and dental therapists were generally not great. The results suggest that calibration of the operators in the service would offer benefits.     

Endodontic treatment performed by Flemish dentists. Part 2. Canal filling and decision making for referrals and treatment of apical periodontitis

AIM: To gather information on root-canal treatment carried out by dentists working in Flanders (Belgium). METHODOLOGY: A questionnaire reported in a previous study was also used to gather information on canal medicaments, canal filling, and in decision making for referrals and treatment of apical periodontitis. RESULTS: Calcium hydroxide as an interappointment dressing was used by 69.7% of the respondents. Approximately one-third of the respondents did not use any intracanal medicament. Caustic products used for pulp tissue fixation were used by 66.8% of the respondents. Cavit (48.2%) and glass-ionomer (31.3%) were the temporary coronal-filling materials used most often, followed by zinc oxide-eugenol and IRM(R). Cold lateral condensation of gutta-percha was the filling technique most used by the respondents (65.8%). Single-cone gutta-percha placement (16%), paste techniques (4.9%) and silver points (3.9%) were still used. Resin-based sealers were used most often (88.6%). Paraformaldehyde containing sealers such as Endomethasone and N2 were used infrequently. Approximately half of the practitioners were satisfied with their canal-filling technique, others felt that they could do better (43.0%); 0.7% were not satisfied. In cases with apical periodontitis, the size of periapical lesions and/or the presence of a root filling influenced the choice of endodontic treatment. The most common reasons for referral of endodontic cases were: retrieval of silver points, surgery, and post removal. CONCLUSIONS: The results of this study indicate that techniques and methods used for canal medication and canal filling were acceptable for the majority of the respondents. Re-treatment was underestimated as a treatment option.     

Factors Influencing the Appropriateness of Restorative Dental Treatment: an Epidemiologic Perspective

Objectives : An epidemiologic analysis was performed to identify patient and dentist factors influencing over- and undertreatment of restorative services in a sample of insured adults. Methods : At baseline, 681 Washington State employees and their spouses, aged 20 to 34 years and residing in the Olympia or Pullman areas, were interviewed by telephone. Oral assessments were conducted to measure personal characteristics, oral disease, and restoration quality. Adults were followed for two years to measure use of restorative services from dental insurance claims. Each adult's baseline and claims data were linked with provider and practice variables collected from the dentist who provided treatment. Results : For overtreatment, 39 percent of adults received one or more replacement restorations in nondecayed teeth with satisfactory fillings at baseline, while 18 percent of adults had one or more restorations placed in teeth with no decay and fillings. An adult's probability of overtreatment was higher if the adult had more fillings at baseline, or if an adult's dentist was younger, had a busy practice, advertised, charged higher fees, had less continuing education, or had a solo practice. For undertreatment, about 16 percent of adults either received no replacement restorations in teeth with unsatisfactory fillings at baseline, or had decayed teeth at baseline that were not filled or crowned. An adult's probability of undertreatment was higher if an adult had less decayed or more missing surfaces at baseline, or if an adult's dentist believed in sharing information with patients, had a busy practice, or reported not placing fillings when radiographic evidence of new caries was present. Conclusion : A minority of adults aged 20 to 34 experienced potential over- or undertreatment of restorative services, which are influenced by both patient and dentist factors.     

Periodontal treatment practices of Finnish dentists

OBJECTIVES: To evaluate the treatment practices of Finnish general practitioners (GPs) and dental teachers (DTs) regarding periodontal treatment modalities, and their knowledge of possible contraindications for periodontal surgery. MATERIAL AND METHODS: A questionnaire on two periodontal cases was mailed to 400 GPs, selected by stratified randomization from the public and private sector, and to 47 DTs. The response rate was 77%. Respondents were asked to choose the optimal treatment for a patient with a bleeding, 8-mm-deep periodontal pocket and to consider the influence on their treatment decision of the six possible contraindications for periodontal surgery presented, two of which were absolute (inadequate oral hygiene and poorly controlled diabetes) and four of which were relative contraindications. The respondents' treatment decisions were compared with recommendations from textbooks and the Consensus Report from the 1996 World Workshop of Periodontology. RESULTS: The majority of public (65%) and private (70%) dentists and almost all of the DTs chose treatment in agreement with recommendations. Correct answers from dentists were associated with a greater number of days in continuing education (OR = 1.5; p= 0.005). The two absolute contraindications were known by 38% of public and 31% of private sector dentists, and by 29% of DTs. The respective figures for relative contraindications were 40, 58 and 53%. CONCLUSION: The majority of Finnish dentists followed the recommendations, but elaboration of international guidelines for good clinical practice is still needed to help clinicians to make optimal treatment decisions.     

Variation in radiographic interpretation and restorative treatment decisions on approximal caries among dentists in Norway

Of a random sample of dentists in Norway (n = 741), 83% responded to a questionnaire about their use of radiographs in and their opinions and knowledge about the diagnosis of approximal caries. There was great disparity in criteria for initiation of restorative treatment of approximal caries based on radiographic appearance. Two thirds of the dentists would do restorative treatment of lesions confined to enamel, the others would wait until lesions had reached the dentin before treatment was commenced. The criteria for restoration based on radiographic appearance was best correlated with the dentists' opinions about cavity formation. About 20% of the variation in criteria among dentists was explained by the radiographic appearance dentists associated wih the presence of a cavity. The majority of the dentists believed that approximal caries progressed faster than is indicated by progression studies. The interval between recall examinations using radiographs was not consistently shorter for dentists who decided to carry out operative caries treatment at a relatively advanced stage.     

How primary care dentists perceive and are influenced by research

Hopper L, Morris L, Tickle M. How primary care dentists perceive and are influenced by research. Community Dent Oral Epidemiol 2011; 39: 97–104.
© 2010 John Wiley & Sons A/S Abstract – Introduction: Little is understood as to how primary care dentists alter their clinical practice. Aim: To develop an understanding of how primary care dentists view and use research to inform their clinical practice. Methods: An iterative approach was followed using two methods of data collection. A focus group was undertaken with dentists and researchers who had been involved in primary care dental research. Subsequently phased, qualitative interviews were undertaken with primary care dentists with a range of research experiences. Focus group and interviews were audio‐recorded and transcribed verbatim. Six people participated in the focus group. Eighteen dentists participated in the interviews. Interviews were undertaken in four phases until saturation was achieved. Data were analysed using constant comparison. Findings: Evidence‐based dentistry was considered the ideal. However, the research base for primary care dentistry was thought to lag behind clinical services, to focus on incorrect endpoints, to disregard the patients’ voice and failed to consider the impact of conducting research on dental practices. Dentists modified their clinical practice based upon research, colleagues’ opinions, courses and ad hoc personal evaluation. Uptake of research was affected by the ethos of the practice, which determined whether the dentists were early or late adopters of research and financial viability of new interventions. Conclusion: Dentists wanted concise, timely evidence‐based guidance to aid their management of patients. Further research needs to be undertaken to understand how to develop an evidence‐based culture in primary dental care.