Variations in restorative treatment decisions: an international comparison

Abstract Variations between dentists in treatment thresholds and diagnostic decisions based on radiographs have not been fully explained. Since variations have been shown to exist between as well as within countries, it is possible that the structure of incentives inherent in different health care systems, and cultural influences on health and health care may play a part. This paper compares the results of a study undertaken in Scotland with a replication study undertaken in Canada concerning dentists' restorative thresholds and treatment decisions based on radiographic evidence. The Canadian dentists operated with greater sensitivity but lower specificity than their Scottish counterparts, although ROC analysis indicated similar overall abilities to detect carious lesions. The dentists' action thresholds also differed. However, methodological issues mean that the data from the study need to be interpreted with caution.     

Deciding about patients' requests for extraction

Background and OverviewDentists frequently are faced with patients' requests for an extraction, sometimes of the entire dentition. In this article, the authors offer guidelines to help dentists and oral surgeons make decisions regarding such requests for extraction.ConclusionsIn most cases of patients' requesting extractions, the ethical principle of nonmaleficence will play a decisive role in the dentist's decision making. In cases in which the request appears influenced by a specific mental condition such as a phobia of dental treatment, extraction rarely is justifiable.Practice ImplicationsDental professionals should keep in mind that they cannot be forced to carry out treatment that is at odds with the ethical principle of nonmaleficence or that is outside of the bounds of accepted treatment. To aid dentists in making treatment decisions in such cases, the authors present a flowchart that integrates possible considerations.     

Restoration of approximal carious lesions – application of decision analysis

Abstract This study uses decision analysis in order to explore the maximum expected utility of positive and negative restorative decisions, made on the basis of bitewing radiography. The a posteriori probabilities of disease, given a positive/negative treatment decision were derived from a study in which 20 dentists made 7200 decisions about 15 pairs of simulated bitewing radiographs. Lesion depths in the teeth examined were ascertained by light microscopy. A review of the available data on lesion progression/regression was undertaken to provide probability values for the decision model, and population utilities for the outcomes of the decision were derived from a survey of 110 members of the public. The decision analysis showed that negative treatment decisions always attracted the highest maximum expected utility, except in highly disease-prone individuals. This analysis demonstrates that lesion depth, likelihood of pain, and the rate of lesion progression have minimal effect on the utility of a positive treatment decision. It is concluded that an over-concentration on the biomedical model of dental health may cause dentists to make decisions which are inappropriate to their patients' values and preferences.     

Diagnostic confidence and the accuracy of treatment decisions for radiopaque periapical lesions

The periapical radiograph is a tool used in the diagnosis of periapical bone pathology. Radiographic diagnosis might therefore influence endodontic treatment planning and the quality and the cost of dental health care. The hypotheses were tested that (1) the subjective prevalence of a lesion would be associated with the accuracy with which it is diagnosed, (2) ‘confident dentists’ would be as accurate in their diagnosis as ‘doubtful dentists’ and (3) the diagnostic confidence of dentists for the diagnosis of periapical pathology would not influence their treatment planning. It was found that the probability of an appropriate treatment decision increased when dentists were relatively confident about a diagnosis. The results showed, furthermore, that the accuracy of diagnostic decisions increased when the dentist's confidence about a particular decision was high. Ways to increase diagnostic accuracy of radiopaque periapical pathology are proposed as a result of this study.     

Dentists' variability in restorative decisions, microscopic and radiographic caries depth

Abstract Restorative and dental caries depth decisions were recorded for 5168 unrestored approximal tooth surfaces by 17 dentists who worked in the school dental clinics of the North York (Ontario) Public Health Department. Each dentist examined 15 pairs of experimental bitewing radiographs for which true caries depth had previously been determined by microscopy of the sectioned teeth following production of the radiographs. The dentists independently recorded their restorative decisions and radiographic caries depth perceptions. The relationship between the variation in the dentists' restorative decisions and their perceptions of caries depth based on a re-reading of the bitewings on the one hand, and true caries depth on the other was also examined. The percentages of total variability in each dentist's restorative decisions attributable to radiographic and to microscopic caries depth were estimated using regression analyses. Large variations were found among the 17 dentists' distributions of overall restorative and depth decisions. The relationship between microscopic caries depth and the dentists' restorative decisions was, understandably, less strong than that of the dentists' radiographic perceptions of caries depth and restorative decisions. Relative to true caries depth, high numbers of false positive and false negative restorative decisions were made. Overall, 50% of the variability in the dentists' restorative decisions was explained by their perceptions of radiographic caries depth; however, among individual dentists, the range was from 29% for one dentist to 69% for another. A much lower percentage of the overall restorative variation was explained by microscopic depth, 18%. Like the findings of the only two previous European studies that quantified the role of radiographs on clinical decisions, this study demonstrated that dentists' perceptions of dental caries depth using bitewing radiographs play a major but variable role in their restorative decisions for approximal tooth surfaces.     

Dentists’ Legal Liability and Duty of Explanation in Dental Malpractice Litigation in Japan

IntroductionDental litigation accounts for approximately 10% of medical cases in Japan. This study sought to identify factors related to dentists’ legal liability in Japan, including their duty to explain procedures and treatments to their patients.MethodsWe analysed court decisions in 166 dental malpractice cases litigated in Japan between 1978 and 2017. To identify factors related to the legal liability of dentists, an analysis was performed to evaluate the associations among patient characteristics, dentist characteristics, litigation, and dentists’ explanatory behaviour.ResultsOf the 36 cases related to dentist liability, the study identified 23 cases (63.9%) of litigation in which the dentists were found to be in violation of their duty to provide an explanation. Regarding the severity of injury, the ratio of death and permanent disability was significantly higher in decisions in which the purpose of the explanation was something other than obtaining the patient's consent compared with decisions to obtain the patient's consent (P = .014).ConclusionsIn cases in which the dentist was found legally responsible, the proportion of cases involving procedural negligence with the explanation of medical guidance was significantly higher. Dentists should pay careful attention not only to the patient's consent but also to their explanations, including “medical guidance.” Moreover, they should recognise that inappropriate explanations correlate with serious errors.     

Variation in restorative treatment decisions: application of Receiver Operating Characteristic curve (ROC) analysis

It has been evident for many years that dentists, when planning treatment for patients, do not act in a standard manner, and previous research has shown there to be wide variations in treatment planning amongst groups of dentists. Signal detection theory and Receiver Operating Characteristic (ROC) analysis allows measurement of an observer's ability to detect a lesion, while at the same time allowing examination of how a lesion, once perceived, is judged to be in need of treatment. An ROC curve is constructed by plotting the sensitivity (or true positive rate) of decisions made, against the false positive rate (equivalent to 1-specificity) when various decision attitudes, from interventionist to non-interventionist, are held. Fifteen pairs of simulated bitewing radiographs were shown to 20 dentists, who were asked to specify, for each approximal lesion, whether or not they would place a conventional restoration. The 7200 decisions made by the dentists were validated by sectioning and microscopically examining the teeth. The mean sensitivity of the dentists' decisions, when the strictest operating thresholds were held and caries into dentine was the validating criterion, was 0.26 and the mean specificity was 0.96. ROC analysis shows that when operating at the strictest threshold, the dentists were implying that specificity was weighted as being 2.7 times more important than sensitivity. ROC analysis leads to insight into how dentists differentially weight the true and false, positive and negative, outcomes of their decisions and thus allows explanation of why two dentists would rarely make exactly the same treatment plan for one patient, and also why different treatments might be offered to two patients exhibiting the same levels of disease.     

Treatment decisions for deep carious lesions in the Public Health Service in Southern Brazil

Objectives: The aim of the present study was to assess Public Health Service clinicians' treatment decisions about deep carious lesions in the city of Porto Alegre, Brazil. Methods: Treatment decisions were assessed with a structured questionnaire (open/discursive and containing information about gender, university and year of college graduation, and college major) and three simulated clinical cases composed of teeth with primary deep carious lesion. All professionals working for the Public Health Service in the city were addressed. Results: Out of 122 professionals, 54 participated in the study (response rate of 44 percent). There was no difference between respondents and non‐respondents regarding gender, year of college graduation, or college major. The most commonly indicated procedure was direct complete excavation (71.1 percent), followed by stepwise excavation (17.6 percent), partial caries removal (8.8 percent), and pulp therapies (direct pulp capping, partial or complete pulpotomy, and endodontics) (2.5 percent). Year of college graduation was the only variable influencing treatment decision. Logistic regression analysis showed that professionals who had graduated after the year 2000 were significantly more likely to indicate a conservative treatment than were dentists who graduated through 1979 (odds ratio = 5.5). Conclusions: The most commonly proposed treatment is the one with the highest risk of pulp exposure, and consequently the poorest prognosis. Younger dentists tended to indicate more conservative approaches, compared with those indicated by older dentists.     

Dentists' Stated Restorative Treatment Thresholds and Their Restorative and Caries Depth Decisions

Objective : This study examines the relationships between stated restorative treatment thresholds of 16 dentists and both their restorative decisions and caries depth determinations for approximal tooth surfaces based on bitewing radiographs. Methods : Sixteen dentists independently examined 15 pairs of experimental bitewing radiographs. They separately recorded restorative and dental caries depth decisions for 4,864 unrestored approximal tooth surfaces, 304 identical surfaces per dentist. In addition to caries depth and restorative decision data, these dentists provided their restorative thresholds using a five-point scale. Results : Three dentists stated it would be appropriate to restore enamel lesions, nine would wait until caries had reached the dentinoenamel junction, and four would wait until caries extended into the dentine. Although dentists stating an enamel restorative threshold intended definitely or probably to restore relatively more surfaces and recorded relatively more surfaces with dentinal caries, ANOVA analyses revealed that the differences among the restorative and the depth means according to the restorative thresholds were not significant. Considerable variation existed in both the restorative and depth decisions among the dentists in each threshold group. Conclusion : Although interesting trends occurred in the restorative and depth decisions relative to the stated thresholds, this study suggests, like others in Europe, that these thresholds cannot be taken at face value to explain restorative decisions     

Validation of the Spanish version of the “Questionnaire on the treatment of approximal and occlusal caries”

Objectives

To translate and validate a Spanish version of the “Questionnaire on the treatment of approximal and occlusal caries” as a method of collecting information about treatment decisions on caries management in Chilean primary health care services.

Materials and methods

The original questionnaire proposed by Espelid et al. was translated into Spanish using the forward–backward translation technique. Subsequently, validation of the Spanish version was undertaken. Data were collected from two separate samples; first, from 132 Spanish-speaking dentists recruited from primary health care services and second, from 21 individuals characterised as cariologists. Internal consistency was evaluated by the generation of Cronbach's alpha, test–retest reliability was evaluated by Cohen's kappa, convergent validity was evaluated by comparing the total scale scores to a global evaluation of treatment trends and discriminant validity was evaluated by investigating the differences in total scale scores between the Spanish-speaking dentist and cariologist samples.

Results

Cronbach's alpha indicated an internal consistency of 0.63 for the entire scale. Cohen's kappa correlation coefficient expressed a test–retest reliability of 0.83. Convergent validity determined a Pearson's correlation coefficient of 0.24 (p?<?0.01). The comparison of proportions (chi-squared) indicated that discriminant validity was statistically significant (p?<?0.01), using a one-tailed test.

Conclusions

The Spanish version of the “Questionnaire on the treatment of approximal and occlusal caries” is a valid and reliable instrument for collecting information regarding treatment decisions in cariology.

Clinical relevance

The clinical relevance of this study is to acquire a reliable instrument that allows for the determination of treatment decisions in Spanish-speaking dentists.     

Caries assessment and restorative treatment thresholds reported by Swedish dentists.

The aim was to study any variability in approximal and occlusal caries diagnoses and restorative treatment decisions among Swedish dentists. The material consisted of a pre-coded questionnaire sent to a random sample of 923 dentists with 4 items concerning approximal and occlusal caries diagnosis and restorative treatment decisions. Responses were received from 651 (70.5%) dentists. In an adolescent with low caries activity and good oral hygiene, more than 90% of the dentists stated that they would not automatically restore a primary approximal caries lesion if its radiographic appearance did not show obvious progression in the outer 1/3 to 1/2 of the dentin. Moreover, 67% of the dentists would only consider immediate restorative treatment of an occlusal surface if obvious cavitation and/or radiographic signs of dentin caries could be observed. When diagnosing questionable occlusal caries, the dentists largely relied on the radiographic appearance. Concerning both approximal and occlusal caries, the threshold for restorative treatment differed between the metropolitan regions in Sweden, and younger more often than older dentists would postpone restorative treatment of approximal caries until the lesion had reached a relatively advanced stage of progression. The responses also showed that dentists in private practice would restore approximal caries at an earlier stage of progression than the dentists in the Public Dental Health Service.     

Relationship between dentists'treatment attitudes and restorative decisions made on the basis of simulated bitewing radiographs

Abstract – The implicit valuations which dentists place on the outcomes of their treatment decisions may be a major contributory factor in dentists'decisions about when to restore teeth. This study sought to examine the relationship between dentists'treatment attitudes and restorative dental treatment decision making. A group of 20 dentists were asked to indicate teeth in need of filling from 15 simulated bitewing radiographs. The dentists graded their level of certainty about their treatment decision as "definite", "probable" or "possible". Afterwards, the teeth were sectioned and examined using a microscope in order to determine how far through the tooth the caries had penetrated. The gold standard treatment criterion was that caries extending into the dentine of the tooth would require restoration. Receiver Operator Characteristic (ROC) analysis was used to examine the apparent weighting the dentists were giving to decision errors when planning treatment on the basis ot bitewing radiographs. The dentists also completed a treatment attitudes questionnaire to determine their views about the relative importance of false negative and false positive treatment decisions. The results suggest that the most appropriate operating point for most of these dentists to achieve an outcome which matched their views about the relative importance of the two types of treatment error would be the point at which a filling would "definitely" be required.     

The role of dentist, practice and patient factors in the provision of dental services

OBJECTIVES: Service provision varies by dentist, practice and patient factors. However, limited subsets of these potential influences on service rates have been explored. More comprehensive models could improve our understanding of the factors influencing the pattern of care delivered. The aim of this study was to examine variation in dental services by dentist (treatment choice, practice beliefs, preferences for patients, demographics), practice (type, location, size and volume of practice) and patient (visit, demographic, oral health and socio-economic) characteristics. METHODS: A random sample of Australian dentists was surveyed in 1997-98 (response rate=60.3%). Private general practitioners (n=345) provided dentist and practice data, and service provision and patient variables were collected from a log of a typical clinical day (n=4,115 patients). Multivariate negative binomial regression models were fitted for diagnostic, preventive, restorative, extraction and prosthodontic services. RESULTS: Significant dentist factors included (P<0.05; RR=rate ratio): lower diagnostic rates (RR=0.78) for dentists with stronger practice beliefs for giving information about cost and treatment options; preventive rates were lower (RR=0.74) for male dentists and higher (RR=1.48) for younger dentists aged 20-29 years; restorative rates were higher (RR=1.27) for dentists that rated patient preferences more highly in treatment choice and in the dentist age group 30-39 years (RR=1.25); extraction rates were lower (RR=0.61) for dentists with stronger preferences for patients that would adhere with treatment but higher (RR=1.57) for dentists with stronger preferences for sociable patients; and prosthodontic rates were lower (RR=0.38) for dentists with stronger preferences for adaptable patients who were willing to cooperate when expected to do so. Practice factors included: higher preventive (RR=1.28) and prosthodontic rates (RR=2.07) in solo practice; higher preventive (RR=1.34) but lower prosthodontic rates (RR=0.42) in capital cities; lower diagnostic (RR=0.82) and extraction rates (RR=0.55) in practices with fewer other dentists; higher diagnostic (RR=1.33) and extraction (RR=1.62) rates but lower restorative rates (RR=0.84) in practices with lower patient visits per year. Patient factors included: lower preventive (RR=0.76) but higher extraction rates (RR=1.45) for emergency visits; lower extraction rates (RR=0.60) for the insured; higher diagnostic rates (RR=1.17) for new patients; higher restorative (RR=1.31) but lower prosthodontic rates (RR=0.46) for patients with decayed teeth; higher prosthodontic rates (RR=2.14) for those with dentures; and lower preventive (RR=0.66), but higher extraction (RR=2.22) and prosthodontic rates (RR=1.82) for patients from lower socio-economic status areas. CONCLUSIONS: Dental service rates were influenced by large number of small effects from a wide range of dentist, practice and patient factors. Socio-economic and geographic barriers may need broad policy innovations to be addressed, but factors such as insurance and visit type have the potential to be altered to achieve better service outcomes and there is scope for research into clinical outcomes to improve the knowledge upon which treatment decisions are based.     

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.     

Communication practices and preferences between orthodontists and general dentists

Objective:To evaluate similarities and differences in orthodontists'' and general dentists'' perceptions regarding their interdisciplinary communication.Materials and Methods:Orthodontists (N  =  137) and general dentists (N  =  144) throughout the United States responded to an invitation to participate in a Web-based and mailed survey, respectively.Results:The results indicated that orthodontists communicated with general dentists using the type of media general dentists preferred to use. As treatment complexity increased, orthodontists shifted from one-way forms of communication (letters) to two-way forms of communication (phone calls; P < .05). Both orthodontists and general dentists reported that orthodontists'' communication regarding white spot lesions was inadequate. When treating patients with missing or malformed teeth, orthodontists reported that they sought input from the general dentists at a higher rate than the general dentists reported (P < .005).Conclusions:Orthodontists'' and general dentists'' perceptions of how often specific types of media were used for interdisciplinary communication were generally similar. They differed, however, with regard to how adequately orthodontists communicated with general dentists and how often orthodontists sought input from general dentists. The methods and extent of communication between orthodontists and general dentists need to be determined on a patient-by-patient basis.     

Dentists' use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network

Riley JL, Gordan VV, Ajmo CT, Bockman H, Jackson MB, Gilbert GH, for The Dental PBRN Collaborative Group. Dentists’ use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice‐Based Research Network. Community Dent Oral Epidemiol 2011; 39: 564–573. © 2011 John Wiley & Sons A/S Abstract – Objectives: Few studies have examined dentists’ subjective ratings of importance of caries risk factors or tested whether dentists use this information in treatment planning. This study tested several hypotheses related to caries risk assessment (CRA) and individualized caries prevention (ICP). Methods: Data were collected as part of a questionnaire entitled ‘Assessment of Caries Diagnosis and Caries Treatment’, completed by 547 practitioners who belong to The Dental Practice‐Based Research Network (DPBRN), a consortium of participating practices and dental organizations. Results: Sixty‐nine percent of DPBRN dentists perform CRA on their patients. Recently graduated dentists, dentists with busier practices, and those who believe a dentist can predict future caries were the most likely to use CRA. The association between CRA and individualized prevention was weaker than expected (r = 0.21). Dentists who perform CRA provide ICP to 57% of their patients, compared with 42% for dentists who do not perform CRA. Based on their responses to radiographic and clinical scenarios in the questionnaire, dentists who use CRA appear to use this information in restorative decisions. Conclusion: A substantial percentage of DPBRN dentists do not perform CRA, and there is not a strong linkage between its use and use of individualized preventive regimens for adult patients. More progress in the implementation of current scientific evidence in this area is warranted.     

Differences in male and female dentists' practice patterns regarding diagnosis and treatment of dental caries: findings from The Dental Practice-Based Research Network

BackgroundA number of articles have addressed differences in productivity between male and female dentists, but little is known about differences between the sexes in practice patterns regarding caries management.MethodsIn this study, the authors surveyed general dentists who were members of The Dental Practice-Based Research Network (DPBRN) and who practiced within the United States. The survey included questions about dentists’, practices' and patients' characteristics, as well as prevention, assessment and treatment of dental caries. The authors adjusted the statistical models for differences in years since dental school graduation, practice model, full-time versus part-time status, and practice owner or employee status before making conclusions about sex differences.ResultsThree hundred ninety-three male (84 percent) and 73 female (16 percent) dentists participated. Female dentists recommended at-home fluoride to a significantly larger number of their patients than did male dentists, whereas male dentists had a preference for using in-office fluoride treatments with pediatric patients. Female dentists also chose to use preventive therapy more often at earlier stages of dental caries. There were few differences between the sexes in terms of diagnostic methods, time spent on or charges for restorative dentistry, and busyness of the practice.ConclusionsFemale DPBRN dentists differ from their male counterparts in some aspects of the prevention, assessment and treatment of dental caries, even with significant covariates taken into account.Practice ImplicationsThe practice patterns of female dentists suggest a treatment philosophy with a greater focus on caries prevention.     

Restorative treatment thresholds and agreement in treatment decision-making

It has been recognised for many years that treatment decision-making among dentists often shows wide variation. This study sought to examine the effect of dentists' stated treatment thresholds as a source of variation between them. Twenty dentists made 360 treatment decisions about the approximal surface of extracted teeth seen in simulated bitewing radiographs. They also stated their personal treatment thresholds, i.e. the depth of lesion which they intended to restore. One hundred and ninety pairwise comparisons of treatment decisions showed that only 16% of the dentist pairs showed substantial agreement. Dentist pairs who reported that they held the same interventive threshold achieved exactly the same mean level of agreement in treatment decision-making as dentist pairs who disagreed about the appropriate threshold for restorative intervention. The study suggests that restorative thresholds which are reported to be used by dentists may be poorly correlated with the number of positive treatment decisions actually made.     

The effect of training on the use of tobacco-use cessation guidelines in dental settings

BackgroundAn increase in the number of dentists conducting tobacco-use cessation treatment is needed. The authors assessed the effects of high-intensity training (HIT) or low-intensity training (LIT) and reimbursement on general dentists' tobacco-use–related attitudes and treatment behaviors.MethodsThe authors randomly selected 265 dentists in three states and assigned them to one of five groups: HIT workshop groups with and without tobacco-use cessation counseling reimbursement, LIT mailed self-study groups with and without reimbursement or a control group. Outcomes at follow-up were dentists' self-reported tobacco-use–related attitudes and behaviors and patients' reports of dentists' behaviors.ResultsSignificantly more dentists in the intervention groups reported having positive attitudes and behaviors at follow-up than did dentists in the control group. Dentists in the HIT groups, however, reported assessing patients' willingness to quit and assisting them with the quitting process significantly more often than did dentists in the LIT groups. Significantly more patients of dentists in the intervention groups who used tobacco reported receiving advice and assistance from their dentists than did patients of dentists in the control group. Adding reimbursement to HIT or LIT conditions did not provide additional intervention effect.ConclusionDentists trained by means of a workshop or self-study program used components of a recommended guideline more frequently and felt more positive toward tobacco-use cessation counseling than did dentists in the control group.Clinical ImplicationsAlthough the workshop training was more successful than the self-study training, the latter's reach among dentists could have a more significant public health impact. The effect of reimbursement needs further study.