Osseointegrated implants for single tooth replacement in general practice: A 1-year report from a multicentre prospective study

The single tooth implant is a treatment option for the replacement of missing single teeth and in many cases is the treatment of choice. It is, however, an expensive treatment requiring a co-ordinated approach to the surgical and restorative aspects of treatment. In this study, a group of dentists in general and restorative dental practice and with no previous experience in implant surgery underwent an intensive training course in all aspects of implant treatment for single teeth. Using a system of simplified instrumentation with a strict adherence to protocol, the group installed and restored single tooth implants ad modum Brånemark in a wide range of clinical situations. At the one year follow-up period following crown insertion, the success rate of treatment compared favourably with results reported from centres using the specialist team approach to treatment. The results of this study indicate that further consideration should be given to the training of general dentists so that improved delivery of dental health care can be provided at a more economic level.     

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.     

Dental patient preferences and choice in clinical decision-making

In economics, the concept of utility refers to the strength of customer preference. In health care assessment, the visual analogue scale (VAS), the standard gamble, and the time trade-off are used to measure health state utilities. These utility measurements play a key role in promoting shared decision-making in dental care. Individual preference, however, is complex and dynamic. The purpose of this study was to investigate the relationship between patient preference and educational intervention in the field of dental health. The data were collected by distributing questionnaires to employees of two companies in Japan. Participants were aged 18-65 years and consisted of 111 males and 93 females (204 in total). One company (Group A) had a dental program of annual check-ups and health education in the workplace, while the other company (Group B) had no such program. Statistical analyses were performed with the t-test and Chi-square test. The questionnaire items were designed to determine: (1) oral health-related quality of life, (2) dental health state utilities (using VAS), and (3) time trade-off for regular dental check-ups. The percentage of respondents in both groups who were satisfied with chewing function, appearance of teeth, and social function ranged from 23.1 to 42.4%. There were no significant differences between groups A and B in the VAS of decayed, filled, and missing teeth. The VAS of gum bleeding was 42.8 in Group A and 51.3 in Group B (p<0.05). The percentage of persons having a regular dental check-up every three months was 34.1 and 31.3% in Groups A and B respectively. These results suggest that low preference results from lack of opportunity or utilization of dental care in the worksite. Ascertaining the factors involved in patient preference may have significant potential benefits in shared decision-making.     

Amalgam or composite resin? Factors influencing the choice of restorative material

Objectives

This study aimed to investigate the patient and tooth factors associated with selection of restorative material in direct posterior restorations in young adults from a population-based birth cohort.

Methods

A representative sample (n = 720) of all 5914 births occurring in Pelotas in 1982 were prospectively investigated, and posterior restorations were assessed in 2006, when the patients were 24 years old. Tooth-related variables (individual level) included restorative material (amalgam or composite), type of tooth, size of cavity, and estimated time in mouth. Data regarding demographic and socio-economic characteristics, oral health, and service utilization patterns during the life course were also assessed (contextual level).

Results

Logistic Regression Multilevel models showed that individuals who have accessed dental services by private insurance by age 15 [odds ratio (OR) = 1.66 (0.93–2.95)] and who had a higher dental caries index at age 15 (high DMFT tertile) [OR 2.89 (1.59–5.27)] presented more amalgam restorations in the posterior teeth. From tooth-level variables, the frequency of amalgams decreases with increasing number of surfaces enrolled in the cavity preparation (p < 0.001) and was almost 5 times greater in molars than in premolars.

Conclusions

The present findings suggest that variables related to type of dental service, dental caries (higher DMFT index), and cavity characteristics (tooth type, size) determine the choice of dentists for restorative materials. Other individual characteristics such as demographic and socioeconomic status have not influenced this choice.

Clinical significance

This is the first population-based study that assesses the determinant factors for the choice of dentists for composite or amalgam in posterior direct restorations, showing that, independently of socioeconomic and demographic characteristics, type of payment of dental services and clinical factors are associated with this choice.     

Do dental educators need to improve their approach to teaching rubber dam use?

Most dentists are educated in rubber dam use in dental school, but there is often disparity between what is taught for various restorative procedures and what is practiced in the private sector. It is a common, although undocumented, belief that few practicing dentists routinely use rubber dam isolation. This study repeated a survey conducted in 1985 evaluating U.S. general dentists' attitudes toward rubber dam usage to see if improvement is needed in current dental educators' approach to this topic. Four hundred dentists were selected randomly from ten major geographically diverse cities using the website YellowPages.com. Each was mailed a letter requesting survey participation, which included a pre-stamped, pre-addressed postcard with the survey printed on the back. The target population, general dentists, returned 164 surveys (41 percent). Their responses can be summarized as follows: 71 percent do amalgams-of those, 53 percent never use a rubber dam whereas 12 percent always use a rubber dam; 100 percent do anterior direct resin composites-of those, 45 percent never use a rubber dam whereas 17 percent always use a rubber dam; 98 percent do posterior direct resin composites-of those, 39 percent never use a rubber dam and 18 percent always use a rubber dam; and 78 percent do endodontic procedures-of those, 11 percent never use a rubber dam whereas 58 percent always use a rubber dam. Most (74 percent) felt that their dental school rubber dam training was adequate; 42 percent felt that its use has an effect on the quality of restorative dentistry. Their most common reasons for not using a dam were the following: inconvenience (40 percent); unnecessary (28 percent); other (12 percent); patient refusal (11 percent); and time (9 percent). No respondent indicated that "cost" was a reason for not using rubber dams. This study indicates that many general dentists in this country continue to ignore the rubber dam for many restorative and some endodontic procedures. It indicates that predoctoral dental educators need to look for opportunities for improvement to reduce the discrepancy between what is taught and the general practice of dentistry.     

Decision making of Hebrew University and Tel Aviv University Dental Schools graduates in every day dentistry--is there a difference?

This study was designed to evaluate decision-making among Jerusalem Hebrew-University and Tel Aviv University dental schools graduates in various restorative dentistry, endodontics and oral surgery issues. A survey was conducted among 52 dentists during a dental military convention. Most of the dentists stated they will not recommend of re-treatment of endodontic-treated tooth with asymptomatic peri-apical pathology that does not need further rehabilitation. The study reveals over treatment and over-medication in restorative and surgery decisions. More than half of the dentists decided to treat caries lesions that extend to the dentino enamel junction, in low and moderate caries risk patients. More Hebrew University graduates than Tel Aviv University graduates recommend of removal of asymptomatic horizontal fully impacted mandibular third molar and disease-free maxillary third molar antagonist. Most of Tel Aviv graduates routinely prescribe antibiotic coverage after complicated tooth extraction. This study supports the need for continuing education on daily performed dental procedures.     

The extensively restored posteriortooth has a high incidence of tooth fracture

A multicentred practice based study was established to test the hypothesis that the extensively restored tooth has a high incidence of posterior tooth fracture (PTF). All patients who presented with PTF in 23 general dental practices over a period of 14 weeks were included in the study. 764 PTF restorations were placed out of a total of 7551, an incidence of 10%. A novel classification proposing increased severity of fracture from I-IV was used. Class I = 19%, II = 54%, III = 22% and IV = 5%. Primary PTFs accounted for 67%, secondary 33%. 92% offractured teeth had a Class 2 restoration in situ. The heavily restored tooth has been shown to have a high incidence of PTF and it is suggested that this is a major restorative problem in general dental practice in the UK.     

Diagnostic levels in dental public health planning

This concept paper discusses the rationale for using different diagnostic criteria for dental caries in public health programs. The author contends that epidemiological data or needs assessment surveys should collect data to provide information on the epidemiology of different stages of the caries process in order to enable planners to design tailored programs to prevent dental caries. In a rapidly progressing caries environment, conventional approaches to delivering preventive measures may not work. The author also contends that dental public health programs should expand their vision to influence how dentists are detecting, diagnosing and managing dental caries. Dentists' restorative decisions have significant impact on the oral health status of a nation. Henceforth, detecting the early or noncavitated caries level and preventing these lesions from progressing to the cavitated stage (or being restored) could have a significant impact on the oral health status around the world. There is a need for more research on the best methods to detect, prevent and treat early carious lesions.     

Four-year cost-utility analyses of sealed and nonsealed first permanent molars in Iowa Medicaid-enrolled children

OBJECTIVES: Dental sealants, by their ability to prevent caries and maintain teeth in better health, have some inherent utility to individuals, programs, or society. This study assessed the 4-year incremental cost utility of sealing first permanent molars of 6-year-old Iowa Medicaid enrollees from a societal perspective and identified the group of teeth or children in whom sealants are most cost effective. METHODS: Dental services for first permanent molars were assessed using claims and encounter data for a group of continuously enrolled Medicaid enrollees who turned 6 between 1996 and 1999. Previously published utilities were used to weight the different health states. The weighted sum of outcomes [Quality-Adjusted Tooth-Years (QATYs)] was the measure of effectiveness. Costs and QATYs were discounted to the time of the child's sixth birthday. RESULTS: For all first molars, the cost of treatment associated with sealed teeth was higher but the utility was also slightly higher over the 4-year period. The relative incremental cost per 0.19 QATY ratio [changing the health state from a restored tooth (utility= 0.81) to a nonrestored tooth (utility = 1)] by sealing the molar ranged from $36.7 to $83.5 per 0.19 QATY. The incremental cost/QATY ratio was lower for sealing lower utilizers and for mandibular versus maxillary molars. CONCLUSIONS: Sealants improved overall utility of first permanent molars after 4 years. The 4-year cost/QATY ratio of sealing the first permanent molar varied by arch and type of utilizers. Sealing first permanent molars in lower dental utilizers is the most cost-effective approach for prioritizing limited resources.     

Do socioeconomic determinants affect the quality of posterior dental restorations? A multilevel approach

Objectives

This study aimed to evaluate posterior restorations placed in young adults, investigating the association between social determinants experienced during the life course and the quality of tooth fillings.

Methods

A representative sample (n = 720) of all 5914 individuals who were born in Pelotas in 1982 was prospectively investigated, and posterior restorations were assessed at 24 years of age. Exploratory variables included demographic and socioeconomic, oral health and dental service payment mode during the life course. Tooth-related variables (type of tooth, material and size of cavity) were also analysed.

Results

Multilevel logistic regression models showed that individuals who were always poor from birth to age 23 [odds ratio (OR) 2.35 (1.38–4.00)] and whose mothers had less years of education at their birth (OR 2.60 (1.44–4.68)) were with unsatisfactory restorations in posterior teeth more often. In addition, caries presence at age 15 (high decayed, missing, filled teeth (DMFT) tertile) (OR 1.95 (1.25–3.03)) and cavities with four or more surfaces (OR 18.67 (9.25–37.68)) were associated with the outcome.

Conclusions

These results show that socioeconomic characteristics of the individuals play an important role in restoration failures, reinforcing the need for preventive dental strategies and public policies to reduce inequalities as a major topic of oral health. In addition, the size of cavity appears as the most important determinant for restoration failure.

Clinical significance

Individual socioeconomic characteristics were associated with failure in posterior restorations in detriment of other clinical variables such as restorative material and type of tooth.     

Rural versus urban analysis of dental procedures provided to Virginia Medicaid recipients

PURPOSE: The purpose of this study was to report the distribution of procedures provided to Virginia Medicaid children by 3 types of dental providers in rural and urban areas. METHODS: Medicaid claims filed for dental patients less than 21 years old were obtained and analyzed for fiscal years 1994-1995. Dental providers were categorized according to their practice type: (1) general practice (GP); (2) pediatric (PD); and (3) public health (PH) dentists. Each type of practice was categorized as practicing in a metropolitan, urban, rural, or completely rural location and evaluated for percentages of preventive, diagnostic, and corrective services provided. RESULTS: Rural areas had a higher percentage of significant providers than did metropolitan or urban areas. General dentists performed more diagnostic and preventive but fewer corrective procedures than pediatric dentists. Pediatric dentists and general dentists in completely rural areas performed more corrective procedures than their counterparts in metropolitan or urban areas. CONCLUSIONS: General, pediatric, and public health dentists in metropolitan and urban areas perform slightly more diagnostic services and fewer corrective services than practitioners in more rural areas.     

Restoration of noncarious tooth defects by dentists in The Dental Practice-Based Research Network

BackgroundThe authors conducted a study to quantify the reasons for restoring noncarious tooth defects (NCTDs) by dentists in The Dental Practice-Based Research Network (DPBRN) and to assess the tooth, patient and dentist characteristics associated with those reasons.MethodsData were collected by 178 DPBRN dentists regarding the placement of 1,301 consecutive restorations owing to NCTDs. Information gathered included the main clinical reason, other than dental caries, for restoration of previously unrestored permanent tooth surfaces; characteristics of patients who received treatment; dentists’ and dental practices’ characteristics; teeth and surfaces restored; and restorative materials used.ResultsDentists most often placed restorations to treat lesions caused by abrasion, abfraction or erosion (AAE) (46 percent) and tooth fracture (31 percent). Patients 41 years or older received restorations mainly because of AAE (P < .001). Premolars and anterior teeth were restored mostly owing to AAE; molars were restored mostly owing to tooth fracture (P < .001). Dentists used directly placed resin-based composite (RBC) largely to restore AAE lesions and fractured teeth (P < .001).ConclusionsAmong DPBRN practices, AAE and tooth fracture were the main reasons for restoring noncarious tooth surfaces. Pre-molars and anterior teeth of patients 41 years and older are most likely to receive restorations owing to AAE; molars are most likely to receive restorations owing to tooth fracture. Dentists restored both types of NCTDs most often with RBC.     

Composite resins and bonded porcelain: the postamalgam era?

The growing demand of patients for esthetic or metal-free restorations, together with the ongoing interest of the dental profession for tissue-preserving materials have led to the actual development of posterior adhesive restorations. It is now clearly established that a new biomimetic approach to restorative dentistry is possible through the structured use of "tooth-like" restorative materials (composite resins and porcelain) and the generation of a hard tissue bond (enamel and dentin bonding). Scientific studies and clinical experience have validated use of bonded tooth-colored restorations, and we may have entered the so-called "postamalgam era". These significant changes have already impacted daily general practice, including pediatric dentists in California, but it is now critical to assure that the corresponding evidence-based process is integrated to the predoctoral programs statewide and nationwide. This paper reviews the foundations of this evolution, based on maximum tissue preservation and sound biomechanics, the so-called "biomimetic principle". Using scientific evidence and clinical experience, a model for the adequate use of current restorative systems is presented. This work, illustrated with cases with up to 10 and 14 years' follow-up, sets the ground rules for the clinical performance of the posterior esthetic restoration. Important considerations about tooth preparation, matrix techniques, layering methods, immediate dentin sealing and base lining are presented.     

A children's oral health status index based on dentists' judgment

The children's oral health status index was developed as an integrated measure for the direct appraisal of pediatric patient populations in private practices, dental clinics, or school programs. The index is derived from a paired preference experiment with five pedodontists and five general dentists acting as judges of oral health in 200 case comparisons. Four easily measured variables are united numerically by the index: decayed teeth, occlusion, tooth position, and missing teeth (which have not been exfoliated). Clinical applications of the index in three geographic areas have all had good results.     

The perceived benefit of endodontic retreatment

AIM: There is substantial variation amongst dentists in the management of symptom-free periapical lesions in root-filled teeth. It has been suggested that this variation can be understood as clinicians' choice of different cut-off points on a continuous periapical health scale (the 'Praxis Concept (PC) theory'). Based on this suggestion, an individual's inclination to propose retreatment can be expressed in the Retreatment Preference Score (RPS). In the present study it was hypothesized that: (i) the PC theory is valid amongst experienced endodontists; and that (ii) interindividual variation in RPS can be explained by a corresponding variation in the perceived benefit of endodontic retreatment. METHODOLOGY: The RPS was determined for 16 experienced Swedish endodontists. The retreatment benefit (RTB) was defined as the gain in utility when a root-filled tooth with a persistent periapical lesion ('health state B') moved to a state where the lesion had healed ('health state A'). For each individual the utility values of the two health states were measured by means of the standard gamble technique. RESULTS: The RPS and RTB were found to be subjected to substantial inter- and intrarater variation. The decision makers acted in accordance with the PC theory. No significant correlation between RPS and RTB was detected. CONCLUSIONS: Findings suggest that the PC theory is valid amongst endodontic experts. The study did not support the notion that the more potential utility that could be produced, the more the individual dentist should tend to perform retreatment. However, alternative consequentialist strategies focusing low risk taking may be involved.     

Despite all--do we have an appropriate substitute for amalgam?

The ultimate success or failure of a restored tooth is largely dependent on clinical management. Clinicians may choose from a number of restorative materials, different clinical techniques and cavity preparation procedures. Composite resin has been used for nearly 50 years as a restorative material in dentistry. The use of this material has recently increased as a result of patients' demands for esthetic restorations. Failure of dental restorations is a major concern in dental practice. Replacement of failed restorations constitutes the majority of operative work. Clinicians should be aware of the longevity of, and likely reasons for the failure of, direct posterior restorations. Higher failure rates were observed in resin-based composite restorations as compares amalgam restorations. Secondary caries was the main reason for failure. Posterior interproximal resin-based composite restorations should be considered with caution, and their limited long-term performance should be kept in mind. Patients should be informed about the potential longevity of restorative treatment for posterior teeth as they make decisions about treatment for their oral restorative needs.     

Patient dental values and their relationship to oral health status, dentist perceptions and quality of care

In this study, 1287 patients completed a questionnaire assessing knowledge of home care procedures, adherence to home care instructions, obstacles presented to the dentist in delivering care, and ability to pay for optimal care. Ninety-seven dentists that provided treatment for these patients completed a parallel questionnaire. Measures of oral health and the quality of restorative care were based on clinical examinations. It was found that though patient values and dental perceptions were associated, dentist perceptions did not closely match patient dental values. Analysis of variance indicated that patient dental values were related positively to both oral health measures and the quality of restorations. Patient-reported compliance with home care recommendations showed the strongest relationship to both oral health and quality of restorations.     

Reasons for restoration replacement: differences in practice patterns

Patients receive varying types and amounts of restorative treatment, depending on the prescribing dentist. The aim of this study was to enhance the understanding of the variation of the restoration replacement practices of dentists. Three dentists in private practice in similar semirural communities with comparable practice demographics were asked to gather data on all restorations they replaced over a period of 1 month. They recorded the tooth number, number of restored surfaces, restorative material being replaced, number of surfaces in the replacement restoration, the replacement restorative material, and the reasons for the replacement restoration. Statistically significant differences were found among the dentists as to the reasons for posterior restoration replacement, replacement materials used, and increase in size of the replacement restorations. Differences were attributed to individual practice philosophies, demonstrating that clinical information was not the sole determining factor as to type of replacement restorations that patients received.