A 24-month evaluation of amalgam and resin-based composite restorations: Findings from The National Dental Practice-Based Research Network

BackgroundKnowing which factors influence restoration longevity can help clinicians make sound treatment decisions. The authors analyzed data from The National Dental Practice-Based Research Network to identify predictors of early failures of amalgam and resin-based composite (RBC) restorations.MethodsIn this prospective cohort study, the authors gathered information from clinicians and offices participating in the network. Clinicians completed a baseline data collection form at the time of restoration placement and annually thereafter. Data collected included patient factors, practice factors and dentist factors, and the authors analyzed them by using mixed-model logistic regression.ResultsA total of 226 practitioners followed up 6,218 direct restorations in 3,855 patients; 386 restorations failed (6.2 percent) during the mean (standard deviation) follow-up of 23.7 (8.8) months. The number of tooth surfaces restored at baseline helped predict subsequent restoration failure; restorations with four or more restored surfaces were more than four times more likely to fail. Restorative material was not associated significantly with longevity; neither was tooth type. Older patient age was associated highly with failure (P N/A .001). The failure rate for children was 4 percent, compared with 10 percent for people 65 years or older. Dentist’s sex and practice workload were associated significantly with restoration longevity.ConclusionsIn this prospective cohort study, these factors were significantly predictive of failure for amalgam and RBC restorations: patient’s age, a higher number of surfaces restored at baseline, the dentist’s sex and the practice workload. Material choice was not significantly predictive in these early results.Practical ImplicationsIf clinicians can recognize and identify the risk factors associated with early restoration failure, more effective treatment plans may be offered to the patient.     

Repair or replacement of defective direct resin-based composite restorations: contemporary teaching in U.S. and Canadian dental schools

BackgroundOpportunities exist to promote minimally invasive dentistry by repairing rather than replacing defective and failing direct resin-based composite restorations. The authors conducted a study to investigate the current teaching of such techniques in U.S. and Canadian dental schools.MethodsIn late 2010, the authors, with the assistance of the Consortium of Operative Dentistry Educators, invited 67 U.S. and Canadian dental schools to participate in an Internet-based survey.ResultsThe response rate was 72 percent. Eighty-eight percent of the dental schools taught repair of defective direct resin-based composite restorations. Of these schools, 79 percent reported providing both didactic and clinical teaching.ConclusionsAlthough teaching repair of defective resin-based composite restorations was included in the didactic curricula of most schools, students in some schools did not gain experience in minimally invasive management of defective resin-based composite restorations by means of performing repair procedures. The American Dental Association's Code on Dental Procedures and Nomenclature does not have a procedure code for resin-based composite restoration repairs, which may limit patients' access to this dental treatment.Clinical ImplicationsTeaching dental students minimally invasive dentistry procedures, including restoration repair, extends the longevity of dental restorations and reduces detrimental effects on teeth induced by invasive procedures, thereby serving the interests of patients.     

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.     

The prevalence of questionable occlusal caries: Findings from The Dental Practice-Based Research Network

BackgroundQuestionable occlusal caries (QOC) can be defined as clinically suspected caries with no cavitation or radiographic evidence of occlusal caries. To the authors' knowledge, no one has quantified the prevalence of QOC, so this quantification was the authors' objective in conducting this studyMethodsA total of 82 dentist and hygienist practitioner-investigators (P-Is) from the United States and Denmark in The Dental Practice-Based Research Network (DPBRN) participated. When patients seeking treatment had at least one unrestored occlusal surface, P-Is quantified their number of unrestored occlusal surfaces and instances of QOC, if applicable. P-Is also recorded information about characteristics of patients who had QOC and had provided informed consent. The authors adjusted for patient clustering within practices.ResultsOverall, 6,910 patients had at least one unrestored occlusal surface, with a total of 50,445 unrestored surfaces. Thirty-four percent of all patients and 11 percent of unrestored occlusal tooth surfaces among all patients had QOC. Patient- and surface-level QOC prevalences varied significantly according to DPBRN region (P < .001 and P = .03, respectively). The highest percentages for patient- and surface-level prevalence occurred in Florida and Georgia (42 percent and 16 percent, respectively).ConclusionsTo the authors' knowledge, this is the first study in which investigators have quantified the prevalence of QOC in routine clinical practice. These results document a high prevalence overall, with wide variation in prevalence among The DPBRN's five main regions.Clinical ImplicationsQOC is common in routine practice and warrants further investigation regarding how best to manage it.     

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.     

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.     

Reasons for Placement of Restorations on Previously Unrestored Tooth Surfaces by Dentists in The Dental Practice-Based Research Network

ObjectiveThe authors conducted a study to identify and quantify the reasons used by dentists in The Dental Practice-Based Research Network (DPBRN) for placing restorations on unrestored permanent tooth surfaces and the dental materials they used in doing so.MethodsA total of 229 DPBRN practitioner-investigators provided data from their practices regarding 9,890 consecutive restorations in 5,810 patients. Information the practitioner-investigators provided included their reasons for restoring the teeth, the specific teeth and surfaces they restored and the restorative materials they used.ResultsPrimary caries (85 percent of teeth, 8,351 of 9,890) and noncarious defects (15 percent, 1,479 of 9,890) were the main reasons participants gave for placing restorations. Participants placed restorations necessitated by caries most frequently on occlusal surfaces (49 percent, 4,091 of 8,351). They used amalgam for 47 percent of the molar restorations and 45 percent of the premolar restorations. They used directly placed resin-based composite (RBC) for 48 percent of the molar restorations, 50 percent of the premolar restorations and 93 percent of the anterior restorations.ConclusionDPBRN practitioner-investigators cited dental caries on occlusal and proximal surfaces of molar teeth as the main reasons for placing restorations on previously unrestored tooth surfaces. RBC was the material they used most commonly for occlusal and anterior restorations. Amalgam remains the material of choice to restore posterior teeth with proximal caries, although the authors noted significant differences in the use of amalgam and RBC by dentists in various regions of the DPBRN.     

Agreement among dentists’ restorative treatment planning thresholds for primary occlusal caries,primary proximal caries,and existing restorations: Findings from The National Dental Practice-Based Research Network

ObjectivesThe aim of this study was to quantify the agreement among individual National Dental Practice-Based Research Network dentists’ self-reported treatment decisions for primary occlusal caries, primary proximal caries, and existing restorations.MethodsFive hypothetical clinical scenarios were presented: primary occlusal caries; primary proximal caries; and whether three existing restorations should be repaired or replaced. We quantified the probability that dentists who recommended later restorative intervention for primary caries were the same ones who recommended that existing restorations be repaired instead of replaced.ResultsDentists who recommended later restorative treatment of primary occlusal caries and proximal caries at a more-advanced stage were significantly more likely to recommend repair instead of replacement. Agreement among dentists on a threshold stage for the treatment of primary caries ranged from 40 to 68%, while that for repair or replacement of existing restorations was 36 to 43%.ConclusionsDentists who recommended repair rather than replacement of existing restorations were significantly more likely to recommend later treatment of primary caries. Conversely, dentists who recommended treatment of primary caries at an earlier stage were significantly more likely to recommend replacement of the entire restoration. Between-dentist agreement for primary caries treatment was better than between-dentist agreement for repair or replacement of existing restorations.Clinical implicationsThese findings suggest consistency in how individual dentists approach the treatment of primary caries and existing restorations. However, substantial variation was found between dentists in their treatment decisions about the same teeth.     

Profiles of Dental Caries and Periodontal Disease in Individuals With or Without Psoriasis

Background: Psoriasis is a chronic inflammatory disease that is manifested on the skin. Studies of oral health in psoriasis patients are limited. The aim of this study is to assess the experience and risk of caries and periodontal disease in individuals with and without psoriasis. Methods: The material consisted of 89 individuals with mild‐to‐moderate chronic plaque psoriasis and 54 without psoriasis, recruited at the University Hospital in Gothenburg, Gothenburg, Sweden. Psoriatic arthritis (PsoA) was diagnosed in 25 of the individuals with psoriasis. All participants answered questionnaires and were subjected to saliva sampling and oral radiologic and clinical examinations. Two computer applications were used for illustration of oral disease risk profiles. Results: Individuals with psoriasis had lower salivary pH, fewer remaining teeth, fewer sites with probing depth ≤4 mm, and a lower radiographic alveolar bone level than individuals without psoriasis (P <0.05). Most of the differences remained significant after controlling for confounders. Differences in alveolar bone levels were no longer significant, particularly after introducing the confounder sex into the regression model. Similar numbers of decayed and filled teeth, sites with deep pockets, sites that bled on probing, and risk profiles were observed. Individuals with PsoA exhibited a lower stimulated salivary secretion rate than those without psoriasis (P <0.05). Conclusions: There were no differences in profiles of caries and periodontal disease experience and risk between individuals with and without psoriasis. Fewer remaining teeth were observed in individuals with psoriasis. However, the exact reason for tooth loss could not be identified. Meanwhile, the reduced salivary pH in individuals with psoriasis and salivary secretion in individuals with PsoA may pose some risk for future caries.     

Random blood glucose testing in dental practice: a community-based feasibility study from The Dental Practice-Based Research Network

BackgroundThe prevalence of diabetes mellitus (DM) has been increasing. Instances of patients' not having received a diagnosis have been reported widely, as have instances of poor control of DM or prediabetes among patient's who have the disease. These facts indicate that blood glucose screening is needed.MethodsAs part of The Dental Practice-Based Research Network, the authors conducted a study in community dental practices to test the feasibility of screening patients for abnormal random blood glucose levels by means of glucometers and finger-stick testing. Practitioners and staff members were trained to use a glucometer, and they then screened consecutive patients older than 19 years at each practice until 15 patients qualified for the study and provided consent. Perceived barriers to and benefits of blood glucose testing (BGT) were reported by patients and dental office personnel on questionnaires.ResultsTwenty-eight practices screened 498 patients. A majority of the respondents from the 67 participating dental offices considered BGT useful and worth routine implementation. They did not consider duration of BGT or its cost to be significant barriers. Among patients, more than 80 percent thought BGT in dental practice was a good idea and found it easy to withstand; 62 percent were more likely to recommend their dentists to others if BGT was offered.ConclusionBGT was well received by patients and practitioners. These results support the feasibility of implementation of BGT in community dental practices.Clinical ImplicationsImproved diagnosis and control of DM may be achieved through implementation of BGT in community dental practices.     

Practitioner, patient and carious lesion characteristics associated with type of restorative material: findings from The Dental Practice-Based Research Network

BackgroundThe authors conducted a study to identify factors associated with the materials that dentists in The Dental Practice-Based Research Network (DPBRN) use when placing the first restoration on permanent posterior tooth surfaces.MethodsA total of 182 DPBRN practitioner-investigators provided data regarding 5,599 posterior teeth with caries. Practitioner-investigators completed an enrollment questionnaire that included the dentist’s age, sex, practice workload, practice type and number of years since graduation. When patients who had provided informed consent to participate in the investigation sought treatment for a previously unrestored carious surface, the practitioner-investigator recorded patient and tooth characteristics.ResultsPractitioner-investigators used amalgam more often than they used direct resin-based composite (RBC) for posterior carious lesions. Practitioner and practice characteristics (years since graduation and type of practice); patient characteristics (sex, race, age and dental insurance status); and lesion characteristics (tooth location and surface, preoperative and postoperative lesion depth) were associated with the type of restorative material used.ConclusionsSeveral practitioner and practice, patient and lesion characteristics were associated significantly with use of amalgam and RBC: geographical region, years since dentist’s graduation, patient’s dental insurance status, tooth location and surface, and preoperative and postoperative lesion depth.Clinical ImplicationsDespite advances in esthetic dentistry, U.S. dentists still are placing amalgam on posterior teeth with carious lesions. Amalgam was used more often than RBC in older patients, who may have had deeper carious lesions.     

Management of initial carious lesions: Iowa survey

BackgroundThe authors explore Iowa dentists’ agreement with the International Caries Classification and Management System (ICCMS) in the nonsurgical management of initial carious lesions in patients at low, moderate, and high caries risk and identify factors related to their agreement.MethodsElectronic surveys were mailed to 916 actively practicing dentists who are alumni of the College of Dentistry at The University of Iowa. Questions included clinical scenarios that used text, clinical photographs, and radiographic images of initial carious lesions. Dentists were asked what type of treatment they would recommend. Treatment options included no treatment, nonsurgical treatment, or surgical treatment. Logistic regression analyses were used to assess associations among agreement with ICCMS, characteristics of the dentist’s practice, and patients’ caries risk level.ResultsA total of 138 Iowa dentists responded to the survey. Agreement with ICCMS regarding nonsurgical management of initial carious lesions for patients at low, moderate, and high risk levels were 73%, 59%, and 51% respectively. Compared with their counterparts, dentists who agreed with the recommendations for nonsurgical treatment were more likely to dry the teeth during caries detection (95% confidence interval [CI], 1.02 to 12.67, P = .0468), use magnification (95% CI, 1.16 to 7.17, P = .0225) for caries detection, have graduated less than 20 years ago (P = .0024), practice in public health settings (P = .0089), and perform a caries risk assessment (95% CI, 1.10 to 4.29, P = .0262).ConclusionsDentists who dry teeth, use magnification for caries detection, graduated in the past 20 years, practice in a public health setting, and perform a caries risk assessment were significantly more likely to make decisions that were consistent with the guidelines of the ICCMS.Practical ImplicationsKnowledge of evidence-based options personalized for a patient’s risk status is essential for applying the best management of initial caries lesions.     

Use of online sources of information by dental practitioners: findings from The Dental Practice‐Based Research Network

Objective: Estimate the proportion of dental practitioners who use online sources of information for practice guidance. Methods: From a survey of 657 dental practitioners in The Dental Practice‐Based Research Network, four indicators of online use for practice guidance were calculated: read journals online, obtained continuing education (CDE) through online sources, rated an online source as most influential, and reported frequently using an online source for guidance. Demographics, journals read, and use of various sources of information for practice guidance in terms of frequency and influence were ascertained for each. Results: Overall, 21 percent (n = 138) were classified into one of the four indicators of online use: 14 percent (n = 89) rated an online source as most influential and 13 percent (n = 87) reported frequently using an online source for guidance; few practitioners (5 percent, n = 34) read journals online, fewer (3 percent, n = 17) obtained CDE through online sources. Use of online information sources varied considerably by region and practice characteristics. In general, the four indicators represented practitioners with as many differences as similarities to each other and to offline users. Conclusion: A relatively small proportion of dental practitioners use information from online sources for practice guidance. Variation exists regarding practitioners' use of online source resources and how they rate the value of offline information sources for practice guidance.     

Concordance between clinical practice and published evidence: Findings from The National Dental Practice-Based Research Network

BackgroundDocumenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network (“the network”).MethodsNetwork dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent (“1”) or inconsistent (“0”) with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.ResultsThe authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).ConclusionDentists reported a medium-range concordance between practice and published evidence.Practical ImplicationsEfforts to bring research findings into routine practice are needed.     

Twenty-month follow-up of occlusal caries lesions deemed questionable at baseline: Findings from The National Dental Practice-Based Research Network

Background.A questionable occlusal caries (QOC) lesion can be defined as an occlusal surface with no radiographic evidence of caries, but caries is suspected because of clinical appearance. In this study, the authors report the results of a 20-month follow-up of these lesions.Methods.Fifty-three clinicians from The National Dental Practice-Based Research Network participated in this study, recording lesion characteristics at baseline and lesion status at 20 months.Results.At baseline, 1,341 QOC lesions were examined; the treatment that was planned for 1,033 of those at baseline was monitoring (oral hygiene instruction, applying or prescribing fluoride or varnish, or both), and the remaining 308 received a sealant (n = 192) or invasive therapy (n = 116). At the 20-month visit, clinicians continued to monitor 927 (90 percent) of the 1,033 monitored lesions. Clinicians decided to seal 61 (6 percent) of the 1,033 lesions (mean follow-up, 19 months) and invasively treat 45 (4 percent) of them (mean follow-up, 15 months). Young patient age (< 18 years) (odds ratio = 3.4; 95 percent confidence interval, 1.7-6.8) and the lesion&apos;s being on a molar (odds ratio = 1.8; 95 percent confidence interval, 1.3-2.6) were associated with the clinician&apos;s deciding at some point after follow-up to seal the lesion or treat it invasively.Conclusions.Almost all (90 percent) QOC lesions for which the treatment planned at baseline was monitoring still were planned to undergo monitoring after 20 months. This finding suggests that noninvasive management is appropriate for these lesions.Practical Implications.Previous study results from baseline indicated a high prevalence of QOC lesions (34 percent). Clinicians should consider long-term monitoring when making treatment decisions about these lesions.