The Evidence-practice Gap in Minimal Intervention Dentistry: An International Comparison Between Dentists in Japan and Brazil

OBJECTIVES

This study was designed to: 1) evaluate and compare the evidence-practice gap (EPG) in minimal intervention dentistry (MID) in Japan and Brazil by measuring concordance between dentists' clinical practice and published evidence; and 2) identify dentists' factors associated with the EPG in both countries.

METHODS

We performed a cross-sectional study using a web-delivered questionnaire among 136 Japanese and 110 Brazilian dentists. The questionnaire consisted of three questions concerning "restoration diagnosis and treatment," "deep caries diagnosis and treatment," and "caries risk assessment" regarding MID. A chi-square test was used to analyze differences in concordance among clinical practice and evidence from the literature between Japanese and Brazilian dentists. Logistic regression analyses were performed to analyze dentists' factors associated with overall concordance for all three questions.

RESULTS

Overall concordance was significantly higher in Brazil (55%) than in Japan (38%) (p<0.01). Concerning how evidence was obtained, textbooks, nonacademic journals, and seminars and workshops were used as information sources more frequently by Japanese than Brazilian dentists (p<0.001), whereas scientific journal articles in English were used more frequently by Brazilian dentists (p<0.001). On logistic regression analysis, overall concordance was higher for Japanese dentists who frequently obtained evidence from scientific journal articles in English (p<0.05), whereas Brazilian dentists who frequently obtained evidence from the Internet were associated with lower overall concordance (p<0.05).

CONCLUSIONS

Because overall concordance was significantly higher in Brazil than in Japan, Japan may have a greater EPG in MID practice. Specific characteristics of Japanese and Brazilian dentists showed significant associations with overall concordance.

Outcomes of root canal treatment in Dental Practice-Based Research Network practices

This study sought to quantify the incidence of root canal treatment (RCT) failure and identify its predictors in root canals that were performed or referred by general dentistry practices in a practice-based research network (PBRN). This retrospective cohort study involved 174 endodontically treated teeth. Mean duration from initial therapy to follow-up was 8.6 years. Permanent restorations were ultimately placed in 89% of teeth, although 18% of teeth were ultimately extracted anyway. Receiving a permanent restoration was a significant predictor of treatment failure (in other words, patients who did not receive a permanent restoration were more likely to experience RCT failure), whether failure was determined clinically or radiographically. This study of PBRN practices suggests a higher failure rate compared with studies that utilized highly controlled environments or populations with high levels of dental insurance.

An operational definition of the homebound

Homebound status is a critical eligibility criterion for Medicare reimbursement of some home care services, yet little discussion has been undertaken to establish a valid definition of it. We propose an operational definition of homebound status, and we measure its validity for community-dwelling elderly in the Massachusetts Health Care Panel Study (MHCPS). The MHCPS is a longitudinal study of a cohort of elderly persons (N = 1,625), which began in 1974, with follow-up surveys in 1976, 1980, and 1985. Validity was measured by comparing responses from the operational measure to persons' responses to questions that we judged should be associated with a valid measure of homebound status. This construct validity method resulted in correlations that were significant and in the expected direction, and that suggested that this operational measure is a highly specific, moderately sensitive, valid measure. These results underscore the need for researchers investigating the homebound to discuss the validity and limitations of their homebound measures, and in what context these measures are useful.

Phenytoin sensitivity of fibroblasts as the basis for susceptibility to gingival enlargement

A side effect of long-term administration of the anti-epileptic drug phenytoin is overgrowth of the connective tissues surrounding the teeth. In this in vitro study of protein and collagen synthesis by diploid fibroblasts from 17 nonepileptic young persons with healthy gingivae, only seven strains of cells responded to phenytoin in culture medium. Because not all phenytoin-treated individuals develop gingival overgrowth, we suggest that susceptibility is predicated upon the presence of a (genetically determined) phenytoin-sensitive subpopulation of gingival fibroblasts. The concept of the participation of sensitive cell subpopulations in other connective tissue disorders is supported by these findings.

Random plasma glucose values measured in community dental practices: findings from the dental practice-based research network

OBJECTIVES

This study aimed to examine feasibility of testing and frequency of abnormal plasma glucose among dental patients in The Dental Practice-Based Research Network.

METHODS

Eligible dental patients were > or = 19 years old and had at least 1 American Diabetes Association-defined risk factor for diabetes mellitus or an existing diagnosis of diabetes or pre-diabetes. Random (fasting not required) plasma glucose was measured in standardized fashion using a commercial glucometer. Readings <70 or >300 mg/dl triggered re-testing. Patients with glucose > or = 126 mg/dl were referred for medical follow-up.

RESULTS

Of 498 subjects in 28 dental practices, 491 (98%) consented and 418 (85.1%) qualified for testing. Fifty-one patients (12.2%) had diabetes; 24 (5.7%) had pre-diabetes. Glucose ranged from 50 to 465 mg/dl. One-hundred-twenty-nine subjects (31%) had readings outside the normal range; of these, 28 (6.7%) had readings < 80 mg/dl and 101 (24.2%) had readings > or = 126 mg/dl; in 9 patients (7 with diabetes), glucose was > 200 mg/dl.

CONCLUSIONS

A significant proportion of patients tested had abnormal blood glucose. Routine glucose testing in dental practice of populations at risk or diagnosed with diabetes may be beneficial and community dental practices hold promise as settings for diabetes and pre-diabetes screening and monitoring.

CLINICAL RELEVANCE

Results suggest that implementation of glucose measurement in dental practice may provide important clinical and health information for both patients and practitioners.

Provision of Specific Dental Procedures By General Dentists in the National Dental Practice-Based Research Network: Questionnaire Findings

BACKGROUND

Objectives were to: (1) determine whether and how often general dentists (GDs) provide specific dental procedures; and (2) test the hypothesis that provision is associated with key dentist, practice, and patient characteristics.

METHODS

GDs (n = 2,367) in the United States National Dental Practice-Based Research Network completed an Enrollment Questionnaire that included: (1) dentist; (2) practice; and (3) patient characteristics, and how commonly they provide each of 10 dental procedures. We determined how commonly procedures were provided and tested the hypothesis that provision was substantively related to the 3 sets of characteristics.

RESULTS

Two procedure categories were classified as "uncommon" (orthodontics, periodontal surgery), 3 were "common" (molar endodontics; implants; non-surgical periodontics), and 5 were "very common" (restorative; esthetic procedures; extractions; removable prosthetics; non-molar endodontics). Dentist, practice, and patient characteristics were substantively related to procedure provision; several characteristics seemed to have pervasive effects, such as dentist gender, training after dental school, full-time/part- time status, private practice vs. institutional practice, presence of a specialist in the same practice, and insurance status of patients.

CONCLUSIONS

As a group, GDs provide a comprehensive range of procedures. However, provision by individual dentists is substantively related to certain dentist, practice, and patient characteristics. A large number and broad range of factors seem to influence which procedures GDs provide. This may have implications for how GDs respond to the ever-changing landscape of dental care utilization, patient population demography, scope of practice, delivery models and GDs' evolving role in primary care.

Change in stated clinical practice associated with participation in the Dental Practice-Based Research Network

Clinical researchers have attempted many methods to translate scientific evidence into routine clinical practice, with varying success. Practice-based research networks (PBRNs) provide an important, practitioner-friendly venue to test these methods. Dentist practitioner-investigators from the Dental Practice-Based Research Network (DPBRN) completed a detailed questionnaire about how they diagnose and treat dental caries. Next, they received a customized report that compared their answers to those from all other practitioner-investigators. Then, 126 of them attended the DPBRN's first network-wide meeting of practitioner-investigators from all five of its regions. During that meeting, certain questions were repeated and new ones were asked about the dentist's intention to change the way that he or she diagnosed or treated dental caries. Less than one-third of practitioner-investigators intended to change how they diagnosed or treated caries as a result of receiving the customized report. However, as a result of the meeting, the majority of these same practitioner-investigators stated an intention to change toward a more conservative, less surgically invasive approach. These findings are consistent with the idea that a highly interactive meeting with fellow practitioner-investigators may be an effective means to translate scientific findings into clinical practice. Practitioner-investigators are open to changing how they treat patients as a result of engaging fellow practitioner-investigators in the scientific process.

Dentists in practice-based research networks have much in common with dentists at large: evidence from the Dental Practice-Based Research Network

Practice-based research networks (PBRNs) aim to improve clinical practice by engaging dental practitioners in studies that are directly relevant to daily clinical practice. The Dental Practice-Based Research Network (DPBRN) consists of dentists from seven U.S. states and three Scandinavian countries. All DPBRN dentists complete an enrollment questionnaire about their practices and themselves; as of this writing, 1,086 have done so. To quantify the similarities between DPBRN dentists and U.S. dentists at large, this article compared DPBRN practice characteristics to those of dentists who responded to the 2004 ADA Survey of dental practice, which is not limited to ADA members. DPBRN dentists were similar to U.S. dentists in terms of gender, race, ethnicity, number of offices, percentage of patients with insurance coverage, number of operatories, patient visits per week, days for a new appointment, and waiting room time. DPBRN dentists were statistically more likely to be recent graduates. The commonalities should increase the likelihood that DPBRN studies will be applicable to U.S. practices, thereby fostering knowledge transfer in both research-to-practice and practice-to-research.

Knowledge About Food Insecurity Among Dental Practitioners: Preliminary Findings From the National Dental Practice-Based Research Network

Food insecurity is a household-level economic and social condition characterized by limited access to nutritious food. This study explored dental practitioners' views on food insecurity screening and its impact on oral health. A five-question survey ("Quick Poll") was conducted through the National Dental Practice-Based Research Network (PBRN) in the United States. A total of 332 dental practitioners responded. Preferences for food insecurity screening in dental practice settings showed substantial variability: 30% in favor, 39% neutral, and 29% against. When identifying the primary oral health issue influenced by food insecurity, 68% pinpointed dental caries. Over half (53%) expressed comfort in directing patients experiencing food insecurity to relevant resources. Notably, 61% of respondents expressed interest in being involved in future food insecurity clinical studies. This preliminary study underscores the relevance of food insecurity in the professional dental setting and suggests that the clinical setting may be well suited for educational programs designed to improve the oral health of patients experiencing food insecurity. Future research may achieve this goal, including a PBRN clinical study of interventions to improve oral health among patients experiencing food insecurity.

Comparison of factors associated with the evidence-practice gap as perceived by Japanese and Brazilian dentists

OBJECTIVES

To identify 1) factors of the evidence-practice gap (EPG) in Japan and Brazil as perceived by dentists and compare these factors between two countries, and 2) mechanisms to close this EPG.

METHODS

The study employed a cross-sectional design by administering a web-based questionnaire to 136 Japanese and 110 Brazilian dentists. The survey queried dentists' reports of which factors possibly cause an EPG, using a newly developed 20-item questionnaire.

RESULTS

An international comparison of 20 items related to factors of the EPG between Japan and Brazil revealed that "Dentists' own experiences are sometimes given priority over evidence" and "Dentists' own thoughts are sometimes given priority over evidence" were common factors to both countries, with over 80 % agreement. In logistic regression, "Insufficient opportunity to learn about evidence in dental education at universities", "Evidence-based treatments are sometimes not covered by the dental insurance system", and "Insufficient evidence which helps dentists choose an appropriate treatment for a patient after careful consideration of his/her own background" were significantly associated with the EPG in Japan (p < 0.05). In Brazil, "Insufficient case reports in which evidence-based dentistry (EBD) is applied to clinical practice" and "Image-based information and devices used for diagnosis vary depending on individual dentists" were significantly associated with the EPG (p < 0.05).

CONCLUSIONS

This study suggests that EPG could be improved in Japan: by promoting EBD education at universities, improving the dental insurance system, and accumulating evidence according to patient background; and in Brazil: by promoting EBD case reports and standardizing diagnostic information and devices.

CLINICAL SIGNIFICANCE

Two factors of EPG common to Japan and Brazil, namely the prioritization of dentists' own "experiences" and "thoughts" over evidence, are urgent issues for improving EPG. In addition, it will be necessary to address the country-specific factors of EPG that were identified in this study.

Management of painful temporomandibular disorders: Methods and overview of The National Dental Practice-Based Research Network prospective cohort study

BACKGROUND

Patients often seek consultation with dentists for temporomandibular disorders (TMDs). The objectives of this article were to describe the methods of a large prospective cohort study of painful TMD management, practitioners' and patients' characteristics, and practitioners' initial treatment recommendations conducted by The National Dental Practice-Based Research Network (the "network").

METHODS

Participating dentists recruited into this study treated patients seeking treatment for painful TMDs. The authors developed self-report instruments based on well-accepted instruments. The authors collected demographics, biopsychosocial characteristics, TMD symptoms, diagnoses, treatments, treatment adherence, and painful TMDs and jaw function outcomes through 6 months.

RESULTS

Participating dentists were predominately White (76.8%) and male (62.2%), had a mean age of 52 years, and were general practitioners (73.5%) with 23.8% having completed an orofacial pain residency. Of the 1,901 patients with painful TMDs recruited, the predominant demographics were White (84.3%) and female (83.3%). Patients' mean age was 44 years, 88.8% self-reported good to excellent health, and 85.9% had education beyond high school. Eighty-two percent had pain or stiffness of the jaw on awakening, and 40.3% had low-intensity pain. The most frequent diagnoses were myalgia (72.4%) and headache attributed to TMDs (51.0%). Self-care instruction (89.4%), intraoral appliances (75.4%), and medications (57.6%) were recommended frequently.

CONCLUSIONS

The characteristics of this TMD cohort include those typical of US patients with painful TMDs. Network practitioners typically managed TMDs using conservative treatments.

PRACTICAL IMPLICATIONS

This study provides credible data regarding painful TMDs and TMD management provided by network practitioners across the United States. Knowledge acquired of treatment recommendations and patient reports may support future research and improve dental school curricula.

Differences between reported and actual restored caries lesion depths: results from The Dental PBRN

OBJECTIVE

The objectives of this research were to: (1) quantify the discordance between the caries lesion depth at which dentists restored initial lesions during a clinical study ("actual depth") and the lesion depth that they reported during a hypothetical clinical scenario ("reported depth"); (2) test the hypothesis that certain practitioner, practice, patient, and caries lesion characteristics are significantly associated with this discordance.

METHODS

Practitioner-investigators who perform restorative dentistry in their practices completed an enrollment questionnaire and participated in 2 consecutive studies on caries diagnosis and treatment. The first study was a survey asking about caries treatment. The second study collected data on restorations placed in routine clinical practice due to caries in patients over 19 years of age on occlusal surfaces only or proximal surfaces only. We report results on 2,691 restorations placed by 205 dentists in 1,930 patients with complete data.

RESULTS

Discordance between actual depth and reported depth occurred in only about 2% of the restorations done due to proximal caries, but about 49% of the restorations done due to occlusal caries. Practice type, restorative material used and the diagnostic methods used were significantly associated with discordance.

CONCLUSION

Dentists frequently restored occlusal caries at a shallower depth as compared to their reported depth, but the discordance was very small for proximal lesions. Discordance for occlusal caries was more common when radiographs were not taken or if a resin restoration was placed.

Dental Sleep Medicine among dental practitioners: Preliminary findings from the National Dental Practice-Based Research Network

Objectives/Introduction

Dental sleep medicine (DSM) focuses on oral appliance therapy (OAT) to manage sleep-disordered breathing (SDB), including obstructive sleep apnea (OSA). This brief poll aimed to assess the interest and practices of dental practitioners in DSM. To this day lack of data exists regarding how DSM practices function in the clinical setting. Therefore, identifying knowledge gaps in DSM among dental practitioners may improve patient outcomes.

Methods

A preliminary brief questionnaire ("Quick Poll") on DSM was conducted through the National Dental Practice-Based Research Network (Network) members (n=311). The poll contained five questions about DSM.

Results

Results showed that 66% of practitioners have involvement in DSM patient care. A total of 44% of practitioners who answered the Quick Poll do not screen for snoring or SDBs. About 40% of respondents are either interested in continuing education courses on the topic or had already taken multiple courses on DSM. The top three topics of DSM research of interest to practitioners were various DSM practice models, response to OAT, and compliance with OAT.

Conclusion

Network dental practitioner respondents face challenges regarding the treatment of SDBs. Despite these challenges, most practitioners are interested in engaging in DSM. Based on these preliminary findings, there are informational needs regarding the current state of clinical care, side effects of OAT, choice of OAT, titration protocols, and patient outcomes.

Practitioner/Practice- and Patient-Based Factors Contributing to Dental Practitioner Treatment Recommendations for Patients with Pain-Related TMDs: Findings from the National Dental PBRN

AIMS

To document National Dental Practice-Based Research Network (PBRN) practitioner treatment recommendations for patients with painful temporomandibular disorders (TMDs) and to identify practitioner/practice- and patient-related factors contributing to treatment recommendations made at the initial clinical visit.

METHODS

This prospective single-sample cohort study formed groups based on treatment recommendations made by 185 dental practitioners who treated 1,901 patients with painful TMDs. At the baseline visit, which this article describes, practitioners provided patients with their diagnoses and a treatment plan and then completed a comprehensive questionnaire.

RESULTS

Self-care, an intraoral appliance, medication, and practitioner-recommended jaw exercises were the most frequently recommended treatments. Practitioners recommended multiple treatments to most patients. TMD signs, symptoms, and diagnoses were primary considerations in treatment planning, but the practitioner's expectations for improvement were only significant for intraoral appliances and self-care. Female practitioners and those with expertise in TMDs more frequently recommended patient-directed and multidisciplinary treatments compared to their counterparts.

CONCLUSIONS

Practitioners used a wide range of treatments for patients with few consistent patterns. The propensity to use TMD signs, symptoms, and diagnoses when making treatment recommendations suggests a tendency to conceptualize patients using the biomedical model. Infrequent referral to nondental providers suggests a lack of availability of these providers, a misunderstanding of the complexity of TMDs, and/or discomfort with assessment of psychosocial factors. Implications include the need for comprehensive training in the assessment and management of TMD patients during dental school and participation in TMD continuing education courses following evidence-based guidelines.

Factors influencing the effectiveness of mailed health surveys

The authors investigated sources of bias in health surveys by examining responses to their 1989 questionnaire mailed to 1,255 Massachusetts men who were eligible for dental care provided by the Department of Veterans Affairs. After a maximum of three mailings and one telephone call to nonrespondents, a total of 1,049 veterans had responded out of 1,228 finally determined to be eligible, a response rate of 85 percent. The investigators found that small differences in univariate estimates would have occurred had the field phase been terminated after the first mailing, which had a response rate of 61 percent. To evaluate multivariate distributions, they duplicated their previously published logistic regression model for sources of dental care, using only those who responded to the first and second mailings. Although model fits would have been substantively the same had the field phase been terminated after the first or the second mailings, analysis of parameter estimates and their statistical significances suggested bias that would have led to different substantive conclusions, in some instances. Another potential source of bias in surveys was found to be item omission. Fifty-eight percent of respondents answered all 46 survey questions, and 90 percent answered at least 91 percent of the questions. Fewer questions were answered by those whose responses were received last, but trends regarding missing data by age or education were not statistically significant. Although the survey using this methodology met all objectives, subject nonresponses, the ineligibility of potential respondents, item nonresponses, and skewed distributions of outcome variables combined to reduce the statistical power to detect differences among groups or to alter the analysis of the differences. These factors need to be planned for by investigators undertaking similar surveys.

Comparison of the accuracy of CBCT effective radiation dose information in peer-reviewed journals and dental media

Accessible sources of clinical information have proliferated over the past decade. Although these new sources that contextualize information for practice are user friendly, there are questions about their accuracy because much of the material is not peer reviewed. On the other hand, traditional peer-reviewed material can be somewhat removed from the needs of practicing dentists, and recently questions have been raised about the accuracy of journals. This study assessed the accuracy of cone beam computed tomography (CBCT) radiation safety information in both professional media and peer-reviewed journals. Articles introducing CBCT technology to dentists and published in peer-reviewed journals were compared to articles appearing in professional magazines, clinically oriented news sites, and blogs written by clinicians for clinicians. The reported radiation doses of CBCT and conventional dental radiographs were recorded, as were conclusions about the comparative doses of these 2 imaging modalities. The proportion of articles reporting CBCT dose to be greater than, equal to, or less than that of conventional dental radiographs was not different between the peer-reviewed and professional media articles during the period 2003-2016. There is weak evidence that the conclusions of peer-reviewed journal articles, but not professional media sources, became more conservative after the 2010 publication of an article in The New York Times that was critical of misinformation concerning the safety and efficacy of CBCT in dentistry. Professional media articles that were not peer reviewed were as accurate as peer-reviewed journals for this topic and during the time period assessed. However, the method used here necessitated a narrow focus, and more studies are needed to broaden understanding.

Use of caries-preventive agents in children: findings from the dental practice-based research network

PURPOSE

Scientific evidence supports the application of caries-preventive agents in children and adolescents, and this knowledge must be applied to the practice of dentistry. There are few multi-region data that allow for comparisons of practice patterns between types of dental practices and geographical regions. The objective of the present study was to characterise the use of specific caries-preventive agents for paediatric patients in a large multi-region sample of practising clinicians.

METHODS

The present study surveyed clinicians from the Dental Practice-based Research Network who perform restorative dentistry in their practices. The survey consisted of a questionnaire that presented a range of questions about caries risk assessment and the use of preventive techniques in children aged 6 to 18 years.

RESULTS

Dental sealants (69%) or in-office fluoride (82%) were the most commonly used caries-preventive agents of the caries preventive regimens. The recommendation of at-home caries-preventive agents ranged from 36% to 7%,with the most commonly used agent being non-prescription fluoride rinse. Clinicians who practised in a large group practice model and clinicians who come from the Scandinavian region use caries risk assessment more frequently compared to clinicians who come from regions that had, predominantly, clinicians in private practice. Whether or not clinicians used caries risk assessment with their paediatric patients was poorly correlated with the likelihood of actually using caries-preventive treatments on patients.

CONCLUSIONS

Although clinicians reported the use of some form of in-office caries-preventive agent, there was considerable variability across practices. These differences could represent a lack of consensus across practising clinicians about the benefits of caries-preventive agents, or a function of differing financial incentives, or patient pools with differing levels of overall caries risk.

Risk factors for osteonecrosis of the jaws: a case-control study from the CONDOR Dental PBRN

Case reports and cohort studies have linked bisphosphonate therapy and osteonecrosis of the jaws (ONJ), but neither causality nor specific risks for lesion development have been clearly established. We conducted a 1:3 case-control study with 3 dental practice-based research networks, using dentist questionnaires and patient interviews for collection of data on bisphosphonate therapy, demographics, co-morbidities, and dental and medical treatments. Multivariable logistic regression analyses tested associations between bisphosphonate use and other risk factors with ONJ. We enrolled 191 ONJ cases and 573 controls in 119 dental practices. Bisphosphonate use was strongly associated with ONJ (odds ratios [OR] 299.5 {95% CI 70.0-1282.7} for intravenous [IV] use and OR = 12.2 {4.3-35.0} for oral use). Risk markers included local suppuration (OR = 7.8 {1.8-34.1}), dental extraction (OR = 7.6 {2.4-24.7}), and radiation therapy (OR = 24.1 {4.9-118.4}). When cancer patients (n = 143) were excluded, bisphosphonate use (OR = 7.2 {2.1-24.7}), suppuration (OR = 11.9 {2.0-69.5}), and extractions (OR = 6.6 {1.6-26.6}) remained associated with ONJ. Higher risk of ONJ began within 2 years of bisphosphonate initiation and increased 4-fold after 2 years. Both IV and oral bisphosphonate use were strongly associated with ONJ. Duration of treatment >2 years; suppuration and dental extractions were independent risk factors for ONJ.

Restorative treatment thresholds for interproximal primary caries based on radiographic images: findings from the Dental Practice-Based Research Network

This study sought to quantify the depths of proximal caries lesions that lead dentists in regular clinical practice to intervene restoratively, based on hypothetical scenarios that present radiographic images and patient background information, and to identify characteristics associated with restorative intervention in lesions that have penetrated only the enamel surface. This study surveyed dentists from the Dental Practice-Based Research Network (DPBRN) who had reported doing at least some restorative dentistry (n = 901). Dentists were asked to indicate the depth at which they would restore a lesion, based on a series of radiographic images depicting interproximal caries at increasing lesion depths in a mandibular premolar; in addition, the dentists were questioned regarding two caries risk scenarios: one involving a patient with low caries risk and another involving a patient at higher risk. Logistic regression was used to analyze associations between the decision to intervene restoratively and specific dentist, practice, and patient characteristics. Of the 901 DPBRN practitioner-investigators, 500 (56%) completed the survey. For a high caries risk patient, 66% of respondents indicated that they would restore a proximal enamel lesion, while 24% would do so once the lesion had reached into the outer third of the dentin. For a low caries risk patient, 39% of respondents reported that they would restore an enamel lesion, and 54% would do so once the lesion had reached into the outer third of the dentin. In multivariate analyses that accounted for dentist and practice characteristics, dentists in large group practices were less likely to intervene surgically for enamel caries, regardless of patient's caries risk.