Dentists' decision strategies for suspicious occlusal caries lesions in a National Dental PBRN study

OBJECTIVE

Case presentations (vignettes) were completed by dentists in the National Dental Practice-Based Research Network study "Decision Aids for the Management of Suspicious Occlusal Caries Lesions (SOCLs)". The objective was to determine dentists' decision strategies for SOCLs.

METHODS

107 dentists viewed a series of 16 vignettes that represented all combinations of 4 clinical cues: color, luster, lesion roughness, and patient-level caries risk. Each vignette included a patient description and a photograph of a tooth presenting the 4 cues. Dentists were asked to decide the likelihood that a suspected lesion extended into dentin. A lens model analysis was used to examine how dentists use these cues in making their decisions.

RESULTS

86% of dentists had a consistent pattern of cue use that defined their decision strategy. On average, 70% of the variance in their decisions was accounted for by their use of the 4 cues. However, there was considerable variability in the individual cues used by each dentist. The percentages of dentists who used the different cues consistently were: luster (58%), color (48%), roughness (36%), and risk (35%). 14% of dentists reliably used only color, 7% used only luster, 4% used only roughness, and 1% used only risk when making SOCL decisions.

CONCLUSIONS

The online vignette system suggests that clinical SOCL decision strategies are highly individualized and dentists do not use all cues available to them to make these decisions.

CLINICAL SIGNIFICANCE

Prior to this study, there has been little evidence about how dentists use these cues (either individually or in combination) when judging the extent of caries progression. Such knowledge would be valuable when designing interventions to help dentists maximize the likelihood of appropriate treatment decisions.

Dentist Practice Patterns and Therapeutic Confidence in the Treatment of Pain Related to Temporomandibular Disorders in a Dental Practice-Based Research Network

AIMS

To quantify the practice patterns of Japanese dentists in the management of pain related to temporomandibular disorders (TMD) and to identify specific characteristics that are significantly associated with the decision to perform occlusal adjustment for TMD-related pain.

METHODS

A cross-sectional study was conducted consisting of a questionnaire survey of dentists affiliated with the Dental Practice-Based Research Network Japan (JDPBRN) (n = 148). Participants were asked how they diagnosed and treated TMD-related pain. Associations between dentist characteristics and the decision to perform occlusal adjustment were analyzed via multiple logistic regression.

RESULTS

A total of 113 clinicians responded to the questionnaire (76% response rate), and 81% of them (n = 89) had treated TMD during the previous year. Dentists treated an average of 1.9 ± 1.8 (mean ± SD) patients with TMD-related pain per month. Most JDPBRN dentists used similar diagnostic protocols, including questions and examinations. The most frequent treatments were splints or mouthguards (96.5%), medications (84.7%), and self-care (69.4%). Occlusal adjustment for TMD-related pain was performed by 58% of the participants. Multiple logistic regression analysis identified two factors significantly associated with the decision to perform occlusal adjustment: dentist lack of confidence in curing TMD-related acute pain (odds ratio [OR] 5.60; 95% confidence interval [CI] 1.260 to 24.861) and proportion of patients with severe TMD-related pain (OR 0.95; 95% CI 0.909 to 0.999).

CONCLUSION

The most common treatments for TMD-related pain were reversible treatments; however, over half of the dentists performed occlusal adjustment for TMD-related pain. The results of this study suggest that an evidence-practice gap exists for occlusal adjustment for TMD-related pain.

Impression evaluation and laboratory use for single-unit crowns: Findings from The National Dental Practice-Based Research Network

BACKGROUND

Objectives were to determine the likelihood that a clinician accepts an impression for a single-unit crown and document crown remake rates.

METHODS

The authors developed a questionnaire that asked dentists about techniques used to fabricate single-unit crowns. The authors showed dentists photographs of 4 impressions and asked them to accept or reject each impression. The authors correlated answers with dentist and practice characteristics. Other questions pertained to laboratory use and crown remake rates.

RESULTS

The response rate was 83% (1,777 of 2,132 eligible dentists). Of the 4 impressions evaluated, 3 received consistent responses, with 85% agreement. One impression was more equivocal; 52% accepted the impression. The likelihood of accepting an impression was associated significantly with the clinician's sex, race, ethnicity, and practice busyness. Clinicians produced 18 crowns per month on average, and 9% used in-office milling. Most dentists (59%) reported a remake rate of less than 2%, whereas 17% reported a remake rate greater than 4%. Lower remake rates were associated significantly with more experienced clinicians, optical impressions, and not using dual-arch trays.

CONCLUSIONS

Although dentists were largely consistent in their evaluation of impressions (> 85%), nonclinical factors were associated with whether an impression was accepted or rejected. Lower crown remake rates were associated with more experienced clinicians, optical impressions, and not using dual-arch trays.

PRACTICAL IMPLICATIONS

These results provide a snapshot of clinical care considerations among a diverse group of dentists. Clinicians can compare their own remake rates and impression evaluation techniques with those in this sample when developing best practice protocols.

Management of dentin hypersensitivity by practitioners in The National Dental Practice-Based Research Network

BACKGROUND

Dentin hypersensitivity (DH) is a condition commonly encountered in clinical dental practice. The authors conduct a study to identify the treatments recommended to manage DH among dentists in the United States.

METHODS

The authors conducted a multicenter study of 1,862 patients with DH who received a diagnosis and were treated by 171 dentists with The National Dental Practice-Based Research Network.

RESULTS

The most common treatment recommended was desensitizing over-the-counter (OTC) potassium nitrate toothpaste (alone or in combination with other treatments) for 924 of 1,862 patients (50%). This was followed by an application of fluoride varnish (FV) for 516 patients (28%) and a prescription for fluoride toothpaste for 314 patients (17%). Restorative treatments were recommended to 151 patients (8%). The most common single treatment recommendation was desensitizing OTC potassium nitrate toothpaste, recommended to 335 patients (18%). The most frequent combination of 2 treatment modalities was FV and desensitizing OTC potassium nitrate toothpaste, recommended to 100 patients (5%). A total of 890 of 1,862 patients (48%) with DH received a recommendation for 1 treatment modality, and 644 of 1,862 patients (35%) received a recommendation for a combination of 2 treatment modalities, most frequently an application of FV along with desensitizing OTC potassium nitrate toothpaste (100/1,862; 5%).

CONCLUSIONS

Desensitizing OTC potassium nitrate toothpaste and fluoride products were the most widely recommended products to manage DH in the practice setting.

PRACTICAL IMPLICATIONS

Our results suggest that most network clinicians preferred noninvasive treatment modalities when treating DH.

Judgment of the Quality of Restorative Care as Predictors of Restoration Retreatment: Findings from the National Dental PBRN

The primary aim of this study was to test the hypothesis that a patient's subjective assessments of the dentist's technical competence, quality of care, and anticipated restoration longevity during a restorative visit are predictive of restoration outcome. This prospective cohort study involved 3,326 patients who received treatment for a defective restoration in a permanent tooth, participated in a baseline patient satisfaction survey, and returned for follow-up. Of the 4,400 restorations that were examined by 150 dentists, 266 (6%) received additional treatment after baseline. Reporting satisfaction with the technical skill of the dentist or quality of the dental work at baseline was not associated with retreatment after baseline. However, patients' views at baseline that the fee was reasonable (odds ratio [OR], 1.6) was associated with retreatment after baseline, whereas satisfaction at baseline with how long the filling would last (OR, 0.6) was associated with less retreatment. These findings suggest that retreatment occurs more often for patients who at baseline are satisfied with the cost or who at baseline have less confidence in the restoration. The authors found no associations between restoration retreatment and the patients' baseline evaluations of the technical skills of their dentists or perceptions of quality care.

KNOWLEDGE TRANSFER STATEMENT

Dental patients' ratings of their dentist's skills were not related to a restoration needing retreatment. Patients focus on other aspects of the dental visit when making this judgment.

Satisfaction with dental care among patients who receive invasive or non-invasive treatment for non-cavitated early dental caries: findings from one region of the National Dental PBRN

BACKGROUND

The objectives were to: (1) quantify patient satisfaction with treatment for early dental caries overall, and according to whether or not (2a) the patient received invasive treatment; (2b) was high-risk for dental caries, and had dental insurance; and (3) encourage practitioners to begin using non-invasive approaches to early caries management.

METHODS

Ten practitioners recorded patient, lesion, and treatment information about non-cavitated early caries lesions. Information on 276 consecutive patients with complete data was included, who received either non-invasive (no dental restoration) or invasive (dental restoration) treatment. Patients completed a patient satisfaction questionnaire and were classified as dissatisfied if they did not "agree" or "strongly agree" with any of 14 satisfaction items.

RESULTS

Patients had a mean (± SD) age of 41.8 (±15.8) years, 64% were female and 88% were white. Twenty-five percent (n = 68) were dissatisfied in at least one of the 14 satisfaction items. Satisfaction levels did not significantly vary by patient's gender, race, caries risk category, or affected tooth surface location. Overall, 11% (28 of 276) received invasive treatment; satisfaction did not differ between patients who had invasive or non-invasive treatment. Seven patients received invasive treatment at their request even though that was not what their practitioner recommended; 5 out of 6 were satisfied with their treatment nonetheless.

CONCLUSIONS

About one-fourth of patients treated for non-cavitated early caries were dissatisfied with at least some aspect of their dental care experience. Satisfaction of patients who received invasive treatment did not differ from those who received non-invasive treatment.

Use of clinical practice guidelines by dentists: findings from the Japanese dental practice-based research network

RATIONALE, AIMS AND OBJECTIVES

The objectives of this study were to: (1) examine differences in the use of dental clinical practice guidelines among Japanese dentists, and (2) identify characteristics associated with the number of guidelines used by participating dentists.

METHODS

We conducted a cross-sectional study consisting of a questionnaire survey in Japan between July 2014 and May 2015. The study queried dentists working in outpatient dental practices who are affiliated with the Dental Practice-Based Research Network Japan (n = 148). They were asked whether they have used each of 15 Japanese dental clinical guidelines. Associations between the number of guidelines used by participants and specific characteristics were analysed via negative binomial regression analysis.

RESULTS

The mean number of guidelines used by participating dentists was 2.5 ± 2.9 [standard deviation (SD)]. Rate of use of guidelines showed substantial variation, from 5% to 34% among dentists. The proportion of dentists that used guidelines was the highest among oral medicine specialists, who had the highest proportion for 10 of 15 guidelines. Negative binomial regression analysis identified three factors significantly associated with the number of guidelines used: 'years since graduation from dental school', 'specialty practice' and 'practice busyness'.

CONCLUSIONS

These results suggest that the use of clinical practice guidelines by Japanese dentists may still be inadequate. Training in the use of the guidelines could be given to dental students as undergraduate education and to young clinicians as continuing education.

Management of Dentin Hypersensitivity by National Dental Practice-Based Research Network practitioners: results from a questionnaire administered prior to initiation of a clinical study on this topic

Background

Dentin hypersensitivity (DH) is a common problem encountered in clinical practice. The purpose of this study was to identify the management approaches for DH among United States dentists.

Methods

One hundred eighty five National Dental Practice-Based Research Network clinicians completed a questionnaire regarding their preferred methods to diagnose and manage DH in the practice setting, and their beliefs about DH predisposing factors.

Results

Almost all dentists (99%) reported using more than one method to diagnose DH. Most frequently, they reported using spontaneous patient reports coupled with excluding other causes of oral pain by direct clinical examination (48%); followed by applying an air blast (26%), applying cold water (12%), and obtaining patient reports after dentist’s query (6%). In managing DH, the most frequent first choice was desensitizing, over-the-counter (OTC), potassium nitrate toothpaste (48%), followed by fluorides (38%), and glutaraldehyde/HEMA (3%). A total of 86% of respondents reported using a combination of products when treating DH, most frequently using fluoride varnish and desensitizing OTC potassium nitrate toothpaste (70%). The most frequent predisposing factor leading to DH, as reported by the practitioners, was recessed gingiva (66%), followed by abrasion, erosion, abfraction/attrition lesions (59%) and bruxism (32%).

Conclusions

The majority of network practitioners use multiple methods to diagnose and manage DH. Desensitizing OTC potassium nitrate toothpaste and fluoride formulations are the most widely used products to manage DH in dental practice setting.

Impression Techniques Used for Single-Unit Crowns: Findings from the National Dental Practice-Based Research Network

PURPOSE

To: (1) determine which impression and gingival displacement techniques practitioners use for single-unit crowns on natural teeth; and (2) test whether certain dentist and practice characteristics are significantly associated with the use of these techniques.

MATERIALS AND METHODS

Dentists participating in the National Dental Practice-Based Research Network were eligible for this survey study. The study used a questionnaire developed by clinicians, statisticians, laboratory technicians, and survey experts. The questionnaire was pretested via cognitive interviewing with a regionally diverse group of practitioners. The survey included questions regarding gingival displacement and impression techniques. Survey responses were compared by dentist and practice characteristics using ANOVA.

RESULTS

The response rate was 1777 of 2132 eligible dentists (83%). Regarding gingival displacement, most clinicians reported using either a single cord (35%) or dual cord (35%) technique. About 16% of respondents preferred an injectable retraction technique. For making impressions, the most frequently used techniques and materials are: poly(vinyl siloxane), 77%; polyether, 12%; optical/digital, 9%. A dental auxiliary or assistant made the final impression 2% of the time. Regarding dual-arch impression trays, 23% of practitioners report they typically use a metal frame tray, 60% use a plastic frame, and 16% do not use a dual-arch tray. Clinicians using optical impression techniques were more likely to be private practice owners or associates.

CONCLUSIONS

This study documents current techniques for gingival displacement and making impressions for crowns. Certain dentist and practice characteristics are significantly associated with these techniques.

Repair or Replacement of Restorations: A Prospective cohort study by dentists in The National Dental Practice-Based Research Network

BACKGROUND

A prospective cohort study that included dentists in The National Dental Practice-Based Research Network was conducted to quantify 12-month failures of restorations that were repaired or replaced at baseline. The study tested the hypothesis that no significant differences exist in failure percentages between repaired and replaced restorations after 12 months. It also tested the hypothesis that certain dentist, patient, and restoration characteristics are significantly associated with the incidence of restoration failure.

METHODS

Dentists recorded data for 50 or more consecutive defective restorations. The restorations that were either - repaired or replaced were recalled after 12 months and characterized for developing defects.

RESULTS

Dentists (N = 195) recorded data on 5,889 restorations; 378 restorations required additional treatment (74 repaired, 171 replaced, 84 teeth received endodontic treatment, and 49 were extracted). Multivariable logistic regression analysis indicated that additional treatment was more likely to occur if the original restoration had been repaired (7%) compared with replaced (5%) (odds ratio [OR], 1.6; P < .001; 95% confidence interval [CI], 1.2-2.1), if a molar was restored (7%) compared with premolars or anterior teeth (5% and 6%, respectively) (OR, 1.4; P = .010; 95% CI, 1.1-1.7), and if the primary reason was a fracture (8%) compared with other reasons (6%) (OR, 1.3; P = .033; 95% CI, 1.1-1.6).

CONCLUSIONS

An additional treatment was more likely to occur within the first year if the original restoration had been repaired (7%) compared with being replaced (5%). However, repaired restorations were less likely to need an aggressive treatment (replacement, endodontic treatment, or extraction) than replaced restorations.

PRACTICAL IMPLICATIONS

One year after repair or replacement of a defective restoration, the failure rate was low. However, repaired restorations were less likely to need an aggressive treatment than replaced restorations.

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.

Online tobacco websites and online communities-who uses them and do users quit smoking? The quit-primo and national dental practice-based research network Hi-Quit studies

Online tobacco cessation communities are beneficial but underused. Our study examined whether, among smokers participating in a web-assisted tobacco intervention (Decide2quit.org), specific characteristics were associated with navigating to BecomeAnEx.org, an online cessation community, and with subsequent quit rates. Among smokers (N = 759) registered with Decide2quit.org, we identified visitors to BecomeAnEx.org, examining associations between smoker characteristics and likelihood of visiting. We then tested for associations between visits and 6-month cessation (point prevalence). We also tested for an interaction between use of other online support-seeking (Decide2quit.org tobacco cessation coaches), visiting, and 6-month cessation. One quarter (26.0 %; n = 197) of the smokers visited BecomeAnEx.org; less than one tenth (7.5 %; n = 57) registered to participate in the online forum. Visitors were more likely to be female (73.0 vs. 62.6 % of non-visitors, P < 0.01) to have visited a cessation website before (33.0 vs. 17.4 %, P < 0.01) and to report quit attempts in the previous year (62.0 vs. 53.0 %, P = 0.03). In analyses of all participants, BecomeAnEx.org visiting was not associated with 6-month quit completion. Among participants who communicated with a coach, BecomeAnEx.org visiting also lacked a significant association with 6 month quit completion, although a non-significant trend toward quit completion in visitors was noted (OR 2.21, 95 % CI 0.81-3.1). Online cessation communities attract smokers with previous cessation website experience and recent quit attempts. Community visiting was not associated with quit rates in our study, but low use may have limited our power to detect differences. Further research should explore whether an additive effect can be achieved by offering community visitors support via online coaches.

Dentist material selection for single-unit crowns: Findings from the National Dental Practice-Based Research Network

OBJECTIVES

Dentists enrolled in the National Dental Practice-Based Research Network completed a study questionnaire about techniques and materials used for single-unit crowns and an enrollment questionnaire about dentist/practice characteristics. The objectives were to quantify dentists' material recommendations and test the hypothesis that dentist's and practice's characteristics are significantly associated with these recommendations.

METHODS

Surveyed dentists responded to a contextual scenario asking what material they would use for a single-unit crown on an anterior and posterior tooth. Material choices included: full metal, porcelain-fused-to-metal (PFM), all-zirconia, layered zirconia, lithium disilicate, leucite-reinforced ceramic, or other.

RESULTS

1777 of 2132 eligible dentists responded (83%). The top 3 choices for anterior crowns were lithium disilicate (54%), layered zirconia (17%), and leucite-reinforced glass ceramic (13%). There were significant differences (p<0.05) by dentist's gender, race, years since graduation, practice type, region, practice busyness, hours worked/week, and location type. The top 3 choices for posterior crowns were all-zirconia (32%), PFM (31%), and lithium disilicate (21%). There were significant differences (p<0.05) by dentist's gender, practice type, region, practice busyness, insurance coverage, hours worked/week, and location type.

CONCLUSIONS

Network dentists use a broad range of materials for single-unit crowns for anterior and posterior teeth, adopting newer materials into their practices as they become available. Material choices are significantly associated with dentist's and practice's characteristics.

CLINICAL SIGNIFICANCE

Decisions for crown material may be influenced by factors unrelated to tooth and patient variables. Dentists should be cognizant of this when developing an evidence-based approach to selecting crown material.

Treatment recommendations for single-unit crowns: Findings from The National Dental Practice-Based Research Network

BACKGROUND

The objectives of this study were to quantify practitioner variation in likelihood to recommend a crown and test whether certain dentist, practice, and clinical factors are associated significantly with this likelihood.

METHODS

Dentists in The National Dental Practice-Based Research Network completed a questionnaire about indications for single-unit crowns. In 4 clinical scenarios, practitioners ranked their likelihood of recommending a single-unit crown. The authors used these responses to calculate a dentist-specific crown factor (range, 0-12). A higher score implied a higher likelihood of recommending a crown. The authors tested certain characteristics for statistically significant associations with the crown factor.

RESULTS

A total of 1,777 of 2,132 eligible dentists (83%) responded. Practitioners were most likely to recommend crowns for teeth that were fractured, cracked, or endodontically treated or had a broken restoration. Practitioners overwhelmingly recommended crowns for posterior teeth treated endodontically (94%). Practice owners, practitioners in the Southwest, and practitioners with a balanced workload were more likely to recommend crowns, as were practitioners who used optical scanners for digital impressions.

CONCLUSIONS

There is substantial variation in the likelihood of recommending a crown. Although consensus exists in some areas (posterior endodontic treatment), variation dominates in others (size of an existing restoration). Recommendations varied according to type of practice, network region, practice busyness, patient insurance status, and use of optical scanners.

PRACTICAL IMPLICATIONS

Recommendations for crowns may be influenced by factors unrelated to tooth and patient variables. A concern for tooth fracture-whether from endodontic treatment, fractured teeth, or large restorations-prompted many clinicians to recommend crowns.

Evidence-practice gap for dental sealant application: results from a dental practice-based research network in Japan

PURPOSE

The study aims were: (i) to examine dentist practice patterns regarding treatment recommendations for dental sealants; and (ii) to identify characteristics associated with this recommendation.

METHODS

The study was performed using a cross-sectional questionnaire survey (Clinicaltrials.gov registration number NCT01680848). Participants were Japanese dentists (n = 282) recruited from the Dental Practice-based Research Network Japan. Three clinical photographs of the occlusal surface of a mandibular first molar were presented, portraying increasing depths of cavitation in a 12-year-old patient with high caries risk. Sealants would be an appropriate treatment in all three scenarios. We asked about the treatment decision for each case. We then performed multiple logistic regression analyses to evaluate associations between the decision to recommend sealants, and dentist, patient and practice characteristics.

RESULTS

Responses were obtained from 189 dentists (response rate = 67%). In the hypothetical scenarios, dentists' recommendations for sealants for the 12-year-old patient varied from 16% to 26% across the three hypothetical clinical scenarios. Multiple logistic regression analysis indicated that dentist agreement with the efficacy of assessment for caries risk showed a significant association with the percentages of patients receiving sealants.

CONCLUSIONS

Dentist practice patterns for sealant treatment recommendation show changes that are dependent on caries severity. The dentists' recommendations for sealants for the 12-year-old patient were low for all three selected scenarios, based on indications for sealants in the American Dental Association guidelines. Recommending a sealant showed a significant relationship with the dentist having a higher agreement with efficacy of caries risk assessment.

Screening Community-Dwelling Elders for Nutritional Risk: Determining the Influence of Race and Residence

This investigation explores nutritional risk among two subgroups of older adults African American and geographically isolated elders (65 years or older). Telephone interviews were conducted with a stratified random sample of 1,126 respondents and included a 10-item nutritional risk appraisal. Results indicated that over one half of the sample may be considered to be at moderate or high nutritional risk, with African American and rural elders at dispropor tionately higher risk and rural Blacks at highest risk across a variety of indicators. The nutritional vulnerability of these groups may prompt practitioners to design and target services specifically for their needs, while also stimulating research to improve our understanding of the factors that account for these differential risks.

Survey Methods to Optimize Response Rate in the National Dental Practice-Based Research Network

Surveys of health professionals typically have low response rates, and these rates have been decreasing in the recent years. We report on the methods used in a successful survey of dentist members of the National Dental Practice-Based Research Network. The objectives were to quantify the (1) increase in response rate associated with successive survey methods, (2) time to completion with each successive step, (3) contribution from the final method and personal contact, and (4) differences in response rate and mode of response by practice/practitioner characteristics. Dentist members of the network were mailed an invitation describing the study. Subsequently, up to six recruitment steps were followed: initial e-mail, two e-mail reminders at 2-week intervals, a third e-mail reminder with postal mailing a paper questionnaire, a second postal mailing of paper questionnaire, and staff follow-up. Of the 1,876 invited, 160 were deemed ineligible and 1,488 (87% of 1,716 eligible) completed the survey. Completion by step: initial e-mail, 35%; second e-mail, 15%; third e-mail, 7%; fourth e-mail/first paper, 11%; second paper, 15%; and staff follow-up, 16%. Overall, 76% completed the survey online and 24% on paper. Completion rates increased in absolute numbers and proportionally with later methods of recruitment. Participation rates varied little by practice/practitioner characteristics. Completion on paper was more likely by older dentists. Multiple methods of recruitment resulted in a high participation rate: Each step and method produced incremental increases with the final step producing the largest increase.

Discordance between presumed standard of care and actual clinical practice: the example of rubber dam use during root canal treatment in the National Dental Practice-Based Research Network

OBJECTIVES

Use of a rubber dam during root canal treatment is considered the standard of care because it enhances patient safety and optimises the odds of successful treatment. Nonetheless, not all dentists use a rubber dam, creating disconnect between presumed standard of care and what is actually done in clinical practice. Little is known about dentists' attitudes towards use of the rubber dam in their practices. The objectives were to: (1) quantify these attitudes and (2) test the hypothesis that specific attitudes are significantly associated with rubber dam use.

SETTING

National Dental Practice-Based Research Network (NationalDentalPBRN.org).

PARTICIPANTS

1490 network dentists.

OUTCOME MEASURES

Dentists completed a questionnaire about their attitudes towards rubber dam use during root canal treatment. Three attitude scales comprised 33 items that used a 5-point ordinal scale to measure beliefs about effectiveness, inconvenience, ease of placement, comparison to other isolation techniques and patient factors. Factor analysis, cluster analysis and multivariable logistic regression analysed the relationship between attitudes and rubber dam use.

RESULTS

All items had responses at each point on the 5-point scale, with an overall pattern of substantial variation across dentists. Five attitudinal factors (rubber dam effectiveness; inconvenient/time-consuming; ease of placement; effectiveness compared to Isolite; patient factors) and 4 clusters of practitioners were identified. Each factor and cluster was independently and strongly associated with rubber dam use.

CONCLUSIONS

General dentists have substantial variation in attitudes about rubber dam use. Beliefs that rubber dam use is not effective, inconvenient, time-consuming, not easy to place or affected by patient factors, were independently and significantly associated with lower rubber dam use. These attitudes explain why there is substantial discordance between presumed standard of care and actual practice.

Techniques and materials used by general dentists during endodontic treatment procedures: Findings from The National Dental Practice-Based Research Network

BACKGROUND

Little is known about which materials and techniques general dentists (GDs) use during endodontic procedures. The objectives were to quantify GDs' use of specific endodontic tools, quantify inappropriate use, and ascertain whether inappropriate use is associated with GDs' practice characteristics.

METHODS

GDs in The National Dental Practice-Based Research Network reported in a questionnaire materials and techniques they use during endodontic procedures.

RESULTS

Among eligible GDs, 1,490 (87%) participated. Most (93%; n = 1,383) used sodium hypochlorite to irrigate. The most commonly used sealers were zinc oxide eugenol (43%) and resin (40%), followed by calcium hydroxide (26%). Most (62%; n = 920) used a compaction obturation technique; 36% (n = 534) used a carrier-based method. Most (96%; n = 1,423) used gutta-percha as a filler; 5% used paste fillers. Few used irrigants (n = 46), techniques (n = 49), or fillers (n = 10) that investigators classified as inappropriate.

CONCLUSIONS

GDs use a broad range of endodontic techniques and materials, often adapting to newer technologies as they become available. Few GDs use tools that the investigators classified as inappropriate.

PRACTICAL IMPLICATIONS

GDs use many types of endodontic techniques and materials, but only a small percentage of them are inappropriate.

Evidence-practice gap for in-office fluoride application in a dental practice-based research network

OBJECTIVE

The aims of this study were to examine dentists' recommendations for in-office fluoride to patients and identify dentists' characteristics associated with these recommendations.

STUDY DESIGN AND SETTING

The study was conducted using a cross-sectional questionnaire survey in Japan. The survey queried dentists (n = 282) in outpatient dental practices affiliated with the Dental Practice-based Research Network Japan (JDPBRN). This network aims to assist dentists in investigating research questions and sharing their experience and expertise.

RESULTS

The responses were obtained by 189 dentists (67 percent). Among valid response, 54 percent of dentists (n = 98) recommend in-office fluoride to more than 50 percent of their patients aged 6-18 years and 15 percent (n = 29) recommended this care to more than 50 percent of their patients aged over 18 years. Multiple logistic regression analysis suggested that factors associated with the percentage of patients who are recommended in-office fluoride included patient's interest in caries prevention and dentist's belief in the effectiveness of caries risk assessment.

CONCLUSIONS

Dentist practice patterns for recommending in-office fluoride vary widely. Recommendation was significantly related to having a higher percentage of patients interested in caries prevention and to the dentist's belief about the effectiveness of caries risk assessment. (Clinicaltrials.gov registration number NCT01680848).

The Decision to Repair or Replace a Defective Restoration is Affected by Who Placed the Original Restoration: Findings from the National Dental PBRN

OBJECTIVES

To evaluate how restoration characteristics are associated with the decision to repair or replace an existing restoration. The following hypotheses were studied: dentists who placed the original restoration are more likely to repair instead of replace restorations (H1) that are in molar teeth; (H2) that are in the upper arch; (H3) that have amalgam restorative material; (H4) if a fracture is not the primary reason for the defect; and (H5) when the restoration comprises more than one surface.

METHODS

This cross-sectional study used a consecutive patient/restoration recruitment design. 194 dentists members of a dental practice-based research network recorded data on restorations in permanent teeth that needed repair or replacement.

RESULTS

For 6,623 of the 8,770 defective restorations in 6,643 patients, the treatment was provided by the dentist who had not placed the original restoration (75%). The 2-way interaction revealed that dentists who had placed the original restoration often chose to repair when the defective restoration was in a molar, relative to premolar or anterior teeth (OR = 2.2, p <.001); and chose to replace when the restoration had amalgam (OR = 0.5, p < .001), and when it was a fracture compared to another reason (OR = 0.8, p = 001).

CONCLUSION

Most dentists are not conservative when they revisit a restoration that they originally placed regardless of type of failure, number of surfaces or material used. However, dentists who had placed the original restoration were significantly more likely to repair it when the defective restoration was in a molar tooth.

CLINICAL SIGNIFICANCE

Most dentists who placed the original restoration were prone to replace it, however if the defective restoration was located in a molar tooth they would consider repairing it.

The dynamic behavior of the early dental caries lesion in caries-active adults and implications

OBJECTIVE

To describe the full range of behavior of the visible, noncavitated, early caries lesion in caries-active adults with substantial fluoride exposure, and to consider implications.

METHODS

The data were from the Xylitol for Adult Caries Trial (X-ACT) collected annually for 33 months using condensed ICDAS caries threshold criteria. Individual tooth surfaces having a noncavitated caries lesion were included, and the patterns of transition to each subsequent annual clinical examination to sound, noncavitated or cavitated, filled or crowned were determined. The resulting sets of patterns for an individual tooth surface, looking forward from its first appearance as a noncavitated lesion, were combined into one of four behavior profiles classified as reversing, stable, oscillating, or continuously progressing, or were excluded if not part of the caries continuum. The distributions of profile types were assessed using the Rao-Scott chi-square test, which adjusts for clustering of tooth surfaces within teeth.

RESULTS

Inter- and intra-examiner kappa scores demonstrated acceptable calibration at baseline and annually. 8084 tooth surfaces from 543 subjects were included. The distribution of profile types differed significantly between coronal and root surfaces. Overall, two-thirds of all coronal noncavitated lesions were first seen at baseline, half reversed, over a fifth were stable, 15% oscillated, and only 8.3% progressed to cavitation, filled, or crowned in 33 months or less (6.3% consistently Progressed plus 2.0% inconsistently, a subset of oscillating, which oscillated before progressing to cavitation). Approximal, smooth, and occlusal coronal surfaces each were significantly different in their individual distributions of profile types. Xylitol showed no significant and consistent effect on this distribution by tooth surface type. This was in keeping with the X-ACT's lack of effect of xylitol at the noncavitated plus cavitated lesion thresholds combined.

CONCLUSIONS

This study demonstrated the full dynamic range of early caries lesion behavior. The great majority were not progressive, and few (8.3%) became cavitated over 33 months in caries-active adults using fluorides. Important caries management implications favoring recorded longitudinal monitoring, prevention of active risks, and minimal restoration only after direct visual determination of cavitation are discussed.

General Dentists' Use of Isolation Techniques during Root Canal Treatment: From the National Dental Practice-based Research Network

INTRODUCTION

A preliminary study done by a National Dental Practice-Based Research Network precursor observed that 44% of general dentists (GDs) reported always using a rubber dam (RD) during root canal treatment (RCT). This full-scale study quantified the use of all isolation techniques, including RD use.

METHODS

Network practitioners completed a questionnaire about isolation techniques used during RCT. Network enrollment questionnaire data provided practitioner characteristics.

RESULTS

One thousand four hundred ninety of 1716 eligible GDs participated (87%); 697 (47%) reported always using an RD. This percentage varied by tooth type. These GDs were more likely to always use an RD, do not own a private practice, perform less than 10 RCTs/month, and have postgraduate training.

CONCLUSIONS

Most GDs do not use an RD all the time. Ironically, RDs are used more frequently by GDs who do not perform molar RCT. RD use varies with tooth type and certain dentist, practice, and patient characteristics.

Concordance between responses to questionnaire scenarios and actual treatment to repair or replace dental restorations in the National Dental PBRN

OBJECTIVE

To quantify the agreement between treatment recommended during hypothetical clinical scenarios and actual treatment provided in comparable clinical circumstances.

METHODS

A total of 193 practitioners in the National Dental Practice-Based Research Network participated in both a questionnaire and a clinical study. The questionnaire included three hypothetical scenarios about treatment of existing restorations. Clinicians then participated in a clinical study about repair or replacement of existing restorations. We quantified the overall concordance between their questionnaire responses and what they did in actual clinical treatment.

RESULTS

Practitioners who recommended repair (instead of replacement) of more scenario restorations also had higher repair percentages in clinical practice. Additionally, for each of the three hypothetical scenario restorations, practitioners who recommended repair had higher repair percentages in clinical practice.

CONCLUSIONS

The questionnaire scenarios were a valid measure of clinicians' tendency to repair or replace restorations in actual clinical practice.

CLINICAL IMPLICATIONS

Although there was substantial variation in practitioners' tendency to repair or replace restorations, responses to questionnaire scenarios by individual practitioners were concordant with what they did in actual clinical practice.

Methods dentists use to diagnose primary caries lesions prior to restorative treatment: Findings from The Dental PBRN

OBJECTIVE

To (1) quantify the diagnostic techniques used by Dental Practice-Based Research Network (DPBRN) dentists before they decide to treat primary caries lesions surgically and (2) examine whether certain dentist, practice, and patient characteristics are associated with their use.

METHODS

A total of 228 DPBRN dentists recorded information on 5,676 consecutive restorations inserted due to primary caries lesions on 3,751 patients. Practitioner-investigators placed a mean of 24.9 (SD = 12.4) restorations. Lesions were categorized as posterior proximal, anterior proximal, posterior occiusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorized as clinical assessment, radiographs, and/or optical. Statistical analysis utilized generalized mixed-model ANOVA to account for the hierarchical structure of the data.

RESULTS

By lesion category, the diagnostic technique combinations used most frequently were clinical assessment plus radiographs for posterior proximal (47%), clinical assessment for anterior proximal (51%), clinical assessment for posterior occlusal (46%), clinical assessment for posterior smooth (77%), and clinical assessment for anterior smooth (80%). Diagnostic technique was significantly associated with lesion category after adjusting for clustering in dentists (p < 0.0001).

CONCLUSION

These results--obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios--quantified the diagnostic techniques most commonly used during the actual delivery of routine restorative care. Diagnostic technique varied by lesion category and with certain practice and patient characteristics.