Factors that Dentists use to Decide Whether or Not to Render a Patient Edentulous

Aims

To identify the factors that dentists use to decide whether to render a patient edentulous, prior to developing a questionnaire to investigate the factors that dentists use when making this decision.

Method

This was a qualitative study involving two groups of seven dentists practising in primary care in East Lancashire who were given scenarios involving patients of different types to facilitate discussion and identify all factors. Audio recordings were used during the focus groups and were subsequently fully transcribed. Two members of the research team independently coded the transcripts and then used thematic analysis to identify key themes.

Results

Analysis of the results identified 12 factors that the dentists considered when making a patient edentulous. These were caries, periodontal disease, position of the teeth, aesthetics, bone support, the transition from partial dentures, patient motivation, medicolegal issues, age of the patient, patient choice, cost of treatment, and the dentist's attitude and skills.

Conclusion

The dentists identified a large number of factors that they might consider before making a patient edentulous. There was a consensus that the change should be made gradually, if possible.

Dentists’ and Specialists’ Knowledge of Chronic Orofacial Pain: Results from a Continuing Professional Development Survey

Aim

To explore the knowledge of chronic orofacial pain within general dental practitioners (GDPs) and dental specialists.

Methods

Following a recent national survey of GDPs and specialists on the diagnosis of facial pain, all those who responded were asked to answer four multiple-choice questions on chronic orofacial pain as part of a continuing professional development exercise. The questions were formulated using a review of the literature and consultation with a facial pain expert and were administered by post.

Results

Of the 380 subjects who completed the original survey, 212 (56%) returned completed multiple-choice questionnaires. Specialists correctly answered significantly more questions than GDPs ( P<0.001). The majority of specialists—49/83 (59%)—obtained a score of three or more, compared to 39/129 (30%) GDPs. This was due to variation in answering one question. Significantly more specialists—50 (60%)—correctly selected trigeminal neuralgia (TN) as a condition that is not associated with COFP, whereas only 41 (32%) GDPs chose this answer. Both specialists and GDPs grossly underestimated the prevalence of COFP in secondary care clinics.

Conclusions

The results suggest that specialists and GDPs may have sufficient knowledge to make an appropriate diagnosis of COFP, but they also highlight the knowledge gaps and perhaps the need for more extensive inclusion of COFP in the dental undergraduate curriculum.

How primary care dentists perceive and are influenced by research

INTRODUCTION

Little is understood as to how primary care dentists alter their clinical practice.

AIM

To develop an understanding of how primary care dentists view and use research to inform their clinical practice.

METHODS

An iterative approach was followed using two methods of data collection. A focus group was undertaken with dentists and researchers who had been involved in primary care dental research. Subsequently phased, qualitative interviews were undertaken with primary care dentists with a range of research experiences. Focus group and interviews were audio-recorded and transcribed verbatim. Six people participated in the focus group. Eighteen dentists participated in the interviews. Interviews were undertaken in four phases until saturation was achieved. Data were analysed using constant comparison.

FINDINGS

Evidence-based dentistry was considered the ideal. However, the research base for primary care dentistry was thought to lag behind clinical services, to focus on incorrect endpoints, to disregard the patients' voice and failed to consider the impact of conducting research on dental practices. Dentists modified their clinical practice based upon research, colleagues' opinions, courses and ad hoc personal evaluation. Uptake of research was affected by the ethos of the practice, which determined whether the dentists were early or late adopters of research and financial viability of new interventions.

CONCLUSION

  Dentists wanted concise, timely evidence-based guidance to aid their management of patients. Further research needs to be undertaken to understand how to develop an evidence-based culture in primary dental care.

Replacement versus repair of defective restorations in adults: amalgam

BACKGROUND

Amalgam is a common filling material for posterior teeth, as with any restoration amalgams have a finite life-span. Traditionally replacement was the ideal approach to treat defective amalgam restorations, however, repair offers an alternative more conservative approach where restorations are only partially defective. Repairing a restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement.

OBJECTIVES

To evaluate the effectiveness of replacement (with amalgam) versus repair (with amalgam) in the management of defective amalgam dental restorations in permanent molar and premolar teeth.

SEARCH STRATEGY

For the identification of studies relevant to this review we searched the Cochrane Oral Health Group Trials Register (to 23rd September 2009); CENTRAL (The Cochrane Library 2009, Issue 4); MEDLINE (1950 to 23rd September 2009); EMBASE (1980 to 23rd September 2009); ISI Web of Science (SCIE, SSCI) (1981 to 22nd December 2009); ISI Web of Science Conference Proceedings (1990 to 22nd December 2009); BIOSIS (1985 to 22nd December 2009); and OpenSIGLE (1980 to 2005). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. There were no language limitations.

SELECTION CRITERIA

Trials were selected if they met the following criteria: randomised or quasi-randomised controlled trial, involving replacement and repair of amalgam restorations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis.

MAIN RESULTS

The search strategy retrieved 145 potentially eligible studies, after de-duplication and examination of the titles and abstracts all but three studies were deemed irrelevant. After further analysis of the full texts of the three studies identified, none of the retrieved studies met the inclusion criteria and all were excluded from this review.

AUTHORS' CONCLUSIONS

There are no published randomised controlled clinical trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled clinical trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, distress and anxiety, time and costs.

Replacement versus repair of defective restorations in adults: resin composite

BACKGROUND

Composite filling materials have been increasingly used for the restoration of posterior teeth in recent years as a tooth coloured alternative to amalgam. As with any filling material composites have a finite life-span. Traditionally, replacement was the ideal approach to treat defective composite restorations, however, repairing composites offers an alternative more conservative approach where restorations are partly still serviceable. Repairing the restoration has the potential of taking less time and may sometimes be performed without the use of local anaesthesia hence it may be less distressing for a patient when compared with replacement.

OBJECTIVES

To evaluate the effectiveness of replacement (with resin composite) versus repair (with resin composite) in the management of defective resin composite dental restorations in permanent molar and premolar teeth.

SEARCH STRATEGY

For the identification of studies relevant to this review we searched the Cochrane Oral Health Group Trials Register (to 23rd September 2009); CENTRAL (The Cochrane Library 2009, Issue 4); MEDLINE (1950 to 23rd September 2009); EMBASE (1980 to 23rd September 2009); ISI Web of Science (SCIE, SSCI) (1981 to 22nd December 2009); ISI Web of Science Conference Proceedings (1990 to 22nd December 2009); BIOSIS (1985 to 22nd December 2009); and OpenSIGLE (1980 to 2005). Researchers, experts and organisations known to be involved in this field were contacted in order to trace unpublished or ongoing studies. There were no language limitations.

SELECTION CRITERIA

Trials were selected if they met the following criteria: randomised or quasi-randomised controlled trial, involving replacement and repair of resin composite restorations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed titles and abstracts for each article identified by the searches in order to decide whether the article was likely to be relevant. Full papers were obtained for relevant articles and both review authors studied these. The Cochrane Collaboration statistical guidelines were to be followed for data synthesis.

MAIN RESULTS

The search strategy retrieved 279 potentially eligible studies, after de-duplication and examination of the titles and abstracts all but four studies were deemed irrelevant. After further analysis of the full texts of the four studies identified, none of the retrieved studies met the inclusion criteria and all were excluded from this review.

AUTHORS' CONCLUSIONS

There are no published randomised controlled clinical trials relevant to this review question. There is therefore a need for methodologically sound randomised controlled clinical trials that are reported according to the Consolidated Standards of Reporting Trials (CONSORT) statement (www.consort-statement.org/). Further research also needs to explore qualitatively the views of patients on repairing versus replacement and investigate themes around pain, anxiety and distress, time and costs.

Reviewing the evidence: can cognitive behavioral therapy improve outcomes for patients with chronic orofacial pain?

AIMS

To review evidence for chronic orofacial pain management using cognitive behavioral therapy (CBT).

METHODS

Electronic databases were searched for randomized controlled trials in which CBT was compared either alone or in combination with other forms of therapy for management of chronic orofacial pain. The quality of trials was assessed blind by three authors using a validated scale that had been specifically designed to score the quality of randomized controlled trials for psychological interventions. Author agreement was assessed using interclass correlation co_efficients.

RESULTS

Fourteen potentially relevant randomized controlled trials were identified. Seven trials were excluded, leaving seven for analysis; two studies were merged as they included the same trial and therefore six trials were used in the final analysis. All but one of the randomized controlled trials identified were based on temporomandibular disorders (TMD). Scoring of the trials showed that the three raters were in close agreement, with four trials performing well (scores of 22-35) whilst the remaining two trials were poor (scores < 18). Of the four trials, one did not show any improvement with CBT prior to conservative treatment whilst the other three showed that CBT alone or in conjunction with conservative treatment improved both short-term and long-term outcomes in functional, dysfunctional, and chronic TMD patients.

CONCLUSIONS

CBT, either alone or in combination with biofeedback, conservative treatment and/or self-care, can improve outcomes for patients with TMD in secondary care. However, further research is needed to assess its effectiveness in primary care and in management of other chronic orofacial pain conditions. Further, the number of sessions needed, mode of delivery, and cost-effectiveness also remain unclear.

A prospective study of dental anxiety in a cohort of children followed from 5 to 9 years of age

BACKGROUND

The development of dental anxiety in children is poorly understood.

AIMS

The aims of this study were to measure changes in dental anxiety over time and to examine the relationship between anxiety, dental care, and other factors.

DESIGN

A prospective cohort study of children in the north-west of England followed from 5 to 9 years of age. The participants were clinically examined and their parents completed the same questionnaire at 5 and 9 years.

RESULTS

The majority (54.3%N = 38) of participants who were anxious at 5 years were no longer anxious at 9 years, but a large proportion of children who were anxious at 5 remained anxious at 9 years of age (45.7%N = 32). During the follow-up period, a larger proportion of children developed anxiety (11.7%N = 85) than the proportion of children who were reported as being anxious at baseline (8.8%N = 70). At 9 years of age, dental anxiety was significantly associated with girls; parental anxiety; a history of extraction; and irregular, asymptomatic dental visiting. These factors were also significantly associated with dental anxiety at 5 years old.

CONCLUSIONS

Dental anxiety was cumulative in the study population over time, and its development influenced by multiple variables. Results suggest that adverse conditioning and vicarious learning are both important in the development of this condition.

Predictive tool for estimating the potential effect of water fluoridation on dental caries

OBJECTIVE

To provide a tool for public health planners to estimate the potential improvement in dental caries in children that might be expected in a region if its water supply were to be fluoridated.

BASIC RESEARCH DESIGN

Recent BASCD (British Association for the Study of Community Dentistry) dental epidemiological data for caries in 5- and 11-year-old children in English primary care trusts in fluoridated and non-fluoridated areas were analysed to estimate absolute and relative improvement in dmft/DMFT and caries-free measures observed in England. Where data were sufficient for testing significance this analysis included the effect of different levels of deprivation.

RESULTS

A table of observed improvements was produced, together with an example of how that table can be used as a tool for estimating the expected improvement in caries in any specific region of England. Observed absolute improvements and 95% confidence intervals were: for 5-year-olds reduction in mean dmft 0.56 (0.38, 0.74) for IMD 12, 0.73 (0.60, 0.85) for IMD 20, and 0.94 (0.76, 1.12) for IMD 30, with 12% (9%, 14%) more children free of caries; for 11-year-olds reduction in mean DMFT 0.12 (0.04, 0.20) for IMD 12, 0.19 (0.13, 0.26) for IMD 20, 0.29 (0.18, 0.40) and for IMD 30, with 8% (5%, 11%) more children free from caries.

CONCLUSIONS

The BASCD data taken together with a deprivation measure are capable of yielding an age-specific, 'intention to treat' model of water fluoridation that can be used to estimate the potential effect on caries levels of a notional new fluoridation scheme in an English region.

The prescription and outcomes of fissure sealants applied to a group of high caries risk children by general dental practitioners working in the North West of England

OBJECTIVE

To describe the use and outcomes of fissure sealants applied to the first permanent molars (FPMs) of children with high caries risk.

DESIGN

Retrospective cohort study.

SETTING

General dental practices in North West England.

PARTICIPANTS

677 children between the ages of 5 and 14 years who had dmfs > or =2, and regularly attended 50 general dental practitioners.

OUTCOMES

Analyses were performed at patient level. Logistic regression models, taking into account the clustering of subjects within dental practices, were fitted to identify whether the decision to fissure seal FPMs was significantly associated with gender, socio-economic status, number of carious primary teeth and percentage of carious primary teeth filled. Similar logistic regression models were fitted for caries experience in FPMs.

RESULTS

Poorer children were significantly (p < 0.05, OR = 0.84, 95% CI = 0.71, 0.99) less likely to receive fissure sealants than affluent children, whilst girls (p < 0.01, OR = 1.54, 95% CI = 1.12, 2.12) were more likely to have sealants than boys. The total number of carious primary teeth was also a significant (p < 0.01, OR = 1.15, 95% CI = 1.06, 1.25) independent predictor of dentists' decisions to fissure seal FPMs. For each carious primary tooth, the odds of having caries in FPMs increased by 1.16 (95% CI = 1.06, 1.26). Analysis showed that pit and fissure caries in FPMs was not affected by the presence or absence of fissure sealants.

CONCLUSIONS

The decision to fissure seal FPMs is affected by caries experience in the primary dentition. Girls and affluent children were more likely to receive fissure sealants. It appears that the placement of fissure sealants by general dental practitioners was not effective in preventing pit and fissure caries in these high-risk children.

A qualitative investigation of the influence of time since graduation on English dentists' approach to the care of young children

BACKGROUND

In the UK, general dental practitioners (GDPs) provide the majority of dental care to young children. The approach to undergraduate teaching of paediatric dentistry varies across UK dental schools. There is no understanding of how undergraduate teaching influences practice in the first few years after qualification and how this influence behaves over time as dentists mature as clinicians.

OBJECTIVE

The aim of this paper is to gain a deeper understanding of the influence of time since graduation on how GDPs manage the dental care of their child patients.

DESIGN

A qualitative study, with three interviewers conducted 93 interviews with GDPs practising in the north-west of England. Interviews were transcribed verbatim and content analysis was used with the purpose of identifying themes from the data.

RESULTS

Findings showed that formal postgraduate education was not a great influence upon the GDPs' approach to care over time. Change in approach was influenced by experiential learning over a GDP's career and external influences such as policy change, but this was not underpinned by any formal reflective practice.

CONCLUSIONS

Education is just one of many influences on clinical practice over the whole of a clinician's career. A gradual change in clinical practice is influenced by the personal experience of dentists treating children.

Approaches taken to the treatment of young children with carious primary teeth: a national cross-sectional survey of general dental practitioners and paediatric specialists in England

AIM

To measure the distribution of choices for the treatment of a child with differing severities of caries in a primary molar tooth among specialists in paediatric dentistry and general dental practitioners (GDPs) in England.

METHOD

Two surveys were undertaken using the same tool. The populations invited to take part in the study were confined to dentists practising in England in 2004. They were 500 GDPs selected at random from the list of all GDPs with a National Health Service (NHS) contract identified by the Dental Practice Board (DPB) and all 148 specialists in paediatric dentistry appearing on the General Dental Council specialist register. The selected dentists were sent a questionnaire containing four hypothetical clinical case scenarios in which the severity of dental caries in a single primary molar differed. Each clinical case scenario had a list of possible treatment options and participants were asked to select their single most preferred treatment option. To maximise the response rate there were three mailing rounds.

RESULTS

Of the 500 GDPs and 148 paediatric specialists sent a questionnaire, 322 (64%) GDPs and 115 (78%) specialists responded. The answers to each of the case scenarios indicate differences of opinion both between and among GDPs and specialists in the care they would recommend for a child with caries in a primary molar tooth. This variation in opinion about care was more pronounced for a single deep carious lesion than for a less severe lesion. The spread of treatment options chosen in each scenario indicates disagreement among GDPs and specialists about restorative techniques and philosophy of care.

CONCLUSION

In England there is wide variation among GDPs and specialists in paediatric dentistry about the best way to treat a young child with caries in a primary molar tooth. Well designed studies are urgently needed to provide strong evidence for the most effective way to manage the dental care of children.

General dental practitioner's views on dental general anaesthesia services

OBJECTIVE

Policy has recently changed on provision of dental general anaesthetic services in England. The aim of this study was to investigate general dental practitioners' views about dental general anaesthetics, the reduction in its availability and the impact on care of children with toothache.

RESEARCH DESIGN

Qualitative study using semi-structured interviews and clinical case scenarios.

PARTICIPANTS

General dental practitioners providing NHS services in the North West of England.

RESULTS

93 general dental practitioners were interviewed and 91 answered a clinical case scenario about the care they would provide for a 7-year-old child with multiple decayed teeth presenting with toothache. Scenario responses showed variation; 8% would immediately refer for general anaesthesia, 25% would initially prescribe antibiotics, but the majority would attempt to either restore or extract the tooth causing pain. Interview responses also demonstrated variation in care, however most dentists agree general anaesthesia has a role for nervous children but only refer as a last resort. The responses indicated an increase in inequalities, and that access to services did not match population needs, leaving some children waiting in pain.

CONCLUSIONS

Most general dental practitioners support moving dental general anaesthesia into hospitals but some believe that it has widened health inequalities and there is also a problem associated with variation in treatment provision. Additional general anaesthetic services in some areas with high levels of tooth decay are needed and evidence based guidelines about caring for children with toothache are required.

Exploring factors that influence general dental practitioners when providing advice to help prevent caries in children

OBJECTIVE

To increase understanding about how and to whom general dental practitioners provide preventive advice to reduce caries in young children.

DESIGN

Qualitative study using semi-structured interviews.

SETTING

The North West of England. Interviews took place between March and September 2003.

SUBJECTS AND METHODS

Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method.

RESULTS

Children with caries were more likely to be questioned about diet and oral hygiene and if dentists believed parents to be motivated they were more inclined to spend time providing advice. Most dentists seemed to believe that education was the key to preventing caries and gave preventive advice in the form of a short educative talk. There was little use of visual aids or material for parents to take home.

CONCLUSION

Preventive advice is given in an ad hoc way with no formal targeting. Most dentists deliver preventive advice as a short educative talk with no props or additional materials. Use of visual aids, providing materials for parents to take home and greater emphasis on partnership might help improve the impact of advice.

Exploring the content of the advice provided by general dental practitioners to help prevent caries in young children

OBJECTIVES

To increase understanding about the content of preventive advice and care offered by general dental practitioners to young children.

DESIGN

Qualitative study using semi-structured interviews. Setting The North West of England. Interviews took place between March and September 2003.

SUBJECTS AND METHODS

Ninety-three general dental practitioners practising within the general dental service were interviewed about the care they provide to young children. The interviews were recorded, transcribed and analysed using a constant comparative method.

RESULTS

Preventive advice given to parents of young children is usually about sugar consumption and tooth brushing behaviour but the emphasis and specific messages provided varies among general dental practitioners. Use of fluorides varied considerably, suggesting that some dentists either have reservations or are unclear about the appropriate use of fluorides. The study indicates important variation in the content of preventive care.

CONCLUSION

There is important variation in the approach of general dental practitioners to the core activity of preventing caries in young children and some views expressed are not supported by the evidence base.

Dental screening in schools: the views of parents, teachers and school nurses

OBJECTIVES

To obtain insight into the views of relevant 'stakeholders' (parents, teachers and school nurses) in dental screening in schools.

METHODS

Eight schools in Chester and Ellesmere Port in the UK formed the setting of this study. A teacher from each school participated in one-to-one interviews, and focus groups for parents were carried out in each school. A focus group for school nurses working in the locality was also held. The same trained researcher undertook the interviews and focus groups; all interviews and focus groups were tape recorded, transcribed verbatim and thematically analysed independently by two trained individuals.

RESULTS

Teachers, school nurses and parents all perceived the process of negative consent and the current dental examination as acceptable. The follow up procedure for identification of screened positive children was seen as inadequate. There was a strong feeling within each group that parents were ultimately responsible for their children's oral health and that state institutions had a limited role in ensuring children attended and received dental treatment.

CONCLUSIONS

All of the groups considered it was primarily the responsibility of parents to take screened positive children to see a dentist. The NHS has limited influence on this process. This fact represents a significant challenge to improving the effectiveness of school dental screening.