Bridging the Gap in Caries Management Between Research and Practice Through Education: The Indiana University Experience

Integration of an evidence-based caries management approach in dental education: The perspectives of dental instructors

PURPOSE/OBJECTIVES

Evidence-based caries management (EBCM) has developed into an internationally recognized tool for integration of comprehensive non-surgical caries treatment in dental education. However, uptake of the EBCM approach remains uneven across Canadian dental schools. Our project sought to understand how dental instructors perceive the challenges and solutions to the integration of the EBCM approach in undergraduate clinical education.

METHODS

Using a qualitative descriptive design, we recruited a purposeful sample of clinical instructors supervising undergraduate dental students in caries-related dental care. Semi-structured, online interviews focused on the main characteristics of EBCM. Interviews were analyzed using the awareness, desire, knowledge, ability, and reinforcement (ADKAR) change management model to understand challenges with EBCM implementation in undergraduate education. The analysis process started with verbatim transcription; then, transcripts were coded deductively based on the interview guide and the ADKAR model domains, and inductively to generate emergent codes. Finally, thematic analysis was used to develop themes and subthemes.

RESULTS

We interviewed 11 dental instructors with a wide range of clinical experience. Our results show that participants had sufficient awareness regarding the need for the EBCM approach and portrayed a strong desire to participate in bringing curricular changes. Knowledge and ability of participants depended on their training, experience, and involvement in continuing education courses. A lack of standardized caries management practices, less chairside time, and poor remuneration for instructors were major barriers in EBCM clinical implementation. Potential solutions suggested included providing continuing education courses, credits for students for non-surgical caries management, and remunerating instructors for implementation.

CONCLUSIONS

In conclusion, most participants were aware of the need for a substantive change toward EBCM and demonstrated the desire to participate and improve its implementation. Our analysis showed that to facilitate full integration of the EBCM approach into the undergraduate dental clinics, organizational focus needs to be placed on the individual's knowledge and ability, with tailored efforts toward reinforcement.

Assessment of implementation of the caries management by risk assessment philosophy in a dental school

OBJECTIVE

This cross-sectional study assessed the implementation of documenting a baseline caries risk assessment (CRA) of patients seen by predoctoral dental students and its association with the presence of caries risk management (CRM) treatment.

METHODS

A convenience sample of 10,000 electronic axiUm patient records at Tufts University School of Dental Medicine was retrospectively assessed for the presence or absence of a completed CRA and CRM after IRB approval following predetermined inclusion and exclusion criteria. The CRM variables (nutrition counseling, sealant, fluoride) were identified by procedure codes that were completed by the student. Associations were assessed via the chi-square test, Kruskal-Wallis test (with Dunn's test and the Bonferroni correction used in post-hoc tests) and Mann-Whitney U test.

RESULTS

Most patients (70.5%) had a CRA completed. However, only 24.9% (out of the 7045 patients with a completed CRA) received CRM, while 22.9% of the 2,955 patients without a CRA received CRM. The difference between the groups with and without a completed CRA in terms of the percentage receiving CRM was not clinically significant. Significant associations were found between a completed CRA and in-house fluoride treatment (p = .034) and between a completed CRA and sealant treatment (p = .001). Patients with higher baseline CRA levels (i.e., greater risk) were more likely to have CRM (16.9% of the 785 patients at low risk, 21.1% of the 1282 patients at moderate risk, 26.3% of the 4347 patients at high risk, and 32.6% of the 631 patients at extreme risk). The association between these two variables was significant (p < .001).

CONCLUSION

There is evidence that students were mostly compliant with completing a CRA for most patients; however, there is a deficiency in implementation of CRM approach to help support dental caries management, and there is still much room for improvement.

Current Novel Caries Diagnostic Technologies: Restorative Dentists' Attitude and Use Preferences

Early detection of caries lesions is key to a successful restorative dental treatment plan. The aim of this study was to investigate the preferences and attitude of graduate restorative dentistry residents (RDRs) regarding novel caries diagnostic technologies (NCDT) and to provide a brief overview of available technologies for both specialized and general dental practice. This cross-sectional study used an online questionnaire (17 questions) concerning RDRs’ attitude, preferences, and insights regarding five available NCDTs. It was distributed among twenty RDRs at a local government dental school following a review session about NCDTs. Collected responses were analyzed statistically using one-way analysis of variance (ANOVA), chi-squared with Bonferroni correction, and Kruskal-Wallis tests at a 0.05 significance level. Sixty-five percent of RDRs reported an interest in NCDTs as a discussion topic and almost half of them were positive towards their use, however, sixty percent of respondents were hesitant to diagnose caries solely using NCDTs. Fiber-optic-transillumination (FOTI) systems were ranked the best overall and with regard to all the investigated criteria (p < 0.05). Chosen reasons for FOTI included price followed by ease of use. In general, high price rated as the most perceived reason for not choosing a given NCDT followed by low practical applicability. Meanwhile, ease of use followed by relevant application ranked as the main reported reasons to choose an NCDTs.

Minimum intervention dentistry in the US: an update from a cariology perspective

Despite evidence strongly supporting use of non-invasive or minimally invasive procedures in caries management, there is still a large gap between evidence-based recommendations and application of these concepts in practice, with the practice of dentistry still largely dominated by invasive procedures in the US. This paper describes efforts in education and clinical practice in the US in the last decade to promote evidence-based cariology strategies, which support a minimum intervention dentistry (MID) philosophy. These include, for example: a competency-based core cariology curriculum framework which has been developed and disseminated. National education accreditation standards supporting caries management are likely to soon be changed to support assessment of best evidence in cariology. There are several ongoing efforts by organised dentistry and other groups involving dental educators, researchers and clinical practitioners to promote cariology concepts in practice, such as the development of evidence-based clinical practice guidelines for caries management by the American Dental Association. Within each of these strategies there are challenges, but also opportunities to expand the implementation of MID in the US, which create optimism for future improvements over time.

Dental Caries Preventive Considerations: Awareness of Undergraduate Dental Students

The aim of this study was to assess awareness and knowledge of undergraduate dental students of common caries-related preventive considerations and to highlight these factors in a concise manner to act as a guide for dental practitioners. A sample of 118 undergraduate students at a local government dental school was included. An interactive survey that contains questions related to common preventive strategies against dental caries was presented to the students. The survey contained 22 questions concerning dietary and therapeutic strategies. Students casted their votes using their mobile cellphones. The correct answer for each question was shown to the students, and further discussion was held. Data was collected, and the statistical analysis was conducted using one-sample z- and chi-squared tests at 0.05 significance level. The students answered the questions related to oral hygiene practices, xylitol, and the common knowledge regarding fluoride. The questions related to the use of chlorhexidine, dietary factors, and fluoride formulations were answered mostly incorrectly. The students seemed to grasp details of important concepts of flossing, brushing, reducing frequency of sugar exposure, and the use of fluoride products. Still, more emphasis should be given to increase students’ awareness of dietary guidelines for caries prevention, since adequate knowledge of these modalities is paramount for graduating dentists.

Evaluation of Final-Year Turkish Dental Students' Knowledge, Attitude, and Self-Perceived Competency towards Preventive Dentistry

BACKGROUND

Dental education plays an important role in providing students with the opportunity to develop their evidence-based knowledge and clinical skills regarding patient-specific preventive care and caries management strategies. The aims of this study were to examine the knowledge, attitude, and self-perceived competency towards preventive dentistry among final-year dental students and to investigate their preventive practice for high-caries-risk children. Methods. Data were collected from a convenience sample of 126 dental students using a questionnaire. The IBM SPSS Statistics version 21 was used for data analysis.

RESULTS

A total of 126 students completed the questionnaire, and 63% of the respondents were female. Significant gender differences were found in the total Professional Preventive Knowledge Scale (PPKS) (p=0.016) and its subscales of the noncariogenic nutrition (p=0.015), dental hygiene/clinical examination (p < 0.001), caries-preventive practice (p=0.02), and the Hiroshima University-Dental Behavioral Inventory (HU-DBI) (p=0.028). Significant differences were observed in the total PPKS (p=0.003) and its subscales of the noncariogenic nutrition (p=0.043) and caries risk management (p=0.006) in terms of self-perceived need to receive education and training. Caries-preventive practice was correlated with the self-perceived competency (r = 0.279; p=0.002), the attitudes (r = 0.394; p < 0.001), the total PPKS (r = 0.457; p < 0.001) and its all subscales of dental hygiene and clinical examination (r = 0.425; p < 0.001), noncariogenic nutrition (r = 0.410; p < 0.001), and caries risk management (r = 0.184; p=0.039). The self-perceived competency was positively correlated with the total PPKS (r = 0.192; p=0.031) and its subscale of noncariogenic nutrition (r = 0.259; p=0.003). Greater self-perceived competence, more positive attitudes, and good knowledge regarding preventive dentistry were found to be important predictors of the caries-preventive practice of dental students, explaining 31% of the variance (adjusted R ² = 0.312, p < 0.001).

CONCLUSION

40% of dental students reported educational and training needs regarding the diagnosis, caries-preventive agents, and risk-based treatment plan. These results should be taken into account by the stakeholders in developing the national core curriculum for undergraduate Turkish dental education.

Patient-Specific, Risk-Based Prevention, Maintenance, and Supportive Care: A Need for Action and Innovation in Education

PURPOSE

To develop a competency-based curriculum framework for prevention, supportive care, and maintenance for use in educational and patient care programs and to seek consensus on an overarching competency statement that embraces these critical learning and patient care concepts.

MATERIALS AND METHODS

A preliminary survey of current preventive and maintenance practices in U.S. dental and prosthodontic programs was completed and summarized with quantitative analysis. The American College of Prosthodontists organized a one-day consensus workshop with 14 participants from various U.S. dental schools with diverse backgrounds to develop a curriculum framework. The curriculum framework was used in the development of a joint competency statement using an iterative, online consensus process of debate and feedback.

RESULTS

The preliminary survey helped frame the initiative and identify potential educational needs and gaps. Consensus was achieved for a recommended competency statement: "Graduates must be competent in promoting oral health through risk assessment, diagnosis, prevention, and management of the hard tissue, soft tissue, and prostheses, and as part of professional recall and home maintenance." This competency statement complements the proposed curriculum framework designed around 3 domains-caries prevention, periodontal supportive care, and prosthesis supportive care-with a set of recommended learning objectives.

CONCLUSIONS

Commission on Dental Accreditation (CODA) learning standards do not outline patient-customized, evidence-based recall and home maintenance programs that highlight prevention of dental caries, periodontal supportive care, prosthesis maintenance, and patient education. The proposed competency-based curricular framework serves as an initial step in addressing student learning and patient care within the context of a recall system and home maintenance program while offering schools the needed flexibility for implementation within their curriculum.

A survey of cariology teaching in Australia and New Zealand

BACKGROUND

The Australian and New Zealand chapter of the Alliance for a Cavity Free Future was launched in 2013 and one of its primary aims was to conduct a survey of the local learning and teaching of cariology in dentistry and oral health therapy programs.

METHODS

A questionnaire was developed using the framework of the European Organisation for Caries Research (ORCA)/Association of Dental Education in Europe (ADEE) cariology survey conducted in Europe in 2009. The questionnaire was comprised of multiple choice and open-ended questions exploring many aspects of the cariology teaching. The survey was distributed to the cariology curriculum coordinator of each of the 21 programs across Australia and New Zealand via Survey Monkey in January 2015. Simple analysis of results was carried out with frequencies and average numbers of hours collated and open-ended responses collected and compiled into tables.

RESULTS

Seventeen responses from a total of 21 programs had been received including 7 Dentistry and 10 Oral Health programs. Key findings from the survey were - one quarter of respondents indicated that cariology was identified as a specific discipline with their course and 41% had a cariology curriculum in written format. With regard to lesion detection and caries diagnosis, all of the program coordinators who responded indicated that visual/tactile methods and radiographic interpretation were recommended with ICDAS also being used by over half them. Despite all respondents teaching early caries lesion management centred on prevention and remineralisation, many taught operative intervention at an earlier stage of lesion depth than current evidence supports. Findings showed over 40% of respondents still teach operative intervention for lesions confined to enamel.

CONCLUSION

Despite modern theoretical concepts of cariology being taught in Australia and New Zealand, they do not appear to be fully translated into clinical teaching at the present time.

Cariology Education in Canadian Dental Schools: Where Are We? Where Do We Need to Go?

The aim of this study was to document cariology education across Canadian dental schools. Ten faculty members who supervise cariology education at each of the ten Canadian dental schools were invited to participate in the study in 2016. An adapted version of the European Organization for Caries Research-Association for Dental Education in Europe cariology curriculum group questionnaire was used. Representatives of all ten dental schools completed the questionnaire, for a 100% response rate. In four schools, cariology and restorative dentistry were taught by the same department. Five schools had didactic/laboratory courses focusing primarily on cariology as well as a specific written curriculum. Six schools provided cariology-related hands-on workshops/laboratories before students started working with patients. In teaching cariology, seven institutions included dental hard tissues defects. The following caries detection methods were addressed didactically in cariology education: visual (10/10 total schools), tactile (9/10), International Caries Detection and Assessment System criteria (6/10), caries activity assessment (9/10), radiographic (10/10), and other detection tools (8/10). Seven schools charted activity of carious lesions in clinic. Only one school used the concept of caries risk assessment regularly in clinic. Clinical cariology teaching was carried out mostly by private dentists hired as clinical instructors (7/10) and faculty members involved in didactic cariology education (9/10). Calibration of faculty members for caries detection criteria was reported by only one school. The main concern reported by all institutions was the difficulty of implementing didactic instruction on cariology into clinical training. This study found that contemporary cariology concepts are in the process of being implemented in didactic education across Canadian dental schools, but all schools lacked appropriate integration of cariology education into clinical training. These findings suggest a need for harmonization of evidence-based cariology education in Canada.

Dental students' and lecturers' perception of the degree of difficulty of caries detection associated learning topics in Brazil

PURPOSE

It aimed to explore the degree of difficulty of caries-detection-associated-topics perceived by dental students and lecturers as pedagogical step in the development of learning objects for e-learning.

METHODS

A convenience sample comprising ninety-eight subjects from different academic levels (undergraduate/graduate students and pediatric dentistry lecturers) participated. Two spreadsheets (isolated/relative) were created considering key topics in the caries detection process. The isolated evaluation intended to explore each topic in an isolated way, while the relative intended to classify, comparatively, the participants' perceived difficulty per topic. Afterwards, data were analyzed. All values on spreadsheets were combined obtaining the subject's final perception. Associations between the subjects' degree of the perceived difficulty and academic level were estimated. ANOVA was used to determine differences regarding the perception among evaluated topics in distinct groups.

RESULTS

Caries histopathology and detection of proximal carious lesions were the topics perceived as the most difficult in the process of caries detection by both students and lecturers. Differentiation between an extrinsic pigmentation and a brown-spot (caries lesion) as well as differential diagnosis between caries and enamel developmental defects or non-carious lesions were considered as more difficult by undergraduates in comparison to graduates/lecturers (regression-coefficient=14.54; Standard Error=3.34; P<0.001 and 8.40, 3.31, and 0.01 respectively).

CONCLUSION

Topics as histopathology and detection of proximal caries lesions were identified as the most difficult despite the academic level. However, some topics are differently perceived according to the group. These results are useful for developing pedagogical material, based on the students real learning needs/expectations.

Sealants and dental caries: insight into dentists' behaviors regarding implementation of clinical practice recommendations

BACKGROUND

The authors conducted a qualitative study of private-practice dentists in their offices by using vignette-based interviews to assess barriers to the use of evidence-based clinical recommendations in the treatment of noncavitated carious lesions.

METHODS

The authors recruited 22 dentists as a convenience sample and presented them with two patient vignettes involving noncavitated carious lesions. Interviewers asked participants to articulate their thought processes as they described treatment recommendations. Participants compared their treatment plans with the American Dental Association's recommendations for sealing noncavitated carious lesions, and they described barriers to implementing these recommendations in their practices. The authors recorded and transcribed the sessions for accuracy and themes.

RESULTS

Personal clinical experience emerged as the determining factor in dentists' treatment decisions regarding noncavitated carious lesions. Additional factors were lack of reimbursement and mistrust of the recommendations. The authors found that knowledge of the recommendations did not lead to their adoption when the recommendation was incongruent with the dentist's personal experience.

CONCLUSIONS

The authors found that ingrained practice behavior based on personal clinical experience that differed substantially from evidence-based recommendations resulted in a rejection of these recommendations.

PRACTICAL IMPLICATIONS

Attempts to improve the adoption of evidence-based practice must involve more than simple dissemination of information to achieve a balance between personal clinical experience and scientific evidence.

Decision-making and preventive non-surgical therapy in the context of a European Core Curriculum in Cariology

This paper is part of a series of papers towards a European Core Curriculum in Cariology for undergraduate dental students. The European Core Curriculum in Cariology is the outcome of a joint workshop of the European Organisation for Caries Research (ORCA) together with the Association for Dental Education in Europe (ADEE), which was held in Berlin from 27 to 30 June 2010. The present paper covers decision-making and non-surgical treatment. In particular, it will provide some background information on this part of the European core curriculum. The dentist, on graduation, must be competent at applying the principles of prevention of dental hard tissue disease processes (primary prevention) and progression when it has manifested itself (secondary prevention). The competences should apply in differing ways to patients of all ages. Goals of prevention should be clearly defined in order for outcomes to be evaluated, and a dentist should be competent at determining these outcomes. Although this concept is recognised by many academics and experts, clinical teaching, practice and health insurance coverage frequently emphasise surgical treatment. There are many reasons and obstacles that might account for this, and this paper suggests some reasons why this might be and makes suggestions for how these can be addressed in the future. One factor that is essential in the provision of a preventive, non-surgical approach is that of communication with the patient. However, this unfortunately takes less space in the dental curricula compared with technical skills aimed at restorative procedures; this weighting needs to be more equally balanced.

Stumbling into the age of evidence

This article presents personal observations on how the concept of evidence-based dentistry is faring in the profession. It considers how the dental profession's concept of evidence has matured, how evidence-based dentistry was originally envisioned, how it is currently embodied, and what its prospects might be for the immediate future. Evidence-based dentistry began in the profession approximately 2 decades ago, initiated by the appearance of the first systematic reviews on dental topics in the late 1980s. The emergence of the concept of evidence-based dentistry--and its fundamental construct, the systematic review--marks what can be considered a fundamental shift in how the dental knowledge base has grown and developed over time.