Tooth retention as an indicator of quality dental care: development of a risk adjustment model

Validation of a Subjective Caries Risk Assessment Tool

OBJECTIVE

The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record.

METHODS

This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification.

RESULTS

The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination.

CONCLUSIONS

The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period.

CLINICAL SIGNIFICANCE

The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.

The evolution of treatment over 80 years at the outpatient department of the Viennese school of dentistry

OBJECTIVES

The delivery of oral health services, diagnostics and treatment underwent significant changes in the 20th century thanks to achievements by pioneers in dentistry. The Golden Age of Dentistry in Vienna, Austria, was marked by renowned dentists like Bernhard Gottlieb in the 1930s. Data records from the outpatient department of this period have been found and served as a source from which to draw comparisons between those days and the present. To date, data supporting an overall perception of advances in dentistry during the last century in tooth preservation and patients' demands have been lacking. The aim of this study was to evaluate changes in treatments and patient characteristics between the interwar period and the present and to assess how treatments for dental emergencies developed.

METHODS

Patients' records were extracted from books handwritten from January to May 1933 and compared with electronically generated data from the same period in 2013. In total, patient data from 10 111 individuals (3878 in 1933 and 6233 in 2013) were analysed. Comparisons were undertaken for gender, age, place of residence, diagnosis and therapy.

RESULTS

Various statistically significant demographic and treatment differences were found between 1933 and 2013. Patients' mean ages in 2013 and 1933 were 42 and 31 years, respectively. In 2013, there were significantly more women than in 1933 (3378 vs 1936), with 54% women in 2013 and 50% women in 1933. In 2013, there were significantly fewer tooth extractions as dental emergency treatment than in 1933 (2% vs 34%).

CONCLUSIONS

Treatment in the outpatient department is much more conservative in the 21^st century. The characteristics of patients visiting the outpatient department have changed over the generations, and treatment needs should be evaluated accordingly.

Integrated Medical-Dental Delivery Systems: Models in a Changing Environment and Their Implications for Dental Education

Models and systems of the dental care delivery system are changing. Solo practice is no longer the only alternative for graduating dentists. Over half of recent graduates are employees, and more than ever before, dentists are practicing in groups. This trend is expected to increase over the next 25 years. This article examines various models of dental care delivery, explains why it is important to practice in integrated medical-dental teams, and defines person-centered care, contrasting it with patient-centered care. Systems of care in which teams are currently practicing integrated oral health care delivery are described, along with speculation on the future of person-centered care and the team approach. Critical steps in the education of dental and other health care professionals and the development of clinical models of care in moving forward are considered. This article was written as part of the project "Advancing Dental Education in the 21^st Century."

Frequency of persistent tooth pain after root canal therapy: a systematic review and meta-analysis

INTRODUCTION

Little is known about the frequency of persistent pain after endodontic procedures even though pain is a core patient-oriented outcome. We estimated the frequency of persistent pain, regardless of etiology, after endodontic treatment.

METHODS

Persistent tooth pain was defined as pain present > or = 6 months after endodontic treatment. Endodontic procedures included in the review were pulpectomy, nonsurgical root canal treatment, surgical root canal treatment, and retreatment. Four databases were searched electronically complemented by hand searching. Two independent reviewers determined eligibility, abstracted data, and assessed study quality. A summary estimate of persistent all-cause tooth pain frequency was established by using a random-effects meta-analysis. Using subgroup analyses, we explored the influence of treatment approach (surgical/nonsurgical), longitudinal study design (prospective/retrospective), follow-up rate, follow-up duration, initial treatment versus retreatment, and quality of reporting (Strengthening the Reporting of Observational Studies in Epidemiology rankings) on the pain frequency estimate.

RESULTS

Of 770 articles retrieved and reviewed, 26 met inclusion criteria. A total of 5,777 teeth were enrolled, and 2,996 had follow-up information regarding pain status. We identified 168 teeth with pain and derived a frequency of 5.3% (95% confidence interval, 3.5%-7.2%, p < 0.001) for persistent all-cause tooth pain. High and statistically significant heterogeneity among studies (I2 = 80%) was present. In subgroup analysis, prospective studies had a higher pain frequency (7.6%) than retrospectives studies did (0.9%). Quality of study reporting was identified as the most influential reason for study heterogeneity.

CONCLUSIONS

The frequency of all-cause persistent tooth pain after endodontic procedures was estimated to be 5.3%, with higher report quality studies suggesting >7%.

Racial differences in baseline treatment preference as predictors of receiving a dental extraction versus root canal therapy during 48 months of follow-up

OBJECTIVE

This study aimed to test hypotheses that: a) treatment preference as stated at baseline predicts subsequent receipt of extraction (EXT) versus root canal treatment; and b) racial differences in treatment preference at baseline account for racial differences in receipt of these treatments during follow-up.

METHODS

Data were taken from the Florida Dental Care Study This stratified random sample included at baseline 873 subjects, all of whom were 45-years-old or older, reported race as non-Hispanic African American or non-Hispanic white, and had at least one tooth. At baseline, participants were asked about past dental care characteristics, history of or current presence of various dental diseases and conditions, and sociodemographic circumstance. An EXT/root canal treatment "CHOICE" scenario was also queried at baseline. Predisposing, enabling, and need factors were tested as predictors of EXT/root canal treatment received during follow-up. Bivariate multivariable logistic regression analyses quantified associations between the outcomes (EXT/root canal) and the predictors.

RESULTS

Receipt of EXT or root canal treatment during follow-up was strongly related to race even after people with mobile teeth at baseline were excluded from the analysis. Certain baseline factors (tooth mobility, periodontal attachment level, and ability to pay an unexpected dental bill) strongly predicted EXT/root canal treatment receipt during follow-up, although significant race effects remained; however, including "CHOICE" removed the race effect.

CONCLUSIONS

Baseline treatment preference strongly predicts subsequent receipt of EXT versus root canal treatment. Racial differences in treatment received during follow-up were explained by baseline racial differences in treatment preference, tooth mobility, and periodontal status.

Root Canal Treatment in a Population-Based Adult Sample: Status of Teeth After Endodontic Treatment

The purpose of this study was to quantify treatment outcomes of endodontically treated teeth, in a representative, population-based adult sample. The "Florida Dental Care Study" was a prospective, longitudinal, cohort study of 873 subjects who had at least one tooth at baseline and who were 45 yr or older. An in-person interview and clinical examination were conducted at baseline, 24 months, and 48 months after baseline, with 6-monthly telephone interviews between those times. Dental record information was abstracted afterward. Seventy-five teeth had conventional root-canal therapy (RCT) performed and met the inclusion criteria of 1-yr of follow-up or extraction. The mean duration of follow-up after RCT was 24.8 months. The mean (SD) attachment loss (AL) on teeth receiving RCT was only 3.3 (1.4) mm. Permanent restorations were placed in 79% of teeth a mean of 4.4 months after the RCT. However, 12% of teeth did not have any restorative treatment after RCT. After RCT had been completed, 81% of teeth were retained and 19% were ultimately extracted. Taken as a whole, this community-based study of a representative sample of adults suggests a higher failure rate than reported from studies in highly controlled environments or insured populations. It also suggests that the length of time to initial restoration of RCT-treated teeth is less than optimal. RCT was almost never performed on teeth with advanced periodontal attachment loss.

Racial Variations in Dental Procedures

BACKGROUND

Racial disparities have been widely documented in medical care, but variations in dental care have not been well examined.

OBJECTIVES

To determine if there is racial variation in use of root canal therapy versus tooth extraction across different levels of dental insurance coverage and adjusting for other factors known to influence treatment decisions.

METHODS

Within 3 different categories of insurance coverage, we examined whether there were racial differences in the provision of the tooth-sparing treatment of root canal therapy (vs. tooth extraction) among 54,423 users of outpatient Veterans Affairs dental care in 1998. Regression analyses adjusted for the severity of tooth- and gum-related disease, age, sex, medical and psychiatric comorbidities, prior use of preventive dental services, tooth extraction and root canal therapy, and clustering by geographic region.

RESULTS

In the adjusted regression models, black patients and those with unknown race were less likely overall to receive root canal therapy than whites, whereas Asians were more likely. Among patients with eligibility for continuing and comprehensive dental care, blacks were less likely and Asians more likely to receive root canals than whites. For patients covered only for emergency dental care, Hispanics had a higher likelihood of receiving root canal therapy. Among all other types of coverage, there were no significant racial differences in the care received.

CONCLUSION

We observed substantial racial variations in the provision of root canal therapy among patients treated in Department of Veterans Affairs dental clinics. Future research should identify the causes of such variations.