The management of incipient or suspicious occlusal caries: a decision-tree analysis

How much dentists are ethically concerned about overtreatment; a vignette-based survey in Switzerland

BACKGROUND

Overtreatment (or unnecessary treatment) is when medical or dental services are provided with a higher volume or cost than is appropriate. This study aimed to investigate how a group of dentists in Switzerland, a wealthy country known to have high standards of healthcare including dentistry, evaluated the meaning of unnecessary treatments from an ethical perspective and, assessed the expected frequency of different possible behaviors among their peers.

METHODS

A vignette describing a situation that is susceptible for overtreatment of a patient was presented to a group of dentists. The vignette was followed by five options. A questionnaire including the vignette was posted to 2482 dentists in the German-speaking areas of Switzerland. The respondents were asked to rate each option according to their estimation about its prevalence and their judgment about the degree to which the behavior is ethically sound.

RESULTS

732 completed questionnaires were returned. According to the responses, the most ethical and the most unethical options are considered to be the most and the least prevalent behaviors among dentists practicing in Switzerland, respectively.

CONCLUSIONS

Suggesting unnecessary treatments to patients seems to be an ethically unacceptable conduct in the eyes of a sample of dentists in Switzerland. Although the respondents believed their colleagues were very likely to behave in an ethical way in response to a situation that is susceptible to overtreatment, they still seemed to be concerned about the prevalence of unethical behaviors in this regard.

Characteristics, detection methods and treatment of questionable occlusal carious lesions: findings from the national dental practice-based research network

Questionable occlusal carious lesions (QOC) can be defined as an occlusal tooth surface with no cavitation and no radiographic radiolucencies, but caries is suspected due to roughness, surface opacities or staining. An earlier analysis of data from this study indicates 1/3 of patients have a QOC. The objective of this report has been to quantify the characteristics of these common lesions, the diagnostic aids used and the treatment of QOC. A total of 82 dentist and hygienist practitioner-investigators from the USA and Denmark in the National Dental Practice-Based Research Network participated. When consenting patients presented with a QOC, information was recorded about the patient, tooth, lesion and treatments. A total of 2,603 QOC from 1,732 patients were analyzed. The lesions were usually associated with a fissure, on molars, and varied from yellow to black in color. Half presented with a chalky luster and had a rough surface when examined with an explorer. There was an association between color and luster: 10% were chalky-light, 47% were shiny-dark and 42% were mixtures. A higher proportion of chalky than of shiny lesions were light (22 vs. 9%; p < 0.001). Lesions light in color were less common in adults than in pediatric patients (9 vs. 32%; p < 0.001). Lesions that were chalky and light were more common among pediatric than among adult patients (22 vs. 6%; p < 0.001). This is the first study to investigate characteristics of QOC in routine clinical practice. Clinicians commonly face this diagnostic uncertainty. Determining the characteristics of these lesions is relevant when making diagnostic and treatment decisions.

The prevalence of questionable occlusal caries: findings from the Dental Practice-Based Research Network

BACKGROUND

Questionable occlusal caries (QOC) can be defined as clinically suspected caries with no cavitation or radiographic evidence of occlusal caries. To the authors' knowledge, no one has quantified the prevalence of QOC, so this quantification was the authors' objective in conducting this study

METHODS

A total of 82 dentist and hygienist practitioner-investigators (P-Is) from the United States and Denmark in The Dental Practice-Based Research Network (DPBRN) participated. When patients seeking treatment had at least one unrestored occlusal surface, P-Is quantified their number of unrestored occlusal surfaces and instances of QOC, if applicable. P-Is also recorded information about characteristics of patients who had QOC and had provided informed consent. The authors adjusted for patient clustering within practices.

RESULTS

Overall, 6,910 patients had at least one unrestored occlusal surface, with a total of 50,445 unrestored surfaces. Thirty-four percent of all patients and 11 percent of unrestored occlusal tooth surfaces among all patients had QOC. Patient- and surface-level QOC prevalences varied significantly according to DPBRN region (P < .001 and P = .03, respectively). The highest percentages for patient- and surface-level prevalence occurred in Florida and Georgia (42 percent and 16 percent, respectively).

CONCLUSIONS

To the authors' knowledge, this is the first study in which investigators have quantified the prevalence of QOC in routine clinical practice. These results document a high prevalence overall, with wide variation in prevalence among The DPBRN's five main regions.

CLINICAL IMPLICATIONS

QOC is common in routine practice and warrants further investigation regarding how best to manage it.

The management of an endodontically abscessed tooth: patient health state utility, decision-tree and economic analysis

BACKGROUND

A frequent encounter in clinical practice is the middle-aged adult patient complaining of a toothache caused by the spread of a carious infection into the tooth's endodontic complex. Decisions about the range of treatment options (conventional crown with a post and core technique (CC), a single tooth implant (STI), a conventional dental bridge (CDB), and a partial removable denture (RPD)) have to balance the prognosis, utility and cost. Little is know about the utility patients attach to the different treatment options for an endontically abscessed mandibular molar and maxillary incisor. We measured patients' dental-health-state utilities and ranking preferences of the treatment options for these dental problems.

METHODS

Forty school teachers ranked their preferences for conventional crown with a post and core technique, a single tooth implant, a conventional dental bridge, and a partial removable denture using a standard gamble and willingness to pay. Data previously reported on treatment prognosis and direct "out-of-pocket" costs were used in a decision-tree and economic analysis

RESULTS

The Standard Gamble utilities for the restoration of a mandibular 1st molar with either the conventional crown (CC), single-tooth-implant (STI), conventional dental bridge (CDB) or removable-partial-denture (RPD) were 74.47 [+/- 6.91], 78.60 [+/- 5.19], 76.22 [+/- 5.78], 64.80 [+/- 8.1] respectively (p < 0.05). Their respective Willingness-to-Pay ($CDN) were 1,782.05 [+/- 361.42], 1,871.79 [+/- 349.44], 1,605.13 [+/- 348.10], 1,351.28 [+/- 368.62] (p < 0.05).The standard gamble utilities for the restoration of a maxillary central incisor with a CC, STI, CDB and RPD were 88.50 [+/- 6.12], 90.68 [+/- 3.41], 89.78 [+/- 3.81] and 91.10 [+/- 3.57] respectively (p > 0.05). Their respective willingness-to-pay ($CDN) were: 1,782.05 [+/- 361.42], 1,871.79 [+/- 349.44], 1,605.13 [+/- 348.10] and 1,351.28 [+/- 368.62]. A statistical difference was found between the utility of treating a maxillary central incisor and mandibular 1st-molar (p < 0.05).The expected-utility-value for a 5-year prosthetic survival was highest for the CDB and the STI treatment of an abscessed mandibular molar (74.75 and 71.47 respectively) and maxillary incisor (86.24 and 84.91 respectively). This held up to a sensitivity analysis when the success of root canal therapy and the risk of damage to the adjacent tooth were varied. The RPD for both the molar and incisor was the favored treatment based on a cost-utility (3.85 and 2.74 CND$ per year of tooth saved respectively) and cost-benefit analysis (0.92 to 0.60 CND$ of cost per $ of benefit, respectively) for a prosthetic clinical survival of 5-years.

CONCLUSION

The position of the abscessed tooth and the amount of insurance coverage influences the utility and rank assigned by patients to the different treatment options. STI and CDB have optimal EUVs for a 5-year survival outcome, and RPD has significantly lower cost providing the better cost:benefit ratio.