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

Rational Antibiotic Prescribing Is Underpinned by Dental Ethics Principles: Survey on Postgraduate and Undergraduate Dental Students' Perceptions

BACKGROUND

Dentists bear the burden of responsibility for antimicrobial resistance since antibiotics are the drugs most prescribed by dentists. Often, "inappropriate" antibiotic use is considered as a "gray area" by dentists mainly due to ethical challenges associated with the clinical judgement depending on patients and/or prescribers.

AIM

The study aimed to assess whether and in what way dental ethical principles underpin rational antibiotic use by investigating perceptions of postgraduate and undergraduate dental students without formal knowledge of dental ethics.

METHOD

A cross-sectional anonymous survey comprised nine close-ended questions and was conducted among dental students (n = 125). The investigated practice of appropriate antibiotic prescribing in the survey relied on the respect of three basic principles of ethics: autonomy, non-maleficence, and beneficence.

RESULTS

Results show that dental students exhibit a lack of dental ethics knowledge that results in an inappropriate antibiotic-prescribing practice: prescribing an antibiotic when it is not necessary, without examination, or for indications that are not within the competence of the dentist. Multivariate regression analysis revealed that there was a significant difference between under- and postgraduates.

CONCLUSIONS

Within the pharmacology course, a review of the clinical scenarios which cover both ethical and clinical complexities regarding the appropriate use of antibiotics should be introduced as an educational approach.

Presenting a Comprehensive Definition of Unnecessary Healthcare Services and Their Drivers: A Systematic Review and Meta-synthesis

Background

Providing unnecessary healthcare services is a major common problem in every health system. The scope and cause of healthcare services must be identified in order to be managed and controlled. Finding the most complete definition of the problem and its causes are the goals of this meta-synthesis.

Methods

A comprehensive search strategy was performed using a wide range of keywords and databases. Based on the defined inclusion and exclusion criteria, 22 articles were selected for content analysis and meta-synthesis. The Graneheim and Lundman method was used for content analysis. The MAXQDA software Version 18.2.0 was used for the first round of content analysis. Content analysis and meta-synthesis were used to comprehensively define the term "unnecessary healthcare services" and find the etiologic factors driving healthcare providers to unnecessary healthcare services.

Results

The term "unnecessary healthcare services" is defined as "overproviding healthcare services that could be harmful, low-value, insufficient, and inappropriate." The etiologic pattern of unnecessary healthcare services shows intrinsic and extrinsic factors as a driving force for unnecessary healthcare services.

Conclusion

A multilayer strategy for efficient management and prevention of unnecessary healthcare services is appropriate due to the multifaceted character of these services. This approach consists of the modification of the intrinsic factors and extrinsic drivers.

Do Norwegian private dental practitioners with too few patients compensate for their loss of income by providing more services or by raising their fees?

OBJECTIVE

In Norway, supply of dental services exceeds demand, mainly because of the marked improvement in dental health during the last few decades. The aim of the study was to investigate whether private dental practitioners counteract a fall in demand for their services by providing more services or by raising their fees.

METHODS

The data were collected using a questionnaire that was sent to all private dental practitioners in Norway. Altogether 1237 practitioners responded, which gave a response rate of 56%. Our sample was representative of the population of practitioners in Norway. As a measure of patient supply, responses from the following questions were used: 'Based on an overall assessment of economy, workload and other personal factors, is the number of regular patients adequate? If not, do you wish to have more patients, or fewer patients?' The outcome variables were dental fees, length of recall interval and mean cost per visit. The data were analysed using ordinary least square regression and a linear probability model. The following characteristics of the private dental practitioners were included as control variables: age, gender, work experience in years and whether they worked in a solo practice. To test the robustness of the findings, a supplementary analysis with the patient as the unit of analysis was carried out, using survey data of Norwegians aged 20 years and older. Based on this survey, the relationship between population: dentist ratio and mean cost per dental visit were examined.

RESULTS

Nearly 40% of all practitioners reported that they had too few patients. They compensated for their loss of income by raising their fees, by recalling their patients more often and by increasing the cost per visit. The finding in the supplementary analysis using survey data from patients was similar to the findings in the main analyses using survey data from private dental practitioners.

CONCLUSION

The findings show that practitioners have market power. They were able to counteract a fall in demand for their services by providing more services and by raising their fees. The dental profession should be encouraged to provide appropriate services, in the present situation where supply exceeds demand.

Ethical Dilemmas for Dental Students in Greece

Professional dental ethics for students are based on promoting oral health for dental patients and reinforcing an anthropocentric approach to communication and dental services. A total of 133 dental students (males 33.8% N1 = 46, females 66.2% N2 = 87) completed the study questionnaire. Descriptive statistics were applied, and non-parametric Kruskal-Wallis tests were used (p < 0.05). Students refuse services to patients that misbehave (37.6%), have irrational demands (18%), and when clinical cases exceed their capabilities (36.8%). Of the participants, 50.4% want to waive confidentiality when abuse is declared. Ethical role models are educators (33.8%), other qualified dentists (25.6%), and their parents (21.8%). Female gender positively affects integrity (p = 0.046), altruism (p = 0.032), and difficulty in conversations among colleagues (p = 0.036). Students outside the capital are less interested in esthetic issues (p = 0.007), in giving more than one treatment plan (p = 0.006), and in being confronted with inadequate treatments from other colleagues (p = 0.005). Family income positively affects clinical skills (p = 0.003), trust issues (p = 0.008), and moral insight and intuition (p = 0.02). Presentation with clinical scenarios is the preferred educational method (49.6%). Dental students show compassion for poor patients, respect patients' autonomy, and guide patients to choose the best treatment plan before receiving dental ethics seminars. There is a positive relationship between the ethical footprints of students and gender, origin, family income, postgraduate studies, and future professional plans. Factors and ways to incorporate ethics in the dental curriculum could be considered when planning relevant courses.

Inappropriate Topical Antibiotics Use in Clean Dermatological Procedures in South Korea in 2018: A Nationwide Population-Based Cross-Sectional Study

BACKGROUND

The use of topical antibiotics (TA) for prophylactic purposes after clean dermatologic procedures (CDP) is generally not recommended, and the prescription of TA needs to be individualized in consideration of each patient's situation and underlying disease. The aim of this study was to determine the proportion of patients who underwent CDP in outpatient settings and were prescribed TA inappropriately, as well as the factors that may affect the prescription of TA.

METHODS

Outpatient visits coded for CDP were selected using claims data from the Health Insurance Review and Assessment Service in 2018. Of these, patients receiving TA prescriptions were classified as having inappropriate TA use, and the proportion was estimated through technical analysis. A logistic regression analysis was used to identify factors influencing inappropriate prescriptions.

RESULTS

Data were analyzed using 423,651 visits, and TA was prescribed for approximately 1.9% of the visits. TA usage was higher among women (2.0%), 0-19 years of age (2.2%), medical aid (2.2%), clinic settings (2.4%), and metropolitan areas (2.0%). TA was prescribed more frequently in urology (8.6%), pediatrics (5.0%), and dermatology (4.2%) than in other specialties.

CONCLUSION

The prescription rate of TA after CDP was 1.9% using the 1.4 million patient sample from the national health insurance claims data in Korea, which is equally weighted to represent 50 million people. Although the proportion of inappropriate TA prescriptions in Korea is lower than that in other nations, it cannot be overlooked because of the large number of cases. Efforts to improve quality are required to reduce the number of inappropriate prescriptions.

Overtreatment in Restorative Dentistry: Decision Making by Last-Year Dental Students

To evaluate the tendency for overdiagnosis and overtreatment upon different clinical situations among last-year students from the degree in dentistry from Valencia University (Spain) during the 2018-2019 course. A questionnaire consisting of 10 case exemplifications examining the diagnosis, treatment, and clinician's attitude towards different common clinical situations regarding restorative dentistry was designed. Fifty-two students were surveyed, from whom 42 completed the questionnaire (80.77%). Data were analyzed descriptively. A total of 58.8% of the students correctly identified an early carious lesion in the occlusal surface of a molar, while 63.2% would perform unnecessary complementary tests for its diagnosis. The treatment for carious lesions in different evolutive phases with a vital pulp was correct between 51.2 and 92.7% of the cases. The treatment for irreversible pulp pathology and the restoration of the tooth with root canal treatment were adequately selected in 56.1% and 78.3% of the cases, respectively. For the repair of a faulty restoration, an overtreatment was proposed by 87.8% of the students. A tendency to perform unnecessary complementary tests for caries diagnosis was observed. Treatment caries proposals were in accordance with available evidence in the majority of the cases. Students tended to overtreat defective restorations and would perform unnecessary treatments in medically compromised patients.

Restorative thresholds for primary and permanent molars in children: French dentist decisions

BACKGROUND

Worldwide, numerous surveys have investigated practices and knowledge about caries management in adults, but few are available for children.

AIM

The present cross-sectional survey aimed to assess the restorative thresholds (RTs) in primary and permanent molars in children used by a population of dentists treating children and practicing in France.

DESIGN

The study population consisted of French dentists treating children (Fr-DTCs) who were registered in the French Society of Pediatric Dentistry (n = 250). A specific questionnaire was developed. Descriptive and statistical analyses were performed.

RESULTS

Response rate was 80.4% (n = 201). Considering that an appropriate RT is at the stage of a moderate lesion (occlusal: International Caries Detection and Assessment System 4; approximal: lesion involving the external third of dentine), more than 50% of respondents showed a tendency for iatrogenic treatment, except for occlusal carious lesions in primary molars. Inappropriate invasive strategies were more often reported for occlusal lesions in permanent than primary molars. Moreover, for both molar types, these inappropriate RTs were more often chosen for approximal than occlusal lesions.

CONCLUSIONS

The present survey suggested that Fr-DTCs tend to overtreat in terms of caries management in both primary and permanent molars.

Overtreatment as an ethical dilemma in Australian private dentistry: A qualitative exploration

BACKGROUND

The phenomenon of overtreatment in dentistry is under-explored and has not been the subject of much research inquiry. Most dental care in Australia is provided by practitioners in private dental practice. This research expands understanding of how the nexus between professionalism and commercialism in dentistry is impacted by the phenomenon of overtreatment.

METHODS

Data were collected through recorded interviews and written reflections from private dentists working in the Australian context. The data were then examined using thematic analysis to understand common themes and reveal deeper insights.

RESULTS

A total of 20 participants were recruited for this study. Participants spoke of their experiences in practice where financial targets and pressure from practice owners to provide high-cost treatments presented challenges to their professionalism. The participants expressed that the way in which dentistry is remunerated based on activity was a motivation towards engaging in overtreatment. The participants also spoke of finding a balance between commercialism and professionalism within private dental practice.

CONCLUSIONS

Participants' reports provided insights into how the mismanagement of the commercial elements of private dental practice led to a transactional ('buyer beware') relationship between the consumers and providers of dental services, rather than a relationship founded upon professional altruism and trust. Consumer empowerment through the commercialization of dentistry has potential to be a positive influence on the patient experience in accessing dental care. However, this research has shown that the shift of power through consumerism also risks attenuating professional appreciation of the imbalanced nature of the patient-clinician relationship in dentistry.

What influences the clinical decision-making of dentists? A cross-sectional study

Clinical decision-making is a complex process influenced by clinical and non-clinical factors. The aim of this study was to investigate the association between provider, patient, and practice factors with clinical decision-making among dentists in Ontario, Canada’s most populated province and its largest dental care market. This was a cross-sectional, self-administered survey of a random sample of general dentists in Ontario (n = 3,201). The 46-item survey collected demographic, professional, and practice information. The outcome (treatment intensity) was measured using a set of clinical scenarios, which categorized dentists as either relatively aggressive or conservative in their treatment decisions. Associations were assessed using bivariate analysis and logistic regressions. One thousand and seventy-five dentists responded (33.6% response rate). Age (p = 0.001), place of initial training (p<0.001), number of dependents (p = 0.001), number of hygienists employed (p = 0.001), and perceptions of practice loans (p = 0.020) were associated with treatment intensity. Dentists who were <40-years old (OR = 2.06, 95% CI:1.39–3.06, p<0.001), American-trained (OR = 2.48, 95% CI:1.51–4.06, p<0.001), and perceived their practice loans as large (OR = 1.57, 95% CI:1.02–2.42, p = 0.039), were relatively more aggressive in their treatment decisions. Various non-clinical factors appear to influence the clinical decision-making of dentists in Ontario.

The influence of clinical experience on dental students' ethical awareness

INTRODUCTION

There has been no structured integration of ethical issues into the dental curriculum and currently no data for certain ethics modules exists in Germany. The study aimed at evaluating the attitudes to ethical issues that affect students at the Dental School in Kiel during patient treatment.

MATERIAL AND METHODS

In the summer of 2017, students were recruited from the 6th and 10th semesters. A qualitative study design with interviews was chosen. The dimensions included, for example, experience with ethical issues, definitions and expectations of teaching content and methods. A qualitative content analysis was performed.

RESULTS

Twelve and eleven students from semesters (32% each) participated. No student was able to name an ethical question based on his own experience (private/study). The need to address ethical issues was justified solely by personal treatment experiences.

DISCUSSION

The study revealed a lack of basic ethical knowledge resulting in a lack of ability to deal with ethical issues. Instead, participants described experiences of psychological pressure, feelings of helplessness.

CONCLUSION

The results suggest that ethical-theoretical foundations should be taught before the beginning of patient treatment. A didactic combination with clinical facts and case vignettes is recommended.

Complaints about dental practitioners: an analysis of 6 years of complaints about dentists, dental prosthetists, oral health therapists, dental therapists and dental hygienists in Australia

BACKGROUND

Previous research has found dental practitioners at elevated risk of complaint compared with other health professions. This study aimed to describe the frequency, nature and risk factors for complaints involving dental practitioners.

METHODS

We assembled a national dataset of complaints about registered health practitioners in Australia between January 2011 and December 2016. We classified complaints into 23 issues across three domains: health, performance and conduct. We compared rates of complaints about dental practitioners and other health practitioners. We used negative binomial regression analysis to identify factors associated with complaints.

RESULTS

Dental practitioners made up 3.5% of health practitioners, yet accounted for approximately 10% of complaints. Dental practitioners had the highest rate of complaints among fourteen health professions (42.7 per 1000 practitioners per year) with higher rates among dentists and dental prosthetists than allied dental practitioners. Male practitioners were at a higher risk of complaints. Most complaints about dentists related to treatments and procedures (59%). Around 4% of dentists received more than one complaint, accounting for 49% of complaints about dentists. In 60% of closed cases no regulatory action was required. Around 13% of complaints resulted in restrictive actions, such as conditions on practice.

CONCLUSION

Improved understanding of patterns may assist regulatory boards and professional associations to ensure competent practice and protect patient safety.

Overtreatment in Caries Management? A Literature Review Perspective and Recommendations for Clinicians

Dentistry, like various branches in the healthcare profession, is susceptible to overtreatment, especially in the management of dental caries, due to the adoption of an aggressive restorative approach. This philosophy provides no actual benefits to the patient in terms of arresting the disease process, which initially led to the carious lesions. Yet practitioners routinely continue to initiate restorative treatment procedures without attempting to understand and alter the biologic factors contributing to the caries process. This paper examines the available scientific literature in this regard and makes recommendations to the clinicians of today based on the available evidence. CPD/Clinical Relevance: The paper provides clinicians an approach to avoiding overtreatment by adhering to established clinical guidelines and accepted operative strategies.