Shared decision-making in scaling and root planing.

INTRODUCTION: Estimate proportion of various approaches used by dental hygienists for engaging patients in decisions commonly arising during scaling and root planing. Distribution of approaches was compared across various task components in this procedure, practice experience of dental hygienists and patient compliance. MATERIALS AND METHODS: Survey of graduates from and students in a baccalaureate dental hygiene program. RESULTS: Paternalism (tell then do) and informed consent (give choices and reasons and ask for permission) were more common than shared decision-making (discuss alternatives, solicit patient input and arrive at a mutual decision) and disengagement (patient refusing offered service or avoiding further involvement) by a ratio of 4 to 1 for the first 2 compared with the latter 2. This relationship was held across selecting treatment, procedural adjuncts, homecare instructions and financial arrangements. Dental hygienists exhibited a range of personal preferences for engagement approaches. No-show rate, patient disengagement outside the office, was high (20%). CONCLUSION: Dental hygienists reported using 'more controlled' approaches to engaging patients in decisions regarding treatment. Patients may prefer to engage in more shared decisions and choose this approach by staying away from the office. This may underestimate patients' decisions to stay away from treatment, for example by not showing for completion of the treatment or disregarding homecare routines.

Dental hygiene students' participation as subjects in a randomized controlled trial: A full evidence-based dentistry experience.

PURPOSE: Demonstrate that dental hygiene students' participation in a randomized controlled trial comparing the plaque-removing capability of two toothbrushes provides a fuller understanding of the factors affecting the potential application of research to practice. METHODS: All students (N = 18) in a baccalaureate dental hygiene class were engaged in the design of a randomized controlled trial using the Consolidated Standards of Reporting Trials (CONSORT) standard and then participated as subjects in a staggered, repeated measures trial using plaque removal as the dependent variable and brush type, brush head wear, and time in study as independent variables. A debriefing of student participation and lessons learned from analyzing the results was conducted. RESULTS: The study found statistically significant differences in plaque removal capability. Brush type accounted for only 4% of the variance, while measures of brush head wear were inconsistent, and time in the study ("experimental fatigue") accounted for the most variance (9%). Students recognized and confirmed by their personal experiences that research that fails to focus on variance can create an overly optimistic impression of research effectiveness. There was strong agreement that subjects/patients vary widely and that performance depends on multiple factors. CONCLUSIONS: Dental hygiene students who participated as subjects in a randomized controlled trial comparing toothbrushes for plaque removal capacity felt that full analysis to account for all sources of variance and estimate the magnitude of measures of effect add to the value of reported research. Variation across patients is important in practice, if often overlooked as an "error" in the literature.

Toward an operational definition of shared decision making: A conceptual analysis.

RATIONALE: Shared decision making has been widely advocated and evaluated in diverse ways for 4 decades. AIMS AND OBJECTIVES: But there is scant evidence that it is commonly accepted by or has influence on practitioners' behaviour or that it positively affects patient health outcomes. This situation may be due in part to the absence of a commonly agreed operational definition of the construct. This is admitted in the literature and has led to multiple approaches to evaluation. METHOD: An operational definition is proposed based on ethical parity among parties, sharing of mutually interacting expectations and analysis of decisions as commitment to action rather than information. RESULTS: Shared decision making occurs when two autonomous and uncoerced agents both commit to actions that neither has reason to want to change based on their understanding of anticipated outcomes given the situation at hand and of the intended actions of the other party. CONCLUSION: It is a broader concept than providing information regarding treatment alternatives in the office.

Characterizing the orthodontic research literature: 2020.

OBJECTIVES: To characterize features of the current orthodontic literature. METHODS AND MATERIALS: All research articles published in 2020 (N = 350) in the American Journal of Orthodontics and Dentofacial Orthopedics, The Angle Orthodontist, and the European Journal of Orthodontics were categorized on 48 features such as type of study (domain of generalization, subjects, and research design), analytical tools (statistical tests, power and normality of data, consistency of measurement, management of covariables, and corrections of multiple independent tests), and reporting characteristics. Consistency of the coding was high (κ > .990). RESULTS: The "most typical" article was a cohort study reporting multiple patient outcomes at a single treatment location. Soundness of analyses was uneven, with about half providing information on power or normality of the data and consistency of measurement. Few articles addressed covariables or adjusted for multiple tests of independent outcomes. Photos and flow charts were commonly used to explain methods, and results were presented in multiple formats. There was a clear association between design and reporting characteristics and type of study for systematic reviews, meta-analyses, and case reports. There were small but consistent differences across the three journals. CONCLUSIONS: The quality of the orthodontic research literature has advanced at an uneven pace, and this review identifies areas that could be strengthened. Substantial gaps remain in achieving accepted standards for randomized controlled trials and opportunities exist for better understanding measures of effect through design and analysis using regression techniques to identify sources of variance.

Consistency of orthodontists' clinical decisions: A systematic review, meta-analysis, and theory development.

INTRODUCTION: The purpose of this systematic review and meta-analysis is to provide a literature-based estimate of the consistency of orthodontists' clinical decisions. METHODS: A systematic review of the literature using a modified Reporting Items for Systematic Reviews and Meta-Analyses approach identified 20 articles, representing 53 unique datasets, reporting kappa statistics and standard errors for situations allowing intrarater or interrater comparison on decisions such as the need for treatment, extraction, surgery, and various specific treatment approaches. Meta-regression based on random effect models was used to explore the shape of the underlying distribution, the prevalence of the target condition in the data set, and the professional experience of raters as covariables. RESULTS: No evidence of publication bias was found. Common patient records accounted for approximately 25% of the variance between orthodontists and 33% of the variance within orthodontists making the same decision from the same records. Random and representative samples were judged more consistently than were samples chosen to contain borderline cases. (P <0.001). Raters were in greater agreement on the presence of target conditions than their absence (P <0.001). Residents were more consistent than were practicing orthodontists or dental students (P <0.006). CONCLUSIONS: Low consistency was found among orthodontists making clinical decisions from common records. Factors associated with samples and raters suggest an underlying pattern of orthodontists viewing cases through personal mental frameworks.

Using program yield to guide dental educational process improvement.

ISSUE: Dental education is a complex system of activities repeated on an annual cycle. Small adjustments are constant in an effort to improve the overall performance of the process. While it is possible to evaluate each change in isolation against standards particular to their circumstances, it is ultimately necessary to ensure that the set of changes has an overall positive impact on the program as a whole. APPROACH: It is valuable to have a school-wide criterion for choosing the best portfolio of constituent activities. This perspective piece describes the use of one such standard: program yield, defined as the proportion of students who are recognized as competent practitioners within a few months of the anticipated graduation date. The success of one program that used this approach is described. It is also suggested that dental education is a cyclical process that involves the four classical components of the quality movement. These are described as Goal, Experience, Assessment, and Refection in this paper. IMPACT: This is the first of three related perspectives. The other two are devoted to quality assurance and improvement and the challenge of transferring innovations published in the literature to application in other schools. The common theme in these perspectives is the value of driving improvement in dental education by focus on the outcome variable.

Quality assurance and quality improvement to enhance yield in the process of dental education.

ISSUE: The second paper in this three-part perspective on improving dental education through focus on outcomes explores the two common ways of controlling variance in processes such as dental education. APPROACH: Quality assurance is based on the view that variance is a characteristic of the material or product produced by the process. In the case of dental education this means students. The reputation of educational programs depends to some extent on identifying and correcting or putting aside output that do match standards. This is an expensive process that does not improve educational programs. Quality improvement, by contrast, is grounded in the assumption that there is unwanted variation in the process itself. IMPACT: Reducing system variation through judicious adjustment at each cycle of the process raises yield, reduces the proportion of defects, and reduces program cost. Examples are given where good decisions in the reflection stage of the GEAR cycle make goals more realistic, improve experiences, and promote more effective assessment.

Issues in transferring education research across dental schools.

ISSUE: Almost all dental educational research describes statistically significant changes using a one-time intervention at a single program. It is hoped that the most significant of these interventions will transfer to other schools. APPROACH: But the research logic of context-specific investigations does not always generalize with the same impact to new situations. This is the transfer problem. There is virtually no systematic research exploring the extent to which transfer from the dental educational literature is attempted, how successful it is, and what factors improve transfer. IMPACT: The paper discusses some of the more prominent issues in transferability such as (a) the meaning of "identical" conditions upon which inductive statistics are based, (b) isolation of causal factors, (c) generalizability, (d) reliability and validity, (e) measures of effect, (f) statistical versus practical significance, and (g) the need to build theory in discussion sections. Eight suggestions are offered for making dental educational research more transferable.

Measuring orthodontic treatment impact: Description or judgment, challenge or result.

INTRODUCTION: Determination of improvement in orthodontic treatment may depend on the measurement method used and the purpose. METHODS: Improvement after orthodontic treatment (from T1 to T2 [beginning to end of treatment]) was assessed 3 ways from a set of 98 patient records: (1) calculated by subtracting judges' assessments at T2 from T1 for records presented in random order, (2) judged as a holistic impression viewing T1 and T2 records side by side, and (3) determined from proxies (American Board of Orthodontics Discrepancy Index, the American Board of Orthodontics Objective Grading System, and the Peer Assessment Rating index). RESULTS: High levels of intramethod consistency were observed, with intraclass correlation coefficient clustering around an intraclass correlation coefficient of 0.900, and distributions were normal. Calculated and judged improvements correlated at r = 0.606. Calculated or judged improvements were correlated at a lower level with proxies. Calculated improvement was significantly associated with "challenge" (T1) scores and judged improvement associated with "results" (T2) scores. Common method bias was observed, with higher correlations among similar indexes than among indexes at the same time that used various methods. Relative to differences in Peer Assessment Rating scores, calculated improvement overestimated low scores and underestimated high ones. The same effect, but statistically greater, was observed using direct judgment of improvement. CONCLUSIONS: These findings are consistent with decision science and measurement theory. In some circumstances, such as third-party reimbursement and research, operationally defined measures of occlusion are appropriate. In practice, the determination of occlusion and improvement are best performed by judgment that naturally corrects for biases in proxies and incorporates background information.

Barriers and opportunities for dental school faculty research.

PURPOSE/OBJECTIVES: Identify barriers and opportunities regarding faculty participation in research. METHODS: Sixty-four faculty members of all ranks and days of employment completed a survey designed to reveal attitudes toward participation in research. RESULTS: Among those responding, three-quarters said they were actively engaged in research, and 45% of these identified no perceived barriers. Those reporting obstacles rank-ordered 10 barriers, but no consistent patterns emerged. A factor analysis revealed three clusters of concerns: (a) school barriers, (b) personal barriers, and (c) team opportunities. A large number of comments were offered, and these tended to group by the three quantitatively identified factors. CONCLUSION: These findings were consistent with the view that lack of time and formal training in standardized research skills were not major impediments to scholarship. Instead, assistance in navigating administrative hurdles and participation on multiskilled teams appeared to offer the best prospect for helping faculty interested in research.

Diagnostic paths for a mouth-breathing patient.

INTRODUCTION: The clinical choice of diagnostic tests or treatment options is determined by the probability that the value of their execution (called the warrant for the test) exceeds their cost, and by their usefulness. The purpose of this study was to determine the warrant and usefulness of STOP-Bang, an obstructive sleep apnea screening questionnaire, and cone-beam computed tomography (CBCT) information about the minimal cross-sectional area for referring a mouth-breathing patient to a sleep specialist and for modifying planned orthodontic treatment. METHODS: A branching survey was used to identify the prominence of paths between the presenting situation, 2 diagnostic tests, and 2 referral and/or treatment options. A description was given of a hypothetical patient: an overweight, mouth-breathing female teenager. Path analysis was used as a method for quantifying diagnostic warrant and usefulness. RESULTS: There was a wide variation among the 125 orthodontists who responded to the survey. All paths were chosen. The use of tests altered the referral (χ2 = 8.039; P = 0.03) and/or treatment decisions (χ2 = 12.636; P = 0.005). Ownership of a CBCT system significantly influenced the use of this diagnostic test, with owning a CBCT system resulting in greater use in-office (χ2 = 50.416; P <0.001) and greater use in the study (χ2 = 22.959; P <0.001). The usefulness of the diagnostic tests could not be determined directly because common values were used for each test, but the variation in the use of this standard stimulus was very large, indicating personal differences in the interpretation of actual data. CONCLUSIONS: Wide variation in the choice and interpretation of diagnostic tests for referral and orthodontic treatment modification relative to airway condition exists among orthodontists. Diagnostic path analysis is a potentially useful model for studying how practitioners make decisions independent of research evidence.

Investigation of foreign materials in gingival lesions: a clinicopathologic, energy-dispersive microanalysis of the lesions and in vitro confirmation of pro-inflammatory effects of the foreign materials.

OBJECTIVES: This study aimed to evaluate the clinical and histopathologic features of gingival lesions containing foreign material (GLFMs). In parallel, the composition of the foreign material and its effects in primary human gingival fibroblasts (HGFs) were investigated. STUDY DESIGN: Eighty-six GLFMs were retrieved from an oral pathology biopsy service. Clinical and microscopic data were analyzed, and the composition of the particles was identified by using energy-dispersive X-ray spectroscopy (EDX). Furthermore, HGFs were stimulated with silica (SiO2) microparticles to investigate the production of collagen type 1 (COL-1), matrix metalloproteinase 2 (MMP2), and inflammatory cytokines. RESULTS: GLFMs were most commonly found in women (60.5%) and most frequently described as white plaques. Histopathologic examination identified verrucous hyperplasia in 59% and epithelial dysplasia in 28% of the cases. EDX microanalysis revealed that Si (94%) was the most frequently detected foreign element. SiO2 microparticles induced higher COL-1 expression; higher levels of proinflammatory cytokines, such as interleukin-6 (IL-6), IL-8, and transforming growth factor-ß, and increased MMP-2 activity in HGFs. CONCLUSIONS: There was a strong association between the presence of foreign material in the gingiva and white verrucous clinical lesions. In addition, the most common element in the foreign material was Si, and our in vitro findings demonstrate the importance of silica-mediated effects on gingival fibroblasts.

How people make decisions about whether or not to seek orthodontic care: Upstream in the treatment chain.

INTRODUCTION: "Upstream" decisions by patients are important in determining whether they seek orthodontic care for their children and for themselves and whether they seek care from general dentists or from orthodontists. Classic marketing theory suggests that purchase decisions naturally progress through a sequence beginning with awareness and proceeding to information, emotional preferences, and final purchase commitment. METHODS: A survey was used to assess patient demographics and care history, motives for seeking care for themselves and their children, perceived barriers to care, trust in various sources of information, and preference for treatment by a general dentist or by an orthodontist. Three hundred fifty-two responses were received from patients in all states in the United Sates attending their general dentists. RESULTS: Care for children was most often initiated in response to a suggestion from the family dentist, and traditional treatment with braces was expected. Adults were slightly more likely to make a decision for care themselves and for appearance reasons, often with "invisible" braces. Cost was the principal barrier to seeking care for either functional or appearance reasons. More personal and individualized sources of information, such as the family dentist or referral to a specialist were strongly more influential, with indirect sources, such as dentist Web pages or advertisements, being least influential. There was a preference for care by orthodontists compared with general dentists for functional reasons and when complications were anticipated. Orthodontists were seen as being better at identifying complications, managing complications, and delivering reliable results. Orthodontic care provided by general dentists was favored for convenience and based on established relationships. Patients with more education, higher incomes, and more preventive oral habits preferred treatment by orthodontists. Although it was expected that orthodontists would charge more, income and cost were not factors among those considering treatment. CONCLUSIONS: This study suggests that orthodontists should focus on educating potential patients about the functional health features of treatment for malocclusions, especially for children. Furthermore, orthodontists would benefit from working with general dentists, given their role as gatekeepers in the sequential process of reaching an upstream decision about seeking orthodontic care.

How Dentists Read a Technique Article: A Grounded Theory Investigation.

PURPOSE: To conduct an empirical investigation using qualitative techniques of the way dentists engage in the process of reading a technique-oriented journal article and what they pay attention to in the process. MATERIALS AND METHODS: Grounded theory was used to identify how dentists read an article describing the fabrication of an interim prosthesis in the esthetic zone. Twenty-one experienced practitioners were videotaped, and their verbatim reflections were coded. The sequence of attending to various features of the paper was noted. RESULTS: Ninety-five percent of readers voiced specific, multiple attempts to identify or refine the main purpose of the article as they processed the material. All readers engaged in various activities to navigate through the article, including skipping and backtracking, and none "read" the article straight through. All readers also made repeated observations about the relevance of the technique to their personal practice situation. Eighty percent used some form of "distancing," whereby the content and value of the article were accepted, but the reader reserved the privilege of not being bound by the results because of technical, sponsorship, or methodological issues that "might be present." The quality of photographs was accepted as a proxy for the quality of technical work performed. CONCLUSIONS: Dentists actively customized the reading of a journal article that described a technical procedure. They imposed a non-linear structure for absorbing information and a standard of personal relevance, and, while accepting the results, created reasons for not necessarily having to accept them as applicable. The approach clinicians use in reading a procedural article may be different from the structure writers use in preparing a paper.