Clinical Performance Measures and Quality Improvement System Considerations for Dental Education.

Quality improvement and quality assurance programs are an integral part of providing excellence in health care delivery. The Dental Quality Alliance and the Commission on Dental Accreditation recognize this and have created standards and recommendations to advise health care providers and health care delivery systems, including dental schools, on measuring the quality of the care delivered to patients. Overall health care expenditures have increased, and the Affordable Care Act has made health care, including dentistry, available to more people in the United States. These increases in cost and in the number of patients accessing care contribute to a heightened interest in measurable quality improvement outcomes that reflect efficiency, effectiveness, and overall value. Practitioners and administrators, both in academia and in the "real world," need an understanding of various quality improvement methodologies available in order to select approaches that support effective monitoring of the quality of care delivered. This article compares and contrasts various quality improvement approaches, programs, and systems currently in use in order to assist dental providers and administrators in choosing quality improvement methodologies pertinent to their practice or institution.

A pilot study of dentists' assessment of caries detection and staging systems applied to early caries: PEARL Network findings.

The International Caries Detection and Assessment System (ICDAS II) and the Caries Classification System (CCS) are caries stage description systems proposed for adoption into clinical practice. This pilot study investigated clinicians' training in and use of these systems for detection of early caries and recommendations for individual tooth treatment. Patient participants (N = 8) with a range of noncavitated lesions (CCS ranks 2 and 4 and ICDAS II ranks 2-4) identified by a team of calibrated examiners were recruited from the New York University College of Dentistry clinic. Eighteen dentists-8 from the Practitioners Engaged in Applied Research and Learning (PEARL) Network and 10 recruited from the Academy of General Dentistry-were randomly assigned to 1 of 3 groups: 5 dentists used only visual-tactile (VT) examination, 7 were trained in the ICDAS II, and 6 were trained in the CCS. Lesion stage for each tooth was determined by the ICDAS II and CCS groups, and recommended treatment was decided by all groups. Teeth were assessed both with and without radiographs. Caries was detected in 92.7% (95% CI, 88%-96%) of the teeth by dentists with CCS training, 88.8% (95% CI, 84%-92%) of the teeth by those with ICDAS II training, and 62.3% (95% CI, 55%-69%) of teeth by the VT group. Web-based training was acceptable to all dentists in the CCS group (6 of 6) but fewer of the dentists in the ICDAS II group (5 of 7). The modified CCS translated clinically to more accurate caries detection, particularly compared to detection by untrained dentists (VT group). Moreover, the CCS was more accepted than was the ICDAS II, but dentists in both groups were open to the application of these systems. Agreement on caries staging requires additional training prior to a larger validation study.

The American Dental Association Caries Classification System for clinical practice: a report of the American Dental Association Council on Scientific Affairs.

BACKGROUND: The caries lesion, the most commonly observed sign of dental caries disease, is the cumulative result of an imbalance in the dynamic demineralization and remineralization process that causes a net mineral loss over time. A classification system to categorize the location, site of origin, extent, and when possible, activity level of caries lesions consistently over time is necessary to determine which clinical treatments and therapeutic interventions are appropriate to control and treat these lesions. METHODS: In 2008, the American Dental Association (ADA) convened a group of experts to develop an easy-to-implement caries classification system. The ADA Council on Scientific Affairs subsequently compiled information from these discussions to create the ADA Caries Classification System (CCS) presented in this article. CONCLUSIONS: The ADA CCS offers clinicians the capability to capture the spectrum of caries disease presentations ranging from clinically unaffected (sound) tooth structure to noncavitated initial lesions to extensively cavitated advanced lesions. The ADA CCS supports a broad range of clinical management options necessary to treat both noncavitated and cavitated caries lesions. PRACTICAL IMPLICATIONS: The ADA CCS is available for implementation in clinical practice to evaluate its usability, reliability, and validity. Feedback from clinical practitioners and researchers will allow system improvement. Use of the ADA CCS will offer standardized data that can be used to improve the scientific rationale for the treatment of all stages of caries disease.

Caries management pathways preserve dental tissues and promote oral health.

In May 2012, cariologists, dentists, representatives of dental organizations, manufacturers, and third party payers from several countries, met in Philadelphia, Pennsylvania, to define a common mission; goals and strategic approaches for caries management in the 21th century. The workshop started with an address by Mr. Stanley Bergman, CEO of Henry Schein Inc. which focused on the imperative for change in academia, clinical practice, and public health. For decades, new scientific evidence on caries and how it should be managed have been discussed among experts in the field. However, there has been some limited change, except in some Scandinavian countries, in the models of caries management and reimbursement which have been heavily skewed toward 'drilling and filling'. There is no overall agreement on a caries' case definition or on when to surgically intervene. The participants in the workshop defined a new mission for all caries management approaches, both conventional and new. The mission of each system should be to preserve the tooth structure, and restore only when necessary. This mission marks a pivotal line for judging when to surgically intervene and when to arrest or remineralize early noncavitated lesions. Even when restorative care is necessary, the removal of hard tissues should be lesion-focused and aim to preserve, as much as possible, sound tooth structure. Continuing management of the etiological factors of caries and the use of science-based preventive regimens also will be required to prevent recurrence and re-restoration. These changes have been debated for over a decade. The Caries Management Pathways includes all systems and philosophies, conventional and new, of caries management that can be used or modified to achieve the new mission. The choice of which system to use to achieve the mission of caries management is left to the users and should be based on the science supporting each approach or philosophy, experience, utility, and ease of use. This document also presents a new 'Caries Management Cycle' that should be followed regardless of which approach is adopted for caries prevention, detection, diagnosis, and treatment. To aid success in the adoption of the new mission, a new reimbursement system that third party payers may utilize is proposed (for use by countries other than Scandinavian countries or other countries where such systems already exist). The new reimbursement/incentive model focuses on the mission of preservation of tooth structure and outcomes of caries management. Also described, is a research agenda to revitalize research on the most important and prevalent world-wide human disease. The alliance of major dental organizations and experts that started in Philadelphia will hopefully propel over the next months and years, a change in how caries is managed by dentists all over the world. A new mission has been defined and it is time for all oral health professionals to focus on the promotion of oral health and preservation of sound teeth rather than counting the number of surgical restorative procedures provided.

The development of a dental diagnostic terminology.

There is no commonly accepted standardized terminology for oral diagnoses. The purpose of this article is to report the development of a standardized dental diagnostic terminology by a work group of dental faculty members. The work group developed guiding principles for decision making and adhered to principles of terminology development. The members used an iterative process to develop a terminology incorporating concepts represented in the Toronto/University of California, San Francisco/Creighton University and International Classification of Diseases (ICD)-9/10 codes and periodontal and endodontic diagnoses. Domain experts were consulted to develop a final list of diagnostic terms. A structure was developed, consisting of thirteen categories, seventy-eight subcategories, and 1,158 diagnostic terms, hierarchically organized and mappable to other terminologies and ontologies. Use of this standardized diagnostic terminology will reinforce the diagnosis-treatment link and will facilitate clinical research, quality assurance, and patient communication. Future work will focus on implementation and approaches to enhance the validity and reliability of diagnostic term utilization.

Electronic patient records for dental school clinics: more than paperless systems.

The Electronic Patient Record (EPR) or "computer-based medical record" is defined by the Patient Record Institute as "a repository for patient information with one health-care enterprise that is supported by digital computer input and integrated with other information sources." The information technology revolution coupled with everyday use of computers in clinical dentistry has created new demand for electronic patient records. Ultimately, the EPR should improve health care quality. The major short-term disadvantage is cost, including software, equipment, training, and personnel time involved in the associated business process re-engineering. An internal review committee with expertise in information technology and/or database management evaluated commercially available software in light of the unique needs of academic dental facilities. This paper discusses their deficiencies and suggests areas for improvement. The dental profession should develop a more common record with standard diagnostic codes and clinical outcome measures to make the EPR more useful for clinical research and improve the quality of care.