A multi-centered epidemiological study evaluating the validity of the treatment difficulty indices developed by the Japan Prosthodontic Society.

PURPOSE: The Japan Prosthodontic Society developed a multi-axis assessment protocol to evaluate the complex variations in patients who need prosthodontic care, and to classify the level of treatment difficulty. A previous report found the protocol to be sufficiently reliable. The purpose of this multi-center cohort study was to evaluate the validity of this multi-axis assessment protocol. METHODS: The treatment difficulty was evaluated using the multi-axis assessment protocol before starting prosthodontic treatment. The time required for active prosthodontic treatment, medical resources such as treatment cost, and changes in the oral health-related QOL before and after treatment, were evaluated after treatment completion. The construct validity of this protocol was assessed by the correlation between the dentist's pre-operative subjective assessment of the treatment difficulty, and the level of difficulty determined by this protocol. The predictive validity was assessed estimating the correlations between a "comprehensive level of treatment difficulty" based on the four axes of this protocol and total treatment cost, total treatment time, and changes in the oral health-related QOL before and after treatment. RESULTS: The construct validity of this protocol was well documented except for psychological assessment. Regarding the predictive validity, the comprehensive level of treatment difficulty assessed before treatment was significantly correlated with the three surrogate endpoints known to be related to the treatment difficulty (total treatment cost, treatment time, and improvement in the oral health-related QOL). To further clarify the validity of the protocol according to patients' oral condition, a subgroup analysis by defects was performed. Analyses revealed that treatment difficulty assessment before treatment was significantly related to one or two surrogate endpoints in the fully edentulous patients and the partially edentulous patients. No significant relationship was observed in the patients with mixture of full/partial edentulism and the patients with teeth problems, possibly due to the small sample size in these groups. CONCLUSION: This study revealed that the multi-axis assessment protocol was sufficiently valid to predict the level of treatment difficulty in prosthodontic care in patients with fully edentulous defects and with partially edentulous defects.

Shortcomings of prosthodontic rehabilitation of patients living in long-term care facilities.

Removable dentures are a non-invasive, cost-effective prosthodontic solution for the reduced dentition. Their intended purpose is the rehabilitation of harmonious oral function and aesthetics on a long-term basis. The prevalence of removable dentures among patients of advanced age is high and the quality of the dentures is often poor. The aim of this study was to find the most important shortcomings of removable dentures and address the main targets for improving the quality of prosthodontic rehabilitation. The records from dental check-ups in Austrian residential homes were analysed retrospectively. Dental anamnesis questionnaires and data from the clinical examinations of 105 denture wearers were analysed. The functional condition and retention of 192 dentures had been assessed, as well as the impact of the dentures on the intra-oral tissues. Insufficient denture retention was very common, particularly in the lower jaw (56·0%). Problems with the masticatory function were reported by 26.7% of the denture wearers, 11·4% were dissatisfied with the denture aesthetics, and 4·8% had difficulties with phonetics. Traumatic ulcers were found in 18·1%. Cracks, broken pieces (6·3%) or missing denture teeth (2·1%) were rare. It may be assumed that the findings of the present study also apply to a great percentage of community-dwelling seniors. The most important issues in prosthodontic rehabilitation with removable dentures are denture retention and masticatory function. Regular dental check-ups, denture adjustment and, when necessary, relining can maintain the primary denture quality and prevent damages of the oral tissues caused by ill-fitting dentures.

Dental students' perceptions of and experiences with prosthodontics: ten graduating classes at one institution.

It is important for members of the dental specialties to understand what motivates students to enter the specialty in order to ensure its continuing development and ability to meet patient needs. The aim of this study was to compare ten graduating classes at Harvard School of Dental Medicine (HSDM) regarding students' experiences with and perceptions of prosthodontics and factors influencing those interested in pursuing prosthodontics as a specialty. In 2013, HSDM students in the classes of 2012-16 were surveyed, achieving a response rate of 81%. Survey questions sought information regarding specialty choice, factors influencing the choice, student experiences with prosthodontics, and student perceptions of the dental disciplines. Responses were compared to those from a prior study of the HSDM classes of 2007-11. The responses showed a decrease in negative student experiences with prosthodontics. The students regarded prosthodontics highly for its impact on patient quality of life; however, students interested in pursuing prosthodontics as a specialty decreased. All students said provider enjoyment was most important in choice of specialty. Cost of program, patient type, and program location were factors that especially influenced students interested in prosthodontics. The improved student experiences with and perspectives on prosthodontics may be a result of a curriculum change that led to more prosthodontics procedures and case completions by students. The fall in students interested in prosthodontics may have resulted from prosthodontic faculty transitions that occurred when the survey was conducted, as well as large debt burdens in spite of the fact that prosthodontists' earnings are among the highest in dentistry. Faculty must educate and mentor students about the realities of the profession, provide positive learning experiences in the field, and encourage students who enjoy prosthodontics to pursue specialty training.

Economic outcomes in prosthodontics.

PURPOSE: A systematic literature review was conducted to identify the types of economic measures currently used in implant prosthodontics and determine the degree to which cost of care is considered in the context of any positive outcome of the care provided. MATERIALS AND METHODS: A literature search was conducted using the following set of terms plus some additional hand searching: "dental implants" (Mesh) AND ("cost") OR "maintenance" OR "healthcare policy" OR "access to care" OR "third party" OR "economic") AND (("1995/01/01"[PDat]:'2009/12/31"[PDat]) AND (Humans[Mesh]) AND (English[lang])). RESULTS: After a review of the 466 titles and abstracts identified by the search, 18 articles were accepted for further consideration, as some attempt at economic outcome measures was made. An additional four articles were identified by hand searching. The 22 accepted articles were grouped into four basic categories: (1) measure of costs of treatment (direct, indirect, and maintenance costs), (2) cost-effectiveness mathematical modeling applied to simulate the lifetime paths and cost of treatment, (3) cost-effectiveness analysis/cost minimization, and (4) willingness-to-pay, willingness-to-accept. Attempts at determining the costs of treatment varied widely. When the OMERACT filters were applied to the various measures it was felt that discrimination and/or feasibility was a problem for most of the current economic outcome measures. CONCLUSIONS: Measures of cost-benefit, cost-effectiveness, and cost-utility are currently the gold standard; however, feasibility of such analyses is an issue. Collaboration with health economists to guide future research is highly recommended.

Predoctoral dental students' perceptions and experiences with prosthodontics.

PURPOSE: The aims of this study were to: (1) investigate the perceptions and experiences of predoctoral dental students and advanced standing students on mentorship, exposure to prosthodontics, and future need for the specialty, and (2) establish a baseline of students' perceptions of the impact of prosthodontics on salary, personal and patient quality of life, and the profession of dentistry. MATERIALS AND METHODS: A survey was distributed to 494 predoctoral and advanced standing students at the University of Pennsylvania School of Dental Medicine. Questions focused on the perceptions and experiences with the specialty of prosthodontics. A total of 410 surveys were analyzed using Chi Square tests and univariate and multivariate analysis with statistical software. RESULTS: Response rate was 83%. A positive initial introduction to prosthodontics was reported by 57% of students. Most students had positive experiences with prosthodontic faculty and enjoyed laboratory work and challenging/complex dentistry. A greater need for prosthodontists in the future was perceived by 82% of respondents, with 63% reporting that the future of prosthodontics had been emphasized. Students reported (1) a preclinical course directed by prosthodontists and (2) working in the clinic with prosthodontic faculty (p < 0.006) as having the biggest impact on their introduction to prosthodontics. A desire to pursue training or a career in prosthodontics was reported by 3.4% of the respondents, with 1.7% of them pursuing prosthodontics. Enjoyment of providing care in prosthodontics was the most important factor for those who decided to pursue prosthodontic postgraduate training. When compared to other specialties, prosthodontics ranked low with regards to its impact on salary (7(th) ), personal quality of life (5(th) ), patient quality of life (4(th) ), and strengthening of the dental field (7(th) ). CONCLUSION: Reasons few students are interested in prosthodontics as a career, despite a positive first introduction and high perceived future need for prosthodontists may be attributed to a number of factors. These include insufficient prosthodontically, trained faculty, lack of a mentorship program, lack of an advanced graduate program, a perception of feeling unprepared upon graduation, and misconception of potential income in prosthodontics.

Increasing predoctoral dental students' motivations to specialize in prosthodontics.

This study provides data about factors that influence dental students' decision of which specialty to pursue and describes program changes in prosthodontics designed to expand student interest in a prosthodontics training program. Of 176 current and recently graduated students at Harvard School of Dental Medicine, 167 responded to the e-mail survey for a 94.9 percent response rate. Using the Pearson chi-square analysis, we analyzed nine factors to determine their contribution to these students' choice of specialty. Two factors, lecture and faculty/mentoring, were highly significant (p<0.006) regarding impact on the students' introductory experience with prosthodontics. When choosing a specialty, 44 percent of all students ranked "enjoyment of providing the specialty service" as the most important factor. Students wishing to specialize in prosthodontics, however, ranked four significant factors: enjoyment of providing the specialty service (p<0.037, p<0.057); faculty influence (p<0.0002, p<0.0001); length of program (p<0.039, p<0.006); and cost of program (p<0.023, p<0.004). Respondents also ranked the nine American Dental Association-recognized specialties regarding their perceptions of future salary and impact on the dental profession. They ranked prosthodontics fourth for future salary and fifth for impact on the profession. At the same time that this study was being conducted, key changes were being made in the graduate prosthodontics program; those appear to have had a positive impact on students' interest in pursuing prosthodontics as a specialty.

Cost-effectiveness of endodontic molar retreatment compared with fixed partial dentures and single-tooth implant alternatives.

INTRODUCTION: One of the most challenging situations in dentistry is a failed root canal treatment case. Should a failed root canal-treated tooth be retreated nonsurgically or surgically, or should the tooth be extracted and replaced with an implant-supported restoration or fixed partial denture? These four treatment alternatives were compared from the perspective of cost-effectiveness on the basis of the current best available evidence. METHODS: The costs of the four major treatment modalities were calculated using the national fee averages from the 2009 American Dental Association survey of dental fees. The outcome data of all treatment modalities were retrieved from meta-analyses after electronic and manual searches were undertaken in the database from MEDLINE, Cochrane, ISI Web of Knowledge, and Scopus up to April 2010. The treatment strategy model was built and run with TreeAge decision analysis software (TreeAge Software, Inc, Williamstown, MA). RESULTS: Endodontic microsurgery was the most cost-effective approach followed by nonsurgical retreatment and crown, then extraction and fixed partial denture, and finally extraction and single implant-supported restoration. CONCLUSIONS: The cost-effectiveness analysis showed that endodontic microsurgery was the most cost-effective among all the treatment modalities for a failed endodontically treated first molar. A single implant-supported restoration, despite its high survival rate, was shown to be the least cost-effective treatment option based on current fees.

Private practice of prosthodontists: current conditions of practice in the United States.

PURPOSE: The purpose of this article is to examine data and results from the 2008 Survey of Prosthodontists. Survey results are used to examine current trends and characteristics of prosthodontists in private practice. MATERIALS AND METHODS: Characteristics of prosthodontists and conditions of private practice are based on surveys conducted in 2002, 2005, and 2008 sponsored by the American College of Prosthodontists. Survey results are used to estimate several characteristics including age, gender, number of patient visits, hours in the practice, employment of staff, referral sources, and financial conditions (gross receipts, expenses of the practice, and net income of prosthodontists). RESULTS: The average age of a private-practicing prosthodontist reached 51 years in 2007; 12.3 is the number of years in the current practice; and most prosthodontists (71%) are solo private practitioners. The average amount of time per week by prosthodontists in the practice averaged 36.1 hours, and prosthodontists treated an average of 44.1 patient visits per week. The largest source of patient referrals is the patient themselves. The largest percentage of a prosthodontist's treatment time is spent rendering procedures in fixed prosthodontics, but this percentage has declined since 2001. In 2007, the average gross billings of a practicing prosthodontist reached $805,675; average total practice expenses were $518,255; the mean net earnings of practitioners were $268,930. CONCLUSION: In 2007, prosthodontists in private practice paid out about $1.4 billion in practice expenses to provide $2.2 billion dollars in prosthodontic care. Based on survey results from 2007 and the previous 6 years, specialization in prosthodontic care continues to be an economically attractive and productive healthcare profession in the United States.

2008 Survey of Pro Bono Services Provided by Practicing Prosthodontists.

PURPOSE: The purpose of this article is to analyze data from the results of the 2008 Survey of Pro Bono Services Provided by Practicing Prosthodontists. Survey results are used to examine characteristics and to compare the charitable care rendered by practicing prosthodontists to the dental field at large. MATERIALS AND METHODS: The character and incidence of pro bono services (PBS) provided by prosthodontists are based on a 2008 survey, made possible through an American College of Prosthodontists Board of Directors' sponsored initiative. Survey results are used to assess the distribution of respondents practicing the specialty of prosthodontics in the United States, percentage of prosthodontists who render pro bono dental services for the community, percentage of total patient care devoted to pro bono treatment at no charge, number of patients treated annually with PBS, monetary value of pro bono care annually, types of pro bono procedures, percentage of practitioners using Prosthodontic Diagnostic Index (PDI), PBS by PDI category to assess complexity of donated work, and percentage of practicing prosthodontists using informatics to track services by the PDI. RESULTS: Thirty-nine states were represented in the survey data. The highest responses were in the most populous states. The percentage of practicing prosthodontists providing PBS was 71.7%. For this cohort, the annual percentage of total care provided for treatment at no fee was greater than 1% in more than 54.8% of the practices. Almost 50% of these prosthodontists reported treating more than five patients per year at no charge. The average annual value of donated services was $25,078.00. The types of services rendered were most frequently diagnostic (83.5%) and radiographic (76.6%), followed by operative dentistry (61.5%) and fixed prosthodontics (49.4%). The percentage of practicing prosthodontists using the PDI to establish the complexity of PBS was 17.9%. For those using the PDI, there was almost an even distribution in categories I-IV. Informatics was used to track PBS in only 3% of the respondents. CONCLUSION: Based on this survey, practicing prosthodontists compare favorably to dental generalists and other specialists in terms of the annual dollar value donated in pro bono care. Their treatment addresses a broad scope of prosthodontic services including the restoration of patients with complex needs.

Prosthodontic treatment of patients with disabilities at dental specialist clinics in the County of Västra Götaland.

In 1998 the Swedish Parliament decided about increased financing of dental support and service given to persons with disabilities who were dependent on nursing personnel or others in their activities of daily life including oral hygiene procedures. One part of the legislation called "Necessary dental care, group 3" (NDC3) includes persons with intellectual disabilities and disabilities due to brain damage, autism and autism-like disorders, and persons with lasting mental and physical disabilities not related to normal ageing. The objectives where to investigate persons affected by this legislation; how many and what patients covered by NDC3 in Västra Götaland County received prosthodontic therapy from 2001 through 2004, at hospital dental clinics or dental specialist clinics. Patients treated with prosthodontic restorations covered financially by the county council under the terms of NDC3 were identified through the county council's registers. The application forms for NDC3 were retrieved and information about patient characteristics and type of treatments were compiled. It was shown that 57 patients covered by NDC3 in Västra Götaland County received prosthodontic therapy at dental specialist clinics and 50 were treated at the hospital dental clinics for extensive prosthodontic treatment needs. The mean age for the patients rehabilitated with removable dentures was higher (56.2 years) compared with patients treated with single tooth implants (39.7 years). About 30 patients, representing 1 to 2% of the NDC3 population in Västra Götaland County were rehabilitated with more advanced prosthodontic restorations in hospital dental clinics or dental specialist clinics each year. In conclusion and with respect to the probably large need for prosthodontic therapy among persons with disabilities, the use of NDC3 has not been properly utilized.

A survey of program directors: trends, challenges, and mentoring in prosthodontics. Part 1.

PURPOSE: This study consisted of two parts. Part 1, a survey of program directors, was conducted to examine current trends in advanced education in prosthodontics in the United States. Part 2 will report on the survey results distributed to the deans of US dental schools to evaluate their observations of trends in prosthodontics. MATERIALS AND METHODS: A national e-mail survey of 45 program directors was used to collect enrollment data for years 1 to 3 of prosthodontics training for US and international dental school graduates, the total number of applicants and applications considered, and the trends over time of applicants to prosthodontic programs for US dental school graduates and for international graduates. In addition, the program directors were asked to rank 13 key factors that may have contributed to any changes in the prosthodontic applicant pool. Comments were accepted on why more or less US- or internationally trained applicants have applied. Program directors were also asked for information on student financial incentives, whether their programs were state or federally funded, and whether their sponsoring institution was a dental school. RESULTS: Of the 45 program directors, 39 responded, for an 86.7% response rate. Respondents reported that 64% of their enrollments were graduates of US dental schools. Between 2000 and 2004 the applicant pool in prosthodontics increased by 23%, with 41% of program directors reporting an increase in US-trained applicants, 46.2% reporting no change, and only 12.8% reporting a decrease. Using the Spearman correlation, there was a moderate, positive statistically significant correlation that the following factors contributed to an increase in the number of US dental graduates applying to prosthodontic programs: (1) mentoring by prosthodontists at the predoctoral level, (2) interest in prosthodontics among US dental students, and (3) society's demand for a higher level of training and credentialing, (4) data depicting current and projected income for dental specialists, and (5) number of trained prosthodontists full- or part-time faculty at the predoctoral level. Only five programs offered no financial packages to offset tuition. The remaining 34 respondents reported some financial package. Among the respondents, there were 25 state-sponsored programs, 9 sponsored by private universities, and 5 sponsored by hospitals or federal agencies. CONCLUSION: An increased applicant pool and more US-trained applicants to prosthodontics programs create a more competitive applicant pool for our specialty. Program directors reported that factors such as mentoring, society's demand for a higher level of training and credentialing, data depicting current and projected income for prosthodontists, exposure to prosthodontic faculty at the predoctoral level, the dollar value of prosthodontic training, and advances in implant, aesthetic, and reconstructive dentistry have all had some impact on increasing the applicant pool to prosthodontic training in the United States.

Why do dentists struggle with removable partial denture design? An assessment of financial and educational issues.

AIM: Published studies in the international dental literature illustrate that the quality of prescription and fabrication of cobalt-chromium removable partial dentures (CCRPDs) by general dental practitioners frequently fail to comply with ethical and legal requirements. The reasons cited for this in the past have broadly related to either financial or educational issues. The aim of this investigation is to determine the effect of financial and educational factors on the quality of CCRPD design and fabrication by general dental practitioners. MATERIALS AND METHODS: This investigation was completed in two parts. (1) A pre-piloted pro-forma was distributed to a number of dental laboratories throughout the UK and Ireland. These sought information relating to the quality of written instructions for CCRPDs received by these laboratories, and details of the remunerative scheme under which they were being provided. Three categories of remunerative scheme were considered, private CCRPDs in Ireland, private CCRPDs in the UK, and CCRPDs being provided by salaried NHS practitioners. (2) A pre-piloted questionnaire was distributed to vocational dental practitioners in the UK and Ireland. This sought information relating to their attitudes, opinions, and educational and clinical experiences of CCRPD design and fabrication. RESULTS: (1) Three hundred completed pro-formas were returned from dental laboratories, 100 of which related to each of the three remunerative schemes. Poor or no written instructions were provided in 47% (n = 47) of CCRPD cases funded privately in the UK, 46% (n = 46) of CCRPD cases funded privately in Ireland, and 50% (n = 50) of CCRPDs being provided by salaried NHS practitioners. (2) One hundred and seven completed questionnaires were returned from vocational trainees. Vocational dental practitioners had completed fewer CCRPDs during VT than in dental school (dental school: median = 4, inter-quartile range = 3 to 5; VT: median = 2, inter-quartile range = 1 to 4). One-fifth of respondents (n = 22) had not completed any CCRPDs during VT. Nine per cent of VT practices (n = 10) had a surveyor on their premises. Only 15% (n = 16) of respondents felt the time they had spent in VT had increased their confidence in the design of CCRPDs. CONCLUSION: Financial factors did not have as significant an effect on the quality of prescription and fabrication of CCRPDs as did educational factors. Serious deficiencies in the teaching of CCRPDs during vocational training were identified.

Prosthodontics as a specialty private practice: net income of private practitioners.

PURPOSE: The aim of this study was to use data from a survey of prosthodontists in the US to examine average net earnings of prosthodontists in private practice. MATERIALS AND METHODS: A survey of 2500 prosthodontists in the US was used to estimate the net earnings of practicing prosthodontists. The national average net earnings of prosthodontists in private practice was estimated along with average earnings for subgroups of prosthodontists. Estimates for private practitioners by age, gender, size of practice, full-time/part-time status, practice ownership, and by type of treatment procedures rendered by the practitioner were also included. RESULTS: Average earnings for prosthodontists in private practice on a primary or secondary basis were estimated to be $215,300 and for prosthodontists who own or share in the ownership of a private practice, $233,920. Reported earnings estimates ranged from $96,160 for non-owners of a private practice and $103,350 for part-time private practitioners to $233,920 for practice owners and $275,170 for prosthodontists in practice with two prosthodontists. The average earnings of prosthodontists who are practice owners were estimated to be 35% higher than the corresponding general practitioners. CONCLUSION: Average net earnings are often used to examine the current economic health of a profession. The average net earnings of prosthodontists in private practice exceed the average net income reported by the American Dental Association for all dentists and all general practitioners and they are competitive with earnings among all specialty groups. This evaluation of the net earnings of prosthodontists shows that prosthodontics offers a competitive career opportunity for the general dentist with a personal desire to pursue advanced dental education in a specialty as a profession.

Guidelines for a minimum acceptable protocol for the construction of complete dentures.

PURPOSE: To investigate the feasibility of obtaining expert consensus on the prosthodontic principles to be followed when constructing complete dentures, so that any modifications to materials and methods would not sacrifice those principles--a philosophy known as "appropriatech." These principles would then comprise a Minimum Acceptable Protocol (MAP) for complete dentures. MATERIALS AND METHODS: A Delphi survey technique was used that requested yes/no answers to a variety of statements describing the different stages in the construction of complete dentures. Respondents could also provide comments on any aspect of the questionnaire. The statements were then modified in light of the responses and comments received, and recirculated. Three rounds of questionnaires were used, and only statements achieving a 90% or greater consensus were included in the MAP. The respondents were randomly selected by country from the 2004 membership e-mail list of the International College of Prosthodontists. RESULTS: Forty-one respondents answered the first questionnaire, 39 the second, and 36 the third. The 75 statements in the first questionnaire were gradually reduced as consensus was reached, and eventually 18 statements remained with 90% or greater agreement. CONCLUSION: Even though expert opinion is regarded as the lowest level of evidence, there are no other methods available to derive such a protocol, and the Delphi technique was useful in obtaining the consensus. This MAP could now be used to help assess clinical techniques that attempt to reduce time and costs while producing a quality service-in other words, which will conform to the philosophy of appropriatech.