Dental skill mix: a cross-sectional analysis of delegation practices between dental and dental hygiene-therapy students involved in team training in the South of England.

BACKGROUND: Research suggests that health professionals who have trained together have a better understanding of one another's scope of practice and are thus equipped for teamwork during their professional careers. Dental hygiene-therapists (DHTs) are mid-level providers that can deliver routine care working alongside dentists. This study examines patterns of delegation (selected tasks and patients) by dental students to DHT students training together in an integrated team. METHODS: A retrospective sample of patient data (n = 2,063) was extracted from a patient management system showing the treatment activities of two student cohorts (dental and DHT) involved in team training in a primary care setting in the South of England over two academic years. The data extracted included key procedures delegated by dental students to DHT students coded by skill-mix of operator (e.g., fissure sealants, restorations, paediatric extractions) and patient demography. χ2 tests were conducted to investigate the relationship between delegation and patient age group, gender, smoking status, payment-exemption status, and social deprivation. RESULTS: A total of 2,063 patients managed during this period received treatments that could be undertaken by either student type; in total, they received 14,996 treatment procedures. The treatments most commonly delegated were fissure sealants (90%) and restorations (51%); whilst the least delegated were paediatric extractions (2%). Over half of these patients (55%) had at least one instance of delegation from a dental to a DHT student. Associations were found between delegation and patient age group and smoking status (P <0.001). Children under 18 years old had a higher level of delegation (86%) compared with adults of working age (50%) and patients aged 65 years and over (56%). A higher proportion of smokers had been delegated compared with non-smokers (45% cf. 26%; P <0.001). CONCLUSIONS: The findings suggest that delegation of care to DHT students training as a team with dental students, involved significantly greater experience in treating children and adult smokers, and providing preventive rather than invasive care in this integrated educational and primary care setting. The implications for their contribution to dentistry and the dental team are discussed, along with recommendations for primary care data recording.

Minimal intervention dentistry procedures: a ten year retrospective study.

UNLABELLED: Minimal Intervention Dentistry (MID) is an effective treatment approach with increasing acceptance among dental professionals. OBJECTIVE: This study aimed to evaluate the MID impact on Dentistry by analyzing procedures performed on patients treated at a Pediatric Dentistry Graduate Program clinic which implemented MID. STUDY DESIGN: The number of procedures including sealants, modified atraumatic restorative treatment (mART), resin crowns, direct pulp capping, pulpotomy, pulpectomy, and deciduous/ permanent extractions from 333 pediatric patients treated between the years 2001 to 2003 and 2008 to 2010 in Distrito Federal, Brazil were analyzed. Statistical analysis involved chi-square and G Williams tests. RESULTS: 783 procedures were analyzed and demonstrated that there was a significant reduction of sealant placement in the last triennium when compared to the first one (p<0.0001). Moreover, there was a significant increase in the amount of mART (p<0.0001). This increase in mART procedures resulted in a significant reduction in procedures with pulp involvement: direct pulp capping (p=0.0014), pulpotomy (p=0.0014) and pulpectomy (p=0.0002). CONCLUSIONS: Based on the results, MID represented a positive impact on the intervention on caries lesions in patients, mainly reflected by the significant reduction in the number of direct pulp capping, pulpotomy and pulpectomy.

Pulp exposures in adults--choice of treatment among Swedish dentists.

This study comprises a survey of Swedish dentists'treatment preferences in cases of carious exposure of the dental pulp in adults.The survey was conducted as part of a comprehensive report on methods of diagnosis and treatment in endodontics, published in 2010 by the Swedish Council on Health Technology Assessment. A questionnaire was mailed to a random subsample of 2012 dental offices where one dentist at each office was requested to answer all questions. Each questionnaire contained one of three sets of questions about endodontic practice routines.Thus around one-third of the subsample received case-specific questions about treating carious exposure. Only general practitioners aged below 70 years were included.The final study sample comprised 412 participants.The dentists were presented with two case scenarios. In Case 1 a 22-year old patient had a deep carious lesion in tooth 36 and in Case 2 a 50-year old patient had a deep carious lesion in tooth 14.The participants were asked to nominate their treatment of choice: pulp capping, partial pulpotomy or pulpectomy. For Case 1, 17 per cent of the respondents selected pulpectomy; the corresponding rate for Case 2 was 47 per cent. Female gender and age group 25-49 years were predictive of selection of less invasive treatment options. However, according to recent guidelines (2011) from the National Board of Health and Wellfare, Swedish dentists are recommended to elect pulpectomy prior to pulp capping/partial pulpotomy when confronted with a tooth having a cariously exposed pulp in adults.

Utilization of emergency services for non-traumatic dental disease.

PURPOSE: To identify and characterize children who utilize emergency dental services for non-traumatic dental disease. STUDY DESIGN: Caregivers of children under 12 years old who seek out emergency services for the treatment of non-traumatic dental disease will be surveyed regarding their child's current oral health status. Patient's clinical data will be obtained and they will be further followed for a period of 2 months to determine if they follow-up with recommendations for comprehensive dental care. RESULTS: One hundred and ninety-eight people participated in the study (97% response rate). Eighty-three percent of the children were diagnosed with dental caries. Seventy-four percent of patients of record presented with an emergency at least once before and 73% had a history of one or more broken appointments. Patients with a history of previous emergency visits (OR = 3.45, CI = 2.05, 5.81) or a history of missed appointments (OR = 2.21, CI = 1.42, 3.58) were significantly more likely to fail to return for comprehensive care (P < .01). CONCLUSION: This study shows that those who utilize emergency services more than once, or have a history of missed appointments are more likely to continue to utilize emergency dental services as their primary means for dental care.

Pulpotomy to stainless steel crown ratio in children with early childhood caries: a cross-sectional analysis.

PURPOSE: This study's purpose was to determine the pulpotomy-to-crown ratio (PCR) in a high-early childhood caries patient population and factors associated with choice of pulpotomy and crown treatments. METHODS: This was a retrospective quality assurance chart review. Five calibrated examiners (kappa=0.86) rated radiographic caries from available films. Demographic data, including age, health status, medications, and pain score, were collected along with pulpotomy- and crown-related treatment characteristics of location of tooth, treatment site, and level of operator skill. RESULTS: The record review of 521 patients (mean age=5.1 ± 1.9 years old) revealed 1,365 stainless steel crowns (SSCs) performed with 461 pulpotomies in a 6-month period, in both operating rooms (1,043 SSCs) and ambulatory settings (322 SSCs). The mean PCR was 0.34, with PCR decreasing with increasing patient age. Pulpotomy and crown treatments increased with radiographic caries severity with a significant association between pulpotomy and radiographic severity (P<.001). More severe pain was associated with greater likelihood of pulpotomy (P<.001). Age, operator type, and site of treatment did not affect choice of pulpotomy. CONCLUSIONS: The mean pulpotomy-to-crown ratio in this high-early childhood caries pediatric population was 0.34. Pain, the American Society of Anesthesiologists classification system, and radiographic caries severity were predictors of pulpotomy, but operator type and location of treatment were not.

An investigation into dentists' management methods of dental trauma to maxillary permanent incisors in Victoria, Australia.

Trauma to anterior teeth in children could become a long-term problem to dental health. To a large extent, the management actions of the dentists involved will determine the clinical outcome and, in turn, these actions will be related to their levels of knowledge. The aim of this study was to investigate dentists' knowledge of managing traumatic injuries to maxillary permanent incisors in children. A self-completion questionnaire containing 19 questions on management methods of treating dental trauma was mailed to 693 dentists in Victoria, Australia. The response rate achieved was 61%. This survey found that some of the respondents had adequate management knowledge for the different types of traumatic injuries, while others did not have the correct information. Approximately half the dentists considered milk as the preferred extraoral storage medium of choice for avulsed teeth and a period of 7-10 days splinting after replantation. A large proportion of dentists showed inadequate knowledge with regard to understanding the biological mechanisms causing replacement root resorption (61%) and external inflammatory root resorption (74%). Overall, the respondents to this survey demonstrated only a moderate level of knowledge in management of traumatic injuries to maxillary permanent incisors in children. Continuing professional development programmes may be a means of improving this deficient knowledge base.

Indirect pulp capping and primary teeth: is the primary tooth pulpotomy out of date?

Formocresol pulpotomy (FP) in the United States is most frequently used to treat asymptomatic caries near the pulp in primary teeth. Indirect pulp therapy (IPT) is also indicated and has a significantly higher long-term success. Pulpotomy is thought to be indicated for primary teeth with carious pulp exposures, but research shows the majority of such teeth are nonvital or questionable for treatment with vital pulp therapy. IPT has a significantly higher success in treating all primary first molars, but especially those with reversible pulpitis compared with FP. The purpose of this article was to review the dental literature and new research in vital pulp therapy to determine the following: (1) Is a pulpotomy indicated for a true carious pulp exposure? (2) Is there a diagnostic method to reliably identify teeth that are candidates for vital pulp therapy? (3) Is primary tooth pulpotomy out of date, and should indirect pulp therapy replace pulpotomy? )

Retrospective Study of the Survival Rates of Indirect Pulp Therapy Versus Different Pulpotomy Medicaments.

PURPOSE: The purposes of this retrospective chart review were to determine: (1) how primary molars in need of vital pulp therapy (VPT) have been treated over a period of four years at a university-based pediatric dental practice (UBP); and which treatments-indirect pulp therapy (IPT), formocresol pulpotomy (FCP), and ferric sulfate pulpotomy (FSP)-have been successful. METHODS: Electronic patient records (axiUm) that contained the procedure codes D3120 (pulp cap-indirect) or D3220 (therapeutic pulpotomy) were totaled by year. Visit records were queried again to identify treatment failures (i.e., extractions [D7140] or pulpectomy [D3221/D3240]). A total of 2,001 primary molar teeth were included in the study. Success was compared using a Kaplan-Meier analysis. RESULTS: At the three-year follow-up, IPT had a 96.2 percent survival rate, FCP had a 65.8 percent survival rate, and FSP had a 62.9 percent survival rate (P<.0001). CONCLUSIONS: Over a four-year period of time, IPT became the more commonly used vital pulp therapy treatment at a university-based pediatric dental practice and had a significantly better survival rate than FCP or FSP.

Treatment policies among Israeli specialists in paediatric dentistry.

AIM: This was to evaluate some suggested diagnostic procedures, treatment policies and professional attitudes of specialists in paediatric dentistry, in light of the periodically published guidelines by The American Academy of Pediatric Dentistry, The European Academy of Paediatric Dentistry and The British Society of Paediatric Dentistry. METHODS: Using a structured questionnaire, 67% of the Israeli specialists in paediatric dentistry, who agreed to participate in this study, were personally interviewed. RESULTS: Only 7.5% of the participants reported that they carry out pulp capping of primary teeth in cases of pulp exposure. Over 50% reported restoring teeth after pulpotomy with preformed crowns. Most indicated sealing pit and fissures after considering depth and morphology of the fissures and correlation with the patient's risk to caries. Cleaning teeth after eruption of the first tooth was suggested by 75.5% of the participants. A striking majority (96%) claimed that they restored permanent anterior teeth with composite resins and most used these materials for occlusal restoration in both primary and permanent posterior teeth. Most specialists advocated the use of amalgam in proximal posterior restorations. The presence of a parent in the operatory/surgery was preferred by 85% of the dentists. CONCLUSIONS: Israeli specialists in paediatric dentistry mostly comply with the mentioned guidelines. Further studies of this nature should also be encouraged in other countries to emphasize the importance of monitoring compliance with established and evidence based guidelines.

Permanent teeth pulpotomy survival analysis: retrospective follow-up.

OBJECTIVES: The aim of the present study is to evaluate risk factors influencing the success rates of pulpotomies both in young and adult populations. METHODS: Pulpotomies (n=273) performed by a single endodontic specialist were analyzed, and data on success rates were collected. Additionally, possible explanatory variables were noted such as: age, gender, clinical findings (teeth, type of restoration after pulpotomy), radiographic findings (dentin bridge formation) and systemic conditions. The follow-up period varied from 1 to 29 years, and the results were analyzed by Kaplan-Meier survival curves and also by Cox regression. RESULTS: Age at the time of pulpotomy ranged from 8 to 79 and had not influenced the success rates (p=0.35). The formation of dentin bridge had a strong protective effect (hazard ratio-HR=0.16, p<0.001). The prosthetic crown restorations following pulpotomy had the smallest failure rate, and amalgam has not increased the risk of failure significantly in relation to prosthesis. Resin composite restorations following pulpotomy increased in 263% the risk of failure (HR=3.63, p<0.001). CONCLUSION: This study allowed inferences that pulpotomy may be a successful treatment at any age, and not only for young permanent teeth. It was also possible to conclude that the use of direct composite restorations following pulpotomies is associated with higher failure rates.

Secular changes in treatment in a school dental service.

The caries decline has affected child dental treatment in many countries. There has been a change towards fewer extractions and pulpotomies in deciduous teeth, and restorative techniques and restorations in deciduous and permanent teeth have become less complex. New materials, particularly glass ionomer cements (GIC), have found acceptance. The School Dental Service (SDS) in Western Australia (WA), one of the world's largest dental care organisations, holds good data on children's dental health and on the types of treatment provided since 1980. This paper reports these data. Oral health is recorded as caries experience on a random sample of patients. Treatment provided is recorded by operators after each patient visit and collated monthly. About 240,000 children (> 90 per cent of those eligible) and currently enrolled in the SDS and the clinical staffing is about 150-160 dental therapists and 27 dentists. Caries experience has fallen in all age groups in recent years, except that in 1992 and 1993 dmft rose slightly in six-year-old children. All types of operative treatment are used less frequently now than in 1980. In deciduous teeth restorations, GIC dominates but amalgam remains the most widely chosen material in permanent teeth. The use of fissure sealants (using GIC) peaked in 1988 and, as a result of management decisions, has declined since then. The decline in the need for dental treatment has reduced costs and enabled the SDS to offer care to an expanding group of children in WA. The results achieved by the SDS in WA demonstrate that a service based primarily on dental auxiliaries is viable and efficient.

Dental services, costs, and factors associated with hospitalization for Medicaid-eligible children, Louisiana 1996-97.

OBJECTIVE: This study compared types and costs of dental services rendered to children who had received care in a hospital operating room (H) with children who had not (NH). METHODS: The study population consisted of all children aged 1-5 years who received a dental service reimbursed by the Louisiana Medicaid EPSDT program from October 1996 through September 1997. Claim files were provided by the Louisiana Bureau of Health Services Financing. A treatment intensity index [TII = 3 x (# extractions) + 2 x (# pulpotomies + # crowns) + # simple restorations] was calculated for H children (n = 2, 142) and NH children (n = 38,423). Using logistic regression, a dichotomous hospitalization variable (H vs NH) was regressed against treatment intensity and selected personal and parish (county) characteristics for each of the five age groups. Total and average reimbursement per child were calculated for both groups of children, by age. RESULTS: The mean treatment intensity scores for H and NH children were 24.02 (SD = 11.82) and 2.16 (SD = 4.78), respectively. For all age groups, children with treatment intensity scores greater than 8 were at least 132 times more likely to be hospitalized than were children with scores less than or equal to 8. The mean cost for care provided to H children was $1,508 compared with $104 for NH. Total costs for dental care rendered to H children (5% of the study population) were $3,229,851 (45% of total dental costs for the study population). CONCLUSION: Reducing severe caries through early interventions could provide substantial cost savings.

Comprehensive dental treatment of healthy and chronically sick children under intubation general anaesthesia during a 5-year period.

OBJECTIVE: To quantify the number of extractions and/or restorations placed in chronically sick children under intubation general anaesthesia and compare these findings with healthy children. SETTING: Two large paediatric dentistry units in Central London: a tertiary referral centre dealing with severe chronic sickness in children and an undergraduate dental school with a large commitment to special needs dentistry in children. DESIGN: Prospective comparison of treatment received for (a) chronically sick children and (b) dentally anxious (otherwise fit) children receiving intubation general anaesthesia during July 1991 to June 1996 inclusive. The statistical tests used were the Shapiro-Wilks test for normality and the Mann Whitney U test for non-parametric comparison of independent groups. MAIN OUTCOME MEASURES: Mean total treatment tally (TTT)--the sum of extractions and restorations for each child presented as summary data. RESULTS: Different patterns of dental care were found between the healthy and chronically sick groups. For similar levels of disease, a significantly greater number of extractions were carried out for chronically sick children (P < 0.0001), and significantly fewer restorations (P < 0.0001). The number of pulpotomies and stainless steel crowns provided to sick children was significantly smaller than to healthy children (P < 0.0001). This paper discusses the influences of chronic ill health on dental treatment provided under general anaesthesia. CONCLUSION: The underlying medical disorder in chronically sick children significantly influences the pattern of treatment when this is provided under general anaesthesia.

Root canal treatment and pulpotomy in Kenya.

This study was carried out to evaluate the practice and depth of knowledge of root canal treatment and pulpotomy by dentists in Kenya. Questionnaires were prepared and mailed to 114 dentists whose addresses were available. Sixty seven (58.8%) dentists responded. Of these, 67.2% carried out root canal treatment (RCT) and 43.3% carried out pulpotomy. The main reasons given by most dentists in the public hospitals for not carrying out these procedures routinely were lack of facilities and materials. Furthermore, it was found that amongst those who carried out these procedures, some used outdated techniques and materials. In order to reduce the large number of teeth lost through extraction, materials and equipment should be made available to enable dentists carry out root canal treatment and pulpotomies routinely. It is also necessary to have continuing dental education amongst dentists to update their knowledge of these procedures.

Evaluation of aggressive pulp therapy in a population of vitamin D-resistant rickets patients: a follow-up of 4 cases.

This investigation collected clinical and radiographic data from a retrospective chart review of 4 patients receiving prophylactic formocresol pulpotomies and stainless steel crowns following a dental abscess associated with a medical diagnosis of vitamin-D resistant rickets (VDRR) at Texas Scottish Rite Hospital for Children in Dallas, Tex. Clinical and radiographic data were available for 29 primary teeth in 4 children, with follow-up times ranging from 2 years, 1 month to 5 years, 6 months. Based on available recalls of 29 teeth treated following the prophylactic formocresol pulpotomy, 22 failed clinically. The earliest failure occurred at 3 months; the longest time to failure was 3 years, 9 months. No trends were discernable between tooth type and failure rate, although the shorter the time between eruption of the tooth and pulpotomy treatment, the greater the chance of success. Presently, there is not enough evidence to suggest that prophylactic pulpotomy therapy in VDRR patients is beneficial in preserving their primary dentition.

Primary tooth pulp therapy as taught in predoctoral pediatric dental programs in the United States.

A survey of all predoctoral pediatric dental programs in the United States was conducted to ascertain the contemporary teaching philosophies and techniques for pulp therapy in primary teeth. All 53 predoctoral programs responded to a two-part survey consisting of multiple choice questions regarding which pulp therapies and specific techniques were taught and which pulp therapies would be employed under certain hypothetical clinical scenarios. The results of the survey confirmed some lack of consensus on the selection and application of certain treatment modalities and techniques taught for primary tooth pulp therapy in predoctoral dental programs in the United States.

An outcomes assessment of 15 years of patient care experiences in predoctoral pediatric dentistry.

The purpose of this study was to examine the trends in numbers, demographic characteristics, and treatment history of pediatric dental patients under the care of dental students over the period 1980 through 1994. Data were collected for: exams, sealants, surfaces of amalgam, composite resin surfaces, pulpotomies, stainless steel crowns, and extractions. Correlations were done across the 15-year period to determine significant trends over time. During the 15-year period, the average number of patient visits required for each student to complete the requisite number of patients, declined from 45 appointments to complete 10 patients in 1980, to 35 visits to complete 13 patients in 1994. Over time, the numbers of amalgam surfaces, pulpotomies, extractions and stainless steel crowns decreased significantly, while the number of composite resin surfaces increased (P < 0.05). Based on a previous outcome assessment that indicated declining numbers of procedures performed between 1980 and 1985, the required number of patients treated per student was raised from 10 to 13, beginning with the 1986 class.

Evaluation of the carbon dioxide laser on vital human primary pulp tissue.

PURPOSE: The purpose of this study was to evaluate the response of the human primary pulp to the carbon dioxide laser and formocresol for vital pulp therapy. METHODS: Fifteen healthy children with intact, caries-and-restoration-free, contralateral primary cuspids with at least two-thirds of the roots remaining who were scheduled for orthodontic extraction were randomly assigned to pulpotomy treatment with a carbon dioxide laser or formocresol. The treated teeth were clinically and radiographically evaluated at 28 and 90 days post-treatment prior to extraction. The extracted teeth were evaluated histologically for pulpal response. RESULTS: All teeth were asymptomatic and clinically normal at both observation periods. Internal root resorption was observed in one formocresol and two laser treated teeth. There was a significant inverse correlation between the laser energy applied to the pulp and the degree of inflammation at 28 days (P = .01) but not at 90 days (P = .27). CONCLUSION: Carbon dioxide laser treatment compared favorably to formocresol for pulpotomy in primary teeth.

The diagnosis, classification and treatment of acute pulpal pain by UK general dental practitioners: results of a survey.

There are several problems related to the diagnosis and treatment of the acute painful tooth associated with a deep carious lesion, including the fact that there is little or no correlation between the clinical signs and symptoms and also that the diagnostic tools are not reliable. It is important to understand the problems experienced by dental practitioners and how they routinely make diagnosis and formulate treatment plans. The way general dental practitioners diagnosed, categorised and treated teeth with acute pain was ascertained by a questionnaire completed by practitioners attending postgraduate courses. The results indicate that dental radiographs and the dental history were most frequently used and that few practitioners had, and fewer used electric pulp testers. The concept of using simple clinical categories which correspond to treatment categories does not seem to be in widespread use, though the generally accepted role of calcium hydroxide as an indirect and direct capping material is widespread. The use of corticosteroid materials is not as widespread in younger practitioners as in their older colleagues and the use of emergency pulpotomy is infrequent.

Changes in dentists' attitudes and practice in paediatric dentistry.

AIM: The purpose of the study was to determine if there had been any changes in the clinical practice and attitudes to the care of children by general dental practitioners over a ten year period from 1986 to 1996, following the introduction of a system of capitation payments in the United Kingdom. METHODS: A questionnaire was mailed to 1,290 general dental practitioners practicing in Yorkshire (UK) in an identical way to a previous survey ten years before. Practitioners were asked questions concerning their practice of dental caries prevention, behaviour management, restoration of primary teeth and pulp therapy. Responses were compared with the results of the 1986 survey. RESULTS: Of the total of 687 replies (53.2% response) 61% practiced, or said they practiced, diet evaluation and gave dietary advice. Oral hygiene instruction was reported by 87% and 57% used fissure sealants. The routine use of amalgam, previously 80%, had declined to 35% in favour of glass ionomer cements (57%). There had been a significant improvement in the use of pulp therapy for primary teeth at 35% compared with previous 3%. The use of rubber dam also increased, but only from 0% before to 9% in the present study. The usage of stainless steel crowns had changed from 2% over ten years to 8% and strip crowns from 1% to 5%. CONCLUSION: The use of paediatric dental techniques by general dental practitioners had generally increased, particularly in preventive measures and pulp treatment. Restorative techniques had marginally changed, but a dramatic shift away from amalgam had occurred. There was still a very low usage of stainless steel crowns and rubber dam was also not used to the extent that it should be.