Comparison of an ultrasonic cleaner and a washer disinfector in the cleaning of endodontic files.

The aim of this study was to compare the amount of residual organic debris on endodontic instruments that had been cleaned in either an ultrasonic bath or a washer disinfector prior to sterilisation. A total of 90 endodontic files of varying sizes were used to clean and shape root canals in extracted teeth and were then placed in endodontic file holders. Test group 1 (36 files) were ultrasonically cleaned for 10 min and test group 2 (36 files) were cleaned in a washer disinfector. A control group (18 files) were not cleaned at all. Following sterilisation, all the files were visually inspected under a light microscope and scored using an established scale. The results showed that both test groups had significantly less residual debris than the control group. Comparing the test groups, the files that had been cleaned ultrasonically had significantly less debris than those cleaned in the washer disinfector. The design of the instrument holder may have been a factor in this result. More research is needed into the use of washer disinfectors in the cleaning of small dental instruments that have a complex surface structure.

Dentists' attitudes toward frustrating patient visits: relationship to satisfaction and malpractice complaints.

A 22-item questionnaire measuring physician frustration in communicating with patients was adapted to dentists, and its reliability and validity assessed, in a sample of 289 English dental surgeons in general practice in Greater Manchester. Subscales were derived assessing the concepts of unpleasant dentist feelings, lack of communication, patient non-compliance, patient control, and practice organization with Cronbach's alpha ranging from 0.59 to 0.77. Three of five subscale scores (unpleasant feelings, lack of communication, and practice organization) were significantly greater for dentists who had official malpractice complaints to insurers. Similarly, all five subscores were greater for dentists who reported larger numbers of unsatisfactory visits and expressed greater dissatisfaction with dental practice.

Dental anxiety and attendance in the north-west of England.

The aim of this study was to record the level of anxiety and last recorded visit for a dental check-up of a random sample of 300 workers at three sites in the North-west of England. All subjects were asked to complete a short written questionnaire and 255 (85 per cent) usable forms were returned. The mean level of anxiety using the Corah Dental Anxiety Scale (DAS) (N.L. Corah, 1969, J. Dent. Res. 48, 596) was 9.1. Females had a statistically higher mean DAS than males but there was no correlation between DAS and either age or occupational status. Those subjects who claimed not to have had a check-up in the past year had a significantly higher mean DAS than those who claimed to have been in the past year. Multiple regression analysis showed that the reported time interval since the last check-up was the most important predictor of the DAS score. The implications of the results are considered for the future of restorative dentistry.

Attitudes of dental students towards elderly people.

Questionnaires were distributed to first, third and fifth year dental students at two British dental schools, to assess their attitudes towards the elderly. A second follow-up questionnaire was given 1 year later to the five student years attending one of these dental schools, to compare attitudes and estimate how they affected their perceptions of treating this section of the community. In both questionnaire surveys, clinical dental students had a more positive attitude towards the elderly than did students in the non-clinical years of the course. In those students who had received both questionnaires on consecutive years, there was an improved attitude score. There were no significant differences in the attitudes of male and female students.

Resource costs of capitation maintenance care in Britain.

The aims of this study were to examine variations in the resource cost of maintenance care for children under capitation by the area in which the dentist worked, the gender of the dentist, the number of years that the dentist had been qualified and the social class mix of the practice locality. Data were analysed from those collected during a clinical trial of capitation and fee-for-service payment systems that took place between 1986 and 1989. The costs of restorative/surgical treatment were over twice as high in Grampian than in Bromley. The costs of all treatment provided were 46 per cent higher in Salford than in Bromley. The date of qualification of the dentist was the only factor significantly associated with the cost of preventive treatment provided, with more recent graduates offering more preventive care than older dentists. The difficulties of using uniform national capitation rates are discussed.

An assessment of capitation in the new General Dental Service contract.

A 2-year study has been completed to examine the dental health and patterns of treatment of samples of children registered under capitation in three areas of England. The opportunity was taken to compare some of these results with those reported in the same areas in 1989 when the dentists were remunerated under fee-for-service. In addition, the validity of the dental health information supplied by general dental practitioners on the FP17C form was assessed. The dental health of 14-15-year-old patients registered for more than a year was compared with that of similar patients in the same areas in 1989. There was a large reduction in the caries experience (mean DMFT) in these patients in all areas between 1989 and 1994 mainly due to a significant fall in the mean numbers of teeth filled. The mean number of teeth extracted for caries remained low in all areas. There was a small increase in the mean number of decayed, untreated teeth in all areas. There was a large increase in the proportion of patients with one or more fissure sealants present. The dental health of 7-8-year-old patients registered for more than a year was examined but, as this age group were not examined in 1989, no comparative data were available. Regularly attending child patients had, on average, one untreated decayed deciduous tooth, but few had more than two. Caries experience in first permanent molars was low in all areas. Data were collected from a sample of general dental practitioners in three areas on the treatment provided over a 12-month period for random samples of patients in two age groups: 6-12 and 13-15 years. There was an increase in two of the three areas in the provision of oral hygiene instruction and dietary advice. The level of fissure sealant use was maintained or increased. There was a reduction in the numbers of both deciduous and permanent teeth filled. Fewer children had teeth extracted. The proportions of patients having bitewing radiography reduced. The mean number of both visits and check-up examinations reduced. There validation of the dental health information on the FP17C was carried out by comparing the data collected for 7-8 and 14-15 year old patients during the dental health examinations with that submitted by general dental practitioners on FP17C forms to the Dental Practice Board for the same children. For the permanent dentition, agreement was good for missing and filled teeth but poor for decayed, untreated teeth. For deciduous teeth, levels of agreement were generally poor except for filled teeth where it was fair.

A trial of a capitation system of payment for the treatment of children in the General Dental Service. Final report. Dental Health Services Research Unit, University of Manchester. September, 1989.

A 3-year clinical trial comparing capitation and fee-for-service remuneration systems for general dental practitioners for the treatment of children has been successfully completed. Capitation dentists restored carious teeth at a later stage in the disease process than fee-for-service controls, and carried out more preventive treatment and advice. However, the disease experience of their patients was little different from that of patients treated under fee-for-service. Capitation dentists saw their patients less frequently and took fewer radiographs than their fee-for-service colleagues. The prevalence of both fissue sealants and arrested caries was low in both groups, as was the prevalence of teeth extracted as a result of caries. Levels of oral cleanliness were similar under both systems. Private treatment was rarely prescribed for children, but was more prevalent for patients of fee-for-service dentists. The profession felt that capitation offered greater clinical freedom and more financial stability to dentists, but a greater temptation to under-prescribe treatment. The profession lacked commitment to capitation as a method of remuneration for the treatment of children in the General Dental Service. Fee-for-service dentists appeared to be more innovative, expressed a greater allegiance to their patients and felt a greater temptation to over-prescribe than capitation dentists. The parents had a high opinion of the service for children, irrespective of the remuneration system, and the children found the service very acceptable. Parents had a stronger allegiance to the fee-for-service than the capitation dentists. The study revealed several short-comings in the capitation model tested, but solutions to all of these became apparent. A capitation agreement of more than 12 months would simplify administration and reduce costs, as would a reduction in the number of forms. The need to notify parents when a dentist was replaced in a practice created considerable difficulties and increased expense. The treatment of trauma and extractions for orthodontic purposes should have been items excluded from the capitation fee. The need for information on dentists' activity in capitation was accepted but should be kept simple and relevant. Monitoring quality of care under capitation can be carried out from the routine data collected for administrative purposes. Capitation does not appear to increase participation. Costs of administering capitation are little different from those for fee-for-service. More resources were spent per dentist and per patient under capitation than fee-for-service. In the clinical trial fee-for-service was more cost-effective than capitation.(ABSTRACT TRUNCATED AT 400 WORDS)

The incidence of occupational exposures among students in four UK dental schools.

OBJECTIVES: To evaluate: the incidence of occupational exposures (OE) to patient body fluids among a sub-group of dental students; the rate of reporting of incidents; and the association of various factors. DESIGN: Multicentre retrospective analysis. SETTING: Four UK dental schools in 2000. SUBJECTS: Dental students from 4 UK schools completed a confidential questionnaire at the end of the clinical years of their undergraduate course. RESULTS: The response rates ranged from 71-100%, showing that 12-40% of students among the schools had experienced one or more OE incidents since starting their course. No statistically significant association was found between OE incidence and age, sex, dominant hand or time of day; most OE occurred with handling of local anaesthetic syringes. 61-78% of incidents were penetrative in nature, and 28-53% of students had not reported their last OE. OE incidence was associated with school, year of course, presence of patient and presence of an assistant. There were substantial differences in the numbers of students experiencing OE among the schools. CONCLUSIONS: Within the limitations of the survey and variations within the clinical activity of schools, it may be seen that improvements are needed in some schools to reduce cross-infection risks, and increase reporting of incidents. Suggestions are offered which may increase the safety of dental treatment.

Factors affecting fee setting for private treatment in general dental practice.

OBJECTIVES: To examine how pricing policies were contrived in general dental practice in terms of fee-for-item and hourly rate and how these were affected by specialist status and the level of private care provided in a practice. DESIGN: A postal questionnaire. SUBJECTS: Members of the British Society for General Dental Surgery working in dental practice. RESULTS: Out of 160 eligible members, responses were received from 124 members (78%). Fifty-seven respondents claimed to specialise in one or more fields of dentistry. The majority of respondents consulted fellow colleagues or partners for advice on fee setting. A minority took external advice. The charging method varied according to the item of treatment with fee-for-item used predominantly for items such as a new patient examination, and hourly rate used more for items such as a direct composite restoration. Seventy-one respondents stated that their practice was 80-100% private treatment and these practitioners were significantly more likely to charge by hourly rate than fee-for-item for many items of treatment. Specialist status did not have any effect on charging method. The most important factors related to the setting of fees-for-item or hourly rate were clinical time spent, practice overheads and laboratory costs. CONCLUSIONS: This project has taken the views of a large group of experienced general dental practitioners, many of whom work purely in the private sector. The most important factors affecting fee setting were clinical time, practice overheads and laboratory costs. The method of charging was most affected by the proportion of private treatment provided by the practice.

Prevalence of complaints by patients against general dental practitioners in greater Manchester.

A postal questionnaire regarding potential and official patient complaints was sent to all dentists on the Family Health Service Authority list of four health districts in Greater Manchester. From an eligible sample of 335 dentists, 306 responses were received (91%), 289 of them from general dental practitioners (GDPs). One hundred of the GDPs (35%) had reported at least one potential complaint to their defence organisation in the past 5 years (1989-1993) and 10 GDPs had reported three or more complaints. The majority of complaints were in the field of restorative dentistry (57%) with complaints about oral surgery accounting for another 20%. Dentists who worked longer hours contacted their defence organisation more often regarding potential complaints. Thirty-two dentists reported that their most recent potential complaint had resulted in an official complaint being filed against them. There was a significant relationship between the prevalence of official complaints and the dentists' reported level of unsatisfactory patient visits.

The sealant restoration: indications, success and clinical technique.

In this paper we have considered the available literature which demonstrates that sealant restorations perform at least as well as amalgam restorations and are more conservative. Success depends on retention of the overlying sealant and if this is fully retained it is unlikely that any residual caries will progress. The diagnosis of occlusal caries and indications for sealant restorations are discussed and the clinical technique is described. We have concluded that sealant restorations are the optimum restoration in small and discrete occlusal cavities.

An investigation into sealant restoration usage in general dental practice in England.

AIM: A study was undertaken to investigate attitudes to sealant restorations and their usage in general dental practice in England. METHOD: Seventy three dentists in three areas (Doncaster, Hereford/Worcester and Wycombe) provided retrospective details of treatment provided over a one year period for 4,250 6-12 and 13-15 year old subjects. Fifty nine of these dentists then completed a telephone questionnaire relating to their treatment patterns and attitudes to sealant restorations. RESULTS: The treatment data indicated that only 59 of the 4,250 children received a sealant restoration during the study period. Of the 44 dentists who claimed in the questionnaire to be using sealant restorations, only 28 had placed them in their selected patients. CONCLUSIONS: Positive attitudes to sealant restorations were expressed but also concerns that may be prejudicing usage.

The ability to successfully include primary dental care practitioners in commissioning groups.

OBJECTIVES: To evaluate two total purchasing (TP) sites and ascertain whether general dental practitioners (GDPs) could be successfully included in the total purchasing model of health care commissioning. Another objective was to examine the role GDPs may play in future primary care commissioning groups and trusts. DESIGN: An observational cross-sectional study of two dental purchasing pilots in the North West Region. SUBJECTS: Two TP sites were studied, one in South Cheshire, the other East Lancashire. Each TP organisation had a dental subgroup which had a formal structure and was given an active role in dental healthcare service decision making. MAIN OUTCOME MEASURES: General dental practitioners' ability to manage dental health care provision in the selected sites and the suitability and effectiveness of the services managed by them. RESULTS: GDPs were willing and able to form cohesive primary care commissioning organisations but attitudes in secondary care prevented the implementation of their decisions. CONCLUSIONS: Structural, organisational and psychological changes would be necessary if GDP led purchasing were to be successfully implemented. Such changes are vital if GDPs and the dental profession are to have an effective role in the newly formed primary care groups and trusts.

Past and present attempts to control health service expenditure and its effects on National Health dentistry.

OBJECTIVE: To examine the methods used by policy makers to try to reduce or limit expenditure within the National Health Service. METHOD: A chronological examination of cost related health care policy and its wider impact on society. Comparison of past developments in the NHS with new methods of health care organisation in the United Kingdom (UK). The experiences of two dental Total Purchasing Pilots are used to describe where the dental profession now stands in relation to current NHS developments. RESULTS: The introduction of Primary Care Groups (PCGs) constitutes part of a continued effort by health care policy makers to control expenditure on health services. In the PCG system, as in Total Purchasing (TP), a group of primary care practitioners control a finite budget. These groups therefore must decide which health care services should be available to the population they represent. Inevitably such systems result in the rationing of health care, but the decisions are instigated by primary health care professionals rather than by government edict. CONCLUSION: Unless GDPs are allowed, willing and able, to participate in and influence the newly emerging Primary Care Groups and Trusts, dental services may once again be pushed to the fringe of NHS care provision. Without adequate representation, the value of dental care may not be recognised and PCGs may decide to make use of traditional dental resources, to fund other services.

An assessment of capitation in the General Dental Service contract 2. Patterns of treatment provided to regularly attending patients.

OBJECTIVE: To compare the patterns of treatment of general dental practitioners working under fee-for-service in 1987/88 with those working under capitation in 1992/93. DESIGN: 73 randomly selected general dental practitioners working under capitation in three contrasting areas in England retrospectively recorded the treatment provided during 1992/93 to a random selection of their regularly attending 6-12- and 14-15-year-old patients. RESULTS: Mean numbers of examinations per year reduced in the three areas from 1.7-1.8 in 1987/88 to 1.2-1.4 in 1992/93. Mean numbers of visits per patient dropped from 2.5-2.9 to 1.8-2.2. Mean numbers of fillings in permanent teeth reduced from 0.15-1.04 to 0.09-0.52 and in deciduous teeth from 0.28-0.53 to 0.24-0.31. Mean percentages of children per dentist having extractions fell from 9.3-28.1% to 4.7-16.2% while the radiographs reduced from 14.0-9.0% to 6.0-10.6%. Mean percentages of children per dentist receiving oral hygiene instruction rose from 18-31% in 1987/88 to 26-33% in 1992/93. Dietary advice increased from 3-18% to 11-20% and fissure sealants from 3-6% to 3-12%. CONCLUSIONS: In 1992/93, dentists working under capitation were carrying out fewer examinations, fillings and extractions and were taking fewer radiographs for their regularly attending child and adolescent patients than dentists working under fee-for-service in 1987/88. These patients also attended less frequently for treatment but received marginally more preventive care and advice.

An assessment of capitation in the General Dental Service Contract. 1. The level of caries and its treatment in regularly attending children and adolescents.

OBJECTIVE: To assess the dental health of regularly attending 7-8- and 14-15-year-olds registered under capitation in 1994. To compare the dental health of regularly attending 14-15-year-olds registered under capitation in 1994 with regularly attending patients of a similar age treated under fee-for-service in 1989. DESIGN: Random samples of 7-8- and 14-15-year-olds. Data were recorded on decayed and filled teeth, extracted for caries and teeth fissure sealed. RESULTS: Prevalence of caries in first permanent molars of 7-8-year-olds was 15-16%. Mean caries experience of deciduous posterior teeth was 1.78-2.51. 83-86% had no more than two untreated, decayed, posterior deciduous teeth. Prevalence of caries in 14-15-year-olds was 44-60% while mean caries experience was 1.29-1.83. Reductions in caries experience of 30-39% in 14-15-year-olds for 1989-1994 were due mainly to falls of 42-45% in mean numbers of teeth filled. Increases in mean numbers of decayed, untreated teeth were 0.07-0.11. The proportion of patients with teeth extracted because of caries was 2.4-3.8%. 30-50% had fissure sealants in 1994 compared with 13-25% in 1989. CONCLUSIONS: Dental health of regularly attending capitation patients is generally satisfactory with little evidence of 'supervised neglect'. Prevalence of fissure sealants has increased while the numbers of filled teeth has reduced. Numbers of decayed, untreated teeth have increased but the numbers of teeth extracted for caries have remained low.

The capitation study. 1. Does capitation encourage "supervised neglect'?

Four matched pairs of geographically and socially contrasting areas of Britain were randomly allocated within pairs to either a capitation or fee-for-service payment system for the dental care of children in a 3-year clinical trial. Measurements were made on the dental health of randomly selected 5-6 and 14-15-year-old patients and the views of their parents elicited. Patterns of treatment were also gained from the clinical records of randomly selected patients. In addition, the views of the dentists taking part, of the profession's representatives, and of the administrators of the systems were obtained. No evidence of systematic neglect could be found among the children treated under capitation, but they had fewer fillings, more untreated diseased teeth and similar disease levels to their counterparts treated under fee-for-service. Dentists in capitation carried out fewer fillings, fewer extractions, took fewer radiographs and saw their patients less frequently than their fee-for-service colleagues.

The Capitation Study. 2. Does capitation encourage more prevention?

The results of a 3-year parallel, controlled clinical trial comparing a capitation system of payment for the dental care of children with fee-for-service, showed that capitation offered dentists more clinical freedom. Dentists in capitation used this to provide more preventive care, particularly advice to parents on the control of dental disease in their children. In contrast, few fissure sealants were placed and few topical fluoride applications were made under either system. However, parents in both systems were satisfied with the preventive service their children received and were confident of their ability to control their children's dental disease. The effect of this increased preventive activity was not yet apparent within the period of the study.

The capitation study. 3. The views of participating dentists and the profession.

During the course of a 3-year parallel, controlled clinical trial comparing a capitation system of remuneration with fee-for-service for the dental care of children, the views of the dentists were gained through meetings, informal communication, and a structured questionnaire sent to every dentist in the study. The questionnaires completed by the dentists who had been in the study from the beginning were used in the analysis. The views of practice principals on practice administration were also gained. Dentists in capitation claimed to have greater clinical freedom than those in fee-for-service, but the system under test involved more practice administration. The trial allowed the two systems to be compared under limited, controlled conditions, thus benefiting any substantive scheme that might be developed from it.

Management information failings and future requirements for dental commissioning groups.

OBJECTIVE: To examine existing secondary care management information systems for dental specialities, and to determine their completeness and suitability for supporting effective primary care led purchasing decisions. DESIGN: An observational cross-sectional study of current information systems in selected secondary care provider units and the applicability of their data for contracting dental services. A comparative study of two information systems in two settings (primary and secondary care) and the utility of the data gathered for contracting for dental services. SUBJECTS: Secondary care activity data was sought from the key secondary dental care providers (hospitals) in two dental total purchasing localities. Referral data were also collected directly from general dental practitioners. MAIN OUTCOME MEASURES: The integrity, quality and accuracy of current secondary care activity data in dental specialities, in comparison to data supplied from primary dental care. RESULTS: The secondary care activity data was found to be incomplete, inadequate and inaccurate. It was found that due to data retrieval insufficiency, indicative budgets for secondary providers may be reduced to less than half of their actual entitlement. The data inflated individual dental outpatient attendance by 3.3 times between 1995/6 and by 2.5 times between 1996/7. CONCLUSION: Existing management information systems within secondary care providers are not structured in a way which will adequately inform future commissioning by the dental profession. Communication between primary and secondary care must be increased and data inputting methods in secondary care provider units must be substantially improved.