Dental care plan assessment using the CAHPS Dental Plan Survey.

OBJECTIVES: The performance of a recently developed survey instrument that inquires about patients' experiences with the receipt of dental care was examined to evaluate its potential utility as a patient-reported outcome measure for dental care plans. METHODS: Individuals with dental insurance (n = 1,216) were surveyed using the Consumer Assessment of Health Care Providers and Systems (CAHPS) Dental Plan Survey. The instrument's pre-established composite and rating scores were compared across dental insurance carriers (6 most common and all others combined) using ANOVA. In addition, each score was analyzed separately using multivariate regression with respondent and plan characteristics as independent variables. RESULTS: There was significant differentiation among dental insurance carriers for three of the six scores (dental care composite, access to care composite, and dentist rating). Several respondent characteristics were associated with higher scores, including age, race, income level, and oral health self-rating. Having a choice of dental plans, and years with one's dental plan were associated with higher dental plan ratings, while having to find a new dentist to use the plan tended to lower all scores except the cost and services composite. CONCLUSIONS: The results reported here reflect differences among dental insurance carriers, rather than among the many different dental plans offered by those carriers. Nevertheless, the CAHPS instrument scores reflected differences among patients' experiences (composite scores) and ratings (rating scores) across carriers, suggesting both that the instrument should be a useful tool for assessing patient-reported outcomes, and that comparisons of these outcomes should control for respondent characteristics as well as specific plan characteristics.

Clinical technical performance of dental therapists in Alaska.

BACKGROUND: The Alaska Dental Health Aide Therapist program has matured to the point that therapists have been in practice for up to four years. METHODS: A case-study evaluation of the program included assessments of the clinical technical performance of five of these therapists practicing in clinics in small Alaskan villages and towns. RESULTS: The results indicate that therapists are performing at an acceptable level, with short-term restorative outcomes comparable with those of dentists treating the same populations. CONCLUSIONS: Therapists' performance when operating within their scope of practice suggested no reason for continued close scrutiny. Further evaluations of therapists should shift their principal focus from clinical technical performance of therapists to effectiveness of the therapist program in improving the targeted population's oral health. CLINICAL IMPLICATIONS: Therapists are capable of providing acceptable restorative treatment under indirect supervision.

Methods dentists use to diagnose primary caries lesions prior to restorative treatment: findings from The Dental PBRN.

OBJECTIVE: To (1) quantify the diagnostic techniques used by Dental Practice-Based Research Network (DPBRN) dentists before they decide to treat primary caries lesions surgically and (2) examine whether certain dentist, practice, and patient characteristics are associated with their use. METHODS: A total of 228 DPBRN dentists recorded information on 5676 consecutive restorations inserted due to primary caries lesions on 3751 patients. Practitioner-investigators placed a mean of 24.9 (SD=12.4) restorations. Lesions were categorised as posterior proximal, anterior proximal, posterior occlusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorised as clinical assessment, radiographs, and/or optical. Statistical analysis utilised generalised mixed-model ANOVA to account for the hierarchical structure of the data. RESULTS: By lesion category, the diagnostic technique combinations used most frequently were clinical assessment plus radiographs for posterior proximal (47%), clinical assessment for anterior proximal (51%), clinical assessment for posterior occlusal (46%), clinical assessment for posterior smooth (77%), and clinical assessment for anterior smooth (80%). Diagnostic technique was significantly associated with lesion category after adjusting for clustering in dentists (p<0.0001). CONCLUSION: These results - obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios - quantified the diagnostic techniques most commonly used during the actual delivery of routine restorative care. Diagnostic technique varied by lesion category and with certain practice and patient characteristics.

Design of the Prevention of Adult Caries Study (PACS): a randomized clinical trial assessing the effect of a chlorhexidine dental coating for the prevention of adult caries.

BACKGROUND: Dental caries is one of the primary causes of tooth loss among adults. It is estimated to affect a majority of Americans aged 55 and older, with a disproportionately higher burden in disadvantaged populations. Although a number of treatments are currently in use for caries prevention in adults, evidence for their efficacy and effectiveness is limited. METHODS/DESIGN: The Prevention of Adult Caries Study (PACS) is a multicenter, placebo-controlled, double-blind, randomized clinical trial of the efficacy of a chlorhexidine (10% w/v) dental coating in preventing adult caries. Participants (n = 983) were recruited from four different dental delivery systems serving four diverse communities, including one American Indian population, and were randomized to receive either chlorhexidine or a placebo treatment. The primary outcome is the net caries increment (including non-cavitated lesions) from baseline to 13 months of follow-up. A cost-effectiveness analysis also will be considered. DISCUSSION: This new dental treatment, if efficacious and approved for use by the Food and Drug Administration (FDA), would become a new in-office, anti-microbial agent for the prevention of adult caries in the United States. TRIAL REGISTRATION NUMBER: NCT00357877.

Restorative treatment thresholds for occlusal primary caries among dentists in the dental practice-based research network.

UNLABELLED: OBJECTIVES. The authors report on a study aimed at quantifying the carious lesion depths at which dentists intervene surgically for cases of varying caries penetration and caries risk. They also aimed to identify characteristics that are associated with surgical intervention. METHODS: The investigators surveyed dentists enrolled in a dental practice-based research network who reported performing at least some restorative dentistry. In the survey, dentists were asked to indicate whether they would intervene surgically in a series of cases involving occlusal caries. Each case presentation included a photograph of an occlusal surface displaying typical characteristics of caries penetration and a written description of a patient at a specific level of risk of developing caries. Using logistic regression, the authors analyzed associations between surgical treatment with dentists' and practices' characteristics and patients' caries risk levels. RESULTS: A total of 517 DPBRN practitioner-investigators responded to the questionnaire. Sixty-three percent of the respondents (326 of 517) indicated that in patients at low risk of developing caries, they would surgically restore teeth with lesions located in inner enamel surfaces and 90 percent would surgically restore teeth with lesions located in outer dentin surfaces. Regarding patients with a high risk of developing caries, 77 percent (398 of 517) of the respondents reported that they would surgically restore inner enamel lesions, and 94 percent (486 of 517) reported that they would restore lesions located on the outer dentin surface. Dentists who did not assess caries risk were more likely than dentists who did assess risk to intervene with dentinal lesions (P = .004). Practitioner-investigators who were in solo practice or a private practice with fewer than four dentists were significantly more likely to intervene surgically with enamel lesions than were dentists in large group practices (those with four or more dentists) (P < .001).

Patient-level and practice-level characteristics associated with receipt of preventive dental services: 48-month incidence.

OBJECTIVES: This study aims to: (a) quantify the incidence of preventive dental services [in-office fluoride application and dental cleaning (prophylaxis)]; (b) determine if these services are effectively targeted to patients with the highest need; and (c) quantify the role of practice characteristics and patient-level factors in service receipt. METHODS: A population-based prospective cohort study was conducted with 873 adults who had at least one tooth at baseline, 743 of whom provided 48-month data. In-person interviews and clinical examinations were conducted biennially for 48 months, with 6-monthly telephone interviews in between. Dental records were abstracted afterward, and practices that served participants completed questionnaires. Analysis was limited to persons with at least one dental visit of any type during follow-up (87 percent of the sample). RESULTS: Only 9 percent of the persons received at least one fluoride application; 75 percent received a dental cleaning. Persons with high need were actually less likely to have received preventive services. In multivariable regression analyses, characteristics of the practice in which the subject received care were very strongly related to fluoride receipt, independent of patient-specific characteristics. CONCLUSIONS: One preventive procedure was common; the other was uncommon. However, practices did not effectively target high-risk patients for either procedure. Instead, both services were typically received by persons with the least need for them. These findings are consistent with the conclusion that practitioners greatly influenced the delivery of fluoride services, with substantial contributions also made by patient-level predisposing and enabling factors for both preventive services.

Exploring the contributions of components of caries risk assessment guidelines.

OBJECTIVE: To examine the relative contribution of current caries activity, past caries experience, and dentists' subjective assessment of caries risk classifications. METHODS: Administrative data from two dental plans were analyzed to determine dentists' risk classification, as well as current caries activity and previous caries experience at the time of the classification. The performance of these predictors in identifying patients who would experience subsequent caries was then modeled using logistic regression. RESULTS: In both plans, current caries activity alone had relatively low sensitivity and high specificity in identifying patients who would experience subsequent caries. Sensitivity improved, but at the cost of specificity when previous caries experience was included in the models. Further improvement in sensitivity accrued when dentists' subjective assessment was included, but performance was different in the two plans in terms of false-positives. CONCLUSIONS: Consideration of previous caries experience tends to strengthen the predictive power of caries risk assessments. Dentists' subjective assessments also tend to improve sensitivity, but overall accuracy may suffer.

Outcomes associated with dentists' risk assessment.

OBJECTIVE: To examine retrospectively the caries-related restorative experience of at-risk individuals who received fluoride-based preventive interventions to determine if the intervention resulted in fewer caries-related procedures. METHODS: Administrative data from two dental health plans were used to determine the relationship between caries risk assessment (CRA) scores, preventive treatment and caries-related treatment procedures. We identified 45 693 adults who were consecutively enrolled for at least 1 year before and 2.5 years after the CRA. Variables representing the number of teeth with any caries-related treatment procedure and receipt of preventive treatment were created. RESULTS: The outcome variable of interest was having at least one tooth with a caries-related procedure in the 2-year follow-up period. In plan A, the recommendation for home-use fluoride was not significantly related to caries-related treatment procedures in the follow-up period for individuals at low, moderate or high risk (P > 0.300). In plan B, application of in-office fluoride was associated with having at least one tooth with a caries-related treatment procedure in the follow-up period (P < 0.001). CONCLUSIONS: We found incomplete compliance with guidelines for recommendation or administration of preventive treatment for patients at elevated risk for caries. We were also unable to identify any significant reductions in caries-related procedures for individuals receiving a fluoride intervention, compared with those who did not, when stratified by risk level.

Validation of a simple approach to caries risk assessment.

OBJECTIVE: This study examined the predictive validity of a simple subjective method promoted to dentists for assessing their patients' caries risk. METHODS: Data from two large group practices that have used guideline-assisted caries risk assessment (CRA) for several years were analyzed retrospectively to determine the receipt of caries-related treatment following a CRA. Patient age and receipt of caries preventive treatment subsequent to the CRA were control variables in logistic regressions to determine the likelihood of caries-related treatment for low, moderate, and high risk groups. RESULTS: Among 45,693 individuals in the two plans, those categorized as being at high caries risk were approximately four times as likely to receive any caries-related treatment as those categorized as being at low caries risk. Those categorized as at moderate risk were approximately twice as likely to receive any treatment. In addition, for those at elevated risk who required any treatment, the number of teeth requiring treatment was larger. CONCLUSION: The results of this study provide the first large-scale, generalizable evidence for the validity of dentists' subjective assessment of caries risk.