Diagnosis, risk assessment, and treatment decisions for tooth wear in daily practice: a case presentation survey among Belgian dentists.

This survey assessed the use of current concepts for tooth wear diagnosis, risk assessment, and treatment decisions in daily practice, and identified factors of significance for treatment decisions. A total of 104 dentists were presented with 10 cases representing varying degrees of tooth wear. The dentists were asked to answer six questions pertaining to the diagnosis, risk assessment, and treatment of each case. A benchmark was established by three experts and the agreement between dentists and the benchmark was calculated. At dentition level, the agreement was moderate for diagnosis (κ = 0.55) and risk assessment (κ = 0.54). At tooth/surface level, the agreement for clinical and radiographic severity of wear was moderate (κ = 0.57) and substantial (κ = 0.65), respectively. The agreement for treatment decision was fair (κ = 0.35). Multivariate logistic regression analysis showed that treatment decisions for operative treatment were associated with moderate to high case risk (OR = 10.1; 95% CI: 5.4-18.9). Belgian dentists performed reasonably well in applying current concepts and strategies for tooth wear diagnosis and risk assessments at dentition level, as well as for assessment of wear severity at tooth/surface level. Improvement is warranted concerning treatment decisions. This survey could be a useful tool for disseminating and improving current knowledge of tooth wear, and for training dentists in daily practice.

Tooth wear risk assessment and care-planning in general dental practice.

Objective To assess charting, risk assessment and treatment-planning of tooth wear between recently qualified and experienced dentists in general dental practice.Design Service evaluation.Setting Multi-setting evaluation of three mixed NHS/Private general dental practices in North-East London.Methods The clinical notes of new patient examinations on dentate adults presenting from the 1 October 2016 to 31 December 2016 were audited collecting data on tooth wear charting, risk assessment and treatment planning. Data were analysed using descriptives, chi square and logistic regressions in SPSS. Significance was inferred at p <0.05.Results Foundation dentists and experienced dentists performed 85 and 200 new patient examinations, respectively, during the evaluation period. Tooth wear was charted for 48% of those attending foundation dentists and 5% of those attending experienced dentists. Diet was assessed in 50.6% of patients examined by foundation dentists and 1.0% of patients examined by experienced dentists. Foundation dentists were more likely to chart tooth wear, risk assess and preventively manage tooth wear compared to experienced dentists (p <0.001).Conclusion This service evaluation highlights that improvements are required in recording, risk assessing and preventive treatment planning of erosive tooth wear. Experienced dentists were less likely to risk assess tooth wear and less likely to provide preventive treatment. Experienced GDPs may benefit from re-training in this area.

Outcome measures for oral health based on clinical assessments and claims data: feasibility evaluation in practice.

BACKGROUND: It is well known that treatment variation exists in oral healthcare, but the consequences for oral health are unknown as the development of outcome measures is still in its infancy. The aim of this study was to identify and develop outcome measures for oral health and explore their performance using health insurance claims records and clinical data from general dental practices. METHODS: The Dutch healthcare insurance company Achmea collaborated with researchers, oral health experts, and general dental practitioners (GDPs) in a proof of practice study to test the feasibility of measures in general dental practices. A literature search identified previously described outcome measures for oral healthcare. Using a structured approach, identified measures were (i) prioritized, adjusted and added to after discussion and then (ii) tested for feasibility of data collection, their face validity and discriminative validity. Data sources were claims records from Achmea, clinical records from dental practices, and prospective, pre-determined clinical assessment data obtained during routine consultations. RESULTS: In total eight measures (four on dental caries, one on tooth wear, two on periodontal health, one on retreatment) were identified, prioritized and tested. The retreatment measure and three measures for dental caries were found promising as data collection was feasible, they had face validity and discriminative validity. Deployment of these measures demonstrated variation in clinical practices of GDPs. Feedback of this data to GDPs led to vivid discussions on best practices and quality of care. The measure 'tooth wear' was not considered sufficiently responsive; 'changes in periodontal health score' was considered a controversial measure. The available data for the measures 'percentage of 18-year-olds with no tooth decay' and 'improvement in gingival bleeding index at reassessment' was too limited to provide accurate estimates per dental practice. CONCLUSIONS: The evaluated measures 'time to first restoration', 'distribution of risk categories for dental caries', 'filled-and-missing score' and 'retreatment after restoration', were considered valid and relevant measures and a proxy for oral health status. As such, they improve the transparency of oral health services delivery that can be related to oral health outcomes, and with time may serve to improve these oral health outcomes.

High-risk esthetically driven restoration: begin with the end in mind.

A high-risk esthetically driven restorative case requires the dental team, along with the patient, to have a clear vision of the final outcome. In this case of a 33-year-old woman who wanted to improve her smile, esthetic problems stemmed from a retained deciduous maxillary left canine along with an impacted tooth No. 11. Among a number of concerns was the shape and color of the deciduous canine and the uneven length of the maxillary central incisors. A treatment plan that included orthodontics with removable aligners, occlusal adjustment, composite restorations, extraction and implant placement, indirect porcelain veneers, and a custom abutment and PFM crown was successfully executed in four phases over the course of more than 4 years.

Usefulness assessment indices of non-carious dental defects with consideration of aetiological factors and the quality criterion.

Much attention is being paid in the current literature to the necessity of raising awareness of the problem of tooth wear. The aim of this paper is to discuss advantages, disadvantages and modifications of currently used tooth wear indices with particular attention drawn to the advantages of their use both in everyday practice and epidemiological research, as well as an attempt to make the choice of a wear index easier and better adjusted for the needs of a single patient or a group of patients. The paper compares index assessment attempts available in the current literature in the context of validity of criteria choices and reliability results. The role of supporting methods is stressed as they facilitate both diagnosis and storing of data on tooth wear, as well as usefulness of indices which comprise therapeutic recommendations.

Recreating an esthetically and functionally acceptable dentition: a multidisciplinary approach.

Patients today demand a youthful, attractive smile with comfortable functional acceptance. The complete oral rehabilitation of patients with a functionally compromised dentition frequently involves a multidisciplinary approach and presents a considerable clinical challenge. To a great extent, proper patient selection and careful interdisciplinary treatment planning, including acknowledgment of the patient's perceived needs, reasons for seeking services, financial ability, and socioeconomic profile, can govern the predictability of successful restorations. This clinical report describes a successful interdisciplinary approach for the management of a severely worn dentition with reduced vertical dimension of occlusion. Treatment modalities included periodontal crown lengthening procedures, endodontic treatment followed by post and core restorations, and prosthetic rehabilitation for severe tooth surface loss and reduced vertical dimension of occlusion comprising metal-ceramic restorations in esthetic zones and full-metal restorations in posterior regions.

Cluster Effects in a National Dental PBRN restorative study.

Items in clusters, such as patients of the same clinician or teeth within the same patient, tend to be more similar than items from different groups. This within-group similarity, represented by the intraclass correlation coefficient (ICC), reduces precision, yielding less statistical power and wider confidence intervals, compared with non-clustered samples of the same size. This must be considered in the design of studies including clusters. We present ICC estimates from a study of 7,826 restorations placed in previously unrestored tooth surfaces of 4,672 patients by 222 clinicians in the National Dental Practice-Based Research Network, as a resource for sample size planning in restorative studies. Our findings suggest that magnitudes of ICCs in practice-based research can be substantial. These can have large effects on precision and the power to detect treatment effects. Generally, we found relatively large ICCs for characteristics that are influenced by clinician choice (e.g., 0.36 for rubber dam use). ICCs for outcomes within individual patients, such as tooth surfaces affected by a caries lesion, tended to be smaller (from 0.03 to 0.15), but were still sufficiently large to substantially affect statistical power. Clustering should be taken into account in the design of oral health studies and derivation of statistical power estimates for these studies (ClinicalTrials.gov, NCT00847470).

Minimum intervention dentistry and the management of tooth wear in general practice.

The incidence of tooth wear, or non-carious tooth surface loss (NCTSL), is increasing and oral rehabilitation of patients with non-carious tooth loss requires strategies that address all the factors relevant to the aetiology and pathogenesis of the condition. The multifactorial nature of tooth wear and the variability in its clinical presentation provides treatment challenges for the clinician and successful management must be more than just restoration. Management must include an appropriate mix of preventive and restorative strategies and an understanding that long-term restorative success is affected by the patient's oral environment, and how diet, lifestyle and medical status can modify this environment. Ultimately, the success of any restorative intervention is very dependent on the stability of the oral environment and the condition of the remaining tooth structure. Minimum intervention dentistry (MID) philosophies are ideally suited to tooth wear cases and an overall MID strategy involving diagnosis, recognition and control of predisposing factors, stabilization of the oral environment, remineralization and restoration of the tooth structure, and ongoing maintenance can be implemented. When restorative treatment is required, contemporary materials and techniques are available that can provide cost-effective and conservative restorative alternatives for patients unable to undergo the complex indirect restorative techniques that are both costly and time consuming to implement. These minimally invasive approaches are not only an economically viable solution, but can provide aesthetic and functional rehabilitation and maintain tooth structure as a precursor to more complex restorative options when required.

Novel decision tree algorithms for the treatment planning of compromised teeth.

In clinical practice, dentists are faced with the dilemma of whether to treat, maintain, or extract a tooth. Of primary importance are the patient's desires and the restorability and periodontal condition of the tooth/teeth in question. Too often, clinicians extract teeth when endodontic therapy, crown-lengthening surgery, forced orthodontic eruption, or regenerative therapy can be used with predictable results. In addition, many clinicians do not consider the use of questionable teeth as provisional or transitional abutments. The aim of this article is to present a novel decision tree approach that will address the clinical deductive reasoning, based on the scientific literature and exemplified by selective case presentations, that may help clinicians make the right decision. Innovative decision tree algorithms will be proposed that consider endodontic, restorative, and periodontal assessments to improve and possibly eliminate erroneous decision making. Decision-based algorithms are dynamic and must be continually updated in accordance with new evidence-based studies.

Oral diagnosis and treatment planning: part 4. Non-carious tooth surface loss and assessment of risk.

Non-carious tooth surface loss or tooth wear is becoming an increasingly significant factor affecting the long-term health of the dentition. The adverse effects of tooth wear are becoming increasingly apparent both in young persons and, as more people retain their teeth, into old age. This situation challenges the preventive and restorative skills of dental practitioners.

Dental management of the elderly patient.

UNLABELLED: The dental management of the elderly individual is becoming more of an issue in both general dental practice and specialist prosthodontic practice. This is because, in general, the population is living longer and often elderly patients are retaining their natural teeth into their old age. In addition, there are often related significant medical, social and oro-dental issues that require consideration. CLINICAL RELEVANCE: The dental management of the elderly patient is an increasing problem. This paper seeks to consider the main relevant issues pertaining to this important subject area.

Caries risk assessment, diagnosis and synthesis in the context of a European Core Curriculum in Cariology.

This paper is part of a series outlining a European Core Curriculum in Cariology for undergraduate dental students. The European Core Curriculum in Cariology is the outcome of a process starting in 2006 and culminating in a joint workshop of the European Organization for Caries Research (ORCA) together with the Association for Dental Education in Europe (ADEE), held in Berlin from 27 to 30 June 2010. For the areas of risk assessment, diagnosis, detection, activity, monitoring and synthesis Cariology, the present paper outlines the key competencies required and the related areas in which knowledge of and familiarity with are needed for dentists graduating at the beginning of 21st century. Three major competencies were identified: Risk Assessment- competent at identifying and estimating the probability for a patient of developing new caries lesions or progression of existing lesions during a specified period of time; Diagnosis- competent through collecting, analysing and integrating data on signs and symptoms of dental caries and assess activity status of a lesion on a tooth surface to arrive at an identification of past or present occurrence of the disease caries; and Synthesis- competent at synthesising all relevant information by combining and interpreting findings from: risk assessment and diagnostic processes; from patients' needs, preferences and best interests; and from monitoring, review and re-assessment findings, when available. Similar competencies were identified for erosion and non-erosive wear. Issues that were felt by the working group panel to be important in this field are discussed, as are approaches to aid curriculum implementation.

Bleaching and bonding for the older patient.

UNLABELLED: Older people who remain reasonably well may wish to maintain or enhance their dental and oral appearance, preferably at minimal biologic and financial costs. Bleaching and bonding represents a very good treatment option and a sensible strategy for this group. Bleaching addresses the discoloration, while direct composite bonding can improve the shape of worn, or otherwise unaesthetic, teeth without damaging the structure or health of the residual tooth tissue. This pragmatic treatment is well tolerated by older patients. The visual and functional improvements are greatly appreciated by this group, partly because of the non-destructive and affordable nature of the benefits. CLINICAL RELEVANCE: Bleaching and bonding represents a proven, sensible, pragmatic, affordable and practical approach to managing the aesthetic problems of older patients, and the benefits are achievable without destroying their residual sound tooth tissue.