The implementation of a decision-tree did not increase decision-making in patients with temporomandibular disorders in the public dental health service.

OBJECTIVE: Many patients with temporomandibular disorders (TMD) seem to go undetected within primary dental health care. Primarily we evaluated if the implemented intervention increased the clinical decision-making for TMD patients; secondarily we evaluated if other factors could be identified that predicted performed or recommended TMD treatment. MATERIAL AND METHODS: This case-control study was carried out within the Public Dental Health service in Västerbotten County, Sweden. An intervention based on a decision-tree with three screening questions for TMD (3Q/TMD) was implemented during 2015 in four clinics and compared with the remaining county. A total of 400 individuals were selected-200 3Q-positives and 200 3Q-negatives. The 3Q/TMD consists of Q1-frequent jaw pain, Q2-frequent pain on function, and Q3-frequent catching and/or locking of jaw. The 3Q/TMD answers were analyzed in relation to TMD treatment and any TMD related decision that was collected from the digital dental records. RESULTS: The intervention did not increase the frequencies of traceable clinical decisions among patients with TMD. CONCLUSIONS: Despite the implemented intervention aimed, the indicated undertreatment of patients with TMD remains. Future studies are still needed to gain a deeper understanding of the clinical decision-making process for TMD patients in general practice dentistry.

A comparison of paediatric dentists' and general dental practitioners' care patterns in paediatric dental care.

AIM: The aim of this study was to compare the care patterns of paediatric dentists and general dentists in the dental treatment of children in the Netherlands. STUDY DESIGN AND METHODS: A case control study was completed based on the financial records of one of the largest Dutch health insurance companies. After medical ethical approval the dental records from 2004, 2005 and 2006 of 16 paediatric dentists were used and compared with the records of general practitioners with the same number of insured paediatric patients from the same age and urbanisation level. Preventive, diagnostic and restorative care for four consecutive age groups (<6, 6-8, 9-11, 12-17 yrs) were used as independent variables. Differences between the dentists and the age groups were tested with the Independent-Sample t-Test and ratios were calculated. RESULTS: Compared with general dentists, paediatric dentists use statistically significant more often rubber-dam (p=0.009) and did more preventive treatments (p<0.001) in children up to aged 11 yrs, more extractions (p<0.001), took more radiographs (p=0.027) and used local analgesia more often (p=0.002) in children until aged 8 yrs and performed more restorations (p=0.02) in children up to 6 yrs of age. There was no significant difference in the care pattern of the dentists for the oldest age group (12-17 yrs). The care-index for paediatric dentists and general dentists from this research was comparable with Dutch epidemiological studies. CONCLUSION: Compared with general dentists, paediatric dentists have a more extensive treatment approach when treating children. In the youngest age groups the differences are the most pronounced. Further studies are needed to clarify whether the cause is the needs of the patient or an attitude of supervised neglect by the general dentists.

Educational experiences and preparedness in dental anesthesia: five-year outcome assessment and conclusions.

A mail survey of 2003-07 dental school graduates was undertaken by the Department of Anesthesiology at the University of Pittsburgh School of Dental Medicine to assess the strengths and weaknesses of the predoctoral curriculum in anesthesia and to determine the preparedness of practicing dentists to provide anesthesia services for their dental patients. Subsets of the survey responses were created to specifically evaluate the effectiveness of an advanced selective program in sedation offered to approximately twenty third- and fourth-year predoctoral students. This fourteen-month Anesthesia Selective Program provides advanced didactic instruction and clinical experiences needed to establish competence in minimal to moderate sedation. Overall, graduates reported being best prepared in assessment of medical histories, physiology, and pharmacology, while being least prepared in oral sedation, intravenous sedation, and general anesthesia. For graduates currently in general practice, those who had participated in the Anesthesia Selective Program reported being better prepared in most subjects relating to anesthesia and patient care. Participants in the selective were also more likely to treat special needs patients in their private practices. Respondents' written comments indicated a desire for a greater number of clinical experiences involving sedation procedures within the predoctoral curriculum. This outcome assessment indicated that a greater emphasis should be placed on instruction and training experiences for enteral sedation within the predoctoral dental curriculum. Advanced training and increased clinical experiences in anesthesia may also be an effective means to better prepare graduates to assess medical histories, to manage medical emergencies, and to be willing to treat medically complex patients as well as patients with special health care needs.

Caries management in the dental practice.

Practical, cost-effective implementation of caries management in general practice has been limited by several factors. The single pathogen model of disease has not been effective in clinical caries management, and the advent of the ecologic plaque model and a better understanding of the management of imbalances in dental biofilms have led to the development of more effective treatment protocols based on the elevation of oral pH. Simplification of caries risk assessment, in combination with more effective treatment regimens, means effective caries management can be readily provided by general dentists. These gains in efficiency and efficacy, in combination with applicable current dental terminology (CDT) codes, means that caries management has become economically viable in private practice.

Changing clinicians' behavior: a randomized controlled trial of fees and education.

The fissure-sealing of newly erupted molars is an effective caries prevention treatment, but remains underutilized. Two plausible reasons are the financial disincentive produced by the dental remuneration system, and dentists' lack of awareness of evidence-based practice. The primary hypothesis was that implementation strategies based on remuneration or training in evidence-based healthcare would produce a higher proportion of children receiving sealed second permanent molars than standard care. The four study arms were: fee per sealant treatment, education in evidence-based practice, fee plus education, and control. A cost-effectiveness analysis was conducted. Analysis was based on 133 dentists and 2833 children. After adjustment for baseline differences, the primary outcome was 9.8% higher when a fee was offered. The education intervention had no statistically significant effect. 'Fee only' was the most cost-effective intervention. The study contributes to the incentives in health care provision debate, and led to the introduction of a direct fee for this treatment.

Diagnostic and restorative behaviour in Dutch dentists' paediatric dental care.

AIM: This was to assess if Dutch dentists have comparable attitudes in providing diagnosis and consecutive dental treatment in children. Prevention, radiographic diagnostics and restorative care were compared in four consecutive age groups [<6 years old, 6-8, 9-11, 12-17]. METHODS: In a cross-sectional study calculations were made using the financial records of one of the largest Dutch health insurance companies. After Medical Ethics approval all dental records of 4,500 dentists over a period of three consecutive years were used to calculate correlations and odds ratios, using early treatment, oral diagnosis, preventive approach and the use of local analgesia as basic independent variables. RESULTS: Early diagnosis based on the use of radiographs in children younger than 6 years increased the likelihood of direct restorative care 2.8 times and the likelihood of restorative care in future age groups 2.2, 2.0 and 1.6 times respectively. Early radiographs increased the likelihood of diagnostics in consecutive older groups by 3.7, 3.4 and 1.9 times respectively. CONCLUSION: An early diagnostic approach based on radiographs in paediatric dental care seems to be indicative for dentists' pattern of dealing with older children. This child-centred approach is limited to a small number of dentists.

A clinical minimum data set for primary dental care.

OBJECTIVE: To achieve consensus within primary dental care on the contents of a clinical minimum data set to measure oral health status. DESIGN: Using the Delphi process a simple random sample of 30 LDCs and 10 CDS services in England were asked to rank a list of existing clinical indicators in order of their perceived importance as a means of measuring oral health. A nominated panel representing the stakeholder organisations of primary dental care reviewed this ranking and identified a core group of clinical indicators to be included in a clinical minimum data set. RESULTS: An 80 percent response rate to the Delphi process was achieved. Consensus was reached on a core group of 10 indicators, which can provide information on patient's perceptions of pain, function and appearance, and professional measurements of caries, teeth present, periodontal disease, oral sepsis, presence of mucosal pathology and tooth wear. CONCLUSIONS: A representative sample of primary care dentists in England and the key representative organisations of primary dental care achieved consensus on the contents of a clinical minimum data set to record oral health status in primary dental care. This is a first step in standardising the measurement of oral health status across primary care.

Recommendations for endodontic referral among practitioners in a dental HMO.

This study assessed the effect of patients' presenting conditions on general practitioners' (GPs') self-reported endodontic referral patterns, and compared GPs' perceived indications for referral with those of endodontists. The study was based on a self-administered, confidential survey distributed to 79 GPs and 7 endodontists who provide care to members of one Dental HMO in the Pacific Northwest. GPs were most likely to recommend referral for teeth they felt needed surgical retreatment, but GPs and endodontists did not always agree on indications for referral. Compared with GPs, endodontists were more likely to recommend referral for patients with complex problems, but not necessarily technically difficult teeth. Compared with those with less experience, GPs with more than 10 yr both in dentistry and at this HMO were more likely to recommend (a) referring difficult cases rather than performing endodontic therapy themselves and (b) extracting perforated or root-fractured teeth prior to obturation rather than continuing treatment. Indications for referral that maximize favorable dental outcomes need to be identified.

The value and use of 'quality of life' measures in the primary dental care setting.

General dental practitioners are used to taking a dental history and carrying out an examination. The history and examination invariably form the basis of the patient-dentist dialogue with regard to the treatment to be provided and the financial costs involved. The dialogue between patient and dentist is complex, and the importance of 'quality of life' for the patient is now emerging as a central focus of this dialogue. This paper explores the concept of 'quality of life'. In terms of oral health, and considers the potential of 'oral health-related quality of life' measures for general dental practice. Examples of their use in general dental practice are considered, in relation to marketing dental services, improving compliance in treatment plans, assessing the quality of care and improving communications between the patient and the dental team. Quality of life indicators are being used in the healthcare sector for commissioning, planning and evaluating services. In addition, primary care researchers are using these indicators as part of their evidence-based treatment approaches. As general dental practitioners become more involved in planning services and research, it is important they understand the impact of 'quality of life' indicators have on their treatment and practice management.