Shared decision-making in scaling and root planing.

INTRODUCTION: Estimate proportion of various approaches used by dental hygienists for engaging patients in decisions commonly arising during scaling and root planing. Distribution of approaches was compared across various task components in this procedure, practice experience of dental hygienists and patient compliance. MATERIALS AND METHODS: Survey of graduates from and students in a baccalaureate dental hygiene program. RESULTS: Paternalism (tell then do) and informed consent (give choices and reasons and ask for permission) were more common than shared decision-making (discuss alternatives, solicit patient input and arrive at a mutual decision) and disengagement (patient refusing offered service or avoiding further involvement) by a ratio of 4 to 1 for the first 2 compared with the latter 2. This relationship was held across selecting treatment, procedural adjuncts, homecare instructions and financial arrangements. Dental hygienists exhibited a range of personal preferences for engagement approaches. No-show rate, patient disengagement outside the office, was high (20%). CONCLUSION: Dental hygienists reported using 'more controlled' approaches to engaging patients in decisions regarding treatment. Patients may prefer to engage in more shared decisions and choose this approach by staying away from the office. This may underestimate patients' decisions to stay away from treatment, for example by not showing for completion of the treatment or disregarding homecare routines.

Consistency of orthodontists' clinical decisions: A systematic review, meta-analysis, and theory development.

INTRODUCTION: The purpose of this systematic review and meta-analysis is to provide a literature-based estimate of the consistency of orthodontists' clinical decisions. METHODS: A systematic review of the literature using a modified Reporting Items for Systematic Reviews and Meta-Analyses approach identified 20 articles, representing 53 unique datasets, reporting kappa statistics and standard errors for situations allowing intrarater or interrater comparison on decisions such as the need for treatment, extraction, surgery, and various specific treatment approaches. Meta-regression based on random effect models was used to explore the shape of the underlying distribution, the prevalence of the target condition in the data set, and the professional experience of raters as covariables. RESULTS: No evidence of publication bias was found. Common patient records accounted for approximately 25% of the variance between orthodontists and 33% of the variance within orthodontists making the same decision from the same records. Random and representative samples were judged more consistently than were samples chosen to contain borderline cases. (P <0.001). Raters were in greater agreement on the presence of target conditions than their absence (P <0.001). Residents were more consistent than were practicing orthodontists or dental students (P <0.006). CONCLUSIONS: Low consistency was found among orthodontists making clinical decisions from common records. Factors associated with samples and raters suggest an underlying pattern of orthodontists viewing cases through personal mental frameworks.

Measuring orthodontic treatment impact: Description or judgment, challenge or result.

INTRODUCTION: Determination of improvement in orthodontic treatment may depend on the measurement method used and the purpose. METHODS: Improvement after orthodontic treatment (from T1 to T2 [beginning to end of treatment]) was assessed 3 ways from a set of 98 patient records: (1) calculated by subtracting judges' assessments at T2 from T1 for records presented in random order, (2) judged as a holistic impression viewing T1 and T2 records side by side, and (3) determined from proxies (American Board of Orthodontics Discrepancy Index, the American Board of Orthodontics Objective Grading System, and the Peer Assessment Rating index). RESULTS: High levels of intramethod consistency were observed, with intraclass correlation coefficient clustering around an intraclass correlation coefficient of 0.900, and distributions were normal. Calculated and judged improvements correlated at r = 0.606. Calculated or judged improvements were correlated at a lower level with proxies. Calculated improvement was significantly associated with "challenge" (T1) scores and judged improvement associated with "results" (T2) scores. Common method bias was observed, with higher correlations among similar indexes than among indexes at the same time that used various methods. Relative to differences in Peer Assessment Rating scores, calculated improvement overestimated low scores and underestimated high ones. The same effect, but statistically greater, was observed using direct judgment of improvement. CONCLUSIONS: These findings are consistent with decision science and measurement theory. In some circumstances, such as third-party reimbursement and research, operationally defined measures of occlusion are appropriate. In practice, the determination of occlusion and improvement are best performed by judgment that naturally corrects for biases in proxies and incorporates background information.

Diagnostic paths for a mouth-breathing patient.

INTRODUCTION: The clinical choice of diagnostic tests or treatment options is determined by the probability that the value of their execution (called the warrant for the test) exceeds their cost, and by their usefulness. The purpose of this study was to determine the warrant and usefulness of STOP-Bang, an obstructive sleep apnea screening questionnaire, and cone-beam computed tomography (CBCT) information about the minimal cross-sectional area for referring a mouth-breathing patient to a sleep specialist and for modifying planned orthodontic treatment. METHODS: A branching survey was used to identify the prominence of paths between the presenting situation, 2 diagnostic tests, and 2 referral and/or treatment options. A description was given of a hypothetical patient: an overweight, mouth-breathing female teenager. Path analysis was used as a method for quantifying diagnostic warrant and usefulness. RESULTS: There was a wide variation among the 125 orthodontists who responded to the survey. All paths were chosen. The use of tests altered the referral (χ2 = 8.039; P = 0.03) and/or treatment decisions (χ2 = 12.636; P = 0.005). Ownership of a CBCT system significantly influenced the use of this diagnostic test, with owning a CBCT system resulting in greater use in-office (χ2 = 50.416; P <0.001) and greater use in the study (χ2 = 22.959; P <0.001). The usefulness of the diagnostic tests could not be determined directly because common values were used for each test, but the variation in the use of this standard stimulus was very large, indicating personal differences in the interpretation of actual data. CONCLUSIONS: Wide variation in the choice and interpretation of diagnostic tests for referral and orthodontic treatment modification relative to airway condition exists among orthodontists. Diagnostic path analysis is a potentially useful model for studying how practitioners make decisions independent of research evidence.

How people make decisions about whether or not to seek orthodontic care: Upstream in the treatment chain.

INTRODUCTION: "Upstream" decisions by patients are important in determining whether they seek orthodontic care for their children and for themselves and whether they seek care from general dentists or from orthodontists. Classic marketing theory suggests that purchase decisions naturally progress through a sequence beginning with awareness and proceeding to information, emotional preferences, and final purchase commitment. METHODS: A survey was used to assess patient demographics and care history, motives for seeking care for themselves and their children, perceived barriers to care, trust in various sources of information, and preference for treatment by a general dentist or by an orthodontist. Three hundred fifty-two responses were received from patients in all states in the United Sates attending their general dentists. RESULTS: Care for children was most often initiated in response to a suggestion from the family dentist, and traditional treatment with braces was expected. Adults were slightly more likely to make a decision for care themselves and for appearance reasons, often with "invisible" braces. Cost was the principal barrier to seeking care for either functional or appearance reasons. More personal and individualized sources of information, such as the family dentist or referral to a specialist were strongly more influential, with indirect sources, such as dentist Web pages or advertisements, being least influential. There was a preference for care by orthodontists compared with general dentists for functional reasons and when complications were anticipated. Orthodontists were seen as being better at identifying complications, managing complications, and delivering reliable results. Orthodontic care provided by general dentists was favored for convenience and based on established relationships. Patients with more education, higher incomes, and more preventive oral habits preferred treatment by orthodontists. Although it was expected that orthodontists would charge more, income and cost were not factors among those considering treatment. CONCLUSIONS: This study suggests that orthodontists should focus on educating potential patients about the functional health features of treatment for malocclusions, especially for children. Furthermore, orthodontists would benefit from working with general dentists, given their role as gatekeepers in the sequential process of reaching an upstream decision about seeking orthodontic care.

How Dentists Read a Technique Article: A Grounded Theory Investigation.

PURPOSE: To conduct an empirical investigation using qualitative techniques of the way dentists engage in the process of reading a technique-oriented journal article and what they pay attention to in the process. MATERIALS AND METHODS: Grounded theory was used to identify how dentists read an article describing the fabrication of an interim prosthesis in the esthetic zone. Twenty-one experienced practitioners were videotaped, and their verbatim reflections were coded. The sequence of attending to various features of the paper was noted. RESULTS: Ninety-five percent of readers voiced specific, multiple attempts to identify or refine the main purpose of the article as they processed the material. All readers engaged in various activities to navigate through the article, including skipping and backtracking, and none "read" the article straight through. All readers also made repeated observations about the relevance of the technique to their personal practice situation. Eighty percent used some form of "distancing," whereby the content and value of the article were accepted, but the reader reserved the privilege of not being bound by the results because of technical, sponsorship, or methodological issues that "might be present." The quality of photographs was accepted as a proxy for the quality of technical work performed. CONCLUSIONS: Dentists actively customized the reading of a journal article that described a technical procedure. They imposed a non-linear structure for absorbing information and a standard of personal relevance, and, while accepting the results, created reasons for not necessarily having to accept them as applicable. The approach clinicians use in reading a procedural article may be different from the structure writers use in preparing a paper.

ORAL PRIMING AND THE ACD BASIC RULE.

James Rest proposed a model of moral behavior with four components: sensitivity, reasoning, character, and courage (or action). Research has shown that moral character is a complex construct. Multiple moral self-concepts exist within each individual, and different context predispose various of these to become dominant in different settings. Moral priming is the practice of manipulating the environment to favor the use of appropriate moral self-concepts. A study is reported, demonstrating that dentists can be primed to express more moral views based entirely on context. The observed effect of priming was large. The ACD Rule for Moral Identity states that when there is conflict between professionalism and economic or other self-interests, professionalism takes precedence.

Interim ACD Gies Ethics Project Report Is Professionalism a Contact Sport or a Spectator Sport?.

This presentation is an interim report on the American College of Dentists Gies Ethics Project. Following the example of William Gies, our work has been grounded in empirical studies, with progress on the first 11 projects summarized here. The following general patterns are beginning to emerge: (a) the traditional model of individual dentists guided by abstract principles seems to exhibit some inadequacies; (b) ethical cases suggest that patients and dentists hold common views or what should be done and why in some areas but they diverge in others; (c) dentists place high value on technical excellence and income and relatively less on ethics and oral health outcomes; (d) ethics education in dental schools has not achieved the status of a discipline and is showing signs of receiving less attention than in recent years; (e) focus groups of both patients and dentists are concerned that private standards that differ across dentists as to what constitutes appropriate care are eroding trust in the profession, both among dentists and between dentists and patients; (f) recent economic trends highlight growing fragmentation within the profession; (g) practice is losing its direct relationship with patients as it becomes more commercial; (h) dentists are confused about their role in self-regulation and thus compromising public trust; (i) dentists seem to be willing to tolerate a significant number of their colleagues cutting corners; (j) educating individual dentists about ethical theory is unlikely to be effective in bringing about needed professional behavior. Based on this preliminary evidence, it may very well be the case that the ACD Gies Ethics Projects makes recommendations such as the following: (a) improving the ethical tone of the profession will require changes at the organizational as well as the individual level; (b) standards may be more effective if shared among dentists and with the public;

Do Patients and Dentists See Ethics the Same Way?

The most common approach to ethics in dentistry and bioethics generally is through principles. To be effective, principles must be interpreted in particular situations, and the skill of interpretation requires many years of practice with feedback. The opinions of 91 dentists and 54 patients regarding multiple potential actions and justifications for these actions were gathered for eight dental ethics cases. The summary responses of dentists and patients have been integrated as feedback in an online ethics education exercise that individual dentists can use (see www.dental ethics.org/idea). The dataset of responses was also analyzed for general findings. It emerged that patients and dentists agree to a substantial extent on the average approaches, but they differ systematically on certain of the details. Some ethical issues stimulated a narrow range of responses while others, especially those of a nonclinical nature were regarded as ambiguous and are thus good candidates for future ethics training. A factor analysis revealed a five-dimension structure underlying dental ethics. Patients are most apt to view dentistry using a lens of oral health outcomes while practitioners prefer to stress the process and the technical dimensions of practice. The largest area of difference was patients' much greater interest in dentists assuming an active role as patient oral health advocates with their colleagues.

Moral Communities and Moral Leadership.

The American College of Dentists is embarking on a multiyear project to improve ethics in dentistry. Early indications are that the focus will be on actual moral behavior rather than theory, that we will include organizations as ethical units, and that we will focus on building moral leadership. There is little evidence that the "telling individuals how to behave" approach to ethics is having the hoped-for effect. As a profession, dentistry is based on shared trust. The public level of trust in practitioners is acceptable, but could be improved, and will need to be strengthened to reduce the risk of increasing regulation. While feedback from the way dentists and patients view ethics is generally reassuring, dentists are often at odds with patients and their colleagues over how the profesion manages itself. Individuals are an inconsistent mix of good and bad behavior, and it may be more helpful to make small improvements in the habits of all dentists than to try to take a few certifiably dishonest ones off the street. A computer simulation model of dentistry as a moral community suggests that the profession will always have the proportion of bad actors it will tolerate, that moral leadership is a difficult posture to maintain, that massive interventions to correct imbalances through education or other means will be wasted unless the system as a whole is modified, and that most dentists see no compelling benefit in changing the ethical climate of the profession because they are doing just fine. Considering organiza-tions as loci of moral behavior reveals questionable practices that otherwise remain undetected, including moral distress, fragmentation, fictitious dentists, moral fading, decoupling, responsibility shifting, and moral priming. What is most needed is not phillosophy or principles, but moral leadership.

Computer simulation of dental professionals as a moral community.

Current empirical studies of moral behavior of healthcare professionals are almost entirely focused on self-reports, usually collected under the assumption that an ethical disposition characterizes individuals across various contexts. It is well known, however, that individuals adjust their behavior to what they see being done by those in their peer group. That presents a methodological challenge to traditional research within a community of peers because the behavior of each individual is both the result of norms and a contributor to the norms of others. Computer simulations can be used to address this methodological challenge. A Markov replicator model that runs on an Excel spreadsheet was used to investigate a community with four agent types in the dental community: devious practitioners, ethical practitioners who avoid involvement in the poor ethics of others, ethical practitioners who accept it as part of their professional responsibility to challenge colleagues who act unprofessionally, and those who enforce ethical standards. A panel of leaders in the profession independently estimated parameters for the model and criteria for a possible distribution of agent types in the community. The simulation converged on distributions of the agent types that were very similar to the expectations of the panel. The simulation suggests the following characteristics of such moral communities: The structure of such communities is robust across a wide distribution. It appears that reduction in unethical behavior is more sensitive to the way ethical practitioners interact with each other than to sanctions the enforcement community imposes on unethical practitioners, and that large external interventions will be short lived.

The ethics of experimenting in dental practice.

There is a common misconception that scientists conduct research in their labs or clinics and practitioners do not experiment, but only use the best results reported in the literature. This confusion comes about because dentists are not trained in, nor do they normally observe, the formal requriments of research protocol or ethics. It is generally believed that the norms that apply to clinical practice also cover all situations where dentists innovate in their treatment protocols with a view toward discovering more effective ways to treat patients or where they modify a standard protocol in hopes of better serving the needs of an atypical patient. In this 2002 paper from the Dental Clinics of North America (Volume 46, Number 1, pp. 29-44), David W. Chambers challenges the concept that useful general knowledge is created only outside dental practice and then transferred into the office. But if it is the case that practitioners experiment, even to the limited extent of customizing materials and methods to their own needs or the particular circumstances of patients, there are ethical considerations. All modifications are not equally justifiable, the patient should be involved in "partially tested" approaches in a different way from the routine, and there needs to be sound reason to believe the innovation will not fall below the standard of care. Experimental practice has the characteristics of high probability of success, structured observation, realistic settings, and careful documentation. Heroic measures can only be undertaken when available options have failed and with full consent of the patient. A two-part ethical test is proposed for experimenting in practice: (a) If the dentist believes members of the community (patients, colleagues, or society generally) would be offended or outraged by an action, provided that they became aware of the relevant details--to not do it! (b) If the dentist believes members of the community would be concerned by an action, provided they became aware of the relevant details--discuss it with them. There is also an ethics of evaluating and adopting the research literature to one's office. Some of the requriments in this area include maintaining a current and critical familiarity with developments, understanding the difference between the internal validity of studies in the context where they were conducted and the likely adaptations or cautions needed when customizing the literature to individual practices, and knowing the proper weights to give to the literature and one's own clinical experience.

Would someone please explain what it means to be ethical?

Definitions are offered to distinguish among behavior that is legal, charitable, professional and moral. Moral acts are especially important because that is what people do to bring about the right and the good that is mutually sought by dentists, patients and the community. Ethics is an academic discipline that teaches about appropriate behavior in an indirect fashion - what we say to justify what we do.

Thinking in a straight line.

Rational human discourse is not as common as we imagine or as we would like it to be. Sometimes it is necessary to use fallacies and fabrication to get to the point we favor. This essay is an illustrated list of 33 handy tools for avoiding thinking straight.

Dental hygiene students' participation as subjects in a randomized controlled trial: A full evidence-based dentistry experience.

PURPOSE: Demonstrate that dental hygiene students' participation in a randomized controlled trial comparing the plaque-removing capability of two toothbrushes provides a fuller understanding of the factors affecting the potential application of research to practice. METHODS: All students (N = 18) in a baccalaureate dental hygiene class were engaged in the design of a randomized controlled trial using the Consolidated Standards of Reporting Trials (CONSORT) standard and then participated as subjects in a staggered, repeated measures trial using plaque removal as the dependent variable and brush type, brush head wear, and time in study as independent variables. A debriefing of student participation and lessons learned from analyzing the results was conducted. RESULTS: The study found statistically significant differences in plaque removal capability. Brush type accounted for only 4% of the variance, while measures of brush head wear were inconsistent, and time in the study ("experimental fatigue") accounted for the most variance (9%). Students recognized and confirmed by their personal experiences that research that fails to focus on variance can create an overly optimistic impression of research effectiveness. There was strong agreement that subjects/patients vary widely and that performance depends on multiple factors. CONCLUSIONS: Dental hygiene students who participated as subjects in a randomized controlled trial comparing toothbrushes for plaque removal capacity felt that full analysis to account for all sources of variance and estimate the magnitude of measures of effect add to the value of reported research. Variation across patients is important in practice, if often overlooked as an "error" in the literature.

Toward an operational definition of shared decision making: A conceptual analysis.

RATIONALE: Shared decision making has been widely advocated and evaluated in diverse ways for 4 decades. AIMS AND OBJECTIVES: But there is scant evidence that it is commonly accepted by or has influence on practitioners' behaviour or that it positively affects patient health outcomes. This situation may be due in part to the absence of a commonly agreed operational definition of the construct. This is admitted in the literature and has led to multiple approaches to evaluation. METHOD: An operational definition is proposed based on ethical parity among parties, sharing of mutually interacting expectations and analysis of decisions as commitment to action rather than information. RESULTS: Shared decision making occurs when two autonomous and uncoerced agents both commit to actions that neither has reason to want to change based on their understanding of anticipated outcomes given the situation at hand and of the intended actions of the other party. CONCLUSION: It is a broader concept than providing information regarding treatment alternatives in the office.