Laboratory Technician Assessment of the Quality of Single-Unit Crown Preparations and Impressions as Predictors of the Clinical Acceptability of Crowns as Determined by the Treating Dentist: Findings from the National Dental Practice-Based Research Network.

PURPOSE: In-laboratory assessment by laboratory technicians may offer insight to increase clinical success of dental crowns, and research in this area is lacking. MATERIALS AND METHODS: Dentists in the National Dental Practice-Based Research Network enrolled patients in a study about single-unit crowns; laboratory technicians evaluated the quality of tooth preparations and impressions. The primary outcome for each crown was clinical acceptability (CAC), as judged by the treating dentist. A secondary outcome was "Goodness of Fit (GOF)," a composite score of several aspects of clinical fit, also judged by the study dentist. A mixed-effects logistic regression was used to analyze associations between laboratory technician ratings and the CAC and GOF. RESULTS: Dentists (n = 205) evaluated 3731 crowns. Technicians ranked the marginal detail of impressions as good or excellent in 92% of cases; other aspects of the impression were ranked good or excellent 88% of the time. Regarding tooth preparation, about 90% of preparations were considered adequate (neither excessive nor inadequate reduction). Factors associated with higher CAC were more preparation taper, and use of optical imaging. Factors associated with better GOF were higher impression quality, greater occlusal reduction, more preparation taper, and optical imaging. CONCLUSIONS: Overall quality of preparations and impressions was very high, as evaluated by laboratory technicians. Several clinical parameters were associated with higher CAC and GOF. Clinicians who struggle with crown remakes might consider less conservative tooth preparation, as well as using digital impression technology.

Clinical acceptance of single-unit crowns and its association with impression and tissue displacement techniques: Findings from the National Dental Practice-Based Research Network.

STATEMENT OF PROBLEM: The definitive impression for a single-unit crown involves many material and technique factors that may affect the success of the crown. PURPOSE: The purpose of this prospective cohort study was to determine whether impression technique (tray selection), impression material, or tissue displacement technique are associated with the clinical acceptability of the crown (CAC). MATERIAL AND METHODS: Dentists in the National Dental Practice-Based Research Network documented details of the preparation, impression, and delivery of 3730 consecutive single-unit crowns. Mixed-effects logistic regression analyses were performed to evaluate associations between impression techniques and materials and the CAC and to assess associations between the presence of a subgingival margin with the displacement technique and the outcome variables CAC and number of impressions required. RESULTS: Of the 3730 crowns, 3589 (96.2%) were deemed clinically acceptable. A significant difference in the CAC was found with different impression techniques (P<.001) and different impression materials (P<.001). The percentage of the CAC for digital scans was 99.5%, 95.8% for dual-arch trays, 95.2% for quadrant trays, and 94.0% for complete-arch impression trays. Although no statistically significant difference was found in the CAC produced with dual-arch trays without both mesial and distal contacts, crowns fabricated under these conditions were less likely to achieve excellent occlusion. The percentage of the CAC for digital scans was 99.5%, 97.0% for polyether impressions, 95.5% for polyvinyl siloxane impressions, and 90.5% for other impression materials. Accounting for the location of the margin, the use of a dual-cord displacement technique was significantly associated with lower rates of requiring more than 1 impression (P=.015, odds ratio=1.43). CONCLUSIONS: Dual-arch trays produced clinically acceptable crowns; however, if the prepared tooth was unbounded, the occlusal fit was more likely to have been compromised. Digital scans produced a slightly higher rate of CAC than conventional impression materials. The use of a dual-cord technique was associated with a decreased need to remake impressions when the margins were subgingival.

Concordance between practitioner questionnaire responses and observed clinical treatment recommendations for treatment of dentin hypersensitivity: findings from the National Dental Practice-Based Research Network.

BACKGROUND: Few published reports have presented concordance between treatment choices selected by dentists in hypothetical clinical scenarios and treatment choices made by the same dentists in actual clinical practice. The aim of the current cross-sectional study, conducted within the Management of Dental Hypersensitivity (MDH) study, was to assess the potential value of practitioners' questionnaire responses regarding their typical treatment provided for management of dentin hypersensitivity (DH), by evaluating agreement between these responses and subsequently-observed recommendations recorded during actual clinical examinations. METHODS: A total of 171 practitioners enrolled in the National Dental Practice-Based Research Network completed both a questionnaire and a clinical study regarding methods they use to treat dental hypersensitivity. The questionnaire solicited first-, second- and third-choice products when prescribing or recommending management of dentin hypersensitivity. Agreement was calculated for first-choice products/recommendations and for inclusion in the top three choices, as identified by the practitioners, from 11 listed treatment options. Overall percent agreement and Cohen's kappa statistic were calculated, with associated 95% confidence intervals (CI). Associations between practitioner characteristics and agreement were also evaluated. RESULTS: For individual treatment modalities, percentage agreement ranged from 63 to 99%, depending on the specific item. Percentage agreement between typical treatment and actual treatment for each practitioner's top three treatment modalities, as a combined grouping, ranged from 61 to 100%. When these same agreement pairings were quantified to account for agreement above that expected by chance, kappa values were poor to low. CONCLUSIONS: Concordance between hypothetical clinical scenarios and treatment choices made by the same dentists in actual clinical practice showed moderate to high levels of percentage agreement, but Cohen's kappa values suggested relatively low levels of agreement beyond that expected by chance. This analysis adds to the larger work of the network which has now observed a wide range of agreement between hypothetical and actual care, depending upon the specific diagnosis or treatment under consideration. Questionnaire data for DH might serve as a useful adjunct to clinical data regarding treatment recommendations, but agreement was not sufficiently high to justify use of questionnaires alone to characterize patterns of treatment for this particular condition.

Electronic and paper mode of data capture when assessing patient-reported outcomes in the National Dental Practice-Based Research Network.

AIM: Our objectives were to describe the approach used in the National Dental Practice-Based Research Network to capture patient-reported outcomes and to compare electronic and paper modes of data capture in a specific network study. METHODS: This was a prospective, multicenter cohort study of 1862 patients with dentin hypersensitivity. Patient-reported outcomes were assessed based on patients' perception of pain using Visual Analog Scales and Labeled Magnitude scales at baseline and at 1, 4 and 8 weeks post-baseline. RESULTS: Eighty-five percent of study patients chose to complete follow-up assessments via an electronic mode; 15% completed them via a paper mode. There was not a significant difference in the proportions of patients who completed the 8-week assessment when comparing the electronic mode to the paper mode (92% vs. 90.8%, P = 0.31, Rao-Scott clustered χ2 -test). CONCLUSION: The electronic mode of data capture was as operational as the traditional paper mode, while also providing the advantage of eliminating data entry errors, not involving site research coordinators in measuring the patient-reported outcomes, and not incurring cost and potential delays due to mailing study forms. Electronic data capture of patient reported outcomes could be successfully implemented in the community dental practice setting.

Choice of cement for single-unit crowns: Findings from The National Dental Practice-Based Research Network.

BACKGROUND: In this article, the authors present clinical factors associated with the type of cement practitioners use for restoration of single-unit crowns. METHODS: A total of 202 dentists in The National Dental Practice-Based Research Network recorded clinical details (including cement type) used for 3,468 single-unit crowns. The authors classified crowns as bonded if the dentist used a resin cement. The authors used mixed-model logistic regression to assess the associations between various clinical factors and the dentist's decision to bond. RESULTS: A total of 38.1% of crowns were bonded, and 61.9% were nonbonded; 39.1% (79 of 202) of dentists never bonded a crown, and 20.3% (41 of 202) of dentists bonded every crown in the study. Crowns with excessive occlusal reduction (as judged by laboratory technicians) were more likely to be bonded (P = .02); however, there was no association with bonding and excessive taper (P = .15) or axial reduction (P = .08). Crowns were more likely to be bonded if they were fabricated from leucite-reinforced glass ceramic (76.5%) or lithium disilicate (70.8%) than if they were fabricated from layered zirconia (38.8%), full-contour zirconia (30.1%), full metal (14.7%), or porcelain-fused-to-metal (13.8%) (P < .01) restorative material. There was no significant association between choice to bond and crown margin location (P = .35). Crowns in the anterior maxilla were more likely to be bonded (P < .01). CONCLUSIONS: Excessive occlusal tooth preparation, anterior location of a crown, and the use of glass ceramic crowns were associated significantly with the decision to bond. PRACTICAL IMPLICATIONS: In this study, the authors identified factors significantly associated with the clinical decision made by practicing dentists when selecting a cement for restoration of single-unit crowns.

Remake Rates for Single-Unit Crowns in Clinical Practice: Findings from The National Dental Practice-Based Research Network.

PURPOSE: Some crowns returned from the laboratory are clinically unacceptable, and dentists must remake them. The objectives of this study were to: (1) quantify the remake rate of single-unit crowns; and (2) identify factors significantly associated with crown remakes and intraoral fit. MATERIALS AND METHODS: Dentists participating in the National Dental Practice-Based Research Network recruited patients needing crowns and documented fabrication techniques, patient characteristics, and outcomes. Crowns were considered clinically acceptable or rejected. Also, various aspects of the clinical fit of the crown were graded and categorized as 'Goodness of Fit (GOF).' Dentist and patient characteristics were tested statistically for associations with crown acceptability and GOF. RESULTS: More than 200 dentists participated in this study (N = 205) and evaluated 3750 single-unit crowns. The mean age (years) of patients receiving a crown was 55. The remake rate for crowns was 3.8%. The range of rejection rates among individual practitioners was 0% to 42%. Most clinicians (118, or 58%) did not reject any crowns; all rejections came from 42% of the clinicians (n = 87). The most common reasons for rejections were proximal misfit, marginal errors, and esthetic failures. Fewer years in practice was significantly associated with lower crown success rates and lower fit scores. GOF was also associated with practice busyness and patient insurance status, patient gender (dentists reported better fit for female patients), and patient ethnicity. CONCLUSIONS: The crown remake rate in this study was about 4%. Remakes and crown GOF were associated with certain dentist and practice characteristics.

Preparation Techniques Used to Make Single-Unit Crowns: Findings from The National Dental Practice-Based Research Network.

PURPOSE: To: (1) determine which preparation techniques clinicians use in routine clinical practice for single-unit crown restorations; (2) test whether certain practice, dentist, and patient characteristics are significantly associated with these techniques. MATERIALS AND METHODS: Dentists in the National Dental Practice-Based Research Network participated in a questionnaire regarding preparation techniques, dental equipment used for single-unit crown preparations, scheduled chair time, occlusal clearance determination, location of finish lines, magnification during preparation, supplemental lighting, shade selection, use of intraoral photographs, and trimming dies. Survey responses were compared by dentist and practice characteristics using ANOVA. RESULTS: Of the 2132 eligible dentists, 1777 (83%) responded to the survey. The top two margin configuration choices for single-unit crown preparation for posterior crowns were chamfer/heavy chamfer (65%) and shoulder (23%). For anterior crowns, the most prevalent choices were the chamfer (54%) and the shoulder (37%) configurations. Regarding shade selection, a combination of dentist, assistant, and patient input was used to select anterior shades 59% of the time. Photographs are used to communicate shade selection with the laboratory in about half of esthetically demanding cases. The ideal finish line was located at the crest of gingival tissue for 49% of respondents; 29% preferred 1 mm below the crest; and 22% preferred the finish line above the crest of tissue. Average chair time scheduled for a crown preparation appointment was 76 ± 21 minutes. Practice and dentist characteristics were significantly associated with margin choice including practice type (p < 0.001), region (p < 0.001), and years since graduation (p < 0.001). CONCLUSIONS: Network dentists prefer chamfer/heavy chamfer margin designs, followed by shoulder preparations. These choices were related to practice and dentist characteristics.

Influence of 2 caries-detecting devices on clinical decision making and lesion depth for suspicious occlusal lesions: A randomized trial from The National Dental Practice-Based Research Network.

BACKGROUND: A suspicious occlusal carious lesion (SOCL) can be defined as a lesion with no cavitation and no radiographic radiolucency but for which caries is suspected. The authors evaluated whether using a device changed the percentage of SOCLs that were opened surgically and, among those SOCLs that were opened, the proportion that had penetrated into dentin. METHODS: Eighty-two dentists participated. In phase 1 of the study, dentists identified approximately 20 SOCLs, obtained patient consent, and recorded information about the lesion, treatment or treatments, and depth, if opened. Dentists were then randomly assigned into 1 of 3 groups: no device, DIAGNOdent (KaVo), and Spectra (Air Techniques). In phase 2, dentists enrolled approximately 20 additional patients and recorded the same phase 1 information while using the assigned device to help make their treatment decisions. A mixed-model logistic regression was used to determine any differences after randomization in the proportion of lesions opened and, if opened, the proportion of lesions that penetrated into dentin. RESULTS: A total of 1,500 SOCLs were enrolled in each phase. No statistically significant difference was found in the change in proportion of lesions receiving invasive treatment from phase 1 to phase 2 across the 3 groups (P = .33) or in the change in proportion of percentage of opened lesions that extended into dentin (P = .31). CONCLUSION: Caries-detecting devices in the study did not change substantially dentists' decisions to intervene or the accuracy of the intervention decision in predicting lesion penetration into dentin. PRACTICAL IMPLICATIONS: The caries-detecting devices tested may not improve dentists' clinical decision making for SOCLs.

Impression Techniques Used for Single-Unit Crowns: Findings from the National Dental Practice-Based Research Network.

PURPOSE: To: (1) determine which impression and gingival displacement techniques practitioners use for single-unit crowns on natural teeth; and (2) test whether certain dentist and practice characteristics are significantly associated with the use of these techniques. MATERIALS AND METHODS: Dentists participating in the National Dental Practice-Based Research Network were eligible for this survey study. The study used a questionnaire developed by clinicians, statisticians, laboratory technicians, and survey experts. The questionnaire was pretested via cognitive interviewing with a regionally diverse group of practitioners. The survey included questions regarding gingival displacement and impression techniques. Survey responses were compared by dentist and practice characteristics using ANOVA. RESULTS: The response rate was 1777 of 2132 eligible dentists (83%). Regarding gingival displacement, most clinicians reported using either a single cord (35%) or dual cord (35%) technique. About 16% of respondents preferred an injectable retraction technique. For making impressions, the most frequently used techniques and materials are: poly(vinyl siloxane), 77%; polyether, 12%; optical/digital, 9%. A dental auxiliary or assistant made the final impression 2% of the time. Regarding dual-arch impression trays, 23% of practitioners report they typically use a metal frame tray, 60% use a plastic frame, and 16% do not use a dual-arch tray. Clinicians using optical impression techniques were more likely to be private practice owners or associates. CONCLUSIONS: This study documents current techniques for gingival displacement and making impressions for crowns. Certain dentist and practice characteristics are significantly associated with these techniques.

Dentists' decision strategies for suspicious occlusal caries lesions in a National Dental PBRN study.

OBJECTIVE: Case presentations (vignettes) were completed by dentists in the National Dental Practice-Based Research Network study "Decision Aids for the Management of Suspicious Occlusal Caries Lesions (SOCLs)". The objective was to determine dentists' decision strategies for SOCLs. METHODS: 107 dentists viewed a series of 16 vignettes that represented all combinations of 4 clinical cues: color, luster, lesion roughness, and patient-level caries risk. Each vignette included a patient description and a photograph of a tooth presenting the 4 cues. Dentists were asked to decide the likelihood that a suspected lesion extended into dentin. A lens model analysis was used to examine how dentists use these cues in making their decisions. RESULTS: 86% of dentists had a consistent pattern of cue use that defined their decision strategy. On average, 70% of the variance in their decisions was accounted for by their use of the 4 cues. However, there was considerable variability in the individual cues used by each dentist. The percentages of dentists who used the different cues consistently were: luster (58%), color (48%), roughness (36%), and risk (35%). 14% of dentists reliably used only color, 7% used only luster, 4% used only roughness, and 1% used only risk when making SOCL decisions. CONCLUSIONS: The online vignette system suggests that clinical SOCL decision strategies are highly individualized and dentists do not use all cues available to them to make these decisions. CLINICAL SIGNIFICANCE: Prior to this study, there has been little evidence about how dentists use these cues (either individually or in combination) when judging the extent of caries progression. Such knowledge would be valuable when designing interventions to help dentists maximize the likelihood of appropriate treatment decisions.

Surface characteristics and lesion depth and activity of suspicious occlusal carious lesions: Findings from The National Dental Practice-Based Research Network.

BACKGROUND: A lesion on an occlusal tooth surface with no cavitation and no radiographic radiolucency but in which caries is suspected owing to surface roughness, opacities, or staining can be defined as a suspicious occlusal carious lesion (SOCL). The authors' objective was to quantify the characteristics of SOCLs and their relationship to lesion depth and activity after these lesions were opened surgically. METHODS: Ninety-three dentists participated in the study. When a consenting patient had an SOCL, information was recorded about the tooth, lesion, treatment provided, and, if the SOCL was opened surgically, its lesion depth. The Rao-Scott cluster-adjusted χ2 test was used to evaluate associations between lesion depth and color, roughness, patient risk, and luster. RESULTS: The authors analyzed 1,593 SOCLs. Lesion color varied from yellow/light brown (40%) to dark brown/black (47%), with 13% other colors. Most (69%) of SOCLs had a rough surface when examined with an explorer. Over one-third of the SOCLs (39%) were treated surgically. Of the 585 surgically treated SOCLs, 61% had dentinal caries. There were statistically significant associations between lesion depth and color (P = .03), luster (P = .04), and roughness (P = .01). The authors classified 52% of the patients as being at elevated caries risk. The authors found no significant associations between lesion depth and patient risk (P = .07). CONCLUSIONS: Although statistically significant, the clinical characteristics studied do not provide accurate guidance for making definitive treatment decisions and result in high rates of false positives. PRACTICAL IMPLICATIONS: Given that 39% of the opened lesions did not have dentinal caries or were inactive, evidence-based preventive management is an appropriate alternative to surgical intervention.

Impression evaluation and laboratory use for single-unit crowns: Findings from The National Dental Practice-Based Research Network.

BACKGROUND: Objectives were to determine the likelihood that a clinician accepts an impression for a single-unit crown and document crown remake rates. METHODS: The authors developed a questionnaire that asked dentists about techniques used to fabricate single-unit crowns. The authors showed dentists photographs of 4 impressions and asked them to accept or reject each impression. The authors correlated answers with dentist and practice characteristics. Other questions pertained to laboratory use and crown remake rates. RESULTS: The response rate was 83% (1,777 of 2,132 eligible dentists). Of the 4 impressions evaluated, 3 received consistent responses, with 85% agreement. One impression was more equivocal; 52% accepted the impression. The likelihood of accepting an impression was associated significantly with the clinician's sex, race, ethnicity, and practice busyness. Clinicians produced 18 crowns per month on average, and 9% used in-office milling. Most dentists (59%) reported a remake rate of less than 2%, whereas 17% reported a remake rate greater than 4%. Lower remake rates were associated significantly with more experienced clinicians, optical impressions, and not using dual-arch trays. CONCLUSIONS: Although dentists were largely consistent in their evaluation of impressions (> 85%), nonclinical factors were associated with whether an impression was accepted or rejected. Lower crown remake rates were associated with more experienced clinicians, optical impressions, and not using dual-arch trays. PRACTICAL IMPLICATIONS: These results provide a snapshot of clinical care considerations among a diverse group of dentists. Clinicians can compare their own remake rates and impression evaluation techniques with those in this sample when developing best practice protocols.

Management of dentin hypersensitivity by practitioners in The National Dental Practice-Based Research Network.

BACKGROUND: Dentin hypersensitivity (DH) is a condition commonly encountered in clinical dental practice. The authors conduct a study to identify the treatments recommended to manage DH among dentists in the United States. METHODS: The authors conducted a multicenter study of 1,862 patients with DH who received a diagnosis and were treated by 171 dentists with The National Dental Practice-Based Research Network. RESULTS: The most common treatment recommended was desensitizing over-the-counter (OTC) potassium nitrate toothpaste (alone or in combination with other treatments) for 924 of 1,862 patients (50%). This was followed by an application of fluoride varnish (FV) for 516 patients (28%) and a prescription for fluoride toothpaste for 314 patients (17%). Restorative treatments were recommended to 151 patients (8%). The most common single treatment recommendation was desensitizing OTC potassium nitrate toothpaste, recommended to 335 patients (18%). The most frequent combination of 2 treatment modalities was FV and desensitizing OTC potassium nitrate toothpaste, recommended to 100 patients (5%). A total of 890 of 1,862 patients (48%) with DH received a recommendation for 1 treatment modality, and 644 of 1,862 patients (35%) received a recommendation for a combination of 2 treatment modalities, most frequently an application of FV along with desensitizing OTC potassium nitrate toothpaste (100/1,862; 5%). CONCLUSIONS: Desensitizing OTC potassium nitrate toothpaste and fluoride products were the most widely recommended products to manage DH in the practice setting. PRACTICAL IMPLICATIONS: Our results suggest that most network clinicians preferred noninvasive treatment modalities when treating DH.

Satisfaction with dental care among patients who receive invasive or non-invasive treatment for non-cavitated early dental caries: findings from one region of the National Dental PBRN.

BACKGROUND: The objectives were to: (1) quantify patient satisfaction with treatment for early dental caries overall, and according to whether or not (2a) the patient received invasive treatment; (2b) was high-risk for dental caries, and had dental insurance; and (3) encourage practitioners to begin using non-invasive approaches to early caries management. METHODS: Ten practitioners recorded patient, lesion, and treatment information about non-cavitated early caries lesions. Information on 276 consecutive patients with complete data was included, who received either non-invasive (no dental restoration) or invasive (dental restoration) treatment. Patients completed a patient satisfaction questionnaire and were classified as dissatisfied if they did not "agree" or "strongly agree" with any of 14 satisfaction items. RESULTS: Patients had a mean (± SD) age of 41.8 (±15.8) years, 64% were female and 88% were white. Twenty-five percent (n = 68) were dissatisfied in at least one of the 14 satisfaction items. Satisfaction levels did not significantly vary by patient's gender, race, caries risk category, or affected tooth surface location. Overall, 11% (28 of 276) received invasive treatment; satisfaction did not differ between patients who had invasive or non-invasive treatment. Seven patients received invasive treatment at their request even though that was not what their practitioner recommended; 5 out of 6 were satisfied with their treatment nonetheless. CONCLUSIONS: About one-fourth of patients treated for non-cavitated early caries were dissatisfied with at least some aspect of their dental care experience. Satisfaction of patients who received invasive treatment did not differ from those who received non-invasive treatment.

Management of Dentin Hypersensitivity by National Dental Practice-Based Research Network practitioners: results from a questionnaire administered prior to initiation of a clinical study on this topic.

BACKGROUND: Dentin hypersensitivity (DH) is a common problem encountered in clinical practice. The purpose of this study was to identify the management approaches for DH among United States dentists. METHODS: One hundred eighty five National Dental Practice-Based Research Network clinicians completed a questionnaire regarding their preferred methods to diagnose and manage DH in the practice setting, and their beliefs about DH predisposing factors. RESULTS: Almost all dentists (99%) reported using more than one method to diagnose DH. Most frequently, they reported using spontaneous patient reports coupled with excluding other causes of oral pain by direct clinical examination (48%); followed by applying an air blast (26%), applying cold water (12%), and obtaining patient reports after dentist's query (6%). In managing DH, the most frequent first choice was desensitizing, over-the-counter (OTC), potassium nitrate toothpaste (48%), followed by fluorides (38%), and glutaraldehyde/HEMA (3%). A total of 86% of respondents reported using a combination of products when treating DH, most frequently using fluoride varnish and desensitizing OTC potassium nitrate toothpaste (70%). The most frequent predisposing factor leading to DH, as reported by the practitioners, was recessed gingiva (66%), followed by abrasion, erosion, abfraction/attrition lesions (59%) and bruxism (32%). CONCLUSIONS: The majority of network practitioners use multiple methods to diagnose and manage DH. Desensitizing OTC potassium nitrate toothpaste and fluoride formulations are the most widely used products to manage DH in dental practice setting.

Effect of Cognitively Stimulating Activities on Symptom Management of Delirium Superimposed on Dementia: A Randomized Controlled Trial.

OBJECTIVE: To determine whether cognitively stimulating activities would reduce duration and severity of delirium and improve cognitive and physical function to a greater extent than usual care. DESIGN: Single-blind randomized clinical trial. SETTING: Eight post-acute care (PAC) facilities. PARTICIPANTS: Community-dwelling older adults with dementia and delirium (N = 283). INTERVENTION: Research staff provided cognitively stimulating activities daily for up to 30 days. MEASUREMENTS: Primary outcomes were delirium duration (Confusion Assessment Method) and delirium severity (Delirium Rating Scale). Secondary outcomes were cognitive function (Digits Forward, Montreal Cognitive Assessment, CLOX) and physical function (Barthel Index). RESULTS: Mean percentage of delirium-free days (intervention: 64.8%, 95% confidence interval (CI) = 59.6-70.1; control: 68.7%, 95% CI = 63.9-73.6; P = .37, Wilcoxon rank sum test) and delirium severity (range 0-39: intervention: 10.77, 95% CI = 10.10-11.45; control: 11.15, 95% CI = 10.50-11.80; difference 0.37, 95% CI = 0.56-1.31, P = .43) were similar in both groups. Significant differences for secondary outcomes favoring intervention were found (executive function (range 0-15): intervention: 6.58, 95% CI = 6.12-7.04; control: 5.89, 95% CI = 5.45-6.33; difference -0.69, 95% CI = 1.33 to -0.06, P = .03; constructional praxis (range 0-15): intervention: 8.84, 95% CI = 8.83-9.34; control: 7.53, 95% CI = 7.04-8.01; difference -1.31, 95% CI = 2.01 to -0.61, P < .001). After adjusting for baseline constructional praxis, the group comparison was no longer significant. Average length of stay was shorter in the intervention (36.09 days) than the control (53.13 days) group (standard error = 0.15, P = .01, negative binomial regression). CONCLUSION: Cognitively stimulating activities did not improve delirium but improved executive function and reduced length of stay. Resolution of delirium may require more-intense nonpharmacological management when the individual has dementia.

Dentist material selection for single-unit crowns: Findings from the National Dental Practice-Based Research Network.

OBJECTIVES: Dentists enrolled in the National Dental Practice-Based Research Network completed a study questionnaire about techniques and materials used for single-unit crowns and an enrollment questionnaire about dentist/practice characteristics. The objectives were to quantify dentists' material recommendations and test the hypothesis that dentist's and practice's characteristics are significantly associated with these recommendations. METHODS: Surveyed dentists responded to a contextual scenario asking what material they would use for a single-unit crown on an anterior and posterior tooth. Material choices included: full metal, porcelain-fused-to-metal (PFM), all-zirconia, layered zirconia, lithium disilicate, leucite-reinforced ceramic, or other. RESULTS: 1777 of 2132 eligible dentists responded (83%). The top 3 choices for anterior crowns were lithium disilicate (54%), layered zirconia (17%), and leucite-reinforced glass ceramic (13%). There were significant differences (p<0.05) by dentist's gender, race, years since graduation, practice type, region, practice busyness, hours worked/week, and location type. The top 3 choices for posterior crowns were all-zirconia (32%), PFM (31%), and lithium disilicate (21%). There were significant differences (p<0.05) by dentist's gender, practice type, region, practice busyness, insurance coverage, hours worked/week, and location type. CONCLUSIONS: Network dentists use a broad range of materials for single-unit crowns for anterior and posterior teeth, adopting newer materials into their practices as they become available. Material choices are significantly associated with dentist's and practice's characteristics. CLINICAL SIGNIFICANCE: Decisions for crown material may be influenced by factors unrelated to tooth and patient variables. Dentists should be cognizant of this when developing an evidence-based approach to selecting crown material.

Treatment recommendations for single-unit crowns: Findings from The National Dental Practice-Based Research Network.

BACKGROUND: The objectives of this study were to quantify practitioner variation in likelihood to recommend a crown and test whether certain dentist, practice, and clinical factors are associated significantly with this likelihood. METHODS: Dentists in The National Dental Practice-Based Research Network completed a questionnaire about indications for single-unit crowns. In 4 clinical scenarios, practitioners ranked their likelihood of recommending a single-unit crown. The authors used these responses to calculate a dentist-specific crown factor (range, 0-12). A higher score implied a higher likelihood of recommending a crown. The authors tested certain characteristics for statistically significant associations with the crown factor. RESULTS: A total of 1,777 of 2,132 eligible dentists (83%) responded. Practitioners were most likely to recommend crowns for teeth that were fractured, cracked, or endodontically treated or had a broken restoration. Practitioners overwhelmingly recommended crowns for posterior teeth treated endodontically (94%). Practice owners, practitioners in the Southwest, and practitioners with a balanced workload were more likely to recommend crowns, as were practitioners who used optical scanners for digital impressions. CONCLUSIONS: There is substantial variation in the likelihood of recommending a crown. Although consensus exists in some areas (posterior endodontic treatment), variation dominates in others (size of an existing restoration). Recommendations varied according to type of practice, network region, practice busyness, patient insurance status, and use of optical scanners. PRACTICAL IMPLICATIONS: Recommendations for crowns may be influenced by factors unrelated to tooth and patient variables. A concern for tooth fracture-whether from endodontic treatment, fractured teeth, or large restorations-prompted many clinicians to recommend crowns.

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 5,676 consecutive restorations inserted due to primary caries lesions on 3,751 patients. Practitioner-investigators placed a mean of 24.9 (SD = 12.4) restorations. Lesions were categorized as posterior proximal, anterior proximal, posterior occiusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorized as clinical assessment, radiographs, and/or optical. Statistical analysis utilized generalized 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.

Concordance between responses to questionnaire scenarios and actual treatment to repair or replace dental restorations in the National Dental PBRN.

OBJECTIVE: To quantify the agreement between treatment recommended during hypothetical clinical scenarios and actual treatment provided in comparable clinical circumstances. METHODS: A total of 193 practitioners in the National Dental Practice-Based Research Network participated in both a questionnaire and a clinical study. The questionnaire included three hypothetical scenarios about treatment of existing restorations. Clinicians then participated in a clinical study about repair or replacement of existing restorations. We quantified the overall concordance between their questionnaire responses and what they did in actual clinical treatment. RESULTS: Practitioners who recommended repair (instead of replacement) of more scenario restorations also had higher repair percentages in clinical practice. Additionally, for each of the three hypothetical scenario restorations, practitioners who recommended repair had higher repair percentages in clinical practice. CONCLUSIONS: The questionnaire scenarios were a valid measure of clinicians' tendency to repair or replace restorations in actual clinical practice. CLINICAL IMPLICATIONS: Although there was substantial variation in practitioners' tendency to repair or replace restorations, responses to questionnaire scenarios by individual practitioners were concordant with what they did in actual clinical practice.