Assessment of Prognosis and Periodontal Treatment Goals Among General Dental Practitioners and Dental Hygienists.

PURPOSE: To evaluate general dental practitioners' (GDPs) and dental hygienists' (DHs) assessment of prognosis, suggested treatment goals, and estimated number of treatment sessions in patients with varying severity of periodontal disease. MATERIALS AND METHODS: Seventy-seven GDPs and fifty DHs in a Swedish county participated in a questionnaire study, based on three patient cases: a patient with generalised bone loss but no clinical signs of inflammation (well-maintained); a patient with clinical signs of inflammation and generalised bone loss (periodontitis); and a patient with clinical signs of inflammation but no bone loss (gingivitis). In open-ended questions, the clinicians assessed the prognosis in case of no treatment and proposed treatment goals. Furthermore, based on given fixed-alternative options, they estimated the number of treatment sessions needed for successful management of the condition. RESULTS: Based on a response rate of 94%, the majority of clinicians expected a worsening of the periodontal condition in all three patients (well-maintained: 80%; periodontitis: 94%; gingivitis: 60%). The most common treatment goal in all 3 cases was to improve oral health awareness. The majority of clinicians estimated that the periodontitis case needed slightly more treatment sessions (mean: 3.04, 95% CI: 2.83-3.24) compared to the gingivitis (mean: 1.93, 95% CI: 1.75-2.11) or well-maintained patient case (mean: 1.84, 95% CI: 1.60-2.07). CONCLUSIONS: The majority of included clinicians did not perform an individualised risk assessment and did not individually match the number of appointments to the actual periodontal treatment needs of the patient. This may result in overtreatment in some cases and in undertreatment in others, and possibly in suboptimal use of resources.

Different treatment strategies are applied to patients with the same periodontal status in general dentistry.

OBJECTIVE: To analyse how general dental practitioners (GDPs) and dental hygienists judge and plan to treat patients with different periodontal conditions. MATERIALS AND METHODS: Seventy-seven GDPs and 50 dental hygienists in a Swedish county, Halland, participated in a questionnaire study. The response rate was 94%. The questionnaire consisted of four simulated patient cases and an attached answer sheet. The patient cases had different periodontal status, ranging from healthy to moderate bone loss with general inflammation. The clinicians judged the periodontal status as healthy or diseased. If judged as diseased the clinicians suggested a diagnosis, selected treatment options and estimated the number of treatment sessions for each patient case. The clinicians were compared to each other regarding their judgement, as healthy or diseased, diagnostics and treatment. RESULTS: Three out of four patients were judged both as healthy and diseased by different clinicians. If judged as diseased the patients were diagnosed as having gingivitis or periodontitis. Regardless of the clinicians' former judgement and diagnostics there were no differences (p > 0.05) in the selected treatment options but there was a difference (p < 0.05) in the suggested number of treatment sessions. CONCLUSIONS: Clinicians' judgement of the same periodontal condition, as healthy or diseased, varies, which partly results in different treatment decisions considering the number of treatment sessions. The suggested number of treatment sessions varied also between clinicians even if they judged and diagnosed the condition likewise. The willingness to treat and suggested treatment options were not influenced by the variation in judgement and diagnostics.

Influence of cross-sectional temporomandibular joint tomography on diagnosis and management decisions of patients with temporomandibular joint disorders.

AIM: To assess whether changes in diagnoses and management of temporomandibular joint disorder (TMJD) patients are influenced by radiographic findings and if there is an association between specific radiologic alterations and management strategy changes. METHODS: A total of 204 patients with TMJ symptoms were examined using the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Diagnoses and management were first decided without the aid of radiographs. Management categories were: pharmacology, physiotherapy, counseling and behavioral treatment, occlusal stabilization, surgery, additional examinations, and referrals, each with subcategories. Sagittal TMJ tomograms were assessed for the presence of flattening, erosion, osteophyte, and sclerosis in the TMJ components. Diagnoses and management were reevaluated after gaining access to the radiographs and radiographic classifications. Logistic regression analyses were performed with changes in management as the dependent variable and age and radiographic findings as the independent variables. RESULTS: Diagnosis was changed for 56 patients, mainly from arthralgia to osteoarthritis. Management was changed for 55 patients. Most changes occurred in pharmacology and physiotherapy followed by counseling and behavioral treatment, occlusal stabilization, referrals, additional examinations, and surgery. Changes were mostly within the categories, and the highest number of changes was seen in pharmacology, physiotherapy, and counseling and behavioral treatment. Radiographic degenerative findings increased the chance of change (any change) (odds ratio [OR] ⋝ 2.03) and the chance of change in pharmacology (OR ⋝ 2.56) and physiotherapy (OR = 2.48) separately. No other significant associations were found. CONCLUSION: Radiographic degenerative findings increased the chance of changes in management strategy. However, 73% of the TMJD patients had no changes in management after radiographic examination. In cases with changes, these were mainly adjustments within management categories.

Economic aspects of mandibular third molar surgery.

OBJECTIVE: The aim of this study was to make estimates from a dental care and societal perspective on costs of mandibular third molar surgery. MATERIAL AND METHODS: A total of 64 patients were recruited from three Swedish oral and maxillofacial specialist clinics. Calculations were made prospectively on utilization of labor time, specific medical services and materials, and standardized utilization of other direct costs. Indirect costs were identified from patient surveys. RESULTS: The base case average direct cost of surgery was 217 Euro. Adding the patient's average cost due to absence from work and transportation of 333 Euro increased overall costs to 550 Euro per patient. About 86% of the patients reported some absence following surgery. CONCLUSIONS: The indirect costs were on average higher than the direct costs, i.e. the patient's loss of time caused higher costs than the intervention per se. Appropriate indications for mandibular third molar removal can minimize the risks of complications and individual or societal costs.

Association between temporomandibular joint symptoms, signs, and clinical diagnosis using the RDC/TMD and radiographic findings in temporomandibular joint tomograms.

AIM: To identify associations between clinical symptoms of temporomandibular joint disorders and radiographic findings. METHODS: Two hundred four adult patients (156 women, 48 men, mean age 40 years) with temporomandibular joint (TMJ) pain/sounds or changes in mandibular motion were examined according to the Research Diagnostic Criteria for Temporomandibular Disorders (RDC/TMD). Bilateral sagittal corrected TMJ tomograms in closed and open positions were assessed for the presence of flattening, erosion, osteophytes, and sclerosis in the joint components and the range of mandibular motion. Logistic regression analyses were performed with the radiographic findings as the dependent variables and the following clinical variables as independent variables: opening pattern, maximal jaw opening, TMJ sounds, number of painful muscle/TMJ sites, duration of pain, presence of arthritic disease, depression and somatization scores, graded chronic pain, and age and gender. RESULTS: Coarse crepitus on opening/closing (odds ratio [OR] > or = 3.12), on lateral excursions (odds ratio > or = 4.06), and on protrusion (OR > or = 5.30) was associated with increased risk of degenerative findings in tomograms. A clinical diagnosis of osteoarthritis increased the risk of radiographic findings (OR > or = 2.95) and so did increasing age (OR > or = 1.03 per year) and the female gender (OR > or = 2.36). Maximal assisted opening and maximal opening without pain (< 40 mm) was associated with a posterior condyle-to-articular tubercle position (OR > or = 2.60). No other significant associations were observed. CONCLUSION: Age, gender, and coarse crepitus, but no pain-related variables, were associated with increased risk of degenerative findings in TMJ tomograms. Maximal opening < 40 mm was associated with a posterior condyle-to-articular tubercle relation on opening.

How confident are general dental practitioners in their decision to administer antibiotic prophylaxis? A questionnaire study.

BACKGROUND: Common dental procedures induce bacteremia. To prevent infectious complications from bacteremia in patients with specific medical conditions, antibiotic prophylaxis is considered. Recommendations are often unclear and ambiguous. In a previous study we reported wide variations in general dental practitioners' (GDPs') administrations of antibiotic prophylaxis. We hypothesized that within such a conflicting clinical area, decisions are made with a high level of personal uncertainty. This study examined GDPs' confidence in their decisions and analyzed the extent to which case-related factors might explain individual variations in confidence. METHODS: Postal questionnaires in combination with telephone interviews were used. The response rate was 51% (101/200). There were no significant differences between respondents and non-respondents regarding sex, age, or place of work. The GDPs were presented to patient cases of different medical conditions, where some should receive antibiotic prophylaxis according to recommendations when performing dental procedures that could cause gingival bleeding. The GDPs assessed on visual analogue scales how confident they were in their decisions. The extent to which case-related factors, medical condition and dental procedure, could explain individual variation in confidence was analyzed. RESULTS: Overall the GDPs exhibited high confidence in their decisions regardless of whether they administered antibiotic prophylaxis or not, or whether their decisions were in accordance with recommendations or not. The case-related factors could explain between 30-100% of the individual variation in GDPs' confidence. For 46%, the medical condition significantly explained the individual variation in confidence. However, for most of these GDPs, lower confidence was not presented for conditions where recommendations are unclear and higher confidence was not presented for conditions where recommendations are more clear. For 8% the dental procedure significantly explained the variation, although all procedures could cause bacteremia. For 46% neither the medical condition nor the dental procedure could significantly explain the individual variation in confidence. CONCLUSION: The GDPs presented high confidence in their decisions, and the majority of GDPs did not present what could be considered a justified varied level of confidence according to the clarity of recommendations. Clinicians who are overconfident in their decisions may be less susceptible to modifications of their behavior to more evidence-based strategies.

What findings do clinicians use to diagnose chronic periodontitis?

The prevalence of chronic periodontitis is around 40% in the adult population and most patients visiting a dental clinic experience an intervention related to this disease, either as prophylaxis, e.g. disease information, oral hygiene instruction and polishing, or as treatment of the disease, per se. Hence, chronic periodontitis is a diagnosis that initiates time and costs consuming interventions. The findings clinicians use to diagnose chronic periodontitis are probably also the base for their choice of treatment. The aim of this study was to examine: What findings dental students, dental hygienist students, dental teachers, and supervisors in Public Dental Health use to diagnose patients with chronic periodontitis. If different categories of clinicians use different findings to diagnose chronic periodontitis. A questionnaire was distributed. Seventy-six clinicians representing the four categories answered the question: "What findings, or combinations of findings, do you use when you diagnose chronic periodontitis"? Twenty-five different findings were identified as findings the clinicians use when they diagnosed chronic periodontitis. The most frequently reported findings were bleeding, deepened pockets and loss of marginal bone tissue. Variations between different categories of clinicians were identified. For example, dental hygienist students used more findings (P < 0.05), and were also more inclined to use irrelevant findings like calculus, plaque, smoking, compared to the other categories of clinicians (P < 0.05). The majority of clinicians used only one finding at a time to diagnose chronic periodontitis, and more seldom combined findings. Only 12 out of 76 clinicians used a finding that provided soft tissue inflammation, e.g. bleeding, in combination with a finding that provided loss of supporting tissue, e.g. marginal bone loss. Few clinicians commented that there should be a progressive loss of supporting tissue over time. Further research is needed to investigate if these variations in findings used to diagnose chronic periodontitis indicate variations in treatment of these patients.

Clinicians' management strategies for patients with dyspepsia: a qualitative approach.

BACKGROUND: Symptoms from the upper gastrointestinal tract are frequently encountered in clinical practice and may be of either organic or functional origin. For some of these conditions, according to the literature, certain management strategies can be recommended. For other conditions, the evidence is more ambiguous. The hypothesis that guided our study design was twofold: Management strategies and treatments suggested by different clinicians vary considerably, even when optimal treatment is clear-cut, as documented by evidence in the literature. Clinicians believe that the management strategies of their colleagues are similar to their own. METHODS: Simulated case histories of four patients with symptoms from the upper gastrointestinal tract were presented to 27 Swedish clinicians who were specialists in medical gastroenterology, surgery, and general practice and worked at three hospitals in the southern part of Sweden. The patients' histories contained information on the patient's sex and age and the localisation of the symptoms, but descriptions of subjective symptoms and findings from examinations differed from history to history. Interviews containing open-ended questions were conducted. RESULTS: For the same patient, the management strategies and treatments suggested by the clinicians varied widely, as did the strategies suggested by clinicians in the same speciality. Variation was more pronounced if the case history noted symptoms but no organic findings than if the case history noted unambiguous findings and symptoms. However, even in cases with a consensus in the scientific literature on treatment, the variations in clinicians' opinion on management were pronounced. CONCLUSION: Despite these variations, the clinicians believed that the decisions made by their colleagues would be similar to their own. The overall results of this study indicate that we as researchers must make scientific evidence comprehensible and communicate evidence so that clinicians are able to interpret and implement it in practice. Of particular significance is that scientific evidence leads to an evidence-based care which is effective clinical practice and to the promotion of health from the perspective of the patient, together with cost-effectiveness as a priority.

Patient flows in the care process of mandibular third molar surgery.

Our aim was to describe patient flows in mandibular third molar surgery at oral and maxillofacial specialist units. Our hypothesis was that there are variations in how care is delivered and that the variations could be explained by inter-individual variations in surgeons' practice, the quality of the radiographs appended to the referral, and the staffing of the specialist units. A flow chart was constructed to simulate all possible patient flows in the care process. The chart begins with treatment planning, which was drawn up based on documents from the referring dentist or another caregiver; continues with the care process at the oral and maxillofacial surgery unit, including surgical consultations and radiological examinations; and ends with surgery. Surgeons at four oral and maxillofacial surgery units in the National Health Service in southern Sweden participated. The intention was to collect data on at least 100 patients who had undergone mandibular third molar surgery at each unit. Data on 361 patients were collected. The radiographs appended to the referral were judged to be inappropriate for the majority of the patients (61%). For 13% of these patients, supplementary radiographic examinations were made at the radiology clinic included in the unit, whilst 48% were examined at the oral and maxillofacial surgery clinic. There were eight different patient flow patterns. In one unit with three surgeons, eight different flow patterns were recorded, indicating an interindividual variation among the surgeons. In a second unit, six different flow patterns were recorded. In the last two units, the patient flows appeared to be the same at each unit, although the predominant patient flows in these two units differed. The number of patient visits to the specialist units ranged between one and three. In three specialist units, most patients were called twice whilst in one specialist unit most patients were called only once, to have the third molar removed. Differences existed in the care process. Overall, the number of patient visits seemed not to depend on whether the preoperative radiographic examination was judged to be appropriate or whether the additional radiographs were made at the radiology clinic.

The major factors that influence endodontic retreatment decisions.

The presence of a new or persistent periapical radiolucency adjacent to a rootfilled tooth is often used as a criterion of endodontic treatment "failure". However, clinicians' suggested management of such cases is subject to substantial interindividual variation. Several components that might influence endodontic retreatment decision making have been explored, but data on which factors dentists actually think they consider, are missing. The aim was to interview 20 general dental practitioners (GDPs) and 20 endodontists about factors they thought would influence the prescription of endodontic retreatment. Six simulated cases were presented as cartoons accompanied with a clinical history. In two of the cases the teeth were planned to serve as an abutment tooth in a fixed prosthodontic construction. The status of the periapical bone tissue and the quality of rootfilling seal were varied. Between 1 and 6 factors per case were reported to influence decision making. In cases not planned to serve as abutment teeth most dentists considered that the periapical condition was the most important factor, whilst they considered the fixed prosthodontic construction to be the most important factor in cases planned as abutment teeth. Generally, endodontists seem to be more inclined to retreat and act on the mere presence of a periapical lesion regardless of size than GDPs. In a real clinical setting in direct contact with patients, additional factors like economy and patients' preferences might be expected to exert a major influence. The majority of the dentists stated that they thought that their colleagues would make similar decisions as they did themselves.

"I'll never forget this": evaluating a pilot workshop in effective communication for dental students.

This study evaluated a pilot workshop for teaching communication skills to dental students. The methodology is based on an experiential learning approach, the use of realistic clinical scenarios, simulated patients, and an integrated teaching team of both educational researchers and dentists. Furthermore, the methodology was adapted for short workshops, which is thought to offer better possibilities for frequent and effective training of communication skills throughout the curriculum. The work-shop was piloted with groups of six to ten students from the sixth and tenth semesters (n=94). Results show that the majority of students found the tasks meaningful and well aligned with how they perceived their future profession as dentists. Most students also thought that they learned from the task. An interesting finding is that students not only found it instructive to practice how to communicate in authentic situations, but that they generally found the workshop to be thought-provoking while at the same time providing structure and intellectual tools for the future. A possible explanation for this finding is the sharing of explicit criteria for high-quality communication.

Risk Judgment by General Dental practitioners: Rational but Uninformed.

BACKGROUND: Decisions by dentists to administer antibiotic prophylaxis to prevent infectious complications in patients involves professional risk assessment. While recommendations for rational use have been published, several studies have shown that dentists have low adherence to these recommendations. OBJECTIVE: To examine general dental practitioners' (GDPs') assessments of the risk of complications if not administering antibiotic prophylaxis in connection with dental procedures in patients with specific medical conditions. METHODS: Postal questionnaires in combination with telephone interviews. Risk assessments were made using visual analogue scales (VAS), where zero represented "insignificant risk" and 100 represented a "very significant risk". RESULTS: Response rate: 51%. The mean risk assessments were higher for GDPs who administered antibiotics (mean = 54, SD = 23, range 26-72 mm on the VAS) than those who did not (mean = 14, SD = 12, range 7-31 mm) (P < 0.05). Generally, GDPs made higher risk assessments for patients with medical conditions that are included in recommendations than those with conditions that are not included. Overall, risk assessments were higher for tooth removal than for scaling or root canal treatment, even though the risk assessments should be considered equal for these interventions. CONCLUSIONS: GDPs' risk assessments were rational but uninformed. They administered antibiotics in a manner that was consistent with their risk assessments. Their risk assessments, however, were overestimated. Inaccurate judgments of risk should not be expected to disappear in the presence of new information. To achieve change, clinicians must be motivated to improve behaviour and an evidence-based implementation strategy is required.

Osseous changes and condyle position in TMJ tomograms: impact of RDC/TMD clinical diagnoses on agreement between expected and actual findings.

OBJECTIVE: The objective of this study was to evaluate the impact of clinical TMJ diagnosis, gender, and age on the agreement between expected and actual radiographic findings. STUDY DESIGN: A total of 204 patients with TMJ symptoms were examined using the Research Diagnostic Criteria (RDC/TMD). Expected radiographic findings were recorded. TMJ tomograms in closed and open mouth position were assessed for osseous changes and condyle position. Expected and actual findings were compared. Logistic regression analyses were performed with agreement on radiographic findings as the dependent variable and with clinical RDC/TMD diagnoses, gender and age as the independent variables. RESULTS: The number of radiographic findings was mostly underestimated. A clinical diagnosis of osteoarthritis and age increased the chance of overestimating osseous changes. Disc displacement and age decreased the chance of agreement on certain condyle positions. CONCLUSION: Tomography often revealed unexpected findings. It was not possible to select particular patient groups who would benefit more or less from a radiographic examination.

Antibiotic prophylaxis in oral health care: administration strategies of general dental practitioners.

OBJECTIVE: To examine the strategies that general dental practitioners (GDPs) use to administer antibiotic prophylaxis and to study the agreement between the administration strategies of GDPs and local recommendations. METHODS: Postal questionnaires in combination with telephone interviews were used. Two hundred GDPs in two Swedish counties, Skåne and Orebro, were asked to participate. The response rate was 51% (n = 101). The GDPs were presented with eight simulated cases of patients with different medical conditions for which antibiotic prophylaxis might be considered necessary when performing dental procedures (scaling, tooth removal, root canal treatment). The administration strategies of the GDPs were compared with local recommendations. RESULTS: In general, the variation in the administration strategies of the GDPs was large. For two medical conditions, type 1 diabetes that was not well controlled and hip prosthesis, significantly more GDPs in Skåne than in Orebro administered antibiotic prophylaxis for tooth removal. Agreement between the administration strategies of the GDPs and local recommendations was low. Differences between the two counties were non-significant. Furthermore, within Orebro, GDPs who did not have formal access to local recommendations did not differ in their administration strategies from those who did. The choice of substance was seldom in agreement with the substance recommended, while the majority followed the recommended duration of treatment. CONCLUSION: Although recommendations existed, their impact appeared to be limited. This is significant, since the implementation of recommendations is crucial in making clinical practice more effective and in promoting the health of patients.

A self-directed summative examination in problem-based learning in dentistry: a new approach.

This paper describes and evaluates a new method of assessment in PBL, which was developed with two cohorts of dental students. The method involves students in PBL groups designing PBL problems and assessment tasks that are in line with the objectives of the course and the principles of PBL. Construction of tasks and feedback were provided. The student groups based the summative assessment on a selection of the PBL assessments provided. The evaluation indicates that senior students are capable of designing challenging PBL assessment tasks that are in line with course objectives and PBL principles. This experience raised the pass rates of the students compared those of with earlier cohorts of students. The students rated the method favourably; they considered it enabled them to demonstrate their competences and that it was more closely in line with PBL principles than other methods of assessment that they had experienced. The method is a promising innovation, which could be used in a variety of PBL courses.

Effect of selected literature on dentists' decisions to remove asymptomatic, impacted lower third molars.

The aim of this study was to assess the effect of studying selected literature on dentists' decisions to remove asymptomatic, impacted lower third molars. A pre-test-post-test control group design was used. Given 36 patient cases, two groups of 16 general dental practitioners each were asked to assess the need for removal of asymptomatic impacted lower third molars. The cases were classified by three parameters: 'position of the third molar', 'impaction type', and 'patient age'. After studying selected literature on this subject by the intervention group, both groups were asked to assess the same cases again. Frequencies of decisions to remove the third molars were calculated. For each participant, tables were composed by crosstabulating the indication to remove a third molar with each of the three parameters. T-tests were used to test the significance of the difference between pre-test and post-test decisions. The overall number of indications to remove asymptomatic, impacted lower third molars decreased by 37% in the intervention group. In the control group, the difference between pre- and post-test was not statistically significant. It was concluded that the provision of selected literature significantly influences treatment decision making by dentists in a third molar decision task.