- Email: [email protected]
Caries management decision: Influence of dentist and patient factors in the provision of dental services
journal of dentistry 37 (2009) 827–834
available at www.sciencedirect.com
journal homepage: www.intl.elsevierhealth.com/journals/jden
Caries management decision: Influence of dentist and patient factors in the provision of dental services S. Dome´jean-Orliaguet a,b,*, S. Le´ger c, C. Auclair d, L. Gerbaud d,e, S. Tubert-Jeannin a,b a
CHU Clermont-Ferrand, Service d’Odontologie, Hoˆtel-Dieu, F-63001 Clermont-Ferrand, France Univ Clermont1, UFR d’Odontologie, EA 3847, F-63000 Clermont-Ferrand, France c Univ Blaise Pascal, De´partement de Mathe´matiques, F-63177 Aubie`re, France d CHU Clermont-Ferrand, Service de Sante´ Publique, Hoˆtel-Dieu, F-63001 Clermont-Ferrand, France e Univ Clermont1, Faculte´ de Me´decine, F-63001 Clermont-Ferrand, France b
article info
abstract
Article history:
Objectives: Little is known about how dentists implement caries management and provide
Received 6 April 2009
restorative dental services in everyday practice. This study explored whether or not recent
Received in revised form
concepts in caries management were implemented in practice by private practitioners. The
18 June 2009
influence of patient and practitioner characteristics on the provision of restorative dental
Accepted 19 June 2009
services was also investigated through multidimensional analyses. Methods: A sample of French general private dental practitioners was asked to record the characteristics of 35 preventive or restorative treatments made on vital permanent teeth.
Keywords:
The data collection form was designed to explore dentists’ attitudes towards caries manage-
Health services research
ment and their use of minimally invasive therapies.
Dentist practice patterns
Results: Twenty-six practitioners recorded the characteristics of 921 treatments performed
Clinical decision-making
on 457 patients. Results indicate that participants rarely performed non-invasive treat-
Dental caries
ments. They used an inappropriate detection tool, as most of decisions to treat were based
Restorative dentistry
on visual inspection frequently associated with probing. Multidimensional analysis showed
Preventive dentistry
that dentists provided different restorative treatments depending on patient characteristics, with minimally invasive, esthetic restorations preferentially performed for healthy, young and well-insured patients. Restorative treatments and detection tools also varied markedly among practitioners. These variations in service patterns were not related to a specific patient profile in each dental practice. Conclusions: Results indicate that recent concepts in caries management have not yet been adopted in everyday practice. Patient and dentist characteristics influence the provision of restorative dental services. Decision-making in caries management not only depends on pathophysiology but also seems to be influenced by many other factors. # 2009 Elsevier Ltd. All rights reserved.
1.
Introduction
Recent insight into the caries process has changed the way caries need to be managed. Probing is known to be an
inadequate detection tool that can cause iatrogenic injury, in particular for non-cavitated initial lesions.1 Visual inspection alone has been demonstrated to be sufficiently valid for the detection of occlusal carious lesions.2 There is also good
* Corresponding author at: UFR d’Odontologie, 11 Boulevard Charles de Gaulle, 63000 Clermont-Ferrand, France. Tel.: +33 4 73 17 73 17; fax: +33 4 73 17 73 09. E-mail address: [email protected] (S. Dome´jean-Orliaguet). 0300-5712/$ – see front matter # 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2009.06.012
828
journal of dentistry 37 (2009) 827–834
evidence that initial posterior bitewing radiographs are required for all new patients.3 Preventive strategies and non-invasive therapies involving fluoride and remineralization are preferred over operative treatments, which are undesirable unless the carious lesion has reached the cavitation stage.4 Clinical decision should also take into account individual patient characteristics determining their caries susceptibility.5,6 Thus, when the dental practitioner is deciding on the best treatment for vital teeth in a specific patient, he/she should first consider preventive and noninvasive therapies such as sealants, topical fluoride (varnish or gel) and chlorhexidine applications before invasive treatments or restorations. The way dental services are provided influences the dental status of the population, particularly adults.3 Clinical trials are focused on evaluating the effectiveness of standardized clinical procedures and are conducted under ideal research conditions, but little is known about the way dentists adopt, use and accept new concepts and treatments developed for caries management. Practice-based surveys can usefully explore the way dentists adopt caries management concepts and provide dental services in everyday practice. According to Bader and Shugars, dentists do not follow a hypotheticodeductive process for taking caries-related treatment decisions. They tend to apply a standardized script, influenced by various external factors, when they decide what treatment to provide for a tooth.7 This practice-based study was designed to explore whether or not French private practitioners put recent concepts in caries management into practice. We also ran multidimensional analyses to investigate the influence of patient and practitioner characteristics on the provision of restorative dental services.
2.
Population and method
2.1.
Population
In spring 2005, 100 private practitioners registered in one of the 22 French metropolitan regions were randomly selected and sent a letter with a ‘‘Reply Paid’’ envelope inviting them to participate in this study. The letter explained the study objectives, the conditions of the survey, and the financial compensation (a 150 Euro coupon) on offer to participants. Non-respondents were contacted by phone by the principal investigator. Of the 100 dentists invited, 33 agreed to participate in the study.
2.2.
Data collection
The practitioners were asked to record, on a form, the characteristics of 35 consecutive preventive and/or restorative treatments that were conducted on vital permanent teeth in their dental practice. For the restorations, the practitioners had to register new placements as well as replacements or repairs of previous fillings. Exclusion criteria were: patients aged less than 7 years old, teeth with pulpal inflammation or pulp exposure, and indirect restorations (inlay, onlay or crown). It was possible to record several treatments for the
same patient. The methodology was based upon the original work of Mjo¨r 8 but adapting the study variables to reflect the evolution of caries management concepts towards actual treatment alternatives (preventive, non-invasive, minimally invasive therapies). The present manuscript only deals with non-invasive treatments and primary restorations. The form the dentists filled out for initial treatments was tested previously in a pilot study to ensure it was comprehensible and acceptable. It was divided into two parts. The first part recorded patient factors including gender, age (<25, 25–45, >45 years), type of dental insurance (partial coverage by the French social security system, full coverage = social security + private insurance, special coverage for economically deprived people), plaque score (no visible plaque, almost no plaque, plaque on several teeth, plaque throughout mouth), frequency of dental appointments (regular or irregular attender, or new patient), number of teeth, number of sound teeth. The second part recorded the characteristics of the preventive or restorative treatments: tooth treated (anterior, posterior teeth), primary reason for treatment (prevention, carious lesion, non-carious defect), detection tools used (visual inspection, probing, radiograph, other), site of any carious lesion—if any (Site 1 = pits and fissures, Site 2 = approximal, Site 3 = cervical area) and size of any carious lesion (Sites 1 and 2: enamel, outer third, middle third or inner third of dentine, Site 3: early lesion, one surface, two surfaces, or more than two surface cavitations), type of therapy used (sealant, restoration, other), type of any cavity drilled (cavity extended or not to sound tissue, tunnels, slots), and finally, type of any restorative material used (composite, amalgam, other). The practitioners were not provided with any guidelines on therapy selection. They were however asked to carefully follow a written guideline precisely setting out the inclusion and exclusion criteria and the description of each variable. Two investigators who were hospital dental practitioners were available during the survey to answer questions by phone, fax or email. Demographic data on the practitioners was also collected, including: gender, years since graduation, university of graduation, presence of an assistant (part-time or full-time), and participation in continuing education on cariology within the last 5 years.
2.3.
Data analysis
The unit of analysis was the treatment. The whole procedure took three successive steps: univariate analysis and selection of the variables, multiple correspondence analysis, and hierarchical classification.
2.3.1. Step 1: univariate analysis and selection of the variables included in the multidimensional analyses With the focus on treatment characteristics, statistical analysis was limited to restorations of carious lesions made on posterior teeth on Sites 1 and 2. Main treatment characteristics were included in multidimensional analyses using the following modalities: lesion initiation location (Site 1 versus Site 2), stage of lesion progression (early stage enamel + outer third of dentine versus later stages), design of cavity preparation (extension to sound tissue versus limited to the lesion) and type of restorative material (tooth-colored
journal of dentistry 37 (2009) 827–834
material versus amalgam). The authors also found it clinically relevant to consider the detection tools used as visual inspection (yes versus no), probing (yes versus no) and radiograph (yes versus no). Certain modalities of the answers were grouped taking into account clinical relevance in order to decrease the number of categories in the analysis. A univariate analysis (Chi-squared test) was conducted using SPSS software to explore the relationships between patient factors and main treatment characteristics. Level of significance was placed at p = 0.05. Since all patient factors except gender were significantly related to certain treatment characteristics (see Section 3), all patient factors were included in multidimensional analyses. Gender was also selected because the authors considered this variable as relevant. Patient factors were included in multidimensional analyses using the following modalities: gender (male versus female), age (<25 years versus 25–45 years versus >45 years), type of dental insurance (full coverage - versus partial or special coverage), plaque score (good oral hygiene - no visible plaque and almost no plaque - versus bad oral hygiene - plaque on several teeth and plaque in the whole mouth), frequency of dentist appointments (regular versus irregular attender versus new patient), ratio of sound teeth to number of teeth (<0.33 versus 0.33–0.66 versus >0.66). Practitioner characteristics were not included as explanatory variables in the statistical analysis due to the small number of dentists involved (n = 26).
2.3.2.
Step 2: multiple correspondence analysis
Using SASv8 software, we performed three factorial analyses to represent the different variable-based modalities in multidimensional spaces. One analysis was conducted including treatment characteristics and detection tools (Analysis 1), one mixing patient factors and treatment characteristics (Analysis 2) and one featuring patient factors only (Analysis 3). Multiple correspondence analysis reduces the number of axes in the space while retaining as much information as possible. Thus, the analysis gives new coordinates called factorial data for all modalities (categories of answers for each variable); reflecting the way the modalities are located in the newly defined space. These factorial datasets made it possible to cluster modalities that are closely linked together. We also studied the location in multidimensional space of the different kinds of variables (patient factors, treatment characteristics, detection tools used). Due to the number of treatments (n = 320), it was not possible to take the variable ‘‘practitioner’’ (26 modalities) into account in the factorial analyses. Nevertheless the practitioners were projected in those spaces (coded from 1 to 26) and were considered as supplementary data.
2.3.3.
Step 3: hierarchical classifications
Three ascendant hierarchical classifications were carried out on these factorial data using SASv8 software to obtain dendrograms expressing proximities between the different types of modalities and with the practitioners. The shorter the dendrogram branch, the greater the similarity between modalities or practitioners in that branch. The number of clusters was determined by the level of the cut-off in the dendrogram tree structure. The optimum number of clusters
829
was a compromise between computer output and clinical relevance. Analysis 1 allowed us to look at practitioner distribution in the multidimensional space defined by treatment characteristics and detection tools in order to detect specific groups of practitioners with the same treatment attitude. In Analysis 2, we explored the relationship between patient risk of caries and the types of treatment provided to them. Analysis 3 explored practitioner distribution in the multidimensional space defined by patient factors in order to detect specific groups of practitioners treating same-profile patients.
3.
Results
Of the 33 dental practitioners who agreed to participate, 26 effectively completed the study; seven practitioners withdrew. Most of the dentists completed the requested information for at least 35 treatments (range 21–51), giving a total of 921 forms. The treatments were performed on a total 457 patients (85 persons received several treatments). The demographic characteristics of the participating practitioners and their patients are presented in Table 1. Fig. 1 presents the different types of treatments reported by the practitioners. These results relate to the 608 initial treatments. The main reason for treatment was the presence of a carious lesion. Restorations represented almost 85% of the initial treatments reported. The majority of the restorations were performed on posterior teeth for Site 1 and Site 2 lesions (n = 320). Design of cavity preparations and restorative materials are described only for restorations made on posterior teeth. The practitioners were asked to describe the type of cavity used as follows: limited to the lesion, extended to sound tissue, tunnel or slot. Tunnels and slots were rarely used (n = 12). Cavity preparations were then classified into two categories: a preparation limited to the lesion (which included tunnel and slot; n = 230) and a preparation that extended to sound tissue (n = 119). Amalgam was the material most frequently used (49%), followed by composite (40%), while other materials such as GIC or compomers were relatively rarely used (12%). The practitioners made their treatment decisions using different detection tools. Visual inspection was used alone for 39% of the treatments and associated with probing for 40% of treatments. Radiographs were taken for 21% of treatments (40 panoramic, 75 periapical, 10 bitewing).
3.1.
Univariate analysis results
Univariate analysis explored the influence of patient factors on the main treatment characteristics. The stage at which a restoration was undertaken was influenced by patient’s health insurance coverage ( p = 0.001), oral hygiene ( p = 0.011) and regularity of dental attendance ( p = 0.038). Cavity design was related to age ( p = 0.01), oral hygiene ( p = 0.002) and health insurance ( p = 0.023). Dental materials used was significantly correlated with health insurance ( p = 0.043), dental attendance ( p = 0.01) and dental status (ratio of sound teeth to teeth present) ( p = 0.036). Patient gender was not related to any treatment characteristics.
830
journal of dentistry 37 (2009) 827–834
Table 1 – Practitioner and patient characteristics. Practitioners: n = 26; patients: n = 457.
Years since graduation <11 11–20 >20
5 (20%) 11 (44%) 9 (36%)
tissue, and amalgam restorations. Cluster 3 grouped the following modalities: use of tooth-colored materials, restorations for Site 1 and Site 2 lesions (whatever the stage of progression), cavity preparations limited to the lesion; treatment decisions based on visual examination without radiograph. Cluster 4 covered the use of radiographs and absence of probing. Practitioners were clearly spread across the four clusters according to their diagnostic and therapeutic attitudes. To illustrate, practitioners #6, #9, #10, #18 and #24 were included in Cluster 2, which was characterized by fallback on the old treatment philosophy.
University Clermont-Ferrand Others
20 (76.9%) 6 (23.1%)
3.2.2. Patient factors and main treatment characteristics: Analysis 2 (n = 320)
Practice setting Urban Rural Small towns
10 (38.4%) 8 (30.8%) 8 (30.8%)
Schedule (days) 3.5–4 4.5–5
16 (61.5%) 10 (38.5%)
Dental assistant Yes No Part time
1 (3.8%) 20 (76.9%) 5 (19.3%)
Continuing education Yes No
10 (38.5%) 16 (61.5%)
Number PRACTITIONERS Gender Male Female
PATIENTS Gender Male Female Insurance coverage Full coverage Partial or special coverage
13 (50%) 13 (50%)
224 (49.6%) 228 (50.4%)
403 (91%) 40 (9%)
Ratio of sound teeth to teeth present Ratio below 0.5 Ratio between 0.5 and 0.75 Ratio above 0.75
160 (35.4%) 154 (34.1%) 138 (30.5%)
Oral hygiene No or almost no plaque Plaque on several teeth Plaque throughout the mouth
290 (64.4%) 109 (24.2%) 51 (11.4%)
Attendance Regular Irregular New patients
172 (38.8%) 165 (37.3%) 106 (23.9%)
Not all data were available for each item.
3.2.
Results of the multidimensional analyses
3.2.1. Main treatments characteristics and detection tools: Analysis 1 (n = 320) Three axes were considered with a percentage of variance explained of 65.4%. The two-dimensional solutions of this factorial analysis and the four identified clusters were plotted in Fig. 2. Cluster 1 was characterized by restorative treatment decisions that were not based on visual examination. Cluster 2 was defined by the use of probing, cavities extended to sound
Five axes were considered with a percentage of variance explained of 54%. Four clusters were identified. Due to the relatively complex links existing between patient factors and treatment characteristics, the results of Analysis 2 are presented in Table 2 rather than in a chart—not visually striking. Two clusters were particularly interesting as they characterized particular care features. Cluster 1 was defined by restorations performed on young patients (<25) with full dental coverage, good oral hygiene, a high proportion of sound teeth (>0.66), and regularly attending dentist appointments. Those restorations were undertaken for Site 1 lesions at an early stage of progression, cavity preparation was limited to the lesion, and cavities were restored with tooth-colored materials. Cluster 2 was characterized by amalgam restorations performed for Site 2 lesions at a later stage of progression, with cavity preparation extended to sound tissue. The restorations in Cluster 2 were performed on older patients (25) with bad oral hygiene, a lower proportion of sound teeth (0.33–0.66), and showing irregular attendance to dental appointments.
3.2.3.
Patient factors and practitioners: Analysis 3 (n = 608)
Four axes were considered with a percentage of variance explained of 59.5%. The two-dimensional solutions of the present factorial analysis are plotted in Fig. 3. Seven clusters were identified, illustrating the range of the practitioners’ patient profiles. The practitioners identified as sharing identical diagnostic and therapeutic attitudes in Analysis 1 were well spread across the different clusters in Analysis 3, which demonstrated that practitioners’ attitudes were not explained by a specific patient profile. To illustrate, practitioners #6, #9, #10, #18 and #24 who employed old-fashioned treatment strategies in Analysis 1 (probing, cavities extended to sound tissue, amalgam) were split here into two different patient profile-differentiated clusters. Practitioners #9 and #24 were close to the modality ‘‘new patients’’ while practitioners #6, #10 and #18 were close to patients who were women, regular attenders, with good oral hygiene and full health coverage.
4.
Discussion
This survey evaluated how dentists manage dental caries in everyday practice and explored the impact of both patient and practitioner factors on dental care procedures. Restorative
journal of dentistry 37 (2009) 827–834
831
Fig. 1 – Different types of treatments reported by the practitioners. Some data were lacking (site of carious lesions n = 4; teeth restored n = 2; site of posterior restorations n = 17).
treatment philosophies used by French dentists have previously been surveyed using questionnaires.9,10 These studies showed broad variation in dentists’ restorative attitudes among general practitioners and university teachers. Restora-
tive treatment philosophies were influenced by the practitioners’ socio-demographic characteristics. Some authors have asserted that there is little correlation between dentists’ stated attitude as reported in questionnaire surveys and their
Fig. 2 – ‘‘Main treatment characteristics and detection tools used’’ (Analysis 1). Figure illustrates the results of multivariate Analysis 1. The practitioners were not considered in the calculation of factorial data but were projected in the multidimensional space. Main treatment characteristics: lesion initiation location (Site 1/Site 2), stage of lesion progression (early stages/later stages), design of the cavity preparation (extension to sound tissue/limited to the lesion) and restorative material (tooth-colored material/amalgam). Detection tools: visual inspection (no visual exam/visual exam), probing (no probing/probing), and radiographs (no X-rays/X-rays). Practitioners codes: from #1 to #26.
832
journal of dentistry 37 (2009) 827–834
Table 2 – Characterization of the four clusters obtained in the multidimensional analysis with patient factors and main treatment characteristics (Analysis 2). Cluster 1 PATIENT FACTORS Gender Age (years) Dental insurance Plaque score Frequency of care Ratio of number of sound teeth to total number of teeth TREATMENT CHARACTERISTICS Site Lesion progression Cavity design Restorative material
Females, males <25 Full coverage Good oral hygiene Regular attenders >0.66
1 Early stages Limited to the lesion Tooth-colored materials
Cluster 2
Cluster 3
Cluster 4
25–45, >45 Partial/special coverage Bad oral hygiene Irregular attenders 0.33–0.66
New patients <0.33
2 Later stages Extension to sound tissue Amalgam
therapy decisions in clinical practice.11–13 Dentists putting their treatment philosophies into practice are forced to modify them as they need to consider the combined realities of patient characteristics and practice circumstances. Practicebased surveys thus add complementary data providing insight into real-world practices. The provision of restorative treatments by dentists in clinical practice has been extensively studied worldwide,8 but few studies have explored how dentists use new concepts in caries management. The present work is also the first French study of its kind. The present study does carry certain limitations, but without biasing the interpretation of the results. The data reported here cannot be considered fully representative of the attitude of dentists in the region studied in view of the low participation rate (26%). Participation rate was comparable to
the rate obtained in a similar German survey (21%)14,15 and to other rates (24–57%) observed for recent questionnaire studies in medicine and dentistry in France.16,17 It should be underlined that the practitioners were selected randomly and had no special interest in the subject studied. Most of the previous similar surveys have involved dentists drawn from particular groups, such as participants in continuing education courses, members of a scientific academy, practitioners involved in teaching or practice-based research staff.18–28 The number of practitioners (n = 26) enrolled in this survey is in the low range of the number of participants (9–659) enrolled in previous similar studies.29,30 However, we were nevertheless able to collect data on the characteristics of 608 initial restorative or non-invasive treatments. The volume of data was insufficient to study the influence of practitioner factors on restorative
Fig. 3 – ‘‘Patient factors and Practitioners’’ (Analysis 3). Figure illustrates the results of multivariate Analysis 3. The practitioners were not considered in the calculation of factorial data but were projected in the multidimensional space. Patient factors: gender (male/female), age (<25/25–45/>45 years), dental insurance (full coverage/partial or special coverage), plaque score (good oral hygiene/bad oral hygiene), frequency of dentist appointments (regular/irregular attender/new patient), ratio of sound teeth/to total number of teeth (ratio < 0.33/ratio 0.33–0.66/ratio > 0.66). Practitioner codes: from #1 to #26.
journal of dentistry 37 (2009) 827–834
treatments, but was sufficient to provide useful information on service provision patterns in preventive and restorative dentistry. The results indicate that preventive dentistry was little used and that practitioners rarely utilized recent concepts in caries management, at least in the sample studied. Noninvasive treatments represented 15% of the initial treatments collected in the survey. Respondents did not follow the statements of the 1987 international consensus on placement and replacement criteria.31 This consensus stipulates that preventive and non-invasive measures should be preferred over invasive therapies, and that operative procedures are only indicated for lesions judged to extend well into the dentine. The low utilization of non-invasive care can also be explained by a lack of detection of initial carious lesions. The results indicate that 8 out of 10 treatment decisions were taken using visual inspection, frequently associated with probing and that bitewing radiographs were very rarely taken. It seems that the French guideline which stipulates that bitewing radiographs should be used for each new patient or at each follow-up visit was not followed.32 This may partly explain the low utilization of non-invasive therapies. Without bitewing radiographs, most of the initial lesions which would best be treated by non-invasive methods such as fluoride applications or sealants cannot be detected. Only cavitated D3 and D4 lesions (Pitts’ classification) which are clinically visible are recorded and operatively treated.33,34 This low utilization of non-invasive therapies can be explained by different factors related to dentists’ knowledge, patient demand, or to the health system. Dentists may opt not to use non-invasive therapies if they lack knowledge on new concepts in caries management. The vast majority of dental practitioners currently practising in France were taught restorative dentistry based on Black’s principles. Few participated regularly in continuous education sessions in the field of caries management. Moreover, patients are used to going to the dentist to receive a filling, and are unaware that early lesions can be re-mineralized. Patient demand for preventive services is low, particularly among socially disadvantaged patients.35 The health system also has an influence, as it determines how the dental care is to be financed. In France, patients pay the dentist according to the item of treatment provided, and then seek reimbursement from an insurance fund. The French system is focused on the reimbursement of restorative care. To qualify for reimbursement, the treatment has to be listed as an approved procedure. Restorative treatments are listed, but professionally provided preventive care (except sealants) does not generally qualify for reimbursement, which consequently discourages prevention and encourages operative care.9,36 This system of remuneration does not promote comprehensive care, as treatments conserving and optimizing the longevity of the patient’s dentition are not covered.31 The development of modern concepts in caries management thus depends on other developments to many factors, such as initial and continuous dental education, health education for patients, and the dental care system. The present findings indicate that restorative services varied according to patient characteristics (Table 2). Minimally invasive restorations were preferentially offered to patients who were young, regular attenders, with good oral hygiene or
833
with a private complementary insurance. These findings corroborate the idea that more favorable service patterns are delivered to socially or medically advantaged patients. On one hand, it can be hypothesized that dentists take into account caries susceptibility when taking decisions on restorative treatment. They make a subjective evaluation of caries risk and tend to adapt their decision accordingly; they evaluate the patient’s oral hygiene and dental attendance as positives and then choose tooth-colored materials for those patients. On the other side, it means that minimally invasive restorations are not offered to disadvantaged patients. This has implications in terms of appropriateness of care and equity in the delivery of dental care.11–13,37–39 Many epidemiological studies have explored the relationship between patient factors and the characteristics of restorative treatments,8 but few have explored the impact of the ‘‘dentist’’ profile. Multivariate models used to describe dental service rates have reported wide variations among providers that were not explainable by differences in patient needs or demand for care.12,38–41 This study could not take into account practitioner characteristics due to the small number of dentists. Nevertheless, we were able to plot the distribution of dentists in the multidimensional spaces and in the different clusters. Practitioners were clearly well spread according to diagnostic and therapeutic attitude; some practitioners were close to old-fashioned attitudes while others seemed to have adopted the concepts of minimally invasive treatment. These variations in service patterns were not related to a specific patient profile in each dental practice. Our results clearly illustrate the concept of ‘‘script’’ described by Bader and Shugars.7 Dentists tend to follow a set script for taking a clinical decision that is not based solely on pathological and physiological observations. Patient’s oral health is not the sole determinant for clinical decision. A range of dentist-related factors also influence practitioner attitude and thus determine the type of patient care provided. Thus, similar health characteristics among patients could result in different proposals for conservative treatments depending on the practitioner’s profile. The present survey highlights that there are multiple dimensions to decision-making in conservative dentistry. It suggests that, in addition to oral health and patient characteristics, other factors linked to the practitioner also contribute to variations in care provision. Further research is needed to more thoroughly evaluate and explain interactions between the multiples factors influencing dental service provision. It would also be useful to verify whether the findings of this survey are replicated in the same region (to test the robustness of the conclusions) as well as in other settings or dental care systems. A better understanding of the decision process would also help identify solutions for improving dentist adoption of modern concepts in caries management.
Acknowledgements This project was funded by the Clermont-Ferrand regional university hospital, France, through a Projet Hospitalier de Recherche Clinique (hospital-led clinical research project). The authors wish to thank the participating dentists for their
834
journal of dentistry 37 (2009) 827–834
diligence and time in completing the data collection forms. The project could not have been carried out without their help. The authors also thank Pr. B. Aublet-Cuvelier for methodological guidance (CHU, Clermont-Ferrand, France), and G. Gouby and P. Lacarin for administrative support.
references
1. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the effect of probing in occlusal surfaces. Caries Research 1987;21:368–74. 2. Downer MC. Validation of methods used in dental caries diagnosis. International Dental Journal 1989;39:241–6. 3. Sheiham A. Impact of dental treatment on the incidence of dental caries in children and adults. Community Dentistry and Oral Epidemiology 1997;25:104–12. 4. Mount GJ, Ngo H. Minimal intervention: a new concept for operative dentistry. Quintessence International 2000;31:527–33. 5. Featherstone JD. The science and practice of caries prevention. Journal American of Dental Association 2000;131:887–99. 6. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health and Preventive Dentistry 2004;2(Suppl 1):259–64. 7. Bader JD, Shugars DA. What do we know about how dentists make caries-related treatment decisions? Community Dentistry and Oral Epidemiology 1997;25:97–103. 8. Mjo¨r IA. Placement and replacement of restorations. Operative Dentistry 1981;6:49–54. 9. Dome´jean-Orliaguet S, Tubert-Jeannin S, Riordan PJ, Espelid I, Tveit AB. French dentists’ restorative treatment decisions. Oral Health and Preventive Dentistry 2004;2:125–31. 10. Tubert-Jeannin S, Dome´jean-Orliaguet S, Riordan PJ, Espelid I, Tveit AB. Restorative treatment strategies reported by French university teachers. Journal of Dental Education 2004;68:1096–103. 11. Bader JD, Shugars DA. Variation in dentists’ clinical decisions. Journal of Public Health Dentistry 1995;55: 181–8. 12. Brennan DS, Spencer AJ. Influence of patient, visit, and oral health factors on dental service provision. Journal of Public Health Dentistry 2002;62:148–57. 13. Brennan DS, Spencer AJ. Service patterns associated with coronal caries in private general dental practice. Journal of Dentistry 2007;35:570–7. 14. Friedl KH, Hiller KA, Schmalz G. Placement and replacement of amalgam restorations in Germany. Operative Dentistry 1994;19:228–32. 15. Friedl KH, Hiller KA, Schmalz G. Placement and replacement of composite restorations in Germany. Operative Dentistry 1995;20:34–8. 16. Clinard F, Bardou M, Sgro C, Lefevre N, Raphael F, Paille F, et al. Non-steroidal anti-inflammatory and cytoprotective drug co-prescription in general practice A general practitioner-based survey in France. European Journal of Clinical Pharmacology 2001;57:737–43. 17. Mahe E, Lahfa M, Mansouri S, Mosharraf-Olmolk H, Le Rebours J, Prud’Homme JF, et al. Physicians’ response to a letter to confirm diagnosis in a genetic study of psoriasis. European Journal of Dermatology 2002;12:66–9. 18. Mjor IA, Toffenetti F. Placement and replacement of resinbased composite restorations in Italy. Operative Dentistry 1992;17:82–5.
19. Mjor IA, Toffenetti F. Placement and replacement of amalgam restorations in Italy. Operative Dentistry 1992;17:70–3. 20. Mjor IA. Repair versus replacement of failed restorations. International of Dental Journal 1993;43:466–72. 21. Mjor IA, Qvist V. Marginal failures of amalgam and composite restorations. Journal of Dentistry 1997;25:25–30. 22. Mjor IA. Selection of restorative materials in general dental practice in Sweden. Acta Odontologica Scandinavia 1997;55: 53–7. 23. Mjor IA. The reasons for replacement and the age of failed restorations in general dental practice. Acta Odontolologica Scandinavia 1997;55:58–63. 24. Mjor IA, Moorhead JE. Selection of restorative materials, reasons for replacement, and longevity of restorations in Florida. Journal of American College of Dentists 1998;65:27–33. 25. Pink FE, Minden NJ, Simmonds S. Decisions of practitioners regarding placement of amalgam and composite restorations in general practice settings. Operative Dentistry 1994;19:127–32. 26. Qvist J, Qvist V, Mjor IA. Placement and longevity of amalgam restorations in Denmark. Acta Odontologica Scandinavia 1990;48:297–303. 27. Qvist V, Qvist J, Mjor IA. Placement and longevity of toothcolored restorations in Denmark. Acta Odontologica Scandinavia 1990;48:305–11. 28. Wilson NH, Burke FJ, Mjor IA. Reasons for placement and replacement of restorations of direct restorative materials by a selected group of practitioners in the United Kingdom. Quintessence International 1997;28:245–8. 29. Mjor IA, Um CM. Survey of amalgam and composite restorations in Korea. International Dental Journal 1993;43:311–6. 30. Forss H, Widstrom E. From amalgam to composite: selection of restorative materials and restoration longevity in Finland. Acta Odontologica Scandinavia 2001;59:57–62. 31. Criteria for placement and replacement of dental restorations: an international concensus report. International Dental Journal 1988;38:193–4. 32. ANDEM. Recommandations et re´fe´rences dentaires. 1996. 33. Pitts NB. Modern concepts of caries measurement. Journal of Dental Research 2004;83:C43–7. Spec No C. 34. Pitts N. ICDAS—an international system for caries detection and assessment being developed to facilitate caries epidemiology, research and appropriate clinical management. Community Dental Health 2004;21:193–8. 35. Bedos C, Brodeur JM, Levine A, Richard L, Boucheron L, Mereus W. Perception of dental illness among persons receiving public assistance in Montreal. American Journal of Public Health 2005;95:1340–4. 36. Tubert-Jeannin S, Morel-Papernot A, Woda A. Evaluation of a dental benefit plan for children conducted in Auvergne, France, since 1992. Community Dentistry and Oral Epidemiology 1998;26:272–82. 37. Bader JD. The emergence of appropriateness-of-care issues. Journal of Dental Research 1992;71:502–4. 38. Brennan DS, Spencer AJ. The role of dentist, practice and patient factors in the provision of dental services. Community Dentistry and Oral Epidemiology 2005;33:181–95. 39. Brennan DS, Spencer AJ, Szuster FS. Service provision patterns by main diagnoses and characteristics of patients. Community Dentistry and Oral Epidemiology 2000;28:225–33. 40. Grembowski D, Milgrom P, Fiset L. Dental decision making and variation in dentist service rates. Social Science and Medicine 1991;32:287–94. 41. Bailit HL, Clive J. The development of dental practice profiles. Medical Care 1981;19:30–46.
available at www.sciencedirect.com
journal homepage: www.intl.elsevierhealth.com/journals/jden
Caries management decision: Influence of dentist and patient factors in the provision of dental services S. Dome´jean-Orliaguet a,b,*, S. Le´ger c, C. Auclair d, L. Gerbaud d,e, S. Tubert-Jeannin a,b a
CHU Clermont-Ferrand, Service d’Odontologie, Hoˆtel-Dieu, F-63001 Clermont-Ferrand, France Univ Clermont1, UFR d’Odontologie, EA 3847, F-63000 Clermont-Ferrand, France c Univ Blaise Pascal, De´partement de Mathe´matiques, F-63177 Aubie`re, France d CHU Clermont-Ferrand, Service de Sante´ Publique, Hoˆtel-Dieu, F-63001 Clermont-Ferrand, France e Univ Clermont1, Faculte´ de Me´decine, F-63001 Clermont-Ferrand, France b
article info
abstract
Article history:
Objectives: Little is known about how dentists implement caries management and provide
Received 6 April 2009
restorative dental services in everyday practice. This study explored whether or not recent
Received in revised form
concepts in caries management were implemented in practice by private practitioners. The
18 June 2009
influence of patient and practitioner characteristics on the provision of restorative dental
Accepted 19 June 2009
services was also investigated through multidimensional analyses. Methods: A sample of French general private dental practitioners was asked to record the characteristics of 35 preventive or restorative treatments made on vital permanent teeth.
Keywords:
The data collection form was designed to explore dentists’ attitudes towards caries manage-
Health services research
ment and their use of minimally invasive therapies.
Dentist practice patterns
Results: Twenty-six practitioners recorded the characteristics of 921 treatments performed
Clinical decision-making
on 457 patients. Results indicate that participants rarely performed non-invasive treat-
Dental caries
ments. They used an inappropriate detection tool, as most of decisions to treat were based
Restorative dentistry
on visual inspection frequently associated with probing. Multidimensional analysis showed
Preventive dentistry
that dentists provided different restorative treatments depending on patient characteristics, with minimally invasive, esthetic restorations preferentially performed for healthy, young and well-insured patients. Restorative treatments and detection tools also varied markedly among practitioners. These variations in service patterns were not related to a specific patient profile in each dental practice. Conclusions: Results indicate that recent concepts in caries management have not yet been adopted in everyday practice. Patient and dentist characteristics influence the provision of restorative dental services. Decision-making in caries management not only depends on pathophysiology but also seems to be influenced by many other factors. # 2009 Elsevier Ltd. All rights reserved.
1.
Introduction
Recent insight into the caries process has changed the way caries need to be managed. Probing is known to be an
inadequate detection tool that can cause iatrogenic injury, in particular for non-cavitated initial lesions.1 Visual inspection alone has been demonstrated to be sufficiently valid for the detection of occlusal carious lesions.2 There is also good
* Corresponding author at: UFR d’Odontologie, 11 Boulevard Charles de Gaulle, 63000 Clermont-Ferrand, France. Tel.: +33 4 73 17 73 17; fax: +33 4 73 17 73 09. E-mail address: [email protected] (S. Dome´jean-Orliaguet). 0300-5712/$ – see front matter # 2009 Elsevier Ltd. All rights reserved. doi:10.1016/j.jdent.2009.06.012
828
journal of dentistry 37 (2009) 827–834
evidence that initial posterior bitewing radiographs are required for all new patients.3 Preventive strategies and non-invasive therapies involving fluoride and remineralization are preferred over operative treatments, which are undesirable unless the carious lesion has reached the cavitation stage.4 Clinical decision should also take into account individual patient characteristics determining their caries susceptibility.5,6 Thus, when the dental practitioner is deciding on the best treatment for vital teeth in a specific patient, he/she should first consider preventive and noninvasive therapies such as sealants, topical fluoride (varnish or gel) and chlorhexidine applications before invasive treatments or restorations. The way dental services are provided influences the dental status of the population, particularly adults.3 Clinical trials are focused on evaluating the effectiveness of standardized clinical procedures and are conducted under ideal research conditions, but little is known about the way dentists adopt, use and accept new concepts and treatments developed for caries management. Practice-based surveys can usefully explore the way dentists adopt caries management concepts and provide dental services in everyday practice. According to Bader and Shugars, dentists do not follow a hypotheticodeductive process for taking caries-related treatment decisions. They tend to apply a standardized script, influenced by various external factors, when they decide what treatment to provide for a tooth.7 This practice-based study was designed to explore whether or not French private practitioners put recent concepts in caries management into practice. We also ran multidimensional analyses to investigate the influence of patient and practitioner characteristics on the provision of restorative dental services.
2.
Population and method
2.1.
Population
In spring 2005, 100 private practitioners registered in one of the 22 French metropolitan regions were randomly selected and sent a letter with a ‘‘Reply Paid’’ envelope inviting them to participate in this study. The letter explained the study objectives, the conditions of the survey, and the financial compensation (a 150 Euro coupon) on offer to participants. Non-respondents were contacted by phone by the principal investigator. Of the 100 dentists invited, 33 agreed to participate in the study.
2.2.
Data collection
The practitioners were asked to record, on a form, the characteristics of 35 consecutive preventive and/or restorative treatments that were conducted on vital permanent teeth in their dental practice. For the restorations, the practitioners had to register new placements as well as replacements or repairs of previous fillings. Exclusion criteria were: patients aged less than 7 years old, teeth with pulpal inflammation or pulp exposure, and indirect restorations (inlay, onlay or crown). It was possible to record several treatments for the
same patient. The methodology was based upon the original work of Mjo¨r 8 but adapting the study variables to reflect the evolution of caries management concepts towards actual treatment alternatives (preventive, non-invasive, minimally invasive therapies). The present manuscript only deals with non-invasive treatments and primary restorations. The form the dentists filled out for initial treatments was tested previously in a pilot study to ensure it was comprehensible and acceptable. It was divided into two parts. The first part recorded patient factors including gender, age (<25, 25–45, >45 years), type of dental insurance (partial coverage by the French social security system, full coverage = social security + private insurance, special coverage for economically deprived people), plaque score (no visible plaque, almost no plaque, plaque on several teeth, plaque throughout mouth), frequency of dental appointments (regular or irregular attender, or new patient), number of teeth, number of sound teeth. The second part recorded the characteristics of the preventive or restorative treatments: tooth treated (anterior, posterior teeth), primary reason for treatment (prevention, carious lesion, non-carious defect), detection tools used (visual inspection, probing, radiograph, other), site of any carious lesion—if any (Site 1 = pits and fissures, Site 2 = approximal, Site 3 = cervical area) and size of any carious lesion (Sites 1 and 2: enamel, outer third, middle third or inner third of dentine, Site 3: early lesion, one surface, two surfaces, or more than two surface cavitations), type of therapy used (sealant, restoration, other), type of any cavity drilled (cavity extended or not to sound tissue, tunnels, slots), and finally, type of any restorative material used (composite, amalgam, other). The practitioners were not provided with any guidelines on therapy selection. They were however asked to carefully follow a written guideline precisely setting out the inclusion and exclusion criteria and the description of each variable. Two investigators who were hospital dental practitioners were available during the survey to answer questions by phone, fax or email. Demographic data on the practitioners was also collected, including: gender, years since graduation, university of graduation, presence of an assistant (part-time or full-time), and participation in continuing education on cariology within the last 5 years.
2.3.
Data analysis
The unit of analysis was the treatment. The whole procedure took three successive steps: univariate analysis and selection of the variables, multiple correspondence analysis, and hierarchical classification.
2.3.1. Step 1: univariate analysis and selection of the variables included in the multidimensional analyses With the focus on treatment characteristics, statistical analysis was limited to restorations of carious lesions made on posterior teeth on Sites 1 and 2. Main treatment characteristics were included in multidimensional analyses using the following modalities: lesion initiation location (Site 1 versus Site 2), stage of lesion progression (early stage enamel + outer third of dentine versus later stages), design of cavity preparation (extension to sound tissue versus limited to the lesion) and type of restorative material (tooth-colored
journal of dentistry 37 (2009) 827–834
material versus amalgam). The authors also found it clinically relevant to consider the detection tools used as visual inspection (yes versus no), probing (yes versus no) and radiograph (yes versus no). Certain modalities of the answers were grouped taking into account clinical relevance in order to decrease the number of categories in the analysis. A univariate analysis (Chi-squared test) was conducted using SPSS software to explore the relationships between patient factors and main treatment characteristics. Level of significance was placed at p = 0.05. Since all patient factors except gender were significantly related to certain treatment characteristics (see Section 3), all patient factors were included in multidimensional analyses. Gender was also selected because the authors considered this variable as relevant. Patient factors were included in multidimensional analyses using the following modalities: gender (male versus female), age (<25 years versus 25–45 years versus >45 years), type of dental insurance (full coverage - versus partial or special coverage), plaque score (good oral hygiene - no visible plaque and almost no plaque - versus bad oral hygiene - plaque on several teeth and plaque in the whole mouth), frequency of dentist appointments (regular versus irregular attender versus new patient), ratio of sound teeth to number of teeth (<0.33 versus 0.33–0.66 versus >0.66). Practitioner characteristics were not included as explanatory variables in the statistical analysis due to the small number of dentists involved (n = 26).
2.3.2.
Step 2: multiple correspondence analysis
Using SASv8 software, we performed three factorial analyses to represent the different variable-based modalities in multidimensional spaces. One analysis was conducted including treatment characteristics and detection tools (Analysis 1), one mixing patient factors and treatment characteristics (Analysis 2) and one featuring patient factors only (Analysis 3). Multiple correspondence analysis reduces the number of axes in the space while retaining as much information as possible. Thus, the analysis gives new coordinates called factorial data for all modalities (categories of answers for each variable); reflecting the way the modalities are located in the newly defined space. These factorial datasets made it possible to cluster modalities that are closely linked together. We also studied the location in multidimensional space of the different kinds of variables (patient factors, treatment characteristics, detection tools used). Due to the number of treatments (n = 320), it was not possible to take the variable ‘‘practitioner’’ (26 modalities) into account in the factorial analyses. Nevertheless the practitioners were projected in those spaces (coded from 1 to 26) and were considered as supplementary data.
2.3.3.
Step 3: hierarchical classifications
Three ascendant hierarchical classifications were carried out on these factorial data using SASv8 software to obtain dendrograms expressing proximities between the different types of modalities and with the practitioners. The shorter the dendrogram branch, the greater the similarity between modalities or practitioners in that branch. The number of clusters was determined by the level of the cut-off in the dendrogram tree structure. The optimum number of clusters
829
was a compromise between computer output and clinical relevance. Analysis 1 allowed us to look at practitioner distribution in the multidimensional space defined by treatment characteristics and detection tools in order to detect specific groups of practitioners with the same treatment attitude. In Analysis 2, we explored the relationship between patient risk of caries and the types of treatment provided to them. Analysis 3 explored practitioner distribution in the multidimensional space defined by patient factors in order to detect specific groups of practitioners treating same-profile patients.
3.
Results
Of the 33 dental practitioners who agreed to participate, 26 effectively completed the study; seven practitioners withdrew. Most of the dentists completed the requested information for at least 35 treatments (range 21–51), giving a total of 921 forms. The treatments were performed on a total 457 patients (85 persons received several treatments). The demographic characteristics of the participating practitioners and their patients are presented in Table 1. Fig. 1 presents the different types of treatments reported by the practitioners. These results relate to the 608 initial treatments. The main reason for treatment was the presence of a carious lesion. Restorations represented almost 85% of the initial treatments reported. The majority of the restorations were performed on posterior teeth for Site 1 and Site 2 lesions (n = 320). Design of cavity preparations and restorative materials are described only for restorations made on posterior teeth. The practitioners were asked to describe the type of cavity used as follows: limited to the lesion, extended to sound tissue, tunnel or slot. Tunnels and slots were rarely used (n = 12). Cavity preparations were then classified into two categories: a preparation limited to the lesion (which included tunnel and slot; n = 230) and a preparation that extended to sound tissue (n = 119). Amalgam was the material most frequently used (49%), followed by composite (40%), while other materials such as GIC or compomers were relatively rarely used (12%). The practitioners made their treatment decisions using different detection tools. Visual inspection was used alone for 39% of the treatments and associated with probing for 40% of treatments. Radiographs were taken for 21% of treatments (40 panoramic, 75 periapical, 10 bitewing).
3.1.
Univariate analysis results
Univariate analysis explored the influence of patient factors on the main treatment characteristics. The stage at which a restoration was undertaken was influenced by patient’s health insurance coverage ( p = 0.001), oral hygiene ( p = 0.011) and regularity of dental attendance ( p = 0.038). Cavity design was related to age ( p = 0.01), oral hygiene ( p = 0.002) and health insurance ( p = 0.023). Dental materials used was significantly correlated with health insurance ( p = 0.043), dental attendance ( p = 0.01) and dental status (ratio of sound teeth to teeth present) ( p = 0.036). Patient gender was not related to any treatment characteristics.
830
journal of dentistry 37 (2009) 827–834
Table 1 – Practitioner and patient characteristics. Practitioners: n = 26; patients: n = 457.
Years since graduation <11 11–20 >20
5 (20%) 11 (44%) 9 (36%)
tissue, and amalgam restorations. Cluster 3 grouped the following modalities: use of tooth-colored materials, restorations for Site 1 and Site 2 lesions (whatever the stage of progression), cavity preparations limited to the lesion; treatment decisions based on visual examination without radiograph. Cluster 4 covered the use of radiographs and absence of probing. Practitioners were clearly spread across the four clusters according to their diagnostic and therapeutic attitudes. To illustrate, practitioners #6, #9, #10, #18 and #24 were included in Cluster 2, which was characterized by fallback on the old treatment philosophy.
University Clermont-Ferrand Others
20 (76.9%) 6 (23.1%)
3.2.2. Patient factors and main treatment characteristics: Analysis 2 (n = 320)
Practice setting Urban Rural Small towns
10 (38.4%) 8 (30.8%) 8 (30.8%)
Schedule (days) 3.5–4 4.5–5
16 (61.5%) 10 (38.5%)
Dental assistant Yes No Part time
1 (3.8%) 20 (76.9%) 5 (19.3%)
Continuing education Yes No
10 (38.5%) 16 (61.5%)
Number PRACTITIONERS Gender Male Female
PATIENTS Gender Male Female Insurance coverage Full coverage Partial or special coverage
13 (50%) 13 (50%)
224 (49.6%) 228 (50.4%)
403 (91%) 40 (9%)
Ratio of sound teeth to teeth present Ratio below 0.5 Ratio between 0.5 and 0.75 Ratio above 0.75
160 (35.4%) 154 (34.1%) 138 (30.5%)
Oral hygiene No or almost no plaque Plaque on several teeth Plaque throughout the mouth
290 (64.4%) 109 (24.2%) 51 (11.4%)
Attendance Regular Irregular New patients
172 (38.8%) 165 (37.3%) 106 (23.9%)
Not all data were available for each item.
3.2.
Results of the multidimensional analyses
3.2.1. Main treatments characteristics and detection tools: Analysis 1 (n = 320) Three axes were considered with a percentage of variance explained of 65.4%. The two-dimensional solutions of this factorial analysis and the four identified clusters were plotted in Fig. 2. Cluster 1 was characterized by restorative treatment decisions that were not based on visual examination. Cluster 2 was defined by the use of probing, cavities extended to sound
Five axes were considered with a percentage of variance explained of 54%. Four clusters were identified. Due to the relatively complex links existing between patient factors and treatment characteristics, the results of Analysis 2 are presented in Table 2 rather than in a chart—not visually striking. Two clusters were particularly interesting as they characterized particular care features. Cluster 1 was defined by restorations performed on young patients (<25) with full dental coverage, good oral hygiene, a high proportion of sound teeth (>0.66), and regularly attending dentist appointments. Those restorations were undertaken for Site 1 lesions at an early stage of progression, cavity preparation was limited to the lesion, and cavities were restored with tooth-colored materials. Cluster 2 was characterized by amalgam restorations performed for Site 2 lesions at a later stage of progression, with cavity preparation extended to sound tissue. The restorations in Cluster 2 were performed on older patients (25) with bad oral hygiene, a lower proportion of sound teeth (0.33–0.66), and showing irregular attendance to dental appointments.
3.2.3.
Patient factors and practitioners: Analysis 3 (n = 608)
Four axes were considered with a percentage of variance explained of 59.5%. The two-dimensional solutions of the present factorial analysis are plotted in Fig. 3. Seven clusters were identified, illustrating the range of the practitioners’ patient profiles. The practitioners identified as sharing identical diagnostic and therapeutic attitudes in Analysis 1 were well spread across the different clusters in Analysis 3, which demonstrated that practitioners’ attitudes were not explained by a specific patient profile. To illustrate, practitioners #6, #9, #10, #18 and #24 who employed old-fashioned treatment strategies in Analysis 1 (probing, cavities extended to sound tissue, amalgam) were split here into two different patient profile-differentiated clusters. Practitioners #9 and #24 were close to the modality ‘‘new patients’’ while practitioners #6, #10 and #18 were close to patients who were women, regular attenders, with good oral hygiene and full health coverage.
4.
Discussion
This survey evaluated how dentists manage dental caries in everyday practice and explored the impact of both patient and practitioner factors on dental care procedures. Restorative
journal of dentistry 37 (2009) 827–834
831
Fig. 1 – Different types of treatments reported by the practitioners. Some data were lacking (site of carious lesions n = 4; teeth restored n = 2; site of posterior restorations n = 17).
treatment philosophies used by French dentists have previously been surveyed using questionnaires.9,10 These studies showed broad variation in dentists’ restorative attitudes among general practitioners and university teachers. Restora-
tive treatment philosophies were influenced by the practitioners’ socio-demographic characteristics. Some authors have asserted that there is little correlation between dentists’ stated attitude as reported in questionnaire surveys and their
Fig. 2 – ‘‘Main treatment characteristics and detection tools used’’ (Analysis 1). Figure illustrates the results of multivariate Analysis 1. The practitioners were not considered in the calculation of factorial data but were projected in the multidimensional space. Main treatment characteristics: lesion initiation location (Site 1/Site 2), stage of lesion progression (early stages/later stages), design of the cavity preparation (extension to sound tissue/limited to the lesion) and restorative material (tooth-colored material/amalgam). Detection tools: visual inspection (no visual exam/visual exam), probing (no probing/probing), and radiographs (no X-rays/X-rays). Practitioners codes: from #1 to #26.
832
journal of dentistry 37 (2009) 827–834
Table 2 – Characterization of the four clusters obtained in the multidimensional analysis with patient factors and main treatment characteristics (Analysis 2). Cluster 1 PATIENT FACTORS Gender Age (years) Dental insurance Plaque score Frequency of care Ratio of number of sound teeth to total number of teeth TREATMENT CHARACTERISTICS Site Lesion progression Cavity design Restorative material
Females, males <25 Full coverage Good oral hygiene Regular attenders >0.66
1 Early stages Limited to the lesion Tooth-colored materials
Cluster 2
Cluster 3
Cluster 4
25–45, >45 Partial/special coverage Bad oral hygiene Irregular attenders 0.33–0.66
New patients <0.33
2 Later stages Extension to sound tissue Amalgam
therapy decisions in clinical practice.11–13 Dentists putting their treatment philosophies into practice are forced to modify them as they need to consider the combined realities of patient characteristics and practice circumstances. Practicebased surveys thus add complementary data providing insight into real-world practices. The provision of restorative treatments by dentists in clinical practice has been extensively studied worldwide,8 but few studies have explored how dentists use new concepts in caries management. The present work is also the first French study of its kind. The present study does carry certain limitations, but without biasing the interpretation of the results. The data reported here cannot be considered fully representative of the attitude of dentists in the region studied in view of the low participation rate (26%). Participation rate was comparable to
the rate obtained in a similar German survey (21%)14,15 and to other rates (24–57%) observed for recent questionnaire studies in medicine and dentistry in France.16,17 It should be underlined that the practitioners were selected randomly and had no special interest in the subject studied. Most of the previous similar surveys have involved dentists drawn from particular groups, such as participants in continuing education courses, members of a scientific academy, practitioners involved in teaching or practice-based research staff.18–28 The number of practitioners (n = 26) enrolled in this survey is in the low range of the number of participants (9–659) enrolled in previous similar studies.29,30 However, we were nevertheless able to collect data on the characteristics of 608 initial restorative or non-invasive treatments. The volume of data was insufficient to study the influence of practitioner factors on restorative
Fig. 3 – ‘‘Patient factors and Practitioners’’ (Analysis 3). Figure illustrates the results of multivariate Analysis 3. The practitioners were not considered in the calculation of factorial data but were projected in the multidimensional space. Patient factors: gender (male/female), age (<25/25–45/>45 years), dental insurance (full coverage/partial or special coverage), plaque score (good oral hygiene/bad oral hygiene), frequency of dentist appointments (regular/irregular attender/new patient), ratio of sound teeth/to total number of teeth (ratio < 0.33/ratio 0.33–0.66/ratio > 0.66). Practitioner codes: from #1 to #26.
journal of dentistry 37 (2009) 827–834
treatments, but was sufficient to provide useful information on service provision patterns in preventive and restorative dentistry. The results indicate that preventive dentistry was little used and that practitioners rarely utilized recent concepts in caries management, at least in the sample studied. Noninvasive treatments represented 15% of the initial treatments collected in the survey. Respondents did not follow the statements of the 1987 international consensus on placement and replacement criteria.31 This consensus stipulates that preventive and non-invasive measures should be preferred over invasive therapies, and that operative procedures are only indicated for lesions judged to extend well into the dentine. The low utilization of non-invasive care can also be explained by a lack of detection of initial carious lesions. The results indicate that 8 out of 10 treatment decisions were taken using visual inspection, frequently associated with probing and that bitewing radiographs were very rarely taken. It seems that the French guideline which stipulates that bitewing radiographs should be used for each new patient or at each follow-up visit was not followed.32 This may partly explain the low utilization of non-invasive therapies. Without bitewing radiographs, most of the initial lesions which would best be treated by non-invasive methods such as fluoride applications or sealants cannot be detected. Only cavitated D3 and D4 lesions (Pitts’ classification) which are clinically visible are recorded and operatively treated.33,34 This low utilization of non-invasive therapies can be explained by different factors related to dentists’ knowledge, patient demand, or to the health system. Dentists may opt not to use non-invasive therapies if they lack knowledge on new concepts in caries management. The vast majority of dental practitioners currently practising in France were taught restorative dentistry based on Black’s principles. Few participated regularly in continuous education sessions in the field of caries management. Moreover, patients are used to going to the dentist to receive a filling, and are unaware that early lesions can be re-mineralized. Patient demand for preventive services is low, particularly among socially disadvantaged patients.35 The health system also has an influence, as it determines how the dental care is to be financed. In France, patients pay the dentist according to the item of treatment provided, and then seek reimbursement from an insurance fund. The French system is focused on the reimbursement of restorative care. To qualify for reimbursement, the treatment has to be listed as an approved procedure. Restorative treatments are listed, but professionally provided preventive care (except sealants) does not generally qualify for reimbursement, which consequently discourages prevention and encourages operative care.9,36 This system of remuneration does not promote comprehensive care, as treatments conserving and optimizing the longevity of the patient’s dentition are not covered.31 The development of modern concepts in caries management thus depends on other developments to many factors, such as initial and continuous dental education, health education for patients, and the dental care system. The present findings indicate that restorative services varied according to patient characteristics (Table 2). Minimally invasive restorations were preferentially offered to patients who were young, regular attenders, with good oral hygiene or
833
with a private complementary insurance. These findings corroborate the idea that more favorable service patterns are delivered to socially or medically advantaged patients. On one hand, it can be hypothesized that dentists take into account caries susceptibility when taking decisions on restorative treatment. They make a subjective evaluation of caries risk and tend to adapt their decision accordingly; they evaluate the patient’s oral hygiene and dental attendance as positives and then choose tooth-colored materials for those patients. On the other side, it means that minimally invasive restorations are not offered to disadvantaged patients. This has implications in terms of appropriateness of care and equity in the delivery of dental care.11–13,37–39 Many epidemiological studies have explored the relationship between patient factors and the characteristics of restorative treatments,8 but few have explored the impact of the ‘‘dentist’’ profile. Multivariate models used to describe dental service rates have reported wide variations among providers that were not explainable by differences in patient needs or demand for care.12,38–41 This study could not take into account practitioner characteristics due to the small number of dentists. Nevertheless, we were able to plot the distribution of dentists in the multidimensional spaces and in the different clusters. Practitioners were clearly well spread according to diagnostic and therapeutic attitude; some practitioners were close to old-fashioned attitudes while others seemed to have adopted the concepts of minimally invasive treatment. These variations in service patterns were not related to a specific patient profile in each dental practice. Our results clearly illustrate the concept of ‘‘script’’ described by Bader and Shugars.7 Dentists tend to follow a set script for taking a clinical decision that is not based solely on pathological and physiological observations. Patient’s oral health is not the sole determinant for clinical decision. A range of dentist-related factors also influence practitioner attitude and thus determine the type of patient care provided. Thus, similar health characteristics among patients could result in different proposals for conservative treatments depending on the practitioner’s profile. The present survey highlights that there are multiple dimensions to decision-making in conservative dentistry. It suggests that, in addition to oral health and patient characteristics, other factors linked to the practitioner also contribute to variations in care provision. Further research is needed to more thoroughly evaluate and explain interactions between the multiples factors influencing dental service provision. It would also be useful to verify whether the findings of this survey are replicated in the same region (to test the robustness of the conclusions) as well as in other settings or dental care systems. A better understanding of the decision process would also help identify solutions for improving dentist adoption of modern concepts in caries management.
Acknowledgements This project was funded by the Clermont-Ferrand regional university hospital, France, through a Projet Hospitalier de Recherche Clinique (hospital-led clinical research project). The authors wish to thank the participating dentists for their
834
journal of dentistry 37 (2009) 827–834
diligence and time in completing the data collection forms. The project could not have been carried out without their help. The authors also thank Pr. B. Aublet-Cuvelier for methodological guidance (CHU, Clermont-Ferrand, France), and G. Gouby and P. Lacarin for administrative support.
references
1. Ekstrand K, Qvist V, Thylstrup A. Light microscope study of the effect of probing in occlusal surfaces. Caries Research 1987;21:368–74. 2. Downer MC. Validation of methods used in dental caries diagnosis. International Dental Journal 1989;39:241–6. 3. Sheiham A. Impact of dental treatment on the incidence of dental caries in children and adults. Community Dentistry and Oral Epidemiology 1997;25:104–12. 4. Mount GJ, Ngo H. Minimal intervention: a new concept for operative dentistry. Quintessence International 2000;31:527–33. 5. Featherstone JD. The science and practice of caries prevention. Journal American of Dental Association 2000;131:887–99. 6. Featherstone JD. The caries balance: the basis for caries management by risk assessment. Oral Health and Preventive Dentistry 2004;2(Suppl 1):259–64. 7. Bader JD, Shugars DA. What do we know about how dentists make caries-related treatment decisions? Community Dentistry and Oral Epidemiology 1997;25:97–103. 8. Mjo¨r IA. Placement and replacement of restorations. Operative Dentistry 1981;6:49–54. 9. Dome´jean-Orliaguet S, Tubert-Jeannin S, Riordan PJ, Espelid I, Tveit AB. French dentists’ restorative treatment decisions. Oral Health and Preventive Dentistry 2004;2:125–31. 10. Tubert-Jeannin S, Dome´jean-Orliaguet S, Riordan PJ, Espelid I, Tveit AB. Restorative treatment strategies reported by French university teachers. Journal of Dental Education 2004;68:1096–103. 11. Bader JD, Shugars DA. Variation in dentists’ clinical decisions. Journal of Public Health Dentistry 1995;55: 181–8. 12. Brennan DS, Spencer AJ. Influence of patient, visit, and oral health factors on dental service provision. Journal of Public Health Dentistry 2002;62:148–57. 13. Brennan DS, Spencer AJ. Service patterns associated with coronal caries in private general dental practice. Journal of Dentistry 2007;35:570–7. 14. Friedl KH, Hiller KA, Schmalz G. Placement and replacement of amalgam restorations in Germany. Operative Dentistry 1994;19:228–32. 15. Friedl KH, Hiller KA, Schmalz G. Placement and replacement of composite restorations in Germany. Operative Dentistry 1995;20:34–8. 16. Clinard F, Bardou M, Sgro C, Lefevre N, Raphael F, Paille F, et al. Non-steroidal anti-inflammatory and cytoprotective drug co-prescription in general practice A general practitioner-based survey in France. European Journal of Clinical Pharmacology 2001;57:737–43. 17. Mahe E, Lahfa M, Mansouri S, Mosharraf-Olmolk H, Le Rebours J, Prud’Homme JF, et al. Physicians’ response to a letter to confirm diagnosis in a genetic study of psoriasis. European Journal of Dermatology 2002;12:66–9. 18. Mjor IA, Toffenetti F. Placement and replacement of resinbased composite restorations in Italy. Operative Dentistry 1992;17:82–5.
19. Mjor IA, Toffenetti F. Placement and replacement of amalgam restorations in Italy. Operative Dentistry 1992;17:70–3. 20. Mjor IA. Repair versus replacement of failed restorations. International of Dental Journal 1993;43:466–72. 21. Mjor IA, Qvist V. Marginal failures of amalgam and composite restorations. Journal of Dentistry 1997;25:25–30. 22. Mjor IA. Selection of restorative materials in general dental practice in Sweden. Acta Odontologica Scandinavia 1997;55: 53–7. 23. Mjor IA. The reasons for replacement and the age of failed restorations in general dental practice. Acta Odontolologica Scandinavia 1997;55:58–63. 24. Mjor IA, Moorhead JE. Selection of restorative materials, reasons for replacement, and longevity of restorations in Florida. Journal of American College of Dentists 1998;65:27–33. 25. Pink FE, Minden NJ, Simmonds S. Decisions of practitioners regarding placement of amalgam and composite restorations in general practice settings. Operative Dentistry 1994;19:127–32. 26. Qvist J, Qvist V, Mjor IA. Placement and longevity of amalgam restorations in Denmark. Acta Odontologica Scandinavia 1990;48:297–303. 27. Qvist V, Qvist J, Mjor IA. Placement and longevity of toothcolored restorations in Denmark. Acta Odontologica Scandinavia 1990;48:305–11. 28. Wilson NH, Burke FJ, Mjor IA. Reasons for placement and replacement of restorations of direct restorative materials by a selected group of practitioners in the United Kingdom. Quintessence International 1997;28:245–8. 29. Mjor IA, Um CM. Survey of amalgam and composite restorations in Korea. International Dental Journal 1993;43:311–6. 30. Forss H, Widstrom E. From amalgam to composite: selection of restorative materials and restoration longevity in Finland. Acta Odontologica Scandinavia 2001;59:57–62. 31. Criteria for placement and replacement of dental restorations: an international concensus report. International Dental Journal 1988;38:193–4. 32. ANDEM. Recommandations et re´fe´rences dentaires. 1996. 33. Pitts NB. Modern concepts of caries measurement. Journal of Dental Research 2004;83:C43–7. Spec No C. 34. Pitts N. ICDAS—an international system for caries detection and assessment being developed to facilitate caries epidemiology, research and appropriate clinical management. Community Dental Health 2004;21:193–8. 35. Bedos C, Brodeur JM, Levine A, Richard L, Boucheron L, Mereus W. Perception of dental illness among persons receiving public assistance in Montreal. American Journal of Public Health 2005;95:1340–4. 36. Tubert-Jeannin S, Morel-Papernot A, Woda A. Evaluation of a dental benefit plan for children conducted in Auvergne, France, since 1992. Community Dentistry and Oral Epidemiology 1998;26:272–82. 37. Bader JD. The emergence of appropriateness-of-care issues. Journal of Dental Research 1992;71:502–4. 38. Brennan DS, Spencer AJ. The role of dentist, practice and patient factors in the provision of dental services. Community Dentistry and Oral Epidemiology 2005;33:181–95. 39. Brennan DS, Spencer AJ, Szuster FS. Service provision patterns by main diagnoses and characteristics of patients. Community Dentistry and Oral Epidemiology 2000;28:225–33. 40. Grembowski D, Milgrom P, Fiset L. Dental decision making and variation in dentist service rates. Social Science and Medicine 1991;32:287–94. 41. Bailit HL, Clive J. The development of dental practice profiles. Medical Care 1981;19:30–46.