The Monitor Practice Programme: is non-invasive management of dental caries in private practice cost-effective?

How do dental practitioners, educators and students diagnose and manage caries risk and caries lesions? A COM-B analysis

OBJECTIVE

The International Caries Classification and Management System (ICCMS™), a comprehensive, evidence-informed, best clinical practice system, comprises a 4D cycle: 1D-Determine risk; 2D-Detect and assess lesions; 3D-Decide on a personalized care plan; and 4D-Do preventive and tooth-preserving care. The aim of this study was to establish how Colombian dental practitioners, educators and students diagnose and manage caries risk and caries lesions using the COM-B model and the ICCMS™ system.

METHODS

A total of 1094 participants (practitioners: n = 277; educators: n = 212; students: n = 605) completed a previously validated 79-item questionnaire which explores, based on the COM-B model, the practitioners' self-reported caries diagnosis and management behaviours. Descriptive statistics, Welch's ANOVAs and multiple linear regressions were computed.

RESULTS

All groups generally performed the behaviours within the 4-D categories 'Most of the time' to 'Always' (students: 4.06 ± 0.95; educators: 3.94 ± 0.98; practitioners: 3.86 ± 1.01). The most frequently performed diagnosis behaviours (1D/2D) were for practitioners assessing initial/moderate lesions (4.09 ± 1.01) and for educators and students cleaning teeth before lesion assessment (4.41 ± 0.80 and 4.38 ± 0.77 respectively). The least frequently performed decision/management (3D/4D) behaviour was non-operative care for moderate-caries lesions (when applicable) (practitioners: 2.64 ± 1.23; educators: 2.68 ± 1.17; students: 3.22 ± 1.41). Opportunity (Resources and Relevance) was the best COM-B predictor for diagnostic behaviours, whereas capability and opportunity (Relevance) were the strongest predictors for management behaviours.

CONCLUSION

Colombian practitioners, educators and students diagnose and manage caries risk and caries lesions implementing best practice with a high to very high frequency.

Perception of Minimum Interventional Dentistry among Dental Undergraduate Students and Interns

Background: The philosophy of minimum interventional dentistry (MID) is to integrate prevention, remineralization, and minimal intervention for the placement and replacement of restorations. All branches of dentistry play an important role in practicing MID, and their primary goal is to realize that any restoration is of less biological significance than the healthy original tissue Objectives: The objective of this study was to assess the perception of MID among dental undergraduate students and interns in terms of knowledge, attitude, and practice at the College of Dentistry. Materials and Methods: This cross-sectional study was conducted among undergraduate students and interns at the College of Dentistry, Qassim University, Saudi Arabia. A self-administered questionnaire was distributed, which included basic demographic profiles and questions about the knowledge, attitude, and practices toward MID. The data were tabulated in MS Excel, and all statistical analyses were performed using SPSS version 21. Results: A total of 163 dental students were recruited, with senior students comprising 73% and interns comprising 27%. Male students were slightly more prevalent (50.9%) than female students (49.1%). About 37.6% of participants received training about MID during educational courses, while 10.3% received it during their internship. A statistical test revealed that the prevalence of interns who were trained in performing MID was significantly higher (p < 0.001). Conclusions: The majority of the participants demonstrated proper knowledge, attitude, and practice in different aspects of MID. Interns reported a higher rate of knowledge, attitude, and practice in MID compared to undergraduate students. However, more education and hands-on training about MID concepts during the college curriculum are necessary to attain better knowledge, attitude, and practices that could be useful for more conservative clinical practice.

Caries risk assessment-related knowledge, attitude, and behaviors among Chinese dentists: a cross-sectional survey

OBJECTIVES

To investigate caries risk assessment (CRA)-related knowledge, attitudes, and practices among dentists in China, to describe their subjective ratings of the significance of specific caries risk factors and to identify factors associated with the level of knowledge, attitudes, and use of CRA in routine clinical practice.

MATERIALS AND METHODS

A cross-sectional anonymous online questionnaire survey was performed. The questionnaire was distributed via WeChat (Tencent, Shenzhen, China) to practicing dentists between November 25 and December 25, 2021. For participant recruitment, we employed purposive and snowball sampling techniques. Data were collected using a specialized web-based survey tool ( www.wjx.cn ) and analyzed with descriptive statistics and regression analyses.

RESULTS

A total of 826 valid questionnaires were collected. Only 292 (35.4%) respondents used CRA in routine practice, among whom a majority (243, 83.2%) did not use a specific CRA tool. The routine use of CRA was associated with the type of practicing office, attendance of caries-related lectures, the habit of reading caries-related literature, geographic location, and the total knowledge score. The mean total knowledge score was 3.13 (score range: 0 to 6). Knowledge levels were related to several sociodemographic characteristics, including geographic location, the type of practicing office, attendance of caries-related lectures and the habit of reading caries-related literature. The risk factor deemed most important was "current oral hygiene."

CONCLUSIONS

Caries risk assessment has not widely entered clinical practice in China. The level of CRA-related knowledge among dentists was generally suboptimal.

CLINICAL RELEVANCE

Strengthening CRA-related education may allow practitioners to develop a better understanding of caries risk assessment and hence promote its implementation.

Economic Evaluations of Preventive Interventions for Dental Caries and Periodontitis: A Systematic Review

OBJECTIVES

To critically examine the methods used for full economic evaluations of preventive interventions for dental caries and periodontitis.

METHODS

Published literature post-2000 was searched to April 2021. Based on a developed intervention classification framework for dental caries and periodontitis, only universal, selective or indicated interventions were included in this review. The Drummond 10-point checklist was used for quality appraisal.

RESULTS

Of 3,007 unique records screened for relevance, 73 studies were reviewed. Most model-based studies (61/73) used cost-effectiveness analysis (49%) or cost-benefit analysis (28%). Trial-based studies (16/73) commonly used cost-effectiveness analysis (59%). Four studies used both economic evaluation methods. Sixty-four papers (88%) were on dental caries, eight papers (11%) focused on periodontitis, and one paper (1%) included both oral diseases; 72% of model-based and 82% of trial-based studies were of good quality. The most frequently investigated dental caries preventive interventions were water fluoridation (universal intervention; cost-saving or cost-effective), fissure sealant and fluoride varnish (selective and indicated interventions; cost-effectiveness outcomes were inconsistent). Supportive periodontal therapy with oral health education (indicated intervention; cost-effective) was the most frequently evaluated preventive intervention for periodontitis. Thirty percent of studies with a time horizon > 1 year did not apply an appropriate discount rate and 26% did not comprehensively discuss other important considerations beyond the technical analysis.

CONCLUSIONS

Generic health outcome measures should be incorporated for economic evaluations on preventive interventions for dental caries and periodontitis, and an increased focus to prevent periodontitis using economic evaluation methods is needed to inform resource allocation and policy decision-making.

Effectiveness of the ICCMS caries management system for children: a 3-year multicentre randomised controlled trial

OBJECTIVE

This 3-year multicentre randomised controlled trial compared, in 6-7-year-old Colombian children, the effectiveness of the ICCMS (International Caries Classification and Management System) with a conventional caries-management system (CCMS) in terms of individual caries-risk, caries lesions, and secondarily, oral-health-related knowledge/attitudes/practices, and number of appointments.

MATERIAL AND METHODS

With ethical approval, 240 6-7-year olds from six Colombian clinics were recruited. Trained examiners conducted the following baseline/follow-up assessments: Caries risk (Cariogram-ICCMS); caries severity/activity staging (ICDAS-merged combined radiographic/visual); sealants/fillings/missing teeth, and oral-health-related knowledge, attitudes and practices. Children received their randomly allocated (ICCMS/CCMS) care from dental practitioners. Outcomes: caries-risk control (children); caries-progression control (tooth surfaces); oral-health-related knowledge/attitudes/practices improvement (parents/children), and appointments' number (children). Descriptive and non-parametric/parametric bivariate analyses were performed.

RESULTS

Three-year-follow-up: n = 187 (77.9%; ICCMS: n = 92; CCMS: n = 95) disclosed a baseline-to-3-year overall high-caries-risk children decrease (ICCMS: 60.9-0%, p < .001; CCMS: 54.7-5.3%, p < .001) (p > .05). ICCMS versus CCMS showed: fewer tooth-surface caries progression (6.2% vs 7.1%, p = .010) and fewer active-caries lesions (49.8% vs. 59.1%, p < .05); higher proportion of children with ≥2/day fluoride-toothpaste tooth-brushing practice (p < .05); similar mean number of appointments (10.9 ± 5.9 vs. 10.0 ± 3.8, p = .15).

CONCLUSION

Both caries-management systems showed similar effectiveness in caries-risk control, with ICCMS more effectively controlling tooth-surface caries progression and improving toothbrushing practices.

CariesCare International adapted for the pandemic in children: Caries OUT multicentre single-group interventional study protocol

Background

Comprehensive caries care has shown effectiveness in controlling caries progression and improving health outcomes by controlling caries risk, preventing initial-caries lesions progression, and patient satisfaction. To date, the caries-progression control effectiveness of the patient-centred risk-based CariesCare International (CCI) system, derived from ICCMS™ for the practice (2019), remains unproven. With the onset of the COVID-19 pandemic a previously planned multi-centre RCT shifted to this “Caries OUT” study, aiming to assess in a single-intervention group in children, the caries-control effectiveness of CCI adapted for the pandemic with non-aerosols generating procedures (non-AGP) and reducing in-office time.

Methods

In this 1-year multi-centre single-group interventional trial the adapted-CCI effectiveness will be assessed in one single group in terms of tooth-surface level caries progression control, and secondarily, individual-level caries progression control, children’s oral-health behaviour change, parents’ and dentists’ process acceptability, and costs exploration. A sample size of 258 3–5 and 6–8 years old patients was calculated after removing half from the previous RCT, allowing for a 25% dropout, including generally health children (27 per centre). The single-group intervention will be the adapted-CCI 4D-cycle caries care, with non-AGP and reduced in-office appointments’ time. A trained examiner per centre will conduct examinations at baseline, at 5–5.5 months (3 months after basic management), 8.5 and 12 months, assessing the child’s CCI caries risk and oral-health behaviour, visually staging and assessing caries-lesions severity and activity without air-drying (ICDAS-merged Epi); fillings/sealants; missing/dental-sepsis teeth, and tooth symptoms, synthetizing together with parent and external-trained dental practitioner (DP) the patient- and tooth-surface level diagnoses and personalised care plan. DP will deliver the adapted-CCI caries care. Parents’ and dentists’ process acceptability will be assessed via Treatment-Evaluation-Inventory questionnaires, and costs in terms of number of appointments and activities. Twenty-one centres in 13 countries will participate.

Discussion

The results of Caries OUT adapted for the pandemic will provide clinical data that could help support shifting the caries care in children towards individualised oral-health behaviour improvement and tooth-preserving care, improving health outcomes, and explore if the caries progression can be controlled during the pandemic by conducting non-AGP and reducing in-office time.

Trial registration: Retrospectively-registered-ClinicalTrials.gov-NCT04666597-07/12/2020: https://register.clinicaltrials.gov/prs/app/action/SelectProtocol?sid=S000AGM4&selectaction=Edit&uid=U00019IE&ts=2&cx=uwje3h. Protocol-version 2: 27/01/2021.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-021-01674-1.

A systematic review of decision analytic modeling techniques for the economic evaluation of dental caries interventions

OBJECTIVES

Dental caries occur through a multifactorial process that may influence all tooth surfaces throughout an individual's life. The application of decision analytical modeling (DAM) has gained an increasing level of attention in long-term outcome assessment and economic evaluation of interventions on caries in recent years. The objective of this study was to systematically review the application of DAM and assess their methodological quality in the context of dental caries.

METHODS

A systematic review of the literature published to 31st December 2018 was conducted in Medline, EMBASE, NHSEED, and Web of Science electronic databases. The main information and model characteristics of studies was extracted with the methodological quality of included studies reviewed and assessed using the Philips' checklist.

RESULTS

Twenty five studies from different settings were included. Modeling techniques mainly comprised main type of modeling including Markov models (n = 12), Markov/microsimulation mixed model (n = 7), systematic dynamic models (n = 3), microsimulation models (n = 2) and decision tree (n = 1). The mean number of criteria fulfilled was 25.1 out of 60 items, which varied between year of study and research groups. The percentage of criteria fulfilled for data dimension was lower than for the structure and consistency dimension. Critical issues were data quality, incorporation of utility values, and uncertainty analysis in modeling.

CONCLUSION

The current review revealed that the methodological quality of DAM in dental caries economic evaluations is unsatisfied. Future modeling studies should adhere more closely to good practice guidelines, especially with respect to data quality evaluation, utility values incorporation, and uncertainty analysis in DAM based studies.

The Monitor Practice Program: implications for dentistry and dental education

The restorative model of care, known colloquially as drilling and filling, has been challenged on the basis of its inappropriateness. The Caries Management System protocol was developed as an evidence-based strategy for non-surgical treatment of caries lesions and the Monitor Practice Program was designed to test the hypothesis that use of the protocol would reduce risk of dental caries experience. After 7 years, patients attending intervention practices, compared with those attending control practices, needed: 30%-50% fewer restorative interventions; 55% fewer first time restorative interventions; 32% fewer repeat restorative interventions; and were only 23% as likely to be classified as high risk. The outcome was cost-effective and patients attending intervention practices highly valued non-invasive care, and intervention dentists derived professional satisfaction from non-surgical caries management. The implications of the program are that the general public will likely embrace the benefits of non-invasive caries management, as will many current and future dental practitioners. This calls for dental practice reform including: the establishment of a clinical discipline in cariology; cariology curriculum development; revised accreditation regulations for cariology programs in dental schools; advanced training in clinical cariology leading to a specialty; support from the dental profession; and public health advocacy.

A scoping review of caries risk management protocols in Australia and New Zealand

To identify and map the caries risk management protocols with multiple strategies, which were used in Australia and New Zealand and reported in the existing literature, a scoping review was carried out by electronically searching PubMed, Web of Science, Scopus, Embase and Dentistry and Oral Science. Studies on caries risk management protocols, written in English, limited to Australia and New Zealand and published up to March 2018 were included in the review. There was no restriction on participants' age. Of 257 studies identified, seven were included in the review. These seven studies were reported in Australia and all but six were based on the caries management system (CMS). There were two descriptive studies, one 3-year multicentre cluster randomized controlled trial (RCT), one 2 to 4-year post-RCT follow-up and two cost-effective evaluations based on Markov decision analytic models. While concentrating on assessing individual behavioural risk factors for dental caries, studies indicated that the CMS would be more cost-effective if its protocol was properly adhered to. Future studies on caries risk management protocols are suggested to consider both the individual characteristics and the social context of different population groups in view of enhancing the effectiveness of oral care.

THE CARIES MANAGEMENT SYSTEM: UPDATING COST-EFFECTIVENESS WITH 4-YEAR POSTTRIAL DATA

Objectives: Long-term follow-up of the Caries Management System (CMS) protocol demonstrated that regular monitoring and noninvasive management of dental caries is effective in reducing the number of caries-related events over a 7-year period. This analysis complements the authors’ original economic evaluation of the CMS by re-evaluating the per-protocol cost-effectiveness of the CMS approach.

Methods: An individual patient-simulation Markov model was developed previously, based on 3-year randomized-controlled trial (RCT) data, to simulate the incidence and progression of dental caries, and resultant interventions, and to evaluate the lifetime cost-effectiveness of the CMS versus standard dental care from the Australian private dental practitioner perspective (in which the baseline age distribution was similar to that of the Australian population). The 4-year posttrial follow-up data are used to re-evaluate the long-term cost-effectiveness of the CMS in a more real-life setting.

Results: The reduction in caries risk was maintained among those practices within which the CMS protocols were adhered to. The per-protocol model appears to be reasonably accurate at predicting the risk of restorative events in the posttrial follow-up period. The per-protocol lifetime cost per restorative event avoided is AUD1,980 (USD1,409; 1 AUD = 0.71 USD).

Conclusions: The current analysis confirms that the CMS approach is both effective, when the protocols are adhered to appropriately, and cost-effective compared with standard care in the Australian private practice setting.

The Caries Management System: are preventive effects sustained postclinical trial?

Objectives

To report, at two and 4 years post‐trial, on the potential legacy of a 3‐year randomized controlled clinical trial (RCT) of the Caries Management System (CMS) at private general dental practices. The CMS was designed to reduce caries risk and need for restorative care.

Methods

Nineteen dental practices located in city, urban, and rural locations in both fluoridated and nonfluoridated communities participated in the RCT. Eight practices were lost to follow‐up post‐trial; however, baseline mean DMFT balance between CMS and control practices was maintained. At the control practices, caries management following usual practice continued to be delivered. The patient outcome measure was the cumulative increment in the DMFT index score, and the practice outcome measures included the practice‐mean and practice‐median increments of patient DMFT index scores. In covariable analysis (patient‐level unit of analysis), as the patients were clustered by practices, mean DMFT increments were determined through multilevel modeling analysis. Practice‐mean DMFT increments (practice‐level unit of analysis) and practice‐median DMFT increments (also practice level) were determined through general linear modeling analysis of covariance. In addition, a multiple variable logistic regression analysis of caries risk status was conducted.

Results

The overall 4‐year post‐trial result (years 4–7) for CMS patients was a DMFT increment of 2.44 compared with 3.39 for control patients (P < 0.01), a difference equivalent to 28%. From the clinical trial baseline to the end of the post‐trial follow‐up period, the CMS and control increments were 6.13 and 8.66, respectively, a difference of 29% (P < 0.0001). Over the post‐trial period, the CMS and control practice‐mean DMFT increments were 2.16 and 3.10 (P = 0.055) and the respective increments from baseline to year 7 were 4.38 and 6.55 (P = 0.029), difference of 33%. The practice‐median DMFT increments during the 4‐year post‐trial period for CMS and control practices were 1.25 and 2.36 (P = 0.039), and the respective increments during the period from baseline to year 7 were 2.87 and 5.36 (P < 0.01), difference of 47%. Minimally elevated odds of being high risk were associated with baseline DMFT (OR = 1.17). Patients attending the CMS practices had lower odds of being high risk than those attending control practices (OR = 0.23, 95% CI = 0.06, 0.88).

Conclusion

In practices where adherence to the CMS protocols was maintained during the 4‐year post‐trial follow‐up period, patients continued to benefit from a reduced risk of caries and, therefore, experienced lower needs for restorative treatment.

The dynamic behavior of the early dental caries lesion in caries-active adults and implications

OBJECTIVE

To describe the full range of behavior of the visible, noncavitated, early caries lesion in caries-active adults with substantial fluoride exposure, and to consider implications.

METHODS

The data were from the Xylitol for Adult Caries Trial (X-ACT) collected annually for 33 months using condensed ICDAS caries threshold criteria. Individual tooth surfaces having a noncavitated caries lesion were included, and the patterns of transition to each subsequent annual clinical examination to sound, noncavitated or cavitated, filled or crowned were determined. The resulting sets of patterns for an individual tooth surface, looking forward from its first appearance as a noncavitated lesion, were combined into one of four behavior profiles classified as reversing, stable, oscillating, or continuously progressing, or were excluded if not part of the caries continuum. The distributions of profile types were assessed using the Rao-Scott chi-square test, which adjusts for clustering of tooth surfaces within teeth.

RESULTS

Inter- and intra-examiner kappa scores demonstrated acceptable calibration at baseline and annually. 8084 tooth surfaces from 543 subjects were included. The distribution of profile types differed significantly between coronal and root surfaces. Overall, two-thirds of all coronal noncavitated lesions were first seen at baseline, half reversed, over a fifth were stable, 15% oscillated, and only 8.3% progressed to cavitation, filled, or crowned in 33 months or less (6.3% consistently Progressed plus 2.0% inconsistently, a subset of oscillating, which oscillated before progressing to cavitation). Approximal, smooth, and occlusal coronal surfaces each were significantly different in their individual distributions of profile types. Xylitol showed no significant and consistent effect on this distribution by tooth surface type. This was in keeping with the X-ACT's lack of effect of xylitol at the noncavitated plus cavitated lesion thresholds combined.

CONCLUSIONS

This study demonstrated the full dynamic range of early caries lesion behavior. The great majority were not progressive, and few (8.3%) became cavitated over 33 months in caries-active adults using fluorides. Important caries management implications favoring recorded longitudinal monitoring, prevention of active risks, and minimal restoration only after direct visual determination of cavitation are discussed.

Treatment of caries in relation to lesion severity: implications for minimum intervention dentistry

OBJECTIVES

To date there is little evidence of minimum intervention in relation to treatment patterns, particularly for initial carious lesions. The objective of this study was to investigate treatment provided to patients with a main diagnosis of coronal caries in relation to the severity of the caries lesion.

METHODS

A random sample of Australian dentists was surveyed by mailed questionnaires in 2009-2010 (response rate 67%). Data on services, patient characteristics and main diagnosis were collected from a service log.

RESULTS

Models of service rates adjusted for age, sex, insurance status and reason for visit showed that compared to the reference category of gross caries lesions, there were higher rates [rate ratio, 95% CI] of restorative services for initial [1.63, 1.31-2.03] and cavitated [1.69, 1.39-2.05] lesions, higher rates of prophylaxis for initial [3.77, 2.09-6.79] and cavitated [3.88, 2.29-6.58] lesions, lower rates of endodontic services for initial [0.07, 0.02-0.30] and cavitated [0.11, 0.04-0.30] lesions, and lower rates of extraction for initial [0.15, 0.06-0.34] and cavitated [0.15, 0.07-0.31] lesions.

CONCLUSIONS

Treatment of coronal caries was characterized by high rates of restorative services, but gross lesions had lower restorative rates and higher rates of endodontic and extraction services. There was little differentiation in treatment of coronal caries between initial and cavitated lesions, suggesting scope for increased management of initial carious lesions by the adoption of more minimum intervention approaches.

Cost-effectiveness of a telephone-delivered education programme to prevent early childhood caries in a disadvantaged area: a cohort study

OBJECTIVES

Early childhood caries is a highly destructive dental disease which is compounded by the need for young children to be treated under general anaesthesia. In Australia, there are long waiting periods for treatment at public hospitals. In this paper, we examined the costs and patient outcomes of a prevention programme for early childhood caries to assess its value for government services.

DESIGN

Cost-effectiveness analysis using a Markov model.

SETTING

Public dental patients in a low socioeconomic, socially disadvantaged area in the State of Queensland, Australia.

PARTICIPANTS

Children aged 6 months to 6 years received either a telephone prevention programme or usual care.

PRIMARY AND SECONDARY OUTCOME MEASURES

A mathematical model was used to assess caries incidence and public dental treatment costs for a cohort of children. Healthcare costs, treatment probabilities and caries incidence were modelled from 6 months to 6 years of age based on trial data from mothers and their children who received either a telephone prevention programme or usual care. Sensitivity analyses were used to assess the robustness of the findings to uncertainty in the model estimates.

RESULTS

By age 6 years, the telephone intervention programme had prevented an estimated 43 carious teeth and saved £69 984 in healthcare costs per 100 children. The results were sensitive to the cost of general anaesthesia (cost-savings range £36 043-£97 298) and the incidence of caries in the prevention group (cost-savings range £59 496-£83 368) and usual care (cost-savings range £46 833-£93 328), but there were cost savings in all scenarios.

CONCLUSIONS

A telephone intervention that aims to prevent early childhood caries is likely to generate considerable and immediate patient benefits and cost savings to the public dental health service in disadvantaged communities.

Experiences of dental care: what do patients value?

Background

Dentistry in Australia combines business and health care service, that is, the majority of patients pay money for tangible dental procedures such as fluoride applications, dental radiographs, dental fillings, crowns, and dentures among others. There is evidence that patients question dentists’ behaviours and attitudes during a dental visit when those highly technical procedures are performed. However, little is known about how patients’ experience dental care as a whole. This paper illustrates the findings from a qualitative study recently undertaken in general dental practice in Australia. It focuses on patients’ experiences of dental care, particularly on the relationship between patients and dentists during the provision of preventive care and advice in general dental practices.

Methods

Seventeen patients were interviewed. Data analysis consisted of transcript coding, detailed memo writing, and data interpretation.

Results

Patients described their experiences when visiting dental practices with and without a structured preventive approach in place, together with the historical, biological, financial, psychosocial and habitual dimensions of their experience. Potential barriers that could hinder preventive activities as well as facilitators for prevention were also described. The offer of preventive dental care and advice was an amazing revelation for this group of patients as they realized that dentists could practice dentistry without having to “drill and fill” their teeth. All patients, regardless of the practice they came from or their level of clinical risk of developing dental caries, valued having a caring dentist who respected them and listened to their concerns without “blaming” them for their oral health status. These patients complied with and supported the preventive care options because they were being “treated as a person not as a patient” by their dentists. Patients valued dentists who made them aware of existing preventive options, educated them about how to maintain a healthy mouth and teeth, and supported and reassured them frequently during visits.

Conclusions

Patients valued having a supportive and caring dentist and a dedicated dental team. The experience of having a dedicated, supportive and caring dentist helped patients to take control of their own oral health. These dentists and dental teams produced profound changes in not just the oral health care routines of patients, but in the way patients thought about their own oral health and the role of dental professionals.

Decision-making and preventive non-surgical therapy in the context of a European Core Curriculum in Cariology

This paper is part of a series of papers towards a European Core Curriculum in Cariology for undergraduate dental students. The European Core Curriculum in Cariology is the outcome of a joint workshop of the European Organisation for Caries Research (ORCA) together with the Association for Dental Education in Europe (ADEE), which was held in Berlin from 27 to 30 June 2010. The present paper covers decision-making and non-surgical treatment. In particular, it will provide some background information on this part of the European core curriculum. The dentist, on graduation, must be competent at applying the principles of prevention of dental hard tissue disease processes (primary prevention) and progression when it has manifested itself (secondary prevention). The competences should apply in differing ways to patients of all ages. Goals of prevention should be clearly defined in order for outcomes to be evaluated, and a dentist should be competent at determining these outcomes. Although this concept is recognised by many academics and experts, clinical teaching, practice and health insurance coverage frequently emphasise surgical treatment. There are many reasons and obstacles that might account for this, and this paper suggests some reasons why this might be and makes suggestions for how these can be addressed in the future. One factor that is essential in the provision of a preventive, non-surgical approach is that of communication with the patient. However, this unfortunately takes less space in the dental curricula compared with technical skills aimed at restorative procedures; this weighting needs to be more equally balanced.