Restorative treatment thresholds for proximal caries in dental PBRN

The Evidence-practice Gap in Minimal Intervention Dentistry: An International Comparison Between Dentists in Japan and Brazil

OBJECTIVES

This study was designed to: 1) evaluate and compare the evidence-practice gap (EPG) in minimal intervention dentistry (MID) in Japan and Brazil by measuring concordance between dentists' clinical practice and published evidence; and 2) identify dentists' factors associated with the EPG in both countries.

METHODS

We performed a cross-sectional study using a web-delivered questionnaire among 136 Japanese and 110 Brazilian dentists. The questionnaire consisted of three questions concerning "restoration diagnosis and treatment," "deep caries diagnosis and treatment," and "caries risk assessment" regarding MID. A chi-square test was used to analyze differences in concordance among clinical practice and evidence from the literature between Japanese and Brazilian dentists. Logistic regression analyses were performed to analyze dentists' factors associated with overall concordance for all three questions.

RESULTS

Overall concordance was significantly higher in Brazil (55%) than in Japan (38%) (p<0.01). Concerning how evidence was obtained, textbooks, nonacademic journals, and seminars and workshops were used as information sources more frequently by Japanese than Brazilian dentists (p<0.001), whereas scientific journal articles in English were used more frequently by Brazilian dentists (p<0.001). On logistic regression analysis, overall concordance was higher for Japanese dentists who frequently obtained evidence from scientific journal articles in English (p<0.05), whereas Brazilian dentists who frequently obtained evidence from the Internet were associated with lower overall concordance (p<0.05).

CONCLUSIONS

Because overall concordance was significantly higher in Brazil than in Japan, Japan may have a greater EPG in MID practice. Specific characteristics of Japanese and Brazilian dentists showed significant associations with overall concordance.

EVIDENCE-PRACTICE GAP IN TREATMENT DECISIONS ABOUT DEFECTIVE COMPOSITE AND AMALGAM RESTORATIONS AMONG BRAZILIAN DENTISTS

Better understanding of dentists' decision-making about defective restorations is needed to close the evidence-practice gap (EPG). Aim: this study aimed to quantify the EPG about defective restorations and identify dentist factors associated with this EPG. Methods: 216 dentists from São Paulo State, Brazil, completed a questionnaire about three clinical case scenarios involving defective composite restorations with cementum-dentin margins (case 1) and enamel margins (case 2), and an amalgam (case 3) restoration. Dentists were asked what treatment, if any, they would recommend, including preventive treatment, polishing, re-surfacing, or repairing the restoration, or replacing the entire restoration. Replacing the entire restoration in any of these three scenarios was classified as inconsistent with the evidence, comprising an EPG. Bivariate analyses using Chi-square, ANOVA, or multiple comparison tests were performed (p<.05). Results: for defective composite restorations, 49% and 55% of dentists chose to replace the entire restoration for cases 1 and 2, respectively. Twenty-nine percent of dentists chose to replace the entire amalgam restoration. Dentists were significantly more likely to choose to replace the defective amalgam restoration than the composite restoration with a defect at the cementum-dentin margins or the enamel margins (both at p < .001). Female dentists were more likely to choose a conservative treatment than male dentists for cases 1 (p=.034) and 2 (p=.009). Dentists with a higher percentage of patients interested in individualized caries prevention were also more conservative in case 1 (p=.045). Conclusion: a substantial EPG regarding treatment decisions for defective restorations exists, especially for composite restorations. This study adds to the international evidence that an EPG exists in this clinical area and that global strategies need to be developed to close the gap.

Knowledge, attitudes, and practice of dentists on Minimal Intervention Dentistry: a systematic review and meta-analysis

OBJECTIVES

To evaluate the knowledge, attitudes, and practice (KAP) of dentists on Minimal Intervention Dentistry (MID).

DATA

Cross-sectional studies that analyzed KAP outcomes on MID principles were included.

SOURCES

Eight databases (Cochrane, DOSS, Embase, LILACS, PsycINFO, PubMed, Scopus, and Web of Science) and the grey literature were searched on January 2022.

STUDY SELECTION

Two independent reviewers selected the included studies, initially by screening titles and abstracts and, finally, by full-text reading. The methodological quality of studies was assessed by using the Joanna Briggs Institute Critical Assessment Checklist for Prevalence Studies. Proportion meta-analysis was conducted using a random effect model for data analysis. Cochran's Q test was used to assess the heterogeneity and the I² statistic for evaluation of true variation due to heterogeneity.

RESULTS

Of 2,079 studies initially identified, twelve were included in the systematic review. Twenty-four statements about MID were included in the meta-analysis, based on data from ten studies (n=1728 participants). The pooled proportion of knowledge on MID was 75.66% (95%CI: 69.33 - 81.48; p<0.01; I²: 97%; Tau2: 0.0456) and of attitudes and practice was 47.95% (95%CI: 38.55 - 57.43; p<0.01; I²: 98%; Tau2: 0.0743). The higher prevalences rates were in the "knowledge" field, and the lowest was in "attitudes and practice".

CONCLUSIONS

The findings suggest that the knowledge of dentists on MID topics is acceptable, and the attitudes and practices need improvements. The studies lacked uniformity in methods and there is still a need for more studies to elucidate the KAP of dentists worldwide.

CLINICAL SIGNIFICANCE

Understanding the cognizance and the way oral healthcare professionals are treating dental caries is the first step to expanding the minimal intervention evidence into a dental practice. The final goal is to change the practice and make Minimal Intervention Dentistry the standard of care for dental caries worldwide.

REGISTRATION

PROSPERO CRD42021257518.

Causes of the Evidence-practice Gap and Its Association with the Effects of Minimal Intervention Dentistry Education to Clinicians

OBJECTIVES

To identify causes of the evidence-practice gap (EPG) in dentistry in Japan and analyze whether these causes are associated with: (a) improvement of EPG in minimal intervention dentistry (MID) following an educational intervention and (b) specific dentist characteristics.

METHODS

We conducted a mixed-methods questionnaire survey among 197 Japanese dentists that integrated both quantitative and qualitative data. Causative factors for the EPG identified in the quantitative survey were clarified by qualitative analysis. We measured the EPG in a baseline survey using an EPG measurement tool based on MID. To examine how feedback using the latest scientific evidence affected change in the EPG, we measured the EPG again immediately after feedback was provided to participating dentists.

RESULTS

Qualitative analysis classified all dentists into one of four "EPG cause" groups, namely "evidence-", "dentist-", "patient-", and "health insurance system-related" causes. Quantitative analysis confirmed that improvement in the EPG following the feedback intervention was indeed associated with group classification. The highest concordance was found for the "evidence-related" group while the lowest concordance was in the "dentist-related" group (p=0.004). Concordance improved after evidence feedback in all groups but was lowest in the "dentist-related" group. More dentists reported practice busyness in the "dentist-related" group.

CONCLUSIONS

In this study, we identified four groups of causes of EPG among Japanese dentists. The degree of concordance between evidence and clinical practice was the lowest in the "dentist-related" group, and the results of this study are expected to provide useful information for the development of intervention methods for closing the EPG in the future.

Web-based intervention to improve the evidence-practice gap in minimal intervention dentistry: Findings from a dental practice-based research network

OBJECTIVES

To determine whether: the evidence-practice gap (EPG) in minimal intervention dentistry (MID) can be improved by a tailored web-based intervention, and specific clinical situations might impede implementing MID.

METHODS

We conducted a before-after intervention study and a qualitative study. Two web-based questionnaire surveys were conducted among 197 Japanese dentists. In the first questionnaire, a baseline EPG was measured using six questionnaire items. Subsequently, feedback material about the EPG was electronically prepared, including results of the first questionnaire, international comparisons with a previous study from the US, and a summary of recent evidence on MID. In the second questionnaire, the EPG was re-measured after participants read the material. The primary outcome was mean overall concordance between published evidence and the dentist's clinical practice for all six questions. During the second questionnaire, we performed qualitative content analysis using free-text responses to a question about difficult situations encountered when conducting MID.

RESULTS

Regarding before and after comparisons of concordance between the first and second questionnaires, mean overall concordance improved significantly, from 66% to 89% (p<0.001). Qualitative content analysis identified five difficult situations: "cases where decision making for treatment and prognosis is difficult", "inadequate practice resources", "limitations on patient visit and treatment period", "discrepancy between MID and the patient's values", and "limitations on health insurance and social understanding".

CONCLUSIONS

These results suggest that it is possible to reduce the EPG in MID using a web-based educational intervention among Japanese dentists. Qualitative content analysis revealed five difficult situations that might hinder implementation of MID.

CLINICAL SIGNIFICANCE

Although this intervention demonstrated educational effects, perfect concordance was not achieved by all participants. This is possibly associated with the five situations that participants reported facing when conducting MID. Creating an environment to improve these situations may facilitate a reduction in the EPG.

Nutrition Care Practices of Dietitians and Oral Health Professionals for Oral Health Conditions: A Scoping Review

Background: Oral health conditions, such as dental caries, pose a substantial burden worldwide. Although there are many risk factors for poor oral health, diet is often implicated as a cause of these issues. The purpose of this scoping review was to identify and map studies that have captured information on the “real-world” nutrition care practices of oral health professionals (OHPs) and dietitians to optimize oral health, and specifically the dentition and periodontium. Methods: A search of peer-reviewed articles was conducted using MEDLINE, CINAHL, and Embase. Articles that addressed the review objective and met the following criteria were included: English language, published since 2000, and study conducted in a high-income country. Results: Overall, 70 articles were included. Most articles reported on cross-sectional survey studies and provided self-reported data on OHP practices; few articles reported on dietitians. Most articles reported only general/unspecific information on assessment and intervention practices, such as dietary analysis, nutrition counselling, and diet advice, and lacked specific information about the care provided, such as the dietary assessment tools used, type of information provided, and time spent on these activities. Barriers to the provision of nutrition care by OHPs were common and included time and lack of remuneration. Few studies reported on collaboration between dietitians and OHPs. Conclusions: Several studies have captured self-reported information on nutrition care practices of OHPs related to oral health; however, there is limited information available on the details of the care provided. Few studies have examined the practices of dietitians.

Awareness, knowledge and treatment decisions for erosive tooth wear: A case-based questionnaire among Danish dentists

Objective

To examine the knowledge and experience of erosive tooth wear (ETW) among Danish dental practitioners and, based on two cases, explore their treatment decisions.

Methods

We sent a validated questionnaire electronically to all active members of The Danish Dental Association and The Association of Public Health Dentists in Denmark. The questionnaire had two parts; the first focused on scoring, recordkeeping, knowledge and experience of ETW. The second part presented two patients with different severity of erosive lesions to explore the dentists preventive and restorative treatment decisions.

Results

We received 442 answers from 4,490 potentially eligible dentists in Denmark (response rate 9.8%). The majority (78%) was female and the median age was 44 years. Nearly all respondents (97%) registered ETW in the charts and 49% recorded “always” or “often” the patients' diet history, most commonly with aid of interviews. The respondents perceived the prevalence of ETW to be higher today than 10–15 years ago and male patients (15–25 years) appeared more affected than females. The majority (82%) thought that they usually found the probable cause of the condition with carbonated beverages being the most common factor. The treatment included dietary guidance, soft tooth brushing with non‐abrasive fluoride toothpaste, topical fluoride applications and direct composite restorations.

Conclusion

The majority of Danish dentists taking part of this survey had adopted a minimally invasive approach for the management of erosive tooth wear in young adults. There was however room for improvements in diagnosis, scoring and case documentation.

Minimum intervention dentistry in the US: an update from a cariology perspective

Despite evidence strongly supporting use of non-invasive or minimally invasive procedures in caries management, there is still a large gap between evidence-based recommendations and application of these concepts in practice, with the practice of dentistry still largely dominated by invasive procedures in the US. This paper describes efforts in education and clinical practice in the US in the last decade to promote evidence-based cariology strategies, which support a minimum intervention dentistry (MID) philosophy. These include, for example: a competency-based core cariology curriculum framework which has been developed and disseminated. National education accreditation standards supporting caries management are likely to soon be changed to support assessment of best evidence in cariology. There are several ongoing efforts by organised dentistry and other groups involving dental educators, researchers and clinical practitioners to promote cariology concepts in practice, such as the development of evidence-based clinical practice guidelines for caries management by the American Dental Association. Within each of these strategies there are challenges, but also opportunities to expand the implementation of MID in the US, which create optimism for future improvements over time.

Evidence-practice gap in minimal intervention dentistry: Findings from a dental practice-based research network

OBJECTIVES

This study aimed to 1) quantify the evidence-practice gap (EPG) between dental clinical practice and published evidence on Minimal Intervention Dentistry (MID) among dentists in Japan; and 2) examine the hypothesis that dentist characteristics have a significant association with the EPG.

METHODS

We conducted a cross-sectional study via use of a web-based questionnaire survey of dentists who were affiliated with the Dental Practice-based Research Network Japan (n = 297). To quantify the EPG on MID, we used a questionnaire that included 10 clinical questions or scenarios to assess concordance between dental practice and published evidence on MID. We evaluated concordance by coding responses to each question as consistent or inconsistent with the evidence. An overall concordance was then determined as percent of responses that were consistent with published evidence for 10 questions. Subsequently, multiple logistic regression analysis was conducted to examine the associations between dentist characteristics and higher overall concordance (≥median) with published evidence.

RESULTS

Mean and median overall dentist-level concordance were both 60 % (SD: 18, interquartile range: 50-75 %). Logistic regression analysis showed that "gender of dentist", "city population", and "frequency of obtaining evidence from the scientific journal articles in English" were significantly associated with high concordance, with odds ratios (95 % CIs) of 2.33 (1.01-5.39), 2.01 (1.02-3.96), and 2.45 (1.08-5.59), respectively.

CONCLUSIONS

Japanese dentists demonstrated medium concordance with published evidence, indicating that an EPG on MID exists in Japanese dental clinical practices. Dentist-specific characteristics had significant associations with high concordance with published evidence.

CLINICAL SIGNIFICANCE

Despite the establishment and dissemination of the concept of MID, the EPG on MID exists in Japanese dental clinical practices. A high concordance was significantly associated with the following dentist characteristics: "female dentist", "dental clinic location in a government-ordinance-designated city", and "frequently obtaining evidence from the English-language scientific journal articles".

Dentists' practice patterns of treatment for deep occlusal caries: Findings from a dental practice-based research network

OBJECTIVES

This study quantified and compared practice patterns of treatment for deep occlusal carious lesions among Japanese dentists, and tested the hypothesis that dentist characteristics are significantly associated with the decision to choose an indirect pulp capping (IPC), a form of selective carious tissue removal that involves leaving a thin layer of demineralized tissue over the pulp, that is then covered with a protective liner.

METHODS

This cross-sectional study was conducted using a questionnaire survey of dentists affiliated with the Dental Practice-based Research Network Japan (n = 297). Dentists were asked to indicate what percentage of time they use three treatment options when treating patients with deep occlusal caries and possible mild pulpitis on a posterior tooth. Response options were "1. Stop before removing all caries and perform an IPC", "2. Remove all caries and proceed with a direct pulp cap", and "3. Remove all caries and proceed with endodontic-related procedures". Percentages of options 1-3 were compared by multiple comparison. Associations between dentist characteristics and a higher percentage of IPC provision (option 1) were analyzed via logistic regression.

RESULTS

Responses were obtained from 206 dentists. Median percentages (interquartile ranges) of options 1, 2 and 3 were 30% (10-59%), 10% (0-30%), and 40% (19-80%), respectively. The differences between option 3 and options 1 and 2 were significant (p < 0.001). In logistic regression analysis, a higher frequency of obtaining evidence from English-language scientific articles was significantly associated with a higher percentage of IPC, with an odds ratio of 2.28 (95%CI: 1.14-4.54).

CONCLUSIONS

Endodontic-related procedures remain the most frequent treatment option for deep occlusal caries. Frequent use of evidence-based information in English-language scientific articles was associated with Japanese dentists' preference toward IPC.

CLINICAL SIGNIFICANCE

Japanese dentists would most frequently choose endodontic-related procedures, followed by IPC and direct pulp capping for treatment of patients with deep occlusal caries with possible mild pulpitis on posterior teeth. Significant association was identified between use of evidence-based information in the English-language scientific literature and Japanese dentists' preference for IPC.

Practice-based research agenda priorities selected by patients: findings from a dental practice-based research network

OBJECTIVES

This study aimed to identify (i) which practice-based research agendas had the highest priority among patients and (ii) whether priorities varied significantly with patient age and gender.

METHODS

We conducted a cross-sectional questionnaire survey of 482 patients from 11 outpatient dental practices. The patients were shown 31 items concerning practice-based research questions and asked to select the three items in which they were most interested. We generated a rank order of the 31 items. Subsequently, the 31 items were categorised into 10 groups, and we performed subgroup analyses according to age and gender using chi-square tests.

RESULTS

"Age-specific care to maintain oral health (n = 86)" was rated as the most interesting research question. When data were analysed according to age, patients less than 40 years old rated "Orthodontic treatment", "Esthetic dental care" and "Topical fluoride application" as interesting questions significantly more frequently than did patients 40 years old or older (P < 0.01)?, while patients 40 years old or older rated "Regular dental check-ups", "Dental implant", "Diet and food" and "Social health insurance" as more interesting than did patients less than 40 years old (P < 0.05). When data were analysed according to gender, female patients rated the questions on aesthetic dental care as more interesting than did male patients (P < 0.01), whereas male patients rated questions on toothbrushing as more interesting than did female patients (P < 0.05).

CONCLUSIONS

Patients assessed "Age-specific care to maintain oral health" as the highest priority among a broad range of research topics. This study also quantified patient priorities for research agendas according to age and gender group. Designing future research with these priorities in mind will promote patient-centred evidence.

Minimally Invasive Intervention for Primary Caries Lesions: Are Dentists Implementing This Concept?

Contemporary minimally invasive treatment concepts for restorative treatment of primary caries lesions include both delayed intervention and smaller-sized preparations restricted to removal of carious tissue. The aim of this study was to investigate whether these concepts have resulted in a trend towards a more conservative choice made by dentists regarding treatment thresholds and restorative techniques. The results from previously conducted, precoded questionnaires developed by Espelid and Tveit, as well as from a recent Dutch questionnaire, were collected and analysed. A worldwide trend towards more minimally invasive strategies in the operative treatment of caries lesions could not be observed, neither for the initiation of operative treatment nor for the preparation techniques. However, in some countries, changes over time could be assessed, especially in Norway, where a reduction in the proportion of interventions is visible for both occlusal and approximal lesions, indicating that more dentists are postponing interventions until the lesions have progressed to a deeper level. From the Dutch national survey, it could be concluded that operators that intervene at an earlier stage of approximal lesioning (stage ≤4) also intervene at an earlier stage of occlusal caries (stage ≤3) (p = 0.012; OR = 2.52; 95% CI: 1.22-5.22). Generally, it can be concluded that dentists worldwide still tend to operatively intervene at a too early stage of caries, although variations exist between countries. A worldwide shift could be observed in the restorative material applied, since composite resin has almost completely replaced amalgam for restoring primary caries lesions.

To fill or not to fill: a qualitative cross-country study on dentists' decisions in managing non-cavitated proximal caries lesions

Background

This study aimed to identify barriers and enablers for dentists managing non-cavitated proximal caries lesions using non- or micro-invasive (NI/MI) approaches rather than invasive and restorative methods in New Zealand, Germany and the USA.

Methods

Semi-structured interviews were conducted, focusing on non-cavitated proximal caries lesions (radiographically confined to enamel or the outer dentine). Twelve dentists from New Zealand, 12 from Germany and 20 from the state of Michigan (USA) were interviewed. Convenience and snowball sampling were used for participant recruitment. A diverse sample of dentists was recruited. Interviews were conducted by telephone, using an interview schedule based on the Theoretical Domains Framework (TDF).

Results

The following barriers to managing lesions non- or micro-invasively were identified: patients’ lacking adherence to oral hygiene instructions or high-caries risk, financial pressures and a lack of reimbursement for NI/MI, unsupportive colleagues and practice leaders, not undertaking professional development and basing treatment on what had been learned during training, and a sense of anticipated regret (anxiety about not restoring a proximal lesion in its early stages before it progressed). The following enablers were identified: the professional belief that remineralisation can occur in early non-cavitated proximal lesions and that these lesions can be arrested, the understanding that placing restorations weakens the tooth and inflicts a cycle of re-restoration, having up-to-date information and supportive colleagues and work environments, working as part of a team of competent and skilled dental practitioners who perform NI/MI (such as cleaning or scaling), having the necessary resources, undertaking ongoing professional development and continued education, maintaining membership of professional groups and a sense of professional and personal satisfaction from working in the patient’s best interest. Financial aspects were more commonly mentioned by the German and American participants, while continuing education was more of a focus for the New Zealand participants.

Conclusions

Decisions on managing non-cavitated proximal lesions were influenced by numerous factors, some of which could be targeted by interventions for implementing evidence-based management strategies in practice.

Electronic supplementary material

The online version of this article (10.1186/s13012-018-0744-7) contains supplementary material, which is available to authorized users.

Dentist's distress in the management of chronic pain control: The example of TMD pain in a dental practice-based research network

We aimed to obtain greater understanding of dentists' distress when they diagnose and treat patients with temporomandibular disorders (TMD), and to explore ways in which TMD can be better treated.We conducted a cross-sectional study based on a questionnaire survey of dentists (n = 148). Dentists were queried using an open-ended questionnaire about distress they experienced when treating patients with TMD. Survey responses were analyzed using mixed methods. Associations between specific dentist and patient characteristics and types of distress were analyzed by one way analysis of variance and residual analysis.One hundred thirteen clinicians responded to the questionnaire, giving a 76% response rate. Thematic analysis identified 6 major themes: difficulty in predicting therapeutic effect and prognosis; difficulty in diagnosis; difficulty in the decision about whether to do occlusal adjustment; difficulty in specifying a cause; difficulty in communicating with patients and mental factors; and health insurance system barriers. Clinicians who reported difficulty in deciding whether to do occlusal adjustment saw significantly more patients who experienced shoulder stiffness and headache (P = .008 and P = .022, respectively). Dentists' knowledge of TMD guidelines was associated with a lower percentage of difficulty in predicting therapeutic effect and prognosis (residual analysis; P = .010).These findings provide important insights into clinician's perception of difficulties with patients experiencing TMD-related pain. Knowledge of the existence of TMD clinical practice guidelines may lower dentist distress, particularly with regard to prognosis. Further studies are needed to decrease dentist's distress and to overcome the evidence-practice gap in TMD treatment.

Dentist Practice Patterns and Therapeutic Confidence in the Treatment of Pain Related to Temporomandibular Disorders in a Dental Practice-Based Research Network

AIMS

To quantify the practice patterns of Japanese dentists in the management of pain related to temporomandibular disorders (TMD) and to identify specific characteristics that are significantly associated with the decision to perform occlusal adjustment for TMD-related pain.

METHODS

A cross-sectional study was conducted consisting of a questionnaire survey of dentists affiliated with the Dental Practice-Based Research Network Japan (JDPBRN) (n = 148). Participants were asked how they diagnosed and treated TMD-related pain. Associations between dentist characteristics and the decision to perform occlusal adjustment were analyzed via multiple logistic regression.

RESULTS

A total of 113 clinicians responded to the questionnaire (76% response rate), and 81% of them (n = 89) had treated TMD during the previous year. Dentists treated an average of 1.9 ± 1.8 (mean ± SD) patients with TMD-related pain per month. Most JDPBRN dentists used similar diagnostic protocols, including questions and examinations. The most frequent treatments were splints or mouthguards (96.5%), medications (84.7%), and self-care (69.4%). Occlusal adjustment for TMD-related pain was performed by 58% of the participants. Multiple logistic regression analysis identified two factors significantly associated with the decision to perform occlusal adjustment: dentist lack of confidence in curing TMD-related acute pain (odds ratio [OR] 5.60; 95% confidence interval [CI] 1.260 to 24.861) and proportion of patients with severe TMD-related pain (OR 0.95; 95% CI 0.909 to 0.999).

CONCLUSION

The most common treatments for TMD-related pain were reversible treatments; however, over half of the dentists performed occlusal adjustment for TMD-related pain. The results of this study suggest that an evidence-practice gap exists for occlusal adjustment for TMD-related pain.

Radiographic diagnosis of proximal caries-influence of experience and gender of the dental staff

OBJECTIVES

The aim of this study was to examine the influence of experience and gender on the radiographic detection of proximal caries lesions and on therapeutic decisions.

MATERIALS AND METHODS

A survey of 220 examiners (students and employees at three universities and dentists in the field) was taken using a standardized written questionnaire concerning radiographic diagnosis and therapy planning. An expert opinion of four dentists was determined as radiographic reference. A mixed effect logistic regression model was used for statistical evaluation and the odds ratio and p values were calculated (α = 0.05).

RESULTS

Examiners with experience had an almost four times greater chance of a correct assessment, if proximal caries lesion was present or not, than examiners with low experience (OR 3.7 (95% CI 2.4-5.8)). No gender-specific differences were discovered (OR women vs. men 0.9 (95% CI 0.6-1.4)). There was a relationship between the severity of the burnout effect on the x-ray and false positive caries diagnosis. Overall, 43% of respondents would plan invasive treatment in the enamel on a patient at low risk of caries and 78% on a high-risk patient. The results showed that the more experienced practitioners would be more likely to postpone restorative therapy on proximal caries until the lesion reached a later stage.

CONCLUSIONS

The results of this study suggest that examiner's experience influences the radiographic diagnosis of proximal lesions. No gender-specific differences could be found.

CLINICAL RELEVANCE

Examiner's professional experience is an important factor when radiography is included for detection and treatment planning of proximal lesions.

Use of clinical practice guidelines by dentists: findings from the Japanese dental practice-based research network

RATIONALE, AIMS AND OBJECTIVES

The objectives of this study were to: (1) examine differences in the use of dental clinical practice guidelines among Japanese dentists, and (2) identify characteristics associated with the number of guidelines used by participating dentists.

METHODS

We conducted a cross-sectional study consisting of a questionnaire survey in Japan between July 2014 and May 2015. The study queried dentists working in outpatient dental practices who are affiliated with the Dental Practice-Based Research Network Japan (n = 148). They were asked whether they have used each of 15 Japanese dental clinical guidelines. Associations between the number of guidelines used by participants and specific characteristics were analysed via negative binomial regression analysis.

RESULTS

The mean number of guidelines used by participating dentists was 2.5 ± 2.9 [standard deviation (SD)]. Rate of use of guidelines showed substantial variation, from 5% to 34% among dentists. The proportion of dentists that used guidelines was the highest among oral medicine specialists, who had the highest proportion for 10 of 15 guidelines. Negative binomial regression analysis identified three factors significantly associated with the number of guidelines used: 'years since graduation from dental school', 'specialty practice' and 'practice busyness'.

CONCLUSIONS

These results suggest that the use of clinical practice guidelines by Japanese dentists may still be inadequate. Training in the use of the guidelines could be given to dental students as undergraduate education and to young clinicians as continuing education.

Managing caries: the need to close the gap between the evidence base and current practice

Underpinned by a changing knowledge of the aetiology of caries and its sequelae, and assisted by established and advancing dental materials, there is growing evidence supporting less invasive management of dental caries based on the principles of minimal intervention dentistry. This narrative review assesses both the evidence and the adoption of less invasive caries management strategies and describes ways in which the gap between evidence and practice might be overcome. While there is increasing data supporting less invasive management of carious lesions, these are not standard in most dental practices worldwide. Usually, clinical studies focused on efficacy as outcome, and did not take into consideration the views and priorities of other stakeholders, such as primary care dentists, educators, patients and those financing services. Involving these stakeholders into study design and demonstrating the broader advantages of new management strategies might improve translation of research into practice. In theory, clinical dentists can rely on a growing evidence in cariology regarding less invasive management options. In practice, further factors seem to impede adoption of these strategies. Future research should address these factors by involving major stakeholders and investigating their prioritised outcomes to narrow or close the evidence gap.

How to Bridge Research Results to Everyday Clinical Care?

Laboratory and clinical studies are essential to the advancement of sciences. However, a significant gap exists between the research findings and clinical practice. Therefore, research findings can be of little importance if their outcome cannot be directly or indirectly applied to everyday clinical care or readily translated. This paper focuses on how we can shorten the gap between the generation of new knowledge and their implementation into everyday clinical care. A new model is discussed where clinicians are the ones generating the research idea are paired with researchers. They collaborate on studies whose results are readily applicable to everyday practice. Partnering with health providers on studies that address everyday clinical research questions is a potential solution to speed up the translation of the research findings. Generating clinically applicable results can better improve the health of the public. Quoting Dr. Lawrence W. Green: "If we want more evidence-based practice, we need more practice-based evidence." This paper presents the practice-based research model as a solution to address this knowledge gap.

Evidence-practice gap for dental sealant application: results from a dental practice-based research network in Japan

PURPOSE

The study aims were: (i) to examine dentist practice patterns regarding treatment recommendations for dental sealants; and (ii) to identify characteristics associated with this recommendation.

METHODS

The study was performed using a cross-sectional questionnaire survey (Clinicaltrials.gov registration number NCT01680848). Participants were Japanese dentists (n = 282) recruited from the Dental Practice-based Research Network Japan. Three clinical photographs of the occlusal surface of a mandibular first molar were presented, portraying increasing depths of cavitation in a 12-year-old patient with high caries risk. Sealants would be an appropriate treatment in all three scenarios. We asked about the treatment decision for each case. We then performed multiple logistic regression analyses to evaluate associations between the decision to recommend sealants, and dentist, patient and practice characteristics.

RESULTS

Responses were obtained from 189 dentists (response rate = 67%). In the hypothetical scenarios, dentists' recommendations for sealants for the 12-year-old patient varied from 16% to 26% across the three hypothetical clinical scenarios. Multiple logistic regression analysis indicated that dentist agreement with the efficacy of assessment for caries risk showed a significant association with the percentages of patients receiving sealants.

CONCLUSIONS

Dentist practice patterns for sealant treatment recommendation show changes that are dependent on caries severity. The dentists' recommendations for sealants for the 12-year-old patient were low for all three selected scenarios, based on indications for sealants in the American Dental Association guidelines. Recommending a sealant showed a significant relationship with the dentist having a higher agreement with efficacy of caries risk assessment.

The Post-Amalgam Era: Norwegian Dentists' Experiences with Composite Resins and Repair of Defective Amalgam Restorations

Amalgam was banned as a dental restorative material in Norway in 2008 due to environmental considerations. An electronic questionnaire was sent to all dentists in the member register of the Norwegian Dental Association (NTF) one year later, to evaluate dentists’ satisfaction with alternative restorative materials and to explore dentists’ treatment choices of fractured amalgam restorations. Replies were obtained from 61.3%. Composite was the preferred restorative material among 99.1% of the dentists. Secondary caries was the most commonly reported cause of failure (72.7%), followed by restoration fractures (25.1%). Longevity of Class II restorations was estimated to be ≥10 years by 45.8% of the dentists, but 71.2% expected even better longevity if the restoration was made with amalgam. Repair using composite was suggested by 24.9% of the dentists in an amalgam restoration with a fractured cusp. Repair was more often proposed among young dentists (p < 0.01), employees in the Public Dental Service (PDS) (p < 0.01) and dentists working in counties with low dentist density (p = 0.03). There was a tendency towards choosing minimally invasive treatment among dentists who also avoided operative treatment of early approximal lesions (p < 0.01). Norwegian dentists showed positive attitudes towards composite as a restorative material. Most dentists chose minimally- or medium invasive approaches when restoring fractured amalgam restorations.

A novel classification system for assessment of approximal caries lesion progression in bitewing radiographs

OBJECTIVES

To design and pilot a novel classification system for the assessment of caries lesion progression in bitewing radiography and to report rater agreement of the system.

METHODS

A classification system with drawings and text was designed to assess caries lesion progression. Guidelines for Reporting Reliability and Agreement Studies were used to study and report rater agreement. Pairs of posterior bitewing radiographs (baseline and 1-year follow-up) with different status concerning caries lesion progression were selected from files from public dental health clinics. 10 raters, 5 general dental practitioners and 5 specialists in oral and maxillofacial radiology were asked to assess the radiographs with the aid of the classification system. Seven raters repeated their assessments. Rater agreement was expressed as percentage of agreement and kappa.

RESULTS

Kappa for the interrater agreement of 10 raters assessing progression was 0.61, indicating substantial agreement. Agreement was moderate for progression in the outer half of the dentine (kappa 0.55) and within enamel (kappa 0.44). Pairwise interrater agreement varied (range 69-92%; kappa 0.42-0.84). For about half of the pairs of raters, kappa was substantial (≥0.61). Intrarater agreement assessing progression was substantial (kappa 0.66-0.82).

CONCLUSIONS

We demonstrated the applicability of the proposed classification system on caries lesion progression with respect to rater agreement. This system can provide a common framework for clinical decision-making on caries interventional methods and patient visiting intervals. Scientifically, this system allows for a comparative analysis of different methods of prevention and treatment of caries as well as of different caries risk assessment methods.

Occlusal Caries Management: Preferences among Dentists in Norway

The aim was to measure variations in the threshold for operative treatment of occlusal caries in permanent teeth and the use of dental materials, compared with results from a similar study conducted in Norway in 1995. In 2009, a precoded questionnaire was sent electronically to 3,654 dentists with E-mail addresses in the member register of the Norwegian Dental Association. The questions were related to caries, treatment strategies and choice of dental materials. Replies were obtained from 61.3% respondents after two reminders. Restorative treatment of occlusal lesions confined to enamel was proposed by 12% of the dentists, compared with 18% in 1995 (p < 0.01). Older dentists more often than younger dentists would operatively treat enamel lesions (p < 0.01). Most dentists preferred to drill only the carious part of the fissure rather than the whole fissure both in 2009 (78.8%) and 1995 (68.3%; p < 0.01). In 2009, 91.9% preferred composite as the restorative material of choice, compared to only 39.1% in 1995. Logistic regression analyses identified higher age of the dentist as the only variable significantly associated with higher risk of restoring occlusal enamel lesions operatively. The authors conclude that especially young dentists appear to be more reluctant to remove tooth substance in 2009 compared with 1995. Composite is the dominating material of choice in 2009 and seems to have substituted the use of most other filling materials in occlusal restorations in permanent teeth.

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.

Evidence-practice gap for in-office fluoride application in a dental practice-based research network

OBJECTIVE

The aims of this study were to examine dentists' recommendations for in-office fluoride to patients and identify dentists' characteristics associated with these recommendations.

STUDY DESIGN AND SETTING

The study was conducted using a cross-sectional questionnaire survey in Japan. The survey queried dentists (n = 282) in outpatient dental practices affiliated with the Dental Practice-based Research Network Japan (JDPBRN). This network aims to assist dentists in investigating research questions and sharing their experience and expertise.

RESULTS

The responses were obtained by 189 dentists (67 percent). Among valid response, 54 percent of dentists (n = 98) recommend in-office fluoride to more than 50 percent of their patients aged 6-18 years and 15 percent (n = 29) recommended this care to more than 50 percent of their patients aged over 18 years. Multiple logistic regression analysis suggested that factors associated with the percentage of patients who are recommended in-office fluoride included patient's interest in caries prevention and dentist's belief in the effectiveness of caries risk assessment.

CONCLUSIONS

Dentist practice patterns for recommending in-office fluoride vary widely. Recommendation was significantly related to having a higher percentage of patients interested in caries prevention and to the dentist's belief about the effectiveness of caries risk assessment. (Clinicaltrials.gov registration number NCT01680848).

Dentists' decisions to conduct caries risk assessment in a Dental Practice-Based Research Network

OBJECTIVES

(i) To quantify the importance that dentists place on caries risk factors when developing a caries treatment plan and (ii) to test the hypothesis that the ratings of importance for specific factors are significantly associated with whether or not the dentist performs caries risk assessment (CRA).

METHODS

This study used a cross-sectional study design consisting of a questionnaire survey. The study queried dentists who worked in outpatient dental practices who were affiliated with the Dental Practice-Based Research Network Japan (JDPBRN), which seeks to engage dentists in investigating research questions and sharing experiences and expertise (n = 282). Participants (n = 189) were asked to rate the importance of caries risk factors when developing a caries treatment plan in both adult and pediatric patients.

RESULTS

Oral hygiene status was rated as the most important risk factor when developing a treatment plan in both adult and pediatric patients, whereas the use of fluorides was rated as the least important. Results of multiple logistic regression analysis showed that the odds ratios for the decision to perform CRA in the adult patient for past caries experience and use of fluorides were 2.61 (95% confidence interval [CI]: 1.29-5.29) and 1.85 (95% CI: 1.12-3.04), respectively, whereas that for oral hygiene was 3.84 (95% CI: 1.15-12.79) and use of fluorides 1.79 (95% CI: 1.06-3.03) in the pediatric patient.

CONCLUSIONS

These results suggest that enhancing dentists' concept of the importance of current use of fluorides when developing a treatment plan may increase the percentage of dentists who conduct CRA in both adult and pediatric patients (clinicaltrials.gov registration number: NCT01680848).

Patient age and dentists' decisions about occlusal caries treatment thresholds

OBJECTIVES

This study was performed to 1) quantify dentists' treatment thresholds for occlusal primary caries; 2) determine if the patient's age affects dentists' decisions to surgically treat these carious lesions; and 3) test the hypothesis that patients', dentists', and practices' characteristics are significantly associated with surgical enamel intervention.

METHODS

The study used a cross-sectional design consisting of a questionnaire survey in Japan. This study queried dentists working in outpatient dental practices who were affiliated with the Dental Practice-Based Research Network Japan (JDPBRN), which aims to allow dentists to investigate research questions and share experiences and expertise (n=282). Participants were asked whether they would surgically intervene in a series of cases depicting occlusal caries. Each case included a photograph of an occlusal surface displaying typical characteristics of caries penetration and written descriptions of adult and pediatric patients at high caries risk.

RESULTS

In a case of a carious lesion within inner enamel, the proportion of dentists who indicated surgical intervention was significantly higher in adult patients (48%) when compared with pediatric patients (34%; p<0.01). Logistic regression analysis showed that using a dental explorer for the diagnosis of primary occlusal caries, type of practice, practice busyness, and percentage of patients who self-pay were significantly associated with dentists' decisions to intervene surgically into the inner enamel carious lesion.

CONCLUSIONS

These findings demonstrate that more than one-third of participants chose to intervene surgically into inner enamel carious lesions, and patients' age affects dentists' decisions about when to intervene surgically (clinicaltrials.gov registration number NCT01680848).

A survey of practices of tunnel preparation among dentists who attended the 100th FDI Annual World Dental Congress

AIM

To study the practice of tunnel restoration (TR) among dentists who attended the 100th World Dental Federation (FDI) Annual World Dental Congress (AWDC).

METHODS

An anonymous questionnaire was administered to a sample of 150 dentists who attended the 100th FDI AWDC in 2012. The participants were asked about TR and their practice of TR. They were also asked to provide their years of dental practice and the countries in which they received their dental training.

RESULTS

Fifteen respondents were not performing restoration, and they were excluded from analysis. Most respondents (123/135) practiced general dentistry. Their basic dental training was from 46 countries and regions. Most of them (n = 117, 87%) knew about TR, and 53% (n = 71) practiced it. There were 12 dentists (9%) who had performed more than 10 TRs in the previous 12 months. Practice of TR among dentists who graduated more than 10 years previously was more common (odds ratio 5.87-5.98) than those who graduated <3 years previously.

CONCLUSIONS

The current study found that about half of the surveyed dentists practiced TR, although most of them knew about it. Tunnel restoration was performed more frequently among dentists who had more than 10 years of clinical experience.

Dentists' practice patterns regarding caries prevention: results from a dental practice-based research network

OBJECTIVE

The purposes of this study were to (1) quantify dentists' practice patterns regarding caries prevention and (2) test the hypothesis that certain dentists' characteristics are associated with these practice patterns.

DESIGN

The study used a cross-sectional study design consisting of a questionnaire survey.

PARTICIPANTS

The study queried dentists who worked in outpatient dental practices who were affiliated with the Dental Practice-Based Research Network Japan, which seeks to engage dentists in investigating research questions and sharing experiences and expertise (n=282).

MEASUREMENT

Dentists were asked about their practice patterns regarding caries preventive dentistry. Background data on patients, practice and dentist were also collected.

RESULTS

38% of dentists (n=72) provided individualised caries prevention to more than 50% of their patients. Overall, 10% of the time in daily practice was spent on caries preventive dentistry. Dentists who provided individualised caries prevention to more than 50% of their patients spent significantly more time on preventive care and less time on removable prosthetics treatment, compared to dentists who did not provide individualised caries prevention. Additionally, they provided oral hygiene instruction, patient education, fluoride recommendations, intraoral photographs taken and diet counselling to their patients significantly more often than dentists who did not provide individualised caries prevention. Multiple logistic regression analysis suggested that the percentage of patients interested in caries prevention and the percentage of patients who received hygiene instruction, were both associated with the percentage of patients who receive individualised caries prevention.

CONCLUSIONS

We identified substantial variation in dentists' practice patterns regarding preventive dentistry. Individualised caries prevention was significantly related to provision of other preventive services and to having a higher percentage of patients interested in caries prevention, but not to the dentist's belief about the effectiveness of caries risk assessment. (Clinicaltrials.gov registration number NCT01 680 848).

The contemporary approach to tooth preservation: minimum intervention (MI) caries management in general practice

The minimum intervention (MI) approach summarises a clinical, evidence-based rationale for the preventive and cause-related approach to oral diseases in general and to caries in particular. MI oral care with respect to the management of patients suffering from dental caries is a concept based on an updated understanding of the histopathological carious process as well as the development of diagnostic technologies and adhesive, bioactive restorative materials. A patient-centred MI care plan for use in general dental practice is described, detailing the four phases of identifying disease, controlling/preventing disease, refurbishing/repairing tooth surfaces/restorations and recall consultations.

Dentists' dietary perception and practice patterns in a dental practice-based research network

Background

Dental caries are largely preventable, and epidemiological evidence for a relationship between diet and oral health is abundant. To date, however, dentists’ perceptions about the role of diet and dentists’ practice patterns regarding diet counseling have not been clarified.

Objective

The purposes of this study were to: (1) examine discordance between dentists’ perception of the importance of diet in caries treatment planning and their actual provision of diet counseling to patients, and (2) identify dentists’ characteristics associated with their provision of diet counseling.

Design

The study used a cross-sectional study design consisting of a questionnaire survey in Japan.

Participants

The study queried dentists working in outpatient dental practices who were affiliated with the Dental Practice-Based Research Network Japan (JDPBRN), which aims to allow dentists to investigate research questions and share experiences and expertise (n = 282).

Measurement

Dentists were asked about their perceptions on the importance of diet and their practice patterns regarding diet counseling, as well as patient, practice, and dentist background data.

Results

The majority of participants (n = 116, 63%) recognized that diet is “more important” to oral health. However, among participants who think diet is “more important” (n = 116), only 48% (n = 56) provide diet counseling to more than 20% of their patients. Multiple logistic regression analysis suggested that several variables were associated with providing diet counseling; dentist gender, practice busyness, percentage of patients interested in caries prevention, caries risk assessment, and percentage of patients who receive blood pressure screening.

Conclusions

Some discordance exists between dentists’ perception of the importance of diet in caries treatment planning and their actual practice pattern regarding diet counseling to patients. Reducing this discordance may require additional dentist education, including nutritional and systemic disease concepts; patient education to increase perception of the importance of caries prevention; or removing barriers to practices’ implementation of counseling.

Trial Registration

ClinicalTrials.gov NCT01680848