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

PURPOSE

In-laboratory assessment by laboratory technicians may offer insight to increase clinical success of dental crowns, and research in this area is lacking.

MATERIALS AND METHODS

Dentists in the National Dental Practice-Based Research Network enrolled patients in a study about single-unit crowns; laboratory technicians evaluated the quality of tooth preparations and impressions. The primary outcome for each crown was clinical acceptability (CAC), as judged by the treating dentist. A secondary outcome was "Goodness of Fit (GOF)," a composite score of several aspects of clinical fit, also judged by the study dentist. A mixed-effects logistic regression was used to analyze associations between laboratory technician ratings and the CAC and GOF.

RESULTS

Dentists (n = 205) evaluated 3731 crowns. Technicians ranked the marginal detail of impressions as good or excellent in 92% of cases; other aspects of the impression were ranked good or excellent 88% of the time. Regarding tooth preparation, about 90% of preparations were considered adequate (neither excessive nor inadequate reduction). Factors associated with higher CAC were more preparation taper, and use of optical imaging. Factors associated with better GOF were higher impression quality, greater occlusal reduction, more preparation taper, and optical imaging.

CONCLUSIONS

Overall quality of preparations and impressions was very high, as evaluated by laboratory technicians. Several clinical parameters were associated with higher CAC and GOF. Clinicians who struggle with crown remakes might consider less conservative tooth preparation, as well as using digital impression technology.

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

BACKGROUND

Few published reports have presented concordance between treatment choices selected by dentists in hypothetical clinical scenarios and treatment choices made by the same dentists in actual clinical practice. The aim of the current cross-sectional study, conducted within the Management of Dental Hypersensitivity (MDH) study, was to assess the potential value of practitioners' questionnaire responses regarding their typical treatment provided for management of dentin hypersensitivity (DH), by evaluating agreement between these responses and subsequently-observed recommendations recorded during actual clinical examinations.

METHODS

A total of 171 practitioners enrolled in the National Dental Practice-Based Research Network completed both a questionnaire and a clinical study regarding methods they use to treat dental hypersensitivity. The questionnaire solicited first-, second- and third-choice products when prescribing or recommending management of dentin hypersensitivity. Agreement was calculated for first-choice products/recommendations and for inclusion in the top three choices, as identified by the practitioners, from 11 listed treatment options. Overall percent agreement and Cohen's kappa statistic were calculated, with associated 95% confidence intervals (CI). Associations between practitioner characteristics and agreement were also evaluated.

RESULTS

For individual treatment modalities, percentage agreement ranged from 63 to 99%, depending on the specific item. Percentage agreement between typical treatment and actual treatment for each practitioner's top three treatment modalities, as a combined grouping, ranged from 61 to 100%. When these same agreement pairings were quantified to account for agreement above that expected by chance, kappa values were poor to low.

CONCLUSIONS

Concordance between hypothetical clinical scenarios and treatment choices made by the same dentists in actual clinical practice showed moderate to high levels of percentage agreement, but Cohen's kappa values suggested relatively low levels of agreement beyond that expected by chance. This analysis adds to the larger work of the network which has now observed a wide range of agreement between hypothetical and actual care, depending upon the specific diagnosis or treatment under consideration. Questionnaire data for DH might serve as a useful adjunct to clinical data regarding treatment recommendations, but agreement was not sufficiently high to justify use of questionnaires alone to characterize patterns of treatment for this particular condition.

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

AIM

Our objectives were to describe the approach used in the National Dental Practice-Based Research Network to capture patient-reported outcomes and to compare electronic and paper modes of data capture in a specific network study.

METHODS

This was a prospective, multicenter cohort study of 1862 patients with dentin hypersensitivity. Patient-reported outcomes were assessed based on patients' perception of pain using Visual Analog Scales and Labeled Magnitude scales at baseline and at 1, 4 and 8 weeks post-baseline.

RESULTS

Eighty-five percent of study patients chose to complete follow-up assessments via an electronic mode; 15% completed them via a paper mode. There was not a significant difference in the proportions of patients who completed the 8-week assessment when comparing the electronic mode to the paper mode (92% vs. 90.8%, P = 0.31, Rao-Scott clustered χ² -test).

CONCLUSION

The electronic mode of data capture was as operational as the traditional paper mode, while also providing the advantage of eliminating data entry errors, not involving site research coordinators in measuring the patient-reported outcomes, and not incurring cost and potential delays due to mailing study forms. Electronic data capture of patient reported outcomes could be successfully implemented in the community dental practice setting.

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

BACKGROUND

In this article, the authors present clinical factors associated with the type of cement practitioners use for restoration of single-unit crowns.

METHODS

A total of 202 dentists in The National Dental Practice-Based Research Network recorded clinical details (including cement type) used for 3,468 single-unit crowns. The authors classified crowns as bonded if the dentist used a resin cement. The authors used mixed-model logistic regression to assess the associations between various clinical factors and the dentist's decision to bond.

RESULTS

A total of 38.1% of crowns were bonded, and 61.9% were nonbonded; 39.1% (79 of 202) of dentists never bonded a crown, and 20.3% (41 of 202) of dentists bonded every crown in the study. Crowns with excessive occlusal reduction (as judged by laboratory technicians) were more likely to be bonded (P = .02); however, there was no association with bonding and excessive taper (P = .15) or axial reduction (P = .08). Crowns were more likely to be bonded if they were fabricated from leucite-reinforced glass ceramic (76.5%) or lithium disilicate (70.8%) than if they were fabricated from layered zirconia (38.8%), full-contour zirconia (30.1%), full metal (14.7%), or porcelain-fused-to-metal (13.8%) (P < .01) restorative material. There was no significant association between choice to bond and crown margin location (P = .35). Crowns in the anterior maxilla were more likely to be bonded (P < .01).

CONCLUSIONS

Excessive occlusal tooth preparation, anterior location of a crown, and the use of glass ceramic crowns were associated significantly with the decision to bond.

PRACTICAL IMPLICATIONS

In this study, the authors identified factors significantly associated with the clinical decision made by practicing dentists when selecting a cement for restoration of single-unit crowns.

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

PURPOSE

To: (1) determine which preparation techniques clinicians use in routine clinical practice for single-unit crown restorations; (2) test whether certain practice, dentist, and patient characteristics are significantly associated with these techniques.

MATERIALS AND METHODS

Dentists in the National Dental Practice-Based Research Network participated in a questionnaire regarding preparation techniques, dental equipment used for single-unit crown preparations, scheduled chair time, occlusal clearance determination, location of finish lines, magnification during preparation, supplemental lighting, shade selection, use of intraoral photographs, and trimming dies. Survey responses were compared by dentist and practice characteristics using ANOVA.

RESULTS

Of the 2132 eligible dentists, 1777 (83%) responded to the survey. The top two margin configuration choices for single-unit crown preparation for posterior crowns were chamfer/heavy chamfer (65%) and shoulder (23%). For anterior crowns, the most prevalent choices were the chamfer (54%) and the shoulder (37%) configurations. Regarding shade selection, a combination of dentist, assistant, and patient input was used to select anterior shades 59% of the time. Photographs are used to communicate shade selection with the laboratory in about half of esthetically demanding cases. The ideal finish line was located at the crest of gingival tissue for 49% of respondents; 29% preferred 1 mm below the crest; and 22% preferred the finish line above the crest of tissue. Average chair time scheduled for a crown preparation appointment was 76 ± 21 minutes. Practice and dentist characteristics were significantly associated with margin choice including practice type (p < 0.001), region (p < 0.001), and years since graduation (p < 0.001).

CONCLUSIONS

Network dentists prefer chamfer/heavy chamfer margin designs, followed by shoulder preparations. These choices were related to practice and dentist characteristics.

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

PURPOSE

Some crowns returned from the laboratory are clinically unacceptable, and dentists must remake them. The objectives of this study were to: (1) quantify the remake rate of single-unit crowns; and (2) identify factors significantly associated with crown remakes and intraoral fit.

MATERIALS AND METHODS

Dentists participating in the National Dental Practice-Based Research Network recruited patients needing crowns and documented fabrication techniques, patient characteristics, and outcomes. Crowns were considered clinically acceptable or rejected. Also, various aspects of the clinical fit of the crown were graded and categorized as 'Goodness of Fit (GOF).' Dentist and patient characteristics were tested statistically for associations with crown acceptability and GOF.

RESULTS

More than 200 dentists participated in this study (N = 205) and evaluated 3750 single-unit crowns. The mean age (years) of patients receiving a crown was 55. The remake rate for crowns was 3.8%. The range of rejection rates among individual practitioners was 0% to 42%. Most clinicians (118, or 58%) did not reject any crowns; all rejections came from 42% of the clinicians (n = 87). The most common reasons for rejections were proximal misfit, marginal errors, and esthetic failures. Fewer years in practice was significantly associated with lower crown success rates and lower fit scores. GOF was also associated with practice busyness and patient insurance status, patient gender (dentists reported better fit for female patients), and patient ethnicity.

CONCLUSIONS

The crown remake rate in this study was about 4%. Remakes and crown GOF were associated with certain dentist and practice characteristics.

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

BACKGROUND

A suspicious occlusal carious lesion (SOCL) can be defined as a lesion with no cavitation and no radiographic radiolucency but for which caries is suspected. The authors evaluated whether using a device changed the percentage of SOCLs that were opened surgically and, among those SOCLs that were opened, the proportion that had penetrated into dentin.

METHODS

Eighty-two dentists participated. In phase 1 of the study, dentists identified approximately 20 SOCLs, obtained patient consent, and recorded information about the lesion, treatment or treatments, and depth, if opened. Dentists were then randomly assigned into 1 of 3 groups: no device, DIAGNOdent (KaVo), and Spectra (Air Techniques). In phase 2, dentists enrolled approximately 20 additional patients and recorded the same phase 1 information while using the assigned device to help make their treatment decisions. A mixed-model logistic regression was used to determine any differences after randomization in the proportion of lesions opened and, if opened, the proportion of lesions that penetrated into dentin.

RESULTS

A total of 1,500 SOCLs were enrolled in each phase. No statistically significant difference was found in the change in proportion of lesions receiving invasive treatment from phase 1 to phase 2 across the 3 groups (P = .33) or in the change in proportion of percentage of opened lesions that extended into dentin (P = .31).

CONCLUSION

Caries-detecting devices in the study did not change substantially dentists' decisions to intervene or the accuracy of the intervention decision in predicting lesion penetration into dentin.

PRACTICAL IMPLICATIONS

The caries-detecting devices tested may not improve dentists' clinical decision making for SOCLs.

Patient-Centered Dentinal Hypersensitivity Treatment Outcomes: Results from the National Dental PBRN

Dentinal hypersensitivity (DH) can have a significant impact on oral health and functioning, and it is a clinical symptom commonly managed by dentists during routine clinical practice. DH symptoms are typically elicited by otherwise innocuous, nonpainful stimuli applied to exposed dentin (e.g., tactile stimuli, warming or cooling temperatures or air puffs). Treatment approaches have sought to directly target the dentinal pulp tissues or close dentinal tubules via dental office care and treatment services (fluoride varnishes, glutaraldehydes, bonding agents, sealants, oxalates, or lasers) or home care services (toothpastes or dentifrices containing fluoride or potassium nitrate compounds). The purpose of this prospective multicenter cohort study was to assess how community-based dentists from the National Dental Practice-Based Research Network (National Dental PBRN) manage DH and whether the effectiveness of DH treatments can be assessed in those settings. A total of 171 dentists recruited 1862 subjects with DH from their existing patients. Dentists then recommended and provided DH treatment as appropriate. Treatment choice was at the discretion of the dentists. Patients rated their DH pain at baseline and 1, 4, and 8 wk during the course of their treatments. They used pain intensity and unpleasantness visual analog scales and 4 labeled magnitude scales and rated their satisfaction with treatment after 8 wk. Patients were provided reminders postbaseline via email, texting, or voice mail. These patient-centered outcomes served as the principal measures for the assessment of treatment because treatments sought to alleviate DH symptoms. The patients with DH who reported pain reduction from dentist-provided treatments (glutaraldehyde/HEMA [hydroxyethyl methacrylate] compounds, oxalates, and bonding agents), dentists' advice and counseling regarding oral habits and diet, and patient-applied fluoride toothpaste reported a concomitant positive rating of satisfaction with DH treatments. The results from this study support the feasibility of engaging network practices to assess the effectiveness of clinical DH treatments. Knowledge Transfer Statement: National Dental PBRN dentists provide a range of procedures to treat dentinal hypersensitivity. In this large nonrandomized study designed to assess clinical care and to capture patient-reported outcomes, about 60% of patients reported improvement in pain. This study demonstrated the feasibility of engaging network dentists and their patients to assess treatment effectiveness. Future studies will explore the feasibility of imposing randomization and measuring patient compliance with treatment in the manner that this treatment is provided.

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

OBJECTIVE

Case presentations (vignettes) were completed by dentists in the National Dental Practice-Based Research Network study "Decision Aids for the Management of Suspicious Occlusal Caries Lesions (SOCLs)". The objective was to determine dentists' decision strategies for SOCLs.

METHODS

107 dentists viewed a series of 16 vignettes that represented all combinations of 4 clinical cues: color, luster, lesion roughness, and patient-level caries risk. Each vignette included a patient description and a photograph of a tooth presenting the 4 cues. Dentists were asked to decide the likelihood that a suspected lesion extended into dentin. A lens model analysis was used to examine how dentists use these cues in making their decisions.

RESULTS

86% of dentists had a consistent pattern of cue use that defined their decision strategy. On average, 70% of the variance in their decisions was accounted for by their use of the 4 cues. However, there was considerable variability in the individual cues used by each dentist. The percentages of dentists who used the different cues consistently were: luster (58%), color (48%), roughness (36%), and risk (35%). 14% of dentists reliably used only color, 7% used only luster, 4% used only roughness, and 1% used only risk when making SOCL decisions.

CONCLUSIONS

The online vignette system suggests that clinical SOCL decision strategies are highly individualized and dentists do not use all cues available to them to make these decisions.

CLINICAL SIGNIFICANCE

Prior to this study, there has been little evidence about how dentists use these cues (either individually or in combination) when judging the extent of caries progression. Such knowledge would be valuable when designing interventions to help dentists maximize the likelihood of appropriate treatment decisions.

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

BACKGROUND

Objectives were to determine the likelihood that a clinician accepts an impression for a single-unit crown and document crown remake rates.

METHODS

The authors developed a questionnaire that asked dentists about techniques used to fabricate single-unit crowns. The authors showed dentists photographs of 4 impressions and asked them to accept or reject each impression. The authors correlated answers with dentist and practice characteristics. Other questions pertained to laboratory use and crown remake rates.

RESULTS

The response rate was 83% (1,777 of 2,132 eligible dentists). Of the 4 impressions evaluated, 3 received consistent responses, with 85% agreement. One impression was more equivocal; 52% accepted the impression. The likelihood of accepting an impression was associated significantly with the clinician's sex, race, ethnicity, and practice busyness. Clinicians produced 18 crowns per month on average, and 9% used in-office milling. Most dentists (59%) reported a remake rate of less than 2%, whereas 17% reported a remake rate greater than 4%. Lower remake rates were associated significantly with more experienced clinicians, optical impressions, and not using dual-arch trays.

CONCLUSIONS

Although dentists were largely consistent in their evaluation of impressions (> 85%), nonclinical factors were associated with whether an impression was accepted or rejected. Lower crown remake rates were associated with more experienced clinicians, optical impressions, and not using dual-arch trays.

PRACTICAL IMPLICATIONS

These results provide a snapshot of clinical care considerations among a diverse group of dentists. Clinicians can compare their own remake rates and impression evaluation techniques with those in this sample when developing best practice protocols.

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

BACKGROUND

Dentin hypersensitivity (DH) is a condition commonly encountered in clinical dental practice. The authors conduct a study to identify the treatments recommended to manage DH among dentists in the United States.

METHODS

The authors conducted a multicenter study of 1,862 patients with DH who received a diagnosis and were treated by 171 dentists with The National Dental Practice-Based Research Network.

RESULTS

The most common treatment recommended was desensitizing over-the-counter (OTC) potassium nitrate toothpaste (alone or in combination with other treatments) for 924 of 1,862 patients (50%). This was followed by an application of fluoride varnish (FV) for 516 patients (28%) and a prescription for fluoride toothpaste for 314 patients (17%). Restorative treatments were recommended to 151 patients (8%). The most common single treatment recommendation was desensitizing OTC potassium nitrate toothpaste, recommended to 335 patients (18%). The most frequent combination of 2 treatment modalities was FV and desensitizing OTC potassium nitrate toothpaste, recommended to 100 patients (5%). A total of 890 of 1,862 patients (48%) with DH received a recommendation for 1 treatment modality, and 644 of 1,862 patients (35%) received a recommendation for a combination of 2 treatment modalities, most frequently an application of FV along with desensitizing OTC potassium nitrate toothpaste (100/1,862; 5%).

CONCLUSIONS

Desensitizing OTC potassium nitrate toothpaste and fluoride products were the most widely recommended products to manage DH in the practice setting.

PRACTICAL IMPLICATIONS

Our results suggest that most network clinicians preferred noninvasive treatment modalities when treating DH.

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

BACKGROUND

The objectives were to: (1) quantify patient satisfaction with treatment for early dental caries overall, and according to whether or not (2a) the patient received invasive treatment; (2b) was high-risk for dental caries, and had dental insurance; and (3) encourage practitioners to begin using non-invasive approaches to early caries management.

METHODS

Ten practitioners recorded patient, lesion, and treatment information about non-cavitated early caries lesions. Information on 276 consecutive patients with complete data was included, who received either non-invasive (no dental restoration) or invasive (dental restoration) treatment. Patients completed a patient satisfaction questionnaire and were classified as dissatisfied if they did not "agree" or "strongly agree" with any of 14 satisfaction items.

RESULTS

Patients had a mean (± SD) age of 41.8 (±15.8) years, 64% were female and 88% were white. Twenty-five percent (n = 68) were dissatisfied in at least one of the 14 satisfaction items. Satisfaction levels did not significantly vary by patient's gender, race, caries risk category, or affected tooth surface location. Overall, 11% (28 of 276) received invasive treatment; satisfaction did not differ between patients who had invasive or non-invasive treatment. Seven patients received invasive treatment at their request even though that was not what their practitioner recommended; 5 out of 6 were satisfied with their treatment nonetheless.

CONCLUSIONS

About one-fourth of patients treated for non-cavitated early caries were dissatisfied with at least some aspect of their dental care experience. Satisfaction of patients who received invasive treatment did not differ from those who received non-invasive treatment.

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

Background

Dentin hypersensitivity (DH) is a common problem encountered in clinical practice. The purpose of this study was to identify the management approaches for DH among United States dentists.

Methods

One hundred eighty five National Dental Practice-Based Research Network clinicians completed a questionnaire regarding their preferred methods to diagnose and manage DH in the practice setting, and their beliefs about DH predisposing factors.

Results

Almost all dentists (99%) reported using more than one method to diagnose DH. Most frequently, they reported using spontaneous patient reports coupled with excluding other causes of oral pain by direct clinical examination (48%); followed by applying an air blast (26%), applying cold water (12%), and obtaining patient reports after dentist’s query (6%). In managing DH, the most frequent first choice was desensitizing, over-the-counter (OTC), potassium nitrate toothpaste (48%), followed by fluorides (38%), and glutaraldehyde/HEMA (3%). A total of 86% of respondents reported using a combination of products when treating DH, most frequently using fluoride varnish and desensitizing OTC potassium nitrate toothpaste (70%). The most frequent predisposing factor leading to DH, as reported by the practitioners, was recessed gingiva (66%), followed by abrasion, erosion, abfraction/attrition lesions (59%) and bruxism (32%).

Conclusions

The majority of network practitioners use multiple methods to diagnose and manage DH. Desensitizing OTC potassium nitrate toothpaste and fluoride formulations are the most widely used products to manage DH in dental practice setting.

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

PURPOSE

To: (1) determine which impression and gingival displacement techniques practitioners use for single-unit crowns on natural teeth; and (2) test whether certain dentist and practice characteristics are significantly associated with the use of these techniques.

MATERIALS AND METHODS

Dentists participating in the National Dental Practice-Based Research Network were eligible for this survey study. The study used a questionnaire developed by clinicians, statisticians, laboratory technicians, and survey experts. The questionnaire was pretested via cognitive interviewing with a regionally diverse group of practitioners. The survey included questions regarding gingival displacement and impression techniques. Survey responses were compared by dentist and practice characteristics using ANOVA.

RESULTS

The response rate was 1777 of 2132 eligible dentists (83%). Regarding gingival displacement, most clinicians reported using either a single cord (35%) or dual cord (35%) technique. About 16% of respondents preferred an injectable retraction technique. For making impressions, the most frequently used techniques and materials are: poly(vinyl siloxane), 77%; polyether, 12%; optical/digital, 9%. A dental auxiliary or assistant made the final impression 2% of the time. Regarding dual-arch impression trays, 23% of practitioners report they typically use a metal frame tray, 60% use a plastic frame, and 16% do not use a dual-arch tray. Clinicians using optical impression techniques were more likely to be private practice owners or associates.

CONCLUSIONS

This study documents current techniques for gingival displacement and making impressions for crowns. Certain dentist and practice characteristics are significantly associated with these techniques.

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

OBJECTIVES

Dentists enrolled in the National Dental Practice-Based Research Network completed a study questionnaire about techniques and materials used for single-unit crowns and an enrollment questionnaire about dentist/practice characteristics. The objectives were to quantify dentists' material recommendations and test the hypothesis that dentist's and practice's characteristics are significantly associated with these recommendations.

METHODS

Surveyed dentists responded to a contextual scenario asking what material they would use for a single-unit crown on an anterior and posterior tooth. Material choices included: full metal, porcelain-fused-to-metal (PFM), all-zirconia, layered zirconia, lithium disilicate, leucite-reinforced ceramic, or other.

RESULTS

1777 of 2132 eligible dentists responded (83%). The top 3 choices for anterior crowns were lithium disilicate (54%), layered zirconia (17%), and leucite-reinforced glass ceramic (13%). There were significant differences (p<0.05) by dentist's gender, race, years since graduation, practice type, region, practice busyness, hours worked/week, and location type. The top 3 choices for posterior crowns were all-zirconia (32%), PFM (31%), and lithium disilicate (21%). There were significant differences (p<0.05) by dentist's gender, practice type, region, practice busyness, insurance coverage, hours worked/week, and location type.

CONCLUSIONS

Network dentists use a broad range of materials for single-unit crowns for anterior and posterior teeth, adopting newer materials into their practices as they become available. Material choices are significantly associated with dentist's and practice's characteristics.

CLINICAL SIGNIFICANCE

Decisions for crown material may be influenced by factors unrelated to tooth and patient variables. Dentists should be cognizant of this when developing an evidence-based approach to selecting crown material.

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

BACKGROUND

The objectives of this study were to quantify practitioner variation in likelihood to recommend a crown and test whether certain dentist, practice, and clinical factors are associated significantly with this likelihood.

METHODS

Dentists in The National Dental Practice-Based Research Network completed a questionnaire about indications for single-unit crowns. In 4 clinical scenarios, practitioners ranked their likelihood of recommending a single-unit crown. The authors used these responses to calculate a dentist-specific crown factor (range, 0-12). A higher score implied a higher likelihood of recommending a crown. The authors tested certain characteristics for statistically significant associations with the crown factor.

RESULTS

A total of 1,777 of 2,132 eligible dentists (83%) responded. Practitioners were most likely to recommend crowns for teeth that were fractured, cracked, or endodontically treated or had a broken restoration. Practitioners overwhelmingly recommended crowns for posterior teeth treated endodontically (94%). Practice owners, practitioners in the Southwest, and practitioners with a balanced workload were more likely to recommend crowns, as were practitioners who used optical scanners for digital impressions.

CONCLUSIONS

There is substantial variation in the likelihood of recommending a crown. Although consensus exists in some areas (posterior endodontic treatment), variation dominates in others (size of an existing restoration). Recommendations varied according to type of practice, network region, practice busyness, patient insurance status, and use of optical scanners.

PRACTICAL IMPLICATIONS

Recommendations for crowns may be influenced by factors unrelated to tooth and patient variables. A concern for tooth fracture-whether from endodontic treatment, fractured teeth, or large restorations-prompted many clinicians to recommend crowns.

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

OBJECTIVE

To quantify the agreement between treatment recommended during hypothetical clinical scenarios and actual treatment provided in comparable clinical circumstances.

METHODS

A total of 193 practitioners in the National Dental Practice-Based Research Network participated in both a questionnaire and a clinical study. The questionnaire included three hypothetical scenarios about treatment of existing restorations. Clinicians then participated in a clinical study about repair or replacement of existing restorations. We quantified the overall concordance between their questionnaire responses and what they did in actual clinical treatment.

RESULTS

Practitioners who recommended repair (instead of replacement) of more scenario restorations also had higher repair percentages in clinical practice. Additionally, for each of the three hypothetical scenario restorations, practitioners who recommended repair had higher repair percentages in clinical practice.

CONCLUSIONS

The questionnaire scenarios were a valid measure of clinicians' tendency to repair or replace restorations in actual clinical practice.

CLINICAL IMPLICATIONS

Although there was substantial variation in practitioners' tendency to repair or replace restorations, responses to questionnaire scenarios by individual practitioners were concordant with what they did in actual clinical practice.

Methods dentists use to diagnose primary caries lesions prior to restorative treatment: Findings from The Dental PBRN

OBJECTIVE

To (1) quantify the diagnostic techniques used by Dental Practice-Based Research Network (DPBRN) dentists before they decide to treat primary caries lesions surgically and (2) examine whether certain dentist, practice, and patient characteristics are associated with their use.

METHODS

A total of 228 DPBRN dentists recorded information on 5,676 consecutive restorations inserted due to primary caries lesions on 3,751 patients. Practitioner-investigators placed a mean of 24.9 (SD = 12.4) restorations. Lesions were categorized as posterior proximal, anterior proximal, posterior occiusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorized as clinical assessment, radiographs, and/or optical. Statistical analysis utilized generalized mixed-model ANOVA to account for the hierarchical structure of the data.

RESULTS

By lesion category, the diagnostic technique combinations used most frequently were clinical assessment plus radiographs for posterior proximal (47%), clinical assessment for anterior proximal (51%), clinical assessment for posterior occlusal (46%), clinical assessment for posterior smooth (77%), and clinical assessment for anterior smooth (80%). Diagnostic technique was significantly associated with lesion category after adjusting for clustering in dentists (p < 0.0001).

CONCLUSION

These results--obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios--quantified the diagnostic techniques most commonly used during the actual delivery of routine restorative care. Diagnostic technique varied by lesion category and with certain practice and patient characteristics.

Differences between reported and actual restored caries lesion depths: results from The Dental PBRN

OBJECTIVE

The objectives of this research were to: (1) quantify the discordance between the caries lesion depth at which dentists restored initial lesions during a clinical study ("actual depth") and the lesion depth that they reported during a hypothetical clinical scenario ("reported depth"); (2) test the hypothesis that certain practitioner, practice, patient, and caries lesion characteristics are significantly associated with this discordance.

METHODS

Practitioner-investigators who perform restorative dentistry in their practices completed an enrollment questionnaire and participated in 2 consecutive studies on caries diagnosis and treatment. The first study was a survey asking about caries treatment. The second study collected data on restorations placed in routine clinical practice due to caries in patients over 19 years of age on occlusal surfaces only or proximal surfaces only. We report results on 2,691 restorations placed by 205 dentists in 1,930 patients with complete data.

RESULTS

Discordance between actual depth and reported depth occurred in only about 2% of the restorations done due to proximal caries, but about 49% of the restorations done due to occlusal caries. Practice type, restorative material used and the diagnostic methods used were significantly associated with discordance.

CONCLUSION

Dentists frequently restored occlusal caries at a shallower depth as compared to their reported depth, but the discordance was very small for proximal lesions. Discordance for occlusal caries was more common when radiographs were not taken or if a resin restoration was placed.

Dentist and practice characteristics associated with restorative treatment of enamel caries in permanent teeth: multiple-regression modeling of observational clinical data from the National Dental PBRN

PURPOSE

Current evidence in dentistry recommends non-surgical treatment to manage enamel caries lesions. However, surveyed practitioners report they would restore enamel lesions that are confined to the enamel. Actual clinical data were used to evaluate patient, dentist, and practice characteristics associated with restoration of enamel caries, while accounting for other factors.

METHODS

Data from a National Dental Practice-Based Research Network observational study of consecutive restorations placed in previously unrestored permanent tooth surfaces and practice/demographic data from 229 participating network dentists were combined. ANOVA and logistic regression, using generalized estimating equations (GEE) and variable selection within blocks, were used to test the hypothesis that patient, dentist, and practice characteristics were associated with variations in enamel restorations of occlusal and proximal caries compared to dentin lesions, accounting for dentist and patient clustering.

RESULTS

Network dentists from five regions placed 6,891 restorations involving occlusal and/or proximal caries lesions. Enamel restorations accounted for 16% of enrolled occlusal caries lesions and 6% of enrolled proximal caries lesions. Enamel occlusal restorations varied significantly (P < 0.05) by patient age and race/ethnicity, dentists' use of caries risk assessment, network region, and practice type. Enamel proximal restorations varied significantly (P < 0.05) by dentist race/ethnicity, network region, and practice type.

Cluster Effects in a National Dental PBRN restorative study

Items in clusters, such as patients of the same clinician or teeth within the same patient, tend to be more similar than items from different groups. This within-group similarity, represented by the intraclass correlation coefficient (ICC), reduces precision, yielding less statistical power and wider confidence intervals, compared with non-clustered samples of the same size. This must be considered in the design of studies including clusters. We present ICC estimates from a study of 7,826 restorations placed in previously unrestored tooth surfaces of 4,672 patients by 222 clinicians in the National Dental Practice-Based Research Network, as a resource for sample size planning in restorative studies. Our findings suggest that magnitudes of ICCs in practice-based research can be substantial. These can have large effects on precision and the power to detect treatment effects. Generally, we found relatively large ICCs for characteristics that are influenced by clinician choice (e.g., 0.36 for rubber dam use). ICCs for outcomes within individual patients, such as tooth surfaces affected by a caries lesion, tended to be smaller (from 0.03 to 0.15), but were still sufficiently large to substantially affect statistical power. Clustering should be taken into account in the design of oral health studies and derivation of statistical power estimates for these studies (ClinicalTrials.gov, NCT00847470).

Agreement among dentists' restorative treatment planning thresholds for primary occlusal caries, primary proximal caries, and existing restorations: findings from The National Dental Practice-Based Research Network

OBJECTIVES

The aim of this study was to quantify the agreement among individual National Dental Practice-Based Research Network dentists' self-reported treatment decisions for primary occlusal caries, primary proximal caries, and existing restorations.

METHODS

Five hypothetical clinical scenarios were presented: primary occlusal caries; primary proximal caries; and whether three existing restorations should be repaired or replaced. We quantified the probability that dentists who recommended later restorative intervention for primary caries were the same ones who recommended that existing restorations be repaired instead of replaced.

RESULTS

Dentists who recommended later restorative treatment of primary occlusal caries and proximal caries at a more-advanced stage were significantly more likely to recommend repair instead of replacement. Agreement among dentists on a threshold stage for the treatment of primary caries ranged from 40 to 68%, while that for repair or replacement of existing restorations was 36 to 43%.

CONCLUSIONS

Dentists who recommended repair rather than replacement of existing restorations were significantly more likely to recommend later treatment of primary caries. Conversely, dentists who recommended treatment of primary caries at an earlier stage were significantly more likely to recommend replacement of the entire restoration. Between-dentist agreement for primary caries treatment was better than between-dentist agreement for repair or replacement of existing restorations.

CLINICAL IMPLICATIONS

These findings suggest consistency in how individual dentists approach the treatment of primary caries and existing restorations. However, substantial variation was found between dentists in their treatment decisions about the same teeth.

Outcomes of root canal treatment in dental PBRN practices

This study sought to quantify the incidence of root canal treatment (RCT) failure and identify its predictors in root canals that were performed or referred by general dentistry practices in a practice-based research network (PBRN). This retrospective cohort study involved 174 endodontically treated teeth. Mean duration from initial therapy to follow-up was 8.6 years. Permanent restorations were ultimately placed in 89% of teeth, although 18% of teeth were ultimately extracted anyway. Receiving a permanent restoration was a significant predictor of treatment failure (in other words, patients who did not receive a permanent restoration were more likely to experience RCT failure), whether failure was determined clinically or radiographically. This study of PBRN practices suggests a higher failure rate compared with studies that utilized highly controlled environments or populations with high levels of dental insurance.

Rubber dam use during routine operative dentistry procedures: findings from the dental PBRN

Rubber dam use during operative dentistry procedures has been quantified based on questionnaires completed by dentists. However, based on the knowledge of the authors of the current study, there are no reports based on use during actual clinical procedures other than in dental materials studies and none based on routine care. The objectives of the current study were to: 1) quantify how commonly the rubber dam is used during operative dentistry procedures; 2) test the hypothesis that certain dentist, restoration and patient-level factors are associated with its use. A total of 229 dentist practitioner-investigators in The Dental Practice-Based Research Network (DPBRN) participated. DPBRN comprises 5 regions: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates; and Scandinavia. Practitioner-investigators collected data on 9,890 consecutive restorations done in previously unrestored tooth surfaces from 5,810 patients. Most dentists (63%) did not use a rubber dam for any restoration in this study. A rubber dam was used for only 12% of restorations, 83% of which were used in 1 DPBRN region. With regions accounted for, no other dentist characteristics were significant. A multi-level multiple logistic regression of rubber dam use was done with restoration and patient-level variables modeled simultaneously. In this multi-variable context, these restoration-level characteristics were statistically significant: tooth-arch type, restoration classification and reason for placing the restoration. These patient-level characteristics were statistically significant: ethnicity, dental insurance, and age. These results, obtained fromactual clinical procedures rather than questionnaires, document a low prevalence of usage of the rubber dam during operative dentistry procedures. Usage varied with certain dentist, restoration, and patient level characteristics.

Tanner Staging of Secondary Sexual Characteristics and Body Composition, Blood Pressure, and Insulin in Black Girls

OBJECTIVE

To assess Tanner staging (breast and pubic hair development) and its relationship to measures of body composition, blood pressure, and fasting insulin and glucose in young black girls.

RESEARCH METHODS AND PROCEDURES

Subjects were 138 black girls, 8 to 12 years of age, recruited from elementary schools in low socioeconomic status neighborhoods. Exclusion criteria included the presence of any acute/chronic medical conditions. Pubertal stages were assessed by one of two pediatricians and analyzed individually, as well as with a composite index (prepubertal, pubertal/premenarcheal, or pubertal/menarcheal). Glucose and insulin were measured after a 12-hour fast. Measures of body composition included height, weight, BMI, waist and hip circumferences, fat mass, fat-free soft tissue, bone mineral density (DXA), and visceral adipose tissue (magnetic resonance imaging). Resting systolic and diastolic blood pressure were measured by Dinamap.

RESULTS

With age in the model, breast development explained significant proportions of the variance in height, weight, fat-free soft tissue, bone mineral density, and insulin. Adding pubic hair development or menarche to those models did not significantly increase the proportion of variance that was explained by breast development. Furthermore, using a composite index of pubertal staging explained a smaller proportion of the variance compared with breast development alone.

DISCUSSION

Combined with age, breast development was a better predictor of body composition and fasting insulin than was pubic hair development or a composite index of pubertal staging.

Spiritually based intervention to increase colorectal cancer screening among African Americans: screening and theory-based outcomes from a randomized trial

Colorectal cancer screening has clear benefits in terms of mortality reduction; however, it is still underutilized and especially among medically underserved populations, including African Americans, who also suffer a disproportionate colorectal cancer burden. This study consisted of a theory-driven (health belief model) spiritually based intervention aimed at increasing screening among African Americans through a community health advisor-led educational series in 16 churches. Using a randomized design, churches were assigned to receive either the spiritually based intervention or a nonspiritual comparison, which was the same in every way except that it did not contain spiritual/religious content and themes. Trained and certified peer community health advisors in each church led a series of two group educational sessions on colorectal cancer and screening. Study enrollees completed a baseline, 1-month, and 12-month follow-up survey at their churches. The interventions had significant pre-post impact on awareness of all four screening modalities, and self-report receipt of fecal occult blood test, flexible sigmoidoscopy, and colonoscopy. There were no significant study group differences in study outcomes, with the exception of fecal occult blood test utilization, whereas those in the nonspiritual intervention reported significantly greater pre-post change. Both of these community-engaged, theory-driven, culturally relevant approaches to increasing colorectal cancer awareness and screening appeared to have an impact on study outcomes. Although adding spiritual/religious themes to the intervention was appealing to the audience, it may not result in increased intervention efficacy.

Comparison of Hologic QDR-1000/W and 4500W DXA Scanners in 13- to 18-Year Olds

OBJECTIVE

Body composition measurements made using Hologic QDR-1000/W pencil-beam and QDR-4500W fan-beam scanners (Bedford, MA) were compared in a sample of 13- to 18-year-old white and black youth (n = 219).

RESEARCH METHODS AND PROCEDURES

Total fat (FAT), fat-free soft tissue (FFST), bone mineral content (BMC), bone mineral density (BMD), and percent body fat (%BF) were compared between repeated measurements using the QDR-4500 and between the two scanners using mixed model ANOVA. Intraclass correlation coefficients and Bland-Altman limits of agreement were used to evaluate inter- and intrascanner reliability.

RESULTS

Intraclass correlation coefficients for repeated measurements using the QDR-4500 ranged from 0.997 to 0.999 for FAT, %BF, FFST, and BMC and 0.987 for BMD. Mean measurements made using the two scanners differed significantly for FAT, %BF, BMC, and BMD (p < 0.0001), and scan by sex interactions were significant (all p < 0.0005). There were no significant differences in mean measurements between repeat scans using the QDR-4500 (all p > 0.19). Limits of agreement for measurements of FAT, FFST, and %BF made using the two scanners were approximately three times as wide as those for two measurements using the QDR-4500. For lower values of FAT and %BF, the QDR-4500 gave higher measurements than the QDR-1000, whereas at higher values, this relationship was reversed. The QDR-1000 tended to give higher BMC measurements, with larger differences for higher values.

DISCUSSION

Using different models of DXA scanners within a study may reduce precision of body composition measurement. This issue needs to be considered in the design of longitudinal studies.

Medication adherence among rural, low-income hypertensive adults: a randomized trial of a multimedia community-based intervention

PURPOSE

Examine the effectiveness of a community-based, multimedia intervention on medication adherence among hypertensive adults.

DESIGN

Randomized controlled trial.

SETTING

Rural south Alabama.

SUBJECTS

Low-income adults (N  =  434) receiving medication at no charge from a public health department or a Federally Qualified Health Center.

INTERVENTION

Both interventions were home-based and delivered via computer by a community health advisor. The adherence promotion (AP) intervention focused on theoretical variables related to adherence (e.g., barriers, decisional balance, and role models). The cancer control condition received general cancer information.

MEASURES

Adherence was assessed by pill count. Other adherence-related variables, including barriers, self-efficacy, depression, and sociodemographic variables, were collected via a telephone survey.

ANALYSIS

Chi-square analysis tested the hypothesis that a greater proportion of participants in the AP intervention are ≥80% adherent compared to the control group. General linear modeling examined adherence as a continuous variable.

RESULTS

Participants receiving the intervention did not differ from individuals in the control group (51% vs. 49% adherent, respectively; p  =  .67). Clinic type predicted adherence (p < .0001), as did forgetting to take medications (p  =  .01) and difficulty getting to the clinic to obtain medications (p < .001).

CONCLUSIONS

Multilevel interventions that focus on individual behavior and community-level targets (e.g., how health care is accessed and delivered) may be needed to improve medication adherence among low-income rural residents.

Study protocol for the recreational stimulation for elders as a vehicle to resolve delirium superimposed on dementia (Reserve For DSD) trial

BACKGROUND

Delirium is a state of confusion characterized by an acute and fluctuating decline in cognitive functioning. Delirium is common and deadly in older adults with dementia, and is often referred to as delirium superimposed on dementia, or DSD. Interventions that treat DSD are not well-developed because the mechanisms involved in its etiology are not completely understood. We have developed a theory-based intervention for DSD that is derived from the literature on cognitive reserve and based on our prior interdisciplinary work on delirium, recreational activities, and cognitive stimulation in people with dementia. Our preliminary work indicate that use of simple, cognitively stimulating activities may help resolve delirium by helping to focus inattention, the primary neuropsychological deficit in delirium. Our primary aim in this trial is to test the efficacy of Recreational Stimulation for Elders as a Vehicle to resolve DSD (RESERVE- DSD).

METHODS/DESIGN

This randomized repeated measures clinical trial will involve participants being recruited and enrolled at the time of admission to post acute care. We will randomize 256 subjects to intervention (RESERVE-DSD) or control (usual care). Intervention subjects will receive 30-minute sessions of tailored cognitively stimulating recreational activities for up to 30 days. We hypothesize that subjects who receive RESERVE-DSD will have: decreased severity and duration of delirium; greater gains in attention, orientation, memory, abstract thinking, and executive functioning; and greater gains in physical function compared to subjects with DSD who receive usual care. We will also evaluate potential moderators of intervention efficacy (lifetime of complex mental activities and APOE status). Our secondary aim is to describe the costs associated with RESERVE-DSD.

DISCUSSION

Our theory-based intervention, which uses simple, inexpensive recreational activities for delivering cognitive stimulation, is innovative because, to our knowledge it has not been tested as a treatment for DSD. This novel intervention for DSD builds on our prior delirium, recreational activity and cognitive stimulation research, and draws support from cognitive reserve theory.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01267682

Taking less than prescribed: medication nonadherence and provider-patient relationships in lower-income, rural minority adults with hypertension

Control of hypertension remains poor, and lack of adherence to medication is considered a primary reason. Few studies have examined the reasons for medication nonadherence in African American, lower-income, rural adults receiving medications at no personal cost. Moreover, our understanding of how the provider-patient relationship influences adherence in this population is limited. In this study, the authors (1) examined reasons for taking less medication than prescribed and (2) examined the association between provider-patient variables and medication adherence. A total of 434 participants (94.8% African American) were included. The most frequently endorsed reasons for taking less medication than prescribed were not having blood pressure medicine when it was time to take a dose (36%), running out of medicine (35%), bothered by side effects (29%), and a change in one's daily routine (27%). Nonadherent individuals were significantly more likely to report discomfort with asking the health provider questions (74% vs 63%), were more likely to report that health care visits were stressful (25% vs 16%), and exhibited more depressive symptoms (58% vs 45%). Adherent patients had lower blood pressure (systolic: 133±15.8 mm Hg vs 138±17.6 mm Hg, P value=.002; diastolic: 80±9.8 mm Hg vs 83±11 mm Hg, P value=.003) than individuals who were less adherent. Clinicians providing care to rural, poor hypertensive patients should routinely assess self-management behaviors, logistical barriers, and emotional health. Creating clinical encounters that minimize the stressful nature of the visit and encourage patient question-asking behavior may also be important for the optimal management of hypertension.

Rubber dam use during routine operative dentistry procedures: findings from the Dental PBRN

Rubber dam use during operative dentistry procedures has been quantified based on questionnaires completed by dentists. However, based on the knowledge of the authors of the current study, there are no reports based on use during actual clinical procedures other than in dental materials studies and none based on routine care. The objectives of the current study were to: 1) quantify how commonly the rubber dam is used during operative dentistry procedures; 2) test the hypothesis that certain dentist, restoration and patient-level factors are associated with its use. A total of 229 dentist practitioner-investigators in The Dental Practice-Based Research Network (DPBRN) participated. DPBRN comprises five regions of the USA: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates and Scandinavia. Practitioner-investigators collected data on 9,890 consecutive restorations done in previously unrestored tooth surfaces from 5,810 patients. Most dentists (63%) did not use a rubber dam for any restoration in this study. A rubber dam was used for only 12% of restorations, 83% of which were used in one DPBRN region. With regions accounted for, no other dentist characteristics were significant. A multi-level multiple logistic regression of rubber dam use was done with restoration and patient-level variables modeled simultaneously. In this multi-variable context, these restoration-level characteristics were statistically significant: tooth-arch type, restoration classification and reason for placing the restoration. These patient-level characteristics were statistically significant: ethnicity, dental insurance and age. These results, obtained from actual clinical procedures rather than questionnaires, document a low prevalence of usage of the rubber dam during operative dentistry procedures. Usage varied with certain dentist, restoration and patient-level characteristics.

Methods dentists use to diagnose primary caries lesions prior to restorative treatment: findings from The Dental PBRN

OBJECTIVE

To (1) quantify the diagnostic techniques used by Dental Practice-Based Research Network (DPBRN) dentists before they decide to treat primary caries lesions surgically and (2) examine whether certain dentist, practice, and patient characteristics are associated with their use.

METHODS

A total of 228 DPBRN dentists recorded information on 5676 consecutive restorations inserted due to primary caries lesions on 3751 patients. Practitioner-investigators placed a mean of 24.9 (SD=12.4) restorations. Lesions were categorised as posterior proximal, anterior proximal, posterior occlusal, posterior smooth, or anterior smooth. Techniques used to diagnose the lesion were categorised as clinical assessment, radiographs, and/or optical. Statistical analysis utilised generalised mixed-model ANOVA to account for the hierarchical structure of the data.

RESULTS

By lesion category, the diagnostic technique combinations used most frequently were clinical assessment plus radiographs for posterior proximal (47%), clinical assessment for anterior proximal (51%), clinical assessment for posterior occlusal (46%), clinical assessment for posterior smooth (77%), and clinical assessment for anterior smooth (80%). Diagnostic technique was significantly associated with lesion category after adjusting for clustering in dentists (p<0.0001).

CONCLUSION

These results - obtained during actual clinical procedures rather than from questionnaire-based hypothetical scenarios - quantified the diagnostic techniques most commonly used during the actual delivery of routine restorative care. Diagnostic technique varied by lesion category and with certain practice and patient characteristics.

Concordance between preoperative and postoperative assessments of primary caries lesion depth: results from the Dental PBRN

This study investigated the concordance between pre- and postoperative assessments of primary caries lesion depths by dentists from The Dental Practice-Based Research Network (DPBRN; www.DentalPBRN.org). A total of 229 DPBRN dentists collected data on 8,351 consecutive restorations inserted due to primary caries in 5,810 patients. Dentists estimated the preoperative depth of caries lesions based on the diagnostic methods they typically used. The preoperative depth was then compared to the postoperative depth, which dentists determined using actual clinical observation. Both estimated and observed depths were recorded as being in the outer half (E1) or inner half (E2) of enamel, or in the outer third (D1), middle third (D2) or inner third (D3) of dentin. Most restorations were placed to treat lesions that were preoperatively assessed as extending to the D1 (53%) and D2 (25%) depths. Of the restored caries lesions, 10% were preoperatively assessed as being limited to E2 depth and 3% to E1 depth. The majority of the restored enamel lesions were located on occlusal surfaces. Preoperative estimates of caries lesion depth were more concordant with postoperative depths when the lesion was at an advanced stage: 88% concordance at the D3 depth, compared to 54% concordance at the E1 depth. DPBRN dentists can discriminate caries lesions at different depths, but the accuracy of their depth assessments was higher for dentin than for enamel lesions. In general, DPBRN dentists were more likely to underestimate than overestimate the depth of caries lesions, and the extent of underestimation was greater for enamel than for dentin lesions.

Multiple uncontrolled conditions and blood pressure medication intensification: an observational study

BACKGROUND

Multiple uncontrolled medical conditions may act as competing demands for clinical decision making. We hypothesized that multiple uncontrolled cardiovascular risk factors would decrease blood pressure (BP) medication intensification among uncontrolled hypertensive patients.

METHODS

We observed 946 encounters at two VA primary care clinics from May through August 2006. After each encounter, clinicians recorded BP medication intensification (BP medication was added or titrated). Demographic, clinical, and laboratory information were collected from the medical record. We examined BP medication intensification by presence and control of diabetes and/or hyperlipidemia. 'Uncontrolled' was defined as hemoglobin A1c >/= for diabetes, BP >/= 140/90 mmHg (>/= 130/80 mmHg if diabetes present) for hypertension, and low density lipoprotein cholesterol (LDL-c) >/= 130 mg/dl (>/= 100 mg/dl if diabetes present) for hyperlipidemia. Hierarchical regression models accounted for patient clustering and adjusted medication intensification for age, systolic BP, and number of medications.

RESULTS

Among 387 patients with uncontrolled hypertension, 51.4% had diabetes (25.3% were uncontrolled) and 73.4% had hyperlipidemia (22.7% were uncontrolled). The BP medication intensification rate was 34.9% overall, but higher in individuals with uncontrolled diabetes and uncontrolled hyperlipidemia: 52.8% overall and 70.6% if systolic BP >/= 10 mmHg above goal. Intensification rates were lowest if diabetes or hyperlipidemia were controlled, lower than if diabetes or hyperlipidemia were not present. Multivariable adjustment yielded similar results.

CONCLUSIONS

The presence of uncontrolled diabetes and hyperlipidemia was associated with more guideline-concordant hypertension care, particularly if BP was far from goal. Efforts to understand and improve BP medication intensification in patients with controlled diabetes and/or hyperlipidemia are warranted.

Outcomes of root canal treatment in Dental Practice-Based Research Network practices

This study sought to quantify the incidence of root canal treatment (RCT) failure and identify its predictors in root canals that were performed or referred by general dentistry practices in a practice-based research network (PBRN). This retrospective cohort study involved 174 endodontically treated teeth. Mean duration from initial therapy to follow-up was 8.6 years. Permanent restorations were ultimately placed in 89% of teeth, although 18% of teeth were ultimately extracted anyway. Receiving a permanent restoration was a significant predictor of treatment failure (in other words, patients who did not receive a permanent restoration were more likely to experience RCT failure), whether failure was determined clinically or radiographically. This study of PBRN practices suggests a higher failure rate compared with studies that utilized highly controlled environments or populations with high levels of dental insurance.

Qualitative assessment of telemedicine network and computer-based telecolposcopy

OBJECTIVE

To qualitatively assess telemedicine network and computer-based telecolposcopy.

MATERIALS AND METHODS

A site expert and local colposcopist examined women presenting consecutively for colposcopic examination at 1 of 2 rural clinics. Images from the exam were transmitted to distant experts at a telemedicine center by an existing telemedicine network and computer-based telecolposcopy system. Colposcopists rated both systems with respect to complications, ease and confidence of procedure, and system resolution and visualization.

RESULTS

Rates of technically defective examinations were similar for network (25.1%) and computer-based (22.5%) telecolposcopy (p =.46). The ease of telecolposcopic examinations and colposcopists' confidence in and comfort with telecolposcopy were practically equal for both systems. Mean perceived quality of care was greater for network (3.92) compared with computer-based (3.82) telecolposcopy (Wilcoxon signed rank test, p =.03; Likert scale, 1 = minimal, 5 = maximum). Image resolution was rated better for computer-based (3.36) compared with network (3.07, p <.0001) telecolposcopy. However, visualization was better for the latter system in comparison (3.43 vs 3.07, p <.0001).

CONCLUSIONS

The quality of telecolposcopy was considered above average based on all parameters evaluated for each type of telecolposcopy. Although a few significant differences were detected, colposcopists perceived network and computer-based telecolposcopy to be very similar by subjective assessment.

Development of a spiritually based educational intervention to increase informed decision making for prostate cancer screening among church-attending African American men

One way of developing culturally relevant health communication in the African American church setting is to develop spiritually based interventions, in which the health message is framed by relevant spiritual themes and scripture. In this article we describe the development of a community health advisor(CHA)-led intervention aimed at increasing informed decision making (IDM) for prostate cancer screening among church-attending African American men. Full-color print educational booklets were developed and pilot tested with extensive community participation of church-attending African American men age-eligible for screening. The intervention development phase consisted of ideas solicited from an advisory panel of African American men (N = 10), who identified core content and developed the spiritual themes. In the intervention pilot testing phase, prototypes of the intervention materials were pilot tested for graphic appeal in two focus groups (N = 16), and content was tested for acceptability and comprehension using individual cognitive response interviews (N = 10). Recommendations were made for project branding and logo and for use of graphics of real people in the educational materials. Significant feedback was obtained from the focus groups, on the graphics, colors, fonts, continuity, titles, and booklet size/shape. The importance of working closely with the community when developing interventions is discussed, as well as the importance of pilot testing of educational materials.

A comparison of a spiritually based and non-spiritually based educational intervention for informed decision making for prostate cancer screening among church-attending African-American men

INTRODUCTION

Health communication interventions have been modestly effective for increasing informed decision making for prostate cancer screening among African-American men; however, knowledge and informed decision making is still questionable even with screening. Church-based programs may be more effective if they are spiritually based in nature.

OBJECTIVE

The aims of the present study were to implement and provide an initial evaluation of a spiritually based prostate cancer screening informed decision making intervention for African-American men who attend church, and determine its efficacy for increasing informed decision making.

DESIGN AND METHOD

Churches were randomized to receive either the spiritually based or the non-spiritual intervention. Trained community health advisors, who were African-American male church members, led an educational session and distributed educational print materials. Participants completed baseline and immediate follow-up surveys to assess the intervention impact on study outcomes.

RESULTS

The spiritually based intervention appeared to be more effective in areas such as knowledge, and men read more of their materials in the spiritually based group than in the non-spiritual group.

CONCLUSIONS

Further examination of the efficacy of the spiritually based approach to health communication is warranted.

Development of a spiritually based educational program to increase colorectal cancer screening among African American men and women

This study describes the development of a spiritually based intervention to increase colorectal cancer screening through African American churches by framing the health message with spiritual themes and scripture. The intervention development phase consisted of ideas from an advisory panel and core content identified in focus groups. In the pilot-testing phase, prototypes of the intervention materials were tested for graphic appeal in additional focus groups, and content was tested for acceptability and comprehension in cognitive interviews. Participants preferred materials showing a variety of African Americans in real settings, bright color schemes, and an uplifting message emphasizing prevention and early detection. Spiritual themes such as stewardship over the body, being well to serve God, and using faith to overcome fear, were well received. The materials were then finalized for implementation and will be used by community health advisors to encourage screening.

Patient-level and practice-level characteristics associated with receipt of preventive dental services: 48-month incidence

OBJECTIVES

This study aims to: (a) quantify the incidence of preventive dental services [in-office fluoride application and dental cleaning (prophylaxis)]; (b) determine if these services are effectively targeted to patients with the highest need; and (c) quantify the role of practice characteristics and patient-level factors in service receipt.

METHODS

A population-based prospective cohort study was conducted with 873 adults who had at least one tooth at baseline, 743 of whom provided 48-month data. In-person interviews and clinical examinations were conducted biennially for 48 months, with 6-monthly telephone interviews in between. Dental records were abstracted afterward, and practices that served participants completed questionnaires. Analysis was limited to persons with at least one dental visit of any type during follow-up (87 percent of the sample).

RESULTS

Only 9 percent of the persons received at least one fluoride application; 75 percent received a dental cleaning. Persons with high need were actually less likely to have received preventive services. In multivariable regression analyses, characteristics of the practice in which the subject received care were very strongly related to fluoride receipt, independent of patient-specific characteristics.

CONCLUSIONS

One preventive procedure was common; the other was uncommon. However, practices did not effectively target high-risk patients for either procedure. Instead, both services were typically received by persons with the least need for them. These findings are consistent with the conclusion that practitioners greatly influenced the delivery of fluoride services, with substantial contributions also made by patient-level predisposing and enabling factors for both preventive services.

Racial differences in baseline treatment preference as predictors of receiving a dental extraction versus root canal therapy during 48 months of follow-up

OBJECTIVE

This study aimed to test hypotheses that: a) treatment preference as stated at baseline predicts subsequent receipt of extraction (EXT) versus root canal treatment; and b) racial differences in treatment preference at baseline account for racial differences in receipt of these treatments during follow-up.

METHODS

Data were taken from the Florida Dental Care Study This stratified random sample included at baseline 873 subjects, all of whom were 45-years-old or older, reported race as non-Hispanic African American or non-Hispanic white, and had at least one tooth. At baseline, participants were asked about past dental care characteristics, history of or current presence of various dental diseases and conditions, and sociodemographic circumstance. An EXT/root canal treatment "CHOICE" scenario was also queried at baseline. Predisposing, enabling, and need factors were tested as predictors of EXT/root canal treatment received during follow-up. Bivariate multivariable logistic regression analyses quantified associations between the outcomes (EXT/root canal) and the predictors.

RESULTS

Receipt of EXT or root canal treatment during follow-up was strongly related to race even after people with mobile teeth at baseline were excluded from the analysis. Certain baseline factors (tooth mobility, periodontal attachment level, and ability to pay an unexpected dental bill) strongly predicted EXT/root canal treatment receipt during follow-up, although significant race effects remained; however, including "CHOICE" removed the race effect.

CONCLUSIONS

Baseline treatment preference strongly predicts subsequent receipt of EXT versus root canal treatment. Racial differences in treatment received during follow-up were explained by baseline racial differences in treatment preference, tooth mobility, and periodontal status.

Risk factors for oral postoperative infection in patients with diabetes

The prevalence of diabetes mellitus in the general population has been increasing sharply. Currently, much is feared but little is known about postoperative complications of oral surgery among persons with diabetes. Existing dental education and practice guidelines cite excess infectious risk among patients with diabetes; however, empiric evidence to support such concerns is lacking. In fact, dentists commonly prescribe antibiotics when dental surgical procedures involve bone. This practice may contribute to the rising problem of microbial resistance and may increase overall healthcare costs. The growing number of dental patients with diabetes warrants strengthening the evidence base to guide their dental care and prevent possible morbid complications.