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My way or the highway: do dental patients really have autonomy?

Ethical dilemmas arise when it is not possible to simultaneously optimize conflicting values, each of which independently is worthy. This paper analyzes three cases where patients' autonomy is in conflict with dentists' professional judgments about their own practice patterns and what is in the best interests of patients' oral health. The hierarchy of values proposed by Ozar and Sokol is a valuable aid in addressing such dilemmas, but the dentist must still engage in a detailed analysis of the situation.

Dentist-Patient Relations↗

Practice activity trends among Australian private general dental practitioners: 1983-84 to 1998-99.

AIM: To investigate time trends in practice activity. DESIGN: Four cross-sectional surveys across a 15 year period. SETTING: Australian private general practice. PARTICIPANTS: A random sample of dentists. METHODS: Dentists were surveyed by mailed questionnaire in 1983, 1988, 1993 and 1998 (response rates 71%-75%). Data were weighted to provide representative estimates for the age by sex distribution of private general practitioners in 1983, 1988, 1993 and 1998. MAIN OUTCOME MEASURES: Hours per year worked, patient visits per hour and patient visits per year. RESULTS: The number of patient visits per year declined across the period, related to parallel decreases in the number of patient visits per hour (ANOVA; P<0.05), while there was no significant difference during the period in the number of hours per year devoted to work. The interaction of dentist sex by time of survey indicated that while numbers of patient visits per year had remained stable for female dentists, there was a trend for the higher number of patient visits per year among male dentists at the beginning of the survey period to decline over time. CONCLUSIONS: Male dentists had higher levels of practice activity compared with female dentists, but a decline in the number of patient visits per year reflected a convergence of male practice patterns towards that of female dentists.

Adult↗

Service provision trends between 1983-84 and 1993-94 in Australian private general practice.

Patterns of service provision are expected to change over time, reflecting the dynamics of factors such as oral health status and trends in population demographics. The aim of this study was to identify trends in service provision over time. Data were collected from a random sample of Australian dentists in 1983-84, 1988-89, and 1993-94. Changes observed between 1983-84 and 1993-94 included a trend towards increased proportions of patients in older age groups, decreases in the percentage of persons receiving restorative care (from 40.2 per cent to 37.7 per cent) and prosthodontic care (9.3 per cent to 8.0 per cent), and increases in diagnostic (from 38.7 per cent to 46.0 per cent), preventive (20.9 per cent to 25.2 per cent), endodontic (5.3 per cent to 7.1 per cent), and crown and bridge services (3.1 per cent to 4.7 per cent) per visit. Other services such as orthodontic and general/miscellaneous services showed increases over the first half of the study period, but these did not continue between 1988-89 and 1993-94. The total number of services per visit increased over the study period for adult patients. These findings indicate changing patterns of practice over time, consistent with an increasing orientation towards prevention of disease and maintenance of a natural dentition.

Adolescent↗

Compliance of Michigan dentists with radiographic safety recommendations.

We surveyed a random sample of 398 Michigan dentists in private practice to determine their compliance with the American Dental Association Council's recommendations for radiographic equipment and techniques. The response rate was 67% of the questionnaires delivered successfully. The majority of dentists use only D-speed film (73%) and round collimation of the x-ray beam (90%). Only 5% have an x-ray machine equipped with a rectangular collimator and 18% have at least one machine with a pointed cone. Leaded apron use is almost universal, but only 49% of the dentists use cervical collars in addition to the apron. The majority of dentists surveyed do not comply with the American Dental Association Council's recommendations on film speed, collimation, and use of leaded cervical collar. Using effective dose equivalents determined by Gibbs et al. for a variety of radiographic techniques, we estimate that an eight-fold reduction in radiation dose could be achieved without eliminating a single radiograph if all dentists used E-speed film and collimation of the beam to the size of the film.

Attitude of Health Personnel↗

Understanding dentists' restorative treatment decisions.

A critical review of the literature is presented that examines variation in dentists' restorative treatment decisions and the factors associated with this variation. Substantial variation has been documented in dentists' assessment of caries, in dentists' decisions to intervene, and in the selection of treatment recommended to the patient. However, the factors associated with this variation are not well documented. Following discussion of this review, a model is proposed to help guide further studies of dentists' restorative treatment decisions. This explanatory model incorporates the factors identified in the review, as well as others either observed informally or found in the medical literature. The implications of variation in dentists' treatment decisions highlight the importance of a full explication of the process dentists follow in making treatment decisions. Understanding this process, which heretofore has been examined only superficially because it has been regarded as a function of "clinical judgement," is fundamental to determinations of normative treatment needs, to interventions designed to reduce the frequency of inappropriate treatment, and to the development of valid practice parameters.

Decision Making↗

The role of dentist, practice and patient factors in the provision of dental services.

OBJECTIVES: Service provision varies by dentist, practice and patient factors. However, limited subsets of these potential influences on service rates have been explored. More comprehensive models could improve our understanding of the factors influencing the pattern of care delivered. The aim of this study was to examine variation in dental services by dentist (treatment choice, practice beliefs, preferences for patients, demographics), practice (type, location, size and volume of practice) and patient (visit, demographic, oral health and socio-economic) characteristics. METHODS: A random sample of Australian dentists was surveyed in 1997-98 (response rate=60.3%). Private general practitioners (n=345) provided dentist and practice data, and service provision and patient variables were collected from a log of a typical clinical day (n=4,115 patients). Multivariate negative binomial regression models were fitted for diagnostic, preventive, restorative, extraction and prosthodontic services. RESULTS: Significant dentist factors included (P<0.05; RR=rate ratio): lower diagnostic rates (RR=0.78) for dentists with stronger practice beliefs for giving information about cost and treatment options; preventive rates were lower (RR=0.74) for male dentists and higher (RR=1.48) for younger dentists aged 20-29 years; restorative rates were higher (RR=1.27) for dentists that rated patient preferences more highly in treatment choice and in the dentist age group 30-39 years (RR=1.25); extraction rates were lower (RR=0.61) for dentists with stronger preferences for patients that would adhere with treatment but higher (RR=1.57) for dentists with stronger preferences for sociable patients; and prosthodontic rates were lower (RR=0.38) for dentists with stronger preferences for adaptable patients who were willing to cooperate when expected to do so. Practice factors included: higher preventive (RR=1.28) and prosthodontic rates (RR=2.07) in solo practice; higher preventive (RR=1.34) but lower prosthodontic rates (RR=0.42) in capital cities; lower diagnostic (RR=0.82) and extraction rates (RR=0.55) in practices with fewer other dentists; higher diagnostic (RR=1.33) and extraction (RR=1.62) rates but lower restorative rates (RR=0.84) in practices with lower patient visits per year. Patient factors included: lower preventive (RR=0.76) but higher extraction rates (RR=1.45) for emergency visits; lower extraction rates (RR=0.60) for the insured; higher diagnostic rates (RR=1.17) for new patients; higher restorative (RR=1.31) but lower prosthodontic rates (RR=0.46) for patients with decayed teeth; higher prosthodontic rates (RR=2.14) for those with dentures; and lower preventive (RR=0.66), but higher extraction (RR=2.22) and prosthodontic rates (RR=1.82) for patients from lower socio-economic status areas. CONCLUSIONS: Dental service rates were influenced by large number of small effects from a wide range of dentist, practice and patient factors. Socio-economic and geographic barriers may need broad policy innovations to be addressed, but factors such as insurance and visit type have the potential to be altered to achieve better service outcomes and there is scope for research into clinical outcomes to improve the knowledge upon which treatment decisions are based.

Adult↗

Gender and the transition into practice.

Since 1990, over half the enrollees in advanced education pediatric dentistry programs have been women. The higher proportion of women in pediatric dentistry should permit examination of the practice patterns of groups of men and women at similar stages in their careers. In 1991 the American Academy of Pediatric Dentistry surveyed 4,950 dentists about a variety of issues related to practice patterns and demographics, obtaining 2,362 responses. This study conducted a secondary analysis of the survey data by developing three age-matched graduation cohorts based on gender and years since graduation: 1 to 5 years, 6 to 10 years, and over 10 years. Four areas were investigated: practice patterns, practice arrangements, distribution of time, and income. The overall differences in practice patterns between males and females were statistically significant for the Early Career Group (1 to 5 years). More males were in private practice and a higher proportion of them were practice owners. More women were dental school faculty or in private practice as an employee or contractor. The differences in practice patterns for males and females were not statistically significant for the Intermediate Career Group (6 to 10 years). In the Established Career group (over 10 years), the differences were again statistically significant, with more males as practice owners and shareholders and more women in solo practices. Analysis of time distribution showed that, in the two earlier career groups, women spend about twice as much time as men in child care. These findings may help to explain why many women in the early stages of their careers might prefer the flexibility of working for someone else. When the effects of gender and employment status on income were tested, significant differences were found for the Intermediate and Established groups, with males and practice owners having higher income levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Adult↗

Antibiotic prescribing practices among Norwegian dentists.

There is scarce information on antibiotics prescription habits among dentists in general. The present investigation was undertaken to study some patterns of antibiotics prescription among Norwegian dentists. A total of 459 dentists (approximately 10% of Norwegian dentists) were randomly selected, and to each was mailed a letter describing the survey, accompanied by a questionnaire about age, type of practice, educational background and pattern of prescription of antibiotics. 78% of the dentists responded to these questions. The results indicate that during a typical week, 32% did not prescribe antibiotics, whereas 5% wrote greater than 5 prescriptions. The mean weekly number of prescriptions per dentist was 2.04. Periodontists and oral surgeons prescribed antibiotics significantly more often than did general practitioners and other disciplines. In addition, those with research and/or teaching experience seemed to prescribe significantly more often than those without. More than 1/3 of the sample indicated that they may prescribe antibiotics when treating periodontal diseases. Compared with other disciplines, periodontists prescribed such drugs significantly more often when treating periodontitis, but significantly less often in acute gingivitis, stomatitis and herpes simplex infections. Moreover, 22% of the dentists might prescribe antibiotics when the patient is in pain, 73 and 38% in cases of abscesses with or without generalized malaise, 2.5% in endodontic therapy, 60% to prevent general complications, and 68% for prophylactic use if the patient revealed a history of endocarditis. Norwegian dentists are somewhat restrictive in their prescription of antibiotics, but they mostly prescribe the correct drugs for the different conditions.

Anti-Bacterial Agents↗

Practice variation: learned and socio-economic factors.

Much variation exists in the practice of dentistry with regard to diagnosis of caries and recommendations for treatment. This is a particular problem with respect to the replacement of restorations, with responsible factors related to both the patient and the dentist. The aim of this paper is to look at factors, exclusive of clinical data, that may explain why there is so much variation in the practice of dentistry, and specifically pertaining to replacement of restorations. Due to the paucity of studies related specifically to dentists, findings from physician studies will be presented. No studies are available that compare variation in medical and dental practices, but since both professions deal with the provision of health care and function in similar circumstances, comparisons are arguably generalizable between the two groups. Development of clinical judgment will be explored based on dental training experiences, and two explanatory models of practice pattern variation will be discussed--the dentist as a self-fulfilling practitioner and the dentist as the patient's agent. Along with these models, the matter of uncertainty in clinical practice and the development of routines will also be discussed in light of explaining variations.

Dental Restoration, Permanent↗

Pediatric dentistry in a period of decreasing numbers of dentists.

The availability of pediatric dental services is considered in terms of the projected decreases in the numbers of dentists to provide services to the general population. This decrease is further accentuated by the dental practice patterns of an increasing number of female dentists, many of whom demonstrate a particular interest in the care of children. There is an evolving demand for pediatric dental services, and a growing number of pediatric dentists overall.

Dentists↗

Dentist service rates and distribution of practice styles over time.

Studies of dentist service rates have identified clusters of dentists with particular styles of practice, but these practice styles need to be investigated to determine whether patterns of care become established and remain characteristic among dentists. The aims of this study were to establish dentist practice styles and to assess the distribution of these styles of practice between 1983 and 1988. A total of 202 private general practitioners who provided service rate data in both 1983 and 1988 were used in a cluster analysis to group dentists into practice styles. For both 1983 and 1988 three clusters of dentists were obtained, characterized by service rates as "High Restorative", "Low Total Rates", and "High Diagnostic and Preventive". However, the distribution of cluster membership changed over time. The percentage of dentists in the "High Restorative" cluster decreased from 27.9% in 1983 to 16.6% in 1988, the "Low Total Rates" cluster decreased for 60.7% in 1983 to 49.2% in 1988, while the "High Diagnostic and Preventive" cluster increased from 11.4% in 1983 to 34.2% in 1988. The distribution of dentists between these practice styles may be related to aging of dentists, practice maturation, population demographics, need or demand changes, or involve subtle differences in cluster classification over time.

Adult↗

Reasons for tooth extractions in dental practices in Ontario, Canada according to tooth type.

In a study of tooth extractions in general dental practices in Ontario, Canada, 165 dental practitioners provided information on 6134 patients attending during a reference week. Of these, 11.6 per cent of patients had one or more permanent teeth extracted. Periodontal disease was given as the reason for 35.9 per cent of these extractions and caries for 28.9 per cent. Analysis by tooth type showed that third molars were the most common tooth type extracted. However, there were differences in the types of teeth extracted by age. Posterior teeth were most frequently lost by the younger age groups and anterior teeth by older subjects. There were also differences in the reasons for the loss of different tooth types. A comparison of these results with those of a similar study in Scotland suggests that age and tooth type does not account for the excess of extractions due to periodontal disease in this Canadian population. Differences in practice patterns and attitudes towards the retention of teeth may be contributing factors.

Adolescent↗

Work-pattern differences between male and female orthodontists.

INTRODUCTION: Traditionally, most orthodontists have been men. In recent years, however, the number of women in dentistry and dental specialties, including orthodontics, has increased dramatically. Because practice patterns of male and female orthodontists might differ, they should be evaluated so that our schools can produce enough providers for the future. METHODS: Questionnaires were mailed to 798 orthodontists; the response rate was 68.8%. Questions about practice behavior and productivity were designed to assess sex difference with respect to age, marital status, and number of children. RESULTS: Number of children appeared to be a good predictor of days worked per week and length of leaves of absence for female orthodontists. Solo practitioners dominate the field of orthodontics, irrespective of age or sex. Although women were less likely than men to be practice owners, only 20% of the women responding were not in an ownership position. Women were slightly more likely to be involved in a group practice, they worked in fewer offices than men, and they employed fewer full-time and part-time people. Female nonowners were more likely to take longer leaves of absence. Overall, women worked slightly fewer days per week and spent fewer hours per week in direct patient care. Annually, they devoted 25 fewer days to practice than men, but, when adjusted for leaves of absence, men and women worked similar numbers of weeks in 1999. CONCLUSIONS: Among orthodontists, work patterns of men and women differ somewhat, but these differences might not be as significant as other factors; more study is required.

Adult↗

Informing research in primary dental care: setting priorities.

This paper suggests that priorities for research in primary dental care should follow the examples set in other areas of primary healthcare. It reviews the history of research in primary dental care, since 1990, and goes on to explain how the Delphi exercise, initiated by the Faculty of General Dental Practice (UK), has identified five priority areas for research in primary dental care. These areas are:1. Research into the application of evidence-based dentistry into practice.2. The effects of different systems of remuneration on treatment patterns in practice.3. The oral health assessment on determining recall intervals and its effect on oral health.4. Factors that influence and affect dentists' treatment modalities.5. The evaluation of the cost benefits of whole team training.

Delphi Technique↗

Practice characteristics of graduates of postdoctoral general dentistry programs.

A mail questionnaire was sent to 900 dentists who completed a Postdoctoral General Dentistry (PGD) program in 1985 and 900 dentists who graduated from dental school in 1985 but did not participate in a PGD program. The response rate was 57 percent. Three-quarters of the PGD graduates trained in civilian programs with the remainder being equally divided between military and Veterans Administration (VA) programs. Graduates of military programs continued to be employed by the military five years after graduation in contrast to the VA where less than 2 percent of graduates were employed after five years. The percent of dentists who are specialists or are enrolled in specialty programs five years after graduation was approximately 13 percent and the rates were similar for PGD and non-PGD dentists. The patterns of care in private practice tended to be similar for both groups; however, in institutions GPR graduates provided more treatment for special care patients and patients who were economically disadvantaged. GPR graduates also were more involved in teaching and in hospital activities.

Community Health Centers↗

Access to dental care for children in the United States: a survey of general practitioners.

BACKGROUND: In response to concern that inadequate dental school training may create a barrier to access to care for children, the authors conducted a survey concerning general practitioners' practice patterns involving child patients. METHODS: The authors requested a list of 4,970 randomly chosen general practitioners from the American Dental Association Survey Center. They then sent those dentists a written survey asking whether and in what numbers they treat children; the ages and caries levels of any children they do treat; their perceptions of their educational experiences in pediatric dentistry, and their perceived needs for continuing education in pediatric dentistry. They analyzed data using chi2. RESULTS: Ninety-one percent of the general dentists surveyed treated children, but those younger than 4 years of age, with high levels of caries, and whose care is funded by Medicaid were represented in very low numbers. The types of patients treated and procedures performed by the respondents were significantly (P < or = .05) associated with the intensity of the respondents' educational experiences, except for the number and types of Medicaid patients they treated. CONCLUSIONS: These data indicate that the vast majority of general practitioners treat children in their practices, but there still are groups of children for whom access to dental care is a problem. PRACTICE IMPLICATIONS: Very young children, children with high levels of caries and Medicaid-covered children have difficulty finding dental care in the general practice community.

Chi-Square Distribution↗

Questionnaire survey on the use of rotary nickel-titanium endodontic instruments by Australian dentists.

AIM: To ascertain the extent of the adoption and use of rotary nickel-titanium (NiTi) instruments and techniques in general dental practice and specialist endodontic practice in Australia in 2001. METHODOLOGY: A questionnaire survey comprising 43 questions was developed by first creating questions, then pilot testing with 10 postgraduate students in endodontics, followed by a final revision. The final series of questions covered demographics, patterns of rotary NiTi usage, issues associated with NiTi usage and training in NiTi use. The sampling frame was 908, comprising 64 endodontists and 844 general dentists. RESULTS: The overall response rate was 87%. Rotary NiTi instruments were used by 22% of general dentists and 64% of endodontists. The two main reasons for not using rotary NiTi were 'no perceived advantage' and 'too fragile'. Instrument fracture had been experienced by 74% of respondents, and 72% of these had fractured one to five files for the two main perceived reasons of 'excessive pressure on the file' and 'over-usage'. The next two most common problems encountered were 'binding' (53%) and 'ledging' (45%). Very high proportions of positive experiences were noted. Most respondents (73%) had attended one or more continuing education courses, most of which were provided by dental supply companies (64%). CONCLUSIONS: The results indicate a sensible and responsible approach to the incorporation of rotary NiTi instruments and techniques into root canal treatment. Dentists were aware of the limitations of the new technology, but were taking steps to become familiar with the properties and behaviour of the instruments. Instrument fracture was common, but it was of low frequency and did not deter dentists from using the technology.

Australia↗

Placement and replacement of composite restorations in Germany.

From 15 September to 15 October 1991, 102 dentists practicing in a rural area of Germany provided information on 3375 composite resin fillings. The purpose of this cross-sectional study was to record the reasons for placement and replacement of composite resin restorations, including any change of material when replacing a filling, and to register the age of any failed restoration. First placements because of primary caries were made in 50.6% of all cases; 49.4% were replacements of failed restorations. Composite resins were used as a material for the first placement of a restoration in 19.2% of primary teeth and in 47.8% of permanent teeth. More amalgams were replaced by composites than vice versa. Secondary caries was the most frequent reason for replacement in permanent teeth and in restorations with less than four surfaces, whereas fracture caused most failures in primary teeth and in fillings with four surfaces. The median age of the replaced restorations was 43.5 months. Failed restorations with four surfaces had the lowest median age.

Adolescent↗