Abstract
Purpose
The overall aim of this study was to quantify dental practice patterns related to caries risk and risk assessment.
Methods
This study surveyed Dental Practice-based Research Network member dentists in four regions in the US and Scandinavia who perform restorative dentistry in their practices. The survey asked a range of questions about caries risk assessment in patients ages 6-18.
Results
Seventy-three percent of dentists reported performing caries risk assessment; 14% assess caries risk using a special form. Regions where dentists were most commonly in a private practice model were the least likely to perform caries risk assessment. Regions where most dentists practiced in a large group practice model were the most likely to use a special form for caries risk assessment. More-recent graduates from dental school were more likely to use caries risk assessment when compared to older graduates. Current oral hygiene, decreased salivary flow, and the presence of active caries were rated as the most important caries factors. Some differences by region were also evident for the risk factor ratings.
Conclusion
These results suggest that not all community dentists assess caries risk. We also observed considerable variability in dentists’ views of the importance of specific caries risk factors in treatment planning and only weak evidence that caries risk assessment is driving clinical practice when preventive treatment recommendations are being considered.
Keywords: Dental Caries, Dentist’s Practice Patterns, Children, Risk Assessment, Preventive Methods, Organized Dentistry, HMO, Private Practice
INTRODUCTION
An important component of any pediatric caries preventive program is the assessment of a child’s risk of developing the disease.1 Risk factors for childhood dental caries include a variety of environmental and behavioral factors that can apply to any age group. The presence of active caries lesions has been identified as a measure of the risk for future lesions.2 Some studies investigating tooth brushing and/or oral hygiene have found a strong, consistent relationship with caries incidence/prevalence, while other studies do not find this association. 3, 4, 5 Sugar consumption is an indicator of a caries risk, particularly in persons who do not have regular exposure to fluoride.5, 6, 7 Socioeconomic status and education are also related to caries risk.3, 4, 8, 9 Finally, the clinician’s subjective assessment has been supported as valid in the assessment of caries risk.10 However, we are unable to find studies that report on clinicians’ subjective ranking of importance of these risk factors. It is also unclear how and if dentists systematically incorporate this information into their treatment decisions.11
The American Academy of Pediatric Dentistry has indicated that the use of caries risk assessment is an essential part of clinical care.12 By 1998, virtually all dental schools in the United States and Canada included lecture and clinical content on caries risk assessment and management.13 The discrepancy between what is taught in dental schools and what actually occurs in daily clinical practice on pediatric patients is poorly understood.
The overall aim of this descriptive study was to characterize dental practice patterns related to caries risk and risk assessment of pediatric dental patients. Therefore, we have quantified the use of risk assessment in pediatric patients in a large multi-region sample of dental practices; tested the hypothesis that use significantly differs by geographic region and other practice characteristics; identified the caries risk factors considered most important by clinical dentists; and tested for an association between the use of individualized caries risk assessment and dentist’s ratings of importance of specific risk factors.
METHODS
Participants
The “Dental Practice-Based Research Network (DPBRN)” is a consortium of participating practices and dental organizations committed to advancing knowledge of dental practice and ways to improve it. DPBRN comprises five regions: AL/MS: Alabama/Mississippi, FL/GA: Florida/Georgia, MN: dentists employed by HealthPartners and private practitioners in Minnesota, PDA: Permanente Dental Associates in cooperation with Kaiser Permanente Center for Health Research, and SK: Denmark, Norway, and Sweden.14 Participants of the DPBRN were recruited through mass mailing to licensed dentists from the participating regions. As part of enrollment in DPBRN, all practitioner-investigators complete an enrollment questionnaire about their practice characteristics and themselves. The enrollment questionnaire and other details about DPBRN are provided at http://www.DentalPBRN.org. We have demonstrated that DPBRN dentists have much in common with dentists at large.15
Dental practices were distributed by region as follows: AL/MS=298, FL/GA=100, MN=30, PDA=51, SK=30. There were two practices within the MN region that were in private practice and not employed by HealthPartners. Two dentists in each of the AL/MS and FL/GA regions work in public health clinics, the others were private practitioners. The SK region consisted of 15 public health dentists and 15 private practitioners.
Procedure
A survey about practice patterns was sent to the 932 DPBRN member dentists who perform restorative dentistry in their practices. The study was approved by the respective Institutional Review Board (IRB) of all participating regions. Participants who were not exempt from IRB signed the appropriate informed consent form. The 534 participating DBPRN dentists represent an overall return rate of 57%. There were no participation differences by gender, area of specialty, or years since dental school graduation.
Measures
Practice of caries risk assessment
A measure of the dentists’ practice of caries risk assessment was created. Dentists were asked whether they assess caries risk in any way and in a second question, those who did assess caries risk were asked if they use a special form that becomes part of the patient’s chart. This variable was created as: risk not assessed=0, risk is assessed but not using a special form=1, risk is assessed with a special form=2.
Caries risk factors
The dentists were asked a series of questions about caries risk factors that are listed on Table 1.
Table1.
Ratings of importance of caries risk factors for treatment plan.
| Risk factor | Mean rating of importance (SD) |
|---|---|
| Current oral hygiene | 4.6 (0.5) |
| Decreased salivary function | 4.3 (0.9) |
| One or more active caries lesions | 4.2 (0.8) |
| Commitment to return for follow-up | 4.2 (0.8) |
| Current diet | 4.0 (0.9) |
| Recent caries | 4.0 (0.8) |
| Presence of dental appliances | 3.9 (0.8) |
| Dentist’s subjective assessment | 3.9 (0.8) |
| Patients (guardians) understanding of caries progression | 3.8 (0.8) |
| Presence of several large restorations | 3.6 (0.8) |
| Age of patient | 3.5 (0.9) |
| Current use of fluorides | 3.5 (0.9) |
| Parents caries status | 3.2 (1.1) |
| Socioeconomic status | 2.6 (1.0) |
Network dentists rated these risk factors which were preceded with the following question. How important is each of the factors below when you decide on a treatment plan? Forced response choices were as follows 1=not at all important, 2=slightly important, 3-moderately important, 4=very important, 5=extremely important.
Full-time/part-time status was determined by asking dentists if they worked 32 or more hours per week (full-time) or less than 32 hours per week (part-time).
Statistical methods
Regional differences in caries risk assessment and ratings of importance of caries risk factors were tested using the Mann Whitney U-test. For interpretation of regional differences, pair-wise comparisons were performed using a Bonferroni correction (p=.005). Other associations involving nominal and ordinal data were tested using the Pearson chi-square and gamma statistics respectively. Because of the large number of bivariate associations performed, we also used the p=.005 criteria for these analyses.
RESULTS
There were 509 practitioners (419 male, 90 female) who treat patients 6-18 years of age in their practices and returned the survey. The mean years of practice was 23.3 (SD=10.4). By specialty, the break down was general practitioner 93% (n=472), pediatric 5% (n=27), and other 2% (n=8).
Dentists risk assessment in practice
Overall, 73% of network dentists perform a caries risk assessment, 59% assess caries risk without using a form, and 14% assess caries risk using a special form. Table 2 lists the caries risk assessment practices for the entire DPBRN and by region. Practices from the PDA and MN regions were significantly more likely to use a caries risk assessment than practices in the SK, AL/MS and FL/GA regions. Practices in the SK region were also more likely to use caries risk assessment than the AL/MS and FL/GA regions.
Table 2.
Dentist’s practice of caries risk assessment by region.
| Region | Caries risk not assessed |
Caries risk assessed, no form |
Caries risk assessed with a special form |
|---|---|---|---|
| AL/MS | 34% (n=98) | 66% (n=190) | <1% (n=1) |
| FL/GA | 35% (n=31) | 64% (n=56) | <1% (n=1) |
| MN | 4% (n=1) | 30% (n=7) | 65% (n=15) |
| PDA | 2% (n=1) | 12% (n=5) | 86% (n=44) |
| SK | 7% (n=2) | 79% (n=23) | 134 (n=4) |
| Total | 27% (n=133) | 59% (n=281) | 14% (n=65) |
Note: The sample size for this table is 479 as 30 dentists did not complete both questions.
The caries risk assessment variable was significantly associated with years since graduation in that more recently trained dentists were more likely to practice caries risk assessment. Gender, specialty, or full/part time variables were not associated with the practice of caries risk assessment.
Importance of risk factors in a treatment plan
Ratings of the importance of caries risk factors for use in a treatment plan are presented in Table 1. Current oral hygiene, decreased salivary flow, and the presence of active caries were rated as the most important factors, whereas parents’ caries status and family socioeconomic status were rated as the least important.
Regional differences were found for only four of the risk factors (Table 3). One or more active caries was rated as more important by a larger percentage of dentists from the PDA and MN regions than dentists from AL/MS and FL/GA. The presence of several large restorations was rated as more important by a larger percentage of FL/GA and AL/MS region dentists than SK dentists. Current oral hygiene was rated as more important by a larger percentage of dentists from the AL/MS and FL/GA regions than dentists from the PDA and MN regions. The current use of fluoride was rated as more important by PDA region dentists compared to AL/MS, FL/GA and MN region dentists.
Table 3.
Six highest rated caries risk factors by region.
| Region | Current oral hygiene |
Decreased salivary flow |
One or more active caries |
Commitment to return |
Current diet | Recent caries |
|---|---|---|---|---|---|---|
| AL/MS | 99% | 87% | 77% | 85% | 70% | 71% |
| FL/GA | 96% | 80% | 77% | 78% | 70% | 71% |
| MN | 84% | 77% | 100% | 80% | 79% | 90% |
| PDA | 84% | 78% | 94% | 77% | 75% | 86% |
| SK | 93% | 96% | 93% | 89% | 96% | 69% |
The percentages listed represent the percentage of dentists that rate the risk factor as very important or extremely important.
Having one or more recent caries lesions and diet were rated as more important risk factors by a larger percentage of female dentists than male dentists. Greater years of practice were associated with higher ratings of importance of active caries and lower ratings of the importance of social economical status. No other practice characteristics were significantly associated with ratings of importance.
Risk assessment and importance of risk factors
Caries risk assessment was associated with ratings of risk for four of the factors. Active caries was rated as more important by dentists who use a risk assessment form than by dentists who assess risk without a form or do not assess risk factors. Current oral hygiene was rated as more important by more dentists who assess risk without a special form or do not assess risk factors at all than dentists who assess risk using a special form. Current use of fluoride was rated as more important by a larger percentage of dentists who assess risk using a special form than dentists who assess risk without a form or do not assess risk factors. Current diet was rated as very/extremely important by a larger percentage of dentists who assess risk using a special form or assess risk without a form or do not assess risk factors.
DISCUSSION
Overall, we found that seventy-three percent of dentists reported they practice risk assessment for individual pediatric patients, although we did not ask whether all children within an office receive this assessment. The dentists in the PDA and MN regions were the most likely to practice individual risk assessment: In fact, 98% of PDA practices reported they perform caries risk assessments. A recent postal survey study of members of the Texas Academy of Pediatric Dentists found that 36% of the respondent 204 practices provided caries risk assessment on more than 76% of their patients and only 9% of dentists did not assess caries risk.16 Unlike findings for the DBPRN practices, this study did not find an association between the use of caries risk assessment and years in practice.
In the two regions that constitute large group practice models (PDA and MN), we found dramatically higher use of formal caries assessment forms. This could reflect practice policy taking advantage of resources available to large organizations, but also indicates good clinical practice. Several authors have designed caries risk assessment forms along with suggesting practical procedures to assist both dental and non-dental health care providers in these evaluations.17 Trueblood et al 16 found that among Texas pediatric dentists, 39% of respondents used both a verbal and written caries risk assessments. Our finding that more recent dental school graduates were more likely to perform caries risk assessments may suggest a trend for increased use of caries risk assessment.
Caries risk assessment is considered a necessary component in the clinical decision making process and the standard of care.18 From a legal perspective, it is important for dentists to document patient’s risk status and show evidence of patient education about risk factors and preventive recommendations. To be effective, risk assessment must be accompanied by an appropriate intervention, prevention and/or surgical treatment, and patient education. Trueblood16 has provided evidence that the families of pediatric patients are receptive to caries-related education and that parent’s interest was not associated with socioeconomic status.
Caries risk factors are variables that either cause the disease directly (e.g., microflora) or have been shown useful in predicting it (e.g., socioeconomic status). Knowledge of these risk factors should guide the clinical management of caries by helping to identify subjects who require caries prevention, guide in treatment planning decisions, and determine the timing of recall appointments.12 Network dentists rated current oral hygiene, decreased salivary flow, the presence of active caries, commitment to return for follow-up, and diet as the most important factors to consider for a treatment plan. There were some differences in the importance of risk factors across regions but little association with other practice characteristics. The Trueblood16 study found a very different set of responses. When they asked dentists about what they considered to be the most important caries risk factors; the dentists responded in the following response frequencies: diet, 88%; caries history, 82%; socioeconomic status, 46%; with salivary flow, oral hygiene, parental attitudes endorsed by 5% or less. A systematic review of the literature concerning caries risk in primary and permanent teeth concluded that previous caries experience was the best predictor.18 Studies using multivariate models have shown factors such as active caries, caries history, diet, oral bacteria counts, salivary markers, and fluoridation history predict future caries activity.19, 20, 21, 22, 23
There were mixed findings for associations between practice characteristics and higher ratings of the importance. There were regional differences for the relative importance of several of the caries risk factors. This could reflect differences in patient populations or could be more associated with practice philosophy or clinical training. The use of caries risk assessment was associated with higher ratings of some of the more important risk factors, suggesting that dentists performing risk assessment were considering these risk factors in treatment planning.
CONCLUSION
Seventy-three percent of network dentists reported performing caries risk assessment.
Regions participating in a private practice model were the least likely to perform caries risk assessment and those consisting of mostly large group practice model were the most likely to use a special form for caries risk assessment.
More recent graduates from dental school were more likely to use caries risk assessment in their practices than older dentists.
Current oral hygiene, decreased salivary flow, and the presence of active caries were rated as the most important caries factors.
Acknowledgement
This investigation was supported by National Institutes of Health, National Institute of Dental and Craniofacial Research grants U01-DE-16746 and U01-DE-16747. An Internet site devoted to details about DPBRN is located at www.DPBRN.org. Opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the respective organizations or the National Institutes of Health. The informed consent of all human subjects who participated in this investigation was obtained after the nature of the procedures had been explained fully. The DPBRN Collaborative Group comprises practitioner-investigators, faculty investigators, and staff who contributed to this DPBRN activity. A list of these names is provided at http://www.dpbrn.org/users/publications/Default.aspx.
Contributor Information
Joseph L. Riley, III, Department of Community Dentistry and Behavioral Science, College of Dentistry, University of Florida, Gainesville, Florida, USA..
Vibeke Qvist, Department of Cariology and Endodontics, School of Dentistry, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark..
Jeffrey L. Fellows, Center for Health Research, Kaiser Permanente Northwest, Portland, Oregon, USA..
D. Brad Rindal, Investigator and Dental Health Provider, HealthPartners, Minneapolis, Minnesota, USA..
Joshua S. Richman, Assistant Professor of Medicine and Biostatistics, University of Alabama, Birmingham, Alabama, USA..
Gregg H. Gilbert, Department of Diagnostic Sciences, School of Dentistry, University of Alabama, Birmingham, Alabama, USA..
Valeria V. Gordan, Department of Operative Dentistry, College of Dentistry, University of Florida, Gainesville, Florida, USA..
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