Abstract
Objectives: This study aimed to explore the preferred treatment for pre-school children with caries of different severities in primary teeth among general dental practitioners (GDPs) and specialists in paediatric dentistry (PDs) in Hong Kong, and to determine the difference in practice patterns between the groups. Methods: A random sample of 476 GDPs (approximately 25% of all registered dentists) and all registered PDs (n = 28) were invited to participate in the study. Both groups were asked to select their single most preferred treatment option on eight hypothetical clinical case scenarios in which the severity of dental caries in a single primary molar/incisor of a 4-year-old healthy and cooperative boy differed. The distribution frequency of responses was tabled. Difference in the care approach patterns of GDPs and PDs were examined in bivariate and regression analyses. Results: The overall response rate of the study was 61.5% (310/504). There were significant differences between the GDPs and PDs on their preferred treatment in six out of eight case scenarios (P < 0.05). PDs favoured comprehensive restorative treatment more than GDPs. Non-interventionist approach, atraumatic restorative technique or extraction were more popular among GDPs. Variation in treatment choices was apparent within both GDPs and PDs, in which spread of treatment options was wider among GDPs. Conclusions: GDPs and PDs have different dental care approach patterns for pre-school children with dental caries. Wide variation in the views about the best way to treat the child exists within both groups.
Key words: Treatment approach, dental caries, dental health care, pre-school children, guidelines
INTRODUCTION
The prevalence of dental caries in pre-school children is still high worldwide and has remained at a similar level over the last few decades1. In Hong Kong, about half of the 5-year-old children have a dental caries experience in which more than 90% remains untreated2., 3.. There is a great need for dental treatment and care among pre-school children.
Specialists in paediatric dentistry (PDs) are trained to provide dental care for children and adolescents. They play a leading role in the development of treatment guidelines in the field. However, there are insufficient PDs to address the current children’s dental needs in Hong Kong’s private sector, as most are based in the government service serving mainly civil servants or the School Dental Care Service (SDCS) for school-age children (age 6–12 years). In most cases, general dental practitioners (GDPs) remain the primary dental care provider for the pre-school children. The variation in the care offered by GDPs and PDs may result in a difference in the quality of dental care received by children attending different dentists, which may affect their oral health and general health outcomes.
Although comprehensive restorative approach to the management of children with carious primary teeth is advocated4, GDPs tended to treat caries conservatively5., 6., 7., 8., 9.. The dental practitioners’ clinical decision making and the actual way in which dental care and treatment is provided to children merit attention. Determining the degree of variation in dental practitioners’ views on the approach to care for pre-school children with dental caries has important implications for dental education and training, future research and development of guidelines.
The purposes of this study were to explore the preferred treatment for pre-school children with caries of different severities in primary teeth among GDPs and PDs in Hong Kong and to determine the difference in patterns of practice between the two groups.
METHODS
Study sample
Two groups of dental practitioners practising in Hong Kong were recruited for this cross-sectional survey in late 2009: GDPs and specialists in paediatric dentistry (PDs). A simple random sample of 476 registered GDPs was drawn from the General Register of the Dental Council of Hong Kong. This accounted for 25% of all 1905 registered Hong Kong dentists. For PDs, all 29 registered specialists (except one who was also a member of the study team) appearing on the list of the Specialist Register of the Dental Council of Hong Kong were included.
Each selected dental practitioner was sent a questionnaire consisting eight hypothetical clinical case scenarios and questions about their practice profile and own sociodemographic backgrounds. They also received a cover letter explaining the purpose of the study. If the practitioner voluntarily consented to participate, they completed the questionnaire and returned it in a sealed envelope anonymously and confidentially. Reminders (a total of four) were sent out to maximise the response rate. The study was approved by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (HKU/HA HKW IRB, IRB reference number: UW 10-039) and was conducted in full accordance with the World Medical Association Declaration of Helsinki.
Data collection
Selected dental practitioners were asked about their clinical opinions on the care offered to a pre-school child with carious primary molar or incisor using eight hypothetical clinical case scenarios. The case scenarios were designed to reflect a cross section of common dental conditions found in pre-school children. Four of the eight hypothetical clinical case scenarios used in this study were employed by Tickle et al.10 These four case scenarios were in a range of severity of caries in a primary molar. The remaining four clinical case scenarios were related to caries of various severities in a primary incisor. They were devised by the study team with reference to the case scenarios of the primary molar.
All the eight clinical case scenarios described a 4-year-old boy who appeared calm and had no medical problems. He had caries of various severities in the mandibular right first primary molar or the maxillary right central incisor. For each of the eight case scenarios, participating dentists were instructed to select just one treatment option that they preferred from a list of treatment options provided. In case scenarios 4 and 8, the boy was described as experiencing pain and dentists were asked to give their preferred treatment options to immediately relieve the child’s pain. The details of the eight case scenarios and their list of treatment options are presented in Table 1.
Table 1.
Summary of the case scenarios and the choice of treatment responses
| Scenario | Description of scenario | Choice of treatment responses |
|---|---|---|
| 1 | A 4-year-old boy has a single distal occlusal cavity affecting less than half the marginal ridge in the lower right first primary molar tooth. The tooth is vital and the child has no history of pain. The child appears calm and has no medical problems | No restorative treatment Fluoride varnish application Atraumatic restorative technique Traditional restorative treatment Stainless steel crown Pulp therapy with glass ionomer/composite or amalgam restoration Pulp therapy with stainless steel crown Extraction under local anaesthetic Refer for extraction under sedation Refer for extraction under general anaesthetic |
| 2 | A 4-year-old boy has a single distal occlusal cavity affecting more than half of the marginal ridge in the lower right first primary molar tooth. The tooth is vital and the child has no history of pain. The child appears calm and has no medical problems | No restorative treatment Fluoride varnish application Atraumatic restorative technique Traditional restorative treatment Stainless steel crown Pulp therapy with glass ionomer/composite or amalgam restoration Pulp therapy with stainless steel crown Extraction under local anaesthetic Refer for extraction under sedation Refer for extraction under general anaesthetic |
| 3 | A 4-year-old boy has a large distal occlusal cavity in a lower right first primary molar, which is non-vital and has an associated sinus. He has no history of pain. The child appears calm and has no medical problems | No restorative treatment Fluoride varnish application Atraumatic restorative technique Traditional restorative treatment Stainless steel crown Pulp therapy with glass ionomer/composite or amalgam restoration Pulp therapy with stainless steel crown Extraction under local anaesthetic Refer for extraction under sedation Refer for extraction under general anaesthetic |
| 4 | A 4-year-old boy has a large distal occlusal cavity in a lower right first primary molar where more than half of the marginal ridge has been destroyed. He is experiencing pain and has a right facial swelling. The child appears calm and has no medical problems. (Dentists were asked to give their preferred treatment options to immediately relieve the child’s pain.) | Open the pulp chamber and drain the tooth Excavate caries and place a sedative temporary dressing Prescribe antibiotics only Prescribe analgesics only Prescribe both antibiotics and analgesics Extraction under local anaesthetic Do nothing immediately but refer for extraction under sedation Do nothing immediately but refer for extraction under general anaesthetic |
| 5 | A 4-year-old boy has a single mesial cavity in the upper right central incisor, affecting less than half of the tooth. The tooth is vital and the child has no history of pain. The child appears calm and has no medical problems | No restorative treatment Fluoride varnish application Atraumatic restorative technique Traditional restorative treatment Composite strip crown Pulp therapy with glass ionomer/composite or amalgam restoration Pulp therapy with composite strip crown Extraction under local anaesthetic Refer for extraction under sedation Refer for extraction under general anaesthetic |
| 6 | A 4-year-old boy has a mesial cavity in the upper right central incisor, affecting more than half of the tooth. The tooth is vital and the child has no history of pain. The child appears calm and has no medical problems | No restorative treatment Fluoride varnish application Atraumatic restorative technique Traditional restorative treatment Composite strip crown Pulp therapy with glass ionomer/composite or amalgam restoration Pulp therapy with composite strip crown Extraction under local anaesthetic Refer for extraction under sedation Refer for extraction under general anaesthetic |
| 7 | A 4-year-old boy has a large mesial cavity in the upper right central incisor, which is non-vital and has an associated sinus. He has no history of pain. The child appears calm and has no medical problems | No restorative treatment Fluoride varnish application Atraumatic restorative technique Traditional restorative treatment Composite strip crown Pulp therapy with glass ionomer/composite or amalgam restoration Pulp therapy with composite strip crown Extraction under local anaesthetic Refer for extraction under sedation Refer for extraction under general anaesthetic |
| 8 | A 4-year-old boy has a large mesial cavity in the upper right central incisor where more than half of the tooth has been destroyed. He is experiencing pain. The child appears calm and has no medical problems. (Dentists were asked to give their preferred treatment options to immediately relieve the child’s pain.) | Open the pulp chamber and drain the tooth Excavate caries and place a sedative temporary dressing Prescribe antibiotics only Prescribe analgesics only Prescribe both antibiotics and analgesics Extraction under local anaesthetic Do nothing immediately but refer for extraction under sedation Do nothing immediately but refer for extraction under general anaesthetic |
Definitions of atraumatic and traditional restorative treatment were given to avoid ambiguity. Atraumatic restorative technique (ART) was defined as ‘a treatment that involves the removal of soft, demineralised tooth tissue using predominately hand instruments followed by restoration of the tooth with glass ionomer and does not usually require the use of local anaesthesia’ and traditional restorative treatment was defined as ‘a treatment that involves the complete removal of soft, demineralised tooth tissue using predominately rotary instruments, followed by restoration of the tooth with either glass ionomer, composite or amalgam and requires the use of local anaesthesia’.
Additional questions regarding the dentists themselves and their current work practice, such as gender, years and types of practice, perception of having adequate paediatric training, postgraduate training and qualification, weekly working hours and percentage of adult and paediatric patients seen per day were also included in the questionnaire.
Data analyses
All data were treated with strict confidence. Data were analysed using IBM® SPSS® Statistics 20 (SPSS Inc., Chicago, IL, USA). Simple frequency distributions of the dentists’ sociodemographic profile and the responses of each case scenario were produced. Distributions were compared using chi-square test. The level of statistical significance was set at α = 0.05.
Furthermore, to identify the association of dentists’ sociodemographic profile with the clinical decision for the most appropriate treatment choice for the case scenarios, a binary dependent variable was constructed, with appropriate treatment choices for the case scenarios set as ‘0’ and ‘1’. Logistic regression analysis was then carried out using a forward stepwise selection method until only variables demonstrating a statistically significant association at the 5% level remained in the final model.
RESULTS
The response rate of the general dental practitioners was 60.1% (286 from 476 GDPs), while the response rate of the paediatric dentists was 85.7% (24 from 28 PDs). The overall response rate of the study was 61.5% (310/504).
Table 2 presents the treatment choices selected by the GDPs and PDs regarding case scenarios 1, 2 and 3. These three cases described a 4-year-old healthy and cooperative boy with a distal occlusal cavity of different severities in a primary molar: small lesion in scenario 1, large lesion in scenario 2 and large lesion with associated sinus in scenario 3. The child was not in pain. There were significant differences between GDPs and PDs in case scenarios 1 (P < 0.001) and 2 (P < 0.05). The majority of the dentists (>90%) would restore the decayed tooth in these three case scenarios. PDs favoured comprehensive restorative treatment (traditional restorative treatment or stainless steel crown) more in case scenarios 1 (83.3% vs. 35.1%) and 2 (91.7% vs. 63.6%) when compared with GDPs. The PDs were also more likely to provide pulp therapy in case scenario 3 (95.9% vs. 91.3%), though with different opinions on the choice of restoration following pulp therapy among them. It is noteworthy that while a number of GDPs opted for a non-interventionist approach (no restorative treatment, fluoride varnish application) in these three scenarios (case scenario 1, 5.2%; case scenario 2, 1%; case scenario 3, 1.7%), some GDPs (4.8%) would choose to extract the carious tooth in case scenario 3. None of the PDs selected to extract the tooth in these case scenarios.
Table 2.
Comparison of the treatments selected for case scenarios 1, 2 and 3 (caries of various severities in a primary molar) by general dental practitioners and paediatric dentists
| Treatment options | Case scenario 1 | Case scenario 2 | Case scenario 3 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| GDPs (n = 286) | Paediatric dentists (n = 24) | GDPs (n = 286) | Paediatric dentists (n = 24) | GDPs (n = 286) | Paediatric dentists (n = 24) | |||||||
| Number | % | Number | % | Number | % | Number | % | Number | % | Number | % | |
| No restorative treatment | 4 | 1.4 | 0 | 0 | 1 | 0.3 | 0 | 0 | 5 | 1.7 | 1 | 4.2 |
| Fluoride varnish application | 11 | 3.8 | 1 | 4.2 | 2 | 0.7 | 0 | 0 | 0 | 0 | 0 | 0 |
| Atraumatic restorative technique | 170 | 59.4 | 3 | 12.5 | 85 | 29.7 | 0 | 0 | 1 | 0.3 | 0 | 0 |
| Traditional restorative treatment | 98 | 34.4 | 20 | 83.3 | 169 | 59.1 | 18 | 75.0 | 4 | 1.4 | 0 | 0 |
| Stainless steel crown | 2 | 0.7 | 0 | 0 | 13 | 4.5 | 4 | 16.7 | 1 | 0.3 | 0 | 0 |
| Pulp therapy with glass ionomer/composite or amalgam restoration | 1 | 0.3 | 0 | 0 | 13 | 4.5 | 2 | 8.3 | 177 | 61.9 | 10 | 41.7 |
| Pulp therapy with stainless steel crown | 0 | 0 | 0 | 0 | 3 | 1.0 | 0 | 0 | 84 | 29.4 | 13 | 54.2 |
| Extraction under local anaesthetic | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 11 | 3.8 | 0 | 0 |
| Refer for extraction under sedation | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 3 | 1.0 | 0 | 0 |
| Refer for extraction under general anaesthetic | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| P-value <0.001* | P-value 0.019* | P-value 0.315 | ||||||||||
GDP, general dental practitioners.
Statistically significant (P ≤ 0.05), Pearson’s chi-square (χ2) test.
The selected treatment choices by the GDPs and PDs for case scenario 5, 6 and 7 are shown in Table 3. These case scenarios were about the same patient but with mesial caries of different severity in a primary incisor: small lesion in scenario 5, large lesion in scenario 6 and large lesion with associated sinus in scenario 7. Choices of treatment differed markedly between GDPs and PDs in all three scenarios (case scenarios 5 and 6, P < 0.001; case scenario 7, P < 0.05). A proportion of the dentists would offer no treatment or just apply fluoride varnish (case scenario 5, 34.9% GDPs, 12.5% PDs; case scenario 6, 12.2% GDPs, 8.4% PDs; case scenario 7, 8.4% GDPs, 4.2% PDs). Among the dentists who said they would restore the tooth, as in the scenarios for primary molar, more PDs preferred to provide comprehensive restorative treatment (traditional restorative treatment or composite strip crown) than GDPs in case scenarios 5 (83.4% vs. 23.4%) and 6 (83.3% vs. 51.0%). Conversely, atraumatic restorative technique was more popular among GDPs (>30% in GDPs vs. <5% in PDs). More PDs claimed that they would perform pulp therapy on the non-vital incisor (87.5% vs. 76.6%) and follow by restoring the tooth with a strip crown (66.7% vs. 27.3%) in case scenario 7; while more GDPs (13.6%) chose to extract the tooth than PDs (8.3%) in the scenario. The GDPs had a wider spread of treatment options.
Table 3.
Comparison of the treatments selected for case scenarios 5, 6 and 7 (caries of various severities in a primary incisor) by general dental practitioners and paediatric dentists
| Treatment options | Case scenario 5 | Case scenario 6 | Case scenario 7 | |||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| GDPs (n = 286) | Paediatric dentists (n = 24) | GDPs (n = 286) | Paediatric dentists (n = 24) | GDPs (n = 286) | Paediatric dentists (n = 24) | |||||||
| Number | % | Number | % | Number | % | Number | % | Number | % | Number | % | |
| No restorative treatment | 31 | 10.8 | 1 | 4.2 | 24 | 8.4 | 1 | 4.2 | 22 | 7.7 | 1 | 4.2 |
| Fluoride varnish application | 69 | 24.1 | 2 | 8.3 | 11 | 3.8 | 1 | 4.2 | 2 | 0.7 | 0 | 0 |
| Atraumatic restorative technique | 118 | 41.3 | 1 | 4.2 | 91 | 31.8 | 0 | 0 | 2 | 0.7 | 0 | 0 |
| Traditional restorative treatment | 65 | 22.7 | 16 | 66.7 | 105 | 36.7 | 2 | 8.3 | 1 | 0.3 | 0 | 0 |
| Composite strip crown | 2 | 0.7 | 4 | 16.7 | 41 | 14.3 | 18 | 75 | 1 | 0.3 | 0 | 0 |
| Pulp therapy with glass ionomer/composite or amalgam restoration | 1 | 0.3 | 0 | 0 | 8 | 2.8 | 0 | 0 | 141 | 49.3 | 5 | 20.8 |
| Pulp therapy with composite strip crown | 0 | 0 | 0 | 0 | 5 | 1.7 | 2 | 8.3 | 78 | 27.3 | 16 | 66.7 |
| Extraction under local anaesthetic | 0 | 0 | 0 | 0 | 1 | 0.3 | 0 | 0 | 36 | 12.6 | 2 | 8.3 |
| Refer for extraction under sedation | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 3 | 1 | 0 | 0 |
| Refer for extraction under general anaesthetic | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 | 0 |
| P-value <0.001* | P-value <0.001* | P-value 0.035* | ||||||||||
GDP, general dental practitioners.
Statistically significant (P ≤ 0.05), Pearson’s chi-square (χ2) test.
In case scenarios 4 (large distal occlusal cavity in molar) and 8 (large mesial cavity in incisor), the tooth was not only non-vital, the child was also in pain; Table 4 shows the preferred treatment choices of the GDPs and PDs to immediately relieve the child’s pain in these two scenarios. There was a difference in opinion how to stabilise the tooth, extract the tooth or leave the tooth untreated for the moment and prescribing pharmaceuticals alone within both groups. In case scenario 4, there was considerable difference between GDPs and PDs in their way of treatment (P < 0.01). Relatively large proportions of GDPs (66.8%) chose to stabilise the tooth (open the pulp chamber and drain the tooth/excavate caries and place a sedative temporary dressing), whereas an equal proportion of PDs chose to stabilise the tooth (33.3%), prescribe pharmaceuticals alone (33.3%) or extraction (33.3%). For case scenario 8, more than half of the GDPs (54.5%) and PDs (62.5%) chose to stabilise the incisor causing pain. Notably, only a small number of the dentists elected to extract the teeth under sedation or general anaesthesia in both case scenarios.
Table 4.
Comparison of the treatments selected for case scenarios 4 (caries in primary molar) and 8 (caries in primary incisor) by general dental practitioners and paediatric dentists†
| Treatment options | Case scenario 4 | Case scenario 8 | ||||||
|---|---|---|---|---|---|---|---|---|
| GDPs (n = 286) | Paediatric dentists (n = 24) | GDPs (n = 286) | Paediatric dentists (n = 24) | |||||
| Number | % | Number | % | Number | % | Number | % | |
| Open the pulp chamber and drain the tooth | 151 | 52.8 | 3 | 12.5 | 101 | 35.3 | 4 | 16.7 |
| Excavate caries and place a sedative temporary dressing | 40 | 14 | 5 | 20.8 | 55 | 19.2 | 11 | 45.8 |
| Prescribe antibiotics only | 4 | 1.4 | 0 | 0 | 1 | 0.3 | 0 | 0 |
| Prescribe analgesics only | 0 | 0 | 0 | 0 | 4 | 1.4 | 1 | 4.2 |
| Prescribe both antibiotics and analgesics | 60 | 21 | 8 | 33.3 | 41 | 14.3 | 2 | 8.3 |
| Extraction under local anaesthetic | 21 | 25 | 6 | 25 | 78 | 27.3 | 5 | 20.8 |
| Do nothing immediately but refer for extraction under sedation | 8 | 2.8 | 1 | 4.2 | 5 | 1.7 | 1 | 4.2 |
| Do nothing immediately but refer for extraction under general anaesthetic | 2 | 0.7 | 1 | 4.2 | 1 | 0.3 | 0 | 0 |
| P-value: 0.002* | P-value: 0.087 | |||||||
GDP, general dental practitioners.
Statistically significance (P ≤ 0.05), Pearson’s Chi-square (χ2) test.
To immediately relieve the child’s pain.
In the regression models (Table 5), no dentists’ socio-demographic factor was found to be associated with the clinical decision for appropriate treatments in case scenarios 1 and 7. Dentists’ group (GDPs or PDs), gender, area in obtaining basic degree, postgraduate qualification, percentage of time working on adult patients and number of child patients seen per week were associated with the decision for appropriate treatments in other case scenarios.
Table 5.
Association of dentists’ sociodemographic profile with the clinical decision for the most appropriate treatment choice for the case scenarios (binary logistic regression)
| Estimated coefficients | 95% Confidence interval | P | Likelihood ratio χ2 | df | P | |||
|---|---|---|---|---|---|---|---|---|
| Exp (B) | Standard error | Lower bound | Upper bound | |||||
| Case 1 | ||||||||
| No associated factors found | ||||||||
| Case 2 | ||||||||
| Number of child patients seen per week (1 = more than 10, 0 = less than 10) | 2.04 | 0.32 | 1.09 | 3.80 | 0.025 | 4.98 | 1 | 0.026 |
| Percentage of time working on adult patients (1 = less than 50%, 0 = more than 50%) | 4.95 | 0.64 | 1.43 | 17.21 | 0.012 | |||
| (Constant) | 0.01 | 1.35 | 0.001 | |||||
| Case 3 | ||||||||
| Gender (1 = female, 0 = male) | 3.44 | 0.63 | 1.01 | 11.77 | 0.049 | 5.10 | 1 | 0.024 |
| (Constant) | 0.01 | 1.20 | 0.000 | |||||
| Case 4 | ||||||||
| Dentists’ group (1 = PDs, 0 = GDPs) | 6.93 | 0.55 | 2.38 | 20.21 | 0.000 | 5.99 | 1 | 0.014 |
| Area in obtaining basic degree (1 = Hong Kong, 0 = elsewhere) | 1.94 | 0.25 | 1.19 | 3.17 | 0.008 | |||
| Number of child patients seen per week (1 = more than 10, 0 = less than 10) | 2.27 | 0.35 | 1.15 | 4.48 | 0.018 | |||
| (Constant) | 0.01 | 1.29 | 0.000 | |||||
| Case 5 | ||||||||
| Area in obtaining basic degree (1 = Hong Kong, 0 = elsewhere) | 0.54 | 0.26 | 0.32 | 0.90 | 0.018 | 5.45 | 1 | 0.020 |
| Obtained postgraduate qualification (1 = Yes, 0 = No) | 1.87 | 0.27 | 1.09 | 3.18 | 0.022 | |||
| Number of child patients seen per week (1 = more than 10, 0 = less than 10) | 2.60 | 0.32 | 1.40 | 4.82 | 0.002 | |||
| (Constant) | 0.14 | 0.70 | 0.006 | |||||
| Case 6 | ||||||||
| Dentists’ group (1 = PDs, 0 = GDPs) | 4.80 | 0.56 | 1.60 | 14.38 | 0.005 | 10.20 | 1 | 0.001 |
| (Constant) | 0.42 | 1.10 | 0.004 | |||||
| Case 7 | ||||||||
| No associated factors found | ||||||||
| Case 8 | ||||||||
| Percentage of time working on adult patients (1 = less than 50%, 0 = more than 50%) | 2.78 | 0.51 | 1.02 | 7.57 | 0.046 | 4.68 | 1 | 0.031 |
| (Constant) | 0.09 | 1.00 | 0.014 | |||||
PDs, paediatric dentists; GDPs, general dental practitioners.
DISCUSSION
The questionnaires were sent by post; the effect of response bias was minimised by maximising the response rate to more than 60% with the use of multiple reminders. The study recruited a representative sample of GDPs and PDs. The sociodemographic profile (gender, practice, years in practice, hours of work, etc.) of recruited participants approximates that of the dentist in Hong Kong11.
The case scenarios were hypothetical. Clinical decision making of the participant based on these controlled cases may not truly reflect their actual clinical activity. It is unavoidable that what practitioners claim that they would do may be different from what they actually do in practice12. The treatment provided may also be affected by other factors such as parental expectations. This limitation of the study has therefore to be considered in interpreting the findings.
Most dentists in the study agreed that the decayed tooth should be restored and the majority of them claimed they would opt to restore a molar (>90%) rather than an incisor (>60%). This could be related to the fact that a primary molar exfoliates later and is needed to function for a longer period. Thus, in general, dentists see the clinical value of restoring the primary dentition.
The spread of treatment options chosen in each scenario indicates disagreement among GDPs and PDs about restorative techniques and philosophy of care. Different opinions on the restorative technique for a decayed primary tooth among the dentists was observed. Traditional restorative technique or restoring a decayed tooth with a crown (stainless steel crown/composite strip crown) was the most preferred restoration method among PDs, whereas atraumatic restorative technique was more popular among GDPs. This is concurrent with other studies that also demonstrated that GDPs were less interventionist in the dental care for children5., 6., 7., 8., 9., 13.. The treatments that GDPs opted for were simpler in nature and mostly temporary measures to solve the problem. Treatment plans and care approach should be driven by clinical evidence and the needs of individual patients.
Clinical decision-making is a multifactorial process and is influenced by a number of factors, such as dentist, patient and health-care system issues14. For dentist factors, gender, age, educational background, work experience, practice profile, speciality, skills and knowledge, diligence and tolerance for uncertainty have been found to be associated with the decision-making process15., 16., 17., 18., 19.. This is in agreement with the results of our survey, in which speciality (GDPs or PDs), gender, area in obtaining basic degree, postgraduate qualification, percentage of time working on adult patients and number of child patients seen per week were found to have a significant effect on decision making for appropriate treatments. This may be related to the fact that specialists and dentists who treat children on a more regular basis may have greater clinical experience and knowledge of paediatric dentistry.
Variations in approach to treatment among dentists has been demonstrated in similar studies conducted in England and Japan10., 20., 21.. Variation in clinical decision-making among practitioners seems to be a worldwide issue10., 20., 21., 22., 23., 24.. The wide disparity in the approach to the care of pre-school children with dental caries between GDPs and PDs, and within the groups, is at odds with an evidence-based approach to health care. This reflects uncertainty within the profession as to which dental care and treatment regimens for pre-school children are most effective. More well-constructed randomised control trials assessing outcomes of different treatment and care approaches are needed25., 26.. The provision of clinical guidelines based on the current best evidence on the approach of care and treatment of pre-school children with dental caries and with consensus among the experts will be beneficial. Guidance can support decision-making processes in patient care of both GDPs and specialists in paediatric dentistry. It also helps to close the gap between latest available evidence and practice.
CONCLUSIONS
The clinical decisions of GDPs and specialists in PDs as to how they would approach treating pre-school children presenting with dental caries in primary teeth was explored using a range of common clinical scenarios. It was found that GDPs and PDs in Hong Kong differ in their views on the best way to treat pre-school children with caries and different patterns in the care and treatment approach were demonstrated. Large variations in clinical care decision-making also exist within both groups, with GDPs showing a wider disparity. Well-designed research studies and provision of clinical guidelines on the most appropriate way to treat children with caries in the primary dentition are urgently needed.
Acknowledgements
We were grateful to all dental practitioners who participated in this survey.
Conflict of interest
None declared.
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