D. Brad Rindal

Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large

BackgroundPractice-based research networks offer important opportunities to move recent advances into routine clinical practice. If their findings are not only generalizable to dental practices at large, but can also elucidate how practice characteristics are related to treatment outcome, their importance is even further elevated. Our objective was to determine whether we met a key objective for The Dental Practice-Based Research Network (DPBRN): to recruit a diverse range of practitioner-investigators interested in doing DPBRN studies.MethodsDPBRN participants completed an enrollment questionnaire about their practices and themselves. To date, more than 1100 practitioners from the five participating regions have completed the questionnaire. The regions consist of: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates, and Scandinavia (Denmark, Norway, and Sweden). We tested the hypothesis that there are statistically significant differences in key characteristics among DPBRN practices, based on responses from dentists who participated in DPBRNs first network-wide study (n = 546).ResultsThere were statistically significant, substantive regional differences among DPBRN-participating dentists, their practices, and their patient populations.ConclusionAlthough as a group, participants have much in common with practices at large; their substantial diversity offers important advantages, such as being able to evaluate how practice differences may affect treatment outcomes, while simultaneously offering generalizability to dentists at large. This should help foster knowledge transfer in both the research-to-practice and practice-to-research directions.

Pay‐for‐Performance in Dentistry: What We Know

&NA; Little is known about the effect of a pay‐for‐performance system (P4P) on primary medical care providers and even less is known about its potential impact in dentistry. Based on the growing acceptance of performance‐based reimbursements in medicine and the dissemination of innovative technologies, structures, and processes of care from medical to dental services, it is likely that the dental profession will face performance‐based payments in the not‐too‐distant future. In this paper, we present the current experience of P4P in primary medical care that has relevance to dentistry and discuss the dental performance‐based programs to date. Taking into consideration these lessons, the structure of dental service delivery in the United States, and the paucity of evidence‐based quality indicators in dentistry, we provide several guidelines for the design of P4P pilot programs for dental services. We conclude that large‐scale implementation of P4P for dentistry may not be a realistic option before significant progress is achieved in quality of dental care indicators.

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.

Computer-Assisted Guidance for Dental Office Tobacco-Cessation Counseling: A Randomized Controlled Trial

BACKGROUND Decreases in smoking prevalence from recent decades have slowed, and national goals to reduce tobacco use remain unmet. Healthcare providers, including those in physician and dental teams, have access to evidence-based guidelines to help patients quit smoking. Translation of those guidelines into practice, however, remains low. Approaches that involve screening for drug use, brief intervention, and referral to treatment (SBIRT) are a promising, practical solution. PURPOSE This study examined whether dentists and dental hygienists would assess interest in quitting, deliver a brief tobacco intervention, and refer to a tobacco quitline more frequently as reported by patients if given computer-assisted guidance in an electronic patient record versus a control group providing usual care. DESIGN A blocked, group-randomized trial was conducted from November 2010 to April 2011. Randomization was conducted at the clinic level. Patients nested within clinics represented the lowest-level unit of observation. SETTING/PARTICIPANTS Participants were patients in HealthPartners dental clinics. INTERVENTION Intervention clinics were given a computer-assisted tool that suggested scripts for patient discussions. Usual care clinics provided care without the tool. MAIN OUTCOME MEASURES Primary outcomes were post-appointment patient reports of the provider assessing interest in quitting, delivering a brief intervention, and referring them to a quitline. RESULTS Patient telephone surveys (72% response rate) indicated that providers assessed interest in quitting (control 70% vs intervention 87%, p=0.0006); discussed specific strategies for quitting (control 26% vs intervention 47%, p=0.003); and referred the patient to a tobacco quitline (control 17% vs intervention 37%, p=0.007) more frequently with the support of a computer-assisted tool integrated into the electronic health record. CONCLUSIONS Clinical decision support embedded in electronic health records can effectively help providers deliver tobacco interventions. These results build on evidence in medical settings supporting this approach to improve provider-delivered tobacco cessation. TRIAL REGISTRATION This study is registered at ClinicalTrials.govNCT01584882.

Large-scale clinical endodontic research in the national dental practice-based research network: Study overview and methods

INTRODUCTION This article reports on the feasibility of conducting a large-scale endodontic prospective cohort study in The National Dental Practice-Based Research Network. This study was designed to measure pain and burden associated with initial orthograde root canal therapy (RCT) and to explore potential prognostic factors for pain outcomes. The main objectives of this first report in a series are to describe the projects feasibility and methods and the demographics of the sample obtained. METHODS Sixty-two dentist practitioner-investigators (ie, 46 generalists and 16 endodontists) in 5 geographic areas were certified within the network and trained regarding the standardized study protocol. Enrollment and baseline data collection occurred over 6 months with postobturation follow-up for another 6 months. Patients and dentists completed questionnaires before and immediately after treatment visits. Patients also completed questionnaires at 1 week, 3 months, and 6 months after obturation. RESULTS Enrollment exceeded target expectations, with 708 eligible patient-participants. Questionnaire return rates were good, ranging between 90% and 100%. Patient demographics were typical of persons who receive RCT in the United States (ie, mean age = 48 years [standard deviation = 13 years], with most being female [59%], college educated [81%], white non-Hispanic [86%], and having dental insurance [81%]). The tooth types being treated were also typical (ie, 61% molars, 28% premolars, and 11% anteriors, with maxillary teeth being predominant [59%]). CONCLUSIONS This study shows the feasibility of conducting large-scale endodontic prospective cohort studies in the network. Patients were rapidly recruited with high levels of compliance in data collection.

Supplementing online surveys with a mailed option to reduce bias and improve response rate: the National Dental Practice-Based Research Network

OBJECTIVE Dentists in the National Dental Practice-Based Research Network are offered online and mail options for most questionnaire studies. We sought to quantify differences a) in characteristics of dentists who completed a questionnaire online as compared with those who completed a mail option offered to online nonresponders and b) in prevalence estimates for certain practice characteristics. METHODS Invitation letters to participants provided an identification number and log-in code with which to complete the online survey. Nonrespondents received a reminder letter after the fourth week, and after an additional 4-week period, a final reminder was sent, along with a paper questionnaire version, allowing completion online or by paper. RESULTS Of 632 US dentists who completed the survey, 84 (13 percent) used the paper version. Completion by paper was more common among males, older dentists, and those in general practice (P<0.05). The proportions of dentists who used electronic dental records, who consistently used a rubber dam when performing root canals, and who either worked with or employed expanded-function auxiliaries were lower among dentists who completed the survey using the paper-mail version than among those who completed it online; these differences remained significant in models adjusted for gender, age, and practice type. CONCLUSION Even in an era of increasingly electronic communication by dentists, not including a paper option when conducting surveys can result in overestimation of the prevalence of key dental practice characteristics.

Repair or replacement of restorations: A prospective cohort study by dentists in The National Dental Practice-Based Research Network

BACKGROUND A prospective cohort study that included dentists in The National Dental Practice-Based Research Network was conducted to quantify 12-month failures of restorations that were repaired or replaced at baseline. The study tested the hypothesis that no significant differences exist in failure percentages between repaired and replaced restorations after 12 months. It also tested the hypothesis that certain dentist, patient, and restoration characteristics are significantly associated with the incidence of restoration failure. METHODS Dentists recorded data for 50 or more consecutive defective restorations. The restorations that were either repaired or replaced were recalled after 12 months and characterized for developing defects. RESULTS Dentists (N = 195) recorded data on 5,889 restorations; 378 restorations required additional treatment (74 repaired, 171 replaced, 84 teeth received endodontic treatment, and 49 were extracted). Multivariable logistic regression analysis indicated that additional treatment was more likely to occur if the original restoration had been repaired (7%) compared with replaced (5%) (odds ratio [OR], 1.6; P < .001; 95% confidence interval [CI], 1.2-2.1), if a molar was restored (7%) compared with premolars or anterior teeth (5% and 6%, respectively) (OR, 1.4; P = .010; 95% CI, 1.1-1.7), and if the primary reason was a fracture (8%) compared with other reasons (6%) (OR, 1.3; P = .033; 95% CI, 1.1-1.6). CONCLUSIONS An additional treatment was more likely to occur within the first year if the original restoration had been repaired (7%) compared with being replaced (5%). However, repaired restorations were less likely to need an aggressive treatment (replacement, endodontic treatment, or extraction) than replaced restorations. PRACTICAL IMPLICATIONS One year after repair or replacement of a defective restoration, the failure rate was low. However, repaired restorations were less likely to need an aggressive treatment than replaced restorations.

Twenty-month follow-up of occlusal caries lesions deemed questionable at baseline : Findings from The National Dental Practice-Based Research Network

BACKGROUND A questionable occlusal caries (QOC) lesion can be defined as an occlusal surface with no radiographic evidence of caries, but caries is suspected because of clinical appearance. In this study, the authors report the results of a 20-month follow-up of these lesions. METHODS Fifty-three clinicians from The National Dental Practice-Based Research Network participated in this study, recording lesion characteristics at baseline and lesion status at 20 months. RESULTS At baseline, 1,341 QOC lesions were examined; the treatment that was planned for 1,033 of those at baseline was monitoring (oral hygiene instruction, applying or prescribing fluoride or varnish, or both), and the remaining 308 received a sealant (n = 192) or invasive therapy (n = 116). At the 20-month visit, clinicians continued to monitor 927 (90 percent) of the 1,033 monitored lesions. Clinicians decided to seal 61 (6 percent) of the 1,033 lesions (mean follow-up, 19 months) and invasively treat 45 (4 percent) of them (mean follow-up, 15 months). Young patient age (< 18 years) (odds ratio = 3.4; 95 percent confidence interval, 1.7-6.8) and the lesions being on a molar (odds ratio = 1.8; 95 percent confidence interval, 1.3-2.6) were associated with the clinicians deciding at some point after follow-up to seal the lesion or treat it invasively. CONCLUSIONS Almost all (90 percent) QOC lesions for which the treatment planned at baseline was monitoring still were planned to undergo monitoring after 20 months. This finding suggests that noninvasive management is appropriate for these lesions. PRACTICAL IMPLICATIONS Previous study results from baseline indicated a high prevalence of QOC lesions (34 percent). Clinicians should consider long-term monitoring when making treatment decisions about these lesions.

Oral Health Program Preferences among Pregnant Women in a Managed Care Organization

OBJECTIVE The purpose of the study was to understand the oral health information preferences of pregnant women and new mothers. METHODS This study was conducted at a Minnesota managed care organization. A random sample of 250 women with public program insurance and 250 privately insured women was selected from the population of pregnant women in the claims systems. The study consisted of a mailed survey and phone contact to nonresponders. The analytic sample consisted of 123 public-pay and 127 private-pay respondents. Descriptive statistics summarize the preferences for oral health care topics. RESULTS Receiving information by mail was preferred by both groups. Women favored information concerning infant-specific oral health more than information on both mother and infant oral health. While public-pay respondents had more enthusiasm for many topics, the topic preference rankings within each sample were similar. CONCLUSION Similarities in program preferences suggest that common interventions could be designed that would appeal to both groups without extensive tailoring.

Provision of specific dental procedures by general dentists in the National Dental Practice-Based Research Network: questionnaire findings.

BackgroundObjectives were to: (1) determine whether and how often general dentists (GDs) provide specific dental procedures; and (2) test the hypothesis that provision is associated with key dentist, practice, and patient characteristics.MethodsGDs (n = 2,367) in the United States National Dental Practice-Based Research Network completed an Enrollment Questionnaire that included: (1) dentist; (2) practice; and (3) patient characteristics, and how commonly they provide each of 10 dental procedures. We determined how commonly procedures were provided and tested the hypothesis that provision was substantively related to the three sets of characteristics.ResultsTwo procedure categories were classified as “uncommon” (orthodontics, periodontal surgery), three were “common” (molar endodontics; implants; non-surgical periodontics), and five were “very common” (restorative; esthetic procedures; extractions; removable prosthetics; non-molar endodontics). Dentist, practice, and patient characteristics were substantively related to procedure provision; several characteristics seemed to have pervasive effects, such as dentist gender, training after dental school, full-time/part-time status, private practice vs. institutional practice, presence of a specialist in the same practice, and insurance status of patients.ConclusionsAs a group, GDs provide a comprehensive range of procedures. However, provision by individual dentists is substantively related to certain dentist, practice, and patient characteristics. A large number and broad range of factors seem to influence which procedures GDs provide. This may have implications for how GDs respond to the ever-changing landscape of dental care utilization, patient population demography, scope of practice, delivery models and GDs’ evolving role in primary care.