Daniel J. Pihlstrom

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.

Rubber Dam Use During Routine Operative Dentistry Procedures: Findings From The Dental PBRN

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

Characteristics, Detection Methods and Treatment of Questionable Occlusal Carious Lesions: Findings from The National Dental Practice-Based Research Network

Questionable occlusal carious lesions (QOC) can be defined as an occlusal tooth surface with no cavitation and no radiographic radiolucencies, but caries is suspected due to roughness, surface opacities or staining. An earlier analysis of data from this study indicates 1/3 of patients have a QOC. The objective of this report has been to quantify the characteristics of these common lesions, the diagnostic aids used and the treatment of QOC. A total of 82 dentist and hygienist practitioner-investigators from the USA and Denmark in the National Dental Practice-Based Research Network participated. When consenting patients presented with a QOC, information was recorded about the patient, tooth, lesion and treatments. A total of 2,603 QOC from 1,732 patients were analyzed. The lesions were usually associated with a fissure, on molars, and varied from yellow to black in color. Half presented with a chalky luster and had a rough surface when examined with an explorer. There was an association between color and luster: 10% were chalky-light, 47% were shiny-dark and 42% were mixtures. A higher proportion of chalky than of shiny lesions were light (22 vs. 9%; p < 0.001). Lesions light in color were less common in adults than in pediatric patients (9 vs. 32%; p < 0.001). Lesions that were chalky and light were more common among pediatric than among adult patients (22 vs. 6%; p < 0.001). This is the first study to investigate characteristics of QOC in routine clinical practice. Clinicians commonly face this diagnostic uncertainty. Determining the characteristics of these lesions is relevant when making diagnostic and treatment decisions.

Barriers to sealant guideline implementation within a multi-site managed care dental practice

BackgroundThe purpose of this study was to identify barriers frequently endorsed by dentists in a large, multi-site dental practice to implementing the American Dental Association’s recommendation for sealing noncavitated occlusal carious lesions as established in their 2016 pit-and-fissure sealant clinical practice guideline. Although previous research has identified barriers to using sealants perceived by dentists in private practice, barriers frequently endorsed by dentists in large, multi-site dental practices have yet to be identified. Identifying barriers for these dentists is important, because it is expected that in the future, the multi-site group practice configuration will comprise more dental practices.MethodsWe anonymously surveyed the 110 general and pediatric dentists at a multi-site dental practice in the U.S. The survey assessed potential barriers in three domains: practice environment, prevailing opinion, and knowledge and attitudes. Results were summarized using descriptive statistics.ResultsThe response rate to the survey was 62%. The principal barrier characterizing the practice environment was concern regarding liability; endorsed by 33% of the dentists. Many barriers of prevailing opinion were frequently endorsed. These included misunderstanding the standard of practice (59%), being unaware of the expectations of opinion leaders (56%) including being unaware of the guideline itself (67%), and being unaware of what is currently being taught in dental schools (58%). Finally, barriers of knowledge and attitudes were frequently endorsed. These included having suboptimal skill in applying sealants (23% - 47%) and lacking knowledge regarding the relative efficacy of the different ways to manage noncavitated occlusal carious lesions (50%).ConclusionsWe identified barriers frequently endorsed by dentists in a large, multi-site dental practice relating to the practice environment, prevailing opinion, and knowledge and attitudes. All the barriers we identified have the potential to be addressed by implementation strategies. Future studies should devise and test implementation strategies to target these barriers.

PS1-31: Osteonecrosis of the Jaw in Two Dental PBRN Health Plans

Objectives: Osteonecrosis of the jaw (ONJ) has been recently associated with exposure to bisphosphonates (BPs). Incidence and risk factors are ill-defined. This Dental PBRN study (www.dpbrn.org; support: DE-16746, DE-16747) used electronic records from two participating health plans to estimate ONJ incidence and assess whether BP use increased the likelihood of ONJ. Methods: We used multiple search strategies and manual chart reviews to identify ONJ cases in members of Kaiser Permanente Northwest and HealthPartners of Minnesota. Our cohort was members age 35 and older with medical and pharmacy coverage for at least one year during 1994–2006. We used a keyword search of electronic physician notes to flag suspected cases among patients with a diagnosis or procedure indicative of ONJ and then confirmed cases through manual chart review. Oral surgeons and general dentists identified additional cases among cohort members. We used logistic regression to estimate the odds of ONJ from BP exposure, adjusting for other risks. Results: 37,290 of 572,602 cohort members had a diagnosis or procedure indicating the potential for ONJ. A key word search of physician notes and chart review found 14 ONJ cases; 5 more cases were found through dental providers. Six cases (31.6%) had an oral BP dispense prior to ONJ onset, compared to 21,163 cohort members (3.7%). Eight cases (42.1%) had a history of cancer, and 5 (26.3%) had osteoporosis, compared to 71,776 (12.5%) and 23,392 (4.1%), respectively, among all cohort members. Univariate and multivariate logistic regression were inconclusive due to the small number of confirmed ONJ cases. Conclusions: The incidence of ONJ in this cohort was very low and limited our ability to assess risks. When compared to the larger cohort, the higher frequencies of oral BPs, cancer, and osteoporosis among ONJ cases suggest these may be risk factors for ONJ. The low number of cases resulted in logistic regression outcome predictors that were no better than random. The rarity of ONJ cases in our study may be good news for the millions of adults currently taking oral bisphosphonates, although more data are needed before we know for sure.

Observable characteristics coincident with internal cracks in teeth: Findings from The National Dental Practice-Based Research Network

BACKGROUND This study determined if there are observable patient-, tooth- and crack-level characteristics markedly associated with whether a tooth with an external crack also has an internal crack. METHODS Two hundred nine dentists in The National Dental Practice-Based Research Network enrolled 2,858 adults with a vital permanent posterior tooth having at least 1 observed external crack. Presence and characteristics of internal cracks were recorded for 435 cracked teeth that were treated. Generalized estimating equations were used to identify significant (P < .05) independent odds ratios associated with the tooth having internal cracks. RESULTS Overall, 389 teeth (89%) had at least 1 internal crack, with 46% of these teeth having 2 or more internal cracks. Sixty-nine percent of treated cracked teeth were associated with 1 or more types of pain assessed before treatment; 53% were associated with cold testing, 37% with bite testing, and 26% with spontaneous pain. In the final model, biting pain, having an external crack that connected with a restoration, or an external crack that extended onto the root was each associated with more than a 2-fold increased odds of having an internal crack. CONCLUSIONS Essentially 9 of 10 teeth that had at least 1 external crack also had at least 1 internal crack. PRACTICAL IMPLICATIONS The external cracks that a dental practitioner should be most concerned about, because they are most likely to be associated with internal cracks in the tooth, are those in which the patient experiences biting pain, is connected with a restoration of some type, or extends onto the root.