Applying evidence-based dentistry to caries management in dental practice
A computerized approach
DOUGLAS K. BENN, B.D.S., Ph.D.
 |
ABSTRACT
|
|---|
Background. It has been suggested that dentists manage patients’ treatment according to their risk of developing caries, as determined on the basis of scientific findings—an example of applying evidence-based dentistry, or EBD, to caries management. This article evaluates the barriers to adopting EBD and suggests possible outcomes for dentists and patients if new EBD caries strategies are adopted.
Methods. The author estimated the complexity of adopting EBD for a general dentist by means of flowchart analysis. He considered the ease of collecting comprehensive patient screening data, identifying risk factors and classifying risk. He examined the adequacy of conventional caries charting methods for representing the different stages and behavior of carious lesions, as well as the difficulty of producing treatment plans according to different caries risk levels. He also modeled the possible financial and organizational results of applying EBD caries management methods and increasing the use of hygienists.
Results. Traditional caries management strategies required only one flowchart page, while EBD needed 16 pages. Two full-time hygienists and 25 percent of a dentist’s time, managing only patients at low risk of developing caries, could generate the equivalent gross income of a full-time dentist working conventionally. Adding a third hygienist and devoting 75 percent of a dentist’s time to managing the remaining patients (those at medium or high risk of developing caries and periodontal disease) could gross a similar amount again.
Conclusions. Changing from traditional to risk-based management of caries requires complex decision making that is unlikely to occur with paper chart methods. Computers are ideal for collecting patient screening data and automating the treatment planning process to reduce the complexity of clinical management. Conventional methods of charting caries are not suited for evidence-based caries risk management.
Practice Implications. One dentist who uses risk-based management of caries and makes efficient use of three hygienists may see a doubling of income and a fourfold increase in the practice’s patient population.
In 1995, JADA published a supplement describing how dentists should consider managing patients according to their risk of developing caries.1 The supplement suggested classifying people into low-, medium- and high-risk categories, with the management varying according to the classification: adults at low risk would be seen once per year, those at medium risk every six months and those at high risk more frequently. It also suggested that in patients at low risk of developing caries, noncavitated lesions in enamel pits and fissures could be sealed and monitored over time instead of immediately receiving restorations, since this would stop caries progression and preserve tooth tissue.
Computers are ideal for collecting patient screening data and automating the treatment planning process.
Although the supplement was well-written, I tried to imagine how general dentists might react to reading it for the first time, and the difficulties they might encounter in altering their office routines to match the recommendations. Certain parts of the supplement were vague, and this could lead to variable interpretations by the reader of how to perform certain procedures. I also began to suspect that the complexity of the decisions would be too great for implementation in clinical practice. Imagine a receptionist trying to decide whether to book the next bitewing radiographic examination at six months, one year, two years or three years depending on the patient’s age, caries risk level and date of last examination.
At this point, I began to wonder if the complexity of evidence-based dentistry, or EBD, would be a barrier to its implementation in a busy dental office. So I produced a set of flowcharts of what EBD might require a dentist to perform in terms of decision making for caries management. It took a week to create 16 pages of detailed flowcharts compared with a simple one-page flowchart representing existing work methods.2 My first reaction was that EBD might be too complex to use in the real world. I then decided to develop methods to facilitate the adoption of EBD in general practice. This article describes some of the results of this work.
|
BARRIERS TO CHANGE
|
|---|
One can envision several possible barriers to using EBD:
- – collecting the patient screening information and looking for risk factors such as frequent sugar intake, inadequate exposure to fluoride, recent restoration for caries, last visit more than 12 months earlier, history of radiotherapy to salivary glands or use of medications reducing salivary flow;
- – being able to distinguish the different stages of caries (noncavitated vs. cavitated lesions, progressing vs. remineralizing lesions, lesion severity in terms of involvement of enamel vs. dentin vs. pulp), as current charting methods do not allow these distinctions to be recorded;
- – tailoring each treatment plan to one of the three risk levels, as the management is different at each level;
- – communicating the treatment plans to the patient;
- – comparing changes in lesion depth or cavitation status over time.
After looking at the barriers, I decided that existing paper methods were not suitable, and that available dental computer systems did not solve the problems. Over the next few years, my small research team (consisting of an assistant professor of engineering, a systems engineer and myself) attempted to overcome the problems of collecting caries risk factors from screening data, more detailed caries recording, risk level classification and matching treatment plans to risk levels.3–5
|
SOLUTIONS
|
|---|
First, we transferred the patient screening questions that had been assembled on paper to a computer, so that patients could enter their information directly. The software was developed at the University of Florida and was generated using Authorware and Flash (Macromedia Inc., San Francisco) to run on IBM-compatible personal computers. Later, the software, EviDent, was licensed by the University of Florida to Healthy Outcomes Technology (Gainesville, Fla.). The software automatically examined the screening data for risk factors. Next, we designed a tooth chart on which up to 30 regions on a tooth could be uniquely identified, and on which the clinical and radiographic depth of each lesion could be recorded by clicking on a palette of options (Figures 1
and 2).
View larger version (88K):
[in this window]
[in a new window]
|
Figure 1. A new method for recording a carious lesion including the cavitation state, depth and activity (EviDent, Health Outcomes Technology Inc., Gainesville, Fla.; patent pending, University of Florida, Gainesville). The estimate of the patient’s risk of developing caries is shown at the top left as a colored tooth. In this case, it is yellow, indicating medium risk; green would indicate low risk and red high risk. The image of each tooth can be enlarged to provide details for each lesion, including a recommendation for management such as "monitor," "seal fissure" or "restore." The recommendation is based on the caries risk level, cavitation state, lesion depth and carious activity. Clinicians decide to accept or change the recommendations based on their findings and knowledge of the patient.
| |
View larger version (65K):
[in this window]
[in a new window]
|
Figure 2. In the EviDent software (Health Outcomes Technology Inc., Gainesville, Fla.; patent pending, University of Florida, Gainesville), the tooth crown and roots are shown as approximately 30 different regions that can be selected separately or in groups. Here, tooth no. 2 is shown as having three lesions. The first, on a distal smooth surface (labeled D), has no apparent clinical caries, but there is a radiolucency in the outer one-half of enamel. The recommendation is to monitor for progression. The second, on an occlusal pit toward the mesial marginal ridge (labeled OM), has a noncavitated enamel-depth lesion (note the icon with a flat upper surface) that appears to be remineralizing (green); no radiolucency is seen. Since the patient has a medium risk of developing caries, the recommendation is to place a fissure sealant. The third, on an occlusal pit toward the distal marginal ridge (labeled OD), has a noncavitated enamel lesion that is progressing (red) and is shown radiographically to extend into the outer one-third of dentin. The recommendation for this lesion is to place a restoration.
| |
In the EviDent software, to record the clinical appearance of a lesion, the dentist selects one icon from the row of "Clinical Caries Classification" icons (Figure 2
). Each icon has a gray band for enamel and a light brown band for dentin. Green patches (for remineralizing caries) and red (for progressing caries) are shown as confined only to enamel, extending into dentin or extending into pulp. Icons with a flat upper surface represent noncavitated lesions, while concavities represent cavities. Radiolucencies in the outer and inner halves of enamel or the outer, middle or inner one-third of dentin can be selected from the "X-Ray Depth" icons. Figure 2 shows three lesions for tooth no. 2.
After designing the caries charting, we hid the complexity of the treatment plan decisions in the software and automatically produced recommendations at the systemic, whole-mouth and lesion levels. For patients at high risk of developing caries, the computerized recommendations included dietary counseling, oral hygiene instruction, prophylaxis at three-month intervals, home and office topical applications of fluoride, use of xylitol gum (three to five times per day) and chlorhexidine rinses (once weekly for six weeks) for their antibacterial effects, and a test for Streptococcus mutans after three months. (Although the algorithms for making the decisions are not shown, a list of the factors found leading to the recommendations for each patient is available from the author.) In this way, both the dentist and the patient were fully informed concerning the functioning of the program. Also, the dentist needed to accept or amend the recommendations before they became the treatment plan. This ensured that the clinician was always in control. To facilitate communication to the patient, the identified caries risk factors and treatment recommendations can be printed out.
The traditional caries chart had to be completely redesigned owing to its limitation of recording one or two lesions per surface but not the depth, state of cavitation or noncavitation, or caries progression or remineralization activity. Since many dental schools do not emphasize the difference between noncavitated, or incipient, lesions and true cavities in which the surface has collapsed, we designed pictorial icons to make the differences obvious (Figure 2). However, as it is so important to explain to dentists that noncavitated lesions potentially can remineralize themselves and do not need a restoration, I designed a World Wide Web–based tutorial to provide this information.6,7
|
PATIENT FEEDBACK
|
|---|
Up to this point, our work had concentrated on designing a computer system for dentists to use and into which patients could enter their screening data. We had not addressed the lack of information patients would feel themselves to have when faced with a dentist who said, "Mrs. Smith, you are at low risk of developing caries, and although you have some staining of a fissure, I can see nothing on a radiograph which leads me to believe that during the next six to 12 months, any significant changes are likely to occur before you return for another assessment." Nothing in the scientific literature reported on surveys of patients’ wishes with regard to a choice of immediate restoration vs. monitoring a suspicious area over time. As we had the caries tutorial on the Web available to dentists and patients, we decided to add to the posting an anonymous 10-item questionnaire to provide us with feedback, after receiving approval from the institutional review board of the University of Florida.
During a 12-month period, there were approximately 5,000 hits to the Web site, and we received 500 completed questionnaires. The majority of respondents were white, had visited a dentist within the last 12 months and could afford $500 of emergency dental care—characteristics of people who regularly seek dental care.8 Approximately 80 percent of the respondents said they would be very likely or likely to agree to monitoring of shallow decay vs. undergoing an immediate restoration. Seventy percent of people said they would be very likely or likely to select a dentist who offered monitoring rather than conventional operative care.
One has to be very careful when using a convenience sample that is not a randomized sample of a population. Nevertheless, we felt the demographic information was strongly indicative of the likely response of people who seek dental care regularly if they were given a choice in the management of early carious lesions.
|
IMPACT ON DENTIST INCOME AND OFFICE POPULATION SIZE
|
|---|
One of the barriers to change is whether dentists feel an incentive to alter the way in which they manage patients. Why change? Improved income is certainly a reason, but how could income increase? If a dentist employs two hygienists for seven hours per day and they have 45-minute appointments with patients at a low risk of developing caries, they take four bitewing radiographs of these patients every two years, and the dentist spends five minutes checking each patient, the hourly gross should be approximately $1,000, or four times the mean hourly gross for a general dentist in solo practice in the United States9,10 (Tables 1 and 2). The dentist can see 18 patients per day for checkups (a total of 90 minutes’ time) and, with the revenue from the two hygienists, produce a combined practice gross of approximately $450,000 per year. If an additional full-time hygienist (making three in total) is employed to look after the periodontal patients who are at medium and high risk of developing caries and the dentist spends his or her remaining time (75 percent of the total time; see Table 1) managing these patients, the total gross could be about $850,000—almost twice the annual gross.
View this table:
[in this window]
[in a new window]
|
TABLE 1 MANAGEMENT OF PATIENTS WITH CARIES RISK: COMPARISON OF TRADITIONAL MANAGEMENT WITH USE OF EVIDENCE-BASED DENTISTRY.
| |
View this table:
[in this window]
[in a new window]
|
TABLE 2 ILLUSTRATION OF DIFFERENT MANAGEMENT STRATEGIES AND COST DIFFERENCES ACCORDING TO A PATIENT’S CARIES RISK ASSESSMENT CLASSIFICATION.
| |
If a low-risk patient is seen only once per year, then such a patient pays one-half as much per year as he or she would for traditional care with six-month checkups—a pattern based on tradition, not clinical need.11 To fill the six-monthly slot available, more patients will need to be attracted. However, we know from our Web survey data that patients are likely to want the evidence-based management approach and to choose a dentist who provides this type of care.7 One dentist who works seven hours per day and employs three hygienists will need approximately 5,000 patients per year, or four times the average office population.12 Fortunately, about 60 to 70 percent of middle-class patients who regularly receive dental care are at low risk of developing caries and periodontal disease.8
|
CURRENT SITUATION
|
|---|
In 2003, the University of Florida College of Dentistry in Gainesville will be installing a new clinical computer system with our EBD program, EviDent, seamlessly integrated into the underlying management software (Quick Recovery, General Systems Design Inc., Cedar Rapids, Iowa). The new system will allow us to test a number of hypotheses. We already have interfaced the DIAGNOdent (KaVo, Biberach, Germany) caries detector with our system via a hand-held computer. This is a significant step, because it will enable dentists to objectively distinguish incipient lesions in outer enamel from those in inner enamel or dentin. This will give dentists the confidence to suggest monitoring of caries, because the DIAGNOdent is a very accurate test, with a sensitivity of 92 percent compared with the 31 to 63 percent sensitivity of conventional visual inspection, examination with explorers or radiography.13
|
CONCLUSION
|
|---|
We have developed a software method to aid the adoption of EBD in the process of determining a patient’s risk of developing caries. Efficient use of dental hygienists may greatly expand the office population pool, as well as significantly increase revenues. For patients who are at low risk of developing either caries or periodontal disease, annual visits will reduce the costs of dental care. EBD should be seen as an opportunity for providing the best care for patients, which—if combined with computer decision support systems, expanded use of hygienists and disease risk assessment—may result in decreased annual patient charges (improving access to care), increased office population size (reducing the impact of the anticipated dental work force reduction) and increased practice income. The combination of providing the best care with significant increases in office income may facilitate the adoption of EBD practices.14
View larger version (114K):
[in this window]
[in a new window]
|
Dr. Benn is a professor of radiology, Department of Oral and Maxillofacial Surgery and Diagnostic Sciences, University of Florida College of Dentistry, P.O. Box 100414, Gainesville, Fla. 32610-0414, e-mail "Benn{at}dental.ufl.edu". Address reprint requests to Dr. Benn.
| |
|
FOOTNOTES
|
|---|
The author acknowledges the assistance and skill of Douglas D. Dankel, Ph.D.; Stephen H. Kostewicz, M.S.; and Nicholas Antonio, M.S., all of the University of Florida College of Engineering, Gainesville, at the time the research described here was conducted. In addition, the author acknowledges the University of Florida Research Foundation Inc., Gainesville, and the University of Florida College of Dentistry, Gainesville, for providing funding.
Dr. Benn is president of Health Outcomes Technology Inc., or HOT, Gainesville, Fla., which has an exclusive license from the University of Florida to market the software decision support system described in this article (EviDent). HOT Inc. has an exclusive license from the University of Florida to market software. HOT Inc. had a contract from KaVo America Corp. (Lake Zurich, Ill.) to develop a personal digital assistant program for entering caries data from KaVo’s DIAGNOdent caries detector into the EviDent software. KaVo will give away an introductory version of EviDent to DIAG NOdent users, and HOT Inc. will receive payment for the software.
|
REFERENCES
|
|---|
- American Dental Association Council on Access, Prevention and Interprofessional Relations. Caries diagnosis and risk assessment: a review of preventive strategies and management. JADA 1995; 126(supplement):1S–24S.[Abstract]
- Benn DK, Dankel DD 2nd, Clark TD, Lesser RB, Bridgwater AB. Standardizing data collection and decision making with an expert system. J Dent Educ 1997;61:885–94.[Abstract]
- Benn DK, Dankel DD, Kostewicz SH. Can low accuracy disease risk predictor models improve health care using decision support systems? In: Chute CG, ed. Proceedings of the American Medical Informatics Association. Philadelphia: Hanley & Belfus; 1998:577–81.
- Benn DK. Acceptance and applications of new caries detection methods: U.S. dental school curriculum considerations. In: Stookey G, ed. Early detection of dental caries II. Proceedings of 4th Annual Indiana Conference, May 17–18, 1999, Indianapolis. Indianapolis: Indiana University; 1999:397–404.
- Benn DK, Clark TD, Dankel DD 2nd, Kostewicz SH. A practical approach to evidence-based management of caries. J Am Coll Dent 1999;66(1):27–35.[Medline]
- Benn DK, Kostewicz SH. How to heal tooth decay and avoid fillings. Available at: "www.oralsurgery.dental.ufl.edu". Accessed July 21, 2002.
- Benn DK, Kostewicz SH, Logan H. An analysis of a web-based oral health tutorial. In: Proceedings of the American Academy of Oral and Maxillofacial Radiology, 51st Annual Session, Nov. 8–12, 2000, Nashville, Tenn. Jackson, Miss.: American Academy of Oral and Maxillofacial Radiology; 2000:66.
- U.S. Department of Health and Human Services. Oral health in America: A report of the surgeon general. Rockville, Md.: DHHS, National Institute of Dental and Craniofacial Research, National Institutes of Health, 2000:61–6.
- Pelehach L. Patients hit with higher treatment costs. Dental Practice Reports 2000;8(8):18–27.
- American Dental Association. 1997 survey of dental practice: Income from the private practice in dentistry. Chicago: American Dental Association; 1998.
- Sheiham A. Is there a scientific basis for six-monthly dental examinations? Lancet 1977;2(8035):442–4.[Medline]
- Benn DK, Kostewicz SH, Ismail AI. Model predicting workforce changes following adoption of risk-based disease management (abstract 1146). J Dent Res 2000; 79(special issue):287.
- Lussi A, Megert B, Longbottom C, Reich E, Francescut P. Clinical performance of a laser fluorescence device for detection of occlusal caries lesions. Eur J Oral Sci 2001;109(1):14–9.[Medline]
- Benn DK. Extending the dental examination interval: possible financial and organizational consequences (editorial). Evidence-Based Dent (in press).
This article has been cited by other articles:
|
|
|
|
 
R. Niederman, E. Gould, J. Soncini, M. Tavares, V. Osborn, and J. M. Goodson
A Model for Extending the Reach of the Traditional Dental Practice: The ForsythKids Program
J Am Dent Assoc,
August 1, 2008;
139(8):
1040 - 1050.
[Abstract]
[Full Text]
[PDF]
|
|
|
|
|
|
|
H. SPALLEK
A resource guide for practice development through technology
J Am Dent Assoc,
October 1, 2004;
135(suppl_1):
38S - 44S.
[Full Text]
[PDF]
|
|
|
|
|
|
|
E. A. Mendonca
Clinical Decision Support Systems: Perspectives in Dentistry
J Dent Educ.,
June 1, 2004;
68(6):
589 - 597.
[Abstract]
[Full Text]
[PDF]
|
|
|
TOP
ABSTRACT
BARRIERS TO CHANGE
