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Assessment of Caries Diagnosis and Caries Treatment on a Dental Practice-Based Research Network

Permanent Link: http://ufdc.ufl.edu/UFE0021692/00001

Material Information

Title: Assessment of Caries Diagnosis and Caries Treatment on a Dental Practice-Based Research Network
Physical Description: 1 online resource (80 p.)
Language: english
Creator: Gordan, Valeria Veiga
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: assessment, based, caries, decision, dental, diagnosis, making, practice, questionnaire, research, risk, treatment
Clinical Investigation (IDP) -- Dissertations, Academic -- UF
Genre: Medical Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Dental caries continues to be a prevalent disease with high incidence among all age groups. Understanding how dentists currently diagnose and treat dental caries is fundamental to designing subsequent interventions to improve prevention of dental caries and restorative treatment. The purpose of the current project was to identify methods that Dental Practice-Based Research Network (DPBRN) dentists use to diagnose and treat caries lesions. The aims of the study were to (1) quantify the percentages of DPBRN dentists who report using selected methods for caries diagnosis; (2) quantify and evaluate the percentages of DPBRN dentists who report using a caries-risk assessment protocol of any variety; (3) quantify the percentages of DPBRN dentists who report intervening surgically at enamel and dentin lesions; and (4) evaluate the treatment options used DPBRN dentists when assessing defective restorations. The aims were met by enrolling 504 DPBRN dentists, each of whom completed a 6-page questionnaire about diagnosis and treatment a of dental caries. This study layed a critical foundation for subsequent intervention studies designed to move the latest scientific advances about caries diagnosis and treatment into daily clinical practice.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Valeria Veiga Gordan.
Thesis: Thesis (M.S.)--University of Florida, 2007.
Local: Adviser: Heft, Marc W.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021692:00001

Permanent Link: http://ufdc.ufl.edu/UFE0021692/00001

Material Information

Title: Assessment of Caries Diagnosis and Caries Treatment on a Dental Practice-Based Research Network
Physical Description: 1 online resource (80 p.)
Language: english
Creator: Gordan, Valeria Veiga
Publisher: University of Florida
Place of Publication: Gainesville, Fla.
Publication Date: 2007

Subjects

Subjects / Keywords: assessment, based, caries, decision, dental, diagnosis, making, practice, questionnaire, research, risk, treatment
Clinical Investigation (IDP) -- Dissertations, Academic -- UF
Genre: Medical Sciences thesis, M.S.
bibliography   ( marcgt )
theses   ( marcgt )
government publication (state, provincial, terriorial, dependent)   ( marcgt )
born-digital   ( sobekcm )
Electronic Thesis or Dissertation

Notes

Abstract: Dental caries continues to be a prevalent disease with high incidence among all age groups. Understanding how dentists currently diagnose and treat dental caries is fundamental to designing subsequent interventions to improve prevention of dental caries and restorative treatment. The purpose of the current project was to identify methods that Dental Practice-Based Research Network (DPBRN) dentists use to diagnose and treat caries lesions. The aims of the study were to (1) quantify the percentages of DPBRN dentists who report using selected methods for caries diagnosis; (2) quantify and evaluate the percentages of DPBRN dentists who report using a caries-risk assessment protocol of any variety; (3) quantify the percentages of DPBRN dentists who report intervening surgically at enamel and dentin lesions; and (4) evaluate the treatment options used DPBRN dentists when assessing defective restorations. The aims were met by enrolling 504 DPBRN dentists, each of whom completed a 6-page questionnaire about diagnosis and treatment a of dental caries. This study layed a critical foundation for subsequent intervention studies designed to move the latest scientific advances about caries diagnosis and treatment into daily clinical practice.
General Note: In the series University of Florida Digital Collections.
General Note: Includes vita.
Bibliography: Includes bibliographical references.
Source of Description: Description based on online resource; title from PDF title page.
Source of Description: This bibliographic record is available under the Creative Commons CC0 public domain dedication. The University of Florida Libraries, as creator of this bibliographic record, has waived all rights to it worldwide under copyright law, including all related and neighboring rights, to the extent allowed by law.
Statement of Responsibility: by Valeria Veiga Gordan.
Thesis: Thesis (M.S.)--University of Florida, 2007.
Local: Adviser: Heft, Marc W.

Record Information

Source Institution: UFRGP
Rights Management: Applicable rights reserved.
Classification: lcc - LD1780 2007
System ID: UFE0021692:00001


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ASSESSMENT OF CARIES DIAGNOSIS AND CARIES TREATMENT
ON A DENTAL PRACTICE-BASED RESEARCH NETWORK




















By

VALERIA GORDAN


A THESIS PRESENTED TO THE GRADUATE SCHOOL
OF THE UNIVERSITY OF FLORIDA IN PARTIAL FULFILLMENT
OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE

UNIVERSITY OF FLORIDA

2007




































O 2007 Valeria Gordan































To Lucio and Julia









ACKNOWLEDGMENTS

I would like to express my appreciation to my supervisory committee members (Dr. Nabih

Asal, Dr. Cyndi Garvan, Dr. Ivar Mjoir), and chair (Dr. Marc Heft) for their advice and

assistance. I want to thank Drs. James Bader, Vibeke Qvist, and Ivar Mj or who provided insight

during the development of the questionnaire. I wish to convey my gratitude to the Chair of the

Dental Practice-Based Research Network (Dr. Gregg Gilbert), to members of the Executive

Committee; and for grants (U01-DE16746, PI: Gregg Gilbert, and U01-DE 16747, PI: Dale

Williams). I am especially grateful to all the practitioner investigators of the Dental PBRN who

responded to the questionnaire used in the study. I would like to acknowledge the research

infrastructure enhancement grant U24DE0 1609-01, awarded to the College of Dentistry (PI:

Robert Burne) which allowed the needed time for completion of the requirements for this Master

of Science degree.












TABLE OF CONTENTS


page

ACKNOWLEDGMENTS .............. ...............4.....


LIST OF TABLES .........__.. ..... .__. ...............7....


LIST OF FIGURES .............. ...............8.....


AB S TRAC T ............._. .......... ..............._ 10...


CHAPTER


1 INTRODUCTION ................. ...............11.......... ......


Purpose of the Study ................. ...............12.......... .....
Context of Study ................. ...............12................

2 MATERIALS AND METHODS .............. ...............14....


Specific Aims............... ...............14..
Inclusion Criteria .............. ... ...............15.......... ......
Selection and Recruitment Process ................. ...............15.___......

Length of Field Phase ................. ...............15....... ....
Data Collection Process .............. .. ......... ...............15...
Pilot Study and Pre-testing of Questionnaire ................. .........___......16.........
Statistical Analysis and Power Calculations............... ..............1
Human Subj ects Research ............... ... .......... ... ...............17.
Risks to the Subj ects and Health Care Providers ............ ............ .........__.....1
Adequacy of Protection Against Risk .............. ..... ....... ..__ .. ......._ ............1
Potential Benefits of the Proposed Research to the Subj ects and Others .......................18
Importance of the Knowledge to Be Gained ................. ...............19........... ..
Inclusion of Women ................. ................. 19......... ...
Inclusion of M minorities ................. ...............19................
Inclusion of Chil dren ................. ...............19........... ....


3 LITERATURE REVIEW ................. ...............21................


Caries Prevalence............... .. .. ..... ... ... .. .................2
Clinical Treatment Planning: Lack of a "Gold Standard" ................... .... ..........2
Caries Risk Assessment: An Overlooked Practice in Treatment Planning ............................22
Caries Treatment: An Issue without a Strong Consensus............... ...............2
Clinical Diagnosis of Existing Restorations ................ ...............23........... ...

4 RE SULT S .............. ...............24....


Response Rate............... ...............24..












General Demographics .............. ...............24....
SA 1: Diagnostic Methods............... ...............24
SA 2: Assessment of Caries Risk ...................... .. .........................2
SA 3: Clinical Case Scenarios (Visual and Radiographic Caries Progression Pictures)........25
Summary of Findings Based on Visual Exam ................. ...............25..............
Summary of Findings Based on Radiographic Exam .........._.... .......__. ................26
Summary of Results According to Caries Risk and Diagnostic Images ................... ......26
SA 4: Treatment of Existing Restorations ..........._..... ....... ....._ ............... ...........2
Summary of the Results for a Composite Existing Restoration Interfacing a Dentin
Surface .............. ....... .. ... .... .. .... .. ...... .........2
Summary of the Results for a Composite Existing Restoration Interfacing an
Enamel Surface .............. ... ... ... ....... ..........2
Summary of the Results for an Amalgam Restoration ..........._..._. ................ ...._..28

5 DI SCUS SSION ................. ...............40................


Response Rate............... ....... ................4
Methods for Diagnosing Carious Lesions .............. ...............40....
Non-Traditional Methods .............. ...............42....
Concluding Remarks ................. ...............43...
Dentist' s Assessment of Caries Risk ................. ...............44......__._...
Caries Diagnosis Based on Clinical Findings............... ...............45
Caries Diagnosis Based on Radiographic Finding .............. ...............47....
Practices' and Dentists' Characteristics ........._._._ ...._. ...............48.
Evaluation of Existing Restorations ........._.___..... .__. ...............51...

6 FUTURE WORK............... ...............53..


7 CONCLUSIONS .............. ...............54....

APPENDIX


A QUESTIONNAIRE: ASSESSMENT OF CARIES DIAGNOSIS AND CARIES
TREATM ENT .............. ...............55....


B ENROLLMENT DATA QUESTIONNAIRE ......__....._.__._ ......._._. ............6

LIST OF REFERENCES ........._.___..... .___ ...............68....


BIOGRAPHICAL SKETCH .............. ...............78....










LIST OF TABLES


Table page

4-1. Summary of eligible dentists that participated in the study according to dentist' s and
practice' s characteristics .............. ...............29....

4-2. Percent of dentists who reported on use of selected diagnostics tools to detecting dental
caries .............. ...............3 0....

4-3. Summary of assessment of caries risk during the treatment planning process according
to dentist's and practice' s characteristics ................. ...............31........... .

4-4. Summary of type of treatment option chosen by dentists according to the visual caries
progression pictures on low caries risk individual (question 9) .............. ...................32

4-5. Summary of intervention option of treatment selected on visual case scenarios for low
caries risk individual (question 9) according to dentist's and practice's characteristics.. .33

4-6. Summary of intervention option of treatment selected on visual case scenarios for high
caries risk individual (question 10) according to dentist' s and practice' s
character sti c s ................ ...............34................

4-7. Summary of level of intervention treatment according to caries risk and diagnostic
im age available .............. ...............35....

4-8. Summary of clinical treatment options chosen on a existing composite restoration
interfacing a dentin surface (question 13) according to dentist' s and practice' s
character sti c s ................ ...............36................

4-9. Summary of clinical treatment options chosen on a existing composite restoration
interfacing an enamel surface (question 14) according to dentist's and practice's
character sti c s ................ ...............37................

4-10. Summary of clinical treatment options chosen on an existing amalgam restoration
(question 15) according to dentist' s and practice's characteristics ................. ................38










LIST OF FIGURES

Figure page

2-1. The sample size estimation. ............. ...............20.....

4-1. Treatment chosen by dentists for clinical case scenarios involving existing
restorations (questions 13 to 15) ................. ...............39........... ..









LIST OF ABBREVIATIONS


AL

ANOVA

CC

CI

DPBRN

DIAGNOdent

FL

FOTI

HMO

HP

KP

OR

SA

SK




Symbols


Alabama

Analysis of variance

Coordinating center

Confidence interval

Dental Practice-Based Research Network.

Quantitative light-induced laser fluorescence

Florida

Fiber-optic transillumination

Health maintenance organization

HealthPartners

Kaiser Permanente and Permanente Dental Associates

Odds ratio

Specific aim

Scandinavia (includes participating countries Denmark, Norway, and
Sweden) .





Alpha

Dollar

Percent









Abstract of Thesis Presented to the Graduate School
of the University of Florida in Partial Fulfillment of the
Requirements for the Degree of Master of Science

ASSESSMENT OF CARIES DIAGNOSIS AND CARIES TREATMENT
ON A DENTAL PRACTICE-BASED RESEARCH NETWORK

By

Valeria Gordan

December 2007

Chair: Marc Heft
Major: Medical Sciences--Clinical Investigation

Dental caries continues to be a prevalent disease with high incidence among all age groups.

Understanding how dentists currently diagnose and treat dental caries is fundamental to

designing subsequent interventions to improve prevention of dental caries and restorative

treatment.

The purpose of the current proj ect was to identify methods that Dental Practice-Based

Research Network (DPBRN) dentists use to diagnose and treat caries lesions. The aims of the

study were to (1) quantify the percentages of DPBRN dentists who report using selected methods

for caries diagnosis; (2) quantify and evaluate the percentages of DPBRN dentists who report

using a caries-risk assessment protocol of any variety; (3) quantify the percentages of DPBRN

dentists who report intervening surgically at enamel and dentin lesions; and (4) evaluate the

treatment options used DPBRN dentists when assessing defective restorations.

The aims were met by enrolling 504 DPBRN dentists, each of whom completed a 6-page

questionnaire about diagnosis and treatment a of dental caries. This study played a critical

foundation for subsequent intervention studies designed to move the latest scientific advances

about caries diagnosis and treatment into daily clinical practice.









CHAPTER 1
INTTRODUCTION

Dental caries continues to be a prevalent oral disease with substantial incidence among all

age groups. Despite advances in the prevention of dental caries, active dental caries still regularly

leads to dental restorations and dental extractions (67, 132, 133).

Treatment choices for dental caries are affected by a multitude of factors, including

variations among dentists regarding caries diagnosis. The subjective assessment of each dentist

when making the diagnosis of caries may be responsible for the greatest variation in treating the

disease. The stage in caries development when operative intervention is indicated is not

established or agreed upon (26,137). A maj or problem may be that dentists lack a "gold

standard" in clinical treatment planning because there is a paucity of research assessing the short

and long-term outcomes of treatment (12, 17, 38, 39, 42, 114).

Many factors play a role in determining patient's caries risk (22,119), such as presence of

active caries lesions and patient characteristics such as race, ethnicity, socioeconomic and

educational levels (22). No strong consensus exists within the dental profession regarding the

use of a preventive versus surgical treatment to reduce dental caries. The lack of consensus exists

not only in general practice (14), but also in teaching programs (5).

Additionally, limited information is available from general dental practice about what

lesion depth practitioners consider appropriate for operative (surgical) intervention. Marked

variations in criteria exist among clinicians in the diagnosis of caries lesions (11, 12, 66, 99, 109)

and in caries management and prevention (13,70). There is lack of consensus in caries diagnosis

(104, 106), and, further dissemination into and adoption by practitioners in daily clinical practice

has been limited.










Purpose of the Study

The purpose of this study was to assess how dentists in clinical practice participating in the

Dental Practice-Based Research Network (DPBRN), diagnose and treat dental caries in adult

pati ents.

Specific Aim 1: quantify the percentages of DPBRN dentists who report using selected

methods for caries diagnosis.

Specific Aim 2: quantify and evaluate the percentages of DPBRN dentists who report

using a caries-risk assessment protocol of any variety.

More specifically, the practice of assessing caries risk for individual patients differs by

characteristics of dentists and characteristics of their practice.

Specific Aim 3: quantify the percentages of DPBRN dentists who report intervening

surgically at enamel and caries lesions (stages El, E2, DI, D2, or D3).

More specifically, decision for intervening surgically in a caries process will differ by

severity of caries, by the practice of assessing caries risk, by characteristics of dentists, and by

characteristics of their practices.

Specific Aim 4: evaluate the treatment options used DPBRN dentists when assessing

existing restorations.

More specifically, treatment approaches chosen by dentists differ by differ by the practice

of assessing caries risk, by characteristics of dentists, and by characteristics of their practices.

Context of Study

This study queried dentist participating in the DPBRN. The DPBRN is a group of

outpatient dental practices that have affiliated to investigate research questions and to share

experiences and expertise. To date, 1,166 dentists have completed a 101-item enrollment

questionnaire. Some of these clinicians have attended a three-four hour orientation session









delivered in a Continuing Education format. The DPBRN comprise dentists in Alabama,

Mississippi, Florida, Georgia, Minnesota, Oregon, Washington, and Scandinavia. A statistical

coordinating center (CC) is part of the DPBRN. The CC comprises a group of about 15 bio-

statisticians, and staff investigators who are responsible for data collection, data management,

and data analysis of the DPBRN. A comprehensive description of the DPBRN is provided in the

DPBRN's web site at http://www.DentalPBRN.org. This study recruited 915 participating

dentists from the DPBRN.









CHAPTER 2
MATERIALS AND METHODS

The study design was cross-sectional, consisting of a single administration of a

questionnaire-based survey (Appendix A) to a convenience sample of dentists participating in the

DPBRN.

Specific Aims

The specific aims were met by having DPBRN dentists complete a questionnaire that

queries the following key components:

Specific Aim 1: Which methods) is (are) currently in use to diagnose caries lesions (SA 1).

Rationale for specific aim 1: Studies have demonstrated substantial differences among

dentists regarding methods used to diagnose dental caries. This component is addressed by

questions 1 through 7 in the questionnaire.

Specific Aim 2: Whether caries risk assessment is part of dentists' treatment planning process
(SA 2).

Rationale for specific aim 2: Not all dentists assess caries risk. Determining if dentists

assess caries risk may impact how dentist diagnose and treat caries. This component is addressed

by question 8 in the questionnaire.

Specific Aim 3: Whether enamel or dentin lesions are intervened operatively (SA 3).

Rationale for specific aim 3: The stage in the caries development process when operative

intervention is indicated is not established or commonly agreed on. However, the initial

intervention can have a significant impact on the health of the tooth structure as well as on the

cost of treatment. This component is addressed by questions 9 through 12 in the questionnaire.

Specific Aim 4: What is the most commonly used approach by dentists to treat existing

restorations (SA 4).









Rationale for specific aim 4: The diagnosis of recurrent caries may vary according to

dental experience (23, 97) and location of original dental restoration (8, 36, 37). This component

is addressed by questions 13 through 15 in the questionnaire.

Questions related to dentist' s and practice' s characteristics had been gathered previously

during the enrollment questionnaire (Appendix B). The enrollment questionnaire comprised 101-

questions inquiring demographic information regarding dentists and their practices. The CC

provided de-identified enrollment data information related to 915 eligible dentists.

Inclusion Criteria

To be eligible to participate in Study 1, dentists had to have been enrolled in the DPBRN

and done at least some restorative dentistry in their practices.

Selection and Recruitment Process

An introductory letter explaining the study (Appendix C) was mailed to each eligible

practice (a total of 915), along with a printed copy of the questionnaire. The questionnaires were

sent to all the participating dentists in Alabama, Florida, Scandinavia, the Permanente Dental

Associates, and the HealthPartners group.

Length of Field Phase

Participating dentists were requested to return the questionnaire within three weeks. A

reminder letter was sent after the third week to clinicians who had not returned the questionnaire.

After an additional three weeks, a second reminder was sent. After a Einal three-week waiting

period, if a dentist had not returned the questionnaire, it was assumed that he or she was not

interested in participating.

Data Collection Process

Preprinted survey form packages were sent by the CC to each regional office. These forms

had the dentist self-checking identification number preprinted on each page of each form.










Dentists were asked to complete the questionnaire by hand and return to his/her assigned

regional coordinator in a pre-addressed envelope. Upon receipt, the regional coordinator

reviewed the questionnaire for completeness and then either scanned for electronic transfer to the

CC or transfer to the CC via mail.

Dentists were paid 50 dollars after they returned a completed questionnaire and had

responded to possible queries from the CC having to do with verifying illegible or unclear

responses.

Pilot Study and Pre-testing of Questionnaire

A pilot version of the questionnaire was submitted to 16 dentists throughout the network.

The pilot-testing assessed the feasibility and comprehension of each questionnaire item.

A subsequent pre-testing phase Einalized documentation of comprehension of questionnaire

items and quantified test-retest reliability of questionnaire items, which involved 35 DPBRN

dentists. Items had to meet a test-retest reliability of kappa > 0.7 to be considered sufficiently

reliable for inclusion in the Einal version of the questionnaire. The lapse in time between test and

retest was 15 days.

Statistical Analysis and Power Calculations

Non-parametric test was used to assess differences between explanatory variables and

methods used. Pearson's chi-square statistic was used to test the hypothesis of association

between outcome and explanatory variables when nominal variables were being analyzed.

Analysis of variance (ANOVA) was used to test associations between outcome and

explanatory variables when the variables analyzed were numerical. A 95% confidence interval

(a=.05) was set.









The 95% confidence level and two-sided CIs and hypothesis tests were assumed for all

power calculations. A minimum sample size of 200 dentists was deemed necessary to answer the

specific aims of the study.

Precision of estimation for the percentages defined in Aiml was based on widths of exact

95% CIs for binomial proportions corresponding to percentages ranging from 10% to 50%. An

estimated percentage of 50% yields the widest CI, and thus the most conservative estimate of

precision. Figure 2-1 shows the widths of CIs for sample sizes of 100 to 300 responding

practitioners. The CI width for an estimated percentage of 50% ranges from 20.3 for a sample

size of 100, to 1 1.6 for a sample size of 300. That is, given an estimated percentage of 50%, for

a sample size of 100, the 95% CI would be (39.85, 60. 15), and for a sample size of 300, the

corresponding CI would be (44.2, 55.8).

Power for the hypotheses tested on Aims 2 thru 4 were based on a chi-square test of equal

proportions (OR = 1.0), assuming equal allocation of respondents between the two categories of

one usage variable, and estimating power to detect a difference from 50% in one of the

categories of the other variable. A sample size of 100 practitioners would provide 80% power to

detect an OR of 3.3 (50% versus 77% in the categories of the second variable). Sample sizes of

200 and 300 would provide 80% power to detect ORs of 2.3 (50% vs 70%) and 1.95 (50% vs

66%), respectively.

Human Subjects Research

Risks to the Subjects and Health Care Providers

Human subject involvement and characteristics. The human subjects directly involved

in this study were the dentists who completed the questionnaire that inquires mainly about the

various methods used to diagnose dental caries and the stages of the caries process that requires

intervention. Subj ects were recruited from the Dental PBRN and needed to meet the eligibility









criteria specific to this protocol and provide informed consent to participate. The Informed

Consent form comprised part of the Introductory letter (Appendix C) that accompanied the

questionnaire. Returning a completed questionnaire constituted verification of consent.

Sources of materials. Data was obtained from the responses given by the dentists who

answered the questionnaire.

Potential risks. The only risk to the participating subjects was the highly unlikely

accidental disclosure of health care provider information. However, every precaution has been

taken to prevent this. No additional exposure was expected from this protocol.

Adequacy of Protection Against Risk

Recruitment and informed consent. We provided the study participants information

that explained the nature of the study, time commitment involved, any risks involved, and

compensation information. We also answered any questions they might have had in a telephone

conversation or in face-to-face discussion with them.

Protection against risks. Records of participation were kept confidential to the extent

permitted by law. Only authorized personnel had access to the data, and all information, whether

electronic or in paper form, was stored in a secure manner. This information will not be sold or

used for any reason other than research. Results may be published for scientific purposes, but

participant identities will not be revealed.

Potential Benefits of the Proposed Research to the Subjects and Others

Subj ects benefited from the opportunity to reflect their views on the current caries

diagnosis and caries risk assessment plans used in their practice and gained information on the

practice methods of their peers. The indirect benefit to the patients of the subj ects answering the

questionnaire might be ultimate improvements in dental treatment in daily clinical practice.

Subj ects might also have benefited from a better understanding of how the risk characteristics of










patients may influence patients' treatment. The potential benefits to the subjects and indirectly

to their patients far exceeded the risk involved with the participation.

Importance of the Knowledge to Be Gained

The knowledge to be gained from the study was to identify the various methods used for

caries diagnosis and caries treatment. Additionally this study will serve as a foundation for

future studies as it will provide the theoretical knowledge about methods used for diagnosis and

treatment of caries.

Inclusion of Women

Dentistry is a profession performed by both men and women; therefore, both genders were

eligible to enroll. Based on the enrollment questionnaires completed by DPBRN dentists, 14%

were female.

Inclusion of Minorities

Racial and ethnic minorities were included in the study proportional to their composition in

the dental community.

Inclusion of Children

This study was designed to investigate caries diagnosis and caries treatment used by

DPBRN dentists, in the treatment of adult patients. Therefore, no children were study

participants.


































100 150 200 250 300

Sample! Size!


25.0 -


20.0


S15.0

S10.0

5.0


0.0


- -40%
-.- 50%


Figure 2-1. Sample Size Estimation.









CHAPTER 3
LITERATURE REVIEW

Caries Prevalence

Treatment of teeth due to primary or recurrent caries consumes about 70% of the treatment

time in general dental practices (92). Over $70 billion are spent annually on dental care in the US

alone, most of which is associated with restorative treatment.

Contrary to the assumption that dental caries is a prevalent disease primarily among

children, new reports show that caries is a disease still prevalent in the middle-aged and older

adult population with substantial incidence rates (54, 56, 74, 79, 121). Caries disease rates vary

substantially among different states in the US and also according to selected demographic

variables (24). In some states the percentage of children experiencing caries can be as high as

72%. African- American population is at greater risk of incidence of caries lesions (32, 75). A

prospective longitudinal cohort study in a diverse community-based population in Florida

showed a 67% incidence rate of caries disease in patients older than 45 years of age over a two-

year period (54). Incidence rates over a three-year period of 57% for coronal caries increments

and 27-39% of root caries increments have been reported in various populations over 50 years of

age in North America (56, 74, 79). In addition, older population remains at risk for dental caries

as the tooth retention rates have increased (24).

Clinical Treatment Planning: Lack of a "Gold Standard"

Comparisons of restorative treatment recommendations showed that dentists had

remarkable differences related to the decision-making process (10, 66, 89, 99, 109). Part of these

inconsistencies are related to the marked variation that dentists have in correctly identifying

caries, with sensitivity values ranging from .77 to 1, and specificity values ranging from .45 to

.93 (42). In quantifying agreement among dentists' recommendations for restorative treatment, it









was concluded that much of the variation in dental practice profiles is due to basic differences in

decision-making (9, 16). Lack of consistency in both dentists' decisions to intervene and

dentists' selection of treatment can have a significant effect on cost of treatment (1 14).

Caries Risk Assessment: An Overlooked Practice in Treatment Planning

Many factors play a role in establishing a patient' s caries risk (22, 119). The presence of

active caries lesions was reported in an extensive literature review as a good measure of the risk

for future lesions (4). Socioeconomic aspects and education are also related to caries risk (22).

In addition, the caries experience of patients who have attended the practice for a minimum of 2

years allows a reliable caries risk assessment (15). Finally, the clinician's subjective assessment

has been suggested as a reliable assessment of caries risk (15). About 65% of North American

dental schools advocate caries risk assessments as part of treatment planning. However, only

about 27% of clinicians apply a caries risk assessment regimen during their treatment planning

(26).

Caries Treatment: An Issue without a Strong Consensus

No well defined and generally accepted criteria exist within the dental profession regarding

the use of a preventive versus surgical treatment to treat dental caries. The lack of consensus

exists not only in general practice (14, 109), but also in teaching programs (5). A review rated

the evidence for efficacy of methods to manage non-cavitated lesions to be incomplete (13).

Marked differences in treatment approach also exist among different countries (76, 78, 88, 90,

100, 108, 112). In Scandinavia, the majority of unfilled carious surfaces have caries lesions

whose depth only extended into enamel (78) and restorative treatment has been predominant for

proximal surfaces that involve dentin only (77).










Clinical Diagnosis of Existing Restorations

The clinical diagnosis of recurrent caries is the most common reason for replacement of

restorations in general dental practice (94). This diagnosis is difficult and it invariably leads to

replacement of the entire restoration (93, 96, 107). Replacement of existing restorations

consistently results in extension of the cavity preparation as compared to the original size.

Clinical and in vitro studies have shown a significant increase in cavity preparations when either

amalgam (35, 36, 95) or resin based composite (50, 51, 52) restorations were replaced. The lack

of standards to determine restoration failure causes the dentists to err on the side of caution when

faced with uncertain diagnosis. Based on these findings and the fact that the cost of care and oral

health are severely impacted by the diagnosis of existing restorations, understanding how dentist

diagnose and treat existing restorations that may be defective remains a critical issue.









CHAPTER 4
RESULTS

Response Rate

A total of 1166 dentists are enrolled at the DPBRN. Nine-hundred and fifteen (78%)

enrolled dentists were eligible for participation in the study. Nine-hundred and fifteen

questionnaires were distributed and 504 (55%) were returned.

General Demographics

Table 4-1 describes characteristics of dentists (i. e., gender, race, years of experience,

region) and characteristics of practices who were eligible for participation in the study.

The response rate from Alabama site was significantly lower than the other sites.

SA 1: Diagnostic Methods

Table 4-2 summarizes which techniques are currently being used by DPBRN participating

dentists to diagnose caries lesions. The frequency of use is also described. All dentists (n=504)

responded to these questions.

The results showed that dental explorer is used as the main diagnostic tool for the

diagnosis of occlusal dental caries (63%) and for the diagnosis of recurrent dental caries (61%).

Laser fluorescence was never used by 87 percent of dentists for the diagnosis of occlusal dental

caries.

For the diagnosis of proximal dental caries, radiograph was the main tool used by dentists

and fiber optic was never used by 34 percent of dentists.

Dentists use radiographs for the diagnosis of proximal dental caries (51%) more often than

they use for the diagnosis of occlusal dental caries (14%).









SA 2: Assessment of Caries Risk

Table 4-3 reports on assessment of caries risk during the treatment planning process

according to characteristics of dentists and their practices. The results showed that the maj ority

of the dentists (69%) assess caries risk for individual patients. From dentist that assess caries

risk, only 18 percent (n=63) use a caries risk assessment form.

Female dentists assess caries risk more often than male dentists, however the difference

was not significant (p<.05).

Significant difference was found for years of experience. Dentists with less years of

experience assessed caries risk more often than those with more years of experience.

Significant differences were found for different practices characteristics. Dentists from AL

and FL participating practices assess caries risk significantly less than dentists from HP, KP, and

SK participating practices.

SA 3: Clinical Case Scenarios (Visual and Radiographic Caries Progression Pictures)

Summary of Findings Based on Visual Exam

The treatment options were grouped in the following subgroups: 1- no treatment, 2-

prevention (in-office fluoride, non-prescription fluoride, prescription of fluoride, sealant,

chlorhexidine treatment), 3- prevention and intervention (minimal drilling and sealant, minimal

drilling and preventive resin restoration, air abrasion and sealant, air abrasion and preventive

resin restoration), and 4- intervention (amalgam restoration, composite restoration, indirect

restoration).

Table 4-4 reports on the various forms of treatment chosen using the visual caries

progression pictures on a low caries risk individual (question 9). Most of the dentists (70%)

reported no treatment for clinical case scenario 1. The no treatment option decreased

significantly as the caries progression increased. Most dentists reported intervention for the









clinical case scenario 2 and this treatment option was increased as the caries progression

increased. Prevention treatment was higher on clinical case scenario 1 and it gradually decreased

as the caries progression increased. The combination of prevention and intervention treatments

was gradually increased as the caries progression increased. A similar trend of treatment

options chosen was observed when a high caries risk individual was described (question 10).

Table 4-5 reports on intervention treatment chosen by dentists on a low caries risk

individual (question 9) according to dentists and practice characteristics. Significant differences

were found for different practices characteristics. Dentists from HP, KP, and SK participating

practices intervene significantly less on enamel lesions than AL and FL participating practices.

Table 4-6 reports on intervention treatment chosen by dentists on a high caries risk

individual (question 10) according to dentists and practice characteristics. Significant differences

were found for the participating practices according to region. Dentists from Al, FL, and KP

participating practices intervene significantly more on enamel lesions than dentists from HP and

SK participating practices.

Summary of Findings Based on Radiographic Exam

Using a radiographic image in a low caries risk scenario, about 41 percent of dentists,

reported that they would start intervening surgically on inner enamel lesions (case 2). In a high

caries risk scenario, the maj ority of dentists (76%) reported that they would start intervening

surgically on inner enamel lesions (case 2).

Summary of Results According to Caries Risk and Diagnostic Images

Table 4-7 reports on level of intervention according to caries risk (i. e., high versus low)

and diagnostic image available (i.e., visual versus radiographic). Caries risk was significant

when deciding on stage of intervention for both visual and radiographic diagnostic images.

Dentists were more readily to choose the intervention treatment on enamel surfaces when










patients were in a high caries risk scenario. Additionally the table shows that dentists choose

more often the intervention treatment on enamel surfaces when they use the visual versus the

radiographic diagnostic tools (p<.0001).

SA 4: Treatment of Existing Restorations

The bar graph on Figure 4-1 illustrates the treatment options chosen by dentists for the

treatment of existing restorations in composite interfacing a dentin surface (question 13), in

composite interfacing an enamel surface (question 14), and in amalgam restoration (question 15).

Tables 4-8 thru 4-10 illustrates the treatment options chosen by dentists according to dentists and

practices characteristics.

Summary of the Results for a Composite Existing Restoration Interfacing a Dentin Surface

The maj ority of dentists chose either the intervention or the prevention and intervention

treatment options for the clinical case scenario on question 13.

Significant differences were found for the different participating practices. Dentists from

AL and FL participating practices reported significantly more intervention than dentists from

KP, HP, and SK practices. Practices with higher percent of patients covered by public insurance

performed more prevention treatment than practices that were not covered by public insurance.

Summary of the Results for a Composite Existing Restoration Interfacing an Enamel
Surface

The maj ority of dentists chose the intervention treatment option for the clinical case

scenario on question 14.

Significant differences were found for assessment of caries risk. Dentists who do not

assess caries risk do more intervention than those who assess caries risk.

Significant differences were also found for practices characteristics. Dentists from AL and

FL practicing regions do more intervention than dentists from KP, HP, and SK regions.










Summary of the Results for an Amalgam Restoration

The maj ority of dentists chose the "no treatment" option for the clinical case scenario on

question 15.

Significant differences were found for dentist' s years of experience and assessment of

caries risk. Dentists with less years of experience chose the prevention treatment option more

often than dentists with more years of experience. Dentists who assess caries risk chose the

prevention treatment option more often than those dentists who do not assess caries risk.

Significant differences were also found for practices characteristics. Dentists from AL and

FL regions chose the intervention treatment option more often than dentists from KP, HP, and

SK regions.









Table 4-1. Summary of eligible dentists that participated in the study according to dentist' s and
practice's characteristics
Number of eligible Participated Did Not Participate p-value
denti sts n= 504 n =411
N=915
Gender
Male % 82.7 84.7 .4729
Female % 17.3 15.3

Race
White % 91.8 90.9 .5078
Hisp % 2.4 1.5
Black % 3 4.4
Other % 2.8 3.2

Years experience
mean (SD) 22 (10.6) 20 (13) .274

Region
AL % (n=667) 57.5 90.4 <.0001*
FL % (n=122) 19.8 6.1
HP % (n=3 5) 6.1 1.3
KP % (n=53) 9.9 1
SK % (n=3 8) 6.7 1.2

Percent of patients
covered by public
insurance 1.9 (2.4) 18(.).06
mean (SD)

* statistical significance










Table 4-2. Percent of dentists who reported on use of selected diagnostics tools to detecting
dental caries
N=504 Dental Dental Radiograph Radiograph Laser f. Fiber o. M;
explorer explorer occlusal proximal occlusal proximal
occlusal recurrent
Never or 2 1 1 0 87 34


ag.


21


0%
1-24%
25-49%
50-74%
75-99%
Every time
or 100%


;9 16
1 6
0 7
5 9
1 41










Table 4-3. Summary of assessment of caries risk during the treatment planning process
according to dentist's and practice's characteristics


N=504


No assessment of
caries risk
n=138 (27%)


Assessment of
caries risk
n=348 (69%)
Use of a special form:
Yes: 63 (18%)
No: 285 (82%)


p-value


Gender
Male %
Female %

Race
White %
Hisp %
Black %
Other %

Years experience
mean (SD)


86.9
13.1


0.1195


.5078


26.8 (10.2)


21 (10.4)


.0093*


<.0001*


Region
AL%
FL %
HP %
KP %
SK %


73.1
23.9
1.5
0
1.5


53.2
16.1
7.3
14.3
9.1


Percent of patients
covered by public
insurance
scheduled
mean (SD)

Percent of Black or
African-American
patients scheduled
mean (SD)


1.6 (1.7)


2 (2.6)


.9711


2.6 (2)


2 (1.6)


18 (4%) participants did not answered this question
* statistical significance





Table 4-4. Summary of type of treatment option chosen by dentists according to the visual caries
progression pictures on low caries risk individual (question 9)
n=504 Casel Case 2 Case 3 Case 4 Case 5


No treatment

Prevention

Prevention &
intervention
Intervention


343 (69%) 121 (25%)


31 (6%)


5 (1%)

3 (0.5%)

148 (30%)


4 (0.8)

4 (0.8)


81 (16%) 60 (12%) 12 (2%)


23 (5%) 76 (15%)


132 (27%)


152 (32%)

319 (67%)


47 (10%) 235 (48%) 321 (65%) 340 (68.5%)


Numbers of cells
missing










Table 4-5. Summary of intervention option of treatment selected on visual case scenarios for
low caries risk individual (question 9) according to dentist' s and practice' s
character stick s
n=504 Intervention Intervention p-value
Case 1 or Case 2 Case 3/Case 4/Case5
(enamel surfaces) (dentin surfaces)
Gender
Male % 84.9 78.6 .0748
Female % 15.1 21.4

Race
White % 92 92.5 .4133
Hisp % 3.5 1.8
Black % 3 2.5
Other % 1.5 3.2

Years experience
mean (SD) 22.2 (10.46) 22 (10.7) .9857

Region
AL% 66.7 42.2 <.0001*
FL % 19.7 19.4
HP % 2.3 12.8
KP % 8.4 12.2
SK % 2.9 13.4

Percent of patients
covered by public 16(.)2.3 (3) .07
insurance
scheduled
mean (SD)

Percent of Black or
African-American 2.3 (1.8) 2 (1.6) .85
patients scheduled
mean (SD)


* statistical significance










Table 4-6. Summary of intervention option of treatment selected on visual case scenarios for
high caries risk individual (question 10) according to dentist' s and practice' s
character stick s
n=504 Level of Level of intervention p-value
intervention Case 3/Case 4/Case5
Case 1 or Case 2 (dentin surfaces)
(enamel surfaces)
Gender
Male % 84.1 77.3 .0952
Female % 15.9 22.7

Race
White % 92 93 .5293
Hisp % 3 1
Black % 3 3
Other % 2 3

Years Experience
Mean (SD) 21.4 (11.1) 23.7 (8.9) .2125

Region
AL% 60.6 47.7 <.0001*
FL % 20.2 17.4
HP % 4.7 11
KP % 10.6 7.3
SK % 3.9 16.6

Percent of patients
covered by public 1.7 (2) 2.5 (3.2) .1609
insurance
scheduled
Mean (SD)

Percent of Black or
African-American 2.3 (1.7) 2 (8.9) .0689
patients scheduled
mean (SD)

* statistical significance










Table 4-7. Summary of level of intervention treatment according to caries risk and diagnostic
image available


n=504


Level of intervention
Case 1 or Case 2
(enamel surfaces)


Level of intervention
Case 3/Case 4/Case5
(dentin surfaces)


p value


Visual exam
Low risk
High risk

Radiographic exam
Low risk
High risk


63.5%
78%


41.4%
75.6%


36.5%
22%


58.6%
24.4%


p<.0001


p<.0001










Table 4-8. Summary of clinical treatment options chosen on a existing composite restoration
interfacing a dentin surface (question 13) according to dentist' s and practice' s
character stick s
N=490 No Prevention Prevention & Intervention p-value
treatment intervention
Gender
Male % 79.1 85 78.9 87.9 .0781
Female % 20.9 15 21.1 12.1

Years Experience
Mean (SD) 26.6 (10.5) 22.3 (6.6) 20.7 (10.7) 22. 1(11.2) .0589

Race
White % 91 85 90 93 .297
Hisp % 3 5 4 2
Black % 2 5 2 3
Other % 4 15 4 2

Access caries risk
YES 9.6 4.4 45.3 40.7 .1657
NO 6.7 3.7 37.8 51.8

Region
AL% 39.5 35 53 69.1 <.0001*
FL % 14 10 21.1 19.5
HP % 2.3 10 8 4.3
KP % 9.2 15 15.5 4.3
SK % 35 30 2.4 2.8

Percent of patients
covered by public 3.3 (3.9) 4.2 (3.9) 15(.).718) .0009*
insurance scheduled
mean (SD)

Percent of Black or 1.4 (1) 15(.)2.2 (1.8) 2.4 (1.7) .952
African-American
patients scheduled
mean (SD)

* statistical significance










Table 4-9. Summary of clinical treatment options chosen on a existing composite restoration
interfacing an enamel surface (question 14) according to dentist's and practice's
character stick s
n=490 No Prevention Prevention & Intervention p-value
treatment intervention
Gender
Male % 83.3 75 76.9 86.4 .0747
Female % 16.7 25 23.1 13.6

Race
White % 92 87 91 93 .9547
Hisp % 2 4 2 2
Black % 2 4 3 3
Other % 4 5 4 2

Years Experience 21.1 (11.1) 23.6 (6.4) 19.3 (10.3) 23.4 (10.6) .1359
Mean (SD)

Access caries risk
YES 10.2 5.5 29.4 54.9 .0049*
NO 8.2 3 16.4 72.4

Region
AL% 41.7 45.8 53.1 63.6 <.0001*
FL % 20.8 12.5 17.2 20.6
HP % 8.3 12.5 7.8 4.6
KP % 8.3 16.7 20.3 5.3
SK % 20.9 12.5 1.6 5.9

Percent of patients 2.7 (3.3) 2.4 (2.9) 1.6 (2) 17(.) .1065
covered by public
insurance scheduled
Mean (SD)

Percent of Black or 16(.) 2.3 (1.9) 21(.) 2.3 (1.7) .388
African-American
patients scheduled
Mean (SD)

* statistical significance










Table 4-10. Summary of clinical treatment options chosen on an existing amalgam restoration
(question 15) according to dentist's and practice's characteristics
n=475 No Prevention Prevention and Intervention p-value
treatment intervention
Gender
Male % 86.8 83.3 77.3 86.8 .3724
Female % 13.2 16.7 22.7 13.2

Race
White % 94 94 89 90 .4288
Hisp % 2 0 2 3
Black % 2 0 2 5
Other % 2 6 7 2

Years Experience 21.7 (10.2) 14.25 (8.1) 20.2 (10.9) 24.5 (11) .0154*
Mean (SD)

Access caries risk
YES 48 5.4 10.8 35.8 .0089*
NO 56.5 0 5.3 38.2

Region
AL% 58.5 27.8 54.8 59.4 <.0001*
FL % 17 0 19.1 26.5
HP % 7.5 16.7 7.1 2.4
KP % 8.7 50 16.7 7.1
SK % 8.3 5.5 2.3 4.6

Percent of patients 2 (2.4) 1.3 (2.3) 1.7 (2.4) 1.6 (2) .0641
covered by public
insurance scheduled
mean (SD)

Percent of Black or 2.2 (1.6) 1.3 (.7) 2 (1.8) 2.3 (1.8) .098
African-American
patients scheduled
mean (SD)

* statistical significance.











70






50-
ur 44 ,1

40 _mno treatmenTt
:r- oprevenTtion
a prevenTtion & intervention
30r Ir a IntevenTtion


20-


3 1 1.1 q r

~o


Q 13 Q 14 Q 15



Figure 4-1. Treatment chosen by dentists for clinical case scenarios involving existing
restorations (questions 13 to 15)









CHAPTER 5
DISCUSSION

Response Rate

Response of 200 clinicians was deemed necessary for proper analysis of the data, as

described in Chapter 2, under Statistical Analysis and Power Calculation. The response rate was

55 percent, and 504 questionnaires were returned which provided a sufficient number of

responses. Nevertheless reasons why the response to the study by DPBRN participants was not

higher should be considered. This was the very first study of the network, and perhaps some

clinicians were afraid to commit to the network or to expose their responses. Care was taken to

re-assure participants that the data used for this study would be de-identified as described in an

introductory letter.

The comprehension of the study questions was assessed in a pilot-testing done with the

assistance of 16 clinicians, participants of the DPBRN. The reliability of the questions was also

assessed in a test-retest of questionnaire items, which involved another 35 DPBRN dentists. We

feel confident that although the response rate was less than expected and more than what was

needed, the quality of the data produced had been carefully thought through pre-testing and test-

retesting.

The lower response rate from Alabama site is probably related to its higher number of

eligible participants with almost a 19-fold difference from Health Partners and Scandinavia sites,

and 5 to 12-fold difference from Florida and Kaiser Permanente sites.

Methods for Diagnosing Carious Lesions

The accurate diagnosis of the presence or absence of disease is paramount for appropriate

care. Even though several methods haven been described for the diagnosis of dental caries, no

consistent criteria used by dentists exit (98). The diagnosis of occlusal caries is highly subj ective









with considerable variation in opinion among clinicians as to appropriate diagnosis and treatment

(7). Reviews of the available literature point methodological difficulties in drawing valid

comparisons between studies due to incompatible criteria and simulations (13, 120). It has also

been concluded that no caries diagnostic tool fulfills all of the ideal criteria for accurate

measurements needed to plan appropriate care (13, 120, 130).

In the current study, dentists use the dental explorer, a tactile tool, as the main instrument

for the diagnosis of occlusal and recurrent dental caries. The low specificity (approximately 40

percent) reported for this diagnostic tool when used as the only diagnostic method is of concern

(25, 65, 122). Dentists tend to over diagnose caries if a sharp instrument is used and stuck to any

deep pit and fissure without the true evidence of caries. A "sticking" probe is not necessarily

indicative of decay and may be entirely due to local anatomic features. The advice of applying

pressure with a sharp explorer has been called into question, particularly in Europe and

Scandinavia, because of documented damage to surface integrity and possible implantation of

organisms, both of which may increase lesion susceptibility (33, 129). Although this issue is

somewhat contentious, the evidence suggests that an explorer should be used lightly or not at all

on occlusal surfaces.

The use of magnification which assists in the visual criteria was consistently used by

almost half of the dentists in the study. The visual criteria for evaluating carious lesions have

been described and, in certain studies, they have been validated in vitro by sectioning the teeth

after the lesions had been visually scored (34); the histological features are considered as the

'gold standard'(84 ). Visual method for evaluation of dental caries has low sensitivity and high

specificity in diagnosing occlusal caries (63, 69, 133).









The use of film radiograph for caries detection has a long history, and is still a widely used

diagnostic technique (106, 130). In the current study, radiographs have been consistently and

widely used for the diagnosis of proximal dental caries and less often for the diagnosis of

occlusal dental caries. It is hypothesized that occlusal lesions are initiated on the fissure walls

and can therefore be obscured by sound superficial tissue (103). Additionally, there is evidence

that one effect of regular use of fluorides is greater opacity of enamel, which may obscure

underlying lesions in dentin, the so-called "hidden lesions". Therefore, dental radiographs have

been reported inadequate for detecting caries in the occlusal surface until the lesion is well

advanced through the enamel and into the dentin (103). False positives can also occur with

radiographic diagnosis, and specificities of 66% to 98% have been recorded in vitro (46, 62).

However, regarding proximal dental caries, studies have reported high sensitivity values for

radiographs for the diagnosis of proximal dental caries (25, 105, 123, 126, 127, 135).

Non-Traditional Methods

Fiber-optic transillumination (FOTI) is a qualitative method that has been used for several

years. In FOTI, white light from a cold-light source is passed through a fiber to an intra-oral

fiber-optic light probe that is placed on the buccal or lingual side of the tooth. The surface is

examined using the transmitted light, seen from the occlusal view. Demineralized areas appear

darker compared with the surrounding sound tissue. The contrast between sound and carious

tissue is then used for detection of lesions. FOTI has been evaluated in a number of studies for

detection of posterior proximal carious lesions reporting low-to good sensitivity and good

specificity (101, 102, 118, 125, 126). One in vitro study suggested that a combination ofFOTI

and visual inspection is valid for determination of occlusal lesion depth (27).

Another non-traditional method inquired in the study is the use of a quantitative light-

induced laser fluorescence. Fluorescence occurs as a result of the interaction of electromagnetic









radiation with molecules in the tissue. The cause of enamel fluorescence is still unclear. Most of

the fluorescence is induced by organic components, proteinic chromophores, but some is

probably attributable to apatite (117). It has been proposed that fluorescence in dentin is caused

by inorganic complexes, as well as some organic components (6). Demineralization of dental

hard tissue, enamel or dentin results in the loss of autofluorescence, the natural fluorescence.

DIAGNOdent (Kavo Inc.) is a laser-based instrument, developed for detection and quantification

of dental caries through laser fluorescence on smooth and occlusal surfaces (57). The light is

transmitted through a descendent optic fiber to a hand-held probe with a beveled tip with a fiber-

optic eye. Factors that may influence the outcome of the measurements in different ways are

presence of plaque, calculus and/or staining on the tooth surface (27, 83) and the degree of

dehydration of tooth tissue (1 13).

Even though advances in technology have made available other assisting diagnostic

methods such as FOTI and DIAGNOdent, the study shows that dentists participating in the

DPBRN do not use these methods. Various levels of sensitivity have been reported for

DIAGNOdent (2, 41, 71, 82, 123, 131, 136) and FOTI (27, 58, 59, 111) for the diagnosis of

occlusal and proximal dental caries. The strength of the evidence however is low as the available

literature information is insufficient to support generalizable estimates of the sensitivity and

specificity studies of these diagnostic methods. The maj or problem relies in variations of the

validation methods and small number of sample size. Although these new technologies hold

significant promise, there is not enough evidence in the current literature for any of these

techniques to be recommended as a substitute for the traditional techniques.

Concluding Remarks

Caries lesions occur in a variety of anatomic locations and have unique aspects of

configuration and rate of spread. These differences make it unlikely that a single diagnostic









method will have the adequate sensitivity and specificity to detect caries at all sites. Reports on

the literature concluded that conventional visual, tactile, and radiographic examinations used as

individual diagnostic methods provide less than ideal diagnostic sensitivity (25, 65, 81, 87, 122).

Neither a black or brown fissure nor the use of an explorer has been shown to improve diagnostic

accuracy. However, the combination of careful visual examination with optimal radiographic

examination affords better diagnostic performance (87). An investigation of the validity of

diagnosis by means of optimal bite-wing radiography combined with careful visual clinical

examination has shown that the maj ority of carious lesions and nearly all sound teeth can be

correctly identified (3, 68).

Dentist's Assessment of Caries Risk

Two key points are essential to understanding caries. First, caries is a bacterial infection

caused by specific bacteria. Second, before cavitation, caries is a reversible multi-factorial

process (43, 44). Changing disease patterns require dentists to critically evaluate the caries risk

of each patient. The assessment of patient' s caries risk will assist in the formulation of an

appropriate treatment plan as it allows specific preventive measures for each patient's needs,

based on the risk grade and the causally-directed diagnosis.

A structured caries risk assessment should be based upon the concept of the caries balance.

The balance between pathological and preventive factors can be swung in the direction of caries

intervention and prevention (43, 44). In the current study, irrespective of how caries risk was

assessed, it had a positive impact on treatment plan as dentists were more readily to choose the

prevention treatment option when facing various clinical case scenarios. Conversely, dentists

who reported no assessment of caries risk during the treatment planning process were more

prone to choose the surgical intervention treatment when facing various clinical case scenarios.









Similarly, one study reported on the impact of not adhering to risk-assessment methods and the

low use of certain preventive treatments, such as dental sealant (72).

Studies reporting on agreement and disagreements among dentists' recommendations for

restorative treatment concluded that much of the variation in dentists' profiles is due to basic

differences in decision-making and caries risk assessment (9, 16). Lack of consistency in

dentists' decisions to intervene can have a significant effect on preservation of tooth structure

and cost of treatment (1 14).

Caries Diagnosis Based on Clinical Findings

Accurate diagnosis of dentinal caries is more challenging on occlusal than on proximal

surfaces. The diagnosis of occlusal dentinal caries is tricky unless cavitation or radiographic

evidence is present. Furthermore, much of the caries for which clinical intervention is required

occurs in the occlusal surfaces of the teeth, particularly the complicated fissure systems of the

molar teeth. The occlusal fissures of the first permanent molar are generally the first sites in the

permanent dentition to develop caries (69)

In recent years, there has been pronounced change in the epidemiology and disease pattern

of dental caries (60, 61, 86). Progression of enamel caries is now slower, and allows preventive

intervention before the stage of irreversible destruction of the tooth is reached. There is also a

pronounced reduction in lesion development on smooth surfaces accessible to fluoride (31, 110,

124).

Most dentists, irrespective of patient' s caries risk, chose not to restore the enamel lesion

with no signs of dark brown pigmentation (as shown in case 1). However, dentists readily

changed their treatment option to surgical intervention, if some minor brown pigmentation was

present on enamel. The frequency of selecting this option was directly proportion to an increase

on patient' s caries risk. The most critical area when deciding on treatment of dental caries lies









on initial or incipient carious lesions (shown in case 1, 2, and 3). Traditionally, all surfaces that

had either deep fissures or superficial staining had to be restored, along with the famous

"extension for prevention" proposed over a century ago by Dr. Greene Vardiman Black in 1891

(20, 21). After the advent of fluoride and resin technology, dentists slowly replaced the

"extension for prevention" approach, limiting to the removal of stained fissure with a small bur

and the placement of a resin sealant. Even though several studies have attested the importance of

fluoride (31, 110, 124) for remineralization of early non-cavitated carious lesions, dentists are

still reluctant to adhere to changes in the progress of the disease pattern and new non-invasive

treatments proposed as shown by the results of the study.

Enamel caries, both occlusal and proximal, can generally be managed without operative

intervention (28). It has been concluded on an international consensus report that the minimum

stage at which surgical intervention is indicated is when the caries disease has reached the dentin

(28). Although the tactile differentiation was not possible in the current study, as only pictures

were provided, the images shown gave a definite notion of the caries progression. All initial

carious lesions start as subsurface lesions located either in enamel (29, 55, 115, 116), dentin (91)

or cementum (49). The caries process at this stage may be arrested if a positive change on

patient' s oral habits is taken place or more obj ectively, if prevention treatment is initiated (45). If

the lesion is arrested at this stage, the porosities may pick up stain from nutrients and liquids in

the oral cavity, but the surface remains intact. These discolorations vary from light brown to dark

brown to almost black. Since these discolored lesions have the surface layer clinically intact (as

shown is case 2), they do not require restoration, except for esthetic reasons, if the lesion is

visible during normal function (45). If the caries is not arrested, the demineralization progresses,

the enamel will eventually crumble, and cavitation of the lesion becomes an irreversible stage in









the caries process that will require restoration to reestablish function and esthetics (Cases 4 and

5).

The presence of visible cavitation of the enamel surface is, in most cases, synonymous

with dentinal involvement. When definite cavitation is present, the question generally becomes

not if, but how far, the carious process has penetrated into the dentin. In one study of 60 molars

with small visible cavitations, caries had reached the dentino-enamel junction in 25% of the

teeth. For the remaining 75%, the caries process extended far into the dentin (128).

Caries experience seems to make a difference in the approach of treatment. On individuals

with high caries experience, 50% of the lesions in the outer half of the dentin are restored, in

contrast to 20% restored in individuals with lower caries experience (77). Similarly, in the

current study, caries risk was significant when deciding the stage of intervention. Dentists were

more readily to choose the intervention treatment on enamel surfaces when patients were in a

high caries risk scenario.

Caries Diagnosis Based on Radiographic Finding

The current study revealed that dentists were more readily to restore surgically enamel

surfaces when they use the visual versus the radiographic diagnostic tool. Even though the

radiographic pictures present a two dimensional stage of caries progression when compared to

the clinical pictures, the majority of the dentists still chose to restore enamel lesions (case 1 and

2), despite the fact that previous studies have demonstrated that proximal enamel lesions with no

cavitation can be arrested by fluoride treatment (31, 110, 124).

As outlined by the radiographic images, the early carious lesion on smooth or flat enamel

surfaces takes on a conical shape (19). If allowed to progress, the lesion will reach the

dentinoenamel junction and continue into dentin. In all areas the enamel lesion will advance in a

direction parallel to the rods and the depth of the demineralization will vary depending on the










time each rod has been subj ected to the demineralization process. Although the lesion evolves as

a unit, the particular shape of the subsurface lesion may be best understood if each enamel rod is

envisioned as developing individually as a "mini-lesion". The oldest, deepest part is located in

the center of the lesion and the youngest, shallowest part is located at the periphery (19).

Histologic and microradiographic evidence show that the first alterations in dentin, as a

response to caries, is a hypermineralized zone that develops even before the enamel lesion

progresses to the dentinoenamel junction (18, 19). Subsequent demineralization of the dentin

takes place when the enamel lesion progresses to the dentinoenamel junction. As the lesion

progresses, the involvement of dentin becomes greater, but the dentin demineralization and the

hypermineralization does not exceed the area corresponding to the limits of the outer enamel

lesion.

Differences in treatment according to caries penetration into enamel and dentin have been

described previously particularly for Scandinavian countries (77, 78). Similarly, in the current

study, dentists from Scandinavia chose not to restore lesions that were limited to enamel, but

instead they chose restorative treatment predominantly for proximal surfaces that involved

dentin. Scandinavian approach to caries diagnosis has been remarkably different as it is outlined

in the next sub-section.

Practices' and Dentists' Characteristics

Remarkable differences when restoring enamel lesions were also detected regarding the

type of practice. Alabama and Florida participating practices were different than Kaiser

Permanente, HealthPartner, and Scandinavia participating practices. The first two were

significantly more aggressive in regard to the nature of their treatments, i.e., they chose the

intervention treatment option on the various case scenarios more often than the other three

participating practices. Additionally Alabama and Florida participating practices assessed caries










risk significantly less than Kaiser Permanente, HealthPartner, and Scandinavia participating

practices.

The participating practices from Alabama and Florida regions were mostly private practice

in nature in which fee-for-service was administered. In fee-for-service type of practice, the cost

of practicing and revenue are function of number and type of procedures being done, and amount

of time used to deliver the services. Therefore, dentists participating in this type of practices

may feel urged to intervene surgically instead of pursuing a less invasive and less costly

treatment.

Practices from HealthPartner and Kaiser Permanente are "health maintenance

organization" (HMO) in which a fixed-salary is paid to the working dentist. Incentives, such as

bonus per production may also exist, however this is not the main incentive for this type of

practice. Practices in Scandinavia work in a similar manner in which the government is

responsible for payment of a fixed-salary to the working dentist. Therefore, participants in this

type of practice feel less pressured to impose services that may carry a higher fee schedule.

Another very important point to be considered regarding differences found for practices in

Scandinavia relies on the fact that in Scandinavian dental school, preventive and restorative

dentistry have, for many years, been integrated in the undergraduate curriculum as one subj ect,

"cariology", and this is reflected in the textbooks of the 1960s, 1970s, and 1980's (40). In North

American textbooks of operative dentistry, however, this concept has only recently been

introduced (64, 80). Current treatment strategy in Scandinavia is based on diagnosis of caries

activity, identification of the main causal and predisposing factors in the individual case, and

assessment of the actual caries risk (73).









A comprehensive review of the literature (8) concluded that "the extent to which variation

in dentists' detection of caries and evaluation of existing restorations are associated with

characteristics of the dentist and the practice is completely unknown". The current study showed

that patient' s race had an impact on selection of treatment of dental caries. Practices with lower

percent of black or African-American patients were more readily to choose the prevention

treatment option and to assess patient' s caries risk. On the other hand, practices with higher

proportion of black patients intervene more often and aggressively on enamel lesions. It has

been suggested that most dentists develop their principal treatment recommendations without

considering many non-clinical patient factors (8). Conversely, in the current study dentists who

belonged to a practice with a certain type of patient population had significant differences related

to diagnosis and treatment of dental caries. The socio-demographic determinants of dental care

have been proposed and they include individuals that reside in a rural area, African-Americans,

and the poor who have all been presumably at higher risk for dental problems (53). Interestingly,

the standard case scenarios proposed in the current study did not request clinicians to consider

patient' s race and patient' s social-economical status, however dentists responded with more

invasive procedures and treatment plans, and less emphasis on preventive measures delivered to

practices that treated a higher proportion of minority population.

Public insurance had a positive impact on participating practices, in which practices with

higher percent of patients covered by public insurance performed more prevention treatment than

practices that were not covered by public insurance. A previous survey study reported that

dentists involved in pediatric practices with high volume of patients under public insurance had

positive opinions about their practice, high levels of knowledge, and assessed risk factors in their

patients (30).









Studies have reported on the relationship of reimbursement and the use of preventive

measures. In one study, it has been suggested that reimbursement by itself could not increase

dentists' use of preventive treatments as after fluoride varnish became a covered benefit, dentists

increase its use, however after two years, the maj ority of the dentists still had not adopted the

preventive measure (47). Another study reported on a similar finding, in which managed care

preventive services were poorly used by patients and the profession due to lack of financial

incentives to increase their use (1).

Even though, no significant differences were found for gender and race of dentists, years of

experience was significant for different outcomes, including assessment of caries risk, as dentists

with less years of experience assessed caries risk more often than those with more years of

experience. Interestingly, dentists with less years of experience were more readily to choose the

prevention treatment option than dentists with more years of experience. Even though the

transition from intervention to prevention in caries treatment has been a slow process, dental

school programs have attempted to study and incorporate various levels of caries risk assessment

and disease control (26). Deficiencies still exist regarding full implementation of caries risk and

prevention programs in dental schools, however a certain exposure of the subj ect seems to have

been given to recently-graduated clinicians.

Evaluation of Existing Restorations

Cross-sectional studies have shown that replacement of failed restorative treatment

constitute 50-70% of all restorative work performed in general dental practice (48, 97). Among

dentists, decisions to replace existing restorations exhibit more variation than do caries diagnosis,

with a fivefold difference in replacement rates (89). As the population ages and people are living

longer with tooth loss across all ages decreasing (24, 64), it is necessary to search for a reliable

diagnostic criteria for evaluation of existing restorations, given that each time a restoration is










replaced, more tooth structure is lost (50, 51, 52). No described criteria exist for the diagnosis of

recurrent caries or caries adj acent to existing restorations. One of the main reasons that

restorations may be placed or replaced precipitately is that dentists do not have a consistent

method to predict the caries progression or to diagnose caries adj acent to existing dental

restorations. The differentiation between active and arrested carious lesions is commonly carried

out with respect to primary caries, and it is not reported in relation to recurrent caries, either in

textbooks of operative dentistry or in cariology textbooks. Consequently, it is not included in

clinical diagnosis and treatment planning of recurrent carious lesions (26, 137). Equally

important is the differential diagnosis between a defective restoration margin and active recurrent

caries.

Because of the nature and color of the tooth-colored composite restoration, dentists, in the

current study, had the tendency to confuse defective margins, which could easily be polished or

repaired, with margins that actually have recurrent caries that may require a more aggressive

treatment, the replacement of the entire restoration. This was particularly evident with the

composite restorations as dentists chose the intervention option of treatment. Conversely, when

dealing with amalgam restorations dentists were generally more conservative choosing the "no

treatment option". A previous study showed a poor correlation between the presence of

defective margins and caries after removal of amalgam restorations (85). The lack of standards

to determine restoration failure causes the dentists to err on the side of caution when faced with

uncertain diagnosis. Based on these findings and the fact that the cost of care and oral health are

severely impacted by the diagnosis of existing restorations, establishing a new evidence-based

criteria for evaluation of existing restorations is a critical issue that may profoundly reflect on the

over-treatment of existing restorations.









CHAPTER 6
FUTURE WORK

The current study has laid a foundation for future studies that may evaluate techniques and

decision-making process when treating dental caries with placement or replacement of

restorations. In fact, three of such studies have been designed and are on-going at the DPBRN:

Reasons for placing the primary restoration on permanent tooth surface; Reasons for

replacement of restorations; and Longitudinal study of dental restorations. The overall goal of

these studies is to capture how dentists are currently treating dental caries. These studies will

inquire primarily about, the reasons for placement of replacement of restorations, the materials

and techniques used to restore, and how long these restorations last. The data from these studies

may then be related to the results of the current study for better understanding the dentist' s

responses to actual treatment of dental caries. The purpose of such evaluation is to determine if

discrepancies exist between what dentists believe should be done during caries diagnosis and

treatment to what is actually delivered. The overall goal is to determine if over-treatment exists

which may directly impact on the health of the tooth, cost of treatment, and access to dental care.









CHAPTER 7
CONCLUSIONS

DPBRN dentists primarily use traditional methods such as dental explorer and radiographs

for the diagnosis of dental caries. Differences were found regarding the use of caries risk

assessment and significant variation exists according to dentist' s experience and certain

characteristics of the practice. The decision to intervene surgically in a caries process differs by

severity of caries, patients' caries risk, and certain characteristics of the practice. Regarding

assessment of existing restorations, treatment options chosen by participating dentists varied

according to the various case scenarios, the use of caries risk assessment, and certain

characteristics of dental practices.







APPENDIX A
QUESTIONNAIRE: ASSESSMENT OF CARIES DIAGNOSIS AND CARIES TREATMENT


Dental Practice-Based Research Network
www. DentaL.PBRNf.org















Completion Date / / 2006


SECTION 1: Questions 1- 7 have to do with methods that you may use to diagnose dental caries.
Please circle the one number that best corresponds to your answer. Patients can vary substantially
from one practice to the next, but we are interested in the patients in YOUR practice.


1. When you examine patients to determine rt they have a caries lesion on a proximal mesiall or disiall
surface~, on a pojstenor loroth, on what percent of these patients do you use radiographs to help
diagnose the lesion?
1 Never or 0%/
2 1 to 24%
3 --25 10 49.
4 50 to 74%
5 75 to 99%
6 Every time or 100%

2. When you examine patients to determine if they have a caries lesion on the occlusal surface, on what
percent of these patients do you use radiographs to help diagnose the lesion?
1 Never or 0%
2 1 to 24%
3 25 to 49JJ
4 50 to 74%A
5 75 to 99%
6 Every time or 100%

3. When you examine patients to determine if they have a primary ocolusal caries lesion, on what
percent of these patients do you use a dental explorer to help diagnose the lesion?
1 Never or 0%
2 1 to 24%
3 25 to 49%
4 50 to 74%
5 75 to 99%
6 Every time or 100%

4. When you examine patients to determine If they have a caries lesion at the margin of an existing
restoration (recurrent/secondary caries) on what percent of these patients do you use a dental
explorer to help diagnose the lesion?
1I Never or 0%
2 1 to 24%
3 25 to 49%
4 50 to 74%
5 75 to 99%
6 Every time or 100%




















5. When you examine patients to determine if they have a primary caries lesion on the occlusal surface,
on what percent of these patients do you use laser fluorescence :for example, Dlagnede~nt P3
1 Never or 0%
2 -1 to 24%
3 25 to 49%
4 50 to 74%
5 75 to 99%
6 Every time or ~100%/


6. When you examine patients to determine If they have a caries lesion on a proximal mesiall or distal)
surface of an anterior tooth on what percent of these patients do you use fiber optic transillumination to help
diagnose the lesion?
1 Never or 0%b
2 1to24%
3 25 to 49%
4 50 to 74%
5 75 to 99%
6 Eivery time or 100%


7. When you examine patients to determine If they have a caries lesion, ton what percent of these patients do
you use some sort of magnification to help diagnose the lesion?
1 Never or 0%
2 -- 1 to 24%
3 25 to 49%
4 50 to 74%/
5 75 to 99%
6 Every time or 100%


SECTION 2: Question 8 has to do with assessment of caries risk during the treatment planning
process. Please: circle the answer that best described what you do in YOUR practice. Pleases indicate if
you use a special form for caries risk assessment.


8. Do you assess caries risk for individual patients in any way?

1 -Yes
a, I record the assessment on a special form that is kept in the patient chart.

b. I do not use a special form to make the assessment.


2 -No




















SECTION 3: Please use the following guide for the treatment codes used in questions 9 and 10.
For each question, circle the letters which correspond to the treatment codes you would recommend
for each of the five cases. If treatment code '"n'" (other) is used, please specify. You may circle more
than one treatment code Per case,

a. No treatment today, follow the patient regullarly h. Minimal dnlllng and preventive resin restoration
b. In-office fluoride i. Air abrasion and a sealant
c. Recommend non-prescription fluoride j. Air abrasion and preventive resin restoration
d. Prescription for fluoride k. Amalgam restoration
e. Use sealant or unfilled resin over tooth i. Composite restoration
f, Chlorhexidine treatment m. Indirect restoration
g. Minimal drilling and sealant n. Other treatment [Please specify]

The patient is a 30 year old female with no re~levant mnedrcal history. She has no complaints and is in your
office today for a routine visit.


9. Indicate how you would treat the tooth shown if the patient has no other teeth with dental restorations or
dental caries and is not missing any teeth


Reprinted from Espella e at' al'"ih permasslort


Case l Case 2 Case 3
a b orde f g a b (:d f g a b ade f g


Case 4
abade fg


Case 5
abcde fg


hi jk Im n h iijk Imn hijiki1mn hijIk Im n hi jk imn



10. If the same patient has 12 teeth with existing dental restorations, heavy plaque and calculus, mnultiple
Class V white spot lesions, and is missing five teeth.
Case 1 Case 2 Case 3 Case 4 Case 5
abode f g abode f g abcde f g abode f g ahede f g
h iijk imn h ijik lmn hi j k imn h iijk Imn h iijklm n



















SECTION 4: For questions 11 and 12, please circle the one number that corresponds to the lesion
depth at which you think it is best to do a permanent restoration (composite, amalgam, etc.) instead of1
only doing preventive therapy?

The patient is a 30-year old female with no relevant medical history. She has no complaints and is in your
office today for a routine visit.


11. The patient has no dental restoratlons, no dental caries, and is not missing any teeth,


1 2 3 4 5


12. The patient has 12 teeth with exrstlng dental restorations, heavy plaque and calculus, multiple Class V
white spot lesions, and is not missing any teeth. At what lesion depth do you think it would be best
to do a permanent restoration instead of only doing preventive therapy?


1 2 3 4 5
















SECTION 5: Please use the following guide for the treatment codes used in questions 13-15, For
each question, circle the letters which correspond to the treatment codes you would recommend
for scenarios described, If treatment code "j" (other) is used, please specify. You may circle more
than one treatment codepe utin
Question Question Question
13 14 15
a. No treatment today, follows the parent regularly a a a
b. Instruct patient In plaque removal for the affected area b b b
c. In-office fluoride c c c
d. Prescription for fuoride d d d
e. Recommend non-prescription fluoride e e e
f, Use sealant or unfilled resin over tooth
g. Chlorhexidine treatment 9 9 9
b. Polish, re-surface, or repair restoration, but not replace h h h
i, Replace entire restoration i
j. Other treatment [picase specify] j ] j


For Questions 13-15: The patient is a 30-year old female with no relevant
medical history. She has no other dental restorations than the one shown,
no dental caries, and is not missing any leelh She has no complaints and
is in your office today for a routine visit. She has been attending your
practice on a regular basis for the past 6 years. (Circle your answers
above)

13. Indicate what treatment you would provide to the restoration in the first
picture on the left.






14. Indicate w~hal irealment you would provide to the restoration in the
second picture on the left.







15. Indicate what treatment you would provide to the restoration in the
third picture on the left.


Reprinted from 4Io~r el al"i with
permission






.


Reprinted fro~m Mjlor at al" wuith
permission





APPENDIX B
ENROLLMENT DATA QUESTIONNAIRE

US Dentists Enrollment Form

Section 1: Contact Information:



Today's date:

Prefix: (e.g., DR, MR, MS)
First Name:
Middle Name:
Last Name:
Suffix: (e.g., Sr., Jr.)
Degree: (e.g., PhD, DDS)
Email address:



Name of Practice: Site 1
Address line 1:
Address line 2:
City:
State:
Zip code:
Country:
Office phone number:
Alternative phone
number:
Fax number:
Assistant: First Name
Assistant: Last Name
Assistant: Email


Name of Additional
Practice: Site 2
Address line 1:
Address line 2:
City:
State:
Zip code:





Country:

Office phone number:
Alternative phone
number:
Fax number:
Assistant: First Name
Assistant: Last Name
Assistant: Email


Name of Additional
Practice: Site 3
Address line 1:
Address line 2:
City:
State:
Zip code:
Country:
Office phone number:
Alternative phone
number:
Fax number:
Assistant: First Name
Assistant: Last Name
Assistant: Email










Section 2: Practitioner Characteristics: [Questions 1 8]
Unless otherwise stated in the question, please provide one answer for each question.

1. Do you practice as a general dentist or as a specialist? Please select the appropriate
answer.

1. General Practitioner
2. Oral/Maxillofacial Surg~eon
3. Periodontist
4. Prosthodontist
5. Endodontist
6. Pediatric Dentist
7. Orthodontist
8. Other (please specify)

2. What is your gender?

1. Male
2. Female

3. What is your age?

4. What is your racial identification?

1. White
2. Black or African-American
3. American Indian or Alaska Native
4. Asian
5. Native Hawaiian or Other Pacific Islander
6. Other (please specify)

5. Are you of Hispanic or Latino origin?

1. Yes
2. No

6. In which of the following dental organizations are you currently a member? (Check all
that apply)

1. American Dental Association/state dental association/local association
2. Academy of General Dentistry/state academy of general dentistry
3. Other (please specify)
4. Other (please specify)
5. Other (please specify)
6. Other (please specify)
7. Other (please specify)










7. What year did you graduate from dental school?


8. From which dental school did you graduate?



Section 3: Practice Characteristics: [Questions: 9-17]

9. At how many dental sites, clinics, or hospitals do you provide direct patient care
(excluding teaching, consulting or management) at least once each week?

1. One
2. Two
3. Three
4. More than three

10. How many hours per week do you personally spend in direct patient care, as opposed to
management or teaching responsibilities (including all sites at which you are practicing)?

hours in patient care

11. How many people (including yourself) in your part of the practice work full-time or
work part-time (including all sites at which you are practicing)?
[Note: If you and another dentist share equally a receptionist, then count that employee as
%Z of an employee.]

full-time employees part-time employees
(32+ hours/week) (less than 32 hours/week)
dental hygienists
dental assistants
lab technicians
office manager, receptionist,
other office personnel

12. How many dental chairs do you, your assistantss, and hygienist(s) use regularly in your
part of the practice (including all sites at which you are practicing)?

dental chairs

13. How many patient visits do you personally (excluding your hygienist's patients) have
during a typical work week (including all sites at which you are practicing)?

patient visits in a typical week









14. Approximately what percentage of your patients have extended payment schedules? If
you do not accept extended payment schedules, please record 0% in the column.

%...of patients on extended payment schedules (e.g., monthly payments)

15. On average, how long does a patient in your practice have to wait:

1. for anew patient exam appointment days
2. for a treatment procedure appointment days
3. In the waiting room after arriving for an appointment minutes

16. Which of the following best describes your part of the practice during the past 12
months?

1. Too busy to treat all people requesting appointments
2. Provided care to all who requested appointments, but the practice was overburdened
3. Provided care to all who requested appointments, and the practice was not overburdened
4. Not busy enough the practice could have treated more patients

17. Please record what your typical fee is for a ...

Please check below if
you do not do this
procedure
2-surface amalgam (ADA 2150) $
3-canal molar root canal (ADA 3330) $
Single simple/uncomplicated extraction
(ADA 7140)
Cast partial denture (ADA 5213 or 5214) $
Full denture (ADA 5110 or 5120) $
Porcelain-to-metal crown (average of
ADA 2750, 2751, 2752)
1-surface posterior composite (ADA 2391) $
2-surface anterior composite (ADA 2331) $










Section 4: Patient Population Characteristics: [Questions: 18-23]
18. Approximately what percentage of the patients in your practice scheduled with you
are... ?

Children & Teenagers (1 to 18 years) %
Young adults (19 to 44 years) %
Middle aged adults (45 to 64 years) %
Elderly (65 or older) %
Please make sure your totals adds up to
100 %

19. Approximately what percentage of the patients in your practice scheduled with you
are... ?

White %
Black or African-American %
American Indian or Alaska Native %
Asian %
Native Hawaiian or Other Pacific Islander %
Other, please specify %
Please make sure your totals adds up to
100 %

20. Approximately what percentage of the patients in your practice scheduled with you are
of Hispanic or Latino origin?



21. Approximately what percentage of the patients in your practice scheduled with you are


Covered by a private insurance program that
pays for some or all of their dental care?
Covered by a public program that pays for
some or all of their dental care?
Not covered by any third party and pay their
own bills?
Not covered by any third party and receive free
care or for a fee that you reduce substantially?
Please make sure your totals adds up to
100 %










22. Approximately what percentage of revenues or charges are derived from different
payment sources? If you do not accept certain payment procedures below, please record
0% in the column.

% of practice revenue or charges from each
payment source
source
dental insurance %
self-pay %
unpaid bills %
Other, please
specify
Please make sure your totals adds up to
100 %

23. What percentage of visits in your part of the practice are...?

Scheduled more than one day in advance %









LIST OF REFERENCES

1. Albert DA. Sealant use in public and private insurance programs. NY State Dent J 1999;
65:24-25.

2. Alj ehani A, Yang L, Shi XQ. In vitro quantification of smooth surface caries with
DIAGNOdent and DIAGNOdent pen. Acta Odontol Scand 2007;65:60-63.

3. Alwas-Danowska HM, Plasschaert AJ, Suliborski S, Verdonschot EH. Relaibility and
validity issues of laser fluorescence measurements in occlusal caries diagnosis. J Dent
2002;30:129-134.

4. Anusavice KJ. Treatment regimens in preventive and restorative dentistry J Amer Dent
Assoc 1995;126:727-743.

5. Anusavice KJ. Benn DK. Is it time to change state and regional dental licensure board
exams in response to evidence from caries research? Crit Rev Oral Biol Med
2001;12:368-372.

6. Armstrong WG. Fluorescence characteristics of sound and carious human dentine
preparations. Arch Oral Biol 1963;8:79-90.

7. Bader JD, Brown JP. Dilemmas in caries diagnosis. J Am Dent Assoc 1993;124:48-50.

8. Bader JD, Shugars DA. Understanding dentists' restorative treatment decisions. J Public
Health Dent 1992; 52: 102-110.

9. Bader JD, Shugars DA. Agreement among dentists' recommendations for restorative
treatment. J Dent Res 1993; 72:891-896.

10. Bader JD, Shugars DA, McClure FE. Comparison of restorative treatment
recommendations based on patients and patients simulations. Oper Dent 1994; 19:20-25.

11. Bader JD, Shugars DA. Variation in dentists' clinical decisions. J Public Health Dent
1995; 55:181-188.

12. Bader JD, Shugars DA. What do we know about how dentists make caries-related
treatment decisions? Community Dent Oral Epidemiol 1997; 25:97-103.

13. Bader J, Shugars D, Bonito A. Systematic reviews of selected dental caries diagnostic
and management methods. J Dent Educ 2001;65:960-968. (A)

14. Bader J, Shugars D, Bonito A. A systematic review of selected caries prevention and
management methods. Community Dent Oral Epidemiol 2001;29:399-411. (B)

15. Bader J, Shugars D, Perrin N, Maupome G, Rindal, Rush W. Validation of a simple
approach to caries risk assessment. J Public Health Dent 2005;65:76-81










16. Bailit HL, Reisine ST, Damuth RL, Richards NP. The validity of the radiographic
method in the pretreatment review of dental claims. J Public Health Dent 1980; 40:26-
38.

17. Benn DK, Meltzer MI. Will modern caries management reduce restorations in dental
practice? J Am Coll Dent 1996; 63:39-44.

18. Bergman G. Studies on mineralized tissues. XIII. Combined micro radiographic and
autoradiographic investigations on carious teeth. J Dent Belge 1959; 50:75-85.

19. Bjorndal L, Thylstrup A. A structural analysis of approximal enamel caries lesions and
subj acent dentin reactions. Eur J Oral Sci 1995;103:25-3 1.

20. Black GV. Operative Dentistry, Vol 1, Pathology of the hard tissues of the teeth.
Chicago, 1L: Mexico Dental Publishing Company, 1908.

21. Black GV. Operative Dentistry, Vol 1, Pathology of the hard tissues of the teeth. London:
Claudius Ash, Sons & Co., 1914.

22. Bratthall D, Hansel Petersson G. cariogram-a multifactorial risk assessment model for a
multifactorial disease. Community Dent Oral Epidemiol 2005; 33:256-264.

23. Burke FJ, Cheung SW, Mjor IA, Wilson NH. Restoration longevity and analysis of
reasons for the placement and replacement of restorations provided by vocational dental
practitioners and their trainers in the United Kingdom. Quintessence Int 1999; 30:234-
42.

24. Center for Disease Control and Prevention (CDC) Public health and aging: retention of
natural teeth among older adults- United States, 2002. Morb Mortal Wkly Rep 2003;
19:1226-1229.

25. Chong MJ, Seow WK, Purdie DM, Cheng E, Wan V. Visual-tactile examination
compared with conventional radiography, digital-radiography, and DIAGNOdent in the
diagnosis of occlusal occult caries in extracted premolars. Pediatr Dent 2003;25:341-349.

26. Clark TD, Mjoir IA Current teaching of cariology in North American dental schools Oper
Dent 2001;26:412-418.

27. Cortes DF, Ellwood RP, Ekstrand KR. An in vitro comparison of a combined
FOTI/visual examination of occlusal caries with other caries diagnostic methods and the
effect of stain on their diagnostic performance. Caries Res 2003;37:8-16.

28. Criteria for placement and replacement of dental restorations: an international consensus
report. Int Dent J 1988;38:193-194.

29. Darling AI. Studies of the early lesion of enamel caries with transmitted light, polarized
light, and microradiography. Brit Dent J 1956; 101:289-297 and 329-341.










30. dela Cruz GG, Rozier RG, Slade G. Dental screening and referral of young children by
pediatric primary case providers. Pediatrics 2004; 114:642-652.

31. Donly KJ, Brown DJ. Indetify, protect, restore: emerging issues in approaching
children' s oral health. Gen Dent 2005;53:106-110.

32. Drake C, Beck J, Lawrence H, Koch G. Three-year coronal caries incidence and risk
factors in North Carolina elderly. Caries Res 1997;31:1-7.

33. Ekstrand KR, Qvist V, Thylstrup A. Light microscope study of the effect of probing in
occlusal surfaces. Caries Res 1987;21:368-374.

34. Ekstrand KR, Ricketts DN, Kidd EA. Reproducibility and accuracy of three methods for
assessment of demineralization depth of the occlusal surface: an in vitro examination.
Caries Res 1997;31:224-231.

35. Elderton RJ. An in vivo morphological study of cavity and amalgam margins on the
occlusal surfaces of human teeth. Ph.D. Thesis, University of London, 1975.

36. Elderton RJ. Assessment of the quality of restorations. A literature review. J Oral
Rehabil 1977; 4:217-26.

37. Elderton RJ. Treatment variation in restorative dentistry. Restorative Dent 1984; 1:3-
6,8.

38. Elderton RJ. Variability in the decision-making process and implications for change
toward a preventive philosophy. In: Anusavice KJ, ed. Quality evaluation of dental
restorations: criteria for placement and replacement. Chicago: Quintessence Publishing
Co., 1989: pp. 211-219.

39. Elderton RJ, Nuttall NM. Variation among dentists in planning treatment. Br Dent J
1983; 154:201-206.

40. Elderton RJ, Mj or IA. Treatment planning. In: Horsted-Bindsley P, Mj or IA, eds. Modern
concepts in operative dentistry. Copenhagen: Munksgaard; 1988: pp.59-92.

41. El-Housseiny AA, Jamj oum H. Evaluation of visual, explorer, and a laser device for
detection of early occlusal caries. J Clin Pediatr Dent 2001;26:41-48.

42. Espelid I, Tveit AB, Mejagre I, Nyvad B. Karies ny viten eller gamle sannheter? Nor
Tannlegefor Tid 1997; 107:66-74.

43. Featherstone JD. The caries balance: the basis for caries management by risk assessment.
Oral Health Prey Dent 20042:259-264.

44. Featherstone JD. Caries prevention and reversal based on the caries balance. Pediatr Dent
2006;28:128-132.










45. Fej erskov O, Nyvad B, Kidd EAM. Clinical and histological manifestations of dental
caries. In: Fejerskov O, Kidd EA eds. Dental Caries: The disease and its clinical
management. Maiden, MA:Blackwell Munksgaard, 2003; pp71-98.

46. Ferreira Zandona AG, Analoui M, Schemehorn BR, Eckert GJ, Stookey GK. Laser
fluorescence detection of demineralization in artificial occlusal fissures. Caries Res
1998;32:31-40.

47. Fiset L, Grembowski D, Aguila M. Third-party reimbursement and use of fluoride
varnish in adults among general dentists in Washington State. J Am Dent Assoc 2000;
131:961-968.

48. Friedl KH, Hiller KA, Schmalz G. Placement and replacement of amalgam restorations in
Germany. Oper Dent 1994; 19:228-232.

49. Furseth R, Johansen E. A microradiographic comparison of sound and carious human
dental cementum. Arch Oral Biol 1968;13:1197-1206.

50. Gordan VV. In vitro evaluation of margins of replaced resin based composite
restorations. J Esthet Dent 2000; 12:217-223.

51. Gordan VV. Clinical evaluation of replacement of class v resin based composite
restorations. J Dent 2001; 29: 485-488.

52. Gordan VV, Mondragon E, Shen C. Evaluation of the cavity design, cavity depth, and
shade matching in the replacement of resin based composite restorations. Quintessence
Inter 2002; 32:273-278.

53. Gilbert GH, Duncan RP, Kulley AM, Coward RT, Heft MW. Evaluation of bias and
logistics in a survey of adults at increased risk for oral health decrements. J Public Health
Dent 1997; 57:48-58.

54. Gilbert G, Foerster U, Dolan T, Duncan R, Ringelberg M. Twenty-four month coronal
caries incidence: the role of dental care and race. Caries Res 2000;34:367-79.

55. Gustayson G. The histopathology of caries of human dental enamel, with special
reference to the division of the lesion into zones. Acta Odontol Scand 1957; 15: 13-55.

56. Hawkins R, Jutai D, Brothwell D, Locker D. Three-year coronal caries incidence in older
Canadian adults. Caries Res 1997;31:405-10.

57. Hibst R, Gall R. Development of a diode laser-based fluorescence caries detector. Caries
Res 1998;32:294.

58. Hintze H, Wenzel A, Danielsen B, Nyvad B. Reliability of visual examination, fiber-
optic transillumination and bite-wing radiography, and reproducibility of direct visual
examination following tooth separation for the identification of cavitated carious lesions
in contacting approximal surfaces. Caries Res 1998;32:204-209.









59. Holt RD, Azevedo MR. Fibre optic transillumination and radiographs in diagnosis of
approximal caries in primary teeth. Community Dent Health 1989;6:239-247.

60. Hugoson A, Koch G, Hallonsten AL, Norderyd J, A~berg A. caries prevalence and
distribution in 3-20-years-olds in Jiinkiiping, Sweden, in 1973, 1978, 1983, 1993.
Community Dent Oral Epidemiol 2000;28:83-89.

61. Hugoson A, Koch G, Slotte C, Bergendal T, Thorstensson B, Thorstensson H. Caries
prevalence and distribution in 20-80-years-olds in Jiinkiiping, Sweden, in 1973, 1983,
1993. Community Dent Oral Epidemiol 2000;28:90-96.

62. Huysmans MC, Longbottom C, Pitts N. Electrical methods in occlusal caries diagnosis:
An in vitro comparison with visual inspection and bite-wing radiography. Caries Res
1998;32:324-329.

63. le YL, Verdonschot EH. Performance of diagnostic systems in occlusal caries detection
compared. Community Dent Oral Epidemiol 1994;22:187-191.

64. Ismail AI. Clinical diagnosis of precavitated carious lesions. Community Dent Oral
Epidemiol 1997;25:13-23.

65. Jahangiri L, Wahlers C, Hittelman E, Matheson P. Assessment of sensitivity and
specificity of clinical evaluation of cast restoration marginal accuracy compared to
stereomicroscopy. J Prosthet Dent 2005;93:138-142.

66. Kay E, Watts A, Paterson R, Blinkhorn A. Preliminary investigation into the validity of
dentists' decisions to restore occlusal surfaces of permanent teeth. Community Dent Oral
Epidemiol 1988; 16 91-94.

67. Kaste L, Selwitz R, Oldakowski R, Brunelle J, Winn D, Brown L. Coronal caries in the
primary and permanent dentition of children and adolescents 1-17 years of age: United
States, 1988-1991. J Dent Res 1996; 75 (special issue):631-641.

68. Ketley CE, Holt RD. Visual and radiographic diagnosis of occlusal caries in first
permanent molars and in second primary molars. Br Dent J 1993;174:364-370.

69. Kidd EAM, Ricketss DNJ, Pitts NB. Occlusal caries diagnosis: a changing challenge for
clinicians and epidemiologists. J Dent 1993;21:323-331.

70. Kidd EAM, Nyvad B. Caries control for the individual patient. In: Fej erskov O, Kidd E
eds. Dental caries. The disease and its clinical management. Oxford, UK: Blackwell
Munksgaard, 2003; pp303-312.

71. Kuhnisch J, Ziehe A, Brandstad A, Heinrich-Weltzien R. An in vitro study of the
reliability of DIAGNOdent measurements. J Oral Rehabil 2004;3 1:895-899.

72. Kumar JV, Wadhawan S. targeting dental sealants in school-based programs: evaluation
of an approach. Community Dent Oral Epidemiol 2002;30:210-215.










73. LagerloifF, Oliveby A. Clinical implications: new strategies for caries treatment. In:
Stookey GK, ed. Early detection of dental caries. Indianapolis, IN:. School of Dentistry,
Indiana University; 1996; pp 297-316.

74. Lawrence HP, Hunt RJ, Beck JD. Three-year root caries incidence and risk modeling in
older adults in North Carolina. J Public Health Dent 1995;55:69-78.

75. Lawrence HP, Hunt RJ, Beck JD, Davies GM. Five-year incidence rates and intraoral
distribution of root caries among community-dwelling older adults. Caries Res 1996;
30:160-179.

76. Lewis DW, Pharoah MJ, El-Mowafy O, Ross DG. Restorative certainty and varying
perceptions of dental caries depth among dentists. J Public Health Dent 1997 57:243-245.

77. Lith A, Pettersson LG, Grondahl HG. Radiographic study of approximal restorative
treatment in children and adolescents in two Swedish communities differing in caries
prevalence. Community Dent Oral Epidemiol 1995;23:211-6.

78. Lith A, Lindstrand C, Grondahl HG. Caries development in a young population managed
by a restrictive attitude to radiography and operative intervention: II. A study at the
surface level. Dentomaxillofac Radiol 2002;31:232-9.

79. Locker D. Incidence of root caries in an older Canadian population. Community Dent
Oral Epidemiol 1996;24:403-7.

80. Lundeen TF, Roberson TM. Cariology: the lesion, etiology, prevention, and control. In:
Sturdevant CM, Roberson TM, Heymann HO, Sturdevant JR, eds. The Art and Science
of Operative Dentistry. St Louis, Missouri: Mosby, 1995; pp: 60-128.

81. Lussi A. validity of diagnostic and treatment decisions of fissure caries. Caries Res
1991;25:296-303.

82. Lussi A, Hellwig E. Performance of a new laser fluorescence device for the detection of
occlusal caries in vitro. J Dent 2006;34:467-471.

83. Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. performance and
reproducibility of a laser fluorescence system for detection of occlusal caries in vitro.
Caries Res 1999;33:261-266.

84. Machiulskiene V, Nyvad B, Baelum V. Prevalence and severity of dental caries in 12-
year-old children in Kaunas,Lithuania. Caries Res 1998;;32:175-180.

85. Maryniuk GA, Brunson WD. When to replace faulty-margin amalgam restorations: a
pilot study. Gen Dent 1989; 37:463-467.

86. Mathaler TM. Caries status in Europe and predictions of future trends. Caries Res 1990;
24:381-396.










87. McComb D, Tam LE. Diagnosis of occlusal caries: Part I. Conventional methods. J Can
Dent Assoc 2001;67:454-457.

88. Mej are I, Stenlund H, Zelezny-Holmlund C. Caries incidence and lesion progression
from adolescence to young adulthood: a prospective 15-year cohort study in Sweden.
Caries Res 2004; 38:130-141.

89. Merrett MCW, Elderton RJ. An vitro study of restorative dental treatment decisions and
dental caries. Br Dent J 1984; 157:128-133.

90. Mileman PA, van der Weele LT. The role of caries recognition: treatment decisions from
bitewings radiographs. Dentinomaxillofac Radiol 1996; 25:228-233.

91. Mjiir IA. Histologic studies of human coronal dentine following cavity preparations and
exposure of ground facets in vivo. Arch Oral Biol 1967; 12:247-263

92. Mjiir IA. Amalgam and composite resin restorations: longevity and reasons for
replacement. In: Anusavice KJ, ed. Quality evaluation of dental restorations. Chicago:
Quintessence 1989;61-68.

93. Mj ir IA. Clinical diagnosis of recurrent caries. J Am Dent Assoc 2005; 136: 1426-1433.

94. Mjiir IA and Qvist V. Marginal failures of amalgam and composite restorations. J Dent
1997;7:25-30.

95. Mj ir IA, Reep RL, Kubilis PS, Mondragon BE. The change in size of replaced amalgam
restorations: A methodology study. Oper Dent 1998;23:272-277.

96. Mjiir IA, Toffenetti F. Secondary caries: A literature review with case reports.
Quintessence Int 2000; 31:165-179.

97. Mjiir IA, Shen C, Eliasson ST, Richter S. Placement and replacement of restorations in
general dental practice in Iceland. Oper Dent 2002;27: 117-123.

98. National Institutes of Health, Office of Medical Application of Research. Consensus
Development Conference Statement: Diagnosis and Management of Dental Caries
Throughout Life, March 26-28, 2001. accessed at:
http ://odp.od.nih.gov/consensus/cons/1 15/115_intro.htm.

99. Noar SJ, Smith BGN. Diagnosis of caries and treatment decisions in approximal surfaces
of posterior teeth in vitro. J Oral Rehabil 1990; 17:209-218.

100. Nuttall NM, Pitts NB, Fyffe HE. Assessment of reports by dentists of their restorative
treatment thresholds. Community Dent Oral Epidemiol 1993; 5:273-278.

101. Obry-Musset AM, Cahen PM, Turlot JC, Frank R. Approximal caries diagnosis in
epidemiological studies: transillumination or bitewing radiographs? J Biol Buccale 1988;
16:13-17.









102. Peers A, Hill FJ, Mitropoulos CM, Holloway PJ. Validity and reproducibility of clinical
examination, fiber-optic transillumination, and bite-wing radiology for the diagnosis of
small approximal carious lesions: an in vitro study. Caries Res 1993;27:307-311.

103. Pitts N. Advances in radiographic detection methods and caries management rationale. In
Stookey GK, ed. Early detection of dental caries. Indianapolis, IN:. School of dentistry,
Indiana University; 1996; pp 39-50.

104. Pitts NB. Diagnostic tools and measurements impact on appropriate care. Community
Dent Oral Epidemiol 1997;25:24-35.

105. Pitts NB, Renson CE. Reproducibility of computer-aided image-analysis-derived
estimates of the depth and area of radiolucencies in approximal enamel. J Dent Res
1985;64:1221-1224.

106. Pitts NB, Stamm JW (eds). Proceedings from the international consensus workshop on
caries clinical trials J Dent Res 2004;83:Spec Issue C: 125-128.

107. Qvist J, Qvist V, Mj or IA. Placement and longevity of tooth-colored restorations in
Denmark. Acta Odontol Scand 1990; 48: 305-311.

108. Ratledge DK, Kidd EA, Beighton D. A clinical and microbiological study of approximal
carious lesions. Pat 1: the relationship between cavitation, radiographic lesion depth, the
site-specific gingival index and the level of infection of the dentine. Caries Res 2001;
35:3-7.

109. Rytomaa I, Jarvinen V, Jarvinen J. Variation in caries recording and restorative treatment
plan among university teachers. Community Dent Oral Epidemiol 1979; 7:335-339.

110. Sawyer KK, Donly KJ. Remineralization effects of a sodium fluoride bioerodible gel.
Am J Dent 2004; 17:245-248.

111. Schneiderman A, Elbaum M, Shultz T, Keem S, Greenebaum M, Driller J. Assessment of
dental caries with digital imaging fiber-otpic transilumination (DIFOTI): in vitro study.
Caries Res 1997;31:103-110.

112. Schwartz M, Grondahl HG, Pliskin JS, Boffa J. A longitudinal analysis from bite-wing
radiographs of the rate of progression of approximal carious lesions through human
dental enamel. Arch Oral Biol 1984; 29:529-536.

113. Shi X-Q, Welander U, Angmar-Mansson B. Occlusal caries detection with Kavo
DIAGNOdent and radiographic examination; an in vitro comparison. Caries Res
2000;34:151-158.

114. Shugars DA, Bader JD. Cost implications of differences in dentists'restorative treatment
decisions. J Public Health Dent 1996; 56:219-222.










115. Silverstone LM. Structure of carious enamel, including the early lesion. Oral Sci Rev
1973;3:100-160.

116. Silverstone LM, Hicks MJ, Featherstone MJ. Dynamic factors affecting lesion initiation
and progression in human dental enamel. II. Surface morphology of sound enamel and
caries like lesions of enamel. Quintessence Int 1988; 19:773-785.

117. Spitzer D, ten Bosch JJ. The total luminescence of bovine and human dental enamel.
Calcif Tiss Res 1976;20:201-208.

118. Stephen KW, Russell JI, Creanor SL, Burchell CK. Comparison of fiber-optic
transillumination with clinical and radiographic caries diagnosis. Community Dent Oral
Epidemiol 1987; 15:90-94.

119. Stewart PW, Stamm JW. Classifieation tree prediction models for dental caries from
clinical, microbiological, and interview data. J Dent Res 1991;70: 123 9-125 1.

120. Stookey GK, Gonzalez-Cabezas C. Emerging methods of caries diagnosis. J Dent Educ
2001;65:1001-1006.

121. Thomson W. Dental caries experience in older people over time: what can the large
cohort studies tell us? Brit Dent J 2004; 196:89-92.

122. Thompson NJ, Boyer EM. Validity of oral health screening in Hield conditions: pilot
study. J Dent Hyg 2006 80:9.

123. Tonioli MB, Bouschlicher MR, Hillis SL. Laser fluorescence detection of occlusal caries.
Am J Dent 2002; 15:268-273.

124. Twesme DA, Firestone AR, Heaven TJ, Feagin FF, Jacobson A. Air-rotor stripping and
enamel demineralization in vitro. Am J Orthod Dentofacial Orthop 1994;105:142-152.

125. Vaarkamp J, ten Bosch JJ, Verdonschot EH, Tranaeus S. Quantitative diagnosis of small
approximal caries lesions utilizing wavelength-dependent fiber-optic transillumination. J
Dent Res 1997;76:875-882.

126. Vaarkamp J, ten Bosch JJ, Verdonschot EH, Bronkhoorst EM. The real performance of
bitewing radiography and fiber-optic transillumination in approximal caries diagnosis. J
Dent Res 2000;79: 1747-1751.

127. Valachovic RW, Douglass CW, Berkey CS, McNeil BJ, Chauncey HH. Examiner
reliability in dental radiography. J Dent Res 1986;65:432-436.

128. van Amerongen JP, Penning C, Kidd EA, ten Cate JM. An in vitro assessment of the
extent of caries under small occlusal cavities. Caries Res 1992;26:89-93.

129. van Dorp CS, Exterkate RA, ten cate JM. The effect of dental probing on subsequent
enamel demineralization. ASDC J Dent Child 1988;55:343-347.









130. Van Rijkom HM, Verdonschot EH. Factors involved in validity measurements of
diagnostic tests for approximal caries-a meta-analysis. Caries Res 1995;29:364-370.

131. Viraj silp V, Thermontree A, Aryatawong S, Paiboonwaraschat D. Comparison of
proximal careis detection in primary teeth between laser fluorescence and bitewing
radiography. Pediatr Dent 2005;27:493-499.

132. Virtanen JI. Changes and trends in attack distributions and progression of dental caries in
three age cohorts in Finland. J Epidemiol Biostat 2001; 6:325-329.

133. Wenzel A, Larsen MJ, Fej erskov O. Detection of occlusal caries without cavitation by
visual inspection, film radiograph, xeroradiographs, and digitized radiographs. Caries Res
1991;25:365-371.

134. Winn F, et al. Coronal and root caries in the dentition of adults in the United States,
1998-1991. J Dent Res 1996; 75 (special issue): 642-651.

135. Yalcinkaya S, Kunzel A, Willers R, Thoms M, Becker J. Subj ective image quality of
digitally filtered radiographs acquired by the Durr Vistascan system compared with
conventional radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod
2006;101:643-651.

136. Yin W, Feng Y, Hu D, Ellwood RP, Pretty IA. Reliability of quantitative laser
fluorescence analysis of smooth surface lesions adj acent to the gingival tissues. Caries
Res 2007;41:186-189.

137. Yorty JS, Brown KB. Caries risk assessment/treatment programs in US dental schools. J
Dent Educ 1999;63:745-747.









BIOGRAPHICAL SKETCH

Dr. Valeria Veiga Gordan received her dental degree from the State University of

Londrina, Brazil, School of Dentistry in 1993. She practiced dentistry for 2 years in a private

practice in Brazil. Soon after that she moved to the United States where she completed her

Master of Science degree and Certificate Program in Operative Dentistry at the University of

lowa in 1997. After she completed her studies at the University of lowa she was appointed

Instructor, Department of Operative Dentistry, University of Florida College of Dentistry

(UFCD). Shortly thereafter she was promoted to Assistant Professor and within 3 years she was

granted tenure with promotion to Associate Professor.

Dr. Gordan brought contemporary concepts and new techniques in preservation of tooth

structure to the UFCD Operative Dentistry Department. She also improved the evidence-based

content and philosophy of the curriculum with innovative methods of teaching and application of

her research findings. Her time has been devoted primarily to pre-clinical and clinical teaching

activities. She wrote 3 chapters on various clinical topics in American and European text-books.

She has worked as a Course Director for several courses at the UFCD: Advanced and Complex

Restorations Course, Preclinical Operative Dentistry III, Esthetic Elective Honors Program, and

Indirect Restorations Course for sophomore, junior, and senior dental students. She was

responsible for formulating new lectures in restorative dentistry, and for creating over fourteen

videos and CDs containing contemporary topics related to dental procedures. She also developed

seven different clinical research proj ects that involved the student participation in the dental

clinics. Her teaching has awarded her the Dental Educator Award in 2000 in recognition of

outstanding contributions to the quality of dental education, by the Florida Dental Association,

the Teacher of the Year Award in 2001 for demonstrating excellence, innovation and

effectiveness in teaching, by University of Florida College of Dentistry, and the Faculty of









Honor at the "Professionalism and Coating Ceremony" for the University of Florida College of

Dentistry Class of 2003.

Dr. Gordan maintains a clinical dental practice in the UFCD Faculty Practice. Her faculty

practice is primarily devoted to patient education and preservation of tooth structure through

minimally invasive dentistry and prevention of dental caries. She dedicates one half day a week

to faculty practice.

Being staffed in a clinical department, where the main mission is clinical teaching, she has

managed to actively engage in dental research through participation in various grant

mechanisms, primarily involving corporate support. Dr. Gordan has published 35 articles and 40

abstracts in peer-reviewed j ournals, and provided more than 50 presentations at national and

international meetings. Another 7 manuscripts have either been submitted for publication or are

in preparation. She has been a mentor for eleven national and international dental students which

originated seven publications in peer-reviewed journals and nine presentations at International

meetings. She serves on the Editorial Board of the Operative Dentistry Journal and has been

invited to be a reviewer for International dental journals. She has served on national and

international committees at the Academy of Operative Dentistry, American Dental Association

of Research, and Intemnational Association of Dental Research.

In 2004 she was accepted in the Advanced Postgraduate Program in Clinical Investigation

and she is currently enrolled in a Master of Sciences degree program in Clinical Investigation.

Her current training has been supported by the K-30 Research Program K30RRO22258, awarded

to the Health Science Center at the University of Florida (PI, Marian Limacher) and by the

research infra-structure enhancement grant U24DE0 16509-01, awarded to the College of

Dentistry (PI, Robert A Burne). The goal of these initiatives is to provide core curriculum in









clinical and translational research and to establish a research enterprise that complements key

clinical and basic science initiatives at the University of Florida.

In 2005, Dr. Gordan started participation in the Dental Practice-based Research Network

(DPBRN) (U01-DE16746, PI: Gregg Gilbert, and U01-DE 16747, PI: Dale Williams). The

DPBRN was the most recently significant effort established by NIDCR to investigate pressing

issues in clinical care. Through collaboration with Dr. Gregg Gilbert, Dr. Gordan helped to

develop the very first study of the network involving methods dentists use to diagnose caries and

to develop caries risk assessment.





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1 ASSESSMENT OF CARIES DIAGNOS IS AND CARIES TREATMENT ON A DENTAL PRACTICE-BASED RESEARCH NETWORK By VALERIA GORDAN A THESIS PRESENTED TO THE GRADUATE SCHOOL OF THE UNIVERSITY OF FLOR IDA IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SCIENCE UNIVERSITY OF FLORIDA 2007

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2 2007 Valeria Gordan

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3 To Lucio and Julia

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4 ACKNOWLEDGMENTS I would like to express my a ppreciation to my supervisory committee members (Dr. Nabih Asal, Dr. Cyndi Garvan, Dr. Ivar Mjr), and chair (Dr. Marc Heft) for their advice and assistance. I want to thank Drs. James Bader, Vibeke Qvist, and Ivar Mjor who provided insight during the development of the questionnaire. I wish to convey my gratitude to the Chair of the Dental Practice-Based Research Network (Dr. Gregg Gilbert), to members of the Executive Committee; and for grants (U01-DE16746, PI: Gregg Gilbert, and U01-DE 16747, PI: Dale Williams). I am especially grateful to all the practitioner investigators of the Dental PBRN who responded to the questionnaire used in the st udy. I would like to ac knowledge the research infrastructure enhancement grant U24DE01609-01, awarded to the College of Dentistry (PI: Robert Burne) which allowed the needed time for completion of the requirements for this Master of Science degree.

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5 TABLE OF CONTENTS page ACKNOWLEDGMENTS...............................................................................................................4 LIST OF TABLES................................................................................................................. ..........7 LIST OF FIGURES................................................................................................................ .........8 ABSTRACT....................................................................................................................... ............10 CHAPTER 1 INTRODUCTION..................................................................................................................11 Purpose of the Study........................................................................................................... ....12 Context of Study............................................................................................................... ......12 2 MATERIALS AND METHODS...........................................................................................14 Specific Aims.................................................................................................................. ........14 Inclusion Criteria............................................................................................................. .......15 Selection and Recruitment Process.........................................................................................15 Length of Field Phase.......................................................................................................... ...15 Data Collection Process........................................................................................................ ..15 Pilot Study and Pre-testing of Questionnaire..........................................................................16 Statistical Analysis a nd Power Calculations...........................................................................16 Human Subjects Research......................................................................................................17 Risks to the Subjects and Health Care Providers............................................................17 Adequacy of Protection Against Risk.............................................................................18 Potential Benefits of the Proposed Re search to the Subjects and Others........................18 Importance of the Knowledge to Be Gained...................................................................19 Inclusion of Women........................................................................................................19 Inclusion of Minorities....................................................................................................19 Inclusion of Children.......................................................................................................19 3 LITERATURE REVIEW.......................................................................................................21 Caries Prevalence.............................................................................................................. ......21 Clinical Treatment Planning: Lack of a Gold Standard......................................................21 Caries Risk Assessment: An Overlooke d Practice in Treatment Planning............................22 Caries Treatment: An Issue without a Strong Consensus.......................................................22 Clinical Diagnosis of Existing Restorations...........................................................................23 4 RESULTS........................................................................................................................ .......24 Response Rate.................................................................................................................. .......24

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6 General Demographics...........................................................................................................24 SA 1: Diagnostic Methods......................................................................................................24 SA 2: Assessment of Caries Risk...........................................................................................25 SA 3: Clinical Case Scenar ios (Visual and Radiographic Ca ries Progression Pictures)........25 Summary of Findings Based on Visual Exam.................................................................25 Summary of Findings Base d on Radiographic Exam......................................................26 Summary of Results According to Ca ries Risk and Diagnostic Images.........................26 SA 4: Treatment of Existing Restorations..............................................................................27 Summary of the Results for a Composite Ex isting Restoration In terfacing a Dentin Surface........................................................................................................................ .27 Summary of the Results for a Composite Existing Restorati on Interfacing an Enamel Surface............................................................................................................27 Summary of the Results for an Amalgam Restoration....................................................28 5 DISCUSSION..................................................................................................................... ....40 Response Rate.................................................................................................................. .......40 Methods for Diagnosing Carious Lesions..............................................................................40 Non-Traditional Methods................................................................................................42 Concluding Remarks.......................................................................................................43 Dentists Assessment of Caries Risk......................................................................................44 Caries Diagnosis Base d on Clinical Findings.........................................................................45 Caries Diagnosis Based on Radiographic Finding.................................................................47 Practices and Dentis ts Characteristics..................................................................................48 Evaluation of Existing Restorations.......................................................................................51 6 FUTURE WORK....................................................................................................................53 7 CONCLUSIONS....................................................................................................................54 APPENDIX A QUESTIONNAIRE: ASSESSMENT OF CARIES DIAGNO SIS AND CARIES TREATMENT...................................................................................................................... ..55 B ENROLLMENT DATA QUESTIONNAIRE........................................................................61 LIST OF REFERENCES............................................................................................................. ..68 BIOGRAPHICAL SKETCH.........................................................................................................78

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7 LIST OF TABLES Table page 4-1. Summary of eligible dentists that partic ipated in the study according to dentists and practices characteristics....................................................................................................29 4-2. Percent of dentists who repor ted on use of selected diagnos tics tools to detecting dental caries......................................................................................................................... .........30 4-3. Summary of assessment of caries risk du ring the treatment planning process according to dentists and practic es characteristics...........................................................................31 4-4. Summary of type of treatment option chosen by dentists according to the visual caries progression pictures on low caries risk individual (question 9)........................................32 4-5. Summary of intervention option of treatment selected on visual case scenarios for low caries risk individual (question 9) according to dentists and practices characteristics...33 4-6. Summary of intervention option of treatment selected on visual case scenarios for high caries risk individual (question 10) ac cording to dentists and practices characteristics................................................................................................................ .....34 4-7. Summary of level of intervention treatment according to caries risk and diagnostic image available................................................................................................................ ..35 4-8. Summary of clinical treatment options c hosen on a existing composite restoration interfacing a dentin surface (question 13) according to dentists and practices characteristics................................................................................................................ .....36 4-9. Summary of clinical treatment options c hosen on a existing composite restoration interfacing an enamel surface (question 14) according to dentists and practices characteristics................................................................................................................ .....37 4-10. Summary of clinical treat ment options chosen on an existing amalgam restoration (question 15) according to dentist s and practices ch aracteristics....................................38

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8 LIST OF FIGURES Figure page 2-1. The sample size estimation................................................................................................20 4-1. Treatment chosen by dentists for clin ical case scenarios involving existing restorations (questions 13 to 15)........................................................................................39

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9 LIST OF ABBREVIATIONS AL Alabama ANOVA Analysis of variance CC Coordinating center CI Confidence interval DPBRN Dental Practice-Ba sed Research Network. DIAGNOdent Quantitative light-induced laser fluorescence FL Florida FOTI Fiber-optic transillumination HMO Health maintenance organization HP HealthPartners KP Kaiser Permanente and Permanente Dental Associates OR Odds ratio SA Specific aim SK Scandinavia (includes participa ting countries Denmark, Norway, and Sweden). Symbols Alpha $ Dollar % Percent

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10 Abstract of Thesis Presen ted to the Graduate School of the University of Florida in Partial Fulfillment of the Requirements for the Degree of Master of Science ASSESSMENT OF CARIES DIAGNOS IS AND CARIES TREATMENT ON A DENTAL PRACTICE-BASED RESEARCH NETWORK By Valeria Gordan December 2007 Chair: Marc Heft Major: Medical Sciences--Clinical Investigation Dental caries continues to be a prevalent di sease with high inciden ce among all age groups. Understanding how dentists currently diagnose a nd treat dental caries is fundamental to designing subsequent interventions to improve prevention of dental caries and restorative treatment. The purpose of the current project was to id entify methods that Dental Practice-Based Research Network (DPBRN) dentists use to diagno se and treat caries lesions. The aims of the study were to (1) quantify the percentages of DP BRN dentists who report using selected methods for caries diagnosis; (2) quantify and evaluate the percentages of DPBRN dentists who report using a caries-risk assessment protocol of any variety; (3) quantify th e percentages of DPBRN dentists who report intervening su rgically at enamel and dentin lesions; and (4) evaluate the treatment options used DPBRN dentists when assessing defective restorations. The aims were met by enrolling 504 DPBRN den tists, each of whom completed a 6-page questionnaire about diagnosis and treatment a of dental caries. This study layed a critical foundation for subsequent intervention studies desi gned to move the latest scientific advances about caries diagnosis and treatmen t into daily clinical practice.

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11 CHAPTER 1 INTRODUCTION Dental caries continues to be a prevalent or al disease with substa ntial incidence among all age groups. Despite advances in the prevention of de ntal caries, active dental caries still regularly leads to dental restorations a nd dental extractions (67, 132,133). Treatment choices for dental caries are aff ected by a multitude of factors, including variations among dentists regardi ng caries diagnosis. The subject ive assessment of each dentist when making the diagnosis of caries may be respons ible for the greatest va riation in treating the disease. The stage in caries development wh en operative interventi on is indicated is not established or agreed upon (26,137). A major pr oblem may be that dentists lack a gold standard in clinical treatment planning because th ere is a paucity of research assessing the short and long-term outcomes of treatment (12, 17, 38, 39, 42, 114). Many factors play a role in de termining patients caries risk (22,119), such as presence of active caries lesions and patient characteristics such as race, ethnicity, socioeconomic and educational levels (22). No st rong consensus exists within the dental profession regarding the use of a preventive versus surgical treatment to re duce dental caries. The l ack of consensus exists not only in general practice (14), but also in teaching programs (5). Additionally, limited information is available from general dental practice about what lesion depth practitioners consid er appropriate for operative (s urgical) intervention. Marked variations in criteria exist among clinicians in the diagnosis of caries lesion s (11, 12, 66, 99, 109) and in caries management and prev ention (13,70). There is lack of consensus in caries diagnosis (104, 106), and, further dissemination into and adopti on by practitioners in da ily clinical practice has been limited.

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12 Purpose of the Study The purpose of this study was to assess how dentis ts in clinical practice participating in the Dental Practice-Based Research Network (DPBRN), diagnose and treat dental caries in adult patients. Specific Aim 1 : quantify the percentage s of DPBRN dentists who report using selected methods for caries diagnosis. Specific Aim 2 : quantify and evaluate the percenta ges of DPBRN dentists who report using a caries-risk assessment protocol of any variety. More specifically, the practice of assessing caries risk for individual patients differs by characteristics of dentists and ch aracteristics of their practice. Specific Aim 3: quantify the percentages of DPBRN dentists who report intervening surgically at enamel and caries lesi ons (stages E1, E2, D1, D2, or D3). More specifically, decision for intervening su rgically in a caries process will differ by severity of caries, by the practi ce of assessing caries risk, by char acteristics of dentists, and by characteristics of their practices. Specific Aim 4: evaluate the treatment options us ed DPBRN dentists when assessing existing restorations. More specifically, treatment approaches chos en by dentists differ by differ by the practice of assessing caries risk, by characteristics of de ntists, and by characterist ics of their practices. Context of Study This study queried dentist participating in the DPBRN. The DPBRN is a group of outpatient dental practices that have affiliated to investigate research questions and to share experiences and expertise. To date, 1,166 de ntists have completed a 101-item enrollment questionnaire. Some of these clinicians have attended a three-four hour orientation session

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13 delivered in a Continuing Education format. The DPBRN comprise dentists in Alabama, Mississippi, Florida, Georgia, Minnesota, Oregon, Washington, a nd Scandinavia. A statistical coordinating center (CC) is part of the DPBR N. The CC comprises a group of about 15 biostatisticians, and staff investigators who are re sponsible for data collection, data management, and data analysis of the DPBRN. A comprehens ive description of the DPBRN is provided in the DPBRN's web site at http://www.DentalPBRN.org This study recruited 915 participating dentists from the DPBRN.

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14 CHAPTER 2 MATERIALS AND METHODS The study design was cross-sectional, cons isting of a single ad ministration of a questionnaire-based survey (Appendi x A) to a convenience sample of dentists participating in the DPBRN. Specific Aims The specific aims were met by having DPBRN dentists complete a questionnaire that queries the following key components: Specific Aim 1: Which method(s) is (are) currently in use to diagnose cari es lesions (SA 1). Rationale for specific aim 1: Studies have demonstrated substantial differences among dentists regarding methods used to diagnose de ntal caries. This component is addressed by questions 1 through 7 in the questionnaire. Specific Aim 2: Whether caries risk assessment is part of dentists treatment planning process (SA 2). Rationale for specific aim 2: Not all dentists assess caries risk. Determining if dentists assess caries risk may impact how dentist diagnos e and treat caries. This component is addressed by question 8 in the questionnaire. Specific Aim 3: Whether enamel or dentin lesions are intervened operatively (SA 3). Rationale for specific aim 3: The stage in the caries development process when operative intervention is indicated is not established or commonly agreed on. However, the initial intervention can have a significant impact on the heal th of the tooth structure as well as on the cost of treatment. This component is addres sed by questions 9 through 12 in the questionnaire. Specific Aim 4: What is the most commonly used approach by dentists to treat existing restorations (SA 4).

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15 Rationale for specific aim 4: The diagnosis of recurrent caries may vary according to dental experience (23, 97) and loca tion of original dental restorat ion (8, 36, 37). This component is addressed by questions 13 th rough 15 in the questionnaire. Questions related to dentists and practices ch aracteristics had been gathered previously during the enrollment questionnai re (Appendix B). The enrollmen t questionnaire comprised 101questions inquiring demographic information regarding dentists and their practices. The CC provided de-identified enrollment data info rmation related to 915 eligible dentists. Inclusion Criteria To be eligible to participat e in Study 1, dentists had to ha ve been enrolled in the DPBRN and done at least some restorativ e dentistry in their practices. Selection and Recruitment Process An introductory letter explai ning the study (Appendix C) was mailed to each eligible practice (a total of 915), along with a printed copy of the questionn aire. The questionnaires were sent to all the participating dentists in Alabam a, Florida, Scandinavia, the Permanente Dental Associates, and the HealthPartners group. Length of Field Phase Participating dentists were requested to retu rn the questionnaire within three weeks. A reminder letter was sent after the third week to cl inicians who had not retu rned the questionnaire. After an additional three weeks, a second reminde r was sent. After a final three-week waiting period, if a dentist had not returned the questi onnaire, it was assumed that he or she was not interested in participating. Data Collection Process Preprinted survey form packages were sent by the CC to each regional office. These forms had the dentist self-checking identification num ber preprinted on each page of each form.

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16 Dentists were asked to complete the questionn aire by hand and return to his/her assigned regional coordinator in a pre-addressed envel ope. Upon receipt, the regional coordinator reviewed the questionnaire for comp leteness and then either scanned for electronic transfer to the CC or transfer to the CC via mail. Dentists were paid 50 dollars after they returned a completed questionnaire and had responded to possible queries from the CC having to do with verifying illegible or unclear responses. Pilot Study and Pre-testing of Questionnaire A pilot version of the questionnaire was submitted to 16 dentists throughout the network. The pilot-testing assessed the feasibility and comprehensi on of each questionnaire item. A subsequent pre-testing phase finalized doc umentation of comprehension of questionnaire items and quantified test-retest reliability of questionnaire items, which involved 35 DPBRN dentists. Items had to meet a te st-retest reliability of kappa > 0.7 to be considered sufficiently reliable for inclusion in the fina l version of the questi onnaire. The lapse in time between test and retest was 15 days. Statistical Analysis a nd Power Calculations Non-parametric test was used to assess di fferences between explanatory variables and methods used. Pearsons chi-square statistic was used to test the hypothesis of association between outcome and explanatory variables when nominal variables were being analyzed. Analysis of variance (ANOVA) was used to test associations between outcome and explanatory variables when the variables analyz ed were numerical. A 95% confidence interval ( =.05) was set.

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17 The 95% confidence level and two-sided CIs and hypothesis tests were assumed for all power calculations. A minimum sample size of 200 de ntists was deemed necessary to answer the specific aims of the study. Precision of estimation for the percentages defi ned in Aim1 was based on widths of exact 95% CIs for binomial proportions corresponding to percentages ranging from 10% to 50%. An estimated percentage of 50% yields the widest CI and thus the most conservative estimate of precision. Figure 2-1 shows the widths of CIs for sample sizes of 100 to 300 responding practitioners. The CI width for an estimated percentage of 50% ranges from 20.3 for a sample size of 100, to 11.6 for a sample size of 300. That is, given an estimated percentage of 50%, for a sample size of 100, the 95% CI would be (39.85, 60.15), and for a sample size of 300, the corresponding CI would be (44.2, 55.8). Power for the hypotheses tested on Aims 2 thru 4 were based on a chi-square test of equal proportions (OR = 1.0), assuming equal allocation of respondents between the two categories of one usage variable, and estimating power to de tect a difference from 50% in one of the categories of the other variable. A sample si ze of 100 practitioners would provide 80% power to detect an OR of 3.3 (50% versus 77% in the categories of the second variable). Sample sizes of 200 and 300 would provide 80% power to detect ORs of 2.3 (50% vs 70%) and 1.95 (50% vs 66%), respectively. Human Subjects Research Risks to the Subjects and Health Care Providers Human subject involvement and characteristics The human subjects directly involved in this study were the dentists who completed the questionnaire that i nquires mainly about the various methods used to diagnose dental caries a nd the stages of the carie s process that requires intervention. Subjects were recruited from the De ntal PBRN and needed to meet the eligibility

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18 criteria specific to this protoc ol and provide informed consent to participate. The Informed Consent form comprised part of the Introductory letter (A ppendix C) that accompanied the questionnaire. Returning a completed questionn aire constituted verification of consent. Sources of materials Data was obtained from the re sponses given by the dentists who answered the questionnaire. Potential risks The only risk to the participating subjects was the highly unlikely accidental disclosure of health care provider in formation. However, every precaution has been taken to prevent this. No additional e xposure was expected from this protocol. Adequacy of Protection Against Risk Recruitment and informed consent We provided the study participants information that explained the nature of the study, time commitment involved, any risks involved, and compensation information. We also answered an y questions they might have had in a telephone conversation or in face-to -face discussion with them. Protection against risks Records of participation were kept confidential to the extent permitted by law. Only authorized personnel ha d access to the data, and all information, whether electronic or in paper form, was stored in a secure manner. This information will not be sold or used for any reason other than research. Results may be published for scientific purposes, but participant identities w ill not be revealed. Potential Benefits of the Proposed Research to the Subjects and Others Subjects benefited from the opportunity to reflect their views on the current caries diagnosis and caries risk assessmen t plans used in their practice and gained information on the practice methods of their peers. The indirect benefit to the patient s of the subjects answering the questionnaire might be ultimate improvements in de ntal treatment in daily clinical practice. Subjects might also have benefited from a better understanding of how the ri sk characteristics of

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19 patients may influence patients treatment. The po tential benefits to the subjects and indirectly to their patients far exceeded the ri sk involved with the participation. Importance of the Knowledge to Be Gained The knowledge to be gained from the study wa s to identify the various methods used for caries diagnosis and caries treatment. Add itionally this study will se rve as a foundation for future studies as it will provide the theoretical knowledge about methods used for diagnosis and treatment of caries. Inclusion of Women Dentistry is a profession performed by both me n and women; therefore, both genders were eligible to enroll. Based on the enrollment questionnaires completed by DPBRN dentists, 14% were female. Inclusion of Minorities Racial and ethnic minorities were included in the study proportional to their composition in the dental community. Inclusion of Children This study was designed to i nvestigate caries diagnosis and caries treatment used by DPBRN dentists, in the treatment of adult patients. Therefore, no children were study participants.

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20 Figure 2-1. Sample Size Estimation.

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21 CHAPTER 3 LITERATURE REVIEW Caries Prevalence Treatment of teeth due to primary or recurren t caries consumes about 70% of the treatment time in general dental practices (92). Over $70 bi llion are spent annually on de ntal care in the US alone, most of which is associated with restorative treatment. Contrary to the assumption that dental ca ries is a prevalent disease primarily among children, new reports show that ca ries is a disease still prevalent in the middle-aged and older adult population with subs tantial incidence rates (54, 56, 74, 79, 121). Caries disease rates vary substantially among different stat es in the US and also according to selected demographic variables (24). In some states the percentage of children experi encing caries can be as high as 72%. AfricanAmerican population is at greater ri sk of incidence of caries lesions (32, 75). A prospective longitudinal cohort study in a di verse community-based population in Florida showed a 67% incidence rate of caries disease in patients older than 45 years of age over a twoyear period (54). Incidence rate s over a three-year period of 57% for coronal caries increments and 27-39% of root caries incremen ts have been reported in vari ous populations over 50 years of age in North America (56, 74, 79). In addition, olde r population remains at risk for dental caries as the tooth retention rate s have increased (24). Clinical Treatment Planning: Lack of a Gold Standard Comparisons of restorative treatment reco mmendations showed that dentists had remarkable differences related to the decisionmaking process (10, 66, 89, 99, 109). Part of these inconsistencies are related to the marked variatio n that dentists have in correctly identifying caries, with sensitivity values ranging from .77 to 1, and specificity values ranging from .45 to .93 (42). In quantifying agreemen t among dentists recommendations for restorative treatment, it

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22 was concluded that much of the variation in dental practice profiles is due to basic differences in decision-making (9, 16). Lack of consistency in both dentists decisions to intervene and dentists selection of treatment can have a sign ificant effect on cost of treatment (114). Caries Risk Assessment: An Overlooked Practice in Treatment Planning Many factors play a role in establishing a pa tients caries risk (22, 119). The presence of active caries lesions was reported in an extensive l iterature review as a good measure of the risk for future lesions (4). Socioeconomic aspects and education are also related to caries risk (22). In addition, the caries ex perience of patients who have attend ed the practice for a minimum of 2 years allows a reliable caries risk assessment (15). Finally, the clinicians subjective assessment has been suggested as a reliable assessment of caries risk (15). About 65% of North American dental schools advocate caries ri sk assessments as part of treatment planning. However, only about 27% of clinicians apply a caries risk assessment regime n during their treatment planning (26). Caries Treatment: An Issue without a Strong Consensus No well defined and generally accepted criteria exist within the dental profession regarding the use of a preventive versus surgical treatment to treat dental caries. The lack of consensus exists not only in general pract ice (14, 109), but also in teachin g programs (5). A review rated the evidence for efficacy of methods to manage non-cavitated lesions to be incomplete (13). Marked differences in treatment approach al so exist among different countries (76, 78, 88, 90, 100, 108, 112). In Scandinavia, the majority of unfilled carious surfaces have caries lesions whose depth only extended into enamel (78) and restorative treatment has been predominant for proximal surfaces that involve dentin only (77).

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23 Clinical Diagnosis of Existing Restorations The clinical diagnosis of recurrent caries is the most common reason for replacement of restorations in general dental practice (94). This diagnosis is difficult an d it invariably leads to replacement of the entire re storation (93, 96, 107). Replacement of existing restorations consistently results in extensi on of the cavity preparation as compared to the original size. Clinical and in vitro studies have shown a significant increase in cavity preparations when either amalgam (35, 36, 95) or resin based composite (50, 51, 52) restorations were replaced. The lack of standards to determine restorat ion failure causes the dentists to err on the side of caution when faced with uncertain diagnosis. Based on these findings and the fact that the cost of care and oral health are severely impacted by the diagnosis of existing restorations, un derstanding how dentist diagnose and treat existing rest orations that may be defec tive remains a critical issue.

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24 CHAPTER 4 RESULTS Response Rate A total of 1166 dentists ar e enrolled at the DPBRN. Nine-hundred and fifteen (78%) enrolled dentists were eligible for partic ipation in the study. Nine-hundred and fifteen questionnaires were distributed and 504 (55%) were returned. General Demographics Table 4-1 describes charact eristics of dentists ( i.e. gender, race, years of experience, region) and characteristics of practices who were eligible for participation in the study. The response rate from Alabama site was si gnificantly lower than the other sites. SA 1: Diagnostic Methods Table 4-2 summarizes which techniques are cu rrently being used by DPBRN participating dentists to diagnose caries lesions. The frequenc y of use is also descri bed. All dentists (n=504) responded to these questions. The results showed that dental explorer is used as the main diagnostic tool for the diagnosis of occlusal dental cari es (63%) and for the di agnosis of recurrent de ntal caries (61%). Laser fluorescence was never used by 87 percent of dentists for the diagnosis of occlusal dental caries. For the diagnosis of proximal dental caries, radiograph was the main tool used by dentists and fiber optic was never used by 34 percent of dentists. Dentists use radiographs for the diagnosis of proximal dental caries (51%) more often than they use for the diagnosis of occlusal dental caries (14%).

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25 SA 2: Assessment of Caries Risk Table 4-3 reports on assessment of caries risk during the treatment planning process according to characteristics of dentists and their practices. The results showed that the majority of the dentists (69%) assess carie s risk for individual patients. From dentist that assess caries risk, only 18 percent (n=63) use a caries risk assessment form. Female dentists assess caries risk more ofte n than male dentists, however the difference was not significant (p<.05). Significant difference was found for years of ex perience. Dentists with less years of experience assessed caries risk more often th an those with more years of experience. Significant differences were found for different practices characte ristics. Dentists from AL and FL participating practices assess caries risk significantly less than den tists from HP, KP, and SK participating practices. SA 3: Clinical Case Scenarios (Visual a nd Radiographic Caries Progression Pictures) Summary of Findings Based on Visual Exam The treatment options were grouped in th e following subgroups: 1no treatment, 2prevention (in-office fluoride, non-prescription fluoride, prescr iption of fluoride, sealant, chlorhexidine treatment), 3prevention and inte rvention (minimal drilling and sealant, minimal drilling and preventive resin re storation, air abrasion and sealan t, air abrasion and preventive resin restoration), and 4inte rvention (amalgam restoration, composite restoration, indirect restoration). Table 4-4 reports on the various forms of treatment chosen using the visual caries progression pictures on a low caries risk individual (questi on 9). Most of the dentists (70%) reported no treatment for clinical case scen ario 1. The no treatment option decreased significantly as the caries progression increase d. Most dentists reporte d intervention for the

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26 clinical case scenario 2 and this treatment option was increased as the caries progression increased. Prevention treatment was higher on clini cal case scenario 1 and it gradually decreased as the caries progression increased. The combin ation of prevention and intervention treatments was gradually increased as the caries progression increased. A similar trend of treatment options chosen was observed when a high caries risk individual was de scribed (question 10). Table 4-5 reports on interven tion treatment chosen by den tists on a low caries risk individual (question 9) according to dentists an d practice characteristics Significant differences were found for different practices characteristics. Dentists from HP, KP, and SK participating practices intervene significantly less on enamel lesi ons than AL and FL participating practices. Table 4-6 reports on interven tion treatment chosen by den tists on a high caries risk individual (question 10) according to dentists and practice characteristics. Significant differences were found for the participating practices accord ing to region. Dentists from Al, FL, and KP participating practices intervene significantly more on enamel lesions than dentists from HP and SK participating practices. Summary of Findings Base d on Radiographic Exam Using a radiographic image in a low caries ri sk scenario, about 41 percent of dentists, reported that they would start intervening surgic ally on inner enamel lesions (case 2). In a high caries risk scenario, the majority of dentists (7 6%) reported that they would start intervening surgically on inner enamel lesions (case 2). Summary of Results According to Caries Risk and Diagnostic Images Table 4-7 reports on level of interv ention according to caries risk ( i.e ., high versus low) and diagnostic image available (i.e ., visual versus radiographic). Caries risk was significant when deciding on stage of inte rvention for both visual and ra diographic diagnostic images. Dentists were more readily to choose the in tervention treatment on enamel surfaces when

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27 patients were in a high caries ri sk scenario. Additiona lly the table shows that dentists choose more often the intervention treatment on enamel surfaces when they use the visual versus the radiographic diagnostic tools (p<.0001). SA 4: Treatment of Existing Restorations The bar graph on Figure 4-1 illu strates the treatment options chosen by dentists for the treatment of existing restorati ons in composite interfacing a de ntin surface (question 13), in composite interfacing an enamel surface (question 14) and in amalgam restor ation (question 15). Tables 4-8 thru 4-10 illustrates th e treatment options chosen by den tists according to dentists and practices characteristics. Summary of the Results for a Composite Existi ng Restoration Interfacing a Dentin Surface The majority of dentists chose either the intervention or the prevention and intervention treatment options for the clinical case scenario on question 13. Significant differences were f ound for the different participating practices. Dentists from AL and FL participating practices reported significantly more inte rvention than dentists from KP, HP, and SK practices. Practices with higher percent of patients cove red by public insurance performed more prevention treatment than practices that were not covered by public insurance. Summary of the Results for a Composite Exis ting Restoration Interfacing an Enamel Surface The majority of dentists chose the interv ention treatment option for the clinical case scenario on question 14. Significant differences were found for assessment of carie s risk. Dentists who do not assess caries risk do more intervention than those who assess caries risk. Significant differences were also found for practices characteris tics. Dentists from AL and FL practicing regions do more intervention than dentists fr om KP, HP, and SK regions.

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28 Summary of the Results for an Amalgam Restoration The majority of dentists chose the no treatm ent option for the clinical case scenario on question 15. Significant differences were found for dentis ts years of experien ce and assessment of caries risk. Dentists with less years of experi ence chose the prevention treatment option more often than dentists with more years of experience. Dentists w ho assess caries risk chose the prevention treatment option more often than th ose dentists who do not assess caries risk. Significant differences were also found for practices characteris tics. Dentists from AL and FL regions chose the interventi on treatment option more often th an dentists from KP, HP, and SK regions.

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29 Table 4-1. Summary of eligible dentists that part icipated in the study acco rding to dentists and practices characteristics Number of eligible dentists N=915 Participated n= 504 Did Not Participate n = 411 p-value Gender Male % Female % 82.7 17.3 84.7 15.3 .4729 Race White % Hisp % Black % Other % 91.8 2.4 3 2.8 90.9 1.5 4.4 3.2 .5078 Years experience mean (SD) 22 (10.6)20 (13) .274 Region AL % (n=667) FL % (n=122) HP % (n=35) KP % (n=53) SK % (n=38) 57.5 19.8 6.1 9.9 6.7 90.4 6.1 1.3 1 1.2 <.0001* Percent of patients covered by public insurance mean (SD) 1.9 (2.4)1.8 (1.9).06 statistical significance

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30 Table 4-2. Percent of dentists who reported on us e of selected diagnosti cs tools to detecting dental caries N=504 Dental explorer occlusal Dental explorer recurrent Radiograph occlusal Radiograph proximal Laser f. occlusal Fiber o. proximal Mag. Never or 0% 211087 34 21 1-24% 312603 39 16 25-49% 421712 11 6 50-74% 571934 10 7 75-99% 232823453 5 9 Every time or 100% 636114511 1 41

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31 Table 4-3. Summary of assessment of caries risk during the treatment planning process according to dentists and practices characteristics N=504 No assessment of caries risk n=138 (27%) Assessment of caries risk n=348 (69%) Use of a special form: Yes: 63 (18%) No: 285 (82%) p-value Gender Male % Female % 86.9 13.1 81 19 0.1195 Race White % Hisp % Black % Other % 91 2 4 3 92 2 3 3 .5078 Years experience mean (SD) 26.8 (10.2)21 (10.4).0093* Region AL% FL % HP % KP % SK % 73.1 23.9 1.5 0 1.5 53.2 16.1 7.3 14.3 9.1 <.0001* Percent of patients covered by public insurance scheduled mean (SD) 1.6 (1.7)2 (2.6) .9711 Percent of Black or African-American patients scheduled mean (SD) 2.6 (2)2 (1.6).07 _________________________________________________________________________ 18 (4%) participants did not answered this question statistical significance

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32 Table 4-4. Summary of type of treatment option chos en by dentists according to the visual caries progression pictures on low caries risk individual (question 9) n=504 Case1 Case 2 Case 3 Case 4 Case 5 No treatment 343 (69%)121 (25%)31 (6%)5 (1%) 4 (0.8) Prevention 81 (16%)60 (12%)12 (2%)3 (0.5%) 4 (0.8) Prevention & intervention 23 (5%)76 (15%)132 (27%)148 (30%) 152 (32%) Intervention 47 (10%)235 (48%)321 (65%)340 (68.5%) 319 (67%) Numbers of cells missing 101288 25

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33 Table 4-5. Summary of intervention option of treatment sele cted on visual case scenarios for low caries risk individual (ques tion 9) according to dentists and practices characteristics n=504 Intervention Case 1 or Case 2 (enamel surfaces) Intervention Case 3/Case 4/Case5 (dentin surfaces) p-value Gender Male % Female % 84.9 15.1 78.6 21.4 .0748 Race White % Hisp % Black % Other % 92 3.5 3 1.5 92.5 1.8 2.5 3.2 .4133 Years experience mean (SD) 22.2 (10.46)22 (10.7).9857 Region AL% FL % HP % KP % SK % 66.7 19.7 2.3 8.4 2.9 42.2 19.4 12.8 12.2 13.4 <.0001* Percent of patients covered by public insurance scheduled mean (SD) 1.6 (1.9)2.3 (3).07 Percent of Black or African-American patients scheduled mean (SD) 2.3 (1.8)2 (1.6).85 statistical significance

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34 Table 4-6. Summary of intervention option of treatmen t selected on visual case scenarios for high caries risk individual (question 10) according to dentists and practices characteristics n=504 Level of intervention Case 1 or Case 2 (enamel surfaces) Level of intervention Case 3/Case 4/Case5 (dentin surfaces) p-value Gender Male % Female % 84.1 15.9 77.3 22.7 .0952 Race White % Hisp % Black % Other % 92 3 3 2 93 1 3 3 .5293 Years Experience Mean (SD) 21.4 (11.1)23.7 (8.9) .2125 Region AL% FL % HP % KP % SK % 60.6 20.2 4.7 10.6 3.9 47.7 17.4 11 7.3 16.6 <.0001* Percent of patients covered by public insurance scheduled Mean (SD) 1.7 (2)2.5 (3.2) .1609 Percent of Black or African-American patients scheduled mean (SD) 2.3 (1.7)2 (8.9) .0689 statistical significance

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35 Table 4-7. Summary of level of intervention trea tment according to caries risk and diagnostic image available n=504 Level of intervention Case 1 or Case 2 (enamel surfaces) Level of intervention Case 3/Case 4/Case5 (dentin surfaces) p value Visual exam Low risk High risk 63.5% 78% 36.5% 22% p<.0001 Radiographic exam Low risk High risk 41.4% 75.6% 58.6% 24.4% p<.0001

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36 Table 4-8. Summary of clinical treatment options c hosen on a existing co mposite restoration interfacing a dentin surface (question 13) according to dentists and practices characteristics N=490 No treatment Prevention Prevention & intervention Intervention p-value Gender Male % Female % 79.1 20.9 85 15 78.9 21.1 87.9 12.1 .0781 Years Experience Mean (SD) 26.6 (10.5) 22.3 (6.6)20.7 (10.7) 22.1 (11.2) .0589 Race White % Hisp % Black % Other % 91 3 2 4 85 5 5 15 90 4 2 4 93 2 3 2 .297 Access caries risk YES NO 9.6 6.7 4.4 3.7 45.3 37.8 40.7 51.8 .1657 Region AL% FL % HP % KP % SK % 39.5 14 2.3 9.2 35 35 10 10 15 30 53 21.1 8 15.5 2.4 69.1 19.5 4.3 4.3 2.8 <.0001* Percent of patients covered by public insurance scheduled mean (SD) 3.3 (3.9) 4.2 (3.9)1.5 (1.8) 1.7 (1.8) .0009* Percent of Black or African-American patients scheduled mean (SD) 1.4 (1) 1.5 (1.4)2.2 (1.8)2.4 (1.7) .952 statistical significance

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37 Table 4-9. Summary of clinical treatment options c hosen on a existing co mposite restoration interfacing an enamel surface (question 14) according to dentists and practices characteristics n=490 No treatment Prevention Prevention & intervention Intervention p-value Gender Male % Female % 83.3 16.7 75 25 76.9 23.1 86.4 13.6 .0747 Race White % Hisp % Black % Other % 92 2 2 4 87 4 4 5 91 2 3 4 93 2 3 2 .9547 Years Experience Mean (SD) 21.1 (11.1) 23.6 (6.4)19.3 (10.3)23.4 (10.6) .1359 Access caries risk YES NO 10.2 8.2 5.5 3 29.4 16.4 54.9 72.4 .0049* Region AL% FL % HP % KP % SK % 41.7 20.8 8.3 8.3 20.9 45.8 12.5 12.5 16.7 12.5 53.1 17.2 7.8 20.3 1.6 63.6 20.6 4.6 5.3 5.9 <.0001* Percent of patients covered by public insurance scheduled Mean (SD) 2.7 (3.3) 2.4 (2.9)1.6 (2)1.7 (2.1) .1065 Percent of Black or African-American patients scheduled Mean (SD) 1.6 (1.3) 2.3 (1.9)2.1 (1.7)2.3 (1.7) .388 statistical significance

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38 Table 4-10. Summary of clinical treatment options chosen on an existing amalgam restoration (question 15) according to dentist s and practices characteristics n=475 No treatment Prevention Prevention and intervention Intervention p-value Gender Male % Female % 86.8 13.2 83.3 16.7 77.3 22.7 86.8 13.2 .3724 Race White % Hisp % Black % Other % 94 2 2 2 94 0 0 6 89 2 2 7 90 3 5 2 .4288 Years Experience Mean (SD) 21.7 (10.2) 14.25 (8.1)20.2 (10.9)24.5 (11) .0154* Access caries risk YES NO 48 56.5 5.4 0 10.8 5.3 35.8 38.2 .0089* Region AL% FL % HP % KP % SK % 58.5 17 7.5 8.7 8.3 27.8 0 16.7 50 5.5 54.8 19.1 7.1 16.7 2.3 59.4 26.5 2.4 7.1 4.6 <.0001* Percent of patients covered by public insurance scheduled mean (SD) 2 (2.4) 1.3 (2.3)1.7 (2.4)1.6 (2) .0641 Percent of Black or African-American patients scheduled mean (SD) 2.2 (1.6) 1.3 (.7)2 (1.8)2.3 (1.8) .098 statistical significance.

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39 Figure 4-1. Treatment chosen by dentists for clinical case scenarios involving existing restorations (questions 13 to 15)

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40 CHAPTER 5 DISCUSSION Response Rate Response of 200 clinicians was deemed necessary for proper analysis of the data, as described in Chapter 2, under St atistical Analysis and Power Ca lculation. The response rate was 55 percent, and 504 questionnaires were return ed which provided a sufficient number of responses. Nevertheless reasons why the respon se to the study by DPBR N participants was not higher should be considered. This was the very first study of the network, and perhaps some clinicians were afraid to comm it to the network or to expose their responses. Care was taken to re-assure participants that the data used for this study would be de-identified as described in an introductory letter. The comprehension of the study questions was assessed in a pilot-te sting done with the assistance of 16 clinicians, participants of the DPBRN. The reliability of the questions was also assessed in a test-retest of que stionnaire items, which involved another 35 DPBRN dentists. We feel confident that although the response rate wa s less than expected and more than what was needed, the quality of the data produced had be en carefully thought through pre-testing and testretesting. The lower response rate from Alabama site is probably related to its higher number of eligible participants with almost a 19-fold differe nce from Health Partners and Scandinavia sites, and 5 to 12-fold difference from Florida and Kaiser Permanente sites. Methods for Diagnosing Carious Lesions The accurate diagnosis of the presence or abse nce of disease is paramount for appropriate care. Even though several methods haven been desc ribed for the diagnosis of dental caries, no consistent criteria used by dentis ts exit (98). The diagnosis of occl usal caries is highly subjective

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41 with considerable variation in opinion among clinic ians as to appropriate diagnosis and treatment (7). Reviews of the available literature poi nt methodological difficulties in drawing valid comparisons between studies due to incompatible criteria and simulations (13, 120). It has also been concluded that no caries diagnostic tool fulfills all of the ideal criteria for accurate measurements needed to plan appropriate care (13, 120, 130). In the current study, dentists use the dental explorer, a tactile tool, as the main instrument for the diagnosis of occlusal and recurrent dent al caries. The low speci ficity (approximately 40 percent) reported for this diagnos tic tool when used as the only diagnostic method is of concern (25, 65, 122). Dentists tend to over diagnose caries if a sharp instrument is used and stuck to any deep pit and fissure without the true evidence of caries. A sticking pr obe is not necessarily indicative of decay and may be entirely due to local anatomic features. The advice of applying pressure with a sharp explorer has been calle d into question, particul arly in Europe and Scandinavia, because of documented damage to surface integrity and possible implantation of organisms, both of which may increase lesion susceptibility (33, 129). Although this issue is somewhat contentious, the evidence suggests that an explorer should be used lightly or not at all on occlusal surfaces. The use of magnification which assists in the visual criteria was c onsistently used by almost half of the dentists in the study. The visual criteria fo r evaluating carious lesions have been described and, in certain studies, they have been validated in vitro by sectioning the teeth after the lesions had been visual ly scored (34); the histological features are considered as the gold standard(84 ). Visual method for evaluatio n of dental caries has low sensitivity and high specificity in diagnosing o cclusal caries (63, 69, 133).

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42 The use of film radiograph for caries detection has a long histor y, and is still a widely used diagnostic technique (106, 130). In the current study, radiographs have been consistently and widely used for the diagnosis of proximal dental caries and less ofte n for the diagnosis of occlusal dental caries. It is hypothesized that occlusal lesions are init iated on the fissure walls and can therefore be obscured by sound superficial tissue (103). Additionally, there is evidence that one effect of regular use of fluorides is greater opacity of enamel, which may obscure underlying lesions in dentin, the so-called hidden lesions. Therefore, de ntal radiographs have been reported inadequate for detecting caries in the occlusal surface until the lesion is well advanced through the enamel and into the dent in (103). False positives can also occur with radiographic diagnosis, and specifi cities of 66% to 98% have b een recorded in vitro (46, 62). However, regarding proximal dental caries, studies have reported high sensitivity values for radiographs for the diagnosis of proxima l dental caries (25, 105, 123, 126, 127, 135). Non-Traditional Methods Fiber-optic transillumination (F OTI) is a qualitative method that has been used for several years. In FOTI, white light from a cold-light so urce is passed through a fiber to an intra-oral fiber-optic light probe that is placed on the bucca l or lingual side of the tooth. The surface is examined using the transmitted light, seen from the occlusal view. Demineralized areas appear darker compared with the su rrounding sound tissue. The contra st between sound and carious tissue is then used for detection of lesions. FO TI has been evaluated in a number of studies for detection of posterior proximal carious le sions reporting low-to good sensitivity and good specificity (101, 102, 118, 125, 126). One in vitro st udy suggested that a combination of FOTI and visual inspection is valid for determ ination of occlusal lesion depth (27). Another non-traditional method inquired in th e study is the use of a quantitative lightinduced laser fluorescence. Fluorescence occurs as a result of the intera ction of electromagnetic

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43 radiation with molecules in the tissue. The cause of enamel fluor escence is still unclear. Most of the fluorescence is induced by organic compon ents, proteinic chromophores, but some is probably attributable to ap atite (117). It has been proposed that fluorescence in dentin is caused by inorganic complexes, as well as some organi c components (6). Demineralization of dental hard tissue, enamel or dentin results in the lo ss of autofluorescence, the natural fluorescence. DIAGNOdent (Kavo Inc.) is a laser-based instrume nt, developed for detection and quantification of dental caries through laser fluorescence on smoo th and occlusal surfaces (57). The light is transmitted through a descendent optic fiber to a ha nd-held probe with a beveled tip with a fiberoptic eye. Factors that may influence the outcom e of the measurements in different ways are presence of plaque, calculus and/or staining on the tooth surface (27, 83) and the degree of dehydration of tooth tissue (113). Even though advances in technology have ma de available other assisting diagnostic methods such as FOTI and DIAGNOdent, the st udy shows that dentists participating in the DPBRN do not use these methods. Various levels of sensitivity have been reported for DIAGNOdent (2, 41, 71, 82, 123, 131, 136) and FOTI (27, 58, 59, 111) for the diagnosis of occlusal and proximal dental cari es. The strength of the evidence however is low as the available literature information is insufficient to support generalizable estimates of the sensitivity and specificity studies of these dia gnostic methods. The major problem relies in variations of the validation methods and small number of sample size. Although these new technologies hold significant promise, there is not enough evidence in the current literature for any of these techniques to be recommended as a subs titute for the traditional techniques. Concluding Remarks Caries lesions occur in a variety of anat omic locations and have unique aspects of configuration and rate of spread. These differe nces make it unlikely that a single diagnostic

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44 method will have the adequate sensitivity and specif icity to detect caries at all sites. Reports on the literature concluded that conventional visual, tactile, and radiographic examinations used as individual diagnostic methods provide less than ideal diagnostic sensitivity (25, 65, 81, 87, 122). Neither a black or brown fissure nor the use of an explorer has been shown to improve diagnostic accuracy. However, the combination of careful visual examination with optimal radiographic examination affords better diagnostic performance (87). An investigatio n of the validity of diagnosis by means of optimal bite-wing radiog raphy combined with careful visual clinical examination has shown that the majority of ca rious lesions and nearly all sound teeth can be correctly identified (3, 68). Dentists Assessment of Caries Risk Two key points are essential to understanding caries. First, cari es is a bacter ial infection caused by specific bacteria. Second, before cavita tion, caries is a reversible multi-factorial process (43, 44). Changing disease patterns require de ntists to critically ev aluate the caries risk of each patient. The assessment of patients caries risk will as sist in the formulation of an appropriate treatment plan as it allows specific preventive measur es for each patients needs, based on the risk grade and th e causally-directed diagnosis. A structured caries risk assessment should be based upon the concept of the caries balance. The balance between pathological and preventive factors can be swung in the direction of caries intervention and prevention (43, 44) In the current study, irresp ective of how caries risk was assessed, it had a positive impact on treatment plan as dentists were more readily to choose the prevention treatment option when facing various c linical case scenarios. Conversely, dentists who reported no assessment of caries risk during the treatment planning process were more prone to choose the surgical inte rvention treatment when facing various clinical case scenarios.

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45 Similarly, one study reported on the impact of not adhering to risk-assessment methods and the low use of certain preventive treatmen ts, such as dental sealant (72). Studies reporting on agreement and disagree ments among dentists recommendations for restorative treatment concluded that much of the variation in dentists profiles is due to basic differences in decision-making and caries risk assessment (9, 16). Lack of consistency in dentists decisions to intervene can have a significant e ffect on preservation of tooth structure and cost of treatment (114). Caries Diagnosis Based on Clinical Findings Accurate diagnosis of dentinal caries is more challenging on occlusal than on proximal surfaces. The diagnosis of occlusal dentinal ca ries is tricky unless cavitation or radiographic evidence is present. Furthermore, much of the caries for which clinical intervention is required occurs in the occlusal surfaces of the teeth, part icularly the complicated fissure systems of the molar teeth. The occlusal fissures of the first permanent molar are generally the first sites in the permanent dentition to develop caries (69) In recent years, there has been pronounced ch ange in the epidemiology and disease pattern of dental caries (60, 61, 86). Pr ogression of enamel caries is now slower, and allows preventive intervention before the stage of irreversible dest ruction of the tooth is reached. There is also a pronounced reduction in lesion development on sm ooth surfaces accessible to fluoride (31, 110, 124). Most dentists, irrespective of patients caries risk, chose not to restore the enamel lesion with no signs of dark brown pi gmentation (as shown in case 1) However, dentists readily changed their treatment option to surgical inte rvention, if some minor brown pigmentation was present on enamel. The frequency of selecting this option was directly pro portion to an increase on patients caries risk. The most critical area wh en deciding on treatment of dental caries lies

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46 on initial or incipient carious lesions (shown in ca se 1, 2, and 3). Traditionally, all surfaces that had either deep fissures or s uperficial staining had to be re stored, along with the famous extension for prevention propos ed over a century ago by Dr. Greene Vardiman Black in 1891 (20, 21). After the advent of fluoride and re sin technology, dentists slowly replaced the extension for prevention approach, limiting to th e removal of stained fissure with a small bur and the placement of a resin sealan t. Even though several studies have attested the importance of fluoride (31, 110, 124) for remineralization of ea rly non-cavitated carious lesions, dentists are still reluctant to adhere to changes in the pr ogress of the disease pattern and new non-invasive treatments proposed as shown by the results of the study. Enamel caries, both occlusal and proximal, can generally be managed without operative intervention (28). It has been concluded on an international consensus report that the minimum stage at which surgical interventi on is indicated is when the caries disease has reached the dentin (28). Although the tactile differentiation was not possible in the current study, as only pictures were provided, the images shown gave a definite notion of the caries pr ogression. All initial carious lesions start as subsurf ace lesions located either in en amel (29, 55, 115, 116), dentin (91) or cementum (49). The caries process at this stage may be arrested if a positive change on patients oral habits is taken place or more objectiv ely, if prevention treatmen t is initiated (45). If the lesion is arrested at this st age, the porosities may pick up stain from nut rients and liquids in the oral cavity, but the surface remains intact. These discolorations vary from light brown to dark brown to almost black. Since thes e discolored lesions have the su rface layer clinical ly intact (as shown is case 2), they do not re quire restoration, except for esthet ic reasons, if the lesion is visible during normal function (45). If the caries is not arrested, the demineralization progresses, the enamel will eventually crumble, and cavitation of the lesion becomes an irreversible stage in

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47 the caries process that will require restoration to reestablish function and esthetics (Cases 4 and 5). The presence of visible cavitation of the enamel surface is, in most cases, synonymous with dentinal involvement. When definite cavitat ion is present, the que stion generally becomes not if, but how far, the carious process has penetr ated into the dentin. In one study of 60 molars with small visible cavitations, caries had reached the dentino-enamel j unction in 25% of the teeth. For the remaining 75%, the caries pr ocess extended far into the dentin (128). Caries experience seems to make a difference in the approach of treatment. On individuals with high caries experience, 50% of the lesions in the outer half of the dentin are restored, in contrast to 20% restored in individuals with lower caries e xperience (77). Similarly, in the current study, caries risk was signi ficant when deciding the stage of intervention. Dentists were more readily to choose the intervention treatm ent on enamel surfaces when patients were in a high caries risk scenario. Caries Diagnosis Based on Radiographic Finding The current study revealed that dentists were more readily to restor e surgically enamel surfaces when they use the visual versus the radiographic diagnostic tool. Even though the radiographic pictures present a two dimensional stage of caries progression when compared to the clinical pictures, the majority of the dentists still chose to restore enamel lesions (case 1 and 2), despite the fact that previous studies have demonstrated that proximal enamel lesions with no cavitation can be arrested by fluoride treatment (31, 110, 124). As outlined by the radiographic images, the earl y carious lesion on smooth or flat enamel surfaces takes on a conical shape (19). If a llowed to progress, the lesion will reach the dentinoenamel junction and continue into dentin. In all areas the enamel lesion will advance in a direction parallel to the rods and the depth of the demineraliz ation will vary depending on the

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48 time each rod has been subjected to the deminera lization process. Althoug h the lesion evolves as a unit, the particular shape of the subsurface lesion may be best understood if each enamel rod is envisioned as developing individu ally as a mini-lesion. The olde st, deepest part is located in the center of the lesion and the youngest, shallowest part is lo cated at the periphery (19). Histologic and microradiographic evidence show that the first alterati ons in dentin, as a response to caries, is a hypermineralized zone that develops even before the enamel lesion progresses to the dentinoenamel junction (18, 19). Subsequent demineralization of the dentin takes place when the enamel lesion progresses to the dentinoenamel junction. As the lesion progresses, the involvement of dentin becomes greater, but the dentin demineralization and the hypermineralization does not exceed the area corr esponding to the limits of the outer enamel lesion. Differences in treatment according to caries pene tration into enamel and dentin have been described previously particularly for Scandinavi an countries (77, 78). Si milarly, in the current study, dentists from Scandinavia chose not to restore lesions th at were limited to enamel, but instead they chose restorative treatment pre dominantly for proximal surfaces that involved dentin. Scandinavian approach to caries diagnosis has been remark ably different as it is outlined in the next sub-section. Practices and Dentists Characteristics Remarkable differences when restoring enamel lesions were also detected regarding the type of practice. Alabama and Florida particip ating practices were di fferent than Kaiser Permanente, HealthPartner, and Scandinavia participating practices. The first two were significantly more aggressive in regard to the natu re of their treatments, i.e ., they chose the intervention treatment option on the various case scenarios more often than the other three participating practices. Additionally Alabama and Florida participating practices assessed caries

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49 risk significantly less than Kaiser Permanente HealthPartner, and S candinavia participating practices. The participating practices from Alabama and Florida regions were mostly private practice in nature in which fee-for-service was administere d. In fee-for-service type of practice, the cost of practicing and revenue are function of number and type of procedures being done, and amount of time used to deliver the servi ces. Therefore, dentists particip ating in this type of practices may feel urged to intervene surgically instea d of pursuing a less inva sive and less costly treatment. Practices from HealthPartner and Kaiser Permanente are health maintenance organization (HMO) in which a fixed-salary is pa id to the working dentist. Incentives, such as bonus per production may also exist, however this is not the main incenti ve for this type of practice. Practices in Scandinavia work in a similar manner in which the government is responsible for payment of a fixedsalary to the working dentist. Therefore, partic ipants in this type of practice feel less pressu red to impose services that ma y carry a higher fee schedule. Another very important point to be considered regarding differences found for practices in Scandinavia relies on the fact that in Scandi navian dental school, pr eventive and restorative dentistry have, for many years, been integrated in the undergraduate curric ulum as one subject, cariology, and this is reflected in the text books of the 1960s, 1970s, and 1980s (40). In North American textbooks of operative dentistry, how ever, this concept has only recently been introduced (64, 80). Current trea tment strategy in Scandinavia is based on diagnosis of caries activity, identification of the main causal and pr edisposing factors in th e individual case, and assessment of the actual caries risk (73).

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50 A comprehensive review of the literature (8) concluded that the extent to which variation in dentists detection of caries and evaluation of existing restorations are associated with characteristics of the dentist a nd the practice is completely u nknown. The current study showed that patients race had an impact on selection of tr eatment of dental caries. Practices with lower percent of black or African-American patients were more readily to choose the prevention treatment option and to assess pa tients caries risk. On the ot her hand, practices with higher proportion of black patients intervene more ofte n and aggressively on enamel lesions. It has been suggested that most dentists develop th eir principal treatment recommendations without considering many non-clinical patien t factors (8). Conversely, in the current study dentists who belonged to a practice with a cert ain type of patient population ha d significant differences related to diagnosis and treatment of dent al caries. The socio-demographi c determinants of dental care have been proposed and they include individuals that reside in a rural area, African-Americans, and the poor who have all been presumably at hi gher risk for dental problems (53). Interestingly, the standard case scenarios proposed in the current study did not re quest clinicians to consider patients race and patients so cial-economical status, however dentists responded with more invasive procedures and treatment plans, and le ss emphasis on preventive measures delivered to practices that treated a highe r proportion of minority population. Public insurance had a positive impact on participating practices, in which practices with higher percent of patients covere d by public insurance performed more prevention treatment than practices that were not covered by public insurance. A previ ous survey study reported that dentists involved in pediatric practices with high volume of patients under public insurance had positive opinions about their practic e, high levels of knowledge, and assessed risk factors in their patients (30).

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51 Studies have reported on the re lationship of reimbursement and the use of preventive measures. In one study, it has been suggested th at reimbursement by itsel f could not increase dentists use of preventive treatments as after fl uoride varnish became a covered benefit, dentists increase its use, however after two years, the ma jority of the dentists still had not adopted the preventive measure (47). Anot her study reported on a similar finding, in which managed care preventive services were poorly used by patient s and the profession due to lack of financial incentives to increase their use (1). Even though, no significant differences were f ound for gender and race of dentists, years of experience was significant for diffe rent outcomes, including assessmen t of caries risk, as dentists with less years of experience assessed caries risk more often than those with more years of experience. Interestingly, dentists with less year s of experience were more readily to choose the prevention treatment option than dentists with more years of experience. Even though the transition from intervention to prevention in carie s treatment has been a slow process, dental school programs have attempted to study and incor porate various levels of caries risk assessment and disease control (26). Deficiencies still exist regarding full implementation of caries risk and prevention programs in dental schools, however a cer tain exposure of the subject seems to have been given to recently-graduated clinicians. Evaluation of Existing Restorations Cross-sectional studies have shown that re placement of failed restorative treatment constitute 50-70% of all restorative work perf ormed in general dental practice (48, 97). Among dentists, decisions to replace existing restorations exhibit more variation than do caries diagnosis, with a fivefold difference in replacement rates (8 9). As the population ages and people are living longer with tooth loss across all ag es decreasing (24, 64), it is necessa ry to search for a reliable diagnostic criteria for evaluation of existing restorations, given th at each time a restoration is

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52 replaced, more tooth structure is lost (50, 51, 52). No described crit eria exist for the diagnosis of recurrent caries or caries adjacent to existing restorations. One of the main reasons that restorations may be placed or re placed precipitately is that de ntists do not have a consistent method to predict the caries pr ogression or to di agnose caries adjacent to existing dental restorations. The differentiation between active and arrested carious lesions is commonly carried out with respect to primary caries and it is not reported in relation to recurrent caries, either in textbooks of operative dentistry or in cariology textbooks. Consequently, it is not included in clinical diagnosis and treatment planning of recurrent carious lesi ons (26, 137). Equally important is the differential diagnosis between a de fective restoration margin and active recurrent caries. Because of the nature and color of the tooth-colored composite restoration, dentists, in the current study, had the tendency to confuse defective margins, which could easily be polished or repaired, with margins that actually have recu rrent caries that may require a more aggressive treatment, the replacement of the entire restora tion. This was particularly evident with the composite restorations as dentists chose the intervention option of tr eatment. Conversely, when dealing with amalgam restorations dentists were generally more conservative choosing the no treatment option. A previous study showed a poor correlation betw een the presence of defective margins and caries afte r removal of amalgam restorations (85). The lack of standards to determine restoration failure causes the dentists to err on the side of caution when faced with uncertain diagnosis. Based on these findings and the f act that the cost of car e and oral health are severely impacted by the diagnos is of existing restorations, es tablishing a new evidence-based criteria for evaluation of existing restorations is a critical issue that may profoundly reflect on the over-treatment of existing restorations.

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53 CHAPTER 6 FUTURE WORK The current study has laid a foundation for future studies that may ev aluate techniques and decision-making process when treating dental caries with placemen t or replacement of restorations. In fact, three of such studies ha ve been designed and are on-going at the DPBRN: Reasons for placing the primary restorati on on permanent tooth surface; Reasons for replacement of restorations; and Longit udinal study of dental restorations. The overall goal of these studies is to capture how dentists are cu rrently treating dental caries. These studies will inquire primarily about, the reasons for placement of replacement of rest orations, the materials and techniques used to restore, and how long these restorations last. The data from these studies may then be related to the results of the cu rrent study for better unders tanding the dentists responses to actual treatme nt of dental caries. The purpose of such evaluation is to determine if discrepancies exist between what dentists be lieve should be done duri ng caries diagnosis and treatment to what is actually delivered. The overall goal is to determine if over-treatment exists which may directly impact on the he alth of the tooth, cost of treat ment, and access to dental care.

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54 CHAPTER 7 CONCLUSIONS DPBRN dentists primarily use traditional methods such as dental explorer and radiographs for the diagnosis of dental caries. Differences were found regarding th e use of caries risk assessment and significant variation exists according to dentists experience and certain characteristics of the practice. The decision to in tervene surgically in a caries process differs by severity of caries, patients caries risk, and cer tain characteristics of the practice. Regarding assessment of existing restorations, treatment opt ions chosen by participating dentists varied according to the various case scenarios, the use of caries risk assessment, and certain characteristics of dental practices.

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55 APPENDIX A QUESTIONNAIRE: ASSESSMENT OF CARIES DIAGNOSIS AND CARIES TREATMENT

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61 APPENDIX B ENROLLMENT DATA QUESTIONNAIRE US Dentists Enrollment Form Section 1: Contact Information: Today's date: _______________________ Prefix: (e.g., DR, MR, MS) _______________________________________________ First Name: _______________________________________________ Middle Name: _______________________________________________ Last Name: _______________________________________________ Suffix: (e.g., Sr., Jr.) _______________________________________________ Degree: (e.g., PhD, DDS) _______________________________________________ Email address: _______________________________________________ Name of Practice: Site 1 _______________________________________________ Address line 1: _______________________________________________ Address line 2: _______________________________________________ City: _______________________________________________ State: _______________________________________________ Zip code: _______________________________________________ Country: _______________________________________________ Office phone number: _______________________________________________ Alternative phone number: _______________________________________________ Fax number: _______________________________________________ Assistant: First Name _______________________________________________ Assistant: Last Name _______________________________________________ Assistant: Email _______________________________________________ Name of Additional Practice: Site 2 _______________________________________________ Address line 1: _______________________________________________ Address line 2: _______________________________________________ City: _______________________________________________ State: _______________________________________________ Zip code: _______________________________________________

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62 Country: _______________________________________________ Office phone number: _______________________________________________ Alternative phone number: _______________________________________________ Fax number: _______________________________________________ Assistant: First Name _______________________________________________ Assistant: Last Name _______________________________________________ Assistant: Email _______________________________________________ Name of Additional Practice: Site 3 _______________________________________________ Address line 1: _______________________________________________ Address line 2: _______________________________________________ City: _______________________________________________ State: _______________________________________________ Zip code: _______________________________________________ Country: _______________________________________________ Office phone number: _______________________________________________ Alternative phone number: _______________________________________________ Fax number: _______________________________________________ Assistant: First Name _______________________________________________ Assistant: Last Name _______________________________________________ Assistant: Email _______________________________________________

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63 Section 2: Practiti oner Characteristics: [Questions 1 8] Unless otherwise stated in the question, pl ease provide one answer for each question 1. Do you practice as a general dentist or as a specialist? Please select the appropriate answer. 1. General Practitioner 2. Oral/Maxillofacial Surgeon 3. Periodontist 4. Prosthodontist 5. Endodontist 6. Pediatric Dentist 7. Orthodontist 8. Other (please specify) ___________________________________________________ 2. What is your gender? 1. Male 2. Female 3. What is your age? _______________ 4. What is your racial identification? 1. White 2. Black or African-American 3. American Indian or Alaska Native 4. Asian 5. Native Hawaiian or Other Pacific Islander 6. Other (please specify) __________________________________________________ 5. Are you of Hispanic or Latino origin? 1. Yes 2. No 6. In which of the following dental organizat ions are you currently a member? (Check all that apply) 1. American Dental Association/state de ntal association/lo cal association 2. Academy of General Dentistry/stat e academy of general dentistry 3. Other (please specify) _____________________________________________________ 4. Other (please specify) _____________________________________________________ 5. Other (please specify) _____________________________________________________ 6. Other (please specify) _____________________________________________________ 7. Other (please specify) _____________________________________________________

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64 7. What year did you graduate from dental school? _____________ 8. From which dental school did you graduate? ____________________________________ Section 3: Practice Characteristics: [Questions: 9-17] 9. At how many dental sites, clinics, or hospitals do you provide direct patient care (excluding teaching, cons ulting or management) at least once each week? 1. One 2. Two 3. Three 4. More than three 10. How many hours per week do you personally spend in direct patient care as opposed to management or teaching responsibilities (incl uding all sites at which you are practicing)? _________ hours in patient care 11. How many people (including yourself) in yo ur part of the practi ce work full-time or work part-time (including all site s at which you are practicing)? [Note: If you and another dentist share equall y a receptionist, then count that employee as of an employee.] full-time employees (32+ hours/week) part-time employees (less than 32 hours/week) dental hygienists _________ _________ dental assistants _________ _________ lab technicians _________ _________ office manager, receptionist, other office personnel _________ _________ 12. How many dental chairs do you, your assistan t(s), and hygienist(s) use regularly in your part of the practice (including a ll sites at which you are practicing)? _________ dental chairs 13. How many patient visits do you personally (excluding your hygienist's patients) have during a typical work week (including all sites at which you are practicing)? _________ patient visits in a typical week

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65 14. Approximately what percentage of your pati ents have extended payment schedules? If you do not accept extended payment schedul es, please record 0% in the column. _______________ %of patients on extended payment schedules (e.g., monthly payments) 15. On average, how long does a patien t in your practice have to wait: 1. for a new patient exam appointment ________ days 2. for a treatment procedure appointment ________ days 3. In the waiting room after arrivi ng for an appointment ________ minutes 16. Which of the following best describes you r part of the practice during the past 12 months? 1. Too busy to treat all people requesting appointments 2. Provided care to all who requested appoint ments, but the practice was overburdened 3. Provided care to all who requested appointme nts, and the practice was not overburdened 4. Not busy enough the practice coul d have treated more patients 17. Please record what you r typical fee is for a ... Please check below if you do not do this procedure 2-surface amalgam (ADA 2150) $ ____________ _______ 3-canal molar root canal (ADA 3330) $ ____________ _______ Single simple/uncomplicated extraction (ADA 7140) $ ____________ _______ Cast partial denture (ADA 5213 or 5214) $ ____________ _______ Full denture (ADA 5110 or 5120) $ ____________ _______ Porcelain-to-metal crown (average of ADA 2750, 2751, 2752) $ ____________ _______ 1-surface posterior composite (ADA 2391) $ ____________ _______ 2-surface anterior composite (ADA 2331) $ ____________ _______

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66 Section 4: Patient Population Characteristics: [Questions: 18-23] 18. Approximately what percentage of the pati ents in your practice scheduled with you are ? Children & Teenagers (1 to 18 years) _______________ % Young adults (19 to 44 years) _______________ % Middle aged adults (45 to 64 years) _______________ % Elderly (65 or older) _______________ % Please make sure your totals adds up to 100 % 19. Approximately what percentage of the patients in your practice scheduled with you are... ? White _______________ % Black or African-American _______________ % American Indian or Alaska Native _______________ % Asian _______________ % Native Hawaiian or Other Pacific Islander _______________ % Other, please specify ____________________ _______________ % Please make sure your totals adds up to 100 % 20. Approximately what percentage of the patients in your practice scheduled with you are of Hispanic or Latino origin? _______________ % 21. Approximately what percentage of the patients in your practice scheduled with you are ... ? Covered by a private insurance program that pays for some or all of their dental care? _______________ % Covered by a public program that pays for some or all of their dental care? _______________ % Not covered by any third party and pay their own bills? _______________ % Not covered by any third party and receive free care or for a fee that you reduce substantially? _______________ % Please make sure your totals adds up to 100 %

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67 22. Approximately what percentage of revenues or charges are derived from different payment sources? If you do not accept certain payment procedures below, please record 0% in the column. payment source % of practice revenue or charges from each source dental insurance _______________ % self-pay _______________ % unpaid bills _______________ % Other, please specify_______________________________ _______________ % Please make sure your totals adds up to 100 % 23. What percentage of visits in yo ur part of the practice are...? Scheduled more than one day in advance _______________ %

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68 LIST OF REFERENCES 1. Albert DA. Sealant use in public and privat e insurance programs. NY State Dent J 1999; 65:24-25. 2. Aljehani A, Yang L, Shi XQ. In vitro qua ntification of smooth surface caries with DIAGNOdent and DIAGNOdent pen. Acta Odontol Scand 2007;65:60-63. 3. Alwas-Danowska HM, Plasschaert AJ, Sulibor ski S, Verdonschot EH. Relaibility and validity issues of laser fluorescence measurem ents in occlusal caries diagnosis. J Dent 2002;30:129-134. 4. Anusavice KJ. Treatment regimens in preven tive and restorative de ntistry J Amer Dent Assoc 1995;126:727-743. 5. Anusavice KJ. Benn DK. Is it time to change state and regional dental licensure board exams in response to evidence from car ies research? Crit Rev Oral Biol Med 2001;12:368-372. 6. Armstrong WG. Fluorescence characteristic s of sound and carious human dentine preparations. Arch Oral Biol 1963;8:79-90. 7. Bader JD, Brown JP. Dilemmas in caries di agnosis. J Am Dent Assoc 1993;124:48-50. 8. Bader JD, Shugars DA. Understanding dentists restorative treatment decisions. J Public Health Dent 1992; 52:102-110. 9. Bader JD, Shugars DA. Agreement among dentists recommendations for restorative treatment. J Dent Res 1993; 72:891-896. 10. Bader JD, Shugars DA, McClure FE. Co mparison of restorative treatment recommendations based on patients and pati ents simulations. Oper Dent 1994; 19:20-25. 11. Bader JD, Shugars DA. Variation in dentists clinical decisions. J Public Health Dent 1995; 55:181-188. 12. Bader JD, Shugars DA. What do we know a bout how dentists make caries-related treatment decisions? Community De nt Oral Epidemiol 1997; 25:97-103. 13. Bader J, Shugars D, Bonito A. Systematic reviews of selected dental caries diagnostic and management methods. J Dent Educ 2001;65:960-968. (A) 14. Bader J, Shugars D, Bonito A. A systematic review of selected caries prevention and management methods. Community Dent Oral Epidemiol 2001;29:399-411. (B) 15. Bader J, Shugars D, Perrin N, Maupome G, Rindal, Rush W. Validation of a simple approach to caries risk assessment. J Public Health Dent 2005;65:76-81

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69 16. Bailit HL, Reisine ST, Damuth RL, Richards NP. The validity of the radiographic method in the pretreatment review of dental claims. J Public Hea lth Dent 1980; 40:2638. 17. Benn DK, Meltzer MI. Will modern caries mana gement reduce restorations in dental practice? J Am Coll Dent 1996; 63:39-44. 18. Bergman G. Studies on minera lized tissues. XIII. Combin ed micro radiographic and autoradiographic investigations on cari ous teeth. J Dent Belge 1959; 50:75-85. 19. Bjrndal L, Thylstrup A. A stru ctural analysis of approximal enamel caries lesions and subjacent dentin reactions. Eur J Oral Sci 1995;103:25-31. 20. Black GV. Operative Dentistry, Vol 1, Pathol ogy of the hard tissues of the teeth. Chicago, IL: Mexico Dent al Publishing Company, 1908. 21. Black GV. Operative Dentistry, Vol 1, Patholog y of the hard tissues of the teeth. London: Claudius Ash, Sons & Co., 1914. 22. Bratthall D, Hansel Petersson G. cariogram-a multifactorial risk assessment model for a multifactorial disease. Community Dent Oral Epidemiol 2005; 33:256-264. 23. Burke FJ, Cheung SW, Mjor IA, Wilson NH. Restoration longevity and analysis of reasons for the placement and replacement of restorations provided by vocational dental practitioners and their traine rs in the United Kingdom. Quintessence Int 1999; 30:23442. 24. Center for Disease Control and Prevention (CDC ) Public health and aging: retention of natural teeth among older adultsUnited States, 2002. Morb Mortal Wkly Rep 2003; 19:1226-1229. 25. Chong MJ, Seow WK, Purdie DM, Cheng E, Wan V. Visual-tactile examination compared with conventional radiography, di gital-radiography, and DIAGNOdent in the diagnosis of occlusal occult caries in ex tracted premolars. Pediatr Dent 2003;25:341-349. 26. Clark TD, Mjr IA Current teaching of cariolo gy in North American dental schools Oper Dent 2001;26:412-418. 27. Cortes DF, Ellwood RP, Ekstrand KR. An in vitro comparison of a combined FOTI/visual examination of occlusal caries w ith other caries diagnostic methods and the effect of stain on their diagnostic performance. Caries Res 2003;37:8-16. 28. Criteria for placement and repla cement of dental restorations: an international consensus report. Int Dent J 1988;38:193-194. 29. Darling AI. Studies of the early lesion of enamel caries with transmitted light, polarized light, and microradiography. Br it Dent J 1956;101:289-297 and 329-341.

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70 30. dela Cruz GG, Rozier RG, Slade G. Dent al screening and refe rral of young children by pediatric primary case provide rs. Pediatrics 2004;114:642-652. 31. Donly KJ, Brown DJ. Indetify, protect, re store: emerging issues in approaching childrens oral healt h. Gen Dent 2005;53:106-110. 32. Drake C, Beck J, Lawrence H, Koch G. Thre e-year coronal caries incidence and risk factors in North Carolina el derly. Caries Res 1997;31:1-7. 33. Ekstrand KR, Qvist V, Thylstrup A. Light mi croscope study of the effect of probing in occlusal surfaces. Caries Res 1987;21:368-374. 34. Ekstrand KR, Ricketts DN, Kidd EA. Reproducib ility and accuracy of three methods for assessment of demineralization depth of the o cclusal surface: an in vitro examination. Caries Res 1997;31:224-231. 35. Elderton RJ. An in vivo morphological study of cavity and amalgam margins on the occlusal surfaces of human teeth. P h.D. Thesis, University of London, 1975. 36. Elderton RJ. Assessment of the quality of rest orations. A literature review. J Oral Rehabil 1977; 4:217-26. 37. Elderton RJ. Treatment varia tion in restorative dentistry. Restorative Dent 1984; 1:36,8. 38. Elderton RJ. Variability in the decision-m aking process and implications for change toward a preventive philosophy. In: Anusavice KJ, ed. Quality evaluation of dental restorations: criteria for placement and repla cement. Chicago: Quintessence Publishing Co., 1989: pp. 211-219. 39. Elderton RJ, Nuttall NM. Variation among dentis ts in planning treatment. Br Dent J 1983; 154:201-206. 40. Elderton RJ, Mjor IA. Treatment planning. In: Horsted-Bindslev P, Mjor IA, eds. Modern concepts in operative dentistry. Copenhagen: Munksgaard; 1988: pp.59-92. 41. El-Housseiny AA, Jamjoum H. Evaluation of visual, explorer, and a laser device for detection of early occl usal caries. J Clin Pe diatr Dent 2001;26:41-48. 42. Espelid I, Tveit AB, Mejre I, Nyvad B. Karies ny viten eller gamle sannheter? Nor Tannlegefor Tid 1997;107:66-74. 43. Featherstone JD. The caries ba lance: the basis for caries management by risk assessment. Oral Health Prev Dent 20042:259-264. 44. Featherstone JD. Caries preven tion and reversal based on the caries balance. Pediatr Dent 2006;28:128-132.

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71 45. Fejerskov O, Nyvad B, Kidd EAM. Clinical a nd histological manife stations of dental caries. In: Fejerskov O, Kidd EA eds. Dent al Caries: The diseas e and its clinical management. Malden, MA:Blackwell Munksgaard, 2003; pp71-98. 46. Ferreira Zandona AG, Analoui M, Scheme horn BR, Eckert GJ, Stookey GK. Laser fluorescence detection of demineralization in artificial occlusal fissures. Caries Res 1998;32:31-40. 47. Fiset L, Grembowski D, Aguila M. Thirdparty reimbursement and use of fluoride varnish in adults among general dentists in Washington State. J Am Dent Assoc 2000; 131:961-968. 48. Friedl KH, Hiller KA, Schmalz G. Placement and replacement of amalgam restorations in Germany. Oper Dent 1994; 19:228-232. 49. Furseth R, Johansen E. A microradiogra phic comparison of sound and carious human dental cementum. Arch Oral Biol 1968;13:1197-1206. 50. Gordan VV. In vitro evaluation of marg ins of replaced resin based composite restorations. J Esthet Dent 2000; 12:217-223. 51. Gordan VV. Clinical evaluation of replacement of class v resin based composite restorations. J Dent 2001; 29: 485-488. 52. Gordan VV, Mondragon E, Shen C. Evalua tion of the cavity design, cavity depth, and shade matching in the replacement of resin based composite restorations. Quintessence Inter 2002; 32:273-278. 53. Gilbert GH, Duncan RP, Kulley AM, Coward RT, Heft MW. Evaluation of bias and logistics in a survey of adults at increased ri sk for oral health decrements. J Public Health Dent 1997; 57:48-58. 54. Gilbert G, Foerster U, Dolan T, Duncan R, Ringelberg M. Twenty-four month coronal caries incidence: the role of dental care and race. Caries Res 2000;34:367-79. 55. Gustavson G. The histopathology of caries of human dental enamel, with special reference to the division of the lesion in to zones. Acta Odont ol Scand 1957;15:13-55. 56. Hawkins R, Jutai D, Brothwell D, Locker D. Three-year coronal caries incidence in older Canadian adults. Caries Res 1997;31:405-10. 57. Hibst R, Gall R. Development of a diode lase r-based fluorescence caries detector. Caries Res 1998;32:294. 58. Hintze H, Wenzel A, Danielsen B, Nyvad B. Reliability of visual examination, fiberoptic transillumination and bite-wing radiogra phy, and reproducibility of direct visual examination following tooth separation for the identification of cavitated carious lesions in contacting approximal surfaces. Caries Res 1998;32:204-209.

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72 59. Holt RD, Azevedo MR. Fibre optic transillumi nation and radiographs in diagnosis of approximal caries in primary teeth. Community Dent Health 1989;6:239-247. 60. Hugoson A, Koch G, Hallonsten AL, Nord eryd J, berg A. caries prevalence and distribution in 3-20-years-olds in Jnkping, Sweden, in 1973, 1978, 1983, 1993. Community Dent Oral Epidemiol 2000;28:83-89. 61. Hugoson A, Koch G, Slotte C, Bergendal T, Thorstensson B, Thorstensson H. Caries prevalence and distribution in 20-80-year s-olds in Jnkping, Sweden, in 1973, 1983, 1993. Community Dent Oral Epidemiol 2000;28:90-96. 62. Huysmans MC, Longbottom C, Pitts N. Electrical methods in occlusal caries diagnosis: An in vitro comparison with visual inspect ion and bite-wing radi ography. Caries Res 1998;32:324-329. 63. Ie YL, Verdonschot EH. Performance of diagnos tic systems in occlusal caries detection compared. Community Dent Oral Epidemiol 1994;22:187-191. 64. Ismail AI. Clinical diagnosis of precavitate d carious lesions. Community Dent Oral Epidemiol 1997;25:13-23. 65. Jahangiri L, Wahlers C, Hittelman E, Ma theson P. Assessment of sensitivity and specificity of clinical evaluation of cast restoration marginal accuracy compared to stereomicroscopy. J Prosthet Dent 2005;93:138-142. 66. Kay E, Watts A, Paterson R, Blinkhorn A. Prel iminary investigation into the validity of dentists decisions to restore occlusal surf aces of permanent teeth. Community Dent Oral Epidemiol 1988; 16 91-94. 67. Kaste L, Selwitz R, Oldakowski R, Brunelle J, Winn D, Brown L. Coronal caries in the primary and permanent dentition of children a nd adolescenets 1-17 years of age: United States, 1988-1991. J Dent Res 1996; 75 (special issue):631-641. 68. Ketley CE, Holt RD. Visual and radiographic diagnosis of occlusal caries in first permanent molars and in second prim ary molars. Br Dent J 1993;174:364-370. 69. Kidd EAM, Ricketss DNJ, Pitts NB. Occlusal caries diagnosis: a changing challenge for clinicians and epidemiol ogists. J Dent 1993;21:323-331. 70. Kidd EAM, Nyvad B. Caries control for th e individual patient. In: Fejerskov O, Kidd E eds. Dental caries. The disease and its clinical management. Oxford, UK: Blackwell Munksgaard, 2003; pp303-312. 71. Kuhnisch J, Ziehe A, Brandstad A, Heinrich -Weltzien R. An in vitro study of the reliability of DIAGNOdent measurem ents. J Oral Rehabil 2004;31:895-899. 72. Kumar JV, Wadhawan S. targeti ng dental sealants in schoo l-based programs: evaluation of an approach. Community Dent Oral Epidemiol 2002;30:210-215.

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73 73. Lagerlf F, Oliveby A. Clinical implications: new strategies for caries treatment. In: Stookey GK, ed. Early detection of dental caries. Indianapo lis, IN: School of Dentistry, Indiana University; 1996; pp 297-316. 74. Lawrence HP, Hunt RJ, Beck JD. Three-year root caries incidence and risk modeling in older adults in North Carolina. J Public Health Dent 1995;55:69-78. 75. Lawrence HP, Hunt RJ, Beck JD, Davies GM Five-year incidence rates and intraoral distribution of root carie s among community-dwelling older adults. Caries Res 1996; 30:160-179. 76. Lewis DW, Pharoah MJ, El-Mowafy O, Ross DG. Restorative certainty and varying perceptions of dental caries depth among dentists. J Public Health Dent 1997 57:243-245. 77. Lith A, Pettersson LG, Grondahl HG. Radi ographic study of approximal restorative treatment in children and adolescents in tw o Swedish communities differing in caries prevalence. Community Dent Oral Epidemiol 1995;23:211-6. 78. Lith A, Lindstrand C, Grondahl HG. Cari es development in a young population managed by a restrictive attitude to radiography and operative intervention: II. A study at the surface level. Dentomaxillofac Radiol 2002;31:232-9. 79. Locker D. Incidence of root caries in an older Canadian population. Community Dent Oral Epidemiol 1996;24:403-7. 80. Lundeen TF, Roberson TM. Cariology: the le sion, etiology, preventi on, and control. In: Sturdevant CM, Roberson TM, Heymann HO, St urdevant JR, eds. The Art and Science of Operative Dentistry. St Loui s, Missouri: Mosby, 1995; pp: 60-128. 81. Lussi A. validity of diagnostic and treatment decisions of fissure caries. Caries Res 1991;25:296-303. 82. Lussi A, Hellwig E. Performance of a new la ser fluorescence device for the detection of occlusal caries in vitro. J Dent 2006;34:467-471. 83. Lussi A, Imwinkelried S, Pitts N, Longbottom C, Reich E. performance and reproducibility of a laser fluorescence system for detection of occlusal caries in vitro. Caries Res 1999;33:261-266. 84. Machiulskiene V, Nyvad B, Baelum V. Preval ence and severity of dental caries in 12year-old children in Kaunas,Lithuania. Caries Res 1998;;32:175-180. 85. Maryniuk GA, Brunson WD. When to replace faulty-margin amalgam restorations: a pilot study. Gen Dent 1989; 37:463-467. 86. Mathaler TM. Caries status in Europe and pr edictions of future tr ends. Caries Res 1990; 24:381-396.

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74 87. McComb D, Tam LE. Diagnosis of occlusal caries: Part I. Conventional methods. J Can Dent Assoc 2001;67:454-457. 88. Mejare I, Stenlund H, Zelezny-Holmlund C. Caries incidence and lesion progression from adolescence to young adulthood: a pros pective 15-year cohor t study in Sweden. Caries Res 2004; 38:130-141. 89. Merrett MCW, Elderton RJ. An vitro study of restorative dental tr eatment decisions and dental caries. Br Dent J 1984; 157:128-133. 90. Mileman PA, van der Weele LT. The role of caries recognition: treatment decisions from bitewings radiographs. Denti nomaxillofac Radiol 1996; 25:228-233. 91. Mjr IA. Histologic studies of human cor onal dentine following cavity preparations and exposure of ground facets in vivo. Arch Oral Biol 1967;12:247-263 92. Mjr IA. Amalgam and composite resin re storations: longevity and reasons for replacement. In: Anusavice KJ, ed. Quality ev aluation of dental restorations. Chicago: Quintessence 1989;61-68. 93. Mjr IA. Clinical diagnosis of recurrent caries. J Am Dent Assoc 2005; 136:1426-1433. 94. Mjr IA and Qvist V. Marginal failures of amalgam and composite restorations. J Dent 1997;7:25-30. 95. Mjr IA, Reep RL, Kubilis PS, Mondragon BE. The change in size of replaced amalgam restorations: A methodology study. Oper Dent 1998;23:272-277. 96. Mjr IA, Toffenetti F. Secondary caries: A literature review with case reports. Quintessence Int 2000; 31:165-179. 97. Mjr IA, Shen C, Eliasson ST, Richter S. Placement and replacement of restorations in general dental practice in I celand. Oper Dent 2002;27:117-123. 98. National Institutes of Health, Office of Me dical Application of Research. Consensus Development Conference Statement: Diagnos is and Management of Dental Caries Throughout Life, Marc h 26-28, 2001. accessed at: http://odp.od.nih.gov/consensus/cons/115/115_intro.htm 99. Noar SJ, Smith BGN. Diagnosis of caries a nd treatment decisions in approximal surfaces of posterior teeth in vitro. J Oral Rehabil 1990; 17:209-218. 100. Nuttall NM, Pitts NB, Fyffe HE. Assessment of reports by dentists of their restorative treatment thresholds. Community Dent Oral Epidemiol 1993; 5:273-278. 101. Obry-Musset AM, Cahen PM, Turlot JC, Fr ank R. Approximal caries diagnosis in epidemiological studies: transillumination or bitewing radiographs? J Biol Buccale 1988; 16:13-17.

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75 102. Peers A, Hill FJ, Mitropoulos CM, Holloway PJ. Validity and reproducibility of clinical examination, fiber-optic transi llumination, and bite-wing ra diology for the diagnosis of small approximal carious lesions: an in vitro study. Caries Res 1993;27:307-311. 103. Pitts N. Advances in radiographic detection methods and caries management rationale. In Stookey GK, ed. Early detection of dental caries. Indianapo lis, IN: School of dentistry, Indiana University; 1996; pp 39-50. 104. Pitts NB. Diagnostic tools and measurements impact on appropriate care. Community Dent Oral Epidemiol 1997;25:24-35. 105. Pitts NB, Renson CE. Reproducibility of computer-aided image-analysis-derived estimates of the depth and area of radiolu cencies in approximal enamel. J Dent Res 1985;64:1221-1224. 106. Pitts NB, Stamm JW (eds). Proceedings fr om the international consensus workshop on caries clinical trials J Dent Res 2004;83:Spec Issue C: 125-128. 107. Qvist J, Qvist V, Mjor IA. Placement and l ongevity of tooth-colored restorations in Denmark. Acta Odontol Scand 1990; 48: 305-311. 108. Ratledge DK, Kidd EA, Beighton D. A clinical and microbiological study of approximal carious lesions. Pat 1: the relationship between cavitation, radiographic lesion depth, the site-specific gingival index a nd the level of inf ection of the dentine. Caries Res 2001; 35:3-7. 109. Rytomaa I, Jarvinen V, Jarvinen J. Variation in caries recording and restorative treatment plan among university teachers. Commun ity Dent Oral Epidemiol 1979; 7:335-339. 110. Sawyer KK, Donly KJ. Remineralization effect s of a sodium fluoride bioerodible gel. Am J Dent 2004;17:245-248. 111. Schneiderman A, Elbaum M, Shultz T, Keem S, Greenebaum M, Driller J. Assessment of dental caries with digital imaging fiber-otpic transilumination (DIFOTI): in vitro study. Caries Res 1997;31:103-110. 112. Schwartz M, Grondahl HG, Pliskin JS, Boffa J. A longitudinal analysis from bite-wing radiographs of the rate of progression of approximal carious lesions through human dental enamel. Arch Or al Biol 1984; 29:529-536. 113. Shi X-Q, Welander U, Angmar-Mansson B. Occlusal caries detection with Kavo DIAGNOdent and radiographic examination; an in vitro comparison. Caries Res 2000;34:151-158. 114. Shugars DA, Bader JD. Cost implications of di fferences in dentistsrestorative treatment decisions. J Public Hea lth Dent 1996; 56:219-222.

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76 115. Silverstone LM. Structure of carious enam el, including the early lesion. Oral Sci Rev 1973;3:100-160. 116. Silverstone LM, Hicks MJ, Featherstone MJ. Dynamic factors affecting lesion initiation and progression in human dental enamel. II. Surface morphology of sound enamel and caries like lesions of enamel Quintessence Int 1988;19:773-785. 117. Spitzer D, ten Bosch JJ. The total lumine scence of bovine and human dental enamel. Calcif Tiss Res 1976;20:201-208. 118. Stephen KW, Russell JI, Creanor SL, Bu rchell CK. Comparison of fiber-optic transillumination with clinical and radiograp hic caries diagnosis. Community Dent Oral Epidemiol 1987;15:90-94. 119. Stewart PW, Stamm JW. Classification tree pr ediction models for dental caries from clinical, microbiological, and inte rview data. J Dent Res 1991;70:1239-1251. 120. Stookey GK, Gonzalez-Cabezas C. Emerging met hods of caries diagnosis. J Dent Educ 2001;65:1001-1006. 121. Thomson W. Dental caries experience in older people over time: what can the large cohort studies tell us? Br it Dent J 2004;196:89-92. 122. Thompson NJ, Boyer EM. Validity of oral h ealth screening in field conditions: pilot study. J Dent Hyg 2006 80:9. 123. Tonioli MB, Bouschlicher MR, Hillis SL. Laser fluorescence detection of occlusal caries. Am J Dent 2002;15:268-273. 124. Twesme DA, Firestone AR, H eaven TJ, Feagin FF, Jacobs on A. Air-rotor stripping and enamel demineralization in vitro. Am J Orthod Dentofacial Orthop 1994;105:142-152. 125. Vaarkamp J, ten Bosch JJ, Verdonschot EH, Tr anaeus S. Quantitative diagnosis of small approximal caries lesions utilizing wavelength-dependent fiber-optic transillumination. J Dent Res 1997;76:875-882. 126. Vaarkamp J, ten Bosch JJ, Verdonschot EH Bronkhoorst EM. The real performance of bitewing radiography and fiberoptic transillumination in approximal caries diagnosis. J Dent Res 2000;79:1747-1751. 127. Valachovic RW, Douglass CW, Berkey CS McNeil BJ, Chauncey HH. Examiner reliability in dental radi ography. J Dent Res 1986;65:432-436. 128. van Amerongen JP, Penning C, Kidd EA, ten Cate JM. An in vitro assessment of the extent of caries under small occlus al cavities. Caries Res 1992;26:89-93. 129. van Dorp CS, Exterkate RA, ten cate JM. The effect of dental probing on subsequent enamel demineralization. ASDC J Dent Child 1988;55:343-347.

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77 130. Van Rijkom HM, Verdonschot EH. Factors en volved in validity measurements of diagnostic tests for approximal cariesa meta-analysis. Caries Res 1995;29:364-370. 131. Virajsilp V, Thermontree A, Aryatawong S, Paiboonwaraschat D. Comparison of proximal careis detection in primary teeth between laser fluore scence and bitewing radiography. Pediatr Dent 2005;27:493-499. 132. Virtanen JI. Changes and trends in attack distributions and pr ogression of dental caries in three age cohorts in Finland. J Epidemiol Biostat 2001; 6:325-329. 133. Wenzel A, Larsen MJ, Fejerskov O. Detecti on of occlusal caries without cavitation by visual inspection, film radiograph, xeroradiogr aphs, and digitized radiographs. Caries Res 1991;25:365-371. 134. Winn F, et al. Coronal and root caries in th e dentition of adults in the United States, 1998-1991. J Dent Res 1996; 75 (s pecial issue): 642-651. 135. Yalcinkaya S, Kunzel A, Willers R, Thoms M, Becker J. Subjective image quality of digitally filtered radiographs acquired by th e Durr Vistascan system compared with conventional radiographs. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 2006;101:643-651. 136. Yin W, Feng Y, Hu D, Ellwood RP, Pretty IA. Reliability of quantitative laser fluorescence analysis of smooth surface lesions adjacent to the gingival tissues. Caries Res 2007;41:186-189. 137. Yorty JS, Brown KB. Caries ri sk assessment/treatment programs in US dental schools. J Dent Educ 1999;63:745-747.

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78 BIOGRAPHICAL SKETCH Dr. Valeria Veiga Gordan received her dent al degree from the State University of Londrina, Brazil, School of Dentistry in 1993. She practiced dentistry for 2 years in a private practice in Brazil. Soon after th at she moved to the United St ates where she completed her Master of Science degree and Certificate Program in Operative Dentistry at the University of Iowa in 1997. After she completed her studies at the University of Iowa she was appointed Instructor, Department of Operative Dentistry, University of Florida College of Dentistry (UFCD). Shortly thereafter she wa s promoted to Assistant Profe ssor and within 3 years she was granted tenure with promoti on to Associate Professor. Dr. Gordan brought contemporary concepts and new techniques in preservation of tooth structure to the UFCD Operative Dentistry Depa rtment. She also improved the evidence-based content and philosophy of the curr iculum with innovative methods of teaching and application of her research findings. Her time has been devoted pr imarily to pre-clinical and clinical teaching activities. She wrote 3 chapters on various clinic al topics in American and European text-books. She has worked as a Course Director for seve ral courses at the UFCD : Advanced and Complex Restorations Course, Preclinical Operative Dentistry III, Esth etic Elective Honors Program, and Indirect Restorations Course for sophomore, junior, and senior dental students. She was responsible for formulating new le ctures in restorative dentistr y, and for creating over fourteen videos and CDs containing contempor ary topics related to dental procedures. She also developed seven different clinical research projects that involved the stud ent participation in the dental clinics. Her teaching has awarded her the Dental Educator Award in 2000 in recognition of outstanding contributions to the quality of dental education, by the Flor ida Dental Association, the Teacher of the Year Award in 2001 for demonstrating excellence, innovation and effectiveness in teaching, by University of Fl orida College of Dentistry, and the Faculty of

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79 Honor at the Professionalism and Coating Cerem ony for the University of Florida College of Dentistry Class of 2003. Dr. Gordan maintains a clinical dental practi ce in the UFCD Faculty Practice. Her faculty practice is primarily devoted to patient educa tion and preservation of tooth structure through minimally invasive dentistry and prevention of dent al caries. She dedicates one half day a week to faculty practice. Being staffed in a clinical department, where the main mission is clinical teaching, she has managed to actively engage in dental rese arch through participa tion in various grant mechanisms, primarily involving corporate support. Dr. Gordan has published 35 articles and 40 abstracts in peer-reviewed jour nals, and provided more than 50 presentations at national and international meetings. Another 7 manuscripts ha ve either been submitted for publication or are in preparation. She has been a mentor for eleven national and international dental students which originated seven publications in peer-reviewed journals and nine presentations at International meetings. She serves on the Editorial Board of the Operative Dentistr y Journal and has been invited to be a reviewer for International dental journals. She has served on national and international committees at the Academy of Operative Dentistry, American Dental Association of Research, and International A ssociation of Dental Research. In 2004 she was accepted in the Advanced Postgr aduate Program in Clinical Investigation and she is currently enrolled in a Master of Scie nces degree program in Clinical Investigation. Her current training has been supported by th e K-30 Research Program K30RR022258, awarded to the Health Science Center at the University of Florida (PI, Marian Limacher) and by the research infra-structure enhancement gran t U24DE016509-01, awarded to the College of Dentistry (PI, Robert A Burne). The goal of thes e initiatives is to provide core curriculum in

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80 clinical and translational research and to establ ish a research enterprise that complements key clinical and basic science initiatives at the University of Florida. In 2005, Dr. Gordan started participation in the Dental Practice-based Research Network (DPBRN) (U01-DE16746, PI: Gregg Gilbert, an d U01-DE 16747, PI: Dale Williams). The DPBRN was the most recently signi ficant effort established by NIDCR to investigate pressing issues in clinical care. Through collaboration with Dr. Gregg Gilbert, Dr. Gordan helped to develop the very first st udy of the network involving methods de ntists use to diagnose caries and to develop caries risk assessment.