Differences in treatment approach between Dutch paediatric dentists and general practitioners, a case control study.
Abstract: AIM: This case control study was to assess whether paediatric dentists perform significantly more diagnostic, preventive and curative care in a clinical setting then do general dental practitioners. METHODS: 16 paediatric dentists were approached and a matching control group of 16 general dental practitioners drawn from an insurance random list were selected based on matching age, practice composition and year of graduation. They were asked by mail to participate. Positive respondents were visited. All children seen during the visit were included in this study. During intra-oral inspection DMFS/dmfs was clinically scored, as were the availability of bitewings, gender, presence of fissure sealants, visibility of plaque and gingivitis and presence of fistulas. STATISTICS: Statistical analysis was carried out by using SPSS 15, p<0.05 was considered statistically significant. RESULTS: Paediatric dentists treat a greater number of younger children (p<0.05), placed more restorations and sealants (p<0.01), take more bitewing radiographs (p<0.01) and give a similar level of care to all children irrespective of their age compared to children seen by general dental practitioners. CONCLUSIONS: Paediatric dentists perform significantly more diagnostic, preventive and curative care in the clinical situation for 0-6 year old children than do general dental practitioners.

Key words: Paediatric dentist, general dental practitioner, treatment approach, restoration
Article Type: Clinical report
Subject: Pedodontics (Practice)
Dental caries (Diagnosis)
Dental caries (Prevention)
Dental caries (Care and treatment)
Children (Diseases)
Children (Diagnosis)
Children (Prevention)
Children (Care and treatment)
Authors: Kuin, D.
Veerkamp, J.S.J.
Pub Date: 02/01/2012
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2012 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: Feb, 2012 Source Volume: 13 Source Issue: 1
Topic: Event Code: 200 Management dynamics
Geographic: Geographic Scope: Netherlands Geographic Code: 4EUNE Netherlands
Accession Number: 279612746
Full Text: Introduction

From invoice data from one of the largest insurance companies in the Netherlands it appeared that dentists who use more diagnostic tools in children perform a more extensive level of care in young children and continue to do this when the children get older [Heijdra and Veerkamp, 2007]. Further studies on a new cohort of insurance data proved that paediatric dentists (PD) especially seemed to be the group responsible for these more elaborate treatment plans in young children. Paediatric dentists perform significantly more diagnostic, preventive and curative care for 0-6 year old children than do general dental practitioners (GDP) [Jensma and Veerkamp, 2010]. The reason for this difference, amongst others, could be that no consensus could be found among GDPs about the treatment of cavities in children up to 6 year of age. In a recent survey however general practitioners did indicate that they considered restorative care in this age group to be important [Jensma and Veerkamp, 2010].

The conclusions and results reported above are based on questionnaires or drawn from data obtained from insurance companies. As Heijdra and Veerkamp [2007] stated these data do not necessarily reflect children's oral health and might be biased by the dentist only claiming the treatment without actually having done it. For this purpose a clinical study was needed, comparing children's oral health to a control group treated by GDPs focusing on the question whether younger children receive comparatively the same treatment at general dental practice as at specialist PDs.

The aim of this study was to assess whether paediatric dentists perform significantly more diagnostic, preventive and curative care in the clinical situation then do general practitioners.

Materials and methods

Selection of clinics: From the study conducted by Heijdra and Veerkamp [2007], 16 paediatric dentists (PD) were selected. Following consent from the Medical Ethical Commission of the insurance company, 16 general practitioners (GDP), out of 4,500, were matched to the paediatric dentists [Heijdra and Veerkamp, 2007]. Matches were made according to age, practice composition and year of dental graduation.

The selected GDPs and PDs received a written letter from the insurance company with the request to participate in this research. Addresses of positive respondents were given to the Department of Paediatric Dentistry at ACTA. The positive respondents were then approached by the Department. A letter was sent to ask permission to contact the practice and again verify that they were interested in participating. The practices were then contacted by telephone to make an appointment at which a dental postgraduate student could come to the dental practice and investigate the children.

Selection of children: Children were randomly selected based on their attending the dental practice at the time the observer was present (convenience sample). Only children up to 18 years were included in the research. Written informed consent was given either by the parent or by both the parent and the child (when the child was over 12 years of age). Practices were visited on random days, though GDPs were frequently visited on Wednesday afternoons due to school schedules.

Clinical investigation: Clinical investigation consisted of filling in a form where information about diagnostic care (presence of bitewings and clinically visible plaque), preventive care (sealants) and restorative care. Decayed (DS and ds), missing (MS and ms) and filled (FS and fs) surfaces were recorded and added up to give a total DMFS/dmfs score, to assess treated and untreated carious lesions. The presence of decayed surfaces was investigated only clinically to make the groups comparable. The criteria for a decayed surface were clinically detectable loss of tooth material due to a carious lesion and black translucencies at the dentine-enamel junction. Missing surfaces were recorded when lost due to caries (this was verified in the history of the patient). Bitewing radiographs were used to compare differences in the level of care. The presence of fistulas, sealants and visible plaque were scored clinically (none, some or much plaque) with a probe and dental mirror. The level of care was calculated as follows: (fs/fs+ds) x 100%. Children without decay were not included.

Researchers: Research was carried out by dental postgraduate masters students. They were trained, by an experienced paediatric dentist (JV), in how to decide on the outcome variables of this study and performed a duplicate-research at a secondary dental care clinic to assess their inter-examiner reproducibility using Cohen's Kappa score (>0.80). A Cohen's Kappa score above 0.70 is considered acceptable. When there was a difference in scoring, results were discussed until mutual consent was reached. During the clinical investigation an attempt was made to not interrupt the practices' schedule. In most of the practices the students had a dental chair at their disposal and could conduct the research independently.

Statistical analysis: Statistical analysis was performed with SPSS 15.0. In comparing averages with a scale or an ordinal variable an independent samples t-test (when comparing PD with GDP) or an ANOVA (when comparing age-groups with one another) was used and p<0.05 was considered statistically significant.

Results

A total of 410 children were seen (mean age 8.2 years, SD [+ or -] 3.5) of which 226 by a PD (mean age 7.8 years, SD[+ or -]3.3) and 184 by a GDP (mean age 8.7 years, SD[+ or -]3.6). The children were divided into four consecutive age groups (Table 1).

Children attending a PD were significantly younger than children attending a GDP (p<0.01). In the 0-8 year age group significantly more children were treated restoratively by a PD than by a GDP (p<0.05). Children older than 9 years old were treated significantly more often by a GDP than by a PD (p<0.01).

Paediatric Dentists: There was no significant difference of the level of DMFS/dmfs between the consecutive age groups treated by PDs. A significant difference existed between the average number of fissure sealants placed between the consecutive age groups (p<0.01) (Table 1). In the children between 0-5 years of age less fissure sealants were applied in comparison with the older age groups (p<0.01, One Way ANOVA ).

General Detal Practitioners: The DMFS/dmfs scores for children between 6-8 years of age treated by GDP's was significantly higher than for 0-5 years of age (p<0.05). The number of fissure sealants applied increased with patients age. The increase was significant (p<0.01) for the 9-11 and >12 year age groups. Most of the children did not have any fissure sealants. From 9-11 years on there was an increase in children with four fissure sealants. In the children treated by PD's a larger number had four fissure sealants in the 0-5, 6-8 and 9-11 age groups whereas those treated by GDP's a significantly higher number of children did not have any fissure sealants (Chi square, adjusted residual, p<0.05).

Paediatric Dentists and General Practitioners: Children treated by a PD had a significant higher DMFS/dmfs score (9.4, SD [+ or -] 10.5) than children treated by a GDP (4.8, SD [+ or -] 7.1) (p<0.01, independent sample t-test). The difference could mainly be attributed to the differences in missing and filled surfaces. Concerning the total number of cavities there was no significant difference between PD's and GDP's. For GDP's there were significantly more cavities in the 0-5 and 6-8 age groups compared to the >12 year group (p<0.05, independent sample t-test). PD's showed no significant difference between the age groups. When PD and GDP data were combined more cavities were found for the 0-5 year than the 9-11 and >12 year age groups (p<0.05).

There were significantly more children with fissure sealants treated by PD (2.8, SD [+ or -] 2.3) than at GDP (1.8, SD [+ or -] 2.7) (p<0.01). There were already some children in the youngest age group with four fissure sealants. All age groups were significantly different to each other (p<0.01) except for the 9-11 year old's who did not differ with the 12 years and older age group.

Level of dental care: In consecutive age groups treated by PD's no significant differences between the care level was found (Table 2). The GDP's 0-5 years of age group had a significantly lower level of care (p<0.01) than the 9-11 and >12 years age groups. The care level for children treated by PD's was significantly higher at age 0-5 and 6-8 years compared with GDP's.

Bitewing radiographs: PD's took fewer bitewings in the 0-5 year old age group compared to the consecutive age groups (p<0.01, ANOVA), but significantly more bitewings were taken compared to GDP's (p<0.01 independent sample t-test). For GDP's significantly more bitewings were taken in the >12 year age group than in any other group (p<0.01, ANOVA).

The GDP's average level of care without using bitewings was 57% and 76.8% with bitewings (p<0.05). Comparing the level of care by PD's there was no significant difference between the absence or presence of bitewings. Overall a significantly higher level of care was found when bitewings were present (p<0.01).

For GDP's in the presence of bitewings, the average DMFS/ dmfs was significantly higher (7.2, SD [+ or -] 9.6) than in the absence of bitewings (3.9, SD [+ or -] 5.6) (p<0.05). PD's assessment showed there was no significant difference in the average DMFS/ dmfs between children with or without bitewings radiographs. Overall a significantly higher DMFS/dmfs score was found in the presence of bitewings (p<0.01 independent sample t-test).

Dental plaque: No significant difference was found between the presence of dental plaque by PD's or GDP's. For GDP's significantly less plaque was found in the 0-5 year age group than in consecutive age groups (p<0.01). The PD's recorded no significant difference between the age groups. Overall, the presence of plaque led to a significantly higher DMFS/dmfs score (p<0.05). This difference was not significant for either PD or GDP alone.

Fistulas: No significant difference was found between the presence of fistulas in children treated by PD's or GDP's. For GDP's there were significantly more children with fistulas in the 6-8 year group compared to the other age groups (p<0.05). PD's recorded no significant difference between the age groups. Both in the GDP and in the PD group, there were no children with fistulas in the permanent dentition.

Discussion

The results of this study indicate that paediatric dentists performed significantly more diagnostic, preventive and curative care in the clinical situation then did GDP. However several aspects need special attention and additional discussion.

In this clinical study children were randomly selected based on their presence at a dental practice at the time the observer was present (convenience sample). The group therefore was a good representation of the entire population under treatment at general dental and paediatric dental practices.

Paediatric Dentist and General Dental Practitioner: A significant difference could be found between the age of children treated by the general and paediatric dentists. Children up to 8 years of age were treated more often in the paediatric dental practice and children from 9 years of age onwards were treated more often in general practice. It seems likely to hypothesise that GDPs refer children up to 8 years of age more frequently to PD. The results of this study are in line with earlier studies [Heijdra and Veerkamp, 2007; Jensma and Veerkamp, 2010]. Children treated at a paediatric practice had a significant higher DMFS/dmfs score than did children treated at general practices. This can be attributed to the referral behaviour of GDP's as they tend to treat compliant children that usually have only a few cavities. Children with numerous carious lesions and children with behavioural problems are more likely to be referred [Jensma and Veerkamp, 2008], possibly since repetitive restorative treatment and behaviour problems are related [ten Berge et al., 2002]. However, PDs are more likely to treat these cavities where a GDP would restrain from treatment [Hanes et al, 1992]. Also notable were the significant differences in untreated caries between the consecutive age groups in general practice where no such significant difference can be found in the paediatric practice.

There was also a large difference in restored and missing teeth between the PD's and GDP's patients. Therefore we can conclude that all groups received the same level of care bt paediatric dentists irrespective of age. These findings indicate GDP's hesitate to treat young children and might wait for untreated carious teeth to be shed [Taylor and Macpherson, 2004] or wait until pain develops, which creates large differences in the care levels between the two research groups. The results are in similar to the earlier study of Jensma and Veerkamp, [2008].

This study focused on restorative and preventive care in paediatric dentistry. There are many other aspects of paediatric dentistry, such as anxiety and behavioural management, that warrant further research that need to be studied to ascertain the true nature of referred paediatric dental patients and that are most interesting (e.g. orthodontics and anxious behaviour).

Fissure sealants: The referral behaviour of GDPs can similarily be the cause for the higher number of sealants placed by the paediatric dentists. In general, referred children have a higher caries risk (at least they have more dental decay) than non-referred children, leading to an increased number of fissure sealants. The average number of fissure sealants seems to be similar to that in the TJZ research from 2005 [Schuller and Poorterman, 2006]. Overall it seems that the paediatric dentist starts sealing immediately after eruption of the first molars whereas the general practitioner will wait, sometimes even till after the age of 12 years.

Bitewing radiographs: This study was a clinical follow-up of the study Heijdra and Veerkamp, [2007] based on data from the insurance company. Since the two studies led to comparable conclusions the assumption that studies based on financial data from insurance companies can be used to discuss the content of a treatment approach seems valid.

In paediatric dental practices there were significantly more bitewing radiographs taken than in general practices, a finding shared by Hanes et al. [1990]. In 6-8 year olds 3.5 times more bitewing radiographs were taken by paediatric dentists than by general practitioners [Jensma and Veerkamp, 2010].

Bitewing radiographs were taken significantly more often after the age of 11 years in general practice. From earlier research it seems that general practitioners consider the age of 12 years an important one for taking bitewing radiographs than at the age of 6 years of age. The reasons given for this lack of taking bitewing radiographs at the age of 6 years of age were insecurity about the cooperation of the child, doubts as to whether to treat the carious lesions and the safety of x-rays [Taylor and Macpherson, 2004].

Although an important age for taking bitewing radiographs is 5 years of age [Espelid et al., 2003], it is also advised to take bitewing radiographs 2-3 years after eruption of the first permanent molar teeth (around the age of 9 years) even when the caries risk seems low. Research has shown that there is an increased caries risk at this age [Lillehagen et al., 2007].

At general dental practices as well as at the paediatric dentists a significant lower percentage of bitewing radiographs were taken in the 0-5 years of age group. An explanation may be that these children, considering their age, were not cooperative and only a clinical assessment was carried out. In general, children seemed to have a significantly higher level of care when bitewing radiographs were taken, though no significance was seen at the paediatric dentist. Because paediatric dentists took bitewing radiographs sooner and more often, more carious lesions were diagnosed and treated.

In general practice the presence of bitewing radiographs led to a significantly higher DMFS/dmfs score. It could be hypothesised that when bitewing radiographs are taken more often in general practice, cavities are found more frequently. This could mean that radiographs are only taken when the caries activity has already advanced and that small lesions are not diagnosed and therefore not treated. The results are in line with those of Heijdra study Heijdra and Veerkamp, [2007]. In the present study the bitewing radiographs were not used to assess the diseased surfaces but only served as a tool to measure and monitor the level of care.

Level of dental plaque: Paediatric dentists not only take more bitewing radiographs more frequently, they also give more preventive care. In general dental practices 0-5 year olds seemed to have more plaque. There appeared to be a significantly higher DMFS/dmfs score in the presence of plaque, though this difference was not found for the individual groups. Probably the conclusions are biased in this group because of the referral mechanism.

Fistulas: The limited difference in the numbers of fistulas between the two group were probably biased too. The referred children had a larger number of restorations and extractions.

Conclusions

Dutch paediatric dentists performed significantly more diagnostic, preventive and curative care in the clinical situation then did general dental practitioners. Major differences were found concerning:

* A significantly greater number of younger children were treated and had significantly higher DMFS/dmfs scores.

* Children in all age groups were treated equally by paediatric dentists unlike by general practitioners where the level of care differed significantly between all age groups.

* Significantly more bitewing radiographs were taken by paediatric dentists there seemed to be a positive relationship between the level of care and the presence of bitewings.

Acknowledgement

Special thanks to the AGIS Health Insurance for their kind cooperation with this study.

References

Espelid I, Mejare I, Weerheijm K. EAPD guidelines for use of radiographs in children, Eur J Paediatr Dent 2003; 4:40-48.

Hanes CM, Myers DR, Dushku JC, Thompson WO, Durham LC. Radiographic recommendations for the pediatric dentition: comparison of general dentists and pediatric dentists. Pediatric Dent 1990; 12:212-216.

Hanes CM, Myers DR, Dushku JC. The influence of practice type, region, and age on treatment recommendations for primary teeth. Pediatr Dent 1992; 14:240-245.

Heijdra J, Veerkamp JSJ. Diagnostic and restorative behaviours in Dutch dentists' pediatric dental care Eur Arch Paediatr Dent 2007; 9:158-163.

Jensma MA, Veerkamp JS. Treatability of children according to Dutch dentists. Ned Tijdschr Tandheelkd 2008; 115:420-422.

Jensma MA, Veerkamp JS. A comparison of paediatric dentists' and general dental practitioners' care patterns in paediatric dental care. Eur Arch Pae diatr Dent 2010; 11:93-96.

Lillehagen M, Grindefjord M, Mejare I. Detection of Approximal Caries by Clinical and Radiographic Examination in 9-Year-Old Swedish Children. Caries Res 2007; 41:177-185.

Schuller AA, Poorterman JH. Trends in oral healthcare. Caries prevalence and frequency of visits to the dentist for checkups. Ned Tijdschr Tandheelkd 2006; 113:303-307.

Taylor GK, Macpherson LMD. An investigation into the use of bitewing radiography in children in Greater Glasgow. British Dental Journal 2004; 196:563-568.

ten Berge, Veerkamp JSJ, Hoogstraten J: The etiology of childhood dental fear: the role of dental and conditioning experiences. J of Anxiety Disorders 2002; 16:321-329.

D. Kuin, J.S.J. Veerkamp

Dept. of Paediatric Dentistry, ACTA, Amsterdam, the Netherlands

Postal address: Dept. of Paediatric Dentistry, ACTA, Gustav Mahlerlaan 3004, 1081 LA Amsterdam, Netherlands.

Email: dieuwertjekuin@gmail.com
Table 1. DMFS/dmfs of Dutch children treated by a Paediatric
Dentist (PD) or General Dental Practitioner (GDP).

               ds/DS                  ms/MS

Age       PD        GDP           PD               GDP
(yrs)

0-5     2.2       2 (1)     4.9 (2)           0.5 (2)
6-8     1.3       2 (1)     3.9               1.3
9-11    0.8       1.2       2.1               0.7
>12     1.4       0.6       2.3               0.9
        1.4       1.4       3.3 (2)           0.9 (2)

               fs/FS                 DMFS/dmfs (SD)

Age       PD        GDP           PD               GDP
(yrs)

0-5     3.2 (2)   0.7 (2)   10.3 (12.9) (2)   3.2 (4.6) (2)
6-8     5.7       3.5       10.8 (10.7)       6.8 (8.5)
9-11    4.8       3.1       7.7 (7.8)         5.0 (5.7)
>12     4.2       2.6       7.8 (8.0)         4.1 (8.1)
        4.5       2.5       9.4 (10.5) (2)    4.8 (7.1) (2)

             Sealants (SD)

Age       PD             GDP
(yrs)

0-5     0.6 (1.5) (4)    0.1 (0.4)
6-8     3.2 (2.3) (2,3)  0.9 (1.6) (2)
9-11    4.3 (1.8) (2,3)  2.3 (2.6) (23)
>12     3.7 (1.1)        3.8 (3.4) (3)
        2.8 (2.3) (2)    1.8 (2.7) (2)

(1) p < 0.05 significant difference with oldest
age group (One Way ANOVA)

(2) p < 0.01 significant difference between research
groups (Independent Sample t-test)

(3) p < 0.01 significant difference with younger
age groups (One Way ANOVA)

(4) p < 0.01 significant difference with older
age groups (One Way ANOVA)

Table 2. Level of care (%) in Dutch children treated by a
Paediatric Dentist compared to those treated by a General
Dental Practitioner

Age(yrs)   PD (SD)           GDP (SD)

0-5        67.2 (39.4) (2)   39.4 (45.8) (1)
6-8        79.4 (34.1) (2)   59.4 (39.2)
9-11       88.0 (20.7)       70.4 (37.3)
>12        84.4 (29.5)       86.1 (40.5)

(1) p < 0.01 significant difference with other age groups

(2) p < 0.01 significant difference between research groups
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