A comparison of paediatric dentists' and general dental practitioners' care patterns in paediatric dental care.
Abstract: AIM: The aim of this study was to compare the care patterns of paediatric dentists and general dentists in the dental treatment of children in the Netherlands. STUDY DESIGN AND METHODS: A case control study was completed based on the financial records of one of the largest Dutch health insurance companies. After medical ethical approval the dental records from 2004, 2005 and 2006 of 16 paediatric dentists were used and compared with the records of general practitioners with the same number of insured paediatric patients from the same age and urbanisation level. Preventive, diagnostic and restorative care for four consecutive age groups (<6, 6-8, 9-11, 12-17 yrs) were used as independent variables. Differences between the dentists and the age groups were tested with the Independent-Sample t-Test and ratios were calculated. RESULTS: Compared with general dentists, paediatric dentists use statistically significant more often rubber-dam (p=0.009) and did more preventive treatments (p<0.001) in children up to aged 11 yrs, more extractions (p<0.001), took more radiographs (p=0.027) and used local analgesia more often (p=0.002) in children until aged 8 yrs and performed more restorations (p=0.02) in children up to 6yrs of age. There was no significant difference in the care pattern of the dentists for the oldest age group (12-17yrs). The care-index for paediatric dentists and general dentists from this research was comparable with Dutch epidemiological studies. CONCLUSION: Compared with general dentists, paediatric dentists have a more extensive treatment approach when treating children. In the youngest age groups the differences are the most pronounced. Further studies are needed to clarify whether the cause is the needs of the patient or an attitude of supervised neglect by the general dentists.

Key words: care pattern, paediatric dentist, general dental practitioner, children, dental care
Article Type: Report
Subject: Dentists (Practice)
Dentists (Comparative analysis)
Dental care (Health aspects)
Dental care (Methods)
Dental hygiene (Health aspects)
Dental hygiene (Methods)
Mouth (Care and treatment)
Mouth (Health aspects)
Mouth (Methods)
Authors: Schorer-Jensma, M.A.
Veerkamp, J.S.J.
Pub Date: 04/01/2010
Publication: Name: European Archives of Paediatric Dentistry Publisher: European Academy of Paediatric Dentistry Audience: Academic Format: Magazine/Journal Subject: Health Copyright: COPYRIGHT 2010 European Academy of Paediatric Dentistry ISSN: 1818-6300
Issue: Date: April, 2010 Source Volume: 11 Source Issue: 2
Topic: Event Code: 200 Management dynamics
Product: Product Code: 8021000 Dentists NAICS Code: 62121 Offices of Dentists
Geographic: Geographic Scope: Netherlands Geographic Code: 4EUNE Netherlands
Accession Number: 277106735
Full Text: Introduction

During the last decades the dental care system for both children and adults in the Netherlands was adapted several times by the Dutch government. The most important change for paediatric dental care (1985) was a full refund of all dental treatments in children up to 19 years of age provided by their dentist. This was done mainly to promote dental visits for children as a start for better oral health care. Prospective evaluative research [van Ouwerkerk and Voss, 2001] found with several interesting conclusions as indicators for future oral care. The caries prevalence in permanent teeth of the 11- and 17-year olds showed a significant reduction between 1987 and 1999. For the 5- and 8-year old children however the oral health did not improve any further after 1987. After the decrease in caries prevalence in the mid 1970's, a further reduction in the decline of caries for the younger age groups did not occur [Truin et al., 1999; Boelens et al., 2001]. The number of untreated (decayed) primary tooth surfaces even increased significantly in 1999 compared with 1993 [Kalsbeek et al., 2002]. The oral health care of the youngest age groups was deteriorating and the number of children with multiple cavities seemed to increase. According to the care index, many cavities in the primary dentition remain untreated.

In 1993, 26% of the decayed primary tooth surfaces of the 5-year-old Dutch children were actually filled. In 1999, the care index declined further to 14%. An interesting finding in these studies was the difference in care index between general dental practitioners and paediatric dental care centres. For the latter the care index nowadays for 5-year olds is substantial higher (60%) than in the general practice (14%) [Schuller, 2005].

Research has described the diagnostic and restorative attitudes in paediatric dental care in the Netherlands. Only 38.5% of dentists performed restorative care in children under 6 years of age. Early diagnosis based on the use of radiographs in children younger than 6 years old is related to more extensive (restorative) care and an early diagnostic approach seems to be indicative for the treatment approach of dentists dealing with older children [Heijdra and Veerkamp, 2007]. According to research of NMT (the Dutch Dental Association) in 2002, 64% of Dutch dentists acknowledge the importance of treating children below 6 years, but they consider this stressful and time consuming as well [Dam van, Bruers 2003]. In an opinion survey of Dutch dentists, they admitted the need to treat the primary dentition though they were aware of the presence of untreated cavities. Apparently problems arise during diagnostics or treatment. For the treatment of children under 6 years old, they would rather refer to a colleague or paediatric dentist [Jensma and Veerkamp 2008]. As the differences between dentists have become clear it is tempting to see if a group more focused on treating children (paediatric dentists, PD) maintains a comparable treatment philosophy as general dental practitioners (GDP). The question arises, is there a difference between the treatment approach of PD and GDPs? Do the GDP's limit themselves to a certain part of restorative dentistry or do they actually do the complete treatment in just a small selective group of patients? The aim of this study was, therefore, to compare the approach and content of the treatment of PDs and GDPs in paediatric dental care in the Netherlands.

Material and Methods

Data base. In a case control study calculations were made using the financial records of one of the largest Dutch health insurance companies. For this study the anonymously collected data from 4,500 GDPs (more than 50% of all dentists in the Netherlands) treating approximately 300,000 child patients from 0-18 years old were used. In 2004, 2005 and 2006 approximately 35 paediatric dentists were registered in the Netherlands. About half of them only work in dental care centres for special needs patients. In these centres dentists are mainly paid by salary that cannot be compared with the financial records of GDPs. However, 16 PDs, are responsible for the treatment of approximately 8,000 children and use the same declaration/payment system as the GDPs.

After research and medical ethical approval the financial records from 2004, 2005 and 2006 of these 16 PDs were used and compared with the records of all GDPs with a same number of insured paediatric dental patients from the same age and urbanisation level. The PDs were informed of the research and asked for (written) consent to use the data of their financial records. All gave permission to use their data. As the GDPs were selected anonymously their approval was not considered necessary.

Date analysis. For the analysis of the data, the treatments performed by all of the dentists were categorized in preventive, diagnostic and restorative clusters. Differences within the clusters were also analysed (for example the materials used for treatment). Furthermore, the patients were divided into the same age categories as in the large TJZ studies of TNO/ACTA (0-5years, 6-8 years, 9-11 years and 12-17 years old) [Kalsbeek and Poorterman, 2000; 2002; 2003; Kalsbeek and Poorterman, 2003] to facilitate a comparison with the national epidemiological data.

The preventive, diagnostic and restorative care in the four consecutive age groups was used as independent variables. Preventive care consisted of the following variables:

* fluoride application,

* nutrition analyses,

* plaque-index score,

* tissue sealant placement

* professional dental cleaning.

The cluster diagnostics included the dental routine check-up, incidental consultations and dental radiographs (bitewings, intra-oral photographs and orthopantomograms). The cluster restorative care consisted of pit restorations, single surface and multiple surface fillings. Also the use of rubber-dam and local analgesia was analysed in the cluster restorative care. Tooth extractions were also included in this study as an extra variable out-with the clusters.

Statistical analysis. Differences between the two groups of dentists, the children of the different age groups and the age groups were tested with the Independent- Samples t-Test and ratios were calculated.

Results

Prevention. Overall the PDs performed significantly more preventive treatments in children up to 11 years old (p< 0.018) than the GDPs. The PDs paid approximately 7 times more attention to preventive care in children under 6 years (p<0.001); 1.7 times more in children up to 8 years old (p=0.004) and 1.7 times more in children up to 11 years old (p< 0.018) compared with the GDPs. (Table 1)

Diagnostics. There was no statistical difference in the frequency of dental routine check-ups between the PDs and the GDPs in all the age groups (Table 1). Not many radiographs were taken in children under 6 years of age by the GDPs. On average the GDPs took 5 radiographs per 100 patients, compared with 46 radiographs per 100 patients taken by the PDs (p= 0.008) in the youngest age group. In children aged between 6 and 8 years old, the PDs used radiographic diagnostics 3.5 times more than the GDPs (p=0.027). In children up to 9 years old, there was no statistical difference.

Restorations. The PDs performed 3 times more restorations than the GDPs in children younger than 6 years old (p=0.020). In the consecutive age group, children between 6 and 8 years old, this was still twice as many fillings, though without statistical significance (p= 0.118). (Figure 1). When performing restorations, there was a big difference in the use of local analgesia and rubber-dam between the two dentist groups. In children up to 9 years old, the PDs use statistically significant more local analgesia (p=0.002). In children up to 12 years old they used more rubber-dam (p=0.009)

Extractions. The PDs extracted 7 times more teeth in children less than 6 years of age (p=0.018) and almost 4 times more in children between 6-8 years old (p< 0.001) (Table 1) than the GDPs. In children above the age of 9 years, there was no statistical difference anymore between the frequency of extractions done by GDPs and PDS.

[FIGURE 1 OMITTED]

Discussion

In this survey PDs had a more preventive, diagnostic and restorative attitude when treating children younger than 9 years old compared with the GDPs. This raises the question of whether these children have a higher treatment need or do PDs use more extensive treatment criteria? It should be emphasized that PDs in the Netherlands only work on a referral base, so they only see children when treatment is needed. The most outstanding difference is seen in the extraction and the restoration sections for children < 6 years. It is suggested that elimination of risk is combined with support/prevention for the future instead of a preventive approach combined with treatment only after pain has occurred. However, we need to emphasise that the results of this study are mainly based on financial records, making the assumption that a dentist's invoices to the oral health insurance are based on true facts.

In the USA a survey was carried out to examine the perceptions of GDPs and PDs regarding the dental needs of the children they treated. The PDs indicated a higher level of caries for all ages except children up to 12 years old, whereas the GDPs indicated a slightly higher level of caries in this group [McKnight Hanes, 1994]. This pattern is comparable with the results of the restorative care in the consecutive age groups in this study. In the youngest age groups the PDs performed more restorative care. From the age of 12 years old there is hardly any difference between the restorative care of GDPs and PDS (Figure 1).

In another Dutch epidemiological study it was found that the care index of GDPs was 14% [Schuller, 2005] in the youngest age group. In the group of PDs in that study they restored 4 times as many teeth as a comparable group of their GDPs, but apparently still not all carious lesions. These findings again support the view that PDs primarily eliminate dental risk with extractions, restore when needed and prevent further decay with preventive measures.

The higher level of caries activity perceived by the PDs probably relates to higher number of young patients with early childhood caries that they treat. In the Netherlands PDs mostly work in a secondary dental care setting providing care for referred children. GDPs are more likely to refer such children to a PD than to treat them themselves [Jensma and Veerkamp, 2008]. Of the dentists who reported that they often refer children below 6 years old, 85% stated that they refer these patients because of severe caries or extensive treatment needs [McQuistan, 2006]. It is also possible, based on previous data regarding radiographic examination practices, that as PDs take more radiographs for caries detection on children younger than 9 years old, they identify caries earlier [McKnight Hanes, 1990; Roeters, 1994]. The detection of caries at an earlier stage could explain the higher amount of restorative care in the youngest age group but also the more preventive approach of PDs depending on the chosen treatment option.

The most striking result of this research is the greater attention PDs pay to prevention in the youngest age group (Table 1). Influencing the caries process in patients at risk is mainly a matter of combining a restorative approach with a strong preventive attitude. Depending on the depth of a carious lesion a preventive approach might be more preferable than a restorative one. Our results indicate that PDs are not mainly focused on restorative care. As both of the groups of dentists studied pay comparable attention to check-ups, it does seem that during these consultations PDs diagnose in a more detailed manner and as a consequence they restore and extract more teeth and pay more attention to prevention. However most impressive is their use of means that are known to improve the quality of care (local analgesia and rubber-dam) and the robustness of their approach, using far more extractions than GDPs. The study supports the child-focused approach of the PDs.

Conclusion

Compared with general dentists in the Netherlands paediatric dentists perform a more extensive treatment approach in their patients. Doing so they equally focus on preventive and restorative care. In the youngest age group of children the differences are the most significant. Further studies need to clarify whether the cause is the patient's needs or the referring dentists supervised neglect.

References

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Heijdra JS, Veerkamp JSJ. Diagnostic and restorative behaviour in Dutch dentists' paediatric dental care. Eur Arch Paediatr Dent 2007;8 (3): 158-162

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van Ouwerkerk WPhL, Vos N. Ziekenfonds en tandheelkunde in de 20e eeuw. De tandheelkundige zorgverlening in her perspectief van de Nederlandse wet-en regelgeving. Ned Tijdschr Tandheelkd 2001; 108: 94-97.

M.A. Schorer-Jensma, J.S.J. Veerkamp

Dept. of Cariology, Endodontology and Paedodontology, Academic Centre of Dentistry Amsterdam [ACTA], Amsterdam, the Netherlands

Postal address: Dr. M.A. Schorer--Jensma, Department of Cariology Endodontology and Paedodontology, Academic Centre of Dentistry Amsterdam [ACTA], Louwesweg 1066 EA Amsterdam, The Netherlands Email: m.jensma@acta.nl
Table 1: Comparison of the mean amount of dental care, by
category provided, per 100 children in 2004-2006, based
on dentist's invoices to the Dutch Oral Health Insurances
for the relevant variable.

Dental checkup         GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6              124.1     52.3    124.6     28.8       n.s.
6-8              125.0     58.4    118.3     36.9       n.s.
9-11             126.2     57.3    128.4     33.7       n.s.
12-17            115.3     53.5    107.3     45.9       n.s.

Prevention             GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6               23.6     67.9    167.0     91.9      0.000
6-8              153.4    154.3    266.3     12.4      0.004
9-11             165.1    174.3    275.8    127.7      0.018
12-17            143.5    160.6    217.7    142.4      0.075

Extraction             GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6               6.2      22.3     41.5     50.8      0.018
6-8               13.5     36.8     48.9     55.5      0,000
9-11              18.4     47.3     23.8     17.6       n.s.
12-17             9.3      32.2     11.2     10.5       n.s.

Restoration            GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6               36.9     82.6    102.8     59.6      0.020
6-8               57.9     93.6     94.7     56.8       n.s.
9-11              41.6     84.2     53.8     34.7       n.s.
12-17             76.6    120.3    121.8    170.2       n.s.

X-rays                 GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6               4.9      26.2     46.3     52.1      0.008
6-8               14.5     40.5     49.3     56.6      0.027
9-11              26.5     45.9     54.6     35.4       n.s.
12-17             64.9     83.8     73.6     62.0       n.s.

Anaesthetic            GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6               9.6      38.5     48.1     36.4      0.000
6-8               19.9     50.3     59.3     40.8      0.002
9-11              15.1     51.4     31.9     34.8       n.s.
12-17             32.2     65.2     64.5     72.0      0.057

Rubber-dam             GDP               Paediatric
                                         dentist

age               mean      sd      mean      sd        Sig.
                                                     (2-tailed)

< 6               1.1      8.8      35.7     39.9      0.005
6-8               3.3      20.4     39.8     49.9      0,011
9-11              2.8      18.1     24.6     26.5      0.009
12-17             4.4      20.9     32.4     60.3      0.094

n.s = not signifi8cant; s.d = standard deviation
of the mean; GDP = gneral dental practitioner
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