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1.  Demand in Pediatric Dentistry for Sedation and General Anesthesia by Dentist Anesthesiologists: A Survey of Directors of Dentist Anesthesiologist and Pediatric Dentistry Residencies 
Anesthesia Progress  2012;59(1):3-11.
This study describes what training programs in pediatric dentistry and dental anesthesiology are doing to meet future needs for deep sedation/general anesthesia services required for pediatric dentistry. Residency directors from 10 dental anesthesiology training programs in North America and 79 directors from pediatric dentistry training programs in North America were asked to answer an 18-item and 22-item online survey, respectively, through an online survey tool. The response rate for the 10 anesthesiology training program directors was 9 of 10 or 90%. The response rate for the 79 pediatric dentistry training program directors was 46 of 79 or 58%. Thirty-seven percent of pediatric dentistry programs use clinic-based deep sedation/general anesthesia for dental treatment in addition to hospital-based deep sedation/general anesthesia. Eighty-eight percent of those programs use dentist anesthesiologists for administration of deep sedation/general anesthesia in a clinic-based setting. Pediatric dentistry residency directors perceive a future change in the need for deep sedation/general anesthesia services provided by dentist anesthesiologists to pediatric dentists: 64% anticipate an increase in need for dentist anesthesiologist services, while 36% anticipate no change. Dental anesthesiology directors compared to 2, 5, and 10 years ago have seen an increase in the requests for dentist anesthesiologist services by pediatric dentists reported by 56% of respondents (past 2 years), 63% of respondents (past 5 years), and 88% of respondents (past 10 years), respectively. Predicting the future need of dentist anesthesiologists is an uncertain task, but these results show pediatric dentistry directors and dental anesthesiology directors are considering the need, and they recognize a trend of increased need for dentist anesthesiologist services over the past decade.
PMCID: PMC3309300  PMID: 22428968
Demand for services; Dental anesthesiologist; Pediatric dentist
2.  Practices and opinions on nitrous oxide/oxygen sedation from dentists licensed to perform relative analgesia in Brazil 
BMC Oral Health  2012;12:21.
Relative analgesia (RA), defined as the use of inhalation sedation with nitrous oxide and oxygen, is one of the most common pharmacological behavior management techniques used to provide sedation and analgesia for dental patients. This study aimed to assess RA licensed Brazilian dentists’ practices and opinions about nitrous oxide/oxygen sedation in the dental setting.
A cross sectional national survey was conducted with 281 dentists who were certified to perform RA, using an electronically mailed self-administered questionnaire containing closed questions about their practices and opinions regarding RA. Practice and opinion were individually analyzed by descriptive statistics. Non-parametric tests assessed the relationships between RA practice and independent variables. To test the interplay between practices and opinions, a k-means clusters analysis was used to divide the group for statistical comparisons.
The response rate was 45.2%. Women made up 64.6% of the respondents, the mean age was 39.1 years (SD = 9.8), and the mean time since graduation in dentistry was 16 years (SD = 9.7). Seventy-seven percent of respondents reported the use of RA in clinical practice, most of them ‘sometimes’ (53.5%), and focusing more on adult patients. Patients with certain physical or mental deficiencies were indications associated with RA practice. ‘Equipment acquisition’ (p < 0.001) and ‘living in Southeast and South regions’ (p < 0.02) were also associated with RA practice. The scores for dentists’ opinions ranged from 15 to 41 points (mean 29.2, SD = 5.6), based on nine items scored from 1 to 5. Two clusters representing more favorable (n = 65) and less favorable (n = 55) opinions were established. Dentists who were women (p = 0.04), practiced RA in dental settings (p < 0.01) or practiced it frequently (p < 0.001), had more favorable opinions about RA.
Most of the RA licensed Brazilian dentists interviewed currently use RA. Current practice of RA and frequency of use determined the degree of favorable opinion about this inhalation sedation among this group of respondents.
PMCID: PMC3412732  PMID: 22808942
Relative Analgesia; Nitrous Oxide; Dental Clinics; Cross Sectional Survey
3.  Illinois Dental Anesthesia and Sedation Survey for 2006 
Anesthesia Progress  2007;54(2):52-58.
This is a 10-year follow-up survey of a 1996 study of all dentists in Illinois holding a permit to administer sedation or general anesthesia. The survey describes the scope of sedation and anesthesia services provided in dental offices in Illinois. A mail survey was sent to 471 dentists who were registered with the department of professional regulation to administer sedation or general anesthesia. Classification by specialty area of practice showed: 63% (84% in 1996) are oral and maxillofacial surgeons, 20% (11% in 1996) general dentists, 6% (5% in 1996) periodontists, 9% (0% in 1996) pediatric dentists, 1% (less than 1% in 1996) dentist anesthesiologists. Advanced cardiovascular life support (ACLS) training was reported by 90% (85% in 1996) of the respondents. The total number of sedations and general anesthetics administered for the year was 115,940. Two mortalities and two cases of long-term morbidity were reported for the 10-year period. Respondents reported that 30 patients required transfer to a hospital but suffered no long-term morbidity. Other practice characteristics were detailed.
PMCID: PMC1893094  PMID: 17579504
Dental sedation; Dental anesthesia; Morbidity and mortality; Practice parameters
4.  Gender differences in practice patterns for diagnosis and treatment of dental caries: Findings from The Dental PBRN 
A number of articles have addressed gender differences in the productivity of dentists, but little is known about differences in practice patterns for caries management. This study compared the use of a comprehensive range of specific diagnostic methods, preventive agents, and restorative decision making for caries management between male and female dentists who were members of The Dental Practice-Based Research Network(DPBRN).
This study surveyed general dentists who were members of DPBRN and who practiced within the United States. The survey asked about dentist, practice, and patient characteristics, as well as prevention, assessment, and treatment of dental caries. Differences in years since dental school graduation, practice model, full/part-time status, and practice owner/employee were adjusted in the statistical models, before making conclusions about gender differences.
Three hundred ninety-three male (84%) and seventy-three female (16%) dentists participated. Female dentists recommended at-home fluoride to a significantly larger proportion of their patients, whereas males had a preference for using in-office fluoride treatments with pediatric patients. Female dentists also choose to restore interproximal lesions at a significantly later stage of development, preferring to use preventive therapy more often at earlier stages of dental caries. There were few differences in diagnostic methods, time spent on or charges for restorative dentistry, and busyness of their practices.
DPBRN female dentists differ from their male counterparts in some aspects of the prevention, assessment, and treatment of dental caries, even with significant covariates taken into account. Practice patterns of female dentists suggest a greater caries preventive treatment philosophy.
PMCID: PMC3079556  PMID: 21454850
Caries; Prevention; Fluoride; Female; Practice patterns; Sealant; Adult; Pediatric; Radiographs; Caries risk assessment
5.  Illinois Dental Anesthesia and Sedation Survey for 1996. 
Anesthesia Progress  1998;45(2):51-56.
Dentists in the state of Illinois who possess a permit to administer sedation or general anesthesia were surveyed. A 71% response rate was achieved. Of the respondents, 86% held permits for deep sedation/general anesthesia and 14% held permits for parenteral conscious sedation. By practice specialty, 84% were oral and maxillofacial surgeons, 11% were general dentists, 5% were periodontists, and fewer than 1% were dental anesthesiologists. Advanced Cardiac Life Support training was possessed by 85% of the respondents. The most common anesthesia team configuration (82%) was a single operator-anesthetist and two additional assistants. Only 4% reported use of a nurse anesthetist, and 2% used an additional MD or DDS anesthesiologist. The vast majority (97%) of the practitioners do not intubate in the office on a routine basis. Supplemental oxygen was used by 81% of the respondents whenever intravenous agents were used. A total of 151,335 anesthetics were administered during the year. One mortality occurred in a patient with an undisclosed pre-existing cardiac condition. Four other events were reported that required medical intervention or hospital evaluation; however, no permanent injuries were reported. Other practice characteristics were described.
PMCID: PMC2148969  PMID: 10356432
6.  Use of caries preventive agents on adult patients compared to pediatric patients by general practitioners: findings from The Dental Practice-Based Research Network 
Evidence suggests that caries prevention reduces caries in adults. This study tested the frequency of recommended caries prevention agents for children compared to adult patients.
This study surveyed 467 Dental Practice-Based Research Network general dentists who practice within the United States and treat both pediatric and adult patients. Dentists were asked the percentage of their patients who are administered or recommended dental sealants, in-office and at-home fluoride, chlorhexidine rinse, and xylitol gum.
Adults were less likely to receive in-office caries preventive agents compared to pediatric patients. However, the rate of recommendation for at-home preventive regimens was very similar. Dentists with a conservative approach to caries treatment were the most likely to use caries prevention at similar rates in adults as in children. In addition, practices with a greater number of patients with dental insurance were significantly less likely to provide in-office fluoride or sealants to adult patients than to their pediatric patients.
In-office caries prevention agents are more commonly used by general dentists for their pediatric patients compared to their adult patients.
Practice Implications
Some general dentists should consider providing additional in-office prevention agents for their adult patients who are at increased risk for dental caries.
PMCID: PMC2880818  PMID: 20516100
Caries; Prevention; Adults
7.  Dentists in Practice-Based Research Networks Have Much in Common with Dentists at Large: Evidence from “The Dental PBRN” 
General dentistry  2009;57(3):270.
Practice-based research networks (PBRNs) aim to improve clinical practice by engaging dental practitioners in studies that are directly relevant to daily clinical practice. A dental PBRN called “DPBRN” (Dental Practice-Based Research Network) comprises dentists from seven U.S. states and three Scandinavian countries.
All DPBRN dentists complete an enrollment questionnaire about their practices and themselves; to date, 1,086 have done so. To quantify how similar DPBRN dentists are to U.S. dentists at large, we compared DPBRN practice characteristics to those of dentists who responded to the 2004 ADA Survey of Dental Practice, which is not limited to ADA members.
DPBRN dentists were similar to dentists nationally with regard to dentist’s gender, race, ethnicity, number of offices, percentage of patients with insurance coverage, number of operatories, patient visits per week, days for a new appointment, and waiting room time. DPBRN dentists were statistically more likely to be recent graduates.
DPBRN practitioners have much in common with U.S. dentists nationally.
Clinical implications
Commonalities between DPBRN dentists and dentists nationally should increase the likelihood that DPBRN studies will be applicable to U.S. practices, thereby fostering knowledge transfer in both the research-to-practice and practice-to-research directions.
PMCID: PMC2819020  PMID: 19819818
practice-based research; dentistry; private practice; health-services research; multi-center studies
8.  Pediatric dental sedation: challenges and opportunities 
High levels of dental caries, challenging child behavior, and parent expectations support a need for sedation in pediatric dentistry. This paper reviews modern developments in pediatric sedation with a focus on implementing techniques to enhance success and patient safety. In recent years, sedation for dental procedures has been implicated in a disproportionate number of cases that resulted in death or permanent neurologic damage. The youngest children and those with more complicated medical backgrounds appear to be at greatest risk. To reduce complications, practitioners and regulatory bodies have supported a renewed focus on health care quality and safety. Implementation of high fidelity simulation training and improvements in patient monitoring, including end-tidal carbon dioxide, are becoming recognized as a new standard for sedated patients in dental offices and health care facilities. Safe and appropriate case selection and appropriate dosing for overweight children is also paramount. Oral sedation has been the mainstay of pediatric dental sedation; however, today practitioners are administering modern drugs in new ways with high levels of success. Employing contemporary transmucosal administration devices increases patient acceptance and sedation predictability. While recently there have been many positive developments in sedation technology, it is now thought that medications used in sedation and anesthesia may have adverse effects on the developing brain. The evidence for this is not definitive, but we suggest that practitioners recognize this developing area and counsel patients accordingly. Finally, there is a clear trend of increased use of ambulatory anesthesia services for pediatric dentistry. Today, parents and practitioners have become accustomed to children receiving general anesthesia in the outpatient setting. As a result of these changes, it is possible that dental providers will abandon the practice of personally administering large amounts of sedation to patients, and focus instead on careful case selection for lighter in-office sedation techniques.
PMCID: PMC4555969  PMID: 26345425
conscious sedation; anesthesia; general; pediatrics
9.  Development and validation of the PROcedural Sedation Assessment Survey (PROSAS) for assessment of procedural sedation quality 
Gastrointestinal endoscopy  2014;81(1):194-203.e1.
Over 20 million invasive procedures are performed annually in the United States. The vast majority are performed with moderate sedation or deep sedation yet there is limited understanding of drivers of sedation quality and patient satisfaction. Currently, the major gap in quality assurance for invasive procedures is the lack of procedural sedation quality measures.
To develop and validate a robust, patient-centered measure of procedural sedation quality, the PROcedural Sedation Assessment Survey (PROSAS).
Through a series of interviews with patients, proceduralists, nurses and anesthesiologists, and an interactive patient focus group, major domains influencing procedural sedation quality were used to create a multipart survey. The pilot survey was administered and revised in sequential cohorts of adults receiving moderate sedation for GI endoscopy. After revision, the PROSAS was administered to a validation cohort.
GI endoscopy unit.
A expert panel of proceduralists, nurses and anesthesiologists, an initial survey development cohort of 40 patients, and a validation cohort of 858 patients undergoing sedation for outpatient GI endoscopy with additional surveys completed by the gastroenterologist, procedure nurse and recovery nurse.
Main Outcomes and Measures
Survey characteristics of the PROSAS.
Patients were able to independently complete the PROSAS after procedural sedation before discharge. 91.6% of patients reported minimal discomfort; however, 8.4% of patients reported significant discomfort and 2.4% of patients experienced hemodynamic and/or respiratory instability. There was a high correlation between patient reported intraprocedure discomfort and both clinician assessments of procedural discomfort and patient recall of procedural pain 24 to 48 hours postprocedure (p<0.001 for all), suggesting high external validity.
Single-center study, variability of sedation technique between providers, inclusion of patients with chronic pain on analgesics
The PROSAS is a clinically relevant, patient-centered, easily administered instrument that allows for standardized evaluation of procedural sedation quality. The PROSAS may be useful in both research and clinical settings.
PMCID: PMC4272880  PMID: 25293829
Endoscopy; Sedation; Quality; Safety; Patient Satisfaction; Patient Reported Outcome
10.  What’s in a dental practice-based research network? 
The authors conducted a study to describe the general dentists, practices, patients and patient care patterns of the dental practice-based research network (PBRN) Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT).
Northwest PRECEDENT is a dental PBRN of general and pediatric dentists and orthodontists from five U.S. states in the Northwest: Idaho, Montana, Oregon, Utah and Washington. The authors collected data from general dentists in Northwest PRECEDENT (n = 101) regarding the diagnosis and treatment of oral diseases in a survey with a systematic random sample of patients (N = 1,943) visiting their practices. They also obtained demographic data from the general dentists and their patients.
The authors found that 50 percent of the general dentists were 51 to 60 years of age, 14 percent were female and 76 percent were non-Hispanic white. More than one-half (55 percent) of the dentists had practiced dentistry for more than 20 years, 83 percent had private solo practices and 32 percent practiced in rural community settings. The majority (71 percent) of patients visiting the dental practices was in the age range of 18 to 64 years, 55 percent were female and 84 percent were non-Hispanic white. In terms of reasons for seeking dental care, 52 percent of patients overall visited the dentist for oral examinations, checkups, prophylaxis or caries-preventive treatment. In the preceding year, 85 percent of the patients had received prophylaxis, 49 percent restorative treatments, 34 percent caries-preventive treatments and 10 percent endodontic treatments.
Northwest PRECEDENT general dentists are dispersed geographically and are racially and ethnically diverse, owing in part to efforts by network administrators and coordinators to enroll minority dentists and those who practice in rural areas. Estimates of characteristics of dentists and patients in Northwest PRECEDENT will be valuable in planning future studies of oral diseases and treatments.
PMCID: PMC3052850  PMID: 20592411
Dental private practice; dentists; office visits; research
11.  Post-sedation Events in Children Sedated for Dental Care 
Anesthesia Progress  2013;60(2):54-59.
Moderate oral sedation is used in pediatric dentistry for safe delivery of dental care to children. However, there is a paucity of data on the effects of pediatric dental sedations after discharge of children from the dental office. The purpose of this study was to evaluate and compare the incidence of adverse events occurring with meperidine and hydroxyzine versus midazolam alone 8 and 24 hours after sedation in pediatric dental patients. In this prospective study, a convenience sample of 46 healthy children presenting to a private pediatric dental practice for dental treatment needs was selected. A telephone survey of the parents of children sedated with either meperidine and hydroxyzine or midazolam alone was conducted 8 and 24 hours after the administration of sedation medications. Data analysis included descriptive statistics, frequency and proportion analysis, and Fisher exact test. Forty children were sedated with meperidine and hydroxyzine, and 6 who were sedated with midazolam. In both groups, 50% of the children slept in the car on the way home. Three children in the meperidine and hydroxyzine group vomited in the car. A significantly larger proportion of children in the meperidine and hydroxyzine group experienced prolonged sleep at home (P = .015). More children in the midazolam group exhibited irritability in the first 8 hours (P = .07). There were no statistical differences between the 2 groups with respect to incidence of pain, fever, vomiting, sleeping in the car, snoring, and difficulty in waking up. The lingering effects of orally administered sedation medications can lead to prolonged sleep, irritability, and vomiting in children after they have been discharged from the dental clinic. Most of these events occurred within the first 8 hours, but in some children the effects were seen up to 24 hours later.
PMCID: PMC3683881  PMID: 23763560
Sedation; Children; Adverse events
12.  Use of Caries Prevention Agents in Children: Findings from the Dental Practice-based Research Network 
Scientific evidence supports the application of caries preventive agents in children and this knowledge must transfer into the practice of dentistry. There is little multi-region data that allow for comparisons of practice patterns between types of dental practices and geographic regions. The aim of this study was to characterize the use of caries preventive agents in pediatric patients in a large multi-region sample of dental practices.
This study surveyed Dental Practice-based Research Network dentists who perform restorative dentistry in their practices. The survey asked a range of questions about caries risk assessment and use of prevention techniques in children ages 6-18.
Dental sealants (69%) or in-office fluoride (82%) were the most commonly used of the caries preventive regimens. The recommendation of at-home caries preventive agents ranged from 36%-7%, with non-prescription fluoride rinse the most common. Dentists who practiced in a large group practice model and dentists from the Scandinavian region more frequently use caries risk assessment than regions that were predominately dentists in private practice. Whether or not dentists used caries risk assessment with their pediatric patients was poorly correlated with the likelihood of actually using caries preventive treatments on patients.
Although dentists reported the use of some form of in-office caries prevention, there was considerable variability across practices. These differences could represent a lack of consensus across practicing dentists about the benefits of caries preventive agents or a function of differing financial incentives or patient pools with differing levels of overall caries risk.
PMCID: PMC3074637  PMID: 21180672
Caries; Fluoride; Dental Sealant; Prevention; Children
13.  Trends in Death Associated with Pediatric Dental Sedation and General Anesthesia 
Paediatric anaesthesia  2013;23(8):741-746.
Inadequate access to oral health care places children at risk for caries. Disease severity and inability to cooperate often result in treatment with general anesthesia (GA). Sedation is increasingly popular and viewed as lower risk than GA in community settings. Currently, few data are available to quantify pediatric morbidity and mortality related to dental anesthesia.
Summarize dental anesthesia-related pediatric deaths described in media reports.
Review of media reports in the Lexis-Nexis Academic database and a private foundation website.
Dental offices, ambulatory surgery centers, and hospitals.
U.S.-based children (≤ 21 y.o.) who died subsequent to receiving anesthesia for a dental procedure between 1980–2011.
Most deaths occurred among 2 –5 year-olds (n=21/44); in an office setting (n=21/44), and with a general/pediatric dentist (n=25/44) as the anesthesia provider. In this latter group, 17/25 deaths were linked with a sedation anesthetic.
This series of media reports likely represent only a fraction of the overall morbidity and mortality related to dental anesthesia. These data may indicate an association between mortality and pediatric dental procedures under sedation, particularly in office settings. However, these relationships are difficult to test in the absence of a database that could provide an estimate of incidence and prevalence of morbidity and mortality. With growing numbers of children receiving anesthesia for dental procedures from providers with variable training, it is imperative to be able to track anesthesia-related adverse outcomes. Creating a national database of adverse outcomes will enable future research to advance patient safety and quality.
PMCID: PMC3712625  PMID: 23763673
Anesthesia; Patient safety; Child; Conscious Sedation/adverse effects; Dental Anxiety/drug therapy; Treatment Outcome
14.  Retrospective Outcomes Evaluation of 100 Parenteral Moderate and Deep Sedations Conducted in a General Practice Dental Residency 
Anesthesia Progress  2008;55(4):116-120.
An abstract of this study was presented at the American Association for Dental Research (AADR) Dental Anesthesiology Research Group in Honolulu, Hawaii, in March of 2004. This study was conducted to correlate the intraoperative and postoperative morbidity associated with moderate and deep sedation, also known as monitored anesthesia care (MAC), provided in a General Practice Residency (GPR) clinic under the supervision of a dentist anesthesiologist. After internal review board approval was obtained, 100 parenteral moderate and deep sedation cases performed by the same dentist anesthesiologist in collaboration with second year GPR residents were randomly selected and reviewed by 2 independent evaluators. Eleven morbidity criteria were assessed and were correlated with patient age, gender, American Society of Anesthesiology Physical Status Classification (ASAPS), duration of procedure, and anesthetic protocol. A total of 39 males and 61 females were evaluated. Patients' ASAPS were classified as I, II, and III, with the average ASAPS of 1.61 and the standard deviation (STDEV) of 0.584. No ASPS IV or V was noted. Average patient age was 33.8 years (STDEV, 14.57), and the average duration of procedure was 97.5 minutes (STDEV, 42.39). Three incidents of postoperative nausea and vomiting were reported. All 3 incidents involved the ketamine-midazolam-propofol anesthetic combination. All patients were treated and were well controlled with ondansetron. One incident of tongue biting in an autistic child was regarded as an effect of local anesthesia. One patient demonstrated intermittent premature atrial contractions (PACs) intraoperatively but was stable. Moderate and deep sedation, also known as MAC, is safe and beneficial in an outpatient GPR setting with proper personnel and monitoring. This study did not demonstrate a correlation between length of procedure and morbidity. Ketamine was associated with all reported nausea and vomiting incidents because propofol and midazolam are rarely associated with such events.
PMCID: PMC2614649  PMID: 19108595
Dental sedation; Sedation training; Sedation outcomes
15.  Sedation, Sleep Promotion, and Delirium Screening Practices in the Care of Mechanically Ventilated Children: A Wake-up Call for the Pediatric Critical Care Community 
Critical care medicine  2014;42(7):1592-1600.
To examine pediatric intensivist sedation management, sleep promotion, and delirium screening practices for intubated and mechanically ventilated children.
An international, online survey of questions regarding sedative and analgesic medication choices and availability, sedation protocols, sleep optimization, and delirium recognition and treatment.
Member societies of the World Federation of Pediatric Intensive and Critical Care Societies were asked to send the survey to their mailing lists; responses were collected from July 2012 to January 2013.
Measurements and Main Results
The survey was completed by 341 respondents, the majority of whom were from North America (70%). Twenty-seven percent of respondents reported having written sedation protocols. Most respondents worked in pediatric intensive care units (PICUs) with sedation scoring systems (70%), although only 42% of those with access to scoring systems reported routine daily use for goal-directed sedation management. The State Behavioral Scale was the most commonly used scoring system in North America (22%), with the COMFORT score more prevalent in all other countries (39%). The most commonly used sedation regimen for intubated children was a combination of opioid and benzodiazepine (72%). Most intensivists chose fentanyl as their first-line opioid (66%) and midazolam as their first-line benzodiazepine (86%), and prefer to administer these medications as continuous infusions. Propofol and dexmedetomidine were the most commonly restricted medications in PICUs internationally. Use of earplugs, eye masks, noise reduction, and lighting optimization for sleep promotion was uncommon. Delirium screening was not practiced in 71% of respondent’s PICUs, and only 2% reported routine screening at least twice a day.
The results highlight the heterogeneity in sedation practices among intensivists who care for critically ill children, as well as a paucity of sleep promotion and delirium screening in PICUs worldwide.
PMCID: PMC4061156  PMID: 24717461
sleep; sedation; analgesia; delirium; pediatric; intensive care units; mechanical ventilation; circadian rhythm
16.  The relationship between price of services, quality of care, and patient time costs for general dental practice. 
Health Services Research  1997;31(6):773-790.
OBJECTIVE: To examine the relationships between price of services, quality of care, and patient time costs in private practices of general dentists. DATA SOURCE/STUDY SETTING: In October 1992, a 3.7 percent sample of eligible general dentists in part-time or full-time private practice in 1991 was randomly drawn from a sampling frame tailored from data gathered by the 1991-1992 American Dental Association Distribution of Dentists census of all United States dentists. DATA COLLECTION: A mail survey was used to collect data on dentist demographic characteristics, dental practice characteristics practice finances, and insurance. The survey was completed and returned by 3,048 general dentists (77 percent response rate). Local area population characteristics were obtained from secondary sources. STUDY DESIGN: Two-stage least squares regression was used to evaluate the structural relationships between price of services, quality of care, and time costs to patients. Structural equations were estimated for four different quality of care measures and two time costs. PRINCIPAL FINDINGS: Price of services and quality of care were significantly related to each other. Higher quality of care was associated with higher price of services and, reciprocally, higher price of services was associated with higher quality of care. Shorter waits for a new patient appointment were associated with higher prices. Higher price of services, lower quality of care, and longer waits for a new patient appointment were related to shorter in-office waiting time. CONCLUSIONS: The implication of these findings is that if price of services is constrained, then the quality of care provided by the dentist may also be reduced.
PMCID: PMC1070158  PMID: 9018216
17.  Restorative Treatment Thresholds for Interproximal Primary Caries Based on Radiographic Images: Findings from The Dental PBRN 
General dentistry  2009;57(6):654.
To: (1) quantify at which proximal caries lesion depths dentists in regular clinical practice intervene restoratively, based on hypothetical scenarios that present radiographic images and patient background information, and (2) identify characteristics that are associated with restorative intervention in lesions that have penetrated only the enamel surface.
Dentists in a practice-based research network ( who reported doing at least some restorative dentistry were surveyed (n=901). Dentists were asked to indicate at which lesion depth they would intervene restoratively based on a series of radiographic images depicting interproximal caries at increasing lesion depths in a mandibular premolar tooth. Dentists were also questioned regarding two caries risk scenarios: one patient with low caries risk and another at higher risk. We used logistic regression to analyze associations between the decision to intervene restoratively and specific dentist, practice, and patient characteristics.
Five hundred (56%) DPBRN practitioner-investigators completed the survey. In a high caries risk patient, 66% of dentists indicated that they would restore a proximal enamel lesion, and 24% would once the lesion had reached into the outer one-third of the dentin. In a low caries risk patient, 39% of dentists reported that they would restore an enamel lesion, and 54% would once the lesion had reached into the outer one-third of the dentin. In multivariate analyses, when accounting for dentist and practice characteristics, dentists in large group practices were less likely to intervene surgically for enamel caries regardless of patient's caries risk.
Restorative treatment thresholds based on radiographic lesion depth varied substantially among dentists. Most dentists would restore lesions that were still within the enamel surface for high caries risk individuals. Dentists’ decisions to intervene surgically in the caries process differ by patient caries risk. For a case scenario involving a high caries risk individual, practice busyness, type of practice model, and gender were significant when deciding for surgical intervention. However, for a case scenario involving a low caries risk individual only type of practice model was significant when deciding for surgical intervention.
PMCID: PMC2819355  PMID: 19906618
caries diagnosis; treatment threshold; practice model; private practice; public health; risk assessment; practice characteristics
18.  Practice patterns of doctors of chiropractic with a pediatric diplomate: a cross-sectional survey 
Complementary and alternative medicine (CAM) is growing in popularity, especially within the pediatric population. Research on CAM practitioners and their specialties, such as pediatrics, is lacking. Within the chiropractic profession, pediatrics is one of the most recently established post-graduate specialty programs. This paper describes the demographic and practice characteristics of doctors of chiropractic with a pediatric diplomate.
218 chiropractors with a pediatric diplomate were invited to complete our survey using either web-based or mailed paper survey methods. Practitioner demographics, practice characteristics, treatment procedures, referral patterns, and patient characteristics were queried with a survey created with the online survey tool, SurveyMonkey©®.
A total of 135 chiropractors responded (62.2% response rate); they were predominantly female (74%) and white (93%). Techniques most commonly used were Diversified, Activator ®, and Thompson with the addition of cranial and extremity manipulation to their chiropractic treatments. Adjunctive therapies commonly provided to patients included recommendations for activities of daily living, corrective or therapeutic exercise, ice pack\cryotherapy, and nutritional counseling. Thirty eight percent of respondents' patients were private pay and 23% had private insurance that was not managed care. Pediatrics represented 31% of the survey respondents' patients. Chiropractors also reported 63% of their work time devoted to direct patient care. Health conditions reportedly treated within the pediatric population included back or neck pain, asthma, birth trauma, colic, constipation, ear infection, head or chest cold, and upper respiratory infections. Referrals made to or from these chiropractors were uncommon.
This mixed mode survey identified similarities and differences between doctors of chiropractic with a pediatric diplomate to other surveys of doctors of chiropractic, CAM professionals, and pediatric healthcare providers. The pediatric diplomate certificate was established in 1993 and provides didactic education over a 2 to 3 year span. The results of this study can be used for historical information as this specialty continues to grow.
PMCID: PMC2898809  PMID: 20546582
19.  Drugs Used for Parenteral Sedation in Dental Practice 
Anesthesia Progress  1988;35(5):199-205.
The relative efficacy and safety of drugs and combinations used clinically in dentistry as premedicants to alleviate patient apprehension are largely unsubstantiated. To evaluate the efficacy and safety of agents used for parenteral sedation through controlled clinical trials, it is first necessary to identify which drugs, doses, and routes of administration are actually used in practice. A survey instrument was developed to characterize the drugs used clinically for anesthesia and sedation by dentists with advanced training in pain control. A random sample of 500 dentists who frequently use anesthesia and sedation in practice was selected from the Fellows of the American Dental Society of Anesthesiology. The first mailing was followed by a second mailing to nonrespondents after 30 days. The respondents report a variety of parenteral sedation techniques in combination with local anesthesia (the response categories are not mutually exclusive): nitrous oxide (64%), intravenous conscious sedation (59%), intravenous “deep” sedation (47%), and outpatient general anesthesia (27%). Drugs most commonly reported for intravenous sedation include diazepam, methohexital, midazolam, and combinations of these drugs with narcotics. A total of 82 distinct drugs and combinations was reported for intravenous sedation and anesthesia. Oral premedication and intramuscular sedation are rarely used by this group. Most general anesthesia reported is done on an outpatient basis in private practice. These results indicate that a wide variety of drugs is employed for parenteral sedation in dental practice, but the most common practice among dentists with advanced training in anesthesia is local anesthesia supplemented with intravenous sedation consisting of a benzodiazepine and an opioid or a barbiturate.
PMCID: PMC2167868  PMID: 3250279
20.  Office-Based Deep Sedation for Pediatric Ophthalmologic Procedures Using a Sedation Service Model 
Aims. (1) To assess the efficacy and safety of pediatric office-based sedation for ophthalmologic procedures using a pediatric sedation service model. (2) To assess the reduction in hospital charges of this model of care delivery compared to the operating room (OR) setting for similar procedures. Background. Sedation is used to facilitate pediatric procedures and to immobilize patients for imaging and examination. We believe that the pediatric sedation service model can be used to facilitate office-based deep sedation for brief ophthalmologic procedures and examinations. Methods. After IRB approval, all children who underwent office-based ophthalmologic procedures at our institution between January 1, 2000 and July 31, 2008 were identified using the sedation service database and the electronic health record. A comparison of hospital charges between similar procedures in the operating room was performed. Results. A total of 855 procedures were reviewed. Procedure completion rate was 100% (C.I. 99.62–100). There were no serious complications or unanticipated admissions. Our analysis showed a significant reduction in hospital charges (average of $1287 per patient) as a result of absent OR and recovery unit charges. Conclusions. Pediatric ophthalmologic minor procedures can be performed using a sedation service model with significant reductions in hospital charges.
PMCID: PMC3312190  PMID: 22496684
21.  Evaluations of Dentists on a German Physician Rating Website: An Analysis of the Ratings 
Physician rating websites have been gaining in importance in both practice and research. However, no evidence is available concerning patients’ ratings of dentists on physician rating websites.
The aim of this study is to present a comprehensive analysis of the ratings of dentists on a German physician rating website over a 2-year period.
All dentist ratings on a German physician rating website (Jameda) from 2012 and 2013 were analyzed. The available dataset contained 76,456 ratings of 23,902 dentists from 72,758 patients. Additional information included the overall score and subscores for 5 mandatory questions, the medical specialty and gender of the dentists, and the age, gender, and health insurance status of the patients. Statistical analysis was conducted using the median test and the Kendall tau-b test.
During the study period, 44.57% (23,902/53,626) of all dentists in Germany were evaluated on the physician rating website, Jameda. The number of ratings rose from 28,843 in 2012 to 47,613 in 2013, representing an increase of 65.08%. In detail, 45.37% (10,845/23,902) of dentists were rated once, 43.41% (10,376/23,902) between 2 and 5 times, and 11.21% (2681/23,902) more than 6 times (mean 3.16, SD 5.57). Approximately 90% (21,324/23,902, 89.21%) of dentists received a very good or good overall rating, whereas only 3.02% (721/23,902) were rated with the lowest scores. Better ratings were given either by female or older patients, or by those covered by private health insurance. The best-rated specialty was pediatric dentistry; the lowest ratings were given to orthodontists. Finally, dentists were rated slightly lower in 2013 compared to 2012 (P=.01).
The rise in the number of ratings for dentists demonstrates the increasing popularity of physician rating websites and the need for information about health care providers. Future research should assess whether social media, especially Web-based ratings, are suitable in practice for patients and other stakeholders in health care (eg, insurance providers) to reflect the clinical quality of care.
PMCID: PMC4319074  PMID: 25582914
physician rating website; dentist; patient experience; Internet; quality of care
22.  How Dentists Diagnose and Treat Defective Restorations: Evidence from The Dental PBRN 
Operative dentistry  2009;34(6):664-673.
to (1) identify and quantify the types of treatment that dentists in general dental practice use to manage defective dental restorations; and (2) identify characteristics that are associated with these dentists’ decisions to replace existing restorations. The Dental Practice-Based Research Network (DPBRN) comprises dentists in outpatient practices from five regions: AL/MS: Alabama/Mississippi, FL/GA: Florida/Georgia, MN: dentists employed by HealthPartners and private practitioners in Minnesota, PDA: Permanente Dental Associates in cooperation with Kaiser Permanente’s Center for Health Research, and SK: Denmark, Norway, and Sweden.
A questionnaire was sent to all DPBRN practitioner-investigators who reported doing at least some restorative dentistry (n=901). Questions included clinical case scenarios that used text and clinical photographs of defective restorations. Dentists were asked what type of treatment, if any, they would do in each scenario. Treatment options ranged from no treatment to full replacement of the restoration, with or without different preventive treatment options. We used logistic regression to analyze associations between the decision to intervene surgically (repair or replace) and specific dentist, practice, and patient characteristics.
512 (57%) DPBRN practitioner-investigators completed the survey. A total of 65% of dentists would replace a composite restoration when the defective margin is located on dentin; 49% would repair it when the defective margin is located on enamel. Most (52%) would not intervene surgically when the restoration in the scenario was amalgam. Dentists participating in solo or small private practice (SPP) chose surgical intervention more often than dentists who participate in large group practices (LGP) or in public health practices (PHP) (p<.0001). Dentists who do not routinely assess caries risk during treatment planning were more likely to intervene surgically and less likely to choose prevention treatment (p<.05). Dentists from the SK region chose the “no treatment” option more often than dentists in the other regions.
Dentists were more likely to intervene surgically when the restoration was an existing composite, compared to an amalgam restoration. Treatment options chosen by dentists varied significantly by specific clinical case scenario, whether the dentist routinely does caries risk assessment, type of practice, and DPBRN region.
PMCID: PMC2843503  PMID: 19953775
23.  Unsedated transnasal endoscopy: A Canadian experience in daily practice 
Esophagogastroduodenoscopy (EGD) is the most frequently performed diagnostic procedure for upper gastrointestinal disorders. The procedure is routinely performed under conscious sedation in North America. A significant proportion of morbidity and mortality associated with EGD is related to hypoxia due to conscious sedation. The use of sedation is also associated with an increase in cost, loss of work on the day of endoscopy and the need for the patient to be accompanied home after the procedure. Transnasal endoscopy has advantages such as no sedation and less patient monitoring, nursing time and expenses than conventional per oral EGD.
To assess the feasibility and acceptability of unsedated transnasal EGD in daily practice.
Patients due to undergo EGD were given a choice of either unsedated transnasal EGD or per oral EGD with sedation. Patients who chose unsedated transnasal EGD had the procedure performed in the office by a senior gastroenterologist with experience in transnasal EGD. All procedures were performed using a small-calibre esophagogastroduodenoscope. All patients were surveyed using a patient satisfaction questionnaire, and were asked to give specific scores in terms of choking sensation, sore throat, nasal discomfort and abdominal discomfort. All variables were assessed by scores between 0 and 10, with 10 indicating the most severe degree of each variable. Any complications were also recorded.
Between March 2002 and August 2003, 231 patients underwent transnasal EGD. The median age of the patients was 57 years (range 15 to 87 years). Complete examinations were possible in 98% of patients. Patients reported a high degree of acceptability (mean score 6.6, range 1 to 10) and low degrees of choking sensation (mean 1.8, range 0 to 10), nasal discomfort (mean 1.7, range 0 to 10), sore throat (mean 0.8, range 0 to 9) and abdominal discomfort (mean 1.1, range 0 to 10). The only complications reported by the patients were epistaxis (n=2, 0.9%) and sinusitis (n=1, 0.4%). Some patients also reported transient light-headedness (n=12, 5%) and mucous discharge (n=2, 0.9%). When asked, 185 patients (88%) stated that they were willing to undergo the same procedure in the future if medically indicated. Of the 84 patients who had conventional EGD under conscious sedation in the past, 52 patients (62%) preferred transnasal EGD without sedation.
Transnasal EGD is generally well tolerated, feasible and safe. It can be performed with topical anesthesia in an outpatient setting. The low complication rate, high patient satisfaction and potential cost savings make transnasal endoscopy an attractive alternative to conventional EGD to screen patients for upper gastrointestinal tract diseases.
PMCID: PMC2662198  PMID: 18354752
EGD; Sedation; Transnasal endoscopy
24.  Demographic and practice characteristics of Medicaid-participating dentists 
The challenges entailed in dental Medicaid programs are well documented. To increase our understanding of Medicaid participation, we surveyed Florida dentists to determine the demographic and practice characteristics of Medicaid-participating dentists.
Our target population was practicing Florida dentists who treat children, including those who do not currently accept Medicaid as well as those who do. The final sample (n = 882) included (1) pediatric dentists and (2) general dentists who self-reported that they treat children. Participants completed a survey concerning their Medicaid participation. Analyses included survey-sample weighted chi-square tests and multivariable logistic regression.
More than two-thirds of the sample dentists are not participating in Medicaid and will not consider doing so. Key findings are that Black dentists across the state and Hispanics in South Florida are more likely to participate in Medicaid than other groups of Florida dentists. Pediatric dentists are more likely to be Medicaid participants than general dentists, but nearly one-fifth of the pediatric dentists might quit participation. Non–Medicaid providers are more likely to report not being busy enough in their practice than Medicaid providers.
If we are to address the shortage of Medicaid dental providers, increasing our understanding of how to capture the excess capacity among general dentists (the reported lack of busyness) in a way acceptable to dentists and to the State of Florida is an important first step. In addition, dental schools should consider implementing a track dedicated to training students for practice success within communities of highest dental need and to seek to increase the number of Black dental students.
PMCID: PMC4469354  PMID: 24102135
dental care access; children’s dental care; Medicaid; Florida surveys; cultural diversity
25.  The dentist's role in cessation of cigarette smoking. 
Public Health Reports  1984;99(5):510-514.
Dentists in general practice were surveyed by mail questionnaire to determine the actions they were taking to promote cigarette smoking cessation among their patients. Findings are based on replies from 376 of the 466 dentists in western New York State to whom the questionnaire was sent in 1981. The responses indicate that less than 18 percent of western New York State dentists smoke. The proportion is continuing its gradual decline, and dentists lead the general population in smoking abstention. Sixty-two percent of the dentists in the survey do not permit smoking in their waiting rooms, and 84 percent advise patients not to smoke. There is clear evidence of a relationship between the dentists' own smoking habits and their inclination to promote smoking cessation among patients. As fewer dentists smoke, more will be inclined to foster nonsmoking. Dentists can use a variety of smoking cessation techniques. To carry out a minimal program of antismoking measures, dentists in general practice can serve as nonsmoking role models for their patients, provide information about the health hazards of smoking, give advice, refer patients to cessation programs, recommend cessation measures, and monitor patients' efforts to quit smoking. While smoking cessation measures taken by dentists are not likely to convert more than 1 or 2 percent of patients who smoke per year, in time the dentists' efforts to promote smoking cessation can have an appreciable impact.
PMCID: PMC1424633  PMID: 6435166

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