Preventive dentistry in Texas, USA

iVIeei-shia Chen Center for Health Adminislration Studies. The University of Chicago, Chicago, Illinois, USA

Chen M-S: Preventive dentistry in Texas, USA, Community Dent Oral Epidemiol 1990; 18: 239^3, Abstract - This paper presents the results of a 1985 survey of 1000 Texas dentists regarding three major types of preventive measures - educational services, preventive procedures, and diagnostic services. The results show that among several given educational services, respondents tended most to instruct on correct brushing or flossing and tended least to counsel on diet. Among preventive procedures, most dentists removed plaque or calculus. A very small portion applied occlusal sealants on patients under the age of 15, As for diagnostic services, most performed oral cancer screening exams. Most performed dental X-rays, but many did not use leaded protection on their patients while taking X-rays. A large number did not check their patients' blood pressure. Income, attendance of continuing education prograrns, and number of dental hygienists were strong, positive predictors of provision of cdl three types of preventive measures. Dentists who practiced in more populous areas, or had practiced for fewer years, tiiore likely provided patients with educational services and preventive procedures. Dentists delivered more preventive procedures if they attended more professional dental meetings. Dentists who worked more hours were more likely to provide educational services and preventive procedures. Patient load correlated negatively with dentists' delivery of preventive procedures.

Accepted for publication 8 February 1990

Dental professionals widely recognize the importance of prevention in the promotion and maintenance of dental health (I), The American public also has become increasingly aware of the benefits of preventive dental behavior. Furthermore, dental providers have been charged with the responsibility to incorporate preventive measures into their practices (2, 3). Previous studies, however, have not shown high levels of preventive dentistry in dentists' clinical practices (3). Many dental professionals have also asserted that preventive care has not been widely incorporated into professional practices in the US (1, 3), It is not clear, then, to what extent, if any, American dentists have engaged in various preventive measures. Surprisingly, very few studies have exainined the practice of preventive dentistry in the US (4), Additionally, most previous studies were conducted before the mid-1970's (e,g. 4, 5). Therefore, it is imperative to examine the current status of preventive dentistry in the US, This paper describes the types and extent of preventive measures delivered by Texas dentists in general practice and in the specialty of pedodonties; it also identifies factors influencing the patterns of their provision of preventive measures.

incomes ofthe respondents range widely from less than $50 000 to more than $200000, The preventive measures studied in this paper fall into three major categories, following AMI:S F. TI^YON'S method of categorization (6), First the educational services category includes those tasks that involve instruction. They are: 1) instruction in correct brtishing and flossing, 2) written instructions for home dental care, 3) diet counseling, 4) patient education from the dentist or dental hygienist, 5) patient instruction from movies or slides, 6) recommendation of the use of toothpaste with fluoride, and 7) use of a recall system. We consider the recall system an educational service because it serves to reintbrce the patient's regular utilization behavior. Second, the preyentiye procedures category contains those tasks involving the use of materials or instruments. This category includes: 1) plaque removal, 2) calculus removal, 3) application of sealants to patients under 15 yr, 4) topical fluoride application, 5) fluoride mouthrinse. We do not consider placement of amalgam a measure of primary prevention, but we do include it in the survey to compare it with other measures. (Please note that, as used in this paper, the terms

iUlethods

The sample comprised 1000 randomly selected dentists in general practice and pedodonties in Texas, USA, who were registered with the Texas Board of Dental Exatiiiners as of 1984, We sent a fivepage questionnaire to these dentists in January, 1985. The questionnaire sought information on: 1) the dentists' provisions of preventive measures, 2) the dentists' socioeeonomic characteristics, and 3) factors related to the dentists' practice of preventive measures. In total, 569 dentists, incltiding 552 general practitioners and 17 pedodontists, completed and returned the questionnaire. Among the 1000 dentists originally selected, 25 had either moved, were retired or deceased. The response rate thus was 58,4%!, based on a denominator of 975 active dentists who received the questionnaire. Table 1 displays the characteristics of the respondents. The majority (95,1%) of these dentists are male. More than half are 30^9 yr old. About 45% have practiced from 1 to 10 yr, and about 23% have practiced from 11 to 20 yr, A high proportion of them work in large cities, while very few (8,1%) practice in small towns or rural areas. The anntial gross

Key words: dentists: preventive dentistry Center for Health Administration Studies, 1101 East 58th Street, Chicago, Illinois, USA 60637

240

CHI-N

Table 1. Charaeteristies of dentists studied Variable Sex Male I-L-maie

ti

%

541 2K

95.1 4.9

62 221 121 90 57 18

10.9 38.8 21.3 15.8 10.0 3.2

136 118 70 60 51 37 55 40 2

23.9 20.7 12.3 10.5 9.0 6.5 9.7 7.0 0.4

Age

70 Years in practice 1-5 6-10 11-15 16-20 21-25 26- 30 31-35 >36 Unknown l^ocation of praetice Large city City or adjacent suburb Large town Small town or rural Unknown

239 168 111 46 5

42.0 29.5 19.5 8.1 0.9

Income from practice Under $50000 $50 000 $100 000 $100 000-$ 150 000 $150 00t)-200 000 More than $2001)00 Unknown

97 140 125 75 114 18

17.0 24.6 22.0 13.2 20.0 3.2

'preventive procedures' and 'preventive measures' are not interchangeable. The term 'preventive proeedures' denotes a subcategory of preventive measures.) Finally, the diagno.stic category contains those tasks which aid in the recognition of dental or health problems. This category includes: 1) tise of X-rays (and leaded proteetion), 2) blood pressure screening, 3) oral cancer exams, and 4) taking dental and medical histories. Previous studies show that dentists' preventive practices relate to their socioeconomic characteristics, work time, staff, attendance of pi'ole.ssional activities, and training (4—9), Our study, using multiple regression analyses, examined how Texas dentists' provision ofthe three types of preventive measures related to their socioeeonomic status, participation in professional activities, number of dental auxiliaries employed, patient load, working hours per week, and time spent with patients. In these analyses, we scored the dependent variable on educational services by summing the values given to each service included in this cate-

gory. (In other words, the score for educational services was obtained by summing the scores for the seven educational tasks listed above,) We scored each ofthe seven services using a Likert scale: service given to all of my patients (4), most of my patients (3), some of my patients (2), and none of my patients (I), This scoring method for the dependent variable assumed that each service was equally valued and that a dentist received higher scores on the educational services variable if he provided more educational services to more patients, (This method was used to demonstrate how widely various preventive services were used by the dentist. It does not, however, imply that all patients should receive all preventive services,) The variable on preventive procedures was scored in the same way; it was the total score of the preventive tasks listed earlier. The dependent variable for diagnostic services was the total .score of the use of X-rays, leaded protection when X-rayed, blood pressure screening, oral cancer exams, and taking dental and medical histories. Resuits Educational services

Table 2 shows the percentage distribution of respondents who applied educational dental services to all, most, some or none of their patients. (Note that "patients" here include those who visit both regularly and non-regularly.) The majority of the respondents (84.5%) provided instructions on correct brushing to all or most of their patients. A large proportion (79.1%) instructed all or most of their patients in the correct method of flossing. A majority (89.2%, data not shown in the Table) of the sampled dentists routinely recommended the use of toothpastes with fluoride. On the other hand, only a small proportion of respondents wrote instructions for home dental care or provided diet counseling. About 8,7%j of the dentists provided written instructions on home dental care for all of their patients, and 16.7% of them did this for most of their patients. Only 5.9% of the respondents offered diet counseling to all of their patients, and only 11,4% offered it to most of their patients, A high percentage ofthe surveyed dentists, however, educated patients themselves; 27.5% delivered this service to all

of their patients and 36.7"/o to most of their patients. In addition, a large proportion of dental hygienists (68%) provided patient education to all or most of their patients. Most respondents did not educate with movies or slides: 85.7yo did not use these audiovisual aids at all. Finally, we asked the dentists whether there exists a recall system for continuing preventive care. Most dentists (80,7%: data not reported in the Table) had a recall systeni on a fixed interval basis and called the patient if he or she missed an appointment. Some dentists (I l,2'/o) had a recall system on a fixed interval basis but did iiot call the patient if he or she missed an appointment.

Preventive procedures

Table 2 also shows how dentists used various preventive dental procedures on their patients. Among the five kinds of preventive procedures studied, dentists practiced plaque and calculus removal most often and occlusal sealants least often. That is, more than 90% removed plaque or calculus on all or most of their patients, whereas only 13,7% offered sealants to all or most of their patients younger than 15, Furthermore, a fair proportion (44.5%) used sealants only on some of their patients younger than 15. Many - almost 42% - did not use them at all. In addition, we included amalgams for comparison purposes and found that these dentists placed amalgams more than they used sealants. They also placed amalgams on all age groups. Besides sealants, we also examined fluoride use, A signillcant proportion of our respondents (more than 45%) applied topical fluoride or fluoride mouthrinse to only some or none of their patients.

Diagnostic services

Table 2 also summarizes the percentage of dentists who performed diagnostic services on all, most, some, or none of their patients. Forty-eight percent of the dentists surveyed took dental X-rays of all their patients, and about 46% took Xrays of most of their patients. Despite the fact that leaded protection lor Xrayed patients continues to be a preventive measure recommended by the American Dental Association (ADA), 25.7%,

Preyentiye dentistry T a b l e 2. Pereentage of dentists who perform various preventive dentai measures on all, most, s o m e , or none of their patients All patienls

Most patienls

Some patients

None patients

Preventive dental measures

(%)

(%)

( /o)

(%)

Eduealionat serviees Instruction in correct hrushing Instruction in correct tlossing 'Written instruetions for home dental eare Diet coun.scling Patient education from the dentisl Patient education from the hygienist Patient edueatioii from movie or slides

42.7 39.2 8.7 5.9 27.5 40.3

41.8 39.9 16.7 11.4 36.7 27.7

14.9 19.8 48.0 62,8 32.5 7.6

0.5

1.3

3.1

9.9

67.4 63.7 1.5 23.6 17,7

27.9 30.7 12.2 29.0 25.7

4.3 5.2

44.5 42.5 47.5

38.5 38.2 37.6 37.1

40.5 41.4 38.7 38.4

17.7 17.1 19.0 19.5

48.0 61.1

45.5 13.2

6.3

0.2

20.1

5.6

23.4 36.2 43.0 40.7

69.5 45.7 30.6 26.1

II.6 10.2 7.2

6.4 3.0 2.4 2.0

Pre yen liye proeedures Plaque removal Calculus removal Occlusal sealants on patients < 15 Topical fluoride

Fluoride mouthrinse Aniatgams 55 Diagnoslic serviees Dental X-rays Leaded protection when X-rayed Blood pressure sereening lor patients < 15 15-29 30-55 >55 Exam for oral eaneer for patients 55

of the respondents did not provide such protection in their practices or only used it on some of their patients. Our respondents tended not to include blood pressure screening in their practices. For example, as Table 2 shows, 26,1 % did not screen high blood pressure for patients older than 55 yr of age, and 40,7% screened only some patients of this age group. Only 16,9% measured the blood pressure of all of their patients

4.3 11.5 13.8 16.9

2.9 12.6 16.3

70.2 73.0 74.1 75.1

11.8 13.8 16.3 16.3

6.6

3.3 3.2 4.7

5.1

6.6

older than 55, In contrast, most surveyed dentists examined the oral mueosa for signs of cancer in patients of all age groups. Finally, dentists were asked whether they took medical and dental histories routinely, occasionally, rarely or never. The study showed that 92,7% of the dentists took medical histories routinely, while a somewhat lower proportion (86,6%) took dental histories routinely (data not shown in Table),

Table 3. Regression relating dentists' socioeeonomic stalus and years of practice to their provision of edueational serviees, preventive proeedures, and diagnostic serviees Variables Location ol praetice Years in praetiee Age

Income R-

Edueational serviees P t 0.11 -0.43 0.23 0.31

2.41* -3.97*** 2.15* 6.94*** 0.16

Preventive dentistry in Texas, USA.

This paper presents the results of a 1985 survey of 1000 Texas dentists regarding three major types of preventive measures--educational services, prev...
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