Recommendations regarding total daily fluoride intake for Canadians.
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Adolescent↗
Biomedical subjects
D W Lewis
Publications and source records attributed to D W Lewis.
Technology assessment in dentistry.
Technology, in the context of dental health care, is a term that can encompass systems such as water fluoridation, clinical procedures such as sealants, or clinical protocols such as antibiotic coverage of patients with a history of heart surgery. Similarly, the term technology assessment (TA) describes a multidisciplinary, scientific process established to guide policy on the adoption and distribution of health technologies. While this process is already well established in medicine, it is just beginning in dentistry. As such, TA is still evolving in dental care in terms of methods and process. TA is required to guide the content of curriculum and standards of practice in a rapidly changing dental environment. It should precede the adoption or deletion of both technologies and of writing practice guidelines. TA makes it possible to shed inappropriate technologies or the inappropriate application of existing technologies, which may free resources to pay for improvements in the dental care we offer.
Canada↗
Ontario dentists: practice variation in referrals to pediatric dentists.
Variations in the pediatric referral practices of general dentists for children aged zero to 14 years may be related to issues concerning quality and standards of care, cost containment, and predictability in third-party payment programs. In September 1992, a survey mailed to a random sample of approximately 10 per cent of Ontario general dentists was used to gather information about pediatric referral practices as well as economic and demographic factors associated with these practices. Responses were received from 381 of the 540 dentists surveyed (69 per cent). Most dentists who gave reasons for pediatric referrals (85.6 per cent) named behavior management problems as the primary cause. However, 21.5 per cent did not refer any children under 14 to pediatric dentists. Due to the variable results obtained using assorted statistical tests to regrade the outcomes of interest, the self-reported nature of the data, and the large amount of pediatric referral practice variation left unexplained by the multivariate analysis (95 per cent), this study's findings are equivocal.
Adolescent↗
Changes in utilization of dental services of Alberta's universal dental plan for the elderly.
Since 1973, Alberta's dental plan for the elderly has made government-sponsored, premium-free comprehensive care by dentists and denturists available to all residents of the province over age 64. Details on the numbers and types of different services provided were previously unavailable from the annual reports. However, an examination of the plan's six-million records, covering nearly 260,000 different patients from 1978 to 1992, has now made it possible, for the first time, to conduct a detailed analysis of these dental services. Many time-related changes have occurred in the types of services provided. The number of removable prosthodontic services declined from 14 per cent of all services offered by dentists in 1978-79 to five per cent of these services in 1991-1992, but the services provided by denturists increased by a factor of four. The relative number of surgical and restorative dentistry services offered by dentists also declined. Preventive services grew modestly, but periodontal services grew dramatically from three per cent of all services provided by dentists to 22 per cent. These shifts in services from prosthodontics, restorative dentistry and oral surgery to preventive and periodontic services have important implications for the planning and administration of dental plans for the elderly.
Age Distribution↗
Continuity of dental treatment by users of Alberta's universal dental plan for the elderly.
To evaluate the longitudinal utilization of Alberta's Extended Health Benefits dental plan for the elderly, its use over the preceding 13 years by patients over age 64, who had used the plan in 1991-92, was examined. Of these 96,596 patients, over half (56 per cent) were female and about two-thirds (68 per cent) received their dental care from a dentist only. However, for the older elderly and for those living outside Calgary and Edmonton, the percentage attending a denturist only or both a denturist and a dentist was greater. Only individuals over age 77, or about 20 per cent of plan participants in 1991-92, were eligible to use the plan over the entire 14-year period examined in this study. However, the regularity of previous annual utilization of the plan was high. About 60 per cent of 70-74 year olds had used the plan for five or more years, while close to 50 per cent of the 80-84 year olds--who were eligible to use the plan for the entire period of the study--had done so in eight or more of the previous 14 years. Despite varying plan eligibility according to patient age, the 96,596 patients who used the plan over the 14-year period made nearly 1.2-million patient visits, at which they received about 3.1-million dental services. The high continuity of annual usage demonstrates that this group is not under-utilizing dental services.
Age Distribution↗
Restorative decision making by Ontario dentists.
One-half of the dentists in general practice in Ontario were randomly selected for a survey in June 1992 to determine their practices and decision-making regarding some aspects of restorative dentistry. Using patient scenarios to describe clinical situations, respondents stated the threshold at which a restoration should be placed in various tooth surfaces of persons of different ages, according to the severity of the carious lesion and the usual restorative procedure for different case situations. A total of 1,276 (52 per cent) dentists responded to a detailed mail questionnaire. Data were entered into a personal computer (PC) and analyzed using frequencies and chi-square with the SPSS/PC+ statistical package. Multivariate analyses were undertaken to examine what characteristics of dentists independently explained variations in their usual restorative procedures for approximal and occlusal caries. With approximal lesions, as seen on bitewing radiographs, 60 per cent of the dentists indicated that they would place a restoration in a 12 year old with an enamel lesion that had not reached the dentino-enamel junction, whereas with 30- and 55-year-old patients, 28 and 20 per cent, respectively, would do so. At each patient age, there was a tendency for significantly younger dentists to restore enamel-only lesions more often than other dentists (p < .01). Variations in proposed treatment for an adult patient with above average oral hygiene, but with a small (1-1.5 mm diameter) occlusal cavity that had penetrated through the dentino-enamel junction, were also observed. In this case, 23 per cent of the dentists would prepare a conventional cavity extending to include all fissures, and restore the tooth with amalgam or composite; 45 per cent would prepare a cavity just larger than the outline of the lesion and restore it in the same way; 32 per cent would prepare a small cavity and place a preventive resin restoration. Significant differences in cavity design were also observed between graduates of the University of Toronto and the University of Western Ontario with respect to restoring approximal carious lesions. A number of the dentists' characteristics were significantly associated (p < .01) with these variations in procedures. These included the dentists' gender, year and university education and type of practice. The documentation and explanation of these large variations in restorative practices have important implications for continuing dental education.
Adult↗
Another update for Canadian dentists regarding chlorhexidine varnish therapy for the prevention of dental caries.
Some of the reasons for my belief that CVT has been marketed prematurely have been described. They include the belief that the only really important outcome from the patients' and dentists' perspectives is proven reductions in dental caries. Associated with this is the need to recognize that, using such a criterion, the numbers of patients who may truly benefit from CVT in Canada are small--much smaller than those who promote the testing for and use of CVT appear to infer. Once proven clinically effective, the cost effectiveness of CVT for different patient groups must be demonstrated. I also think that studies to determine Cariescreen's accuracy in terms of predictive values for the "gold standard" plate counts of mutans streptococci should be undertaken. These results should then be given to dentists to help them in their decisions about using CVT in their practices, and if this decision is affirmative, in their discussions with patients for whom they decide CVT will be beneficial. Similarly, the effectiveness of the single application of CVT must be proven by a properly-designed study, since the current justification is inadequate for so important an issue. Finally, dentists should have been provided with all of this basic information before CVT was marketed in Canada.
Adolescent↗
Periodic health examination, 1993 update: 3. Periodontal diseases: classification, diagnosis, risk factors and prevention. Canadian Task Force on the Periodic Health Examination.
OBJECTIVE: To review the 1979 Canadian Task Force on the Periodic Health Examination recommendations on the diagnosis and prevention of periodontal disease. OPTIONS: Self-care at home, professional care, treatment with antimicrobial agents and management of patients at high risk. OUTCOMES: Maintaining the gingiva, alveolar bone and periodontal ligament in a healthy state (absence of gingival bleeding and no loss of epithelial attachment). EVIDENCE: A literature search for articles published from 1980 to 1993 was conducted. Selected studies published before 1980 were also reviewed if there were no recent updates. Evidence was evaluated and classified as good, fair or poor according to the criteria of the task force. VALUES: The task force's evidence-based rules for recommendations were used. In addition, whenever feasible, and on the basis of advice from the reviewers and experts, recommendations were modified in the interest of maintaining oral health (e.g., dental flossing in children). BENEFITS, HARMS AND COSTS: The recommendations are not expected to increase the costs of preventing periodontal diseases for the general population. They could benefit dental patients and reduce costs because they are based on the periodontal needs of patients rather than on the current universal application approach.
Adult↗
Ontario dentists: 1. Radiologic practices and opinions.
In February 1991, about 10 per cent of Ontario's general dentists were polled via a mail survey to gather information about their radiological practices and opinions. Responses were received from 413 out of 537 general practitioners, for a response rate of 77 per cent. A large majority of dentists (86 per cent) have no written office policy and/or protocol for selecting patients for X-ray examination, and just over half (54 per cent) primarily use clinical experience to select patients for these examinations. In the majority of practices (57 per cent), radiographs of asymptomatic recall patients are taken after both their history and clinical examination are complete. A similar percentage (56 per cent) of dentists are opposed to explicit guidelines for radiological examinations.
Dental Caries↗
Ontario dentists: 2. Bitewing utilization and restorative treatment decisions.
Guidelines for the selection of patients requiring radiological examination have recently been published in Canada and the United States. The purpose of this paper, the second in a three-part series on the results of a questionnaire to Ontario general practitioners, is to compare bitewing use in Ontario against the U.S. guidelines. This questionnaire determined the frequency of recall bitewing examination for low and high caries risk patients, as well as the factors that influence the diagnostic and treatment decisions of the responding dentists. For example, 49 to 78 per cent of dentists order recall bitewings--in accordance with U.S. guidelines--for their patients in individual low caries risk categories. Similarly, 49 to 88 per cent of dentists order recall bitewings for individual patients in high caries risk categories, which is also consistent with the U.S. guidelines. However, across all low and high caries risk groups of patients, the percentages of dentists who followed the recommended guidelines were 34 and 15 per cent, respectively. The responding dentists' estimates of the length of time required for caries to progress through enamel are indirectly associated with the interval prescribed for recall bitewing examination.
Adolescent↗
Ontario dentists: 3. Radiographs prescribed in general practice.
In February 1991, a mail survey was used to poll a sample consisting of about 10 per cent of Ontario's general dentists. The data obtained provided information about the radiographs prescribed by dentists for five different patient types, which were described to the respondents. The per cent agreement between the radiographic procedures prescribed by Ontario dentists and the ADA-approved Center for Devices and Radiological Health (CDRH) guidelines ranged from three per cent to 79 per cent, depending on patient type and disease risk. For each patient and risk type, there was considerable variation in the radiographs prescribed.
Adult↗
A macroeconomic review of dentistry in the 1980s.
Dental expenditures in Canada receive less attention than other expenditures in the health care sector. Using publicly-available records, the authors have shown that the overall expenditures on dental care rose from $1.3 billion to $3.1 billion during the 1980s, or from $54.35 per person to $117.78 per person. Inflation and population growth would account for about 64 per cent of the increase, and the balance ($650 million) would therefore result from more services being provided. Per capita dental expenditures by province and territory show that people in the territory purchase the least care ($33.01 per person in 1989) and those in British Columbia purchase the most care ($145.54 per person in 1989). Even though some costs are not included in the data sources used for this paper, the direct costs of preventing and treating dental diseases ranks third among all diseases or conditions, exceeded only by the costs related to cardiovascular diseases and mental disorders.
Canada↗
Hair-grooming syncope seizures.
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Adolescent↗
What was wrong with Tiny Tim?
One of the most endearing characters in English literature is Tiny Tim, the crippled son of Ebenezer Scrooge's clerk, Bob Cratchit. Yet the nature of Tiny Tim's multifaceted and implicitly reversible illness is a mystery and open to debate and speculation. From details of the original manuscript and the eight film versions, it is possible to construct a differential diagnosis for Tim's short stature, asymmetric crippling disorder, and curious intermittent weakness that would lead to his death, if untreated, within a period of 1 year. Following the ghostly visitations, Scrooge vows to assist the struggling Cratchit family financially, thereby making available the best medical care money could buy. From review of pediatrics texts from 1830 to 1850, a recommended treatment plan would have included (1) general measures such as country air and exercise, and fish oils such as cod and halibut (vitamin D), and (2) specific treatments of tonics (containing combinations of belladonna, opium, sodium bicarbonate, sodium citrate, and potassium chloride) emphasizing alkalis, and splinting and bracing the limbs. Such treatments with vitamin D and alkalinization with sodium bicarbonate and sodium citrate suggest the plausible speculation that Tiny Tim had renal tubular acidosis (type I), a disorder that is characterized by growth failure and, if left untreated, complicated by osteomalacia with pathologic fractures, hypokalemic muscle weakness and periodic paralysis, nephrocalcinosis leading to renal failure, and death. I propose that Tiny Tim had distal renal tubular acidosis (type I).
Acidosis, Renal Tubular↗
Utilization in Alberta's universal dental plan for the elderly, 1974-91.
Since 1973 the government of Alberta, a Canadian province of 2.4 million people, has funded a dental care plan for all residents over 64 years old and their dependents. It is the only dental plan in North America that covers all seniors and their dependents residing in a state or province. Under this plan, just over 270,000 persons (in 1990-91) are eligible for comprehensive, premium-free dental services provided by dentists and denturists in private practice on a fee-for-service basis. The plan's design, administration, utilization, and costs are reviewed. Utilization increased from 27 percent of eligibles using the plan in 1974-75 to 44 percent in 1990-91, and the mean number of services per user rose from 4.9 to 6.9 during the same time period. Although the cost per eligible person has increased about 200 percent, from Canadian (C) $42 to C $131, these costs only began to exceed the rate of inflation in 1986-87. Even though just 12 percent of the two main providers participating in the plan are denturists, nearly 22 percent of plan patients attended denturists rather than dentists for their complete dentures. Fees paid to dentists by the plan have decreased over time relative to the standard fees for the various services listed annually in the Alberta Dental Association fee guide. The apparent growth of direct additional billing by dentists of plan users to recover the difference between their usual fees and those paid by the plan and the effects of greater plan utilization are discussed, as are future potential difficulties in the plan's administration.
Aged↗
Long-term retention after self-instructional methods.
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Analysis of Variance↗
Dental implants and decision making.
Treatment choice and effectiveness in prosthodontics has largely depended on educated anecdote and asseveration. Still, this approach has to a very large extent enabled dentists to enrich the quality of their patients' lives. However, the trade-off between the need for prosthetic intervention per se and the biologic price inherent in certain therapeutic endeavors has demanded strict concerns regarding clinical decision making and treatment outcomes. The technique of implant prosthodontics is certainly one that has focussed such concerns, particularly since the concept of osseointegration was introduced to North American dentists at the 1982 Toronto Conference. Clinical research and opinion in this area have elicited both clinical euphoria and polarization vis-a-vis newer possibilities for resolving the predicaments of partial or complete edentulism. The past decade has witnessed clinical trials, as well as highly relevant exemplary reports, on the application of the osseointegration technique. It is now necessary to compare the merits of implant prosthodontics to traditional therapies, and to determine those criteria which comprise optimal functional and aesthetic restoration, with minimal risk of morbidity, along with cost concerns. This paper seeks to provide a systematic and rational basis for the identification of such criteria.
Contraindications↗