J. Dent. 1992;
20: 345-347
345
GDPs’ and specialists’ decisions management of fissure caries*
in the
M. H. Davis, R. M. Harden and N. B. Pittst Centre for Medical Education, Ninewells Hospital and Medical Department of Dental Health, University of Dundee, UK
School,
tDenral
Health
Research
Unit
and
ABSTRACT As part of a continuing education programme in dentistry, four specialists and 27 selected general dental practitioners were asked to rate 58 clinical management options relating to fissure caries in six simulated patient management problems called challenges. Their ratings are presented and the advantages and disadvantages of the approach are discussed. Areas of agreement and disagreement are highlighted and possible reasons for these explored. KEY WORDS:
Caries, Diagnosis,
J. Dent. 1992;
20: 345-347
Education
(Received
8 August
1991;
reviewed
29 October
1991;
accepted
19 May
Correspondence should be addressed to: Dr M. H. Davis, Centre of Medical Education, Ninewells
Hospital
1992)
and Medical
School, Dundee DDl
9SY, UK.
INTRODUCTION
METHOD
General dental practitioners (GDPs) and those working in dental hospitals see patients in different contexts. The hospital practitioner sees a selected group of patients mostly in an academic environment and may have a particular interest in recent advances in the subject, while the GDP has to operate within the constraints of a busy routine practice and may have little opportunity to keep up to date with recent developments (Schanschieff et al., 1985; Boyd, 1989; Seward, 1990). The question arises as to whether, given these differences, the clinical management decisions of the two groups differ. In this paper we have explored the decisions taken by members of the two groups and looked at the levels of agreement and disagreement in one area, the clinical management of patients with fissure caries. This area was selected as a common problem and one in which traditional approaches are being supplemented by newer techniques.
This work was carried out as part of the development of a distance learning programme for GDPs called ‘Trends in the management of fissure caries’ which has been described in detail elsewhere (Davis et al., 1992; Pitts et al., 1992). Six simulated patients were developed called ‘Joyce’, ‘Ryan’, ‘Tracy’, ‘Frances’, ‘Robert’ and ‘Don’. These formed the basis of six patient management problems (PMPs) called challenges, reflecting the spectrum of management decisions appropriate in fissure caries. These challenges were sent to Scottish GDPs at monthly intervals after the programme resource book had been distributed. In each challenge background information about the simulated patient was given accompanied by an enlarged colour photograph of the occlusal surface of the tooth in question and/or, where appropriate, a bitewing radiograph and/or an enlarged colour photograph of a prepared cavity. During the development of the challenges four dental specialists were asked to nominate a number of GDPs whom they would be happy to have treat members of their own families. Of the 30 GDPs identified in this way, 27 agreed to participate in the study. Of these, 27 returned
*The programme of which this work is part, is an initiative of the Scottish Office’s Home and Health Department. The views expressed above are those of the authors and not necessarily Scottish Office. @ 1992 Butterworth-Heinemann 0300-5712/92/060345-03
Ltd.
those of the
J. Dent
346
1992;
20:
No. 6
their clinical management decisions to the first two challenges, and 24 returned them to the remaining four challenges. For each challenge the possible clinical management options were listed and the four dental specialists and the GDPs were asked individually to rate them on the 5-l scale where: 54321-
Definitely agree with this treatment, or management Partially agree with this treatment, or management Uncertain about this treatment, or management Partially reject this treatment, or management Definitely reject this treatment, or management
At a subsequent meeting the specialists discussed their ratings and, where possible, agreed on a consensus rating. There was no organized consultation between the GDPs. There were 58 clinical management options in the six challenges.
COMPARISON
OF RATINGS
To compare the ratings of the GDPs with those of the specialists the mode or modes of the GDP’s ratings was selected. It was compared with the specialists’ consensus rating for all 58 clinical management options. Where there was no specialist consensus the specialists’ individual ratings were used. In no case were there more than two values. There were judged to be three possible outcomes: G M D -
General agreement ‘Minimal’ differences ‘Definite’ difference more)
(rating (rating
discrepancy discrepancy
of 1) of 2 or
Where there was divergence of the specialists’ ratings, if the mode of the GDPs’ rating agreed with one of the two appropriate specialist’s rating, it was considered to be in general agreement.
RESULTS GDP ratings show three patterns. Most show wide agreement, some a uniform spread and others a bipolar distribution. Table I shows the level of agreement between GDPs and specialists, and between the specialists for all 58 clinical management options. There was general agreement in the majority but in a number there were either minimal or definite differences. The clinical management options fell into a number of categories and these are shown in Table ZZwith the Tab/e 1. Level of agreement between the GDPs and the specialists, and between the specialists Outcome
GM D-
general agreement ‘minimal’ difference ‘definite’ difference
Between GDPs and specialists
Between specialists
42
54 2 2
Table II. Number of options disagreements betweenspeciaks category
and number of definite and GDPs’ mode in every
Options in Category of clinical management option Observe and review Fissure seal Bitewing radiograph Investigate with a small bur Class I amalgam Composite and fissure sealant Glass ionomer and fissure sealant Laminate restoration
category (no.)
Definite disagreements (no.1 2
9 11 6
:,
9
1
11
1
4
1
4
1
4
1
number of options in each category and the number of instances where there was definite disagreement. Minimal differences may reflect only minor differences of interpretation and therefore we have shown here only instances of definite disagreements. The numbers of such disagreements ranged from none of six in the category relating to bitewing radiographs to one of four in the categories relating to when to place the sealant restorations. The eight instances where there was definite disagreement between the specialists’ and GDPs’ mode have been identified in Table ZZZ,and for each instance the specialists’ rating and the mode of the GDPs’ ratings has been given. The challenge called ‘Tracy’ contains most disagreements. No disagreements occurred in the challenges called ‘Joyce’ and ‘Robert’. The two outcomes where definite differences within the specialists group occurred related to one case, ‘Robert’. One of the specialis& wished to fissure seal the tooth and so scored that option as 5 and the ‘investigate with a small bur’ option as 3. The other three specialists advocated investigation of the fissure with a small bur, and scored that option as 5, scoring the fissure seal option as 3.
DISCUSSION While other approaches have been described previously (Kay et al., 1988), simulated PMPs provide a useful approach for highlighting areas of agreement and disagreement about aspects of dental practice. In contrast to observation of dentists’ actual practice, the use of simulated PMPs provides a more standardized approach with all dentists being assessed on the same information. In addition, it is a relatively inexpensive method and one that can be distributed easily throughout the country. The cases can be so designed that attention is focused on areas where there is room for differences of opinion about legitimate clinical management; that is, where specialists disagree among themselves or with the bulk of GDPs. Such differences may be particularly evident in rapidly developing areas, where new trends are being incorporated
Davis et al.: Management
of fissure
caries
347
Table III. Definite disagreements between specialists’ and GDPs’ mode showing management option and challenge to which they relate Disagreement number
Challenge
Category of clinical management option
Ratings Specialists GDP mode
1
‘Ryan’
Glass ionomer and fissure sealant
2
5
2
‘Frances’
Laminate (sandwich) restoration
1
4
3 4 5 6 7
‘Tracy’ ‘Tracy’ ‘Tracy’ ‘Tracy’ ‘Don’
Observe Observe Fissure seal Investigate Composite and fissure sealant
2 z 2
4 1 1 5
3
1
8
‘Don’
Amalgam
2
5
in NHS practice. The approach may also be useful for purposes of audit, and this is an area of ongoing research. Nevertheless, the approach is not without disadvantages. The problem presented is a simulation, not reality, and the difficulties inherent in this became apparent in the challenge called ‘Tracy’, in which four of the nine definite disagreements occurred (see 3, 4, 5 and 6 in Table III). These may at least in part be due to differences in interpretation of photographic material, rather than a true difference in approach between GDPs and specialists. Every effort was made to ensure that photographs and copy radiographs were of the highest quality. However, in this case, the coincidence of an apparent shadow on the tooth, caused by ‘fall-out’ of flash, and a clinically insignificant radiolucency on the radiograph resulted in many GDPs feeling certain that caries was present, when the tooth was, in fact, judged to be normal on actual examination. Developers and users of PMPs need to be aware of PMPs’ limitations and make allowances for them. Another disadvantage of the approach is that the PMP looks at what participants say they do in a simulated situation and not what they actually do in their practice. However, it may provide a more valid reflection of a dentist’s competence than just a test of knowledge; for example using multiple-choice or short-answer questions. This study has identified a high level of overall agreement between specialists and GDPs regarding the management of patients with fissure caries in contrast to some other studies (Elderton and Nuttall, 1983). In a few instances, discrepancies were identified and while some could be explained by the method, a real discrepancy seems to have been revealed in disagreements 1,2,7 and 8 in TableZZZ, where GDPs may not have been familiar with thespecialists’criteria for placing the sealant restorations. Familiarizing GDPs with such criteria is one of the major needs that the distance learning programme, of which this work is part, was developed to meet. It is interesting to note that there was no disagreement over when it was appropriate to take bitewing radiographs. It has to be noted, however, that the GDP participants were selected from practices perceived as ‘good’ rather than ‘poor’ and
so the measures obtained might be artificially high. Also, the use of the mode of GDPs’ ratings excludes consideration of the ratings of GDPs outwith the mode and the possible reasons for this. In spite of these qualifications it is encouraging that, even in a rapidly evolving area such as this, our study seems to show that some GDPs have kept up to date. Further studies are required to see if this applies to all GDPs and not just this small selected sample.
Acknowledgements The authors wish gratefully to acknowledge the contributions of Professor R. C. Paterson, Dr A. Watts and Dr W. P. Saunders of the Department of Conservative Dentistry, University of Glasgow, who participated in the development of the distance learning programme and without whom this study would not be possible. Professor Pitts acknowledges financial support from the Scottish Office’s Chief Scientist’s Office, the opinions expressed are those of the authors and not necessarily of the Scottish Office. References Boyd M. A. (1989) In: Annsavice K. J. (ed.), Amalgam Replacement: Are Decisions Based on Fact or Tradition in Quality Evaluation of Dental Restorations. New Malden, Quintessence, pp. 73-80. Davis M. H., Harden R. M., Laidlaw J. M. et al. (1992) Continuing education for general dental practitioners using a printed distance learning programme. Med. Educ. (in press). Elderton R. J. and Nuttall N. M. (1983) Variation among dentists in planning treatment. Br. Dent. J. 154, 201-206. Kay E. J., Watts A., Paterson R. C. et al. (1988) Preliminary investigation into the validity of dentists’ decisions to restore occlusal surfaces of permanent teeth. Community Dent Oral Epidemiol. 16,91-94. Pitts N. B., Davis M. H. and Harden R. M. (1992) General dental practitioners needs for continuing education on the management of fissure caries. Br. Dent J. (in press). Schanschieff S. G., Shovelton D. S. and Toulmin J. K. (1985) Report of the Committee of Enquiry into Unnecessary Dental Treatment London, HMSO. Seward M. (Leader) (1990) All is not well. Br. Dent J 169, 345.
20: 345-347
345
GDPs’ and specialists’ decisions management of fissure caries*
in the
M. H. Davis, R. M. Harden and N. B. Pittst Centre for Medical Education, Ninewells Hospital and Medical Department of Dental Health, University of Dundee, UK
School,
tDenral
Health
Research
Unit
and
ABSTRACT As part of a continuing education programme in dentistry, four specialists and 27 selected general dental practitioners were asked to rate 58 clinical management options relating to fissure caries in six simulated patient management problems called challenges. Their ratings are presented and the advantages and disadvantages of the approach are discussed. Areas of agreement and disagreement are highlighted and possible reasons for these explored. KEY WORDS:
Caries, Diagnosis,
J. Dent. 1992;
20: 345-347
Education
(Received
8 August
1991;
reviewed
29 October
1991;
accepted
19 May
Correspondence should be addressed to: Dr M. H. Davis, Centre of Medical Education, Ninewells
Hospital
1992)
and Medical
School, Dundee DDl
9SY, UK.
INTRODUCTION
METHOD
General dental practitioners (GDPs) and those working in dental hospitals see patients in different contexts. The hospital practitioner sees a selected group of patients mostly in an academic environment and may have a particular interest in recent advances in the subject, while the GDP has to operate within the constraints of a busy routine practice and may have little opportunity to keep up to date with recent developments (Schanschieff et al., 1985; Boyd, 1989; Seward, 1990). The question arises as to whether, given these differences, the clinical management decisions of the two groups differ. In this paper we have explored the decisions taken by members of the two groups and looked at the levels of agreement and disagreement in one area, the clinical management of patients with fissure caries. This area was selected as a common problem and one in which traditional approaches are being supplemented by newer techniques.
This work was carried out as part of the development of a distance learning programme for GDPs called ‘Trends in the management of fissure caries’ which has been described in detail elsewhere (Davis et al., 1992; Pitts et al., 1992). Six simulated patients were developed called ‘Joyce’, ‘Ryan’, ‘Tracy’, ‘Frances’, ‘Robert’ and ‘Don’. These formed the basis of six patient management problems (PMPs) called challenges, reflecting the spectrum of management decisions appropriate in fissure caries. These challenges were sent to Scottish GDPs at monthly intervals after the programme resource book had been distributed. In each challenge background information about the simulated patient was given accompanied by an enlarged colour photograph of the occlusal surface of the tooth in question and/or, where appropriate, a bitewing radiograph and/or an enlarged colour photograph of a prepared cavity. During the development of the challenges four dental specialists were asked to nominate a number of GDPs whom they would be happy to have treat members of their own families. Of the 30 GDPs identified in this way, 27 agreed to participate in the study. Of these, 27 returned
*The programme of which this work is part, is an initiative of the Scottish Office’s Home and Health Department. The views expressed above are those of the authors and not necessarily Scottish Office. @ 1992 Butterworth-Heinemann 0300-5712/92/060345-03
Ltd.
those of the
J. Dent
346
1992;
20:
No. 6
their clinical management decisions to the first two challenges, and 24 returned them to the remaining four challenges. For each challenge the possible clinical management options were listed and the four dental specialists and the GDPs were asked individually to rate them on the 5-l scale where: 54321-
Definitely agree with this treatment, or management Partially agree with this treatment, or management Uncertain about this treatment, or management Partially reject this treatment, or management Definitely reject this treatment, or management
At a subsequent meeting the specialists discussed their ratings and, where possible, agreed on a consensus rating. There was no organized consultation between the GDPs. There were 58 clinical management options in the six challenges.
COMPARISON
OF RATINGS
To compare the ratings of the GDPs with those of the specialists the mode or modes of the GDP’s ratings was selected. It was compared with the specialists’ consensus rating for all 58 clinical management options. Where there was no specialist consensus the specialists’ individual ratings were used. In no case were there more than two values. There were judged to be three possible outcomes: G M D -
General agreement ‘Minimal’ differences ‘Definite’ difference more)
(rating (rating
discrepancy discrepancy
of 1) of 2 or
Where there was divergence of the specialists’ ratings, if the mode of the GDPs’ rating agreed with one of the two appropriate specialist’s rating, it was considered to be in general agreement.
RESULTS GDP ratings show three patterns. Most show wide agreement, some a uniform spread and others a bipolar distribution. Table I shows the level of agreement between GDPs and specialists, and between the specialists for all 58 clinical management options. There was general agreement in the majority but in a number there were either minimal or definite differences. The clinical management options fell into a number of categories and these are shown in Table ZZwith the Tab/e 1. Level of agreement between the GDPs and the specialists, and between the specialists Outcome
GM D-
general agreement ‘minimal’ difference ‘definite’ difference
Between GDPs and specialists
Between specialists
42
54 2 2
Table II. Number of options disagreements betweenspeciaks category
and number of definite and GDPs’ mode in every
Options in Category of clinical management option Observe and review Fissure seal Bitewing radiograph Investigate with a small bur Class I amalgam Composite and fissure sealant Glass ionomer and fissure sealant Laminate restoration
category (no.)
Definite disagreements (no.1 2
9 11 6
:,
9
1
11
1
4
1
4
1
4
1
number of options in each category and the number of instances where there was definite disagreement. Minimal differences may reflect only minor differences of interpretation and therefore we have shown here only instances of definite disagreements. The numbers of such disagreements ranged from none of six in the category relating to bitewing radiographs to one of four in the categories relating to when to place the sealant restorations. The eight instances where there was definite disagreement between the specialists’ and GDPs’ mode have been identified in Table ZZZ,and for each instance the specialists’ rating and the mode of the GDPs’ ratings has been given. The challenge called ‘Tracy’ contains most disagreements. No disagreements occurred in the challenges called ‘Joyce’ and ‘Robert’. The two outcomes where definite differences within the specialists group occurred related to one case, ‘Robert’. One of the specialis& wished to fissure seal the tooth and so scored that option as 5 and the ‘investigate with a small bur’ option as 3. The other three specialists advocated investigation of the fissure with a small bur, and scored that option as 5, scoring the fissure seal option as 3.
DISCUSSION While other approaches have been described previously (Kay et al., 1988), simulated PMPs provide a useful approach for highlighting areas of agreement and disagreement about aspects of dental practice. In contrast to observation of dentists’ actual practice, the use of simulated PMPs provides a more standardized approach with all dentists being assessed on the same information. In addition, it is a relatively inexpensive method and one that can be distributed easily throughout the country. The cases can be so designed that attention is focused on areas where there is room for differences of opinion about legitimate clinical management; that is, where specialists disagree among themselves or with the bulk of GDPs. Such differences may be particularly evident in rapidly developing areas, where new trends are being incorporated
Davis et al.: Management
of fissure
caries
347
Table III. Definite disagreements between specialists’ and GDPs’ mode showing management option and challenge to which they relate Disagreement number
Challenge
Category of clinical management option
Ratings Specialists GDP mode
1
‘Ryan’
Glass ionomer and fissure sealant
2
5
2
‘Frances’
Laminate (sandwich) restoration
1
4
3 4 5 6 7
‘Tracy’ ‘Tracy’ ‘Tracy’ ‘Tracy’ ‘Don’
Observe Observe Fissure seal Investigate Composite and fissure sealant
2 z 2
4 1 1 5
3
1
8
‘Don’
Amalgam
2
5
in NHS practice. The approach may also be useful for purposes of audit, and this is an area of ongoing research. Nevertheless, the approach is not without disadvantages. The problem presented is a simulation, not reality, and the difficulties inherent in this became apparent in the challenge called ‘Tracy’, in which four of the nine definite disagreements occurred (see 3, 4, 5 and 6 in Table III). These may at least in part be due to differences in interpretation of photographic material, rather than a true difference in approach between GDPs and specialists. Every effort was made to ensure that photographs and copy radiographs were of the highest quality. However, in this case, the coincidence of an apparent shadow on the tooth, caused by ‘fall-out’ of flash, and a clinically insignificant radiolucency on the radiograph resulted in many GDPs feeling certain that caries was present, when the tooth was, in fact, judged to be normal on actual examination. Developers and users of PMPs need to be aware of PMPs’ limitations and make allowances for them. Another disadvantage of the approach is that the PMP looks at what participants say they do in a simulated situation and not what they actually do in their practice. However, it may provide a more valid reflection of a dentist’s competence than just a test of knowledge; for example using multiple-choice or short-answer questions. This study has identified a high level of overall agreement between specialists and GDPs regarding the management of patients with fissure caries in contrast to some other studies (Elderton and Nuttall, 1983). In a few instances, discrepancies were identified and while some could be explained by the method, a real discrepancy seems to have been revealed in disagreements 1,2,7 and 8 in TableZZZ, where GDPs may not have been familiar with thespecialists’criteria for placing the sealant restorations. Familiarizing GDPs with such criteria is one of the major needs that the distance learning programme, of which this work is part, was developed to meet. It is interesting to note that there was no disagreement over when it was appropriate to take bitewing radiographs. It has to be noted, however, that the GDP participants were selected from practices perceived as ‘good’ rather than ‘poor’ and
so the measures obtained might be artificially high. Also, the use of the mode of GDPs’ ratings excludes consideration of the ratings of GDPs outwith the mode and the possible reasons for this. In spite of these qualifications it is encouraging that, even in a rapidly evolving area such as this, our study seems to show that some GDPs have kept up to date. Further studies are required to see if this applies to all GDPs and not just this small selected sample.
Acknowledgements The authors wish gratefully to acknowledge the contributions of Professor R. C. Paterson, Dr A. Watts and Dr W. P. Saunders of the Department of Conservative Dentistry, University of Glasgow, who participated in the development of the distance learning programme and without whom this study would not be possible. Professor Pitts acknowledges financial support from the Scottish Office’s Chief Scientist’s Office, the opinions expressed are those of the authors and not necessarily of the Scottish Office. References Boyd M. A. (1989) In: Annsavice K. J. (ed.), Amalgam Replacement: Are Decisions Based on Fact or Tradition in Quality Evaluation of Dental Restorations. New Malden, Quintessence, pp. 73-80. Davis M. H., Harden R. M., Laidlaw J. M. et al. (1992) Continuing education for general dental practitioners using a printed distance learning programme. Med. Educ. (in press). Elderton R. J. and Nuttall N. M. (1983) Variation among dentists in planning treatment. Br. Dent. J. 154, 201-206. Kay E. J., Watts A., Paterson R. C. et al. (1988) Preliminary investigation into the validity of dentists’ decisions to restore occlusal surfaces of permanent teeth. Community Dent Oral Epidemiol. 16,91-94. Pitts N. B., Davis M. H. and Harden R. M. (1992) General dental practitioners needs for continuing education on the management of fissure caries. Br. Dent J. (in press). Schanschieff S. G., Shovelton D. S. and Toulmin J. K. (1985) Report of the Committee of Enquiry into Unnecessary Dental Treatment London, HMSO. Seward M. (Leader) (1990) All is not well. Br. Dent J 169, 345.
