Recommended treatment of cracked teeth: Results from the National Dental Practice-Based Research Network.

STATEMENT OF PROBLEM: Despite the high prevalence of posterior cracked teeth, questions remain regarding the best course of action for managing these teeth. PURPOSE: The purpose of this clinical study was to identify and quantify the characteristics of visible cracks in posterior teeth and their association with treatment recommendations among patients in the National Dental Practice-Based Research Network. MATERIAL AND METHODS: Network dentists enrolled patients with a single, vital posterior tooth with at least 1 observable external crack. Data were collected at the patient, tooth, and crack levels, including the presence and type of pain and treatment recommendations for subject teeth. Frequencies according to treatment recommendation were obtained, and odds ratios (ORs) comparing recommendations for the tooth to be restored versus monitored were calculated. Stepwise regressions were performed using generalized models to adjust for clustering; characteristics with P<.05 were retained. RESULTS: A total of 209 dentists enrolled 2858 patients with a posterior tooth with at least 1 crack. Mean ±standard deviation patient age was 54 ±12 years; 1813 (63%) were female, 2394 (85%) were non-Hispanic white, 2213 (77%) had some dental insurance, and 2432 (86%) had some college education. Overall, 1297 (46%) teeth caused 1 or more of the following types of pain: 1055 sensitivity to cold, 459 biting, and 367 spontaneous. A total of 1040 teeth were recommended for 1 or more treatments: restoration (n=1018; 98%), endodontics (n=29; 3%), endodontic treatment and restoration (n=20; 2%), extraction (n=2; 0.2%), and noninvasive treatment, for example, occlusal device, desensitizing (n=11; 1%). The presence of caries (OR=67.3), biting pain (OR=7.3), and evidence of a crack on radiographs (OR=5.0) were associated with over 5-fold odds of recommending restoration. Spontaneous pain was associated with nearly 3-fold odds; pain to cold, having dental insurance, a crack that was detectable with an explorer or blocked transilluminated light, or connected with a restoration were each weakly associated with increased odds of recommending a restoration (OR<2.0). CONCLUSIONS: Approximately one-third of cracked teeth were recommended for restoration. The presence of caries, biting pain, and evidence of a crack on a radiograph were strong predictors of recommending a restoration, although the evidence of a crack on a radiograph only accounted for a 3% absolute difference (4% recommended treatment versus 1% recommended monitoring).

Comparison of Dental Students' PAT Scores with Their Performance in Preclinical Technique Courses: Identifying the Need for Early Interventions.

The aim of this study was to determine if lower scores on the Perceptual Ability Test (PAT) of the Dental Admission Test (DAT) predicted which dental students required remediation in three preclinical restorative dentistry courses at Rutgers School of Dental Medicine. The academic records of 489 dental students from the graduating Classes of 2010 through 2015 were evaluated. The results showed that, for all three courses (Preclinical General Dentistry I, Preclinical General Dentistry II, and Preclinical Fixed Prosthodontics), the remediating students had significantly lower mean PAT scores than did the passing students. A one-unit decrease in a student's PAT score was associated with a 43% increase in the odds of remediating the Preclinical General Dentistry I lab, a 29% increase in the odds of remediating the Preclinical Fixed Prosthodontics lab, and a 47% increase in the odds of remediating the Preclinical General Dentistry II lab. The mean PAT score for passing students was 18.84 (standard deviation 2.35), and the mean PAT score for students requiring remediation was 17.03 (standard deviation 2.18). Studies like this can be useful because if students at risk of failing these courses are identified early and appropriate supports are provided, the need for remediation may be reduced if not eliminated.

An exploratory analysis of the impact of family functioning on treatment for depression in adolescents.

This article explores aspects of family environment and parent-child conflict that may predict or moderate response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive behavioral therapy, their combination, or placebo. Outcomes were Week 12 scores on measures of depression and global impairment. Of 20 candidate variables, one predictor emerged: Across treatments, adolescents with mothers who reported less parent-child conflict were more likely to benefit than their counterparts. When family functioning moderated outcome, adolescents who endorsed more negative environments were more likely to benefit from fluoxetine. Similarly, when moderating effects were seen on cognitive behavioral therapy conditions, they were in the direction of being less effective among teens reporting poorer family environments.

Service use and costs of care for depressed adolescents: who uses and who pays?

Major depressive disorder is common in adolescence and is associated with significant morbidity and family burden. Little is known about service use by depressed adolescents. The purpose of this article is to report the patterns of services use and costs for participants in the Treatment for Adolescents with Depression Study sample during the 3 months before randomization. Costs were assigned across three categories of payors: families, private insurance, and the public sector. We examined whether costs from payors varied by baseline covariates, such as age, gender, insurance status, and family income. The majority (71%) of depressed youth sought services during the 3-month period. Slightly more than one-fifth had contact with a behavioral health specialist. The average participant had just under $300 (SD = $437.67, range = $0-$3,747.71) in treatment-related costs, with most of these costs borne by families and private insurers.

Acute time to response in the Treatment for Adolescents with Depression Study (TADS).

OBJECTIVE: To examine the time to response for both pharmacotherapy and psychotherapy in the Treatment for Adolescents with Depression Study (TADS). METHOD: Adolescents (N = 439, ages 12 to 17 years) with major depressive disorder were randomized to fluoxetine (FLX), cognitive-behavioral therapy (CBT), their combination (COMB), or pill placebo (PBO). Defining response as very much improved or much improved on the Clinical Global Impression-Improvement Scale (CGI-I), survival analyses using Cox proportional hazards models, and Kaplan-Meier curves were conducted to evaluate time to first response and time to stable response for subjects receiving pharmacotherapy (COMB, FLX, PBO) as well as for subjects receiving CBT (COMB, CBT). Direct comparisons between pharmacotherapy and CBT were not made because of differences in visit schedules. RESULTS: Based on pharmacotherapist CGI-I scores, COMB and FLX showed faster onset of benefit than PBO on time to response and time to stable response (p < .001), and COMB was faster than FLX on time to stable response (p = .034). The probability of sustained early response was approximately threefold greater for COMB than PBO, twofold greater for FLX than PBO, and 1.5-fold greater for COMB than FLX. On the psychotherapist CGI-I scores, both first response and stable response occurred faster in COMB than CBT (p < .001), with a probability of sustained early response approximately threefold greater for COMB than CBT. CONCLUSIONS: In the acute treatment of depressed adolescents, FLX and COMB accelerate response relative to PBO, and COMB accelerates response relative to CBT alone.

Functioning and quality of life in the Treatment for Adolescents with Depression Study (TADS).

OBJECTIVE: To test whether 12-week treatment of major depression improved the level of functioning, global health, and quality of life of adolescents. METHOD: The Treatment for Adolescents With Depression Study was a multisite, randomized clinical trial of fluoxetine, cognitive-behavioral therapy (CBT), their combination (COMB), or clinical management with placebo in 439 adolescents with major depression. Functioning was measured with the Children's Global Assessment Scale (CGAS), global health with the Health of the Nation Outcome Scales for Children and Adolescents (HoNOSCA), and quality of life with the Pediatric Quality of Life Enjoyment and Satisfaction Questionnaire (PQ-LES-Q). Random-effects regression models were applied to the data. RESULTS: Compared with placebo, COMB was effective on the CGAS (p < .0001), HoNOSCA (p < .05), and PQ-LES-Q (p < .001), whereas fluoxetine was superior to placebo on the CGAS only (p < .05). COMB was superior to fluoxetine on the CGAS (p < .05) and PQ-LES-Q (p = .001). Fluoxetine was superior to CBT on the CGAS (p < .01). CBT monotherapy was not statistically different from the placebo group on any of the measures assessed. Treatment effects were mediated by improvement in depressive symptoms measured on the Child Depression Rating Scale-Revised. CONCLUSIONS: The combination of fluoxetine and CBT was effective in improving functioning, global health, and quality of life in depressed adolescents. Fluoxetine monotherapy improved functioning.

Predictors and moderators of acute outcome in the Treatment for Adolescents with Depression Study (TADS).

OBJECTIVE: To identify predictors and moderators of response to acute treatments among depressed adolescents (N = 439) randomly assigned to fluoxetine, cognitive-behavioral therapy (CBT), both fluoxetine and CBT, or clinical management with pill placebo in the Treatment for Adolescents With Depression Study (TADS). METHOD: Potential baseline predictors and moderators were identified by a literature review. The outcome measure was a week 12 predicted score derived from the Children's Depression Rating Scale-Revised (CDRS-R). For each candidate moderator or predictor, a general linear model was conducted to examine main and interactive effects of treatment and the candidate variable on the CDRS-R predicted scores. RESULTS: Adolescents who were younger, less chronically depressed, higher functioning, and less hopeless with less suicidal ideation, fewer melancholic features or comorbid diagnoses, and greater expectations for improvement were more likely to benefit acutely than their counterparts. Combined treatment, under no condition less effective than monotherapy, was more effective than fluoxetine for mild to moderate depression and for depression with high levels of cognitive distortion, but not for severe depression or depression with low levels of cognitive distortion. Adolescents from high-income families were as likely to benefit from CBT alone as from combined treatment. CONCLUSIONS: Younger and less severely impaired adolescents are likely to respond better to acute treatment than older, more impaired, or multiply comorbid adolescents. Family income level, cognitive distortions, and severity of depression may help clinicians to choose among acute interventions, but combined treatment proved robust in the presence of moderators.

Characteristics and Components of the TADS CBT Approach.

In this paper, we describe the Acute phase of a cognitive-behavioral therapy (CBT) developed for and utilized in the Treatment for Adolescents with Depression Study (TADS). The Acute phase of TADS CBT consists of eight skills that were considered essential to any CBT intervention for adolescent depression (e.g., mood monitoring, increasing pleasant activities, identifying cognitive distortions and developing realistic counter-thoughts). In addition, five optional individual CBT skills (e.g., relaxation, affect regulation) can be incorporated into treatment, depending on the needs of the adolescent. We describe each of these individual skills by reviewing the rationale for their inclusion in the treatment protocol and describing the format that is used to teach the skill area. Recommendations are provided for dealing with common challenges that can occur in the teaching of each skill module. It is our hope that clinicians will find this a useful introduction to this particular form of treatment and a practical guide to dealing with clinical problems common to the delivery of any cognitive behavioral intervention with depressed teens.