Developing evidence-based programme guidelines for children's dental care in a dental public health unit in Ontario, Canada.

The North York Public Health Department operates a school-based dental care programme. Dental care providers are expected to follow guidelines in order that the programme shall achieve the best outcomes for the clients served. A model is described by which published evidence informs the guideline development process. The process is considered to require knowledge of the epidemiology of dental disease in the target population; skills in collecting, critically appraising and summarising the scientific literature; working with internal and external advisory panels to write the guidelines; disseminating results and assessing both compliance and health outcomes. This work is one example of a larger trend to evidence-based health care.

The use of dental radiographs to estimate the probability of cavitation of carious interproximal lesions. Part I: Evidence from the literature.

It is generally recommended that a cavitated, carious lesion be present before an interproximal tooth surface is restored. These lesions often are not clinically visible, however, and must be diagnosed using dental radiographs. Radiographic results can underestimate and overestimate the size of a carious lesion. The purpose of this study was to review and graphically summarize studies that have investigated the relationship between the radiographic image and the presence of a cavitated lesion on the interproximal surfaces of permanent teeth. A search of the literature identified 13 studies, eight of which were suitable for inclusion in our summary. Using the positive and negative likelihood ratios from each study, a graphical summary was developed showing the probability of cavitation based on the radiographic test result and the dentist's pre-radiograph estimate of the probability of cavitation. This graph should allow dentists to more accurately inform their patients of the probability of a cavitated interproximal lesion being present or absent. As a further observation, our findings suggest that to avoid frequent false positive diagnoses, dentists should estimate the probability of cavitation to be at least 30 per cent before they prescribe radiographs for patients who visit them on a regular basis.

The use of dental radiographs to estimate the probability of cavitation of carious interproximal lesions. Part II: Two patient scenarios.

Diagnosis of a cavitated interproximal lesion is often not confirmed until the tooth is treated. Before treatment, clinicaians and patients are dealing with probabilities which can be estimated from clinical evidence, radiographic evidence, and information found in the dental literature. The probability of a diagnostic test result being correct is affected by the threshold of the test and the pretest probability of the disease in question, which varies with the prevalence of the disease. We illustrate how clinicians can inform themselves and their patients of the probability of a radiographic lesion being truly cavitated based on graphs that summarize the currently available evidence. Dentists who use these graphs can more accurately inform their patients who can then choose the course of care that best meets their individual needs.

Oral health and family characteristics of children attending private or public dental clinics.

The City of North York Public Health Department (NYPHD) operates a school-based dental programme that provides preventive and treatment services to children according to evidence-based practice guidelines. This programme and private dental practices (PDP) represent the only sources of dental care for children in North York. The purpose of our study was to compare the oral health and family characteristics of clients from the NYPHD and PDP using a dental examination and a parent interview. Results showed that NYPHD and PDP clients had similar levels of fluorosis, calculus, and periodontal health, but NYPHD clients had experienced greater levels of decay. Clients of the NYPHD and PDP also had significantly different family characteristics, many of which were significantly associated with the presence of one or more decayed primary or permanent teeth. Multivariate logistic regression identified mother's immigration history, past caries experience, and parents' rationale for scheduling their child's dental appointments as the principle risk makers for dental decay. When compared with PDP clients, the NYPHD serves higher-needs children who otherwise might not receive care.

Report on the RCDS-CDHSRU workshop on developing clinical guidelines/standards of practice.

Investigators from the Community Dental Health Services Research Unit (CDHSRU) held a workshop to test a model for developing clinical guidelines/standards of practice, which are required under the Regulated Health Professions Legislation. Forty-two individuals from Ontario and Canada, including dentists, representatives of the public, and professionals, participated in the three-day workshop, held under the auspices of the quality assurance committee of the Royal College of Dental Surgeons of Ontario (RCDS). Through direct experience, workshop participants sought to learn each of the steps, as defined by the literature, involved in clinical guideline development. Ultimately, they hoped to recommend steps for RCDS to follow in developing standards of practice. To ensure that a realistic and valid model emerged from the workshop, a real topic, namely the management of smooth surface enamel lesions in permanent teeth, was used to develop and test clinical guidelines. Prior to the workshop, participants were sent literature on one of five aspects of the topic, as well as papers describing the methodology of critically appraising the literature, and partially-completed templates outlining the basic steps to be followed. During the first evening and first morning of the workshop, participants listened to presentations on the development of clinical guidelines, the prevalence of smooth surface lesions, the role of economics in guideline development, and the necessary considerations in writing clinical guidelines. Under the leadership of trained facilitators, they then worked in small groups to write evidence-based recommendations and report them to the other workshop participants for feedback. Using this feedback, they returned to their groups to revise their recommendations and work on the workshop's overall recommendations to the RCDS. The day concluded in the evening, when the workshop facilitators and coordinators met to edit the groups' recommendations into a consistent format for presentation to all participants. On the second morning, the participants attended a plenary session to review the evidence-based recommendations developed by the groups, as well as their overall recommendations on the steps to be followed by the RCDS. Ultimately, workshop participants partially completed the templates and developed preliminary evidence-based recommendations on the management of enamel smooth-surface caries. Based on their experiences, they recommended a seven-step process for the future development of clinical practice guidelines/standards of practice in Ontario. These steps are recommendations only, and are not RCDS policy.

Estimation of procedure times in a publicly funded dental programme.

For the purposes of planning and evaluation, knowing the time-costs associated with each dental procedure carried out in a publicly funded dental programme is very helpful. This knowledge, along with the expected or known benefits, also allows researchers to assess the efficacy of a dental procedure. However, only a few estimates of dental procedure times exist in the literature, and most of these focus on restorative treatments. The North York Public Health Department operates a school-based public dental programme, where each dental procedure carried out by a dentist or hygienist is entered into a dental management information system database, along with the date of the procedure and the hours worked by the provider on that date. Using these data and multiple regression analyses it was possible to estimate the average time required to carry out the most common procedures in North York's dental programme. These estimates were found to be similar to estimates published in the dental literature and very similar to estimates of the Ontario Dental Association. Thus, this method of calculating procedure times appears valid and may be very useful to managers of public dental programmes and public dental health researchers.