Compliance with key practices of root canal treatment varies by the reward system applied in public dental services

Introduction: To assess clinical practices in root canal treatments (RCTs) performed by general dental practitioners under 2 different reward schemes applied in public dental services. Methods: This study used a retrospective design with tooth as the observation unit. The data included all teeth (n = 547) with nonsurgical primary RCT completed in 2016. Electronic documents included treatment details and radiographs. RCT assessment covered 4 key items: taking pre- and postoperative radiographs, using a rubber dam, measuring working length. Assessed dichotomies indicated whether practices were adequate. Dentists' reward schemes were "salaried" and "fee-for-service." Chi squared tests analyzed frequency differences. Results: RCTs formed 2 groups by the reward scheme: 305 RCTs were performed by salaried dentists and 242 by fee-for-service dentists. Preoperative radiographs were diagnosable for 76.1% and postoperative radiographs, for 95.1% of all RCTs. Rubber dam use was documented for 28.9% of the RCTs, more frequently when performed by salaried than by fee-for-service dentists (43.9% vs 9.9%, P < .001). Working length measurement was documented for 72.9% of the RCTs, more frequently for RCTs performed by salaried than by fee-for-service dentists (85.2% vs 57.4%, P < .001). All 4 key items were assessed as adequate in 19.0% of all RCTs, more frequently when performed by salaried than by fee-for-service dentists (29.5% vs 5.8%, P < .001). Conclusions: Deficiencies in RCTs, particularly underuse of rubber dams call for further research to understand the reasons for noncompliance with good clinical practice guidelines.Peer reviewe

Operator-related aspects in endodontic malpractice claims in Finland

Objective: We analyzed operator-related differences in endodontic malpractice claims in Finland.Materials and methods: Data comprised the endodontic malpractice claims handled at the Patient Insurance Centre (PIC) in 2002-2006 and 2011-2013. Two dental advisors at the PIC scrutinized the original documents of the cases (n=1271). The case-related information included patient ' s age and gender, type of tooth, presence of radiographs, and methods of instrumentation and apex location. As injuries, we recorded broken instrument, perforation, injuries due to root canal irrigants/medicaments, and miscellaneous injuries. We categorized the injuries according to the PIC decisions as avoidable, unavoidable, or no injury. Operator-related information included dentist ' s age, gender, specialization, and service sector. We assessed level of patient documentation as adequate, moderate, or poor. Chi-squared tests, t-tests, and logistic regression modelling served in statistical analyses.Results: Patients ' mean age was 44.7 (range 8-85) years, and 71% were women. The private sector constituted 54% of claim cases. Younger patients, female dentists, and general practitioners predominated in the public sector. We found no sector differences in patients' gender, dentists' age, or type of injured tooth. PIC advisors confirmed no injury in 24% of claim cases; the advisors considered 65% of injury cases (n=970) as avoidable and 35% as unavoidable. We found no operator-related differences in these figures. Working methods differed by operator ' s age and gender. Adequate patient documentation predominated in the public sector and among female, younger, or specialized dentists.Conclusions: Operator-related factors had no impact on endodontic malpractice claims.Peer reviewe

Trends in Endodontic Malpractice Claims and their Indemnity in Finland in the 2000s

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Direct restorations and enhanced caries prevention among 20-to 60-year-olds attending Helsinki City Public Dental Service - a register-based observation

Objective Our retrospective register-based observational study evaluated age-specific aspects and changes in volume and content of direct restorative procedures, pulp cappings and enhanced caries prevention measures given to adults. Methods Data included all treatments provided for 20- to 60-year-olds visiting the Helsinki City Public Dental Service (PDS) in 2012 and 2017. For both years, the data were aggregated into 5-year age groups. Data included means of DMFT indices, number and size of direct restorations, number of specific codes for pulp cappings and enhanced prevention. Results Around half of all patients received restorations, 39,820 (50.9%) in 2012 and 43,392 (45.9%) in 2017. The greatest increase in DMFT means by age cohort was found for the 2012 age cohort of 25- to 29-year-olds and the smallest for the 2012 age cohort of 45- to 49-year-olds. In each same-age group and each age cohort, the enhanced prevention in 2017 was less frequent than in 2012. The proportion of two-surface restorations accounted for 44.7% of procedures in 2012 and 45.9% in 2017, followed by an increasing proportion of one-surface restorations, from 28.3% in 2012 to 32.9% in 2017. Associations between restoration size and age group were highly significant (p < .001). Conclusions The volume of direct restorative procedures and enhanced prevention measures were strongly age-dependent. Restorative treatment procedures were more frequent in older age groups than in younger age groups, and vice versa for enhanced prevention and pulp cappings. The magnitude of restorative treatment decreased slowly from 2012 to 2017, and overall enhanced preventive treatment was limited.Peer reviewe

Root Canal Irrigants and Medicaments in Endodontic Malpractice Cases : A Nationwide Longitudinal Observation

Introduction: The aim of this study was to assess the role of root canal irrigants and medicaments in endodontic injuries verified in Finland and to estimate the rate of such events over time. Methods: The study material comprised all endodontic injuries verified by the Patient Insurance Centre in 2002 to 2006 (n = 521) and 2011 to 2013 (n = 449). The data, based on patient documents scrutinized by 2 specialists in endodontics, included patients' and dentists' sex and age and the service sector. We recorded the use of root canal irrigants and medicaments, each as a dichotomy. Furthermore, we dichotomized the injuries as those related to root canal irrigants/medicaments and any other injuries. The injuries were also dichotomized as avoidable (could have been avoided by following good clinical practice) or unavoidable (normal treatment-related risks). Statistical evaluation used chi-square tests and t tests; logistic regression produced odds ratios (ORs). Results: The verified injuries (N = 970) comprised 635 (65%) avoidable and 335 (35%) unavoidable injuries. The number of irrigant-/medicament-related injuries was 69, accounting for 7.1% of all verified injuries; all resulted from sodium hypochlorite and calcium hydroxide, and 87% were avoidable. The overall rate of sodium hypochlorite/calcium hydroxide injuries was 4.3 cases per 100,000 endodontic patients per year. Compared with other injuries, sodium hypochlorite/calcium hydroxide injuries were more likely avoidable (OR = 3.8) and more than 5-fold likely in 2011 to 2013 than in 2002 to 2006 (OR = 5.6). Conclusions: Extreme care is needed when applying sodium hypochlorite and calcium hydroxide into root canals to avoid increasing harmful consequences.Peer reviewe

Accidental perforations during root canal treatment: an 8-year nationwide perspective on healthcare malpractice claims

Objectives To assess occurrence and its variation over time of serious accidental perforations during endodontic treatment and the fate of perforated teeth by tooth type and characteristics of patients and dentists. Materials and methods Data, based on patient documents on healthcare malpractice claims, comprised all endodontic injuries (n = 970) verified by the Patient Insurance Centre in Finland in 2002-2006 and 2011-2013. Two specialists in endodontics scrutinized the documents. Accidental perforations were recorded by location (tooth type, chamber/canals) and dichotomized as avoidable (could have been avoided by following good clinical practice) or unavoidable (normal treatment-related risks). Fate of perforation cases was recorded as treatment discontinued, root canal(s) filled, or tooth extracted. Background information included patients' and dentists' sex and age and the service sector. Statistical evaluation used Chi-square tests. Results Serious accidental perforations comprised 29% of all verified injuries. Most perforations were judged as avoidable: 93% in patients aged below 35 years, 87% when located in the pulp chamber or in molars (84%); 70% of all perforations and 75% of those in molars resulted in tooth extraction. The overall rate of serious accidental perforations was 17.6 cases per 100,000 endodontic patients per year. Conclusions The rate of serious accidental perforations increased over time. The majority was in molars and resulted in tooth extraction.Peer reviewe

Age of patient at the extraction of the third molar

The purpose of this study was to assess the age of patients at the time of extraction of third molars. Our data included all routine and surgical extractions of third molars (n = 8199 teeth) performed by general and specialist dentists of the public oral health services of the city of Helsinki over the period 2013-2014. Measurements included patient's age, gender, the identified third molar, the type of anaesthesia, the method of extraction, and the diagnosis at extraction. Patients' ages ranged from 10 to 99 years. We found significant differences between younger and older age groups: third molar extractions occurred more often for women than for men below the age of 30 years (P <0.001) and vice versa for patients older than 30. Extractions were more prevalent for the upper jaw (P <0.001), and surgical extractions were more common than routine extractions (P <0.001) below the age of 40 years, but the corresponding prevalences reversed after the age of 40 years. Diagnoses at extraction differed between younger and older patients. We conclude that the treatment pattern of third molars at public health services varies greatly over a lifetime, and that a greater variety exists than had been reported previously from oral and maxillofacial units.Peer reviewe

Impact of systemic diseases and tooth-based factors on outcome of root canal treatment.

Aim To investigate the impact of systemic health and tooth-based factors on the outcome of root canal treatment (RCT). Methodology The target population consisted of all patients receiving RCT at the Helsinki University Clinic in 2008-2011. The inclusion criteria were diagnosable pre- and postoperative (minimum 6 months after root filling) radiographs and adequate patient records of RCT available. Teeth extracted for nonendodontic reasons were excluded. Patient documents including digital radiographs of 640 permanent teeth in 504 patients were scrutinized. The radiographs were assessed by two examiners under standardized conditions. The Periapical Index was used to define radiographically 'healthy' and 'healing' cases as successful. Data included systemic health, technical quality of root fillings, type of restoration and level of alveolar bone loss. Statistical evaluation of differences between groups included chi-squared tests and Fisher's exact tests. Logistic regression modelling utilizing robust standard errors to allow for clustering within patients was applied to analyse factors related to the outcome of RCT. Results The mean age of patients was 51.5 years (standard deviation (SD) 15.0; range 10-83), and 49% were female. In 41 cases (6%), the patient had diabetes mellitus (DM), in 132 (21%) cardiovascular disease and in 284 (44%) no systemic disease. The follow-up period was 6-71 months (mean 22.7). In the primary analyses, the success rate of RCT was 73.2% in DM patients and 85.6% in patients with no systemic disease (P = 0.043); other systemic diseases had no impact on success. In the multifactorial analysis, the impact of DM became nonsignificant and RCTs were more likely to succeed in the absence of apical periodontitis (AP; odds ratio (OR) = 4.4; P <0.001), in teeth with optimal root filling quality (OR = 2.5; P <0.001), in teeth restored with indirect restorations (OR = 3.7; P = 0.002) and in teeth with none/mild alveolar bone loss (OR = 2.4; P = 0.003). Conclusions DM diminished the success of RCT, especially in teeth with apical periodontitis. However, tooth-based factors had a more profound impact on the outcome of RCT. This should be considered in clinical decision-making and in assessment of RCT prognosis.Peer reviewe

Age-related variation in volume and content of restorative private dental care for adults in Finland in 2012-2017: a nationwide register-based observation

Objectives: This study assessed age-related variation in the volume and content of restorative dental care performed by private dentists for adults in Finland in 2012-2017. Methods: This retrospective register-based observational study utilized the Social Insurance database of private dental services in 2012 and 2017, including all patients. The data were aggregated into 5-year age groups for 20-89-year-olds; those aged 90+ formed one group. A patient was one who had received at least one treatment, and a restoration patient one who received at least one restoration (direct/indirect), excluding prosthetic crowns. Attendance rate was the proportion of the population treated. Volume of restorative treatment was the proportion of restoration patients among all patients using private dental services. Content of restorative treatment was described as the number of teeth receiving restoration and the size of restoration (number of surfaces restored). Correlation coefficient demonstrated associations between age groups and numbers of restorations. Results: Rate of restoration patients was 64.8 % in 2012 and 61.1 % in 2017, the rate for individuals aged under 80 years in each calendar year being smaller than in previous years. Mean number of restorations received per patient was 1.59 in 2012 and 1.42 in 2017, increasing with age (r = 0.85 in 2012; r = 0.95 in 2017). Small restorations dominated; one to two surfaces were covered in 72.3 % and 75.5 % of restorations in 2012 and 2017, respectively. Conclusions: Volume and content of restorative dental care for adults vary by age and have decreased slightly over time. Clinical significance: Restorative treatments are a prominent part of dental care for adults. This paper sheds light on the entity of restorative dental care for adults visiting private dentists. Variation in restoration volume and content is shown according to patient's age group, and changes are assessed across six years.Peer reviewe

Radiographic outcome of root canal treatment in general dental practice: tooth type and quality of root filling as prognostic factors

Objective:This study evaluated the radiographic outcome of root canal treatments (RCTs) performed by general dental practitioners (GDPs) with focus on tooth type and quality of root filling. Materials and methods:The target population included all patients receiving root filling by GDPs in City of Helsinki in 2010-2011. Equal numbers of each tooth type (anteriors, premolars, molars) by jaw were included, resulting in 426 teeth. Pre- and post-operative periapical radiographs were assessed to evaluate periapical status and quality of root filling. Statistical evaluation utilized Chi-squared tests, Cohen's kappa and logistic regression modelling. Results:The overall success rate of RCT was 67.4%, being 76.8%, 69.7% and 55.6% (p <.001) for anteriors, premolars and molars, respectively. The quality of root fillings varied by tooth type (p <.001); optimal fillings were least frequent (43%) in molars. In multifactorial analysis, RCTs were more likely to succeed in non-molars (OR = 1.8), in teeth with optimal root fillings (OR = 3.6) and in teeth without apical periodontitis (OR = 3.2). Conclusion:The quality of root fillings and radiographic outcome of RCTs varied considerably according to tooth type; success was least likely in molars. Improvement is needed in quality of RCTs by GDPs.Peer reviewe