Dentists ignoring high-risk patients' needs, survey finds

Dentists know that some patients need more care than others, yet most aren't following professional guidelines for these patients. So say San Francisco Bay Area researchers who presented a survey of 410 dentists last week at the International Association for Dental Research (IADR) meeting in Toronto.

"Knowledge doesn't necessarily transfer to behavior," said Nathaniel Kaufman, D.D.S., a private practice dentist in Berkeley, CA.

Dr. Kaufman and researchers from the University of California, San Francisco drew data from a larger survey of dentists who were Delta Dental Providers in California, Pennsylvania, and West Virginia. Of the 265 who responded to the survey, most were white males who had practiced at least 15 years.

Almost all of the dentists (94%) agreed that dentists should take special care of patients at high risk of caries. And they reported such basic steps as advising these patients that they're at risk (96%) and recommending fluoride toothpaste (98%).

At the same time, however, only 82% of the surveyed dentists recommend home fluoride rinse, 58% provide dietary counseling, 50% recommend antimicrobials, and 34% apply in-office fluoride varnish.

The low percentage of dentists applying fluoride varnish is particularly striking because the ADA has made a very clear recommendation in favor of this procedure. "Higher-risk patients should receive fluoride varnish or gel applications at three- to six-month intervals," reads a 2006 guideline published in the Journal of the American Dental Association (August 2006, Vol. 137:8, pp. 1151-1159).

The ADA hasn't made as clear an endorsement of antimicrobials or rinses, but in November 2007 the Journal of the California Dental Association published a consensus statement signed by most of the leading experts on caries in the U.S. that includes this statement: "Topical antibacterial therapy should be used whenever a high cariogenic bacterial challenge is identified and patients should be informed it could require repeated treatments" (JCDA, November 2007, Vol. 35:11, pp. 799-805).

The ADA is also less specific on dietary counseling and fluoride rinses, but the JCDA statement includes 0.05% sodium fluoride rinses among the possible sources of fluoride to be recommended.

So why would so many dentists fail to carry out recommendations by the leading authorities in their field? You might think that financial incentives would help; if you reimbursed dentists more for applying fluoride varnishes, maybe they'd do it more often. But studies aimed at addressing that question have showed a big change in reimbursement only makes a small change in behavior, said James Bader, D.D.S., M.P.H, a research professor of operative dentistry at the University of North Carolina who has published similar research.

"It's human nature," he said. "It's more difficult to change than not to change."

The problem isn't limited to dentists. Dr. Bader cited other research on medical doctors finding a lag of about 17 years between the time a new procedure is identified as effective and the time it is widely adopted.

One clue to the reason for dentists' inertia may be a lack of confidence in their ability to prevent caries. In the survey, 70% of those dentists who felt effective in addressing high caries activity used some sort of topical fluoride (varnishes, gels, foams, etc.) versus only 47% of those who felt ineffective, a statistically significant difference.

In other words, said Dr. Kaufman, the dentists had to believe these added measures would really make a difference. "To say 'I've been wrong for 25 years' -- that's hard to swallow."