Knowledge and Use of Caries Risk Assessment for Adult Patients Croatian Dentists.

OBJECTIVE: The aim of this study was to evaluate the usage of caries risk assessment (CRA) by Croatian general practitioners and evaluate their knowledge and attitudes towards CRA.
MATERIAL AND METHODS: A link to an online questionnaire was sent via e-mail to a sample of 1,500 general dentists in Croatia. The obtained data were analyzed using descriptive statistics, logistic regression analyses and chi-square tests.
RESULTS: Of 257 respondents, 47% performed CRA routinely, but only 4.5% of them used a specific CRA form. The significance of different factors in the development of a treatment plan varied considerably among respondents. Furthermore, in 77% of the respondents CRA was a basis for planning individual caries prevention (ICP). The association between CRA and ICP, and between CRA and treatment planning was statistically significant (p=0.001). The practitioners doing CRA more often plan their treatment and ICP according to CRA. The use of CRA was not influenced by specialty and dentists' experience.
CONCLUSIONS: In a considerable percentage (53%) of Croatian general dentists, CRA is not part of their routine practice, and there is a strong association between the use of CRA and treatment plans and ICP. There is a need to promote the use of CRA in daily dental practice in Croatia.

Introduction

Dental caries is a dynamic process which depends on the balance between protective and pathogenic factors. Weak acids, produced as a result of bacterial metabolism of carbohydrates, cause demineralization of dental hard tissues (). This process can be halted or reversed if the balance is shifted towards protective factors (, ). Preventing or arresting carious lesions requires a systematic approach towards assessing and monitoring the factors leading to demineralization, namely caries risk (CR) factors (, ).

For the purpose of assessing CR factors for individual patients, various tools have been developed. Based on the risk factors, treatment recommendations such as behavioral (oral hygiene and diet), chemical (fluoride), and minimally invasive procedures could be followed (, ). Caries prevalence and other specific characteristics of the population can influence the predictive validity of a caries risk assessment (CRA) tool. Different CRA tools are designed for different populations so that the predictive value of each predictor is maximized ().

There are reports on the use of CRA in dental practice in France and Japan, but also in a dental practice based research network (DPBRN) covering different geographical regions (United States, Scandinavian countries and Japan) reflecting dentists at large (-). These reports suggest that CRA is not widely used in dental practice, and that the information obtained from CRA was not appropriately used to make treatment decisions (-). There are no data in the available literature toward the use of CRA by Croatian dental practitioners and its impact on treatment decisions.

The aim of this research was to determine the percentage of Croatian practitioners performing CRA, their ratings of the importance of specific CR factors in making a caries treatment plan in their adult patients, and to correlate the ratings of the specific risk factors with performing or not performing CRA. The research also aimed to determine to what extent they are informed about and interested in minimum intervention (MI) approaches in caries management.

Material and methods

Study design and data collection

The study has been reviewed independently and approved by the Ethics Committee of the School of Dental Medicine, University of Zagreb and conducted in full accordance with the World Medical Association Declaration of Helsinki. Since this was an online questionnaire, it was not possible to obtain a standard written informed consent with participants’ signatures; hence the participants gave their online consent to participate in the study. The consent was approved by the above mentioned authorities.

The questionnaire used in this study was developed by Doméjean et al (). It was originally available in both English and French but the English version was used for translation into Croatian by two bilingual (Croatian and English) dentists. The first Croatian version was discussed and harmonized, and then back-translated into English by a third dentist who was blinded concerning the original English version. The original English and back-translated versions of the questionnaire were compared by two experts (IM and CH). After minor modifications, the Croatian version of the questionnaire was pilot-tested on a sample of 10 dentists at School of Dental Medicine in Zagreb, Croatia; no further modifications were required.

The questionnaire consisted of 22 questions: nine related to socio-demographic characteristics of the respondents, 10 to CRA use, individual caries prevention (ICP) and preferred management options in cariology and the last three to respondents’ interest for further continuing education about CRA and their understanding of the minimal intervention concept.

Participants

The survey was administrated, to a random sample of 1500 dentists selected from the School of Dental Medicine Zagreb University's database of Croatian dentists and registered dental offices in Croatia, via e-mail using Survey Monkey®. The survey was anonymous.

Statistical methods

The data obtained were analyzed using descriptive statistics. Logistic regression analysis was used with the CRA (dichotomous variable) as dependent variable and dentists’ experience and specialty as factors. Chi-square tests were used to test if there was significance of the differences between the CRA and ICP, and between CRA and treatment plan. The level of significance was set at P<0.05. Statistical analysis was performed using Statistical Package for the Social Sciences (SPSS), version 20 (trial version) (IBM corp, Armonk, New York, USA).

Results

The response rate was 17.1% (n=257). Table 1 shows that the socio-demographic characteristics of respondents were similar to those of general population of Croatian dentists. More than 60% of Croatian dentists work in private dental practices and have a contract with the National Social Health insurance fund – the Croatian Institute for Health Insurance; others work for a fixed salary at health centers.

Table 1

Demographic characteristics of the sample dentists and general population dentists in Croatia.

Demographic characteristics	Respondents; n=257
Gender (n)	Male	71	27.6%
	Female	186	72.3%
Age (years)	Mean	40.5 years	± 10.1 years
	Min	24
	Max	71
Year of graduation:	More than 15 years from graduation	126	49%
	Less than 15 years from graduation	131	51%
University of graduation	Zagreb	225	87.6%
	Rijeka	23	9%
	Split	2	0.8%
	Elsewhere (foreign University)	7	2.9%
Working in clinical practice:	Yes	236	91.8%
	No	21	8.2% *
Working in private practice	Yes	160	62.3%
Cont. education in cariology in past 5 years	Yes	152	59.4%
	No	105	40.9%
Reading scientific articles on MI	Yes	227	88.3%
	No	30	11.7%

* pharmacy, basic or preclinical subjects/desks at the School of Dental Medicine

There was great variation among respondents with respect to the importance given to different factors to be considered for the development of a treatment plan (Figure 1). Oral hygiene and the presence of active caries lesions were rated as the most important factors.

Figure 1

Respondents' answers about the factors that influence a treatment plan for patients ≥18 years old (N=257).

Oral hygiene (29.7%), patient motivation (13.4%) and nutritional habits (11.3%) were considered the most important factors in estimating CR for their adult patients, while socio-economic status, age and a subjective judgment were considered to be the least important factors (Figures 2 and 3).

Figure 2

Respondents' answers about the most important factors for CRA for patients ≥18 years old (N=257).

Figure 3

Respondents answers about the least relevant or irrelevant factors for the CRA for patients ≥18 years old (N=257).

Of the respondents, 47% reported that CRA was part of their routine practice, but only 4.5% did so using a specific evaluation form. Moreover, 77% of the respondents plan ICP based on the CRA. Treatment plans according to the individual patient’s CR established 68.1% of the respondents, while 31.9% did not. The most common form of prevention used were pits and fissure sealants (87.2%) with topical application of fluoride gel as the second most used (52.9%), (Figure 4). There was statistically significant association between CRA and ICP (p<0.001), and between CRA and treatment plan (p=0.001). The respondents who performed CRA were more likely to plan ICP and modify their treatment plan according to CRA. The results also showed that dentists’ experience did not influence the use of CRA (p=0.531).

Figure 4

Respondents' answers about the used preventive treatment

Discussion

This is the first study to assess Croatian dentists’ subjective ratings of specific CR factors in making a caries treatment plan in their adult patients, and about the percentage of Croatian practitioners performing CRA. Unfortunately, the response rate to the questionnaire was rather low (17.1%), similar to Mayer et al study (). This might partially be due to the use of an internet based questionnaire since the response rate in a similar postal questionnaire survey undertaken in France in 2015 was considerably higher (34.7%), (). It should, however, be noted that in the CAMBRA study of Rechmann et al (), even though dentists were informed through a newsletter about the study, the response rate was only 13.7%, as well as in a study about the restorative threshold where an online questionnaire survey was used, and the response rate was 11.3% (). Nevertheless, the demographic data of the survey respondents and practitioners at national level are relatively comparable (general population of dentists in Croatia, n = 5062, males = 33.8%, females = 66.2%).

It is interesting to note that while 47% of respondents reported the use of CRA as part of their routine practice, 77% of all respondents claim to plan ICP based on a CRA. This might be due to a problem with the interpretation of the question "Do you establish your treatment plans, according to the individual patient's CR“, where a dentist's overall impression of CR might not necessarily be consistent with a full and proper CRA. Furthermore, health insurance in Croatia is dominated by the Croatian Institute for Health Insurance system which covers most dental procedures but does not include CRA as a diagnostic-therapeutic procedure and it is, therefore, not compensated. This is probably the reason why the practitioners who lack time are not motivated to systematically perform a full and proper CRA but still base their preventive and therapeutic strategies on their impression of CR. This might also explain why only 47% of respondents perform CRA, and only 4.5% use a specific form.

There appears to be lack of consensus among Croatian practitioners on the priority of certain CR factors. This may be explained by the fact that there are no national recommendations about CRA and caries management according to the assessed risk. Moreover, most of the CRA systems are not officially available in Croatia for a wider population of dental practitioners, but are merely present in academic settings. Practitioners in Croatia find oral hygiene far most important factor in assessing CR, followed by a patient’s motivation and diet. A similar tendency was observed in France (), where practitioners singled out oral hygiene, diet and the patient’s motivation. Oral hygiene was also considered important by DPBRN dentists from United States, Denmark, Norway and Sweden, along with salivary flow (). In the Trueblood et al study (Texas), practitioners had different perceptions as they considered diet and caries history the most important ().

We have noticed that respondents insufficiently recognized the presence of an active carious lesion as risk factor, but this might be due to the fact that it is rather difficult for practitioners to assess the lesion activity, since the combined information obtained from visual appearance, location of the lesion, tactile sensation during probing and gingival health must be considered ().

Furthermore, socioeconomic factors were estimated by the respondents in our study as the least important factors in assessing CR, followed by a subjective assessment of the patient. However, socio-demographic factors were shown to influence the prevalence of oral diseases, and the risk factor is proposed as relevant for CRA (, , , ). It is, therefore, hard to explain the low rating of socio-economic factors. It is very likely that the social climate of ''political correctness'' made the respondents choose this answer. Furthermore, a subjective evaluation certainly has its merit and there are studies that evaluated clinicians’ subjective assessment and treatment decision, where more skilled dentists are less likely to perform CRA (, ).It was reported that the dentist’s subjective judgment increases sensitivity in the risk assessment process ().

Our results also showed that there was no significant difference between the respondents considering the year of graduation, although the curriculum was changed. Cariology was only introduced into the undergraduate curriculum in 2006. However, as explained above, there are no official recommendations about CRA at the national level, and there are no CRA systems available in the Croatian language outside academic setting that would be recognized by the National Health Insurance Fund as a chargeable diagnostic procedure. This is probably the reason, apart from the lack of time, why even more recent graduates in Croatia are not encouraged to perform CRA despite having been taught CRA and MI concepts since 2006. However, there are procedures that the National Health Insurance Fund compensates, that promote the concept of MI, such as first examination and recording initial dental/oral status, patient motivation, fluoridation, control exam, oral hygiene instructions and fissure sealing.

Croatia has relatively recently joined the European Union (2013) and DMFT is higher than in other EU countries (). In an attempt of designing a specific CRA tool for a population with high DMFT, such as the case in Croatia, it should be considered that a strong predictor of future caries – past caries experience, cannot simply be assessed from the DMFT index value since it does not inform about the factors to be corrected to counterbalance the risk to develop further lesions ().The present paper shows that there is a need for combined efforts of the universities, professional associations, such as the Society for Minimally Invasive Dentistry in Croatia, the Croatian Dental Chamber and the Croatian Institute for Health Insurance to develop MI and CRA that would be practical and efficient for Croatian patients in a specific health care model.

Conclusions

This study revealed that Croatian dental practitioners have considered oral hygiene, patient’s motivation and diet as most important factors in assessing caries risk. Most dentists plan individual caries prevention based on caries risk assessment. Still, most of practitioners do not assess caries risk using a specific evaluation form. There is a need to encourage the use of CRA systems in Croatia.