Community Dent Oral Epidemiol 2012; 40: 239246 All rights reserved

2012 John Wiley & Sons A/S

Relative performance of different dental professional groups in screening for occlusal caries
Brocklehurst P, Ashley J, Walsh T, Tickle M. Relative performance of different dental professional groups in screening for occlusal caries. Community Dent Oral Epidemiol 2012. 2012 John Wiley & Sons A S Abstract Objectives: The use of role substitution, where different levels of practitioner undertake the duties of the most qualied clinician, is common in medicine and dentistry. Proponents argue that role substitution has the potential to increase dentists efciency and effectiveness, thereby freeing up resources to improve access and reduce oral health inequalities. Given the current global economic climate, many countries are re-examining models of service provision to utilize role substitution. The objective of this study was to determine whether different members of the dental team could meet the diagnostic threshold set by the World Health Organization, when screening photographs of occlusal surfaces for dental caries. Methods: Participants were sampled purposively and included; nal-year dental students, nal-year hygiene-therapy students, primary care dentists, hygiene-therapists and dental nurses. Following a brief training package, participants were asked to score 102 clinical photographs of both carious and noncarious extracted teeth and determine whether the tooth was healthy or had suspected decay. The time delay between consecutive photographs was set at 8-s. Judgment decisions were compared against the International Caries Detection and Assessment System as the gold standard, with scores of two or less representing healthy. Sensitivity, specicity and predictive values were determined for each participant and clinical group. Kappa was calculated to determine testretest reliability. Results: Dental nurses had the highest median sensitivity (87.9%), although all groups were comparable. The median specicity for the groups was lower than their sensitivity scores, with dentists scoring the highest (71.0%). Dentists also scored the highest median positive predictive value (57.8%), whilst dental nurses scored the highest negative predictive value (91.3%). The median level of agreement was high for all groups; the highest median score was for the nal-year dental students (88.9%). Conclusions: Even with minimal training, different members of the dental team show the potential to screen for occlusal caries to a similar standard as primary care dentists. This requires further testing in vivo, but has important implications for the productivity and design of the future dental workforce.

Paul Brocklehurst1, James Ashley1, Tanya Walsh2 and Martin Tickle1

Department of Dental Public Health, School of Dentistry, The University of Manchester, Manchester, UK, 2Cochrane Oral Health Group, School of Dentistry, University of Manchester, Manchester, UK
1

Key words: caries; clinical research; coronal; diagnostic research Paul Brocklehurst, Department of Dental Public Health, School of Dentistry, University of Manchester, Coupland 3, Oxford Road, Manchester, M13 9PL, UK Tel.: +161 275 6609 e-mail: paul.brocklehurst@manchester.ac.uk Submitted 5 October 2011; accepted 31 December 2011

The use of role substitution, where different members of the dental team undertake the clinical tasks previously provided by dentists, is long established in many countries (1, 2). In the United Kingdom, the role of dental hygienists and dental therapists is well described in their Scope of Practice (3), and many higher education institutes now offer the dual qualication of dental hygienist-therapist. In
doi: 10.1111/j.1600-0528.2012.00671.x

the United States (US), the use of therapists started in 2003 with the Alaska Native Tribal Health Consortium (4) followed by Minnesota in 2009 (5). In addition to dental hygienists, which are well established in North America, other oral health practitioners include: dental assistants, expanded-function dental hygienists, advanced dental hygiene practitioners, community dental health

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coordinators and paediatric oral health educators (68). A common theme to all is their limited duties and restrictions on formulating a diagnosis or treatment plan (3, 9). Proponents argue that role substitution has the potential to increase the efciency and effectiveness of dentists working in the primary care environment (9), thereby freeing up resources to improve access and reduce oral health inequalities (1012). Given that the supply of dentists lies predominantly in urban centres (13), proponents also argue that the development of alternative models to workforce delivery could increase the supply of care to rural communities. As a result of these factors and the global nancial climates impact on healthcare budgets (14, 15), many countries are reexamining potential models of service provision including the greater use of role substitution (16). However, new workforce models have met with resistance over concerns relating to quality, effectiveness and safety (2, 12, 17), with opponents arguing that they are an inappropriate and a disruptive innovation that threatens the existence of the profession (9). The utilization of role substitution by dental therapists in many countries has also been modest (18, 19). In addition, given the restriction on formulating a diagnosis, all patients have to see their dentist initially, and this can reduce the technical efciency and protability of practices that utilize substitution (20). Financial incentives within remuneration systems can further compound this problem and so make role substitution sensitive to contractual changes and at worst, an unviable proposition (9). One possible alternative is the greater use of substitution by members of the dental team to screen for disease (21), where only positive cases are referred onto the dentist for treatment and negative cases are provided with appropriate preventive advice. This could be undertaken as a supplementary procedure between visits to the dentist using a more extended recall frequency or as a substitution for the check-up visit. A service designed on this form of substitution could have the potential for cost-savings or the reallocation of resources to reduce dental health inequalities, given that many patients who attend their dentist on a regular basis do not require any active treatment (9, 21). For example, in England, 60% of patients who attend for a regular dental check-up do not receive any further intervention other than a scale and polish (22). This costs the National Health

Service (NHS) 333 million per annum and represents approximately a third of the total NHS spent on dentistry (22). In contrast, half of the population do not attend a dentist, and this group tends to be the most deprived and experience the majority of the disease (2325). Screening has the potential to reduce the problem inherent in the current system in the United Kingdom and other similar populations, where patients with the least need are seen and treated by the most expensive resource, whilst patients with high levels of need have problems accessing dental services (25). Screening is formally dened as a process of identifying apparently healthy people who may be at an increased risk of a disease or a condition (26). It is analytically distinct from an examination as its purpose is to simply determine the probable presence or absence of disease, not to record or detail the condition to enable a diagnosis to be formulated, pursuant to the skill of a trained dentist. The only systematic review undertaken on the use of role substitution in dentistry concluded that other members of the dental team such as dental hygienists and dental therapists could detect caries, although many of the studies identied were criticized for being old and of poor quality (27). More recently, Hecksher et al. and Adewakun & Amaechi (28, 29) found that teachers and dental assistants could screen for dental caries as part of a community-based programme. Although thresholds for screening do not exist, thresholds for diagnostic tests do; the World Health Organization (WHO) recommends an upper limit for agreement to lie within the range of 8590% (30). The aim of this study was, therefore, to compare the accuracy of different dental professional groups against the WHO standard, when screening for caries from photographs of occlusal surfaces of teeth that had been subsequently sectioned and graded according to the International Caries Detection and Assessment System (ICDAS) criteria (31).

Materials and methods

Participants
Participants were sampled purposively and included; nal-year dental students and nal-year hygiene-therapy students from the School of Dentistry, Manchester. Dentists practising in a primary care environment, denoted as primary care dentists, dental nurses and dental hygiene-therapists

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who had attended a continuing professional development meeting also formed a further three convenience samples.

Design and procedure

Following consultation with the University of Manchester ethics committee, the study was passed as low risk and was not deemed to require full ethics approval. This is consistent with the new policy on ethics for staff employed in the NHS (32). All the participants who took part in the study did so voluntarily. For the students, this formed an additional component to their standard curricula, and for the primary care dentists, hygiene-therapists and dental nurses, the study was delivered alongside a routine evening postgraduate lecture. No coercion or payment for lost time was made. The participants were informed about the study at the beginning of a Microsoft Ofce Powerpoint 2003 presentation, where it was explained that all the data would be treated condentially and anonymized at source. The demographic details of all the participants who agreed to take part was then recorded and included: age, gender, year of qualication, extent of patient contact, place of work and the number of days working for the NHS. Following this, the participants were then presented with further information about the study and a standardized educational training package devised by two of the authors (PRB and JA) on how to screen for dental caries. This was again delivered using Microsoft Ofce Powerpoint 2003 using ve photographs of occlusal surfaces of teeth, dened as that part of the tooth that contacts the opposing surface of a tooth in the opposing jaw. All the photographs for the study had been taken with a digital SLR camera with a minimum image size of 3 MB and were presented on the main lecture theatre screen with the lights dimmed. Participants were asked to score each photograph and then were provided with verbal feedback as part of their training. Immediately following the 5-min training exercise, the participants were notied that the study would commence. In similarity to the training exercise, participants were asked to score clinical photographs of both carious and noncarious extracted teeth and had to simply determine whether the tooth was deemed to be healthy or had suspected decay. The time delay between consecutive photographs was set at 8-s. All the photographs used in both the training exercise and the study had been scored according

to the ICDAS criteria. ICDAS is a clinical scoring system that provides a framework with sufcient discrimination and sensitivity to enable caries lesions to be closely monitored over time for long-term health outcomes (31). As a research tool, it allows subtle changes to the tooth surface to be recorded and so facilitates a systematic approach to caries diagnosis (31). Subsequent to the photographs, all the teeth had been sectioned and examined histologically under a microscope, so the ICDAS score was based on both the clinical and histological appearance. The reference standard was based on the Bogota 2008 convention for ICDAS (31), where an ICDAS score of two or less was deemed to represent healthy, whilst an ICDAS score of three or above was deemed to represent suspected decay. The total number of images of the sectioned teeth that had ICDAS scores of 0, 1 and 2, deemed healthy was 69, and the total number of images of the sectioned teeth that had ICDAS scores of 3, 4 and 5 or 6, deemed, suspected decay was 33. Eighteen images were repeated to test for testretest reliability (12 healthy and six suspected decay). All the participants demographics and judgement decisions were recorded on a record sheet, which was then subsequently loaded into SPSS (v19, IBM, http:// www 01.ibm.com/software/analytics/spss/) by two of the authors (PRB and JA). After the scoring of the images had been completed, the participants were debriefed and thanked for their participation.

Calculation of sample size

Based on a two-sided 95.0% condence interval for a single proportion (sensitivity or specicity) using the z-test approximation, an effect size of 0.1 and expected observed proportion of 0.90, the number of cases that satised a power of 0.8 was calculated to be 35 [n (Z2 m2)*p (1 p)]. Given the lack of evidence from the literature on the prevalence of true-positive and true-negative cases in a population that is being screened for occlusal caries, this was estimated to be 35% and 65%, respectively. Based on the developing guidance from Cochrane on diagnostic test accuracy, the sample size was then inated by the reciprocal of the prevalence to determine the nal numbers for the study [n 35*100 35 = 100]. This is in line with the nomogram produced by Carley et al. (33).

Analysis
The sensitivity and specicity of each participants screening decision were calculated based on the

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reference standard of the ICDAS score for each of the sectioned teeth. Summary values of the different professional groups sensitivity and specicity were presented as median scores with interquartile ranges. Median scores and interquartile ranges for the positive and negative predictive values were also determined.

Results
The demographics of the participants from the different groups are provided in Table 1. Apart for the undergraduates, the median ordinal age group for the primary care dentists, dental nurses and hygiene-therapists was 4049, 3039 and 40 49 years of age; most practitioners had been qualied for 1019 years. All the groups worked in primary care, and whilst the primary care dentists and dental nurses worked 75100% in the NHS, the hygiene-therapists worked 5074%.

The median of each groups sensitivity, specicity, positive and negative predictive value is provided in Table 2. The dental nurses had a higher median sensitivity than the remaining groups (87.9%), although all groups were comparable. The median specicity for the groups was lower than the sensitivity, with the primary care dentists scoring 71.0%. The primary care dentists also scored the highest median positive predictive value (57.8%), whilst the dental nurses scored the highest negative predictive value (91.3%). Table 3 highlights the testretest reliability. The median level of agreement was high for all groups; the highest median score was for nal year dental students (88.9%), with the remaining groups scoring 83.3%. The difference between level of agreement and kappa scores was minimal, given the probability of agreement occurring by chance in a binomial distribution involving 18 repeated observations is low.

Table 1. The demographics of the participants from the different groups Male (%) 37.7 0 53.8 0 18.8 Female (%) 62.3 100 46.2 100 87.2 Agea (years) 2029 2029 4049 3039 4049 Qualieda (years) Not yet qualied Not yet qualied 1019 1019 & 09 09 Patient contacta (days) 3 4 5 4 4 NHS time (%)a 75100 75100 75100 75100 5074

Group Final-year dental students Final-year hygiene-therapy students Primary care dentists Dental nurses Hygiene-therapists
a

N 70 11 54 47 39

Workplacea Undergraduate Undergraduate Primary care Primary care Primary care

Median.

Table 2. Sensitivity, specicity and predictive values Final-year dental students Median sensitivity (IQR) Median specicity (IQR) Median positive predictive value (IQR) Median negative predictive value (IQR) 84.9 (9.09) 65.2 (13.04) 54.6 (8.82) 90.48 (4.75) Final-year hygiene-therapy students 84.9 (9.09) 53.62 (16.63) 49.21 (9.28) 90.91 (5.55) Primary care dentists 84.9 (9.09) 71.0 (16.3) 57.8 (15.27) 89.16 (3.12) Dental nurses 87.9 (9.09) 62.3 (12.58) 52.7 (6.94) 91.30 (5.64) Hygienetherapists 84.9 (6.06) 67.2 (10.72) 54.7 (8.71) 89.7 (3.73)

IQR, interquartile range (the difference between the rst and third quartiles of the distribution). Table 3. Median level of agreement and Kappa statistics Fina1-year dental students Median level of agreement (IQR) Median Kappa (IQR) 0.889 (0.150) 0.889 (0.153) Final-year hygiene-therapy students 0.833 (0.065) 0.833 (0.066) Primary care dentists 0.833 (0.166) 0.833 (0.169) Dental nurses 0.833 (0.156) 0.830 (0.198) Hygienetherapists 0.833 (0.166) 0.833 (0.112)

IQR, interquartile range (the difference between the rst and third quartiles of the distribution).

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Final year dental students
1 0.9 0.8 0.7 Sensitivity Sensitivity 0.6 0.5 0.4 0.3 0.2 0.1 0 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Specificity 1 0.9 0.8 0.7 Sensitivity Sensitivity 0.6 0.5 0.4 0.3 0.2 0.1 0 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Specificity 0 0 1 0.9 0.8 0.7 Sensitivity 0.6 0.5 0.4 0.3 0.2 0.1 0 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Specificity 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Specificity 0 0

Final year hygiene-therapy students

1 0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 1

Primary care dentists

0.9 0.8 0.7 0.6 0.5 0.4 0.3 0.2 0.1 Specificity

Dental nurses

Hygiene-therapists

Fig. 1. Summary of individual sensitivity and specicity values.

Figure 1 presents the individual values for sensitivity plotted against the false positives (1-specicity). The results appear comparable, although there is slightly more spread in the responses from the dental nurse group.

Discussion
The main nding of this study is that there is little difference in the performance of different categories of dental professionals for sensitivity and specicity when screening for dental caries, after a 5-min training exercise. Across all the groups tested, the participants sensitivity met the WHOs reference standard (30), but the median scores for specicity were lower than the recommended threshold (Table 2); the latter was statistically signicant, falling outside of the 95% condence interval around the WHO reference standard. The main weakness of the study is that the presentation of photographs to participants is articial, compared with the judgement ecology of the task in the dental ofce; the teeth presented were dry and magnied, and each participant had

8-s to make a decision. This contrasts with the clinical environment, where not all practitioners dry the tooth, there is often no magnication, the time taken for each tooth is likely to be less than 8-s and diagnostic adjuncts can be utilized. However, the ability of the latter to improve test accuracy for occlusal surfaces is notoriously problematic, with little improvement in diagnostic yield (34). In addition, in a recent study to quantify the diagnostic techniques used by dentists before intervening on primary caries lesions, Rindal et al. (35) found that the diagnostic technique combinations used most frequently for occlusal surfaces were clinical assessment alone. This is in line with the ndings of Baders systematic review, who found that occlusal surfaces are best diagnosed by visual examination (34). A further criticism is that the occlusal surface only represents one surface of a posterior tooth that requires examination, the others being the approximal and smooth surfaces. However, with falling levels of dental caries in many populations, like the United Kingdom, new lesions in permanent teeth are commonly seen in occlusal ssures (36), which represent one of the most difcult diagnostic

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challenges for clinicians. Given the comparable test accuracy in this study across all the groups tested, the results suggest that, at the very least, the technical efcacy of screening by different members of the dental team warrants further testing in vivo. The ndings are also consistent with Galloways review (27), who found a similar diagnostic yield. As highlighted previously, Hecksher et al. and Adewakun & Amaechi (28, 29) also found that teachers and dental assistants were more than capable of acting in a sign-posting role. Another potential criticism is the numbers of healthy and diseased teeth used in the study. Whilst sufcient to provide power to detect whether the sensitivity of the groups met the threshold set by the WHO, the values for specicity were much lower than expected. As a result, more healthy teeth would be required to maintain the power to test against the reference standard. However, the WHO standard of 0.850.90 relates to diagnostic test accuracy, and there currently is a lack of consensus or guidance for screening tests. It was also uncertain a priori what the relative proportion in the population of the ICDAS categories deemed to represent healthy (02) and suspected decay (36) would be, to inate the numbers required. The authors were also concerned about test fatigue, with the participants scoring over one hundred lesions, with a new image every 8-s. This was born out in the feedback after the study; participants expressed a view that they would not want to score many more than the number presented. The higher value for sensitivity is understandable, given that judgement under uncertainty often favours safety (37), that is, scoring a tooth as suspected decay when in doubt in order for it to be re-examined and exposed to further tests. This is reected in the lower positive predictive values across the groups, although the value of 57.8% for primary care dentists was surprising, given that this is a task they perform many times a day. In contrast, dental nurses with only minimal training were not substantially different. High values for the negative predictive values and for testretest reliability are also reassuring, the former highlighting the low numbers of false negatives that were generated and the latter the high level of agreement across the groups (38). In the context of a screening programme, these initial results suggest that other members of the dental team are good at detecting disease and, when uncertain, refer on. High negative predictive values and low numbers of false negatives make a

screening programme potentially viable in a population like the United Kingdom. Moderate numbers of false positives also make screening feasible from a health economic perspective, although this requires modelling and further work. It is also important to acknowledge that dental caries is a slow-growing disease (3941) and so a false negative of itself is not life threatening, particularly in the context of routine attendance, where patients would be seen again. As highlighted previously, it was surprising that experienced dentists were no better than the other groups. From the psychological literature, the cognitive structures that are used in pattern recognition in diagnosis are divided into two principal components; perceptual processing and conceptual processing (42). The former describes how information is extracted from the environment and the latter describes how individuals retrieve and utilize stored memories of medical knowledge and case histories. The integration of these two components has been shown to be a fundamental aspect of diagnosis (42). Expertise studies reveal differences in perceptual learning between novices and experts that apply in many different domains (43), including medicine (44, 45). Rather than simple pattern recognition, it is possible that the dentists were using more elaborated and highly developed illness scripts, given their experience of managing carious lesions (45) and so over-complicating the judgement task. Whatever the reason, this is the rst study to demonstrate that dental nurses were capable of performing in a similar manner to dentists after a simple 5-min training programme. This suggests that caries detection is imprecise and that it is unlikely to change substantially with training, given the greater experience of the dentists. However, in the context of a screening programme, individuals who have gone through a training programme and were judged to have poor intra-rater reliability could be removed from the programme. It should again be emphasized that screening is not the same as diagnosis or treatment planning, which requires substantial training and the development of clinical reasoning, pursuant to a qualied dentist. In addition to dental caries, regular dental inspection assesses and monitors another common problem; periodontal disease, and so work is required to test the efcacy of other members of the dental team to screen for patients with periodontal disease. Oral cancer is another important problem, given its high mortality rate and associ-

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ated morbidity (46). However, research suggests that suitably trained auxiliaries can screen for oral cancer, in the context of both a clinical trial (47) and a community-based intervention (48); it is also not seen as frequently in dental practice compared with general medical practice (49). In medicine, Laurant et al.s (50) systematic review found that services provided by nurse practitioners were associated with higher levels of patient compliance and satisfaction. In the United States, studies have suggested that physician assistants can undertake 75% of the work of a physician, save resources and deliver high-quality care for patients (51). In addition to precision, the social acceptability of undertaking a screening programme would be another important determinant of success, alongside a detailed policy analysis to explore the views of the profession (9).

Conclusion
Even with minimal training, different members of the dental team have shown the potential to perform screening to a similar standard as primary care dentists. This requires further testing in vivo, but has important implications for the productivity and design of the future dental workforce. In addition to testing in vivo performance, the social acceptability and policy implications of role substitution, further modelling is required from a health economic perspective to examine the potential of different members of the dental team to screen for disease in a primary care environment.

Acknowledgements
The authors would like to thank the Dental Health Unit for the provision of the original images.

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