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Table 3 Similarities and differences between dentists in the three participating countries. (−) Barriers, (+) enablers

From: To fill or not to fill: a qualitative cross-country study on dentists’ decisions in managing non-cavitated proximal caries lesions

Themes New Zealand Germany USA
(−) Lack of or less remuneration for non/micro-invasive measures and healthcare regulation Oh well actually one of the things that does come to mind is the way that the fee structure is set up for the adolescent children, the contract with the Health Board, I mean that is an external factor I suppose because if a person is looking to just for income and they see a number of small spots on the enamel you know they may decide, I mean that is a clinical judgement but the way the fee structure is set up there’s nothing for doing fluoride treatment but there is something for doing fillings. (NZ2).
There’s… a lot more advantages for the dentist to cut a filling ‘cause… you get the fee for doing the filling and…eventually you … get the fee for replacing that filling at some time. (NZ4)
The flip side of the coin is the economic situation. National health insurance does not pay for non- or micro-invasive measures. There is no real financial support for it and hmmm, that’s why, speaking from an economical perspective, support (from the national health insurance) will only happen once we start using the drill. (G3)
It’s really only the invasive measures that make it worth it. You get more money with it. It’s not like the national health insurance covers non-invasive treatments. Unbelievable. (G12)
Non-invasive procedures are desirable for the patient and of course are very good, but in reality, one has to place some fillings (G3)
There’s also another thing that I’ve encountered is with a lot of insurers now, they have a delay before they would allow a new restoration to be placed in the tooth so I think that kind of pushes providers to take an incipient lesion and restore it. (US12)
Well… unfortunately the financial advantage is kind of negative because I’m financially advantaged to go in and do invasive… care, I’m not saying that that’s a good thing but when you look at it strictly like that… (US7)
Mentioned (%) 83% 100% 70%
(−) Time to enact non/micro-invasive measures I mean some procedures can be more time consuming, smaller and fiddler to do than cutting a nice big hole in the tooth. (NZ8) G8: The disadvantage is that minimal invasive treatments require more time, compared to those that are not minimal invasive. (G6) So I guess sometimes the barrier can be time if a patient needs extra time and educating (US4).
Mentioned (%) 8% 42% 33%
(−) Anticipated regret Sometimes you will see a cavity and it is small and you think, oh I should drill that and then you second guess yourself and say, you shouldn’t. Then two years later they are back again and you think, oh thank goodness, I didn’t drill that and other times there is a massive cavity there and you bitterly regret your decision. (NZ1) The disadvantage is that if one cannot see the patient for a follow up then it can turn to custard, rather quickly and 2 years down the track the next dentist would say: “This dentist had used micro-invasive treatments and now the tooth needs to be taken out, because no one removed the decay”. That is why I would be careful. (G1) I might find that some of these things come back to bite me or patients who…really haven’t been able to change to oral hygiene… you change your eating habits or what not and now I see the patient back in two years and they didn’t come back in six months or what not and now we have got a tooth that needs a lot more work than if they were treated early on. (US18).
Mentioned (%) 92% 75% 23%
(−) Basing treatment on what they had learned in dental school and not undertaking ongoing professional development. Int: Are you recommendations, the one you mentioned, based on studies?
G1: I really can’t tell you. I haven’t looked at any studies for 20 years.
Int: Where did you get your knowledge for using non and micro invasive?
US11: The dental education when I was in Dental School.
Mentioned (%) 0% 42% 23%
(+) Goal priority––non/micro-invasive measures If I did do it I would be um, ah my patients would have more decay. I just think that enables success for my patients. I want it for my patients. I’m passionate about helping them to achieve oral, yeah that’s it really. (NZ3) Well the biggest benefit is to the patient directly to avoid having restorative work done on their teeth and preserving the natural tooth structure because it’s widely accepted that once a restoration is placed in the tooth…it’s going to lead to a lifetime of more restorations, they’re going to get larger and larger and maintaining… existing tooth structure should be of paramount priority”. (G2) US3: Yeah absolutely. I definitely like to be more on the conservative side.
Int: Is it a priority in your professional role to do that?
US3: Yeah, yeah definitely.
Mentioned (%) 83% 17% 15%
(+) Colleagues supportive of non/micro-invasive measures Int: So your colleagues would be supportive of um non or micro invasive measures?
NZ11: Incredibly supportive. In fact, we, we yeah, no that would be yeah, it would be looked down upon and discussed if there was a choice to fill and yeah certainly people would want to have a discussion about it and it would be an interesting point though, as I said, it’s quite protective of the person and the tooth and what you’re doing and how you’re doing it and yeah. If there was a big crack there and there was a big R1 and there was an occlusal and you know the, it might be that we chose to add that onto the filling so I suppose I might at that stage.
G7: One would have to rather ask, what would
prevent me from using non or micro invasive
measures within my practice? But to answer
your question, there is nothing... There is the patient, then there is myself and one has to
fully inform and instruct the patient and that
is simple a time factor, but one has to take
this time.
Int: What about your colleagues? Do they
have the same opinion?
G7: No. They have a similar attitude.
Well our practice is kind of unique in the fact that we are part of a large, I won’t mention the net, but we’re part of a large insurance group, and they have used our facility as a cusp model for trying different preventative measures. For instance, over the past couple of years we have documented that as the preventative procedures increase in our patients, the restorative has decreased. And we can show that on a graph which is particularly interesting to um insurance providers and to patients, it benefits the patient too, but the insurance providers want to know if there’s a value to that, and how they can assign a value to it. (US20)
Mentioned (%) 67% 25% 41%
Undertaking professional development–belonging to professional groups/study groups/professional discussions with peers/attending lectures or conferences Int: Yep. No, that’s cool. So do you there’s strong evidence for the recommendations for that CAMBRA technique and acronym that you just said, do you think that there’s strong evidence behind that?
NZ3: Yeah. There is. Yep.
Int: Thousands of cases that I have been following the process for about 15 years and yeah Professor Featherstone from America presented a couple of years ago in Auckland…It was Minimal Intervention Dentistry Conference.
Well. The dentists that I meet up with at advanced training/education courses and attend advanced training/education courses together or that I meet there are all, hmm, working not the same concept as myself. However, we are not representing all the dentists. Sadly this is how it is. (G5) I mean it’s covered pretty well in Dental School, CE courses, manufacturers raps, introducing new product, journal articles, clinical studies, things like that. (US12)
Mentioned (%) 92% 25% 85%