Copyrigtu Munksgaard 1997

Cottmnmity Dem Orat Eptdemtot 1997: 25: 97 103

Printed in Denmark . Att rights reserved

Communify Dentistry
and Oral Epidemiology
ISSN 0301-5661

What do we know about how dentists

make caries-related treatment
decisions?

James D, Bader and

Daniel A. Shugars
School of Dentistry, University of North Carolina,
Chapel Hill, NC, USA

Bader ,ID, Shugars DA: What do we know about how dentists tnake caries-related
treatment decisions? Community Dent Oral Fpidemiol 1997; 25: 97-103.
Munksgaard, 1997
Abstract - A conceptual model of dentists' treatment decision-making is discussed. The model suggests that dentists do not use a hypothetico-deductive
process for the diagnosis of caries. Rather, caries is idetitified through a process
of pattern recognition that in most instances is inextricably linked to intervention decisions. Individual dentists have inventories of caries scripts that, when
matched by a particular clinical presentation, lead to decisions to treat. The
scripts comprise salient factors that are dependent on individual dentist's characteristics and biases, and thus vary substantially across dentists. The scripts tend to
be complex, highly visual, and difficult to describe. All of these characteristics
suggest that efforts to improve dentists' caries-related treatment decisions
should acknowledge this knowledge structure and be designed to change the salient factors or interpretations of salient factors within the context of the caries
script.

When Dr, Fejerskov originally invited

us to participate in this workshop, he
suggested we address the topic of "how
do dentists utilize criteria in making
treatment decisions?" In agreeing to
prepare a paper, we indicated that if we
tackled this suggested topic, the paper
would be quite short, and the conclusion would consist of three words, i,e.,
"we don't know." For that reason we
broadened the title to include more
than just criteria and we added the tentative phrase "what do we know about"
to the suggested title. While we could
now condense our conclusion into the
single word "nothing," we chose to interpret the concept of "knowing" a bit
more leniently for the purposes of this
presentation. Thus, this paper describes
what we consider to be clues, hints, and
incomplete insights into the complex
question of how dentists tnake cariesrelated treatment decisions. It reflects
our opinions and experiences, bolstered

where convenient by support from the

literature. In short, our approach to addressing this topic resembles our view
of how dentists make treatment decisions.
The presentation is based on a conceptual model of dentists' treatment decision-making (Fig. 1), We originally
developed the model to help guide our
investigations in a project that sought
to "predict" dentists' restorative treatment plans as a measure of normative
treatment needs (1). We subsequently
modified the model for a presentation
at a conference on caries diagnosis (2).
We have respecified the model to focus
on caries-related treatment decisions
for this discussion. We emphasize that
this is a conceptual model. It is not
based on a single underlying theoretical
framework. Rather, it borrows from
several theories of decision-making and
incorporates our empirical observations, A final caveat is that the model

Key wcrds: dental caries, diagnosis; dental

caries, therapy; decision making; dentists,
psychology; observer variation; patient care
planning
J, Bader, Sheps Center, CB#7590, University of
North Caroiina, Chapei Hill, NC 27599-7590,
USA
Accepted for publication t996

reflects the decision-making processes

we think are employed by experienced
dentists, as opposed to learners or novices. The model outlines a process of
dentists' decision-making that may be
helpful both in understanding why dentists show such variation in their decisions and in guiding attempts to reduce
the variation and thereby, it is assumed,
improve the appropriateness of such decisions overall.
Diagnosis of caries

The traditional view of how dentists

make caries-related treatment decisions
involves a diagnosis of caries, followed
by a decision concerning treatment. In
contrast, the model suggests that dentists do not "diagnose" caries in the
classic sense of making a differential diagnosis (3, 4), There is no distinct process that is akin to the standard hypothetico-deductive method. Upon reflec-

98

BADER & SHUGARS

Dentist Factors
Characteristics
age/experience
skills/diligence
tolerance for
uncertainty
knowledge

Biases
restoration utiiity
treatmenl preferences
diagnostic techniques
outiier experiences

Practice
busyness
scale
personnei

Characteristics
delivery system
guidGlJnes
equipment

Automatic
Decision to Treat

Script Match
Initial
Uncertaint]
Examination

Addition:
Scrutiny

No Script Matcii

Dedsion
to Treat

Treatment
Seiection and
Recommendation

Treatment
Negotiation
and
Acceptance

bio Treatment Recommended

Patient Factors
Tooth Levet
visual signs
tactiie signs
- discontinuity - contour
- color
- conststency
- contour
- "catch"
- shadow
radioiucencies

MoLittt Levet
caries
- tiistory (FS) ttow rate
- conststency
- status (DS)
gingival recess
oral hygiene
maiaiignment R,P,D,

Pattent Levet
diet
diseases
fluoride exposure prerererioes
- history
SES
- current status
insurance
medications

Eig. I. Conceptual model of dentists' caries-related treatment decisions.

tion, it is not altogether surprising that

this method is not evident because the
diagnostic problem is different. The
usual situation where the hypotheticodeductive process is applied to arrive at
a differential diagnosis involves a patient presenting with signs and symptoms of unknown origin. Data are
gathered through questioning and examination and, in so doing, a number
of alternative hypotheses explaining the
origin of the signs and symptoms from
a pathophysiological perspective are
generated and evaluated. The process
concludes with the selection of one of
the alternative hypotheses as probable.
At that point, the diagnostic process
ends and a process of treatment selection begins. In contrast, when a patient
presents for a dental examination, the
diagnostic problem is rarely identifying
"what the patient has." Usually, the
question is "does the tooth have anything?" and the question is repeated for
every tooth or tooth surface. We'll suggest later that this question might more
accurately be phrased as "does the
tooth need anything?"

of clinical observations, the answer is

no. However, to the extent that the term
refers to deciding whether the surviving
hypothesis is probable, the answer may
be yes, although we think that the term
"detection" is a more appropriate description of the process. Ideally, a single
unstated hypothesis is always being
evaluated whenever a tooth is examined
for caries. Depending on the orientation of the exatnitier, the hypothesis
may be null, that the tooth in question
does not have caries, or the alternative,
that the tooth does have caries. In either event, a search for clinical and radiological signs usually comprises the
data-gathering activity that leads to a
decision concerning the probability of
the presence of caries. Realistically, as
indicated by the tnodel (Fig. 1) we believe that both the initial evaluation of
the hypothesis and the ultimate determination of a probability are largely
unconscious or automatic and inextricably linked to the decision to intervene. Thus, for most teeth, the actual
process of diagnosis, if it occurs, is not
easily distinguishable. The results of the
If the hypothetico-deductive process process are expressed only in terms of
is not a principal feature of caries diag- the decision to intervene. We will argue
nosis, should this repetitious search that the absence of a definitive diagnosprocess be termed "diagnosis"? To the tic step contributes to the extensive
extent that the term diagnosis refers to variation among practitioners when
the process of postulating and evalu- they are asked to provide caries diagating alternative explanatiotis for a set noses (5),

There is some anecdotal support for

this model of how caries diagnosis or
detection is integrated into the treatment decision process, A similar view
has been described by ETTtNGER (6),
who based his arguments on his own
observations and those presented in an
unpublished paper by PROSHEK. Dentists who have treatment-planned patients for our projects often have identified a diagnostic finding by naming its
intended treatment, e.g., pointing to a
radiolucency and stating "that's a DO
amalgam" (2), Also, when describing
their plans for treatment of each tooth
to recorders during clinical examinations, dentists were often unable to immediately state a reason for the recommended treatment when this information was requested by the recorder (2).
Finally, both the sheer paucity of available alternative diagnoses for the signs
associated with caries and the technical
orientation of the profession also support a view of the process where differential diagnosis is de-emphasized and a
confirmed hypothesis (or a rejected null
hypothesis) is expressed in terms of subsequent treatment.
Note that an extended diagnostic
pathway is also available in the model.
This pathway involves the collection of
additional data prior to a decision concerning ititervention being made when
uncertainty is present. In a narrow
sense, this pathway more closely resembles the classic diagnostic process, in
that evaluation of the hypothesis alternates with data collection. However,
note too that the outcome of this pathway is also a treatment decision, not a
diagnosis.
Carles scripts

If there is no discrete analytical diagnostic step in the caries examination,

what does happen during the examination? We think a process of pattern recognition, or non-analytical processing,
occurs. Recognition that caries is present depends on the similarity of what is
seen on examination with presentations
encountered previously that have been
deemed to be caries requiring treatment. The particular mechanism of
pattern recognition operative in caries
diagnosis is unknown. We suggest that
presentations of caries are stored in
practitioners' memories in a form sim-

Detttists' caries-rektted treattnettt decisions 99

ilar to illness scripts (7), Illness scripts ies-related treatment decisions are meare highly summarized versions of a diated by these scripts most of the time.
provider's cumulative experience with Thus, as each tooth is inspected, either
similar clinical presentations of health clinically or radiographically, any deand disease. They differ from a con- parture from "normal" triggers an undensed form of the traditional differen- conscious and rapid review ofthe invential diagnosis because they minimize or tory of relevant caries scripts to deterexclude the pathophysiological basis of mine if one of them matches the
the disease in question and they sequen- presentation. No conscious reflection
tially emphasize sets of salient features, on any of the specific salient factors is
i.e., predisposing factors, limiting con- involved, and caries pathophysiology is
not at issue. Although the number of
ditions, signs, and symptoms.
The scripts that we suggest practi- caries scripts in a practitioner's inventotioners employ in their caries examina- ry is presumably large, presorting and
tions, i.e., caries scripts, differ from ill- ordered review by frequency of presetiness scripts described in medical prac- tation permits the expression of most
tice in that caries scripts end with a treatment decisions after almost imperdecision regarding intervention, rather ceptible pauses. The time spent in denthan a probable diagnosis. Also, the tal examinations is consumed principalsigns contained in the script are usually ly in collecting the visual and tactile
visual and less frequently tactile. Symp- data needed for matching scripts.
toms are rarely an important feature.
Only occasionally does an abnormal
Like illness scripts, caries scripts consist presentation not result in a satisfactory
of salient features, i,e,, the distinguish- match with an existing caries script.
ing characteristics of the particular ex- When such uncertainty arises, a dentist
pression of caries, A caries script might usually seeks more information. It is
have very few salient features, such as a not clear whether the additional inforcotie-shctped proxitnal shadow on a ra- mation is used to strengthen a possible
diograph, or a perntattettt tooth with a match with an existing caries script, or
"sticky" fissure aitd associated gray/ whether the dentist has entered an anabrowtt .shadow. Alternatively a caries lytical mode where the probability of
script might be highly focused with sev- caries is addressed more directly and
eral factors, such as a two-sttrface atttal- the pathophysiology of disease again
gittn restoratiott iti a molar e.xhihititig tiofiecomes relevant. In any event, the conradiological evidence of carles hut havittgclusion of this additional process also is
several ttncrofraetures of the occlusal a decision regarding intervention.
titargiti that have resulted itt shallow
Most but not all caries scripts will
ditching, an adult patietit with moderate end in a decision to intervene. Examples
plaque aecuntulatioti. a cavitated lesiott of "non-intervention" caries scripts are
elsewhere itt the tnouth, and several those leading to watches, i.e., notations
antalgatn resioratiotts ttot placed by the in the treatment record indicating the
exatnltiittg dentist that have itttperfect need for future comparisons with curtnargins. If these features are closely rent conditions to detect change (8),
matched by a particular tooth in a par- and those where a practitioner has reticular patient, then the practitioner will cently abandoned what was once a rovi"automatically" recommend an inter- tine decision to intervene. Watches are
vention. No diagnosis has been made, placed most frequently when uncertainand no explicit estimation of the prob- ty is present. We think that abandoned
ability of caries being present or occur- intervention scripts linger in the invenring in the future has been made. The tory, and are only gradually lost to the
practitioner has simply matched the pa- matching process. Some anecdotal suptient's tooth with a pattern for which he port for this view is found in comments
or she routinely recotnmends treatment. we have heard in our treatment-planThe absence of a specific distinction be- ning sessions frotn practitioners distween the probability of current and fu- cussing why their treatment decisions
ture caries may explain practitioners' differed from those of colleagues, A not
synonymous use of the terms "second- infrequent explanation would be the
ary caries" and "defective margin,"
observation that "1 used to treat those."
Caries scripts are not necessarily asThe model reflects our assumption
that during a caries examination, car- sociated with the demonstrable pres-

ence of caries, simply the probability

that it is present. As evident in the previous example, a caries script associated
with a treatment decision to intervene
due to caries might comprise a set of
tooth-level salient factors that pertain
only to visual and tactile assessments of
an existing restoration. For the dentist
etnploying the script, these factors may
be associated with some presumed high
likelihood that caries is present or soon
will be present. Agreement among dentists on the presence of secondary caries
requiring treatment that is associated
with restoration margins is weaker than
agreement on the presence of primary
caries (9). Also, agreement among dentists that a treatment intervention is indicated for a given tooth is stronger
than agreement that caries is the primary reason for the intervention (2, 9).
These observations suggest that in the
absence of "definitive" signs of caries,
dentists' caries scripts have varying
probafiilities for caries being associated
with specific indirect signs such as
ditching or staining. Thus, while caries
need not be evident, caries scripts are
characterized by some probability that
caries is present, or that caries formation will occur.

Factors influencing intervention

decisions

The model indicates that a variety of

patient and practitioner factors may affect decisions regarding treattnetit intervention, either the decision to intervene
or the selection of a specific intervention. The factors in the model have
been included largely on the basis of reports in the literature identifying an association with treattnent decisions (1),
although some factors are iticluded because they are routinely discussed in the
literature even in the absence of any formal evidence of an association. While
explanations for how these factors influence treattnent decisions seem obvious in most instances, for many factors
the actual mechanism has never been
evaluated formally. For example, differences among dentists in their aliility to
detect small marginal gaps have been
demonstrated (10), but whether such
differences lead to differences in caries
treatment decisions is unknown. In this
same vein, it is worth noting that while
caries signs are largely visual in clinical

100

BADER & SHUGARS

examinations and wholly visual in radiographic examinations, practitioners'

visual acuity has received little attention
as a factor explaining variation among
dentists in caries diagnoses (11).
Many of the influencing facfors included in the model are poorly defined.
For example, differences in practitioner
diligence are cited anecdotally as causing variation in diagnoses and treatment decisions. However, no measure of
diligence has been suggested, and the
precise nature of diligence remains undefined. Another example is the concept
of patients being at "high risk" for caries. The constellation of factors denoting elevated risk of caries varies across
practitioners (12), Also, the measurement of any given factor, such as "oral
hygiene," can be problematic and the
magnitude of risk associated with different values of the factor is generally
unknown. We argue that the ill-defined
nature of many of these factors leads to
the development of highly individualistic caries scripts, which contributes in
turn to substantial variation among
dentists in their treatment decisions.
The model lists three types of patient
factors thought to influence the cariesrelated decision-making process. The
types are identified by their "level," i,e,,
those involving a specific tooth or tooth
surface, those describing general intraoral conditions, and those related to patient history, behavior, preferences, and
socioeconomic status. We suggest that
the tooth- and mouth-level factors are
likely to be included in caries scripts,
while most patient-level factors are
more likely to play a role in decisions
involving the extended pathway and
treatment selection. Clearly, many of
these factors will also operate in the negotiation and acceptance phase that follows the presentation of a treatment recommendation to a patient.
Three types of dentist factors also are
listed in the model; biases, personal
characteristics, and practice-related
characteristics. We suggest that these
factors, which remain constant across
patients, exert their effects on treatment
decisions indirectly by influencing which
salient factors are included in a caries
script and the magnitude of the probability of caries associated with a specific
caries script. Biases arc opinions or preferences held by individual dentists. We
have termed these opinions and prefer-

ences "biases" under the assumption

that they introduce subjective variation
into what is otherwise an objective process. While the objectivity of the underlying process is open to debate, we
chose this terminology to emphasize the
role of probability and perceptions of
probability in influencing treatment decision-making.
The biases included in the model are
beliefs about treatment utilities, personal treatment preferences, the diagnostic
methods they employ, and "outlier experiences," Obviously, dentists' beliefs
about the absolute and relative utility of
various types of restorations in terms of
outcomes such as longevity, effectiveness in restoring function, and preventing further disease, will play a role
in decisions to intervene as well as decisions concerning the nature ofthe intervention. Treatment preferences, which
are presumably based on the aforementioned beliefs as well as personal experience in treatment provision and outcomes, will also influence these treatment decisions. Personal preferences for
diagnostic techniques (e,g., use of radiographs, other diagnostic measures, a
probe) can influence the presentation of
disease as perceived by a practitioner
(13). "Outlier experiences," which are
unusual or unexpected outcomes of
treattnent decisions, often with serious
consequences, can affect subsequent
treatment decisions by being given
greater consideration or weight by the
practitioner than their incidence would
suggest they merit.
The personal characteristics that are
included in the model are skills/diligence, age/experience, knowledge, and
tolerance for uncertainty. As noted, we
know little about how and even whether
dentist tactile and visual skills and dihgence operate to influence treatment decisions. Also, we have not defined, let
alone measured diligence. We do know
that age is associated with differences in
treatment decisions (1), although it is
not completely clear whether observed
age differences are due entirely to the
effects of maturation (experience), or
whether history also is involved (14). It
has been common to find that older
practitioners are less aggressive in their
diagnoses and decisions to intervene
(1). Presumably older practitioners'
greater experience has led them unconsciously to alter the probabilities for

caries presence or caries progression

that are associated with decisions to intervene. Knowledge is a function of initial professional education and subsequent formal and informal learning. As
used in the model, knowledge refers to
accurate information describing the epidemiology and pathophysiology of caries and the outcomes of its treatments.
The characteristic of tolerance of uncertainty has received no attention in
the dental diagnostic literature. Dentists
with a low tolerance for uncertainty
may be more likely to recommend "doing something," i.e., intervening when
uncertainty arises simply because intervening lowers their anxiety over
"not doing anything" (15), Establishing
watches for uncertain situations represents a means of lowering anxiety without intervention. Uncertainty tolerance
plays a yet-to-be-elucidated role in establishing so-called "treatment thresholds," which can be thought of as the
magnitudes of the perceived probability
of caries at which various dentists will
intervene.

Making decisions to intervene

A decision to intervene can be viewed in

the abstract as a complex probabilistic
judgment. Ideally, the judgment includes
a Baysian approach to the determination of the probability of disease based
on certain criteria, followed by a decision analytic approach to weighting the
relative merits of intervention and nonintervention given that probability. The
decision analysis process is dependent
on information about outcomes of treatment, usually also expressed in terms of
probability. In actuality, these judgments
are too complex and cumbersome to be
completed de novo for each new tooth.
We suggest that practitioners routinely
rely on caries scripts to free themselves
of the necessity for repetitive high-level
cognitive activity. However, proposing
the presence of caries scripts begs the
question of how practitioners associate
particular scripts, or presentations, with
decisions to recommend treatment in the
first place. Also, we have posited a
number of factors that may influence
these decisions, but we have not described the mechanisms through which
these influences operate. The unfortunate truth is that little is known about

Detitists' caries-related treatment decisions 101

the mechanisms or criteria dentists use
for making treatment decisions.
What is becoming clear is that the
mechanisms are complex and the criteria are both several and situational. For
example, some evidence is available to
suggest that dentists' stated physiological criteria for caries they regard as requiring treatment, the aforementioned
treatment thresholds, are not supported
by their treatment decisions tnade on
the basis of radiographs (16, 17), This
finding has been viewed as a possible
indication of the tnisinterpretation of
the radiographic representation of the
caries process, the inability of dentists
to adequately verbalize their treatment
thresholds, and the relative unimportance of a specific depth of penetration
criterion among all other factors involved in treatment decisions. As additional analyses are reported (18, 19), the
latter explanation gains additional
strength. Thus, the use of stated thresholds as predictors of practitioners'
treatment decisions will probably not
be successful. The explanation of one
group of investigators for why practitioners may have had difficulty describing their treatment thresholds essentially duplicates our view of caries
scripts in all but name; "There may be
... a complex web of cues and signs associated with a lesion judged to need a
filling, which the dentist may be unaware of" (16),
We do not know precisely where or
when dentists begin to create and rely
on their personal caries scripts. Presumably, the process begins in the preclinical operative laboratory when instruction and demonstration are based on
natural teeth, and development continues during courses in oral diagnosis and
throughout students' clinical experiences. Practitioners at this formative
stage are likely to already possess
unique individual scripts based on their
own experiences and their interactions
with a variety of unstandardized instructors. It is virtually certain that
practitioners' subsequent clinical experiences play a powerful continuing role
in first elaborating and then tnodifying
these nascent caries scripts over a lifetitne. It is probable that virtually all of
the other dentist factors that can influence these scripts must act through the
filter of personal experience.
We suspect that there are several

types of experience-based feedback that lack of definitive knowledge of probabilact to modify caries scripts. Clearly, im- ities. The hypothesis states that the more
mediate feedback on the presence or uncertainty is tolerated, the less likely a
absence of caries associated with re- decision to intervene will be made. A
storations will arise from decisions to corollary is that, given afixedtolerance,
intervene in such circumstances. That more uncertainty is likely to lead to more
the behavior of replacing "suspicious" intervention. Thus, increased confidence
restorations has not been extinguished in perceived probability estimates
in the face of the fact that, upon remov- brought about by increased experience
al, many of these restorations cannot be would have the effect of reducing uncerassociated with caries (20) suggests that tainty, and hence, the tendency to infairly low perceived probabilities of car- tervene. New knowledge regarding caries
ies are sufficient to trigger decisions to probability could have the same effect if
intervene, at least for dentists with a confidence in the new knowledge was
low tolerance for uncertainty. This ob- greater than confidence in personal exservation also illustrates the imperfect perience.
nature of feedback with respect to risk.
One additional type of experiential
The absence of caries is not "negative" feedback also influences caries probafeedback if the practitioner intervened bilities associated with specific caries
because of concern over future caries. scripts. This type of feedback is listed
Rather, the practitioner may regard the in the model as outlier experiences. In
absence of disease as positive feedback, fact, the effect is more widely known as
i.e., that the intervention was per- the availability heuristic (4, 15), This
formed "in titne." Two longer-term type of experiential feedback leads to
types of feedback, the outcomes of deci- biased estimates of probability, either of
sions to intervene and not to intervene, caries or of particular outcomes associalso will modify intervention decisions. ated with treatment. Heuristics are
For example, if the observations that shortcuts to analytical thinking propractitioners become more conservative cesses (4). The availability heuristic opin their intervention decisions are valid, erates whenever experience is used to
it would seem that with experience assess the plausibility of a particular decomes feedback that restorative inter- velopment (such as a white spot lesion
ventions are not without their own ad- of a particular size and location proverse outcomes. Also, decisions not to gressing to cavitation). In theory more
intervene under uncertainty would seem frequent events are more easily recalled,
to be frequently rewarded with long so that probability of occurrence is asperiods of quiescence.
sociated with ease of recall. Unfortunately, ease of recall is also associated
The mechanism through which feedwith other characteristics such as the
back acts to modify intervention decivividness of an event, the consequences
sions is not established, but is likely some
of an event for the patient or for the
combination of gradual change in the
practitioner, or the recentness of the
perceived probability of caries or particevent. Thus, although the intervention
ular outcomes of treatment associated
decision associated with a specific caries
with a particular caries script and
script may be based on long experience
change in contents of the script itself,
with the outcomes of the decision in the
i.e., the inclusion or exclusion of salient
past, a single spectacular instance when
factors in an existing script. Changes in
the intervention decision led to an unknowledge as well as increased confifortunate outcome will bias future decidence in the accuracy of perceived probsions in the short term by inflating the
abilities are likely to be itivolved in this
perceived probability of the occurrence
process as well. As noted, decision-makof such outcomes.
ing is an exercise in probabilistic judgment, and in dentistry a great many of
the probabilities involved in this judgment are simply not known (21). Thus Implications for change
uncertainty is introduced. An informal Known changes in the prevalence, inciset of assumptions has been adopted dence, and progression of dental caries,
over time, the "uncertainty hypothesis" coupled with variation in dentists' car(15), that describes physician behavior ies diagnoses and caries-related treatunder conditions of uncertainty, i.e., the ment decisions and the lack of evidence

102

BAt:)ER & St^uGARS

supporting the need for much of the

caries-related treatment currently provided, have fostered a general attitude
that the entire process of caries diagnosis and treatment decision-making
needs improvement (22), It would appear that if the concept of caries scripts
is a reasonable approximation of how
caries diagnoses and treatment decisions arc integrated by practicing dentists, attempts to improve these processes must be designed specifically to
help dentists abandon old scripts and
adopt new ones if they are to be fully
successful.
The typical continuing education approach to improving the process would
be to provide information "from the experts" about new interpretations to be
associated with specific signs of caries,
or about new diagnostic tests and their
interpretations. In the extreme, complete
decision trees would be taught together
with the pathophysiological basis for selecting alternatives at each decision
node. There are several reasons why it is
likely that such approaches will not be
effective in changing practitioners' diagnostic behaviors. First, the continuing
education literature would suggest that
straightforward educational interventions are the least effective of all available means to influence practitioner behavior (23). Second, as we have just argued, practitioners typically do not
pursue straightforward deductive diagnostic strategies based on the pathophysiology ofthe disease. Thus, teaching
new techniques from this perspective
may actually place an obstacle in the
path of learning and acceptance. Third,
rightly or wrongly, our model suggests
that dentists place a high degree of confidence in their previous clinical experience. We argue that if new information
docs not agree with this experience, it is
more likely to be disregarded.
If these arguments are correct, then it
seems clear that those who wish to
change dentists' diagnostic and treatment decision behaviors must select one
of two possible levels at which they
would achieve change. At one level, the
goal might be to have dentists incorporate into their caries scripts an additional salient factor such as a new diagnostic
test, or a re-intcrpretation of an existing
salient factor such as the prognosis associated with proximal radioiucencies penetrating to but not into the dentin. At the

other level, the goal is more ambitious,

i.e., having dentists change the framework they use to diagnose caries.
Strategies to achieve the first level of
change are fairly clear-cut. The new information should be presented in the
context of caries scripts. Thus, the new
test or the re-interpretation should be
presented and discussed in the presence
of other specific salient factors included
in most practitioners' caries scripts. The
presentation should be visually based to
the maximum extent possible because it
is unlikely that written descriptions provide adequate representations, or even
include all important salient factors. Arguments intended to support the adoption ofthe new information should show
explicitly what old information is being
replaced, and why. The old information
represents practitioners' experience,
which they trust. If it is to be replaced,
practitioners need to have equal confidence in the replacement. Thus, not only
are results of empirical studies necessary,
but also they should be accompanied by
material explaining why previous experience no longer can be assumed to represent unbiased truth.

beginning to appear that describes the

outcomes of treatment for caries.
Within this framework, effective
scripts would have readily distinguishable salient clinical factors, would be
firmly linked to appropriate treatment
options, and would be based on the
most current evidenced-based understanding of the disease process and its
management. For example, PITTS has

proposed a scheme that links the stages

of the caries process with appropriate
treatment options based on current
knowledge (25). A set of replacement
scripts might be based on the salient
clinical factors that characterize the
stages in PITTS' scheme, and might also
be further differentiated by additional
salient factors that represent assessments of the risk of progression.
A closing observation seems appropriate. Our ability to improve the appropriateness of dentists' caries-related
treatment decisions will be limited until
we better understand the process. We
can identify some obvious weak points,
such as the lack of standardization for
assessment of fundamental concepts
like oral hygiene, risk, and even caries,
Strategies to achieve the second level and the lack of outcome information
of change must be more ambitious. It associated with various treatment strais unlikely that the process of pattern tegies. But there is far more that we do
recognition that we hypothesize as the not understand, such as how dentists'
principal process in diagnosis and treat- characteristics and biases interact, how
ment decision-making will be aban- the environment of practice affects
doned. This repetitive task of inspection treatment decisions, ancf how (and if)
and assessment detnatids an efficient dentists incorporate the values and utiprocess, and some variation on caries lities of their patients into their treatscripts would seem to be the inevitable ment decisions. Without a deeper unresult. Thus, the framework underlying derstanding of the mechanisms una practitioner's inventory of caries derlying the diagnostic and decisionscripts must be the target for change. making processes, as well as the factors
Perhaps the greatest improvement pos- that affect them, the chaos that characsible would be to ensure that the scripts terizes the current scene will continue
are based on the "medical model" of (21). This paper has described one
caries treatment (24), An inspection of model of these mechanisms and factors.
the salient factors in the model suggests Other models are certainly possible, but
that caries scripts are composed almost they remain to be proposed. The profesexclusively of signs of the consequences sion has an obligation to devote the efof caries, rather than signs of the fort and resources necessary to underdisease itself. A new set of scripts that stand how its members make perhaps
incorporates salient factors associated the most basic of all patient-related
with the infectious status of the patient protessional decisions.
would be based on the pathophysiology
of the disease. The scripts themselves
would not involve pathophysiology, but
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