A placebo-controlled trial of maintenance therapy with fluconazole after treatment of cryptococcal meningitis in the acquired immunodeficiency syndrome. California Collaborative Treatment Group

BACKGROUND AND METHODS

In patients with the acquired immunodeficiency syndrome (AIDS), the rate of relapse after primary treatment for cryptococcal meningitis remains high. We conducted a controlled, double-blind trial to evaluate the efficacy of maintenance therapy with fluconazole. At entry into the study, all participants had sterile cultures of cerebrospinal fluid, blood, and urine after following a standardized course of therapy for culture-proved cryptococcal meningitis. The patients were randomly assigned to take either fluconazole or placebo as maintenance therapy. The dose of fluconazole was 100 mg daily in the first phase of study and 200 mg daily in the second phase.

RESULTS

Of 84 patients initially enrolled, 16 (19 percent) were found to have silent, persistent infection on the basis of cultures that became positive after entry into the study; 7 other patients were lost to follow-up shortly after entry. Of the remaining 61 patients, 10 of 27 assigned to placebo (37 percent) and 1 of 34 assigned to fluconazole (3 percent) had a recurrence of cryptococcal infection at any site (difference in risk, 34 percent; 95 percent confidence interval, 15 to 53). Of the 11 recurrent infections, 7 were detected in urine obtained after prostatic massage. There were four recurrent meningeal infections in the patients taking placebo, but none in those taking fluconazole (mean duration of follow-up, 164 days) (P = 0.03). In multivariate analyses, the best predictors of recurrence-free survival were fluconazole treatment (P = 0.02; relative hazard, 13.2), a lower serum cryptococcal-antigen titer (P = 0.05; relative hazard, 1.2), and more prolonged primary therapy with flucytosine (P = 0.09; relative hazard, 1.1). Survival and toxicity were similar in the two maintenance-treatment groups.

CONCLUSIONS

In patients with AIDS, silent persistent infection is common after clinically successful treatment for cryptococcal meningitis. Maintenance therapy with fluconazole is highly effective in preventing recurrent cryptococcal infection.

Risk factors for osteonecrosis of the jaws: a case-control study from the CONDOR dental PBRN

Case reports and cohort studies have linked bisphosphonate therapy and osteonecrosis of the jaws (ONJ), but neither causality nor specific risks for lesion development have been clearly established. We conducted a 1:3 case-control study with three dental Practice-based Research Networks, using dentist questionnaires and patient interviews for collection of data on bisphosphonate therapy, demographics, co-morbidities, and dental and medical treatments. Multivariable logistic regression analyses tested associations between bisphosphonate use and other risk factors with ONJ. We enrolled 191 ONJ cases and 573 controls in 119 dental practices. Bisphosphonate use was strongly associated with ONJ (odds ratios [OR] 299.5 {95%CI 70.0-1282.7} for intravenous [IV] use and OR = 12.2 {4.3-35.0} for oral use). Risk markers included local suppuration (OR = 7.8 {1.8-34.1}), dental extraction (OR = 7.6 {2.4-24.7}), and radiation therapy (OR = 24.1 {4.9-118.4}). When cancer patients (n = 143) were excluded, bisphosphonate use (OR = 7.2 {2.1-24.7}), suppuration (OR = 11.9 {2.0-69.5}), and extractions (OR = 6.6 {1.6-26.6}) remained associated with ONJ. Higher risk of ONJ began within 2 years of bisphosphonate initiation and increased four-fold after 2 years. Both IV and oral bisphosphonate use were strongly associated with ONJ. Duration of treatment > 2 years; suppuration and dental extractions were independent risk factors for ONJ.

Social determinants of tooth loss

OBJECTIVES

To quantify racial and socioeconomic status (SES) disparities in oral health, as measured by tooth loss, and to determine the role of dental care use and other factors in explaining disparities.

DATA SOURCES/STUDY SETTING

The Florida Dental Care Study, comprising African Americans (AAs) and non-Hispanic whites 45 years old or older who had at least one tooth.

STUDY DESIGN

We used a prospective cohort design. Relevant population characteristics were grouped by predisposing, enabling, and need variables. The key outcome was tooth loss, a leading measure of a population's oral health, looked at before and after entering the dental care system. Tooth-specific data were used to increase inferential power by relating the loss of individual teeth to the disease level on those teeth.

DATA COLLECTION METHODS

In-person interviews and clinical examinations were done at baseline, 24, and 48 months, with telephone interviews every 6 months.

PRINCIPAL FINDINGS

African Americans and persons of lower SES reported more new dental symptoms, but were less likely to obtain dental care. When they did receive care, they were more likely to experience tooth loss and less likely to report that dentists had discussed alternative treatments with them. At the first stage of analysis, differences in disease severity and new symptoms explained tooth loss disparities. Racial and SES differences in attitudes toward tooth loss and dental care were not contributory. Because almost all tooth loss occurs by means of dental extraction, the total effects of race and SES on tooth loss were artificially minimized unless disparities in dental care use were taken into account.

CONCLUSIONS

Race and SES are strong determinants of tooth loss. African Americans and lower SES persons had fewer teeth at baseline and still lost more teeth after baseline. Tooth-specific case-mix adjustment appears, statistically, to explain social disparity variation in tooth loss. However, when social disparities in dental care use are taken into account, social disparities in tooth loss that are not directly due to clinical circumstance become evident. This is because AAs and lower SES persons are more likely to receive a dental extraction once they enter the dental care system, given the same disease extent and severity. This phenomenon underscores the importance of understanding how disparities in health care use, dental insurance coverage, and service receipt contribute to disparities in health. Absent such understanding, the total effects of race and SES on health can be underestimated.

Purpose, structure, and function of the United States National Dental Practice-Based Research Network

OBJECTIVE

Following a successful 2005-2012 phase with three regional practice-based research networks (PBRNs), a single, unified national network called "The National Dental PBRN" was created in 2012 in the United States to improve oral health by conducting practice-based research and serving dental professionals through education and collegiality.

METHODS

Central administration is based in Alabama. Regional centres are based in Alabama, Florida, Minnesota, Oregon, New York and Texas, with a Coordinating Centre in Maryland. Ideas for studies are prioritized by the Executive Committee, comprised mostly of full-time clinicians.

RESULTS

To date, 2763 persons have enrolled, from all six network regions; enrollment continues to expand. They represent a broad range of practitioners, practice types, and patient populations. Practitioners are actively improving every step of the research process, from idea generation, to study development, field testing, data collection, and presentation and publication.

CONCLUSIONS

Practitioners from diverse settings are partnering with fellow practitioners and academics to improve clinical practice and meet the needs of clinicians and their patients.

CLINICAL SIGNIFICANCE

This "nation's network" aims to serve as a precious national resource to improve the scientific basis for clinical decision-making and foster movement of the latest evidence into routine practice.

Dentist material selection for single-unit crowns: Findings from the National Dental Practice-Based Research Network

OBJECTIVES

Dentists enrolled in the National Dental Practice-Based Research Network completed a study questionnaire about techniques and materials used for single-unit crowns and an enrollment questionnaire about dentist/practice characteristics. The objectives were to quantify dentists' material recommendations and test the hypothesis that dentist's and practice's characteristics are significantly associated with these recommendations.

METHODS

Surveyed dentists responded to a contextual scenario asking what material they would use for a single-unit crown on an anterior and posterior tooth. Material choices included: full metal, porcelain-fused-to-metal (PFM), all-zirconia, layered zirconia, lithium disilicate, leucite-reinforced ceramic, or other.

RESULTS

1777 of 2132 eligible dentists responded (83%). The top 3 choices for anterior crowns were lithium disilicate (54%), layered zirconia (17%), and leucite-reinforced glass ceramic (13%). There were significant differences (p<0.05) by dentist's gender, race, years since graduation, practice type, region, practice busyness, hours worked/week, and location type. The top 3 choices for posterior crowns were all-zirconia (32%), PFM (31%), and lithium disilicate (21%). There were significant differences (p<0.05) by dentist's gender, practice type, region, practice busyness, insurance coverage, hours worked/week, and location type.

CONCLUSIONS

Network dentists use a broad range of materials for single-unit crowns for anterior and posterior teeth, adopting newer materials into their practices as they become available. Material choices are significantly associated with dentist's and practice's characteristics.

CLINICAL SIGNIFICANCE

Decisions for crown material may be influenced by factors unrelated to tooth and patient variables. Dentists should be cognizant of this when developing an evidence-based approach to selecting crown material.

Multidimensionality of oral health in dentate adults

OBJECTIVES

An understanding of the validity and usefulness of self-reported measures (as distinct from clinically determined measures) of oral health is emerging. These self-reported measures include self-rated oral health (SROH). Three objectives were to: (1) describe self-rated oral health in dentate adults, (2) quantify associations between self-rated oral health and other measures of oral health (oral disease and tissue damage, pain and discomfort, functional limitation, and disadvantage), and (3) assess the construct validity of a model of oral health proposed herein.

METHODS

The Florida Dental Care Study is a longitudinal study of oral health, which included at baseline 873 subjects who had at least one tooth, were 45 years or older, and who participated for an interview and clinical examination.

RESULTS

The prevalence of self-rated oral health decrements was substantial; approximately one fourth of subjects reported their oral health as only fair or poor. Bivariate and multivariate results provided consistent evidence of the construct validity of the proposed model of oral health. Additionally, the salience of one measure of dental appearance suggests that persons may use esthetic cues when rating their oral health.

CONCLUSIONS

The proposed multidimensional model of oral health has construct validity. Self-rated oral health is affected by oral disease and tissue damage, oral pain and discomfort, oral functional limitation, and oral disadvantage. These self-reported measures and the proposed model should provide useful information for dental care effectiveness research. General health status has been disaggregated into the "physical" and the "mental;" an additional separation into the "oral" aspects of health seems warranted.

Mouth dryness as reported by older Floridians

Thirty-nine percent of 600 community-dwelling older Floridians (mean age of 78 yr) reported having mouth dryness. Seventy-nine percent of respondents reported at least one medical condition, 57% were taking at least one prescribed or over-the-counter medication, and 33% were taking at least one potentially xerostomic medication. Reported mouth dryness was highly associated with the number of potentially xerostomic medications. After stratification by medication usage, age, diabetes, arthritis, perceived medical health, and dependence in physical functioning were significantly associated with mouth dryness. Persons with dry mouth were also more likely to have reported dental symptoms, signs of dental disease, sensory changes, and other oral symptoms. Ten percent of those who reported mouth dryness also said that their mouths felt dry when eating a meal, 10% said that they had difficulties swallowing foods, and 15% of persons with dry mouth also said that the amount of saliva in their mouths was too little. Sixty-five percent of persons with dry mouth reported doing one or more dryness-related behaviors. These results suggest that the prevalence of xerostomia was high, and the impact of dry mouth on individuals' daily behaviors was significant.

Dental health attitudes among dentate black and white adults

OBJECTIVES

Blacks and poor persons share a greater burden of oral disease and are less likely to seek dental care on a regular basis. The role of dental attitudes and knowledge of services on this circumstance is unclear. The authors quantified group differences in dental attitudes and knowledge of services and related them to regularity of dental care use.

METHODS

As part of the baseline phase of The Florida Dental Care Study, a longitudinal study of oral health, 873 respondents who had at least one tooth and who were 45 years or older participated for an interview and a clinical dental examination. Dental care use, seven dental attitudinal constructs, and knowledge of dental services were queried.

RESULTS

Forty-five percent of respondents reported going to a dentist only when they have a problem, and 17% of respondents had not seen a dentist in more than 5 years. Ten percent of respondents reported that they had at least one permanent tooth removed by someone other than a dentist (typically, the respondent himself). Blacks and poor persons had more negative attitudes toward dental care and dental health and were less knowledgeable of dental services. Multivariate analyses suggested that dental attitudes were important to understanding the use of dental care services for this diverse group of adults, and that race and poverty contributed independently to dental care use even with dental attitudes taken into account.

CONCLUSIONS

Dental attitudes contribute to race and poverty differences in dental care use among adults. The persistence of race and poverty effects with attitudes taken into account suggests that additional explanatory factors contribute as well. These differences may contribute to more prevalent and severe oral health decrements among the same adults who also are more likely to suffer from other health decrements.

Behavioral risk indicators of attachment loss in adult Floridians

This study investigated behavioral and sociodemographic risk indicators of attachment loss (AL) at baseline in subjects of the Florida Dental Care Study: 873 subjects with at least 1 tooth, and who were 45+ years or older, participated for an in-person interview and dental examination; 761 subjects were probed for AL. Calibrated examiners used a modified NIDR protocol from the 1985-86 Survey of US Employed Adults and Seniors. Results were weighted to reflect actual population proportions. 92% of subjects had at least 1 site of 4+ mm AL, and 35% had at least 1 severe site (7+ mm AL). In a single multivariate regression, not having a recent dental check-up, not using dental floss, being a current smoker, and being diabetic were significantly associated with a higher probability of having 1 or more severe sites. Blacks were less likely than whites to be regular users of dental care, use dental floss, and be non-smokers. Similar findings were found for low income adults and rural residents. Risk groups (low income, blacks, rural residents) were more likely to present with modifiable risk indicators for AL, suggesting the need for targeted interventions.

Repair or replacement of defective restorations by dentists in The Dental Practice-Based Research Network

BACKGROUND

The authors aimed to determine whether dentists in practices belonging to The Dental Practice-Based Research Network (DPBRN) were more likely to repair or to replace a restoration that they diagnosed as defective; to quantify dentists' specific reasons for repairing or replacing restorations; and to test the hypothesis that certain dentist-, patient- and restoration-related variables are associated with the decision between repairing and replacing restorations.

METHODS

This cross-sectional study had a consecutive patient and restoration recruitment design. Practitioner-investigators (P-Is) recorded data for consecutively seen restorations in permanent teeth that needed repair or replacement. The DPBRN is a consortium of dental practitioners and dental organizations in the United States and Scandinavia. The collected data included the primary reason for repair or replacement, tooth surface or surfaces involved, restorative materials used and patients' demographic information.

RESULTS

P-Is collected data regarding 9,484 restorations from 7,502 patients in 197 practices. Seventy-five percent (7,073) of restorations were replaced and 25 percent (2,411) repaired. Secondary caries was the main reason (43 percent, n = 4,124) for treatment. Factors associated with a greater likelihood of repairing versus replacing restorations (P < .05) included having graduated from dental school more recently, practicing in a large group practice, being the dentist who placed the original restoration, patient's being of an older age, the original restorative material's being something other than amalgam, restoration of a molar and the original restoration's involving fewer tooth surfaces.

CONCLUSIONS

DPBRN dentists were more likely to replace than to repair restorations. Secondary caries was the most common reason for repairing or replacing restorations. Certain dentist-, patient- and restoration-related variables were associated with the repair-or-replace decision.

CLINICAL IMPLICATIONS

The selection of minimally invasive treatment for an existing restoration is critical, as it may affect the longevity of the tooth.

Orofacial pain symptoms: an interaction between age and sex

This study investigated sex and age cohort differences in the subjective report of orofacial pain symptoms in a stratified sample of community dwelling adults. The subjects were 724 participants in the Florida Dental Care Study, a longitudinal study of oral health among dentate adults, age 45 and older at baseline. Pain prevalence and subjective ratings were assessed for a range of orofacial pain sites using a standardized telephone interview. The results suggest that the 6-month prevalence of jaw joint pain (8.3%), face pain (3.1%), toothache pain (12.0%), painful oral sores (15.6%), and burning mouth (1.6%) found in the FDCS sample are similar to United States population estimates. In addition, prevalence for pain when chewing and temperature sensitivity were also reported as 23% and 24% respectively, suggesting that these two seldom documented painful experiences are common. Female respondents reported higher 6-month prevalence for multiple symptoms and painful oral sores, with trends also observed for female sex as a risk factor for jaw joint pain and face pain, whereas males were more likely to report temperature sensitivity. A higher percentage of females rated their pain as severe enough to impact behavior for jaw joint pain, toothache pain, and painful oral sores. Few overall age effects were found, with the exception of higher prevalence of temperature sensitivity and pain when chewing in the 45--64-year-old group, compared to respondents in the 65+ age cohort. However, the most interesting finding was that when sex by age cohort comparisons were made, with the exception of painful oral sores, all significant differences in pain ratings were found within the 45--64-year-old cohort and not the 65+ group. This finding clarified inconsistencies found in earlier studies in the orofacial pain literature where sex differences in pain ratings were found in several adult samples of a wide range of ages but not in a sample of older adults.

Evaluation of bias and logistics in a survey of adults at increased risk for oral health decrements

OBJECTIVES

Designing research to include sufficient respondents in groups at highest risk for oral health decrements can present unique challenges. Our purpose was to evaluate bias and logistics in this survey of adults at increased risk for oral health decrements.

METHODS

We used a telephone survey methodology that employed both listed numbers and random digit dialing to identify dentate persons 45 years old or older and to oversample blacks, poor persons, and residents of nonmetropolitan counties. At a second stage, a subsample of the respondents to the initial telephone screening was selected for further study, which consisted of a baseline in-person interview and a clinical examination. We assessed bias due to: (1) limiting the sample to households with telephones, (2) using predominantly listed numbers instead of random digit dialing, and (3) nonresponse at two stages of data collection.

RESULTS

While this approach apparently created some biases in the sample, they were small in magnitude. Specifically, limiting the sample to households with telephones biased the sample overall toward more females, larger households, and fewer functionally impaired persons. Using predominantly listed numbers led to a modest bias toward selection of persons more likely to be younger, healthier, female, have had a recent dental visit, and reside in smaller households. Blacks who were selected randomly at a second stage were more likely to participate in baseline data gathering than their white counterparts. Comparisons of the data obtained in this survey with those from recent national surveys suggest that this methodology for sampling high-risk groups did not substantively bias the sample with respect to two important dental parameters, prevalence of edentulousness and dental care use, nor were conclusions about multivariate associations with dental care recency substantively affected.

CONCLUSIONS

This method of sampling persons at high risk for oral health decrements resulted in only modest bias with respect to the population of interest.

How dentists diagnose and treat defective restorations: evidence from the dental practice-based research network

OBJECTIVES

To (1) identify and quantify the types of treatment that dentists use to manage defective dental restorations and (2) identify characteristics that are associated with these dentists' decisions to replace existing restorations. The Dental Practice-Based Research Network (DPBRN) consists of dentists in outpatient practices from five regions: AL/MS: Alabama/Mississippi; FL/GA: Florida/Georgia; MN: dentists employed by HealthPartners and private practitioners in Minnesota; PDA: Permanente Dental Associates in cooperation with Kaiser Permanente's Center for Health Research and SK: Denmark, Norway and Sweden.

METHODS

A questionnaire was sent to all DPBRN practitioner-investigators who reported doing some restorative dentistry (n = 901). Questions included clinical case scenarios that used text and clinical photographs of defective restorations. Dentists were asked what type of treatment, if any, they would use in each scenario. Treatment options ranged from no treatment to full replacement of the restoration with or without different preventive treatment options. The authors of the current study used logistic regression to analyze associations between the decision to intervene surgically (repair or replace) and the specific dentist, practice and patient characteristics.

RESULTS

A total of 65% of dentists would replace a composite restoration when the defective margin was located on dentin and 49% would repair it when the defective margin was located on enamel. Most (52%) dentists would not intervene surgically when the restoration in the scenario was amalgam. Dentists participating in a solo or small private practice (SPP) chose surgical intervention more often than dentists participating in large group practices (LGP) or in public health practices (PHP) (p < .0001). Dentists who do not routinely assess caries risk during treatment planning were more likely to intervene surgically and less likely to choose prevention treatment (p < .05). Dentists from the SK region chose the "no treatment" option more often than dentists in the other regions.

CONCLUSIONS

Dentists were more likely to intervene surgically when the restoration was an existing composite, compared to an amalgam restoration. Treatment options chosen by dentists varied significantly by specific clinical case scenario, whether the dentist routinely performs caries risk assessment, type of practice and DPBRN region.

Determinants of dental care use in dentate adults: six-monthly use during a 24-month period in the Florida Dental Care Study

The objective of this study is to describe for a diverse sample of dentate adults the incidence of dental care use and predisposing, enabling, and need correlates of that use. The Florida Dental Care Study (FDCS) is a prospective longitudinal cohort study of persons who at baseline had at least one natural tooth, were 45 years or older, and who resided in north Florida, U.S.A. An in-person interview and clinical dental examination were conducted at baseline and 24 months after baseline, with 6-monthly telephone interviews between those times. Seventy-seven percent of subjects reported one or more dental visits during the 24 months of follow-up. Six-monthly use ranged from 46% to 55%. Incident perceived need for care and certain incident self-reported oral signs and symptoms were strongly predictive of incident dental care use. Decrements in oral functional limitation, oral disadvantage, and self-rated oral health were predictive of less care bivariately, but were not salient in a multivariate model, with two notable exceptions: two measures related to esthetics. The conclusions are that certain measures of need (perceived need and specific self-reported signs and symptoms) were important predictors of incident dental care. However, persons with need as determined by direct clinical examination and persons with need as determined by self-reported decrements in the more distal measures of oral health (oral functional limitation, oral disadvantage, and self-rated oral health) were actually less likely to seek dental care. The salience of esthetics in predicting use is consistent with cross-sectional findings that dental esthetic cues are important to oral "health". Typical approach to care, dental attitudes, ability to pay for care, race, and sex were also important for understanding incident dental care use.

Orofacial pain symptom prevalence: selective sex differences in the elderly?

This study investigated sex differences in orofacial pain symptoms in a sample of elderly adults. Furthermore, differences across sex were tested on symptom continuity, overall duration, pain severity, activity reduction, and health care utilization, related to each specific symptom. Telephone interviews were conducted with a stratified random sample of community dwelling older (65+) north Floridians. A total of 5860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Of the remaining households, 1636 completed the interview. Of the total sample, 17.4% reported experiencing at least one of the four target orofacial pain symptoms (jaw joint pain, face pain, oral sores, burning mouth) during the past year, suggesting that orofacial pain symptoms are common in older adults. Our findings for prevalence of each specific symptom (jaw joint pain, 7.7%; face pain, 6.9%; oral sores, 6.4%; toothache, 12.0%; burning mouth, 1.7%) are similar to those estimated by the 1989 National Health Interview Survey, for the US adult population. Consistent with other epidemiological and clinical studies, we found that females were more likely to report jaw joint pain and face pain than males. In contrast to clinical studies, no differences were found on subjective ratings of pain severity, for any symptom. Differences across sex were most likely to be reported for jaw joint pain related variables, suggesting undetermined sex-uniqueness for these symptoms. In contrast to previous studies, older females tended to report lower levels of health care utilization than older males. This is the first study to our knowledge that reports orofacial symptom-specific sex differences among the elderly.

Relationship of dental status, sociodemographic status, and oral symptoms to perceived need for dental care

OBJECTIVE

Previous studies have noted a discrepancy between clinically determined oral health status (normative need), patients' perceptions, and perceived significance of dental signs and symptoms. Our objective was to quantify the relationships between normative need and self-reports to improve our understanding of the factors that contribute to perceived need for care.

METHODS

Clinical examination and questionnaire data were derived from the Florida Dental Care Study, a study of oral health and dental care, in a representative sample of community-dwelling adults aged > or = 45 years. The questionnaire provided information about presence of signs and symptoms, self-ratings of oral health, perceived need for dental care, and sociodemographic status (SDS). Perceived need was measured on a 4-point nominal scale.

RESULTS

Self-reported broken filling, broken denture, cavities, loose tooth, teeth that look bad, and toothache were strongly associated with self-reported perceived need for dental care. Satisfaction with dental health was also associated with perceived need, but self-rated oral health was not. Most measures of SDS were associated with perceived need. However, in a single multiple regression, with self-reported signs and symptoms accounted for, race, age group, sex, and educational attainment were not significantly associated with a currently perceived dental problem.

CONCLUSIONS

Certain dental signs and symptoms were significantly associated with perceived need for dental care, as were certain aspects of SDS; even once differences in dental signs and symptoms had been taken into account. Disaggregating measurement of perceived need from a single dichotomous ('yes/no') scale to a 4-point nominal scale was elucidative.

Risk indicators of edentulism, partial tooth loss and prosthetic status among black and white middle-aged and older adults

OBJECTIVES

To describe the prevalence and risk indicators of edentulism; to describe the frequencies of wearing removable dentures; to describe the prevalence and risk indicators of fixed prosthetic restorations; to test the hypothesis that fixed prosthetic restorations are most likely to have been placed in persons at lower risk for dental and periodontal diseases, and to test the hypothesis that, with dental disease, dental behaviors, dental attitudes and ability to afford crowns taken into account, blacks are less likely than whites to have received crowns.

METHODS

The Florida Dental Care Study is a cohort study of subjects 45 years old or older. A telephone screening interview was done as a first stage to identify 5254 subjects who met eligibility requirements and who self-reported whether they were edentulous. In a second stage, a subsample of dentate subjects was contacted after they completed their telephone screening interview. Of these, 873 subjects completed a baseline in-person interview and dental examination.

RESULTS

A total of 19% of first-stage subjects were edentulous. In a single multiple logistic regression, having a poorer self-rated level of general health was significantly associated with edentulism, as were being poor, older and white. Among the second-stage participants (all of whom were dentate), several prosthetic patterns were observed. For example, a total of 64% of maxillary full denture wearers reported wearing their denture all the time. Participants had also received numerous fixed prosthodontic services. The proportion of subjects with at least one crown varied widely by subject characteristics.

CONCLUSIONS

A substantial percentage of non-ideal frequencies of wearing removable prostheses was reported, as were prosthesis-related soreness and broken prostheses. Although we expected and observed an association between having a fixed prosthetic crown and periodontal status, dental fillings, dental attitudes and financial resources, a residual association with race suggests that blacks are much less likely to receive prosthetic crowns. The several possible reasons for this circumstance warrant further investigation.

Concordance between clinical practice and published evidence: findings from The National Dental Practice-Based Research Network

BACKGROUND

Documenting the gap between what is occurring in clinical practice and what published research findings suggest should be happening is an important step toward improving care. The authors conducted a study to quantify the concordance between clinical practice and published evidence across preventive, diagnostic and treatment procedures among a sample of dentists in The National Dental Practice-Based Research Network ("the network").

METHODS

Network dentists completed one questionnaire about their demographic characteristics and another about how they treat patients across 12 scenarios/clinical practice behaviors. The authors coded responses to each scenario/clinical practice behavior as consistent ("1") or inconsistent ("0") with published evidence, summed the coded responses and divided the sum by the number of total responses to create an overall concordance score. The overall concordance score was calculated as the mean percentage of responses that were consistent with published evidence.

RESULTS

The authors limited analyses to participants in the United States (N = 591). The study results show a mean concordance at the practitioner level of 62 percent (SD = 18 percent); procedure-specific concordance ranged from 8 to 100 percent. Affiliation with a large group practice, being a female practitioner and having received a dental degree before 1990 were independently associated with high concordance (≥ 75 percent).

CONCLUSION

Dentists reported a medium-range concordance between practice and published evidence.

PRACTICAL IMPLICATIONS

Efforts to bring research findings into routine practice are needed.

Validity of self-reported tooth counts during a telephone screening interview

OBJECTIVES

Telephone screening has become a common method used in health services research to identify efficiently persons in specific populations of interest. In this research, we used a large-scale telephone screening survey to assess: (1) the effectiveness of the telephone method in gathering tooth count information by measuring response rate (cooperation) to specific questions and (2) the validity of subjects' reports of the number of remaining natural teeth.

METHODS

We used a telephone screening methodology to identify dentate persons (at least one natural tooth remaining) who were 45 years old or older and resided in one of four counties of north Florida. At a second stage, a sample of the telephone screening participants was selected for further study, which consisted of a baseline in-person interview and a clinical examination. We compared the number of remaining teeth reported during the telephone interview with the number determined at baseline examination.

RESULTS

The telephone method was effective at gathering tooth count information, although response rates varied with the level of specificity required. Almost all subjects reported the number of teeth at least at the nominal and ordinal levels, but fewer than three-fourths reported the number at the interval level. When the unit of analysis was the overall sample, self-reported number of teeth was a valid measure of the true number. When the unit of analysis was the individual subject, validity was associated with certain clinical and sociodemographic factors.

CONCLUSIONS

When the unit of analysis is the overall sample, these results suggest that self-reported tooth counts during a telephone interview are sufficiently valid to meet all but the most stringent data requirements. When the unit of analysis is the individual subject, these tooth counts may not be valid, depending upon the degree of specificity required and subject characteristics.

Tooth-specific and person-level predictors of 24-month tooth loss among older adults

OBJECTIVES

To describe: (1) the 24-month incidence of tooth loss in a diverse sample of dentate adults; and (2) the clinical, attitudinal, behavioral, and sociodemographic correlates of tooth loss incidence.

METHODS

The Florida Dental Care Study is a prospective longitudinal cohort study of persons who at baseline had at least one tooth, were 45 years or older, and who resided in north Florida. An in-person interview and clinical examination were conducted at baseline and 24-months after baseline, with 6-monthly telephone interviews between those times. A two-level hierarchical generalized linear regression (logit model) was used to quantify tooth-specific and person-level factors simultaneously.

RESULTS

Of the 739 persons who attended for a 24-month examination, 24% lost one or more teeth during follow-up. Tooth loss was more common in persons with dental disease at baseline, incident dental signs or symptoms, those with negative attitudes toward dental care and dental health, those with limited financial resources, older adults, blacks, females, and problem-oriented users of dental care (as distinct from regular attenders). Although disease presence at baseline was a major factor associated with incident tooth loss, most diseased teeth were in fact still present 24 months after baseline.

CONCLUSIONS

Other than periodontal attachment loss, severe tooth mobility, and dental caries, no single factor was a dominant predictor of tooth loss; instead, numerous factors made statistically significant but small contributions to variation in tooth loss. Tooth loss apparently is the result of complex interactions among dental disease, incident dental signs and symptoms, tendency to use dental care in response to specific dental problems, dental attitudes, and ability to afford non-extraction treatment alternatives.

Familial hidradenitis suppurativa: evidence in favour of single gene transmission

The three English families in this report have a total of 21 members (16 females and five males) suffering from chronic hidradenitis suppurativa. In family A the condition is associated with acne conglobata and there is vertical transmission of the disorder through three generations. In the others there is no associated cystic acne, but all those affected had a history of acne vulgaris with comedone formation, and the condition has been confirmed in two generations. It is likely that a male in an earlier generation in family B suffered from the disease and affected sibs in family C were born to different fathers. The familial aggregation and number of affected subjects suggests a single gene disorder and the pattern of transmission is consistent with autosomal dominant inheritance. Males and females are affected in successive generations and there is the anticipated variation in clinical severity in those suffering from the condition.

A prospective study of the validity of data on self-reported dental visits

OBJECTIVE

To measure the validity of self-reported dental visits from a diverse sample of adults.

METHODS

The Florida Dental Care Study was a longitudinal cohort study of a diverse sample of residents of north Florida, USA. In-person interviews and dental examinations were conducted at baseline, 24 and 48 months after baseline, with half-yearly telephone interviews in between. Dental record information was abstracted afterward.

RESULTS

Agreement between self-report and dental record at each half-yearly interview ranged from 84 to 91%. Validity did not differ between persons of key sociodemographic groups (sex, race, age group, rural/urban residence, poverty status, level of formal education, or problem-oriented/regular approach to dental care). In a single bivariate multiple logistic regression (two outcomes: (i) self-reported use; and (ii) use measured from the dental chart), odds ratio estimates over-lapped for each of the 20 predictors.

CONCLUSIONS

Validity of self-reported dental care use was good. There would have been few differences in conclusions made about predictors of dental care use had chart data been available earlier.

Practices participating in a dental PBRN have substantial and advantageous diversity even though as a group they have much in common with dentists at large

BACKGROUND

Practice-based research networks offer important opportunities to move recent advances into routine clinical practice. If their findings are not only generalizable to dental practices at large, but can also elucidate how practice characteristics are related to treatment outcome, their importance is even further elevated. Our objective was to determine whether we met a key objective for The Dental Practice-Based Research Network (DPBRN): to recruit a diverse range of practitioner-investigators interested in doing DPBRN studies.

METHODS

DPBRN participants completed an enrollment questionnaire about their practices and themselves. To date, more than 1100 practitioners from the five participating regions have completed the questionnaire. The regions consist of: Alabama/Mississippi, Florida/Georgia, Minnesota, Permanente Dental Associates, and Scandinavia (Denmark, Norway, and Sweden). We tested the hypothesis that there are statistically significant differences in key characteristics among DPBRN practices, based on responses from dentists who participated in DPBRN's first network-wide study (n = 546).

RESULTS

There were statistically significant, substantive regional differences among DPBRN-participating dentists, their practices, and their patient populations.

CONCLUSION

Although as a group, participants have much in common with practices at large; their substantial diversity offers important advantages, such as being able to evaluate how practice differences may affect treatment outcomes, while simultaneously offering generalizability to dentists at large. This should help foster knowledge transfer in both the research-to-practice and practice-to-research directions.

Dentists' use of caries risk assessment and individualized caries prevention for their adult patients: findings from The Dental Practice-Based Research Network

OBJECTIVES

Few studies have examined dentists' subjective ratings of importance of caries risk factors or tested whether dentists use this information in treatment planning. This study tested several hypotheses related to caries risk assessment (CRA) and individualized caries prevention (ICP).

METHODS

Data were collected as part of a questionnaire entitled 'Assessment of Caries Diagnosis and Caries Treatment', completed by 547 practitioners who belong to The Dental Practice-Based Research Network (DPBRN), a consortium of participating practices and dental organizations.

RESULTS

Sixty-nine percent of DPBRN dentists perform CRA on their patients. Recently graduated dentists, dentists with busier practices, and those who believe a dentist can predict future caries were the most likely to use CRA. The association between CRA and individualized prevention was weaker than expected (r = 0.21). Dentists who perform CRA provide ICP to 57% of their patients, compared with 42% for dentists who do not perform CRA. Based on their responses to radiographic and clinical scenarios in the questionnaire, dentists who use CRA appear to use this information in restorative decisions.

CONCLUSION

A substantial percentage of DPBRN dentists do not perform CRA, and there is not a strong linkage between its use and use of individualized preventive regimens for adult patients. More progress in the implementation of current scientific evidence in this area is warranted.

Smoking and smokeless tobacco: increased risk for oral pain

Tobacco has been linked with several pain conditions that include musculoskeletal pain, rheumatoid arthritis, and fibromyalgia. This study documented associations between smoking and smokeless tobacco use and measures of orofacial pain and oral pain impacts (activity reduction and trouble with sleep) assessed during a 48-month time period. These data were collected as part of the Florida Dental Care Study, a longitudinal study of oral health among 873 adults aged 45 years and older at baseline. Twenty-five percent of the study participants were current users of some form of tobacco, and 34% were former users. Separate models were tested for smoking and smokeless tobacco. Current tobacco users were at increased risk of experiencing a range of painful oral symptoms. We also found that behavioral impacts associated with oral pain are sensitive to differences in tobacco use status. Our data also support the supposition that once tobacco cessation occurs, the risk for pain associated with oral disease decreases significantly. No differences were found between former users and those never having used tobacco across any of the pain measures. Strengths of the current study include the longitudinal methodology, assessment of different pain symptoms with potentially differing etiology, and that several markers of tobacco use were used (prevalence, consumption, and duration).

PERSPECTIVE

This study considers the harmful effects of tobacco use on oral health. Smokers were at significantly increased risk for oral pain and related limitation of daily activities. The data also suggest that the risk for oral pain associated with tobacco use decreases significantly if tobacco cessation occurs.