Relationship of clinical depression to periodontal treatment outcome

BACKGROUND

Depression has been associated with periodontal disease; however, its relationship to periodontal treatment outcome (PTO) has not been investigated.

METHODS

Data were obtained by chart abstraction and computer databases on 1,299 health maintenance organization (HMO) patients aged 30 to 64 who had concurrent medical, dental, and pharmacy benefits, and who had an initial periodontal examination during 1996, 1997, or 1998. Depression (yes/no) was the main independent variable and was determined by presence of any diagnosis code for depression on the patient record. PTO was determined by the difference in percent of sites with probing depth (PD) > or = 5 mm between the initial and 1-year post-treatment periodontal exams. Sub-median periodontal treatment outcome (SMPTO) was defined as a reduction in fewer than the median percent of sites (7.33%) with PD > or = 5 mm. Information on sociodemographics, periodontal therapy, calculus and plaque, number of remaining teeth, smoking, antidepressant medications, and diabetes were collected.

RESULTS

A total of 697 patients had a periodontal exam at both baseline and follow-up. Of these, 12.2% had depression. In a multivariable logistic model, depression (odds ratio [OR] 2.16, 95% confidence interval [Cl] 1.12 to 4.16) and 4-month recall treatment (OR 2.34, Cl 1.46 to 3.75) were associated with SMPTO, while percent of sites at baseline with PD > or = 5 mm (OR 0.93, Cl 0.91 to 0.94), number of remaining teeth at baseline (OR 0.94, Cl 0.89 to 0.99), and number of teeth lost during the study period (OR 0.75, Cl 0.58 to 0.96) were negatively associated. Periodontal surgery, age, gender, smoking, plaque, calculus, diabetes, and antidepressant medication were not significant in the model.

CONCLUSION

Clinical depression may have a negative effect on periodontal treatment outcome in this group model HMO population.

Movement of teeth adjacent to posterior bounded edentulous spaces

Bounded edentulous spaces (BES)-a missing posterior tooth with intact adjacent teeth-are thought to lead to arch collapse resulting from the movement of adjacent teeth. To determine the rate of change in distance between teeth adjacent to a BES, we examined three successive measurable radiographs of 116 untreated posterior BES cases. The distance between the teeth (DBT) adjacent to the space was measured, and change in DBT (delta DBT) between pre-extraction and follow-up radiographs was calculated. We used linear spline regression to construct models for tooth movement and to identify factors associated with delta DBT. The mean delta DBT was < 1 mm during the first year post-extraction, and the DBT continued to decrease at a successively slower rate each following year. Overall and for each tooth type, the greatest rates of decrease in DBT were seen in the zero to two-year period. In a multivariable model, time since extraction and tooth type were significantly associated with delta DBT. These findings suggest that movement of teeth adjacent to a posterior BES after the first two years is usually gradual and minor within the time frame of this study.

Clinical decision-making for dental caries management

Scientific information on diagnosis, prevention, and management of dental caries and associated indicators of risk continues to increase rapidly. Patients vary in clinically important ways, however, and uncertainty affects our understanding of risk; diagnostic and prognostic information; efficacy and effectiveness of many preventive, diagnostic, and treatment alternatives; and outcomes associated with clinical strategies. Consequently, challenges abound for clinicians to identify, evaluate, and incorporate new information, patient preferences, and uncertainties into clinical practice. Clinical decision-making--an analytical approach that makes explicit use of information to quantify probabilities and outcomes to analyze decisions under conditions of uncertainty--can provide a framework to analyze the impact of uncertainty of clinical information. Diagnostic, effectiveness, and outcome information is quantified and combined in an explicit way to serve as a tool for clinicians, not as a replacement for clinical judgment or experience. Such an approach has the potential to improve clinical practice and help dentists do their jobs better by structuring the decision problem and assessing probabilities and utilities. Clinical decision-making also helps dentists communicate with each other by identifying clinical controversies, thereby characterizing how and why disagreements may arise and what additional data may be needed to address a clinical question.

State of the evidence base for medically necessary oral health care

OBJECTIVE

The purpose of this article was to highlight the recent call for an evidence-based approach to public policy decision making with respect to funding dental services and the need this creates for enhanced clinical research activities.

STUDY DESIGN

Systematic reviews on topics of importance to oral health care practitioners are being conducted and published by various national and international groups. Recent activities to assess evidence to support medically necessary dental services were reviewed.

RESULTS

An Institute of Medicine Committee on Medicare Coverage Extensions found little published scientific evidence that directly assessed the effectiveness of dental services in preventing or managing systemic health outcomes for patients with head and neck cancer, lymphoma, leukemia, organ transplantation, and heart valve repair or replacement.

CONCLUSIONS

The scientific community must strive to meet the challenge of conducting well-designed randomized, controlled trials that test the impact of dental treatment interventions on systemic health to meet the growing need for evidence to support or refute widely accepted dental treatment protocols for medically complex patients.

Extending Medicare coverage to medically necessary dental care

BACKGROUND

Periodically, Congress considers expanding Medicare coverage to include some currently excluded health care services. In 1999 and 2000, an Institute of Medicine committee studied the issues related to coverage for certain services, including "medically necessary dental services."

METHODS

The committee conducted a literature search for dental care studies in five areas: head and neck cancer, leukemia, lymphoma, organ transplantation, and heart valve repair or replacement. The committee examined evidence to support Medicare coverage for dental services related to these conditions and estimated the cost to Medicare of such coverage.

RESULTS

Evidence supported Medicare coverage for preventive dental care before jaw radiation therapy for head or neck cancer and coverage for treatment to prevent or eliminate acute oral infections for patients with leukemia before chemotherapy. Insufficient evidence supported dental coverage for patients with lymphoma or organ transplants and for patients who had undergone heart valve repair or replacement.

CONCLUSIONS

The committee suggested that Congress update statutory language to permit Medicare coverage of effective dental services needed in conjunction with surgery, chemotherapy, radiation therapy or pharmacological treatment for life-threatening medical conditions.

PRACTICE IMPLICATIONS

Dental care is important for members of all age groups. More direct, research-based evidence on the efficacy of medically necessary dental care is needed both to guide treatment and to support Medicare payment policy.

Identification of patterns of transmission of Salmonella within swine production systems using pulsed field gel electrophoresis (PFGE) and repetitive sequence polymerase chain reaction (REP-PCR): a quantitative analysis

Pulsed field gel electrophoresis (PFGE) using 3 enzymes (Spe I, Xba I, Avr II) and repetitive sequence polymerase chain reaction (REP-PCR) with 3 primers (BOX, ERIC, REP) were compared with respect to their validity as a method for identifying transmission of Salmonella on swine farms. Sixty-eight isolates of Salmonella were obtained from feces of swine, cats, mice, and birds, insect body parts, water and floor samples, and boot scrapings collected on 9 swine farms in Illinois USA. Genetic distances between isolates were calculated using the Dice matching coefficient. Cluster analysis of distance matrices was conducted using the UPG-MA algorithm. There was no significant difference between PFGE and REP-PCR in the genetic diversity detected; however, REP-PCR differentiated between 14 pairs of isolates which PFGE identified as identical. There were no significant differences between PFGE and REP-PCR in identifying all or most close genetic links as isolates from the same farm, the same building, and from the same sampling visit, suggesting ecological validity for both methods. Thus, REP-PCR should be considered as an acceptable and perhaps preferable alternative to PFGE as a genotyping method for studies of Salmonella transmission.

Clinical factors related to noncompletion of root canal therapy

OBJECTIVES

This study identified clinical factors related to noncompletion of root canal therapy (RCT) among patients in a dental health maintenance organization (HMO) based in Portland, OR.

METHODS

A secondary analysis of a case-control study was conducted using data from 303 individuals enrolled continuously in the HMO from January 1, 1987, through December 31, 1994, who received endodontic access on a permanent nonwisdom tooth in 1987 or 1988. Person- and tooth-level characteristics were evaluated to compare patients whose accessed tooth was obturated by December 31, 1994, with patients whose accessed tooth was not obturated by that date. Written and electronic records were reviewed to ascertain study variables, and multivariate logistic regression models were developed to describe differences between the two groups.

RESULTS

Incomplete RCT was more common among patients who were symptomatic prior to access and had more missing first molars at access. It also was more common among teeth that were decayed, had more pockets > or = 5 mm, and had fewer decayed or filled surfaces at access.

CONCLUSIONS

Because patients with greater evidence of past and current oral disease were less likely to have completed RCT, they may require additional counseling about the importance of carrying through with prescribed treatment.

Health care utilization and cost among health maintenance organization members with temporomandibular disorders

AIMS

Little has been reported on the use of health care services and consequent costs among persons with temporomandibular disorders (TMD). This project compared the use and cost of medical and dental care services for TMD patients and matched comparison subjects.

METHODS

Patients were continuously enrolled members of Kaiser Permanente Northwest Division who had at least 1 TMD Clinic visit or TMD-related procedure between January 1990 and December 1995 (n = 8,801). An equal number of comparison subjects were identified electronically and matched on 14 variables, including age and gender. Utilization and cost estimates were determined and compared for selected medical and dental services.

RESULTS

For both groups, the mean age was about 40.5 years, and approximately 80% were female. The TMD subjects used significantly more services than did comparison subjects and had mean costs that were 1.6 times higher for all services. Outpatient visits accounted for about 40% of the difference in mean costs. About 10% of TMD subjects and comparison subjects accounted for about 40% and 47% of the costs in each group, respectively. Female TMD subjects and comparison subjects had higher costs than their male counterparts, and male TMD subjects had higher costs than female comparison subjects.

CONCLUSION

Patients with TMD used more of all types of services and had higher costs. A small proportion of the subjects accounted for a large proportion of the costs. Gender was an important factor in utilization and cost. Utilization and cost differences were consistent over a wide range of service categories and could not be explained by TMD alone.

Characterization of a putative membrane receptor for progesterone in rat granulosa cells

Progesterone (P(4)) inhibits granulosa cell apoptosis in a steroid-specific, dose-dependent manner, but these cells do not express the classic nuclear P(4) receptor. It has been proposed that P(4) mediates its action through a 60-kDa protein that functions as a membrane receptor. The present studies were designed to determine the P(4) binding characteristics of this protein. Western blot analysis using an antibody that recognizes the P(4) binding site of the nuclear P(4) receptor (C-262) confirmed that the 60-kDa protein was localized to the plasma membrane of both granulosa cells and spontaneously immortalized granulosa cells (SIGCs). To determine whether this protein binds P(4), proteins were immunoprecipitated with the C-262 antibody, electrophoresed, transferred to nitrocellulose, and probed with a horseradish peroxidase-labeled P(4) in the presence or absence of nonlabeled P(4). This study demonstrated that the 60-kDa protein specifically binds P(4). Scatchard plot analysis revealed that (3)H-P(4) binds to a single site (i.e., single protein), which is relatively abundant (200 pmol/mg) with a K(d) of 360 nM. (3)H-P(4) binding was not reduced by dexamethasone, mifepristone (RU 486), or onapristone (ZK98299). Further studies with SIGCs showed that P(4) inhibited apoptosis and mitogen-activated protein kinase kinase (MEK) activity, and maintained calcium homeostasis. These studies taken together support the concept that the 60-kDa P(4) binding protein functions as a low-affinity, high-capacity membrane receptor for P(4).

Ten-year survival rates of teeth adjacent to treated and untreated posterior bounded edentulous spaces

STATEMENT OF PROBLEM

Failure to replace a single missing posterior tooth may lead to a variety of dental problems, which may ultimately result in tooth loss. However, little is known about the fate of the adjacent teeth if a missing posterior tooth is not replaced.

PURPOSE

This retrospective study evaluated the survival of teeth adjacent to treated and untreated posterior bounded edentulous spaces.

MATERIAL AND METHODS

Data were obtained from electronic treatment records from the Kaiser Permanente Dental Care Program, Portland, Ore. A final sample of 317 patients who met the study inclusion criteria was identified. Each bounded edentulous space was placed in 1 of 3 treatment categories: untreated, restored with a fixed partial denture, or restored with a removable partial denture. Subsequent treatment and the status of the teeth adjacent to the bounded edentulous space were followed through December 1999. Ten-year Kaplan-Meier survival estimates were generated for each treatment group, and differences in survival were evaluated with the log-rank chi-square test (alpha=.05).

RESULTS

There was a significant difference in survival among the 3 treatment categories (P=.005). Spaces restored with a fixed partial denture had longer 10-year survival estimates (92%) than those that remained untreated (81%). Spaces restored with a removable partial denture had the poorest 10-year survival rate (56%).

CONCLUSION

Under the conditions and selection bias associated with this retrospective study, the survival of teeth adjacent to a single posterior edentulous space was negatively associated with removable partial denture placement compared with no treatment or the use of a fixed partial denture.

Characterization of two novel saccharolytic, anaerobic thermophiles, Thermoanaerobacterium polysaccharolyticum sp. nov. and Thermoanaerobacterium zeae sp. nov., and emendation of the genus Thermoanaerobacterium

Two anaerobic, thermophilic, Gram-positive, non-spore forming bacteria with an array of polysaccharide-degrading enzymes were isolated from the leachate of a waste pile from a canning factory in Hoopeston, East Central Illinois, USA. The results of 16S rDNA sequence homology indicated that their closest relatives belong to the saccharolytic, thermophilic and anaerobic genera of Thermoanaerobacterium and Thermoanaerobacter. Although, the evolutionary distances between these bacteria and their closest relatives are greater than 11%, there is no defining phenotypic characteristic for the creation of a new genus. It is proposed that these bacteria should be placed in the genus Thermoanaerobacterium, which requires emendment of the genus description with regard to the reduction of thiosulfate to sulfur, because neither isolate is capable of this reduction. Thermoanaerobacterium polysaccharolyticum reduces thiosulfate to sulfide, whereas Thermoanaerobacterium zeae is unable to reduce thiosulfate. The cells of both isolates are rod-shaped and exist as single cells or sometimes in pairs. Cells are motile by means of flagella. Growth occurs between 45 and 72 degrees C, with optimum temperature of 65-68 degrees C at pH 6.8. The pH range for growth is from 4 to 8 at a temperature of 65 degrees C. Both organisms ferment glucose, arabinose, maltose, mannose, rhamnose, sucrose, trehalose, xylose, cellobiose, raffinose, melibiose and melezitose. The major end products of fermentation with glucose are ethanol and CO2, with lesser amounts of acetate, formate, lactate and hydrogen. The DNA G+C contents of Thermoanaerobacterium polysaccharolyticum sp. nov. and Thermoanaerobacterium zeae sp. nov. are 46 and 42 mol%, respectively. The type strains are KMTHCJT (= ATCC BAA-17T = DSM 13641T) and mel2T (= ATCC BAA-16T = DSM 13642T), respectively.

Identification of adult populations at high risk for dental caries using a computerized database and patient records: a pilot project

OBJECTIVES

The purpose of this study is to test the usefulness of dental insurance claims history, supplemented with radiographic caries diagnoses, as a means of identifying caries-active and caries-inactive working adults, as determined by bacterial levels. Computerized identification of at-risk groups may facilitate subject selection for clinical trials designed to test caries-preventive strategies.

METHODS

Two groups of subjects were initially selected from an insurance database based upon their dental service utilization during a one-year period: a "low restorative" group of individuals defined as persons who had received no restorative treatment, and a "high restorative" group comprised of individuals who had received at least three multisurfaced restorations. A chart review confirmed a diagnosis of caries in the high restorative group and an absence of caries in the low restorative group. Subjects were then approached for saliva collection. The low and high restorative groups were compared for salivary mutans streptococci and lactobacilli levels, stimulated flow rate, and buffer capacity (n = 48).

RESULTS

The high and low restorative groups differed in mutans streptococci levels, but not on other measures.

CONCLUSIONS

A group of subjects who had recently received multisurfaced restorations that were placed for reasons of caries had significantly higher levels of mutans streptococci and potential for continued caries activity when compared to a group of subjects who had received no restorations and were caries free.

The dentogingival epithelial surface area revisited

Recent studies implicating periodontitis as a cause of systemic diseases have reported that the surface area of periodontal pockets exposed to bacterial biofilm ranges from 50 cm2 to 200 cm2. Since the root surface area of the typical human dentition (excluding 3rd molars) is 75 cm2, these estimates appear too large. The goal of this study was to relate linear periodontal probing measurements to the dentogingival surface area (DGES). The DGES comprises both the sulcular and junctional epithelium, present in health, as well as any intervening pocket epithelium present in periodontitis. Formulas to estimate the DGES from clinical measures were derived from a meta-analysis of root surface areas, published values of root length, and a study that related the percent remaining root surface area to the percent remaining root length. These formulas were applied to a survey of the adult US population, the Veterans Affairs (VA) Dental Longitudinal Study, and a population of individuals visiting a periodontist. Individuals without periodontitis had a typical DGES of 5 cm2. Among individuals with periodontitis, the mean DGES in the three samples ranged from 8 cm2 (ranging from 1 cm2 to 29 cm2) to 20 cm2 (ranging from 2 cm2 to 44 cm2). It was concluded that the mean DGES among individuals with periodontitis ranges from 8 cm2 to 20 cm2, considerably smaller than the range of 50 cm2 to 200 cm2 currently assumed.

The consequences of not replacing a missing posterior tooth

BACKGROUND

Failure to replace a missing posterior tooth is assumed to result in host of adverse consequences, which include shifting of teeth and loss of alveolar bone support.

METHODS

A retrospective longitudinal study (median follow-up period 6.9 years), using the radiographs of 111 patients who had an untreated bounded edentulous space, or BES, was conducted to determine the extent to which these adverse outcomes occurred.

RESULTS

The majority of patients lost 1 millimeter or less of the distance between teeth adjacent to the space, extrusion of the opposing tooth was < or = 1 mm in 99 percent of the cases, and the amount of alveolar bone loss next to the adjacent teeth was < or = 1 mm in 83 percent of the cases.

CONCLUSIONS

Within the follow-up time in this study, this group of patients did not exhibit the expected adverse consequences with either the frequency or severity generally assumed to be associated with nonreplacement of a single posterior tooth.

CLINICAL IMPLICATIONS

These findings suggest that for the large majority of patients who experience a single-tooth posterior BES, immediate treatment may not be critical to the maintenance of arch stability. Instead, regular follow-up assessments to monitor change in stability and periodontal health may be warranted.

Non-surgical periodontal therapy and tooth loss. A cohort study

BACKGROUND

No reliable evidence is available regarding the effect of periodontal therapy on major disease endpoints such as tooth loss, edentulism, or quality of life. The primary objective of this study was to assess the association between tooth loss and the non-surgical periodontal treatment history of 1,021 members of the Kaiser Permanente Dental Care Program.

METHODS

Tooth loss rates were estimated using Poisson regression models, adjusting for some of the potentially confounding variables such as initial disease severity and extent.

RESULTS

Continuous non-surgical therapy (one or more non-surgical procedures performed during 3 successive years), as opposed to no therapy during such a 3-year period, reduced the subsequent tooth mortality rate by 58% (relative rate, 0.42; 95% confidence interval, 0.29-0.61). Intermittent non-surgical therapy reduced the tooth mortality rate by 48% (RR = 0.52; 95% confidence interval, 0.34-0.80). As the number of non-surgical procedures increased, tooth loss rates decreased.

CONCLUSIONS

These findings suggest that non-surgical periodontal therapy may be associated with a substantial reduction in tooth mortality. Different study designs and populations are needed to confirm these findings.