The association of oral status with systemic health, quality of life, and economic productivity

It is well established that many systemic adverse health conditions have manifestations in the oral cavity. The purpose of this paper is to summarize the available scientific evidence that describes the opposite effect, how adverse oral health conditions affect three aspects of daily living: 1) systemic health, 2) quality of life, and 3) economic productivity. Examples of oral health affecting systemic health include rheumatic fever patients who develop infective endocarditis from oral bacteria and organ transplant patients who develop severe complications from oral infections. Both systemic health and quality of life are compromised when edentulousness, xerostomia, soft tissue lesions, or poorly fitting dentures affect eating and food choices. Conditions such as oral clefts, missing teeth, severe malocclusion, or severe caries are associated with feelings of embarrassment, withdrawal, and anxiety. Oral and facial pain from dentures, temporomandibular joint disorders, and oral infections affect social interaction and daily behaviors. The results of oral disorders can be felt not only physically and socially but also economically in our society. Dental disease accounts for many lost work and school days. Lower wage earners and minorities are disproportionately affected. Although there are many studies that evaluate these relationships, most are case reports, cross-sectional studies, or studies restricted to small or unique population groups. Lack of standardized measurements make comparisons across studies difficult. More population-based and longitudinal studies are needed to better understand the nature of these relationships.

A retrospective analysis of the cost-effectiveness of dental sealants in a children's health center

A retrospective patient record analysis was conducted to study the cost-effectiveness of dental sealants placed under routine, unrestricted practice condition in a fluoridated community. The 26 dentists who provided care at the clinic over the period of the study used their own clinical judgement to determine sealant placement or alternative treatment. Dental services for 275 patients at a children's dental clinic for low-income families were evaluated. All children had at least 3 years between their first and last dental visit (mean = 5.8 years). A lifetable analysis was conducted to compare the probability of survival (restoration-free tooth years) and costs incurred to first molars of children who did not receive sealants, received any sealants, or received sealants on all first molars. Among the children with sealants, comparisons were also made between sealed and unsealed teeth in children who did and did not have a first molar restoration prior to sealant placement. Costs included the costs of sealants and restorative treatments for these teeth over time. Depending on the conditions under which sealants were placed, cost-savings or improving cost-effectiveness with time were found. A strategy of identifying children with prior restorations and sealing the remaining molars showed cost-savings within 4-6 years. For other comparisons, incremental cost-effectiveness ratios became more favorable over time.

University of North Carolina Caries Risk Assessment Study: comparisons of high risk prediction, any risk prediction, and any risk etiologic models

The purpose of this analysis is to compare three different statistical models for predicting children likely to be at risk of developing dental caries over a 3-yr period. Data are based on 4117 children who participated in the University of North Carolina Caries Risk Assessment Study, a longitudinal study conducted in the Aiken, South Carolina, and Portland, Maine areas. The three models differed with respect to either the types of variables included or the definition of disease outcome. The two "Prediction" models included both risk factor variables thought to cause dental caries and indicator variables that are associated with dental caries, but are not thought to be causal for the disease. The "Etiologic" model included only etiologic factors as variables. A dichotomous outcome measure--none or any 3-yr increment, was used in the "Any Risk Etiologic model" and the "Any Risk Prediction Model". Another outcome, based on a gradient measure of disease, was used in the "High Risk Prediction Model". The variables that are significant in these models vary across grades and sites, but are more consistent among the Etiologic model than the Predictor models. However, among the three sets of models, the Any Risk Prediction Models have the highest sensitivity and positive predictive values, whereas the High Risk Prediction Models have the highest specificity and negative predictive values. Considerations in determining model preference are discussed.

Factors influencing the selection of dental hygiene as a profession

Since the mid-1970s, the dental hygiene profession has experienced a decline in the number of applicants. Reasons cited for this decline are fewer traditional college-age students, an increase in the career opportunities available to women, and a decrease in student financial aid. Four-year dental hygiene programs have experienced applicant decline faster than two-year programs. The purpose of this study was to determine factors that influenced university freshmen to designate dental hygiene as a career choice. Factors examined included reasons for choosing or not choosing a career in dental hygiene, and retention in the college major chosen. A questionnaire was mailed to three groups of students who entered the University of North Carolina-Chapel Hill as freshmen from 1985 through 1987: (1) all students who designated dental hygiene as a major on their entrance application; (2) a random sample who did not; and (3) all the freshman during that time period who subsequently matriculated into the dental hygiene program. The overall response rate was 78% (n = 80). Subjects began to explore career opportunities at a mean age of 16. Having a family member/friend in the selected field was found to be the most influential factor in career selection. Among dental hygiene students, contact with a dental hygienist was perceived to be influential in their career choice. Entering college freshmen exhibited a lack of knowledge about the dental hygiene profession, and most had not received any information about dental hygiene in high school. These findings can be used to develop recruitment strategies.

Consistency of orthodontic treatment decisions relative to diagnostic records

The purpose of this study was to evaluate how incremental information obtained from different types of diagnostic records contributes to the determination of orthodontic treatment decisions. Pretreatment records of 57 orthodontic patients were assessed by five orthodontists who were part-time faculty members and also in private practice. This sample consisted of dental school orthodontic patients who had Class II malocclusions and included patients at three different dental developmental stages. The following diagnostic records were used: study models (S), facial photographs (F), a panoramic radiograph (P), a lateral cephalogram (C), and its tracing (T). Five combinations of diagnostic records were presented to the orthodontists in the following sequence: (1) S; (2) S + F; (3) S + F + P; (4) S + F + P + C; and (5) S + F + P + C + T. The simultaneous interpretation of all diagnostic records (S + F + P + C + T) was used as the "diagnostic standard." There was a diagnostic standard for each of the patients and for each of the orthodontists. The diagnostic standard was achieved: (1) S = 54.9%, (2) S + F = 54.2%, (3) S + F + P = 60.9%, and (4) S + F + P + C = 59.9%. Thus, in a majority of cases (55%), study models alone provided adequate information for treatment planning, and incremental addition of information from other types of diagnostic records made small differences.

The advantages of including dental public health in schools of public health in the United States

This paper describes the history and current status of schools of public health and graduate level programmes in dental public health in the United States. The broad core curricula for all public health students undertaking a course for a master's degree in public health is outlined, as well as the specialised course offerings available to dental public health students. The advantages and disadvantages of including dental public health programmes in schools of public health, instead of in dental schools, are discussed. There is a need for the integration of activities between dental schools and schools of public health to alleviate the traditional isolation of dentistry and prevent the omission of dentistry in health policy formation. When possible, the inclusion of the dental public health programmes in schools of public health is recommended so that public health and dental public health students can learn about each other's disciplines and share a common educational experience.

Maternal and child oral health issues: research

There is currently little oral research directed toward the maternal and child health population, especially outside of the National Institute of Dental Research funded programs. Although many agencies are involved with research in this area, there is no central national coordination, policy, or research agenda. Not all segments of the population are benefiting from existing knowledge. To improve oral health for all segments of the population, leadership in the establishment of research priorities is needed to direct activities that will benefit the population groups most affected by oral disease. New directions and perspectives are needed in the type of research conducted. The populations and conditions studied and the depth of the analyses performed must be extended. Additional emphasis should be placed on behavioral, evaluation, and health services research and collaborative research with other health fields. The population groups studied need to be expanded from the historical focus on relatively healthy elementary schoolchildren. As discussed by Waldman, information is particularly needed pertaining to children under age five, all women, and special population groups. As Frazier and Horowitz indicated, research on health promotion and health education within these target populations, as well as among other family members and care givers is needed. Data collected from surveys need to be analyzed more thoroughly. As new diagnostic systems and oral health care technologies are developed, they need to be evaluated adequately for safety, effectiveness, and efficiency. To accomplish all these activities, financial and human resources are needed--funding from appropriate sources in the public and private sector and qualified dental researchers interested in public health and clinical issues of concern to the maternal and child population.

The duration of orthodontic treatment with and without extractions: a pilot study of five selected practices

Contemporary orthodontic practice is diverse, both in the variety of clinical problems treated and in the methods used. Practices differ with respect to their patient composition as well as in many variables relative to treatment protocols. Such heterogeneity makes it difficult to make valid generalizations concerning the characteristics of orthodontic treatment procedures or outcomes; yet data and methods are required for assessment of issues of efficacy and utility. The frequency of orthodontic extractions is an objective criterion that distinguishes practices and may also be related to differences in treatment outcome variables, such as duration. Following a telephone survey to estimate extraction rates in the practices of 238 Michigan orthodontists, five practices with very high or low reported rates were chosen for this pilot study. Our primary aim was to determine whether a systematic relationship existed between the relative frequency of extraction treatments and the duration of active appliance therapy. Records of 438 patients from these practices were examined. The extraction rates of the practices ranged from a low of 25% to a high of 84%. Treatment duration was affected by several variables, such as the number of arches treated, the number of treatment phases, and the practice selected. When the data for all five practices were pooled, and all of the extraction versus nonextraction treatments were compared, the mean durations of treatment were 31.2 and 31.3 months, respectively. Data from individual practices, however, indicated that extraction treatment in each of the practices was of longer duration than nonextraction therapy. These differences in duration were 3.0, 6.6, 2.4, 3.0, and 7.3 months in the five practices.(ABSTRACT TRUNCATED AT 250 WORDS)

The prevalence of orthodontic extractions

The controversy regarding extractions for orthodontic treatment continues and today is invoked by some as a feature of the "standard of care." For this and other reasons, it is necessary to have contemporary data on the general prevalence of orthodontic extractions and the interpractice range of extraction rates in current specialty practice and, if possible, also to establish possible reasons for, and consequences of, the extraction versus nonextraction decision. Although all treatment decisions are made on a case-by-case basis, practitioners appear to have personal preferences for or against extractions and hence adopt policies with different degrees of aversion to or bias toward extraction therapy. A number of factors enter into the extraction decision. These include features of the malocclusion, objectives of treatment, and the technique selected to accomplish desired results. The present study does not address such issues but merely serves to provide epidemiologic data to estimate extraction frequency in contemporary orthodontic practice. Accordingly, a telephone survey of all licensed orthodontists in Michigan was conducted to determine their subjective estimates of extraction rates for patients in their practices. There were 238 respondents, for a response rate of 90.2%. Reported rates range from 5% to 87%. We then selected five practices from the extremes of the reported extraction rates. Three practices from the high end and two from the low end were included for an examination of patient records. Records of a total of 438 patient whose treatment had been completed were reviewed. The actual extraction rates for these practices ranged from 25% to 85%, which differed considerably from the clinicians' subjective estimates.(ABSTRACT TRUNCATED AT 250 WORDS)

The effectiveness of pit and fissure sealants

This review addresses two major issues related to the use of pit and fissure sealants. First, the epidemiology of occlusal caries for children and adults is examined to determine if there is a basis for administering sealant programs to different age groups. Second, the effectiveness of pit and fissure sealants in fluoridated and non-fluoridated communities is compared. Changes in effectiveness of sealant over time are evaluated in terms of percent effectiveness, complete retention, caries incidence, and reapplication rates. Based on epidemiologic evidence, sealant programs can be justified for children and young adults, but not for older age groups. Based on the literature reviewed, following one application of autopolymerized or visible-light-cured sealant, the median percent effectiveness declines from 83 percent after one year to 55 percent after seven years. Similarly, the median complete retention declines from 92 percent after one year to 66 percent after seven years. Conversely, the median percent of sealed first molars becoming carious and/or restored increases from 4 percent after one year to 31 percent after seven years. Large differences in sealant effectiveness are not apparent between studies performed in fluoridated and fluoride-deficient communities.

The effects of sugars intake and frequency of ingestion on dental caries increment in a three-year longitudinal study

A three-year longitudinal study was carried out with a group of children, initially aged 11-15, residing in non-fluoridated rural communities in south-central Michigan. This report analyzes the relation between caries increment and consumption of sugars from all sources to see if accepted relationships have changed with the caries decline in the United States. There were 499 children who provided three or more 24-hour dietary recall interviews, and who received dental examinations at baseline and after three years. Caries increment averaged 2.91 DMFS over the three years, with 81% of new lesions on pit-and-fissure surfaces. Consumption of sugars from all sources averaged 156 g per day for males and 127 g per day for females, an average of 52 kg per person per year. Sugars constituted one-quarter of total caloric intake for both boys and girls, and the average number of eating occasions per day was 4.3. Children who consumed a higher proportion of their total energy intake as sugars had a higher increment of approximal caries, though there was little relation to pit-and-fissure caries. The average number of daily eating occasions was not related to caries increment, nor was the average number of sugary snacks (defined as foods with 15% or more of sugars) consumed between meals, but the average consumption of between-meal sugars was related to the approximal caries increment. When children were categorized by high caries increment compared with no caries increment, a tendency toward more frequent snacks was seen in the high-caries children.(ABSTRACT TRUNCATED AT 250 WORDS)

Fissure sealant knowledge and characteristics of parents as a function of their child's sealant status

A survey was conducted to identify and compare sealant knowledge and sources of sealant information of parents whose children had and had not received fissure sealants. The socioeconomic characteristics of these individuals were also compared. The sealant group was composed of the parents of children found to have a sealant on at least one permanent tooth during dental examinations of 2,036 elementary schoolchildren in southwestern Michigan. Another group of children was selected from the same population and matched to the children with sealants by child's age, sex, school location, and community. Surveys were returned by 210 of 260 sets of parents (81% response rate). Significant differences were found between the two groups with regard to parents' ages and levels of income. Parents of children with sealants had more correct information about the procedure and 74 percent of these individuals reported that the dental office was their primary source of information. For the group without sealants, 48 percent of respondents reported no source of sealant information. Findings suggest that dental personnel may strongly influence dissemination of information about sealants and utilization of this preventive procedure.

Periodontal effects and dental caries associated with smokeless tobacco use

The prevalence of smokeless tobacco use has been increasing in the United States with concomitant social, medical, legal, and regulatory ramifications. This paper examines the association between the use of smokeless tobacco and the occurrence of periodontal disease and dental caries. Existing literature consists primarily of case reports and cross-sectional studies among teenagers. The limited evidence suggests an association between smokeless tobacco use and gingival recession. There is insufficient evidence to support any associations between smokeless tobacco use and gingivitis, periodontitis, or dental caries. Methods to improve future epidemiologic research to examine possible associations between smokeless tobacco use and periodontal effects or dental caries are discussed.

Comparison of Medicaid and non-Medicaid dental providers

A statewide mail survey of a stratified sample of 640 Michigan general dentists was conducted in 1983, with a response rate of 41 percent, n = 261. An analysis was performed to compare Medicaid and non-Medicaid providers. About half of all respondents reported that they were not seeing any Medicaid patients (Group 1); 29 percent reported that less than 10 percent of their patients were Medicaid-eligible (Group 2), and 22 percent reported that 10 percent or more of their patients were Medicaid-eligible (Group 3). Significant differences existed among the three groups for age of respondent, length of time in practice, and number of new patients seen each month. Respondents with greater percentages of Medicaid patients in their practices were more likely to be in group practice. Stratification of respondents by location suggested that rural providers were more likely than urban respondents to have some Medicaid patients in their practices. Over 40 percent of respondents from all groups reported themselves as being not busy enough. In 1984, more than one million persons in Michigan were eligible for Medicaid dental benefits, but only one-fourth of these individuals were recipients of dental care. Factors that may limit dentists' participation in the Medicaid program, despite the presence of a large eligible population and self-reported lack of business, are discussed.

Developing a sealant program: the Massachusetts approach

This paper describes the program structure and strategies being used by the Massachusetts Department of Public Health to promote the utilization of sealants. The program design includes four components: clinical demonstration, consumer education, professional education, and reimbursement. Eighteen Massachusetts neighborhood health centers and six local health departments are participating in the clinical demonstration component. Since March 1984, dental personnel from these sites have applied sealants to 4,398 schoolchildren. The promotional theme "Save Teeth: Seal Them" has been incorporated into brochures designed to increase knowledge and awareness of consumers. Curriculum materials have been developed to educate dentists and dental hygienists to apply sealants and understand the rationale and scientific basis for their use. Since January 1984, 18 sealant educational sessions have been conducted statewide for 630 dental providers. Information is being presented to third-party carriers, some of whom have subsequently adopted a policy to include reimbursement for sealants.

What Massachusetts residents know about fluoridation

The Massachusetts Department of Public Health conducted a comprehensive, statewide telephone health interview survey during 1980. Adult members of 1,091 households were interviewed. The purpose of this paper is to report the attitudes and knowledge of the Massachusetts residents surveyed regarding fluoridation, as well as the relation of their attitudes with demographic and socioeconomic variables, dental and other health behaviors, and outcome of fluoridation referenda. The majority, 60 percent, were in favor of community water fluoridation. As expected, groups that were most likely to favor fluoridation were parents, those who were better educated, and those with higher incomes. About three-fourths of those surveyed were correctly aware of the purpose of fluoridation. Public opinion about fluoridation, as measured by this survey, did not correspond with the outcome of fluoridation referenda held in 14 Massachusetts communities between 1980 and 1983, which showed that 61 percent of the voters were not in favor of fluoridation.