Childhood dental history and adult dental attitudes and beliefs

OBJECTIVE

To examine associations between childhood dental visits and attitudes and beliefs about dental care, and oral health as measured during adulthood.

METHODS

The data were taken from the Florida Dental Care Study (FDCS), a prospective longitudinal study of oral health and dental care, among 683 adults 45 years of age and older who answered questions about early dental history at the 54-month follow-up interview.

RESULTS

Fifty-nine per cent (n = 400) reported having had a dental visit before 18 years of age. Of those with a childhood visit, 72% reported that the first dental visit was a negative experience. Having a childhood dental visit was associated with several positive attitudes and beliefs about dental care. In addition, having early experiences with a dentist was associated with preventive and restorative dental visits and several objective and subjective measures of oral health. Having a negative childhood experience was associated with only one of the adult dental attitude and beliefs subscales, and none of the oral health behaviours.

CONCLUSIONS

Our data suggest that the socialisation associated with early dental visits may occur even though the experience may have been painful or frightening. Although this study design precluded direct inference about causation, these findings do support the utility of further investigations into possible causative linkages between childhood dental experiences and adult attitudinal and dental health outcomes.

Forty-Eight–Month Periodontal Attachment Loss Incidence in a Population-Based Cohort Study: Role of Baseline Status, Incident Tooth Loss, and Specific Behavioral Factors

BACKGROUND

The objectives of this study were to: 1) test hypotheses that behavioral factors, baseline clinical status, and incident tooth loss are significantly associated with attachment loss incidence (ALI) and 2) quantify the effect of incident tooth loss on conclusions made about ALI.

METHODS

The Florida Dental Care Study was a prospective study of persons > or =45 years old. In-person interviews and examinations were conducted at baseline and 48 months, with telephone interviews in between.

RESULTS

Of 560 persons with baseline and 48-month examinations, 22% of persons and 1.8% of teeth had ALI. This was highest among persons with no dental visit during follow-up (person-level incidence of 46%; 5.0% tooth-level incidence). Statistically significant covariates in a multivariable regression of ALI were: losing a tooth due to periodontal reasons after baseline, but before the 48-month examination; not receiving a dental cleaning; and baseline factors (worst attachment level of > or =7 mm, not flossing, a molar tooth, current smoker).

CONCLUSIONS

A substantial percentage of persons experienced ALI. Baseline attachment level and behavioral factors were significantly associated with ALI. Persons with incident tooth loss were also at increased risk for ALI, and teeth lost during follow-up had worse baseline attachment level. Had these teeth not been lost before the final examination, the ALI estimate could only have been higher. These findings demonstrate that those at greatest risk for ALI are least likely to enter the dental care system, and among those who do, one health outcome (tooth loss) can affect conclusions made about the incidence of another (ALI).

Orofacial pain: patient satisfaction and delay of urgent care

OBJECTIVE

Accomplishing the Healthy People 2010 goal of eliminating disparities in oral disease will require a better understanding of the patterns of health care associated with orofacial pain. This study examined factors associated with pain-related acute oral health care.

METHODS

The authors used data on 698 participants in the Florida Dental Care Study, a study of oral health among dentate adults aged 45 years and older at baseline.

RESULTS

Fifteen percent of the respondents reported having had at least one dental visit as the result of orofacial pain. The majority of the respondents reportedly delayed contacting a dentist for at least one day; however, there was no difference between respondents reporting pain as the initiating symptom and those with other problems. Once respondents decided that dental services were needed, those with a painful symptom were nearly twice as likely as those without pain to want to be seen immediately. Rural adults were more likely than urban adults to report having received urgent dental care for a painful symptom. When orofacial pain occurred, those who identified as non-Hispanic African American were more likely than those who identified as non-Hispanic white to delay care rather than to seek treatment immediately, and women were more likely then men. Having a pain-related oral problem was associated with significantly less satisfaction with the services provided; non-Hispanic African American respondents were less likely than non-Hispanic white respondents to report being very satisfied, and rural residents were less likely than urban residents. Furthermore, men were more likely than women to suffer with orofacial pain without receiving either scheduled dental care or an urgent visit.

CONCLUSIONS

Barriers to care are complex and likely to be interactive, but must be understood before the goals of Healthy People 2010 can be accomplished.

Research in general dental practice

Spurred by an initiative by the National Institute of Dental and Craniofacial Research in the USA, this article presents the need for a change in clinical dental research towards practice-based research. It outlines the shortcomings of past and present-day research in dentistry, with emphasis on the lack of clinical relevance of much of the research performed. The slow transfer of sound research findings to clinical practice is also a major problem. The article reviews some problems related to restorative dentistry and how they have adversely affected general dental practice. Practice-based research places emphasis on the problems experienced by clinicians in the routine care of patients. Clinicians should be linked together in research networks. The problems they face in dental practice and the clinical experience they have will form the basis for studies by the network. Experienced clinical researchers will provide guidance and statistical support for the studies initiated by the clinicians.

Effectiveness of dental services in facilitating recovery from oral disadvantage

OBJECTIVE

To determine the effectiveness of dental health care services in facilitating recovery from quality of life decrements in symptom-specific subgroups with the most prevalent chronic infectious diseases (periodontal disease and dental caries), and a 'stained teeth' subgroup.

METHODS

Data were taken from the prospective longitudinal Florida Dental Care Study of 873 individuals 45+ years old. Logistic regression modeling quantified associations between recovery from oral health-related quality of life decrements ('recovery') and dental services.

RESULTS

Adjusting for age, race, gender, income, approach to dental care, and signs/symptoms, any dental visit (odds ratio, OR: 4.0; 95% confidence interval, CI: 2.3, 6.9), corrective treatment (OR: 3.8; 95% CI: 1.6, 8.7), denture visit (OR:4.8; 95% CI: 1.1, 21.9), or extraction (OR: 6.2; 95% CI: 2.2, 17.4) were positively associated with recovery. Upon conditioning the analyses on specific symptoms, point estimates increased substantially for most service types, and dental cleaning was associated with recovery for the stained teeth subgroup (OR: 10.9; 95% CI: 1.2, 99.4).

CONCLUSION

Dental care was highly effective in treating quality of life decrements. Treatment effectiveness increased substantially when analyses were restricted to symptom-specific subgroups similar to selection criteria of randomized clinical trials (RCTs). Restricted cohort analyses can be applied to many other health outcomes for which RCTs are not feasible or ethical.

A SAS macro for the analysis of multivariate longitudinal binary outcomes

Multiple binary outcomes occur quite frequently in oral health research, as well as other areas of health care research. When there is interest in comparing whether covariates influence one outcome more than another, statistical methods that adjust for the correlation that may exist between outcomes are warranted. Available software is limited to the extent that some pre-processing of the data is required. The main objective of this paper is to describe a SAS macro that can be used to estimate separate covariate effects on multiple, correlated binary outcomes. We demonstrate the utility of the macro by applying it to fit a trivariate logistic regression model using GEE where the three correlated longitudinal outcomes of interest include whether a subject had a problem-oriented visit, a dental cleaning, or a routine check-up, or some combination thereof. All three outcomes were measured at four 6-monthly intervals (0-24 months). Estimates from the trivariate logistic regression model are compared to results obtained by fitting three separate binary longitudinal models using GEE for each oral health outcome. The odds of having a problem-oriented visit were greater for males compared to females as estimated from the multivariate model (P = 0.0407), but the odds were not significant in the univariate model (P = 0.0641). The multivariate model also aided in confirming expected results that consistent regular attenders (compared to consistent problem-oriented attenders) had greater odds of having received dental cleaning and check-ups relative to having problem-oriented visits (chi2 = 33.47, P < 0.01), and that those with broken teeth or broken filling (compared to those without) are at greater odds of having a problem-oriented visit relative to having dental cleaning or checkups (chi2 = 34.12, P < 0.01 and chi2 = 17.11, P < 0.01).

A cohort study found racial differences in dental insurance, utilization, and the effect of care on quality of life

OBJECTIVE

To describe racial differences in receipt of dental services and dental insurance; and to determine the effectiveness of specific dental services in facilitating recovery in symptom-specific and race-specific subgroups.

STUDY DESIGN AND SETTING

Using a restricted cohort analytic method, Florida Dental Care Study prospective cohort data were used to quantify associations between dental service use and the quality of life measure, "recovery" from oral disadvantage due to functional limitation.

RESULTS

Non-Hispanic Whites (NHW) were more likely to have a dental visit [odds ratio (OR); 95% confidence interval: 3.5; 2.2-5.3], corrective treatment (OR=2.1; 1.3-3.3), caps (OR=28.8; 6.6-126.4), and dental insurance coverage for caps (OR=2.9; 1.4-5.9). After adjusting for other covariates: (1) among NHW with severe gum disease, those receiving extractions were more likely to recover (OR=7.8; 1.0-59.1), but those receiving caps were less likely to recover (OR=0.1; 0.01-0.6); (2) among Non-Hispanic Blacks (NHB) with a sensitive tooth, those receiving corrective treatment (OR=3.2; 1.2-8.8) or extractions (OR=3.8; 1.3-11.2) were more likely to recover; (3) among NHB with tooth disease, those receiving corrective treatment (OR=2.3; 1.0-5.0) and extractions (OR=2.8; 1.2-6.5) were more likely to recover.

CONCLUSION

There were racial differences in dental insurance, in the receipt of dental services and in the effectiveness of dental services in improving oral health-related quality of life.

Root Canal Treatment in a Population-Based Adult Sample: Status of Teeth After Endodontic Treatment

The purpose of this study was to quantify treatment outcomes of endodontically treated teeth, in a representative, population-based adult sample. The "Florida Dental Care Study" was a prospective, longitudinal, cohort study of 873 subjects who had at least one tooth at baseline and who were 45 yr or older. An in-person interview and clinical examination were conducted at baseline, 24 months, and 48 months after baseline, with 6-monthly telephone interviews between those times. Dental record information was abstracted afterward. Seventy-five teeth had conventional root-canal therapy (RCT) performed and met the inclusion criteria of 1-yr of follow-up or extraction. The mean duration of follow-up after RCT was 24.8 months. The mean (SD) attachment loss (AL) on teeth receiving RCT was only 3.3 (1.4) mm. Permanent restorations were placed in 79% of teeth a mean of 4.4 months after the RCT. However, 12% of teeth did not have any restorative treatment after RCT. After RCT had been completed, 81% of teeth were retained and 19% were ultimately extracted. Taken as a whole, this community-based study of a representative sample of adults suggests a higher failure rate than reported from studies in highly controlled environments or insured populations. It also suggests that the length of time to initial restoration of RCT-treated teeth is less than optimal. RCT was almost never performed on teeth with advanced periodontal attachment loss.

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.

Incidence of Tooth Loss and Prosthodontic Dental Care: Effect on Chewing Difficulty Onset, a Component of Oral Health–Related Quality of Life

OBJECTIVES

To quantify incidence of tooth loss, prosthodontic dental restoration, and chewing difficulty onset and the effect of tooth loss and prosthodontic restoration on chewing difficulty onset.

DESIGN

A prospective cohort study of oral health and related behaviors with in-person interviews and clinical examinations conducted at baseline and 24 months. Telephone interviews were conducted every 6 months between these sessions.

SETTING

A community-based sample of four counties in north Florida.

PARTICIPANTS

Eight hundred seventy-three persons who had at least one tooth and were aged 45 and older at baseline.

MEASUREMENTS

Persons were queried regarding onset of chewing difficulty, an important component of oral health-related quality of life (OHRQoL). The chewing index of Leake, with minor revision, was the primary outcome of interest. Tooth loss was measured using direct clinical examination. Dental care use was reported during each interview.

RESULTS

Approximately 22% of participants reported tooth loss during follow-up. Fixed prosthodontics (crowns and bridges) was the most common form of new prosthodontic treatment. People who reported tooth loss were 2.7 times more likely to report chewing difficulty onset than people without tooth loss (P<.001). Having fewer occluding pairs of teeth at baseline was significantly associated with an increased probability of chewing difficulty onset. People who received removable prosthodontic treatment were much less likely to report chewing difficulty onset than people who did not (P<.01).

CONCLUSION

Incident tooth loss and removable prosthodontic restoration strongly predicted chewing difficulty, an important component of OHRQoL.

Patient characteristics associated with receipt of dental radiographic procedures during a 48-month population-based study of dentate adults

OBJECTIVE

The objective was to test hypotheses that patient characteristics are associated with receipt of specific types of radiographic procedures.

STUDY DESIGN

The Florida Dental Care Study was a prospective cohort study of dentate adults.

RESULTS

From 19% to 59% of participants received a full-mouth series, panoramic, bitewing, or periapical radiograph(s), depending on procedure type. Receipt varied with reason(s) for dental visit(s), baseline clinical condition, race, approach to care (problem-oriented or regular dental attender), and socioeconomic status.

CONCLUSION

These findings underscore the distinction between what dentists hypothetically would prescribe, compared to what is actually received, receipt that results from the interaction between dentist recommendations and what patients will accept and pay for. Blacks and lower-income persons received dental radiograph types that were consistent with less comprehensive dental treatment, even with entry into the dental care system, reason(s) for incident dental visit(s), baseline clinical status, and regular versus problem-oriented attendance taken into account.

Oral health attitudes and communication with laypersons about orofacial pain among middle-aged and older adults

Communication patterns with persons outside the health care system during a pain episode are poorly understood, yet can have a significant influence on patient behavior. This study examined associations between attitudes and beliefs about oral disease and dental care and talking about orofacial pain with laypersons and health care professionals. The subjects were 724 participants in the Florida Dental Care Study, a longitudinal study of oral health among community-dwelling adults. This study used a prospective design with data collected at baseline and the 42-month follow-up using a standardized interview format. Persons with negative attitudes and beliefs were more likely to have talked to a layperson about pain and less likely to have talked to a health care provider. In addition, the attitude that most consistently differentiated between respondents who had communicated only with a layperson from those who had talked to a health care provider was quality of recent visits, a variable representing more of the interpersonal aspects of a health care visit than the eventual outcomes from the treatment received. Our data are consistent with the hypothesis that lay consultation during a pain episode may substitute for formal care for persons with less positive views of the health care system. Intensity ratings and temporal characteristics of pain were also important determinants of these pain-related communication patterns. These findings emphasize the importance of understanding the communication between persons with pain and non-health care professionals, and how these attitudes and communication preferences relate to the management of pain.

The dynamics of toothache pain and dental services utilization: 24-month incidence

OBJECTIVES

The aims of this study were twofold: (1) to describe patterns of change in reported toothache pain, and (2) to examine the impact of toothache pain on dental care utilization and vice versa.

METHODS

Data from the Florida Dental Care Study (FDCS), a longitudinal study of oral health and dental service utilization conducted in north Florida, were used to measure self-reported toothache pain among dentate adults at baseline and four subsequent times during a 24-month period. Only persons 45 years of age or older with at least one remaining natural tooth at baseline were eligible. A total of 873 subjects participated, 764 of whom participated through 24 months. The analysis is focused on modeling transitions in the reported experience of toothache pain during intervals of six months.

RESULTS

At the time of the baseline interview, 11.5 percent of subjects reported current toothache pain. During subsequent six-monthly interviews, from 13.4 percent to 21.6 percent of subjects reported having experienced toothache pain during the prior six-month interval. Among those with no toothache pain at baseline (n = 772), 31.2 percent experienced toothache pain at some time during the 24-month study period. The six-month incidence probability reflects the likelihood of developing toothache pain by estimating the conditional probability of reporting a toothache in a later interval given that this problem was not reported in the earlier one (for consecutive pairs of intervals). Overall, the six-month incidence probability for toothache pain in this study was. 11. Significantly higher 24-month incidence was observed for African-American subjects, those with less formal education, those in poorer financial circumstances, and problem-oriented dental attenders.

CONCLUSIONS

In this diverse sample of adults, toothache pain occurs frequently and is quite variable overtime. Toothache occurs in conjunction with various forms of self-reported oral disease (e.g., abscess, cavities) or tissue damage (e.g., loose tooth, broken tooth, bleeding gums). Subjects who experience toothache are slightly more likely than others to utilize dental services in the time period proximate to the toothache pain.

Chronic oral disadvantage, a measure of long-term decrements in oral health-related quality of life

Few studies have investigated the relation between oral health-related quality of life (HRQL) and key demographic, socioeconomic, and oral health decrements.

METHODS

Data were taken from 873 participants from the Florida Dental Care Study. Chronic oral disadvantage was defined from incident oral disadvantage, a measure of oral HRQL, reported for a minimum of two consecutive 6-month intervals. Patterns of chronic oral disadvantage over the 24-month period were described. Associations between the dependent variable, chronic oral disadvantage, and demographic variables, socioeconomic variables, oral health decrements, and dental services were evaluated.

RESULTS

During 24 months of follow-up, 30% of subjects reported chronic oral disadvantage. Chronic oral disadvantage was significantly associated with approach to dental care, area of residence, situation if faced with an unexpected dollars 500 dental bill, teeth that are stained or look bad, cavities, sore or infected gums, loose tooth or cap, toothache or abscess, dental sensitivity, and chewing difficulty. A recent dental visit was associated with reduced progression to chronic oral disadvantage.

CONCLUSION

A large proportion of subjects avoided certain daily activities due to oral health decrements for longer than 6 months. Recent dental visits were significantly associated with limitation of long-term progression of oral disadvantage.

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.

Incidence of Endodontic Treatment: A 48-Month Prospective Study

The purpose of this study was to determine the incidence of endodontic services provided to participants in a longitudinal cohort study. The "Florida Dental Care Study" was a prospective cohort study using a representative baseline sample of 873 dentate adults. An in-person interview and clinical dental exam were conducted at baseline, 24, and 48 months after baseline, with telephone interviews every 6 months between those times. Dental record information was abstracted afterward. Thirteen percent of participants received at least one endodontic procedure after baseline. Endodontic services constituted approximately 2% of all dental procedures performed. Conventional root canal therapy comprised 94% of the endodontic services and was approximately evenly distributed among anterior teeth, premolars, and molars. Retreatment and apicoectomy each accounted for 3% of the endodontic procedures. The most common self-reported reasons for the dental visit in which a root canal occurred were "toothache," "abscess," and "dental sensitivity." A significant percentage of persons received some type of endodontic treatment in this diverse adult sample. Dental abscesses or toothaches were the main reason(s) for endodontic treatment, but not all persons with these conditions during follow-up sought dental treatment of any variety.

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.

Incidence of dental radiographic procedures during a 48-month population-based study of dentate adults

OBJECTIVES

The purpose of this population-based study was to quantify the incidence of radiographic procedures and the intervals between radiographic exposures.

STUDY DESIGN

The Florida Dental Care Study was a prospective cohort study of a representative sample of dentate adults. In-person interviews and dental examinations were conducted at baseline, with subsequent interviews every 6 months during 48 months of follow-up. Dental record information was abstracted afterward.

RESULTS

Thirteen percent of all dental procedures, and 42% of all diagnostic procedures, were radiographic. Annual person-level incidence of receipt of any radiograph was 48%. Incidence of specific types of radiographic procedures ranged from 5% to 30%. Among the 45% of the sample population who had had more than 1 bitewing procedure, 70% of the intervals between bitewing exposures were 1 year or longer. Receiving more than 1 full-mouth series or panoramic radiographic in any 24-month period was very rare.

CONCLUSIONS

Annual incidence of radiographic procedures was substantially higher than the incidence reported in previous studies based on responses by dentists to hypothetical situations, but was stable during the 4 years of follow-up. On the basis only of intervals between exposures, and not of clinical status on the day of service, there was no substantial evidence of inappropriately frequent radiographic examinations.

Comparing longitudinal binary outcomes in an observational oral health study

Observational studies continue to be recognized as viable alternatives to randomized trials when making treatment group comparisons, in spite of drawbacks due mainly to selection bias. Sample selection models have been proposed in the economics literature, and more recently in the medical literature, as a method to adjust for selection bias due to observed and unobserved confounders in observational studies. Application of these models has been limited to cross-sectional observational data and to outcomes that are continuous in nature. In this paper we extend application of these models to include longitudinal studies and binary outcomes. We apply a two-stage probit model using GEE to account for correlated longitudinal binary chewing difficulty outcomes. Chewing difficulty was measured every six months during a 24-month period between two groups of subjects: those either receiving or not receiving dental care. Dental care use was measured at six-month intervals as well. Results from our proposed model are compared to results using a standard GEE model that ignores the potential selection bias introduced by unobserved confounders. In this application, accounting for selection bias made a major difference in the substantive conclusions about the outcomes of interest. This is due in part to an adverse selection phenomenon in which those most in need of treatment (and consequently most likely to benefit from it) are actually the ones least likely to seek treatment. Our application of sample selection models to binary longitudinal observational outcome data should serve as impetus for increased utilization of this promising set of models to other health outcomes studies.

Predictors of chewing difficulty onset among dentate adults: 24-month incidence

OBJECTIVES

Chewing ability is an important measure of health-related quality of life, yet few studies have examined predictors of chewing difficulty in community-based samples. This study describes longitudinal patterns of chewing difficulty and identifies predictors of chewing difficulty onset.

METHODS

The Florida Dental Care Study (FDCS) was a longitudinal study of oral health and related behaviors. Interviews and a clinical exam were conducted with a sample that included persons who had at least one tooth and were aged 45 years or older (n = 873). The five-item chewing index of Leake (1990), with minor revision, was the outcome of interest.

RESULTS

Approximately 21 percent of baseline participants reported chewing difficulty and about 34 percent reported difficulty during the study. Having infected or sore gums, loose tooth, loose crown or bridge, toothache pain, lower numbers of opposing pairs of teeth, dry mouth, and being female were significant predictors of incident chewing difficulty.

CONCLUSIONS

Self-reported oral disease and tissue damage and toothache pain were strong predictors of decline in chewing ability. Additionally, women were identified as a high-risk group for incident chewing difficulty. Future research should elaborate further the pathways through which these factors affect oral function.

A prospective study of the validity of self-reported use of specific types of dental services

OBJECTIVE

The purpose of this study was to quantify the validity of self-reported receipt of dental services in 10 categories, using information from dental charts as the "gold standard."

METHODS

The Florida Dental Care Study was a prospective cohort study of a diverse sample of adults. In-person interviews were conducted at baseline and at 24 and 48 months following baseline, with telephone interviews at six-month intervals in between. Participants reported new dental visits, reason(s) for the visit(s), and specific service(s) received. For the present study, self-reported data were compared with data from patients' dental charts.

RESULTS

Percent concordance between self-report and dental charts ranged from 82% to 100%, while Kappa values ranged from 0.33 to 0.91. Bivariate multiple logistic regressions were performed for each of the service categories, with two outcomes: self-reported service receipt and service receipt determined from the dental chart. Parameter estimate intervals overlapped for each of the four hypothesized predictors of service receipt (age group, sex, "race" defined as non-Hispanic African American vs. non-Hispanic white, and annual household income < 20,000 US dollars vs. > or = 20,000 US dollars), although for five of the 10 service categories, there were differences in conclusions about statistical significance for certain predictors.

CONCLUSIONS

The validity of self-reported use of dental services ranged from poor to excellent, depending upon the service type. Regression estimates using either the self-reported or chart-validated measure yielded similar results overall, but conclusions about key predictors of service use differed in some instances. Self-reported dental service use is valid for some, but not all, service types.

Two-year incidence of oral disadvantage, a measure of oral health-related quality of life

Dental research has progressed from describing the burden of oral disease using traditional epidemiologic measures of incidence and prevalence, to measuring how oral disease, oral signs, and oral symptoms affect the daily activities and the overall quality of life of the individual. However, longitudinal evaluation of these associations remains rare.

OBJECTIVES

To (i). describe the 2-year incidence and patterns of oral disadvantage; (ii). identify dimensions of oral health measures that are significant antecedents of oral disadvantage; and (iii). determine which oral health dimensions are the most strongly predictive of oral disadvantage.

METHODS

The Florida Dental Care Study was a longitudinal study of oral health in diverse groups of persons who at baseline had at least one tooth and were 45 years or older. Incidence rates, odds ratios, and 95% confidence intervals were used to describe oral disadvantage and its relation to other measures of oral health.

RESULTS

Nearly one-half of the participants experienced oral disadvantage at least once during 24 months of follow-up. The strongest antecedents associated with oral disadvantage were toothache pain and chewing difficulty.

CONCLUSIONS

The incidence of oral disadvantage is substantial and consistent with the notion that oral health has a substantial impact on quality of life. Measures of oral pain and oral functional limitation were more strongly predictive of oral disadvantage than disease and tissue damage antecedents.

The paradox of dental need in a population-based study of dentate adults

BACKGROUND

Studies typically find that predisposing and enabling factors strongly predict dental utilization, but that need factors do not. However, few longitudinal studies have been conducted, and few have comprehensively measured dental need.

OBJECTIVES

To describe the paradox of dental need, and to test three hypotheses regarding need and dental care use.

MATERIALS AND METHODS

An observational study that included 873 persons who participated for interview and clinical examination at baseline and 24 months, with 6-month telephone interviews in between.

RESULTS

Persons who entered the dental care system during follow-up were actually in better dental health than those who did not. The ability of need factors to predict dental care use, and in which direction, varied with how dental need and the dental care use outcome were measured (eg, care of any type, problem-related care, to receive a dental cleaning, to get a dental checkup).

CONCLUSIONS

A substantial number of dental problems remained or developed among the population that did not enter the dental care system. The paradox of dental need has three components: (1) need predicts dental care use but is dependent upon how need is measured; (2) however, persons with a higher probability of new dental problems are actually less likely to seek dental care; and (3) self-reported disease and oral pain are associated with a higher likelihood of seeking care, whereas clinically-determined need, such as chewing difficulty, lower self-rating, and satisfaction with oral health, are actually associated with a lower likelihood, the former direction being the predominant and expected direction.

Socioeconomic and demographic disparities in symptoms of orofacial pain

OBJECTIVES

The purpose of this study was to document the association between socioeconomic status (SES) and the prevalence and impact of orofacial pain by anatomical location. In addition, differential effects of SES on orofacial pain across levels of sex, race, and age were documented.

METHODS

The subjects were 724 participants in the Florida Dental Care Study, a study of oral health among dentate adults, aged 45 years and older at baseline. Pain prevalence and subjective ratings were assessed for a range of orofacial pain sites using a standardized telephone interview.

RESULTS

Lower SES was associated with reporting pain and pain impact at many, but not all, of the orofacial sites. Some sex, race, and age cohort differences in orofacial pain were found when adjusting for differences in socioeconomic position. The most consistent result, as evidenced by similar findings across orofacial pain sites, was that the effects of SES on orofacial pain appear to have a sex-differentiated effect.

CONCLUSION

Consistent with findings for other subjective measures of oral health, persons of lower SES are at increased risk for orofacial pain and pain-related behavioral impact.