Validity of self-reported periodontal questions in a New Zealand cohort

Self-perceived quality of social roles, activities and relationships predicts incident gingivitis

OBJECTIVES

While physical health status is known to impact social functioning, a growing literature suggests that social well-being may affect oral health. This investigation evaluated whether self-perceived quality of social roles, activities and relationships (social well-being) influences gingival inflammation.

METHODS

Data were from the Population Assessment of Tobacco and Health Study, a nationally representative cohort of US adults, biennial waves 4 (2017) to 6 (2021). Social well-being was derived from the validated PROMIS Global-10 survey instrument, categorized for this longitudinal analysis as high, moderate or low. The main outcome was incident self-reported gum bleeding (dichotomous, proxy for gingivitis). Survey-weighted logistic regression modelling adjusted for overall health status, sociodemographic (e.g. age, sex, race/ethnicity), socioeconomic (e.g. income, education) and behavioural (e.g. tobacco, alcohol) confounders and was used to predict marginal mean gum bleeding incidence.

RESULTS

Cross-sectionally at wave 4 (N = 23 679), gum bleeding prevalence was higher along a stepwise gradient of decreasing satisfaction with social activities and relationships (extremely satisfied: 20.4%; not at all: 40.1%). Longitudinally, among participants who had never reported gum bleeding through wave 4 (N = 9695), marginal predicted new gum bleeding at wave 6 was greater with each category of lower wave 4-5 social well-being (high: 7.6%; moderate: 8.6%; low: 12.4%). Findings were robust to alternative model specifications. Results should be interpreted considering study limitations (e.g. potential unmeasured confounding; outcome by self-report).

CONCLUSIONS

Social functioning may affect physical health. Specifically, social roles, activities and relationships may influence inflammatory oral conditions, like gingivitis. Confirmatory research is warranted, along with policies and interventions that promote social well-being.

Validity of individual self-report oral health measures in assessing periodontitis for causal research applications

BACKGROUND

Self-reported measures of periodontitis developed for use in population surveillance are increasingly used in causal research. Numerous studies evaluate the validity of these measures against clinical parameters of periodontitis, yet few include validation parameters outside of multivariable models. Individual item validity is necessary to adequately inform use of these measures in causal research.

METHODS

We used data from the National Health and Nutrition Examination Survey 2011-2014 in which dentate participants completed full-mouth periodontal examinations (N = 6966). We evaluated six self-report questionnaire items related to periodontal disease status against periodontitis case definitions developed by the Centers for Disease Control and Prevention and American Academy of Periodontology (CDC-AAP). We estimated the sensitivity and specificity of individual items using severe and moderate-to-severe periodontitis classifications. We additionally combined items to evaluate the validity of joint measures.

RESULTS

Sensitivity was highest when measures were evaluated against severe periodontitis. Self-rated oral health of fair/poor demonstrated the highest sensitivity for severe (0.60) and moderate-to-severe periodontitis (0.48). Specificity was highest when evaluated against moderate-to-severe periodontitis, with self-reported history of tooth mobility as the most specific measure (0.87 for severe disease; 0.92 for moderate-to-severe) followed by a history of bone loss (0.88 for severe; 0.91 for moderate-to-severe). Combining questions generally improved specificity at the expense of sensitivity.

CONCLUSIONS

Our findings related to item-specific validity and the associated clinical profiles facilitate needed considerations for the use of self-reported measures of periodontitis in causal research. Additionally, item-specific validity can be used to inform assessments of misclassification bias within such investigations.

Suitability of machine learning models for prediction of clinically defined Stage III/IV periodontitis from questionnaires and demographic data in Danish cohorts

AIM

To evaluate if, and to what extent, machine learning models can capture clinically defined Stage III/IV periodontitis from self-report questionnaires and demographic data.

MATERIALS AND METHODS

Self-reported measures of periodontitis, demographic data and clinically established Stage III/IV periodontitis status were extracted from two Danish population-based cohorts (The Copenhagen Aging and Midlife Biobank [CAMB] and The Danish Health Examination Survey [DANHES]) and used to develop cross-validated machine learning models for the prediction of clinically established Stage III/IV periodontitis. Models were trained using 10-fold cross-validations repeated three times on the CAMB dataset (n = 1476), and the resulting models were validated in the DANHES dataset (n = 3585).

RESULTS

The prevalence of Stage III/IV periodontitis was 23.2% (n = 342) in the CAMB dataset and 9.3% (n = 335) in the DANHES dataset. For the prediction of clinically established Stage III/IV periodontitis in the CAMB cohort, models reached area under the receiver operating characteristics (AUROCs) of 0.67-0.69, sensitivities of 0.58-0.64 and specificities of 0.71-0.80. In the DANHES cohort, models derived from the CAMB cohort achieved AUROCs of 0.64-0.70, sensitivities of 0.44-0.63 and specificities of 0.75-0.84.

CONCLUSIONS

Applying cross-validated machine learning algorithms to demographic data and self-reported measures of periodontitis resulted in models with modest capabilities for the prediction of Stage III/IV periodontitis in two Danish cohorts.

Preconception Periodontitis and Risk of Spontaneous Abortion in a Prospective Cohort Study

Few studies have evaluated the association between periodontitis and spontaneous abortion (SAB), and all had limitations. We used data from the Pregnancy Study Online (PRESTO), a prospective preconception cohort study of 3,444 pregnancy planners in the United States and Canada (2019-2022), to address this question. Participants provided self-reported data on periodontitis diagnosis, treatment, and symptoms of severity (i.e., loose teeth) via the enrollment questionnaire. SAB (pregnancy loss at <20 weeks' gestation) was assessed via bimonthly follow-up questionnaires. Participants contributed person-time from the date of a positive pregnancy test to the gestational week of SAB, loss to follow-up, or 20 weeks' gestation, whichever came first. We fitted Cox regression models with weeks of gestation as the time scale to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), and we used inverse probability of treatment weighting to account for differential loss to follow-up. We used probabilistic quantitative bias analysis to estimate the magnitude and direction of the effect of exposure misclassification bias on results. In weighted multivariable models, we saw no appreciable association between preconception periodontitis diagnosis (HR = 0.97, 95% CI: 0.76, 1.23) or treatment (HR = 1.01, 95% CI: 0.79, 1.27) and SAB. A history of loose teeth was positively associated with SAB (HR = 1.38, 95% CI: 0.88, 2.14). Quantitative bias analysis indicated that our findings were biased towards the null but with considerable uncertainty in the bias-adjusted results.

The association of periodontal disease and oral health with hypertension, NHANES 2009-2018

BACKGROUND

Hypertension is a worldwide public health problem. We sought to explore the interaction of oral health and smoking on hypertension, and periodontal disease and smoking on hypertension.

METHODS

We included 21,800 participants aged ≧ 30 years from the National Health and Nutrition Examination Survey (NHANES) 2009-2018. Information of oral health and periodontal disease were self-reported. Blood pressure was taken by trained personnel and/or physicians at mobile testing center. Multiple logistic regression was used to estimate the association between oral health, periodontal disease and the prevalence of hypertension. The effects of oral health and periodontal disease on hypertension under smoking status and age were analyzed by stratified and interaction analysis.

RESULTS

A total of 21,800 participants were investigated, including 11,017 (50.54%) in hypertensive group and 10,783 (49.46%) in non-hypertensive group. Compared with the excellent/very good of oral health, the multivariable-adjusted OR of good, fair, and poor were 1.13 (95% CI, 1.02-1.27), 1.30 (95% CI, 1.15-1.47), and 1.48 (95% CI, 1.22-1.79) (p for trend < 0.001) for hypertension, respectively. Compared without periodontal disease group, the multivariable-adjusted OR of periodontal disease for hypertension was 1.21 (95% CI ,1.09-1.35) (p for trend < 0.001). Furthermore, we found the interactions between periodontal disease and smoking, oral health and smoking, periodontal disease and age, oral health and age were p < 0.001.

CONCLUSIONS

An association between oral health and periodontal disease with the prevalence of hypertension was identified. There exists interactive effect of periodontal disease and smoking, oral health and smoking, periodontal disease and age, oral health and age on hypertension in American population over 30 years of age and older.

Relationship between the Social Development Index and Self-Reported Periodontal Conditions

Inequalities in oral health are influenced by the social strata of the population. Few studies have focused on the multitude of factors related to social development as indicators of living conditions and periodontal health status. The aim of this study is to evaluate the association between self-reported periodontal conditions and the Social Development Index (SDI). A cross-sectional validated questionnaire was carried out among 1294 Mexican adults. Descriptive statistics and multivariate logistic regression models were used to identify the best predictors of self-reported periodontal conditions. Bone loss reporting was used as a proxy for the presence of periodontal disease. We found that higher global scores on the SDI and quality and available space in the home (QASH) increase the probability of having bone loss. Global SDI (OR = 7.27) and higher QASH (OR = 3.66) were indeed the leading societal factors related to periodontal disease. These results have pointed out how SDI and its indicators, in particular QASH, can be used to further explore inequities related to privileged access to dental care in the context of periodontal diseases.

Who to Be Treated: Nomogram Using Self-Reported Periodontal Screening Instrument among English-Speaking Adults in Multi-Ethnic Singapore

Periodontal disease is a major public health problem. This study aimed to develop a nomogram using a self-reported periodontitis screening instrument in predicting severe periodontitis (SP), defined by the World Workshop on Classification of Periodontal and Peri-Implant Diseases and Conditions, and evaluate its utility in clinical setting. An Akaike information criterion selected multivariable model was developed to predict SP using a self-reported questionnaire, with a nomogram developed based on its regression coefficients. Discriminatory capability was evaluated by Receiver-operating characteristic curve. Ability to predict SP of individual patients was evaluated with bootstrapping. Decision curve analysis (DCA) was performed to evaluate its potential clinical utility by evaluating clinical net benefit at different thresholds. 58.1% of 155 participants were classified with SP. Older males without tertiary education, with ‘loose teeth’, ‘bone loss’ and ‘mouth rinse use’ had higher SP risk. The nomogram showed excellent discriminatory capability with Area under Curve of 0.83 (95% CI = (0.76, 0.89)), good calibration (intercept = 0.026) and slight overestimation of high risk and underestimation of low risk (slope = 0.834). DCA showed consistent clinical net benefit across the range of thresholds relative to assumption of ‘no patient’ or ‘all patient’ with SP. Our nomogram using a self-reported periodontitis instrument is useful in SP screening in English-speaking Singaporean adults.

Influence of symptomatic periodontal disease on changes in skeletal bone density during medication therapy for osteoporosis in postmenopausal women: the Japanese Osteoporosis Intervention Trial (JOINT)-04 and JOINT-05

Japanese postmenopausal women with symptomatic periodontal disease had a significantly smaller increase in the T-score for total hip bone density than those without periodontal disease during medication therapy for osteoporosis. Intervention to treat symptomatic periodontal disease before and/or during osteoporosis therapy could maintain the effect of osteoporosis medications.

PURPOSE

Women with periodontal disease may be more likely to develop osteoporosis. We evaluated whether the presence of symptomatic periodontal disease can influence changes in skeletal bone mineral density (BMD) during medication therapy for osteoporosis in Japanese postmenopausal women.

METHODS

A total of 4,258 postmenopausal women participated in the Japanese Osteoporosis Intervention Trial protocol number 4 (JOINT-04 trial) and number 5 (JOINT-05 trial), which were multi-center, open-label, randomized controlled trials in Japan. Of these, 3,670 non-edentulous subjects participated in the study. Subjects who had self-reported symptoms of periodontal disease at baseline were defined as having periodontal disease. The study outcome was the difference in BMD changes during the study between subjects with and without periodontal disease. Mixed models for repeated measures after adjusting for covariates were used to investigate the difference in the BMD changes during the study between subjects with and without periodontal disease.

RESULTS

Subjects with periodontal disease had significantly lower T-scores for total hip (p = 0.035) and metacarpal (p = 0.048) BMD than those without periodontal disease at baseline. During medication therapy for osteoporosis, subjects with periodontal disease had a significantly smaller increase in T-score for total hip BMD than those without periodontal disease (p = 0.021), although no significant differences were observed in the changes in T-scores for other skeletal BMD measurements between subjects with and without periodontal disease.

CONCLUSIONS

The presence of self-reported symptoms of periodontal disease may be associated with a decrease in the effect of osteoporosis medications in Japanese postmenopausal women.

Should We Be Screening for and Treating Periodontal Disease in Individuals Who Are at Risk of Rheumatoid Arthritis?

There is increasing evidence supporting an association between periodontal disease (PD) and rheumatoid arthritis (RA), both mechanistically and clinically. Trials have shown that treating PD in people with RA may improve RA disease activity. Patients with musculoskeletal symptoms without arthritis, who test positive for cyclic-citrullinated protein antibodies, are at risk of RA (CCP+ at-risk), with seropositivity preceding arthritis onset by months or years. Importantly, there is evidence to suggest that periodontal inflammation may precede joint inflammation in CCP+ at-risk and, therefore, this could be a trigger for RA. There has been increased research interest in RA prevention and the phenotyping of the pre-RA disease phase. This review will examine the merits of identifying individuals who are CCP+ at-risk and performing screening for PD. In addition, we discuss how PD should be treated once identified. Finally, the review will consider future research needed to advance our understanding of this disease association.

Assessed and perceived oral health of older people who visit the dental practice, an exploratory cross-sectional study

OBJECTIVES

To assess the oral health of older people who visit the community dental practice from both the dentists' and the patients' perspective.

MATERIALS AND METHODS

In this exploratory cross-sectional study the oral health of Dutch community dwelling older people was assessed. A representative sample of general dental practitioners was asked to randomly and prospectively select one older patient and describe this patient using a specially-developed registration form; in addition the patient was requested to complete a questionnaire. The oral health of older people was described from the perspective of the dentists and the perspective of the older people themselves based on the definition of oral health from the World Dental Federation (FDI]. Relations between oral health of older people and dentist and older patient characteristics were analysed using Spearman's rank correlation coefficient (rho) and an ordinal regression model.

RESULTS

In total, 923 dentists were asked to participate in the study; data was available for 39.4% dentist-patient pairs. Dentists assessed the oral health of older patients as good or acceptable in 51.4% of the cases while this was the case in 76.2% of older patients themselves. The assessment of the dentist gets more negative with high treatment intensity and with older patients having certain diseases and more medication, while the assessment is more positive for older patients who visit the dentist on a regular basis. Older people's assessment of their oral health gets more negative by being female and with high treatment intensity, having certain diseases and higher use of medication.

CONCLUSIONS AND CLINICAL RELEVANCE

Chronically illness as expressed by the number of diseases and the use of medication, seems to be a risk factor for poor oral health. Older patients themselves assess their oral health differently, mostly more positive, than their dentist.

Development and validation of a latent, multidimensional, self-report periodontal disease measure

BACKGROUND

Self-report measures of periodontal disease have utility for screening, but have not capitalized on a latent variable approach based on psychometric theory to validate such measures. This study aimed to develop a psychometrically valid self-report measure of periodontal disease using latent variable factor analysis and other evidence-based psychometric analyses.

METHODS

Likert-type items reflecting periodontal disease were administered to a sample of adults (n = 828) in the United States via an online survey. Items were adapted from prior self-report measures or were newly developed based on psychometric item development theory and theoretical knowledge of periodontal disease. Psychometric analyses included exploratory and confirmatory factor analysis, parallel analysis, and a calculation of internal consistency.

RESULTS

Exploratory factor analysis (EFA) was indicative of the goodness-of-fit with two factors (root mean square error of approximation (RMSEA) = 0.08; comparative fit index (CFI) = 0.97; Tucker Lewis index (TLI) = 0.96; standardized root mean squared residual = 0.06); five of the 22 original survey questions were eliminated based on the results of this EFA. Parallel analysis supported a two-factor model to represent the similarities across items-one factor reflecting physiologic components and another reflecting functional components of periodontal disease. Confirmatory Factor Analysis also indicated adequate model fit (RMSEA = 0.07; CFI = 0.98; TLI = 0.98; and weighted root mean square residual = 1.20).

CONCLUSIONS

Psychometric analyses of a new 17-item periodontal disease self-report measure provided initial evidence of construct/factor validity. This approach to developing self-report periodontal disease measures may facilitate useful and cost-effective estimates of periodontal disease and provide a testable scale. Future work should include clinical validation.

Self-perception of periodontal health status among individuals with Fanconi anemia

Introduction

Fanconi anemia (FA) is a rare genetic disease characterized by congenital malformations and bone marrow failure. One of the most common oral diseases in individuals with FA is periodontitis and adequate self-perception of periodontal status could contribute to its prevention and early detection.

Aim

To compare oral health self-perception, measured by a questionnaire, with the clinical oral condition of patients with FA.

Methods and Results

Fifty-six patients with FA, over 11 years of age, answered a questionnaire about dental history and self-reported oral health. Decayed, missing, and filled teeth (DMFT), Visible Plaque Index (VPI) and Gingival Bleeding Index (GBI) were measured. The median age of participants was 21 years (min 11, max 44), 31 (55%) were females and 25 (45%) males. Thirty-five (62.5%) participants rated their oral condition as satisfactory and 7 (12.5%) participants reported tooth mobility, 10 (17.9%) exposed roots and 21 (37.5%) gingival bleeding. Clinical examination detected average DMFT = 5.23, VPI = 31.36% and GBI = 33.77%. The gingival bleeding report was more frequent among individuals with higher GBI (p =  0.014). The DMFT was higher in those who had already undergone dental treatments (p =  0.031). There was an association between participants who presented dental caries and who rated their oral health as poor (p =  0.03). The question “Do your gums bleed easily?” had good accuracy in the evaluation of periodontal disease (p =  0.68).

Conclusion

Oral health self-perception of individuals with FA about gingival inflammation was associated with their gingival bleeding index.

The added value of periodontal measurements for identification of diabetes among Saudi adults

BACKGROUND

The aims of this study were to develop a prediction model for identification of individuals with diabetes based on clinical and perceived periodontal measurements; and to evaluate its added value when combined with standard diabetes screening tools.

METHODS

The study was carried out among 250 adults attending primary care clinics in Riyadh (Saudi Arabia). The study adopted a case-control approach, where diabetes status was first ascertained, and the Finnish Diabetes Risk Score (FINDRISC), Canadian Diabetes Risk questionnaire (CANRISK), and periodontal examinations were carried out afterward.

RESULTS

A periodontal prediction model (PPM) including three periodontal indicators (missing teeth, percentage of sites with pocket probing depth ≥6 mm, and mean pocket probing depth) had an area under the curve (AUC) of 0.694 (95% Confidence Interval: 0.612-0.776) and classified correctly 62.4% of participants. The FINDRISC and CANRISK tools had AUCs of 0.766 (95% CI: 0.690-0.843) and 0.821 (95% CI: 0.763-0.879), respectively. The addition of the PPM significantly improved the AUC of FINDRISC (P = 0.048) but not of CANRISK (P = 0.144), with 26.8% and 9.8% of participants correctly reclassified, respectively. Finally, decision curve analysis showed that adding the PPM to both tools would result in net benefits among patients with probability scores lower than 70%.

CONCLUSIONS

This study showed that periodontal measurements could play a role in identifying individuals with diabetes, and that addition of clinical periodontal measurements improved the performance of FINDRISC and CANRISK.

Validity of Self-Reported Periodontitis in Japanese Adults: The Japan Public Health Center-Based Prospective Study for the Next-Generation Oral Health Study

This study evaluated the validity of self-reported periodontitis measures among 2404 Japanese adults aged 40 to 75 years. A self-administered questionnaire survey and a clinical periodontal examination were conducted from 2013 through 2016. The self-reported periodontitis questions included 3 sociodemographic, 3 health, and 5 periodontal health-related items. Based on the clinical case definition of periodontitis, 26.5% of participants were found to be periodontally healthy, 2.7% had mild periodontitis, 55.2% moderate periodontitis, and 15.6% severe periodontitis. No single self-reported question demonstrated satisfactory validity in predicting the presence or absence of periodontitis. The predictive ability in mild and/or moderate periodontitis was poor even after combining multiple sociodemographic, health, and periodontal health-related questions. In severe periodontitis, the model including age, sex, education level, smoking status, diabetes history, body mass index, informed by a dentist, gingival bleeding, calculus deposit, and tooth mobility, presented moderate predictive performance (C-statistic: 0.676, sensitivity: 65.2%, and specificity: 61.1%). An age-stratified analysis on severe periodontitis showed that sensitivity was higher, and specificity was lower in older age group (60-75 years) than younger age group (40-59 years). Further refinement of questions in the self-report is required to increase the accuracy of the prediction of clinical periodontitis.

Self-Perception of Periodontal Health and Associated Factors: A Cross-Sectional Population-Based Study

The aim of this cross-sectional study was to explore sociodemographic, behavioral, and clinical factors associated with self-awareness of periodontal health. Data were collected from a representative sample of 736 adults (25–75 years old) in a city of Northern Italy who self-assessed gingival bleeding, oral malodor, and tooth mobility in a questionnaire and who underwent clinical periodontal examination and organoleptic evaluation. Approximately 50% of the subjects were aware of their actual gingival health status and oral odor. The logistic regression analysis revealed that females presented higher odds of correctly perceiving their gingival conditions and mouth odor, while those who were older and smokers had a greater probability of being less objective in reporting them. Tooth type and position in the dental arches were positively associated with self-perception of tooth mobility. These findings reflected a low level of self-awareness that may influence oral care-seeking behavior. Subjects may be unconcerned about their periodontal health condition or lack enough knowledge to be aware of it. This points to the need for planning strategies to improve education and knowledge about periodontal health, which, by enhancing self-perception of periodontal symptoms, could help everyone to seek treatment in the initial stage of the disease.

High prevalence of periodontitis in blood donors and the possibility of questionnaire-based screening - results of a cross-sectional study

BACKGROUND

Periodontitis is an inflammatory disease of high prevalence and, thus, of potential relevance to the management of blood donation.

OBJECTIVES

The aim of this cross-sectional study was to assess periodontal health and its associations to common blood parameters, as well as questionnaire-based periodontitis screening in blood donors.

METHODS

Generally healthy blood donors were recruited and underwent oral examination. Thereby, the decayed-, missing- and filled-teeth index (DMF-T) and periodontal status, including periodontal probing depth and clinical attachment loss, were assessed. Based on periodontal status, periodontitis severity was classified into no/mild, moderate or severe. Six yes/no questions regarding periodontal complaints and history were asked. Furthermore, common blood parameters were analysed.

RESULTS

A total of 148 participants (mean age 53·33 years) were included. The DMF-T was 15·28 ± 6·44. Nearly three quarters of participants suffered from a periodontitis (moderate 59·5% and severe 14·8%, total periodontitis 74·3%). Periodontitis severity was associated with the history of dental visits caused by periodontal complaints (P < 0·01) and previous periodontal therapy (P < 0·01). Only procalcitonin was initially found to be associated with blood periodontitis severity (P = 0·02). This observation was not confirmed by post-hoc testing between subgroups (P_i  > 0·2). No further association between periodontitis severity and blood parameters was found (P_i  > 0·05).

CONCLUSION

The prevalence of periodontitis in German blood donors is high. However, further studies with sensitive testing of bacteria in peripheral blood are required in order to determine the relevance of this result for the safety of blood components.

A public health perspective on personalized periodontics

In this paper, we consider personalized periodontics from a public health perspective. Periodontitis is an under-acknowledged and important public health problem, and there has long been interest in identifying and treating those who are at high risk of developing this disease. Although susceptibility/risk-assessment tools in periodontology are currently in their early stages of development, personalized periodontics is increasingly becoming a realistic approach. At the population level, however, personalized periodontics is not an effective way of improving periodontal health because it would target only those who seek help or are able to access care. The occurrence of periodontitis in populations is socially patterned, with those of lower socio-economic position having poorer periodontal health and being far less likely to seek care. There is the potential for social inequalities actually to worsen as a result of personalized periodontics. In most health systems, personalized periodontics is likely to be accessible only to the social strata for whom it is affordable, and those with the greatest need for such an intervention will remain the least likely to be able to get it. Thus, personalized periodontics is likely to be a niche service for a small proportion of the adult population. This is at odds with the public health approach.