Oral health of US adults: NIDR 1985 national survey

Factors influencing the periodontal referral process

BACKGROUND

General dental practitioners (GPs) assess the periodontal status of patients and make decisions to treat patients or refer them to a periodontist. There is little information available regarding this process. The purpose of this study is to identify significant factors that GPs consider important in selecting a particular periodontist. The findings were compared and contrasted with responses of periodontists to gain perspectives from both groups involved in the referral process.

METHODS

Data from an online cross-sectional survey of GPs (n = 533) and periodontists (n = 533) who practice in the southeastern region of the United States (from the databases of the American Dental Association and American Academy of Periodontology member directories) were obtained.

RESULTS

The specialist's clinical skill was identified as the most important factor influencing periodontal referrals by GPs, whereas periodontists identified a previous positive experience between a GP and periodontist as the most important factor. In a descending order of importance, the top three rating averages (rated out of five) by GPs were clinical skill (4.84), a previous positive experience between a GP and periodontist (4.57), and communication (4.52). The top three factors of periodontists were a previous positive experience between a GP and periodontist (4.66), communication (4.40), and the likelihood of a good patient and periodontist rapport (4.29).

CONCLUSIONS

The periodontist's clinical skill was chosen by GPs as the primary factor influencing the referral decisions of GPs. Periodontists perceived a previous positive experience between the GP and periodontist as the most influential factor. Further studies are required to gain more insight into the referral process.

Identification of the primary mechanism of complement evasion by the periodontal pathogen, Treponema denticola

Treponema denticola, a periodontal pathogen, binds the complement regulatory protein Factor H (FH). Factor H binding protein B (FhbB) is the sole FH binding protein produced by T. denticola. The interaction of FhbB with FH is unique in that FH is bound to the cell and then cleaved by the T. denticola protease, dentilisin. A ∼ 50-kDa product generated by dentilisin cleavage is retained at the cell surface. Until this study, a direct role for the FhbB-FH interaction in complement evasion and serum sensitivity had not been demonstrated. Here we assess the serum resistance of T. denticola strain 35405 (Td35405wt) and isogenic mutants deficient in dentilisin (Td35405-CCE) and FhbB production (Td35405ΔfhbB), respectively. Both dentilisin and FhbB have been postulated to be key virulence factors that mediate complement evasion. Consistent with conditions in the subgingival crevice, an environment with a significant concentration of complement, Td35405wt was resistant to serum concentrations as high as 25%. Deletion of fhbB (Td35405ΔfhbB), which resulted in the complete loss of FH binding ability, but not inactivation of dentilisin activity (Td35405-CCE), rendered T. denticola highly sensitive to 25% human serum with 80% of the cells being disrupted after 4 h of incubation. Heat treatment of the serum to inactivate complement confirmed that killing was mediated by complement. These results indicate that the FH-FhbB interaction is required for serum resistance whereas dentilisin is not. This report provides new insight into the novel complement evasion mechanisms of T. denticola.

Analysis of a unique interaction between the complement regulatory protein factor H and the periodontal pathogen Treponema denticola

Treponema denticola, a spirochete associated with periodontitis, is abundant at the leading edge of subgingival plaque, where it interacts with gingival epithelia. T. denticola produces a number of virulence factors, including dentilisin, a protease which is cytopathic to host cells, and FhbB, a unique T. denticola lipoprotein that binds complement regulatory proteins. Earlier analyses suggested that FhbB specifically bound to factor H (FH)-like protein 1 (FHL-1). However, by using dentilisin-deficient mutants of T. denticola, we found that T. denticola preferentially binds FH and not FHL-1, and that FH is then cleaved by dentilisin to yield an FH subfragment of approximately 50 kDa. FH bound to dentilisin-deficient mutants but was not cleaved and retained its ability to serve as a cofactor for factor I in the cleavage of C3b. To assess the molecular basis of the interaction of FhbB with FH, mutational analyses were conducted. Replacement of specific residues in widely separated domains of FhbB and disruption of a central alpha helix with coiled-coil formation probability attenuated or eliminated FH binding. The data presented here are the first to demonstrate the retention at the cell surface of a proteolytic cleavage product of FH. The precise role of this FH fragment in the host-pathogen interaction remains to be determined.

Analytical epidemiology of periodontitis

AIMS

To review the literature related to the analytical epidemiology of periodontitis generated over the past decade. This review does not deal with descriptive epidemiologic studies of the prevalence, extent and severity of periodontitis with respect to global geography, but focuses exclusively on analytical epidemiology issues, including the challenges posed by the use of different case definitions across studies, current theories and models of disease progression, and risk factors associated with the onset and progression of periodontitis.

METHODS

Relevant publications in the English language were identified after Medline and PubMed database searches.

FINDINGS AND CONCLUSIONS

There is a conspicuous lack of uniformity in the definition of periodontitis used in epidemiologic studies, and findings from different research groups are not readily interpretable. There is a lack of studies that specifically address the distinction between factors responsible for the onset of periodontitis versus those affecting its progression. Colonization by specific bacteria at high levels, smoking, and poorly controlled diabetes have been established as risk factors for periodontitis, while a number of putative factors, including specific gene polymorphisms, have been identified in association studies. There is a clear need for longitudinal prospective studies that address hypotheses emerging from the cross-sectional data and include established risk factors as covariates along with new exposures of interest. Intervention studies, fulfilling the "targeting" step of the risk assessment process, are particularly warranted. Obvious candidates in this context are studies of the efficacy of elimination of specific bacterial species and of smoking cessation interventions as an alternative to the traditional broad anti-plaque approach in the prevention and control of periodontitis. Ideally, such studies should have a randomized-controlled trial design.

Factors related to the non-attendance in a clinical oral health study on the home-dwelling old elderly

OBJECTIVE

To evaluate how elderly home-dwelling subjects' background factors, state of health, functional capacity and edentulousness related to their attendance in a comprehensive clinical dental study.

DESIGN

Cross-sectional population study; interview and clinical dental data.

SETTING

The City of Helsinki; clinical dental examinations at the Institute of Dentistry, University of Helsinki.

SUBJECTS

600 elderly aged 76, 81 and 86 years, participants in the medical examinations in the Helsinki Ageing Study one year earlier, 81% being home-dwelling.

MEASURES

Age, gender, marital status, family structure, educational level, former line of work, self-perceived general health, dentulousness, ability to move, sense of hearing, state of memory, clinical findings of dementia, other medical diagnoses, and intake of drugs.

OUTCOME MEASURE

Participation in clinical dental examinations.

RESULTS

The overall participation was 63% being reduced by high age and female gender, 75% of the 76-year-olds, but only 53% of those aged 81 or 86 years were clinically examined, figures were for men 72% and for women 60%. As shown by a multifactorial logit model, the strongest factors related to non-participation were the home-dwelling subjects' old age (OR = 3.6), deteriorated ability to move (OR = 5.3), clinically diagnosed symptoms of dementia (OR = 4.1), or edentulousness (OR = 2.5).

CONCLUSION

Non-participation selectively by those edentulous will lead to prevalence figures on numbers of teeth being too optimistic for the entire elderly population.

Periodontal status in an urban adult population in Sweden

The purpose was to describe the current periodontal status in a Swedish urban population aged 31-40 yr. 1681 individuals, 840 men and 841 women, participated in the study. 68.5% of the subjects had low amount of plaque, 82.8% low level of calculus and 28.9% healthy gingiva or mild gingivitis. 82.8% of the subjects had no pockets with probing depth (PD) > or = 5 mm. 4.9% of the subjects had one tooth with PD > or = 5 mm, 6.7% 2-5 teeth, 2.4% 6-9 teeth and 3.2% > or = 10 teeth with pockets. 55.8% of the subjects had no missing teeth, third molars excluded. 16.5% had one tooth missing, 23.8% 2-5 teeth, 2.7% 6-9 teeth and 1.2% > or = 10 teeth. 8.6% of the subjects had at least one front tooth missing, 28.7% one premolar and 24.1% one molar missing. Men had significantly higher scores than women for plaque (DI-S), calculus (CI-S), gingivitis (GI-M), and number and percent of remaining teeth with PD > or = 5 mm. Smokers had significantly higher scores than non-smokers for DI-S, CI-S, GI-M, number and percent of remaining teeth with PD > or = 5 mm, and number of missing teeth. The individuals who visited the dentist every year had better oral hygiene and gingival status than those who attended for > 3 yr. The multiple regression analysis showed that calculus (P = 0.0001) smoking (P = 0.001), and dental visits (P = 0.0284) were significantly correlated to the number of teeth with PD > or = 5 mm.

Productivity in Minnesota dental practices with increased visits by older patients

There is little scientific information on the economic impact of treating increased numbers of older adults, despite the current growth in this population. To assess the impact of patient age on dental practice productivity, we evaluated an economic production function that included the proportions of patient visits in two older age groups (61-69 years, 70+ years) as factors that might affect the dental service production process. We used data from 12,818 patient visits to 31 Minnesota dental practices enrolled in the Minnesota Dental Practice Analysis System (DPAS) between 1980 and 1984. Ordinary least squares multiple linear regression was used to detect potential associations between practice productivity, measured in standardized time and monetary outputs, and the proportions of visits by older patients. We found that increases in the proportion of visits by patients aged 70 years and older were associated with decreases in productivity when we controlled for differences in the mix of services used. Our results support the notion that dental practices may be less productive when providing services to older patients compared to younger patients. These findings may have implications for personnel and policy planning. Further investigation of this issue is warranted because of the limited number of practices included in the study.

Clinical correlates of dental anxiety among older adults

Most studies of the relationship between dental anxiety and oral health status have used subjective rather than clinical indicators of oral health. In this paper we examine differences between older adults who are and are not dentally anxious using a broad range of clinical measures. The data show that dentally anxious individuals were more likely to be edentulous, and among the dentate, had more missing and fewer filled teeth. As a result, dentally anxious dentate subjects were more likely to need prosthodontic treatment. They were also more likely to need immediate treatment for the relief of pain and infection and periodontal care. There was evidence to suggest differences in patterns of dental treatment between those who were and were not dentally anxious and some evidence consistent with the hypothesis that aging influences the relationship between dental anxiety and oral health status.

Social factors and tooth loss in a 12-year follow-up study of women in Gothenburg, Sweden

Representative samples of women in different age groups in Gothenburg, Sweden, were examined by means of panoramic radiography in 1968-69 and in 1980-81. Edentulousness and number of remaining teeth were assessed from the radiographs. Data on socioeconomic conditions, educational background and dental care attendance were obtained from a questionnaire. Cross-sectional results showed that improvements in dental status had occurred irrespective of socioeconomic conditions and educational levels and that differences between groups had decreased over the 12-yr period. Dental care attendance was high in all socioeconomic groups, but differences noted in 1968-69 remained in 1980-81.

Trends in the prevalence and severity of periodontal diseases in the US: a public health problem?

This article reviews trends in the prevalence and severity of periodontal diseases in US adults and examines the implications of these trends regarding the recognition of periodontal disease as a public health problem. Data from the National Center for Health Statistics (NCHS) examination surveys, 1960-62 and 1971-74, and the National Institute of Dental Research (NIDR) 1985-86 Survey of Employed and Senior Adults are examined. Issues of comparability and generalizability are discussed. Changes in the prevalence and severity of gingivitis and periodontitis are presented for the time periods 1960-62 to 1971-74 and 1971-74 to 1985-86. We concluded (1) it is difficult to document the changes occurring in the prevalence of gingivitis; however, given the available evidence, the prevalence and severity of gingivitis have probably declined; (2) it appears that periodontitis continues to affect approximately the same proportions of the overall US adult population; but with those affected, the extent and severity of the disease have declined; and (3) older adults continue to exhibit more disease and greater levels of severe disease than the younger age groups. Renewed efforts to clarify the epidemiologic confusion concerning trends in the prevalence and severity of periodontal disease should remain high on the agenda for public health dentistry.

The effect of a fluoridated dentifrice on root and coronal caries in an older adult population

Little information is available on the effect of fluorides on root surface caries in adults. This double-blind clinical study of 810 healthy adults, aged 54 and older, demonstrated decided cariostatic effects of a fluoridated dentifrice containing 1,100 ppm F as sodium fluoride. Statistically significant differences on both coronal (41%) and root surface caries (67%) incidence were produced in the test group and compared with a control dentifrice group during 1 year of study.

Occurrence of root caries in relation to dental health behavior

We studied the relationship between the occurrence of untreated root caries and a subject's dental health habits, such as the frequency of tooth-brushing, the avoidance of sugar, and regularity of dental visits. A representative sample of 5028 adults was examined. Information on dental health habits was collected by professional interviewers one to six weeks before the clinical examination. A high frequency of tooth-brushing was strongly related to a low occurrence of root caries. The use of sugar in coffee or tea was strongly associated with root caries occurrence among men. The use of sweets was related to root caries occurrence moderately in men but not at all in women. Regular dental check-up behavior was strongly related to an infrequent occurrence of root caries. It was concluded that dental health behavior influences root caries occurrence and that caries on root surfaces is associated with poor dental health habits. Age and gender differences in root caries occurrence, reported earlier, may relate to different dental health behavior of women and men.