Trends in Oral Diseases in the U.S. Population

Oral Health Differences Between Middle-Aged and Older Adults in South Korea

INTRODUCTION AND AIMS

The oral health characteristics of middle-aged and older adults exhibit variations. This study identifies the various factors associated with oral health among middle-aged and older adults through a subgroup analysis by age group of data representative of the South Korean population.

METHODS

We examined influencing factors: demographic, socioeconomic, dental, physical attributes, psychological, and mental attributes. Oral health was assessed using the Geriatric Oral Health Assessment Index. The participants were divided into two groups: those under 65 years of age (middle-aged) and those over 65 years of age (older adults). We used multiple linear regression analysis and dominance analysis to determine the dominant factors associated with oral health.

RESULTS

A total of 6369 participants were aged 69.2 ± 9.8 years on average, and 57.5% were women. Dominance analysis revealed that lower educational levels and activity difficulty caused by diseases were significantly associated with both groups. Moreover, depressive symptoms were the foremost adverse factor linked to oral health in the middle-aged (P < .001, standardized beta [β] = -4.30, general dominance index [GDI] = 19.00) and older (P < .001, β = -0.30, GDI = 10.70) adults. The number of teeth exhibited the most positive association with oral health in both middle-aged (P < .001, β = 0.20, GDI = 5.30) and older (P < .001, β = 0.23, GDI = 7.40) adults. However, cognitive function, dental visits, body mass index, severe pain, functional limitations, and cognitive function exhibited distinct patterns between the age groups.

CONCLUSION

Depressive symptoms and the number of teeth significantly influence oral health in middle-aged and older adults, though the impact varies by age. These findings stress the importance of tailored strategies considering age-specific attributes for effective oral health improvement.

CLINICAL RELEVANCE

Enhancing oral health requires healthcare providers to prioritize monitoring age-specific risk factors. Further, educational plans should highlight the importance of preventive oral care and regular dental visits.

Comparison of Implant-Retained Overdenture and Conventional Complete Denture: A Survey Study to Measure Patients' Satisfaction and Quality of Life in Dental School Clinics

Patient satisfaction and quality of life are integral to assessing oral health care quality. For many Americans still using conventional complete dentures (CDs) or implant-retained mandibular overdentures (IODs), it remains essential to consider improving their oral health outcomes and quality of life. Due to inexperienced student dentists providing dental care to dental school patients, patient grievances are generally considered a problem. Patient feedback and satisfaction have proven valuable resources for monitoring and improving patient safety. While CDs and IODs are the 2 leading treatment options for edentulism, more comparative studies in the literature need to compare their outcomes in a school setting. The research question that guided this comparative analysis was, "Is patient satisfaction and quality of life affected by the type of prostheses and provider?" A validated questionnaire was mailed to 520 individuals selected from records of patients who had received treatment for edentulous mandible at a student prosthodontic clinic at the University of Kentucky College of Dentistry from 2014 to 2016 with at least 1 year of follow-up time. A validated questionnaire for edentulous patients based on the Oral Health Impact Profile (OHIP-19) was used. In addition, information on patients' oral health-related quality of life, including questions related to the edentulous patients' satisfaction with their dentures, was collected. The response rate was 33% (N = 171). The study's findings confirm previous findings, suggesting that IODs may significantly impact oral health-related quality of life. Data show that 76% of the IOD group reported improvement in experience when using the implants to retain the mandibular denture. However, there were no statistically significant differences in the OHIP scores between overall CD and IOD patient groups. Males with IODs had lower physical pain, limitations, and disability scores than males with CD. However, females with IODs reported more significant concerns associated with a social disability and handicap domains. Comparing users who had experiences with both treatment options, this study discerned essential characteristics that contribute to increased patient satisfaction with IODs and identified significance in outcomes by gender. These findings guide prosthodontic practitioners' patient care practices and identify a continuing need to discuss CD and IOD treatment protocols within dental school curricula.

Multiple Imputation for Partial Recording Periodontal Examination Protocols

AIM

Partial-mouth recording protocols often result in underestimation of population prevalence and extent of periodontitis. We posit that multiple imputation of measures such as clinical attachment loss for nonselected tooth sites in partial-mouth samples can reduce bias in periodontitis estimates.

METHODS

Multiple imputation for correlated site-level dichotomous outcomes in a generalized estimating equations framework is used to impute site-level binary indicators for clinical attachment loss exceeding a fixed threshold in partial-mouth samples. Periodontitis case definitions are applied to the imputed "complete" dentitions, enabling estimation of prevalence and other summaries of periodontitis for partial-mouth samples as if for full-mouth examinations. A multiple imputation-bootstrap procedure is described and applied for point and variance estimation of these periodontitis measures. The procedure is evaluated with pseudo-partial-mouth samples based on random site selection protocols of 28 to 84 periodontal sites repeatedly generated from full-mouth periodontal examinations of 3,621 participants in the 2013 to 2014 National Health and Nutrition Examination Survey (NHANES) survey.

RESULTS

Multiple imputation applied to partial-mouth samples overestimated periodontitis mean extent, defined as the number of sites with clinical attachment loss 3 mm or greater, by 9.5% in random site selection protocols with 84 sites and overestimated prevalence by 5% to 10% in all the evaluated protocols.

CONCLUSIONS

In the 2013 to 2014 NHANES data, multiple imputation of site-level periodontal indicators provides less biased estimates of periodontitis prevalence and extent than has been reported from estimates based on the direct application of full-mouth case definitions to partial-mouth samples. Multiple imputation provides a promising solution to the longstanding, vexing problem of estimation bias in partial-mouth recording, with potential application to a wide array of case definitions, periodontitis measures, and partial recording protocols.

KNOWLEDGE TRANSFER STATEMENT

Partial-mouth sampling, while a resource-efficient strategy for obtaining oral disease estimates, often results in underestimation of periodontitis metrics. Multiple imputation for nonselected periodontal sites produces pseudo-full-mouth data sets that may be analyzed and combined to produce estimates with small bias.

Using machine learning algorithms to investigate factors associated with complete edentulism among older adults in the United States

AIMS

Edentulism is an incapacitating condition, and its prevalence is unequal among different population groups in the United States (US) despite its declining prevalence. This study aimed to investigate the current prevalence, apply Machine Learning (ML) Algorithms to investigate factors associated with complete tooth loss among older US adults, and compare the performance of the models.

METHODS

The cross-sectional 2020 Behavioral Risk Factor Surveillance System (BRFSS) data was used to evaluate the prevalence and factors associated with edentulism. ML models were developed to identify factors associated with edentulism utilizing seven ML algorithms. The performance of these models was compared using the area under the receiver operating characteristic curve (AUC).

RESULTS

An overall prevalence of 11.9% was reported. The AdaBoost algorithm (AUC = 84.9%) showed the best performance. Analysis showed that the last dental visit, educational attainment, smoking, difficulty walking, and general health status were among the top factors associated with complete edentulism.

CONCLUSION

Findings from our study support the declining prevalence of complete edentulism in older adults in the US and show that it is possible to develop a high-performing ML model to investigate the most important factors associated with edentulism using nationally representative data.

Racial/ethnic disparities in preventive dental services use and dental caries among children

OBJECTIVE

To assess disparities in preventive dental service use in four major racial/ethnic groups and assess whether racial/ethnic and income-related disparities among children were reduced from 2016 to 2020.

METHODS

Data were from the 2016 and 2020 National Survey of Children's Health (NSCH). The outcomes of interest were having dental sealants, fluoride treatment, and dental caries in the past 12 months. Racial/ethnic groups included non-Hispanic (NH) whites, blacks, Hispanics, Asians, and others. Family income level was categorized as below or above the 200% federal poverty level (low-income vs. high-income). Children ages 2-17 were included (N = 161,539). All data were self-reported by parents/guardians. We estimated the trends of racial/ethnic disparities in having fluoride treatment, dental sealants, and dental caries from 2016 to 2020 and tested two 2-way interactions (i.e., year by race/ethnicity, year by income) and one 3-way interaction (year by income by race/ethnicity) to assess the change in disparities from 2016 to 2020.

RESULTS

Overall, no significant trends in receipt of fluoride treatment, dental sealants, or having dental caries were found from 2016 to 2020 among the racial/ethnic groups, except for a decreasing trend in dental sealants for Asian American children (p = 0.03). Overall, NH white children were more likely to have received preventive dental services than children from minority groups (all p < 0.05); Asian American children (AOR = 1.31) were more likely to have dental caries than NH white children.

CONCLUSION

Disparities in receipt of evidence-based preventive services by children persisted. Continuous efforts are needed to promote the use of preventive dental services among children of minority populations.

Dental hygienists' scope of practice regulations and preventable non-traumatic dental emergency department visits: A cross-sectional study of 10 U.S. states

OBJECTIVES

As emergency department (ED) visits for non-traumatic dental complaints continue to rise in the United States (U.S.), some states are implementing initiatives to expand access to the oral health workforce. This study examines the associations between the 2014 Dental Hygiene Professional Practice Index (DHPPI) and preventable dental ED visits.

METHODS

In 2020, we used ED data from 10 U.S. states and ordinary least squares models to examine the relationship between the states' DHPPI scores and preventable dental ED use. We stratified regressions by age to examine this relationship across different age cohorts and introduced interaction terms to assess the same relationship among rural and urban residents.

RESULTS

On average, 23.8% of all non-traumatic dental ED visits were identified as preventable. Controlling for other factors, a one-point increase in DHPPI scores was associated with a decrease of 0.01 (95% CI -0.03, -0.02) preventable dental ED visits per 1000 county population in each year-quarter. In the age-stratified models, the strength of the association between DHPPI scores and preventable dental ED visits was higher in the 20 to 34 (-0.03, 95% CI -0.04, -0.02), and the 35 to 50 age cohorts (-0.17, 95% CI -0.00, -0.00). U.S. states with DHPPI scores below 60 saw significantly higher preventable dental ED visits among rural residents.

CONCLUSIONS

This study demonstrates that stringent state policies regarding the dental hygienist workforce are associated with higher preventable dental ED visits in the U.S. Policy makers and stake holders must address the scope of practice policies to alleviate the burden of access to oral healthcare.

Caries-Free Prevalence among Schoolchildren in Malaysia-Time-Series Analysis of Trends and Projections from 1996 to 2030

This study assessed caries-free prevalence trends over two decades from 1996 to 2019 and projected the caries-free prevalence from 2020 to 2030 among schoolchildren in Malaysia. The study consisted of secondary data analysis of caries-free prevalence from 1996 to 2019 in six-, twelve- and sixteen-year-old schoolchildren obtained from Health Information Management System (HIMS) reports. Three time-series models were compared: double exponential smoothing (DES), autoregressive integrated moving average (ARIMA) and the error, trend and seasonal (ETS) model, and the best model with the smallest error was chosen for univariate projection of caries-free prevalence of each age group until 2030. An upward trend of caries-free prevalence was observed for all age groups over the years. Caries-free prevalence was projected to increase with a different increment in each age group for the next decade, with a slightly damped trend noted in 16-year-old schoolchildren. Of all the age groups, the caries-free prevalence trend and projection demonstrated to be highest in 12-year-olds, followed by 16-year-olds, while 6-year-old schoolchildren revealed the lowest caries-free prevalence over three decades. The 16-year-old schoolchildren demonstrated the smallest predicted increment in caries-free prevalence. Future work can explore multivariate projections. Meanwhile, more resources and interventions could prioritise all age groups.

Early Childhood Caries in a Preschool-based Sample in Northeast Italy: Socioeconomic Status and Behavioral Risk Factors

Aim

To assess the relationship among caries and age, gender, immigrant condition, socioeconomic status (SES), and a behavioral risk factor (toothbrushing) in a sample of 3-5-year-old children.

Materials and methods

We performed a random cross-sectional survey from January to December 2017, carrying out clinical examinations to estimate the decayed, missing, and filled teeth (dmft) score. Parents filled in a questionnaire reporting their education level (SES) and the daily frequency of children's toothbrushing. The multivariate analysis assessed the association between caries occurrence and the independent variables. The dmft score was assessed by zero-inflated negative binomial regression (ZINBR).

Results

Out of 1,441 children in the sample, 357 (26.0%) presented at least one caries-affected tooth. Caries risk significantly increased with age and irregular toothbrushing, and it was significantly higher in children with lower SES levels. We modeled caries risk by means of ZINBR. The degree of caries experience increased in children from lower SES positions, immigrant status, and of older age; regular toothbrushing (twice a day) is a predicting factor to belong to the "zero caries" group.

Conclusion

Dental caries represent a significant burden in preschool children and can be regarded as an early marker of social disadvantage.

Clinical significance

The confirmation of the earliest preventive approach as the only chance to grant a "caries free" dentition in all ages and the first target for a pediatric dentist.

How to cite this article

Ferro R, Besostri A, Olivieri A, et al. Early Childhood Caries in a Preschool-based Sample in Northeast Italy: Socioeconomic Status and Behavioral Risk Factors. Int J Clin Pediatr Dent 2022;15(6):717-723.

Fluoride Prescribing Behaviors for Medicaid-Enrolled Children in Oregon

INTRODUCTION

This study aims to examine physician and dentist fluoride prescription patterns and identify the factors associated with fluoride prescriptions for Medicaid-enrolled children. The hypothesis is that dentists will be the primary prescribers of fluoride and that caries risk factors will be associated with fluoride prescriptions.

METHODS

Data were analyzed for Oregon children aged 0-17 years enrolled in Medicaid for ≥300 days in both 2016 and 2017. The outcome variable was receiving a fluoride prescription in 2017. A 2-tailed chi-square test was used to assess fluoride prescribing differences between physicians and dentists. Multivariable logistic regression models were used to examine the likelihood of receiving a fluoride prescription in 2017 and to generate ORs. Model covariates included child's age, sex, race, ethnicity, Medicaid plan type, previous fluoride prescription, previous restorative dental treatment, and water fluoridation status.

RESULTS

Of 200,169 Medicaid-enrolled children, 6.7% (n=13,337) received fluoride prescriptions. Physicians were >3 times as likely to prescribe fluoride as dentists (73.4% vs 23.0%, p<0.001). Children with a history of fluoride prescriptions (OR=14.30, p<0.001) and any restorative dental treatment (OR=1.58, p<0.001) were significantly more likely to receive a fluoride prescription, whereas children living in areas with water fluoridation were significantly less likely (OR=0.50, p=0.01).

CONCLUSIONS

Physicians play an important role in prescribing fluoride to Medicaid-enrolled children, especially those at increased dental caries risk. Additional research is needed on strategies to ensure that all high-risk children have an opportunity to benefit from prescription fluoride.

Improvements in Dental Health and Dentists' Workload in Norway, 1992 to 2015

OBJECTIVES

There has been a marked improvement in dental health in Norway during the last few decades. What effect has this had on provision of dental services, and how has private dental practitioners' assessment of their workload changed?

METHODS

The data were from 2 large surveys of private dental practitioners carried out in 1992 (n = 1056) and 2015 (n = 1237). An analysis of nonresponders showed that they were evenly distributed according to their age, gender, and the region in which their practice was located. Thus, the samples were representative of private dental practitioners. For 1 representative week in practice, the practitioners were asked to report the number of visits and the number of patients who received 1 or more of the following items of treatment: filling, crown, bridge, denture, root filling, extraction, and periodontal treatment. As a measure of patient supply, the responses from the following questions were used: "Based on an overall assessment of economy, workload, and other personal factors, is the number of regular patients adequate? If not, do you wish to have more patients or fewer patients?"

RESULTS

From 1992 to 2015, the annual number of visits per practitioner decreased by 23%. The number of patients per practitioner who received fillings, crowns, bridges, dentures, root fillings, or extractions decreased by 50% or more. The decrease was largest for practitioners younger than 35 years and for men. The proportion of practitioners who reported a deficit of patients increased from 20% to 37%.

CONCLUSIONS

Many dentists will have too few patients and a fall in income in the years to come is expected.

Validation of a Subjective Caries Risk Assessment Tool

OBJECTIVE

The objective was to evaluate the predictive validity of the American Dental Association's caries risk assessment (CRA) tool, adapted with permission, and used by the U.S. Department of Veterans Affairs dental services within their electronic dental record.

METHODS

This analytic epidemiologic study with a retrospective longitudinal design included Veterans who had a minimum of three years of available data. The primary outcome was caries-related treatment during the twelve-month predictive period following the CRA category identification.

RESULTS

The sample included 57,675 Veterans; 50.1% classified as low, 33.2% as moderate and 16.8% as high caries risk. During the twelve-month predictive period, both teeth/person and teeth with caries-related treatment rose sequentially from low to high CRA categories. However, poor sensitivity (0.34-0.58) and better specificity (0.53-0.78) values were observed. Similarly, better negative predictive values (0.72-0.79) compared to positive predictive values (0.28-0.34) were found. Adjusted logistic regression models showed that current treated caries (caries detected at the time of the CRA exam) was more strongly associated with future caries-related treatment than the subjective CRA determination.

CONCLUSIONS

The subjective CRA tool evaluated in this study is better at identifying patients at low risk of requiring future caries-related treatment versus those at higher risk. This makes it difficult to target the most caries susceptible patients with preventive measures. Furthermore, we found that the amount of caries treatment required at the time of the CRA exam had the strongest association with caries-related treatment during the subsequent twelve-month predictive period.

CLINICAL SIGNIFICANCE

The amount of caries-related treatment required at the time of the caries risk classification is the strongest predictor of future caries.

Trends in socioeconomic inequality of periodontal health status among Dutch adults: a repeated cross-sectional analysis over two decades

Background

Studies exclusively focusing on trends in socioeconomic inequality of oral health status in industrialized countries are relatively sparse. This study aimed to assess possible differences in oral hygiene and periodontal status among people of different socioeconomic status (SES) in the Netherlands over two decades.

Methods

A repeated cross-sectional analysis of 3083 participants aged 25–54 years was conducted on the Dutch National Oral Health Surveys of 1995, 2002, 2007, and 2013. Plaque-free was defined according to the Simplified Oral Hygiene Index (OHI-S = 0). Periodontal status was classified in two different ways, either periodontal health/disease (probing pocket depth index [PDI] = 0/ ≥ 1) or with/without deep pockets (PDI = 2). We used the regression-based absolute and relative effect index to measure the absolute and relative socioeconomic inequalities. Multivariable logistic regressions were used to explore temporal trends in oral hygiene and periodontal status by low- and high-SES groups.

Results

Age-standardized percentages of individuals with plaque-free increased in the whole population from 1995 to 2013 (12.7% [95% CI 10.5–14.9] to 28.1% [24.8–31.5]). Plaque-free showed significant socioeconomic differences in absolute and relative inequalities in 2007 and 2013. Between 1995 and 2013, age-standardized percentage of periodontal health increased (from 51.4% [48.1–54.7] to 60.6% [57.0–64.1]). The significant absolute inequalities for periodontal health were seen in 2002 and 2013. The relative scale presented a similar pattern. Regarding deep pockets, there was little difference in the age-standardized overall prevalence in 1995 versus 2013 (from 6.5% [4.9–8.2] to 5.4% [3.7–7.0]). The significant absolute and relative inequalities in deep pockets prevalence were found in 1995. Yet, all interaction terms between survey year and SES did not reach significance (plaque-free: P = .198; periodontal health: P = .490; deep pockets: P = .678).

Conclusions

Socioeconomic inequalities in oral hygiene and periodontal status were present in the Netherlands in the last two decades.

Predictors of tooth loss: A machine learning approach

Introduction

Little is understood about the socioeconomic predictors of tooth loss, a condition that can negatively impact individual’s quality of life. The goal of this study is to develop a machine-learning algorithm to predict complete and incremental tooth loss among adults and to compare the predictive performance of these models.

Methods

We used data from the National Health and Nutrition Examination Survey from 2011 to 2014. We developed multiple machine-learning algorithms and assessed their predictive performances by examining the area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, specificity, and positive and negative predictive values.

Results

The extreme gradient boosting trees presented the highest performance in the prediction of edentulism (AUC = 88.7%; 95%CI: 87.1, 90.2), the absence of a functional dentition (AUC = 88.3% 95%CI: 87.3,89.3) and for predicting missing any tooth (AUC = 83.2%; 95%CI, 82.0, 84.4). Although, as expected, age and routine dental care emerged as strong predictors of tooth loss, the machine learning approach identified additional predictors, including socioeconomic conditions. Indeed, the performance of models incorporating socioeconomic characteristics was better at predicting tooth loss than those relying on clinical dental indicators alone.

Conclusions

Future application of machine-learning algorithm, with longitudinal cohorts, for identification of individuals at risk for tooth loss could assist clinicians to prioritize interventions directed toward the prevention of tooth loss.

Randomized trial of a photography-aided behavioural intervention to reduce risk factors for caries and malocclusion in high-risk infants

OBJECTIVE

To assess the efficacy of a photography-aided behavioural intervention in reducing risk factors for dental caries and malocclusion in high-risk infants.

MATERIALS AND METHODS

In this randomized trial conducted in a maternity hospital, 55 mothers of recently born infants at high risk of developing oral diseases were allocated to either the intervention (n = 28) or usual care (n = 27). The intervention arm received the same usual care plus an enhanced, behaviour-oriented, photography-aided, two-stage (0 and +6 months) educational programme addressing nutritional, behavioural, lifestyle and familial factors that affect child's oral health. The primary outcome was the proportion of children classified as being at a 'low risk' of developing dental caries at the age of 12 months using a modified score based on the Caries-risk Assessment Form of the American Academy of Pediatric Dentistry. Secondary outcomes included risk factors for malocclusion, such as duration of exclusive breastfeeding, pacifier use and bottle-feeding and/or sippy cup usage.

RESULTS

At 12 months, the proportion of children considered at low risk for dental caries was significantly higher in the intervention group compared to usual care (71% vs 15%, respectively, relative risk = 4.82, 95% confidence interval = 1.89-12.3, p < 0.001). The median duration of exclusive breastfeeding in the intervention group was 1.7 times higher than in the control arm (5 months vs 3 months, p = 0.03).

CONCLUSION

Altogether, our findings provide evidence that a low-cost, two-stage preventive strategy using photographs to deliver a stronger visual impact might significantly reduce the incidence of risk factors for dental caries and malocclusion in 12-month-old children.

Development and initial testing of an in vitro model simulating class II furcation defects

OBJECTIVE

To compare surface topography of porcine and human root dentin and to develop a new in vitro model for class II furcation defects. The hypothesis for this study was that porcine mandible blocks can function as a model for class II furcation defects.

BACKGROUND

Treatment of mandibular class II furcation defects is unpredictable. There is a need for in vitro models to investigate new treatment methods.

METHODS

A model to investigate the surface topography of porcine and human root dentin was developed and the two tissues compared by SEM imaging and profilometer. A novel method for studying class II furcation defects was then tested. Blocks of porcine mandibles with molar 3 were prepared. Buccal class II furcation defects were created. The furcation area was isolated and bioluminescent Staphylococcus epidermidis Xen43 was used to form a biofilm in the furcation area to test the functionality of the novel furcation model.

RESULTS

Micromechanical damage caused by debridement on porcine and human root dentin showed similar pattern. No significant difference in the surface morphological parameters was observed between the corresponding porcine and human samples. The model allowed for assessment of the root surface inside the furcation area. While the number of viable bacteria in the furcation following debridement could be quantified, no significant difference between the treatment groups was detected, likely due to bacterial colonization within the periodontal ligament space.

CONCLUSION

Porcine and human root dentin show similar surface topography following surface debridement. Porcine mandible blocks can function as a model for class II furcation defects. However, further development and refinement of the novel in vitro model is warranted.

Beneficiaries' perspectives on improved oral health and its mediators after Medicaid expansion in Michigan: a mixed methods study

OBJECTIVE

To investigate self-reported improved oral health and its mediators, and job-related outcomes, of Medicaid expansion beneficiaries in Michigan.

METHODS

This cross-sectional mixed-methods study of adult "Healthy Michigan Plan" (HMP) Medicaid expansion beneficiaries included qualitative interviews with a convenience sample of 67 beneficiaries enrolled for ≥6 months, a stratified random sample survey of 4,090 beneficiaries enrolled for ≥12 months; and Medicaid claims data. We examined unadjusted associations between demographic variables and awareness of dental coverage, self-reported dental care access, dental visits, and self-reported oral health; and between improved oral health and job seeking and job performance. Multivariate analysis examined factors associated with self-reported oral health improvement, adjusting for sociodemographic characteristics, prior health insurance, and having at least one dental visit claim.

RESULTS

Among surveyed beneficiaries, 60 percent received ≥1 dental visit and 40 percent reported improved oral health. Adjusted odds ratios (aOR) for improved oral health were higher for African-American beneficiaries [aOR = 1.61; confidence interval (CI) = 1.28-2.03] and those previously uninsured for ≥12 months (aOR = 1.96; CI = 1.58-2.43). Beneficiaries reporting improved oral health were more likely to report improved job seeking (59.9 percent vs 51 percent; P = 0.04) and job performance (76.1 percent vs 65.0 percent; P < 0.001) due to HMP. Interviewees described previously unmet oral health needs, and treatments that improved oral health, functioning, appearance, confidence, and employability.

CONCLUSION

Michigan's Medicaid expansion contributed to self-reported improved oral health, which was associated with improved job outcomes. Policymakers should consider the importance of Medicaid dental coverage in reducing oral health disparities and improving the health and socioeconomic well-being of low-income adults and communities when considering this optional benefit.

Antibiofilm effects of titanium surfaces modified by laser texturing and hot-pressing sintering with silver

Peri-implant diseases are one of the main causes of dental implant failure. New strategies for dental implants manufacturing have been developed to prevent the accumulation of bacteria and related inflammatory reactions. The main aim of this work was to develop laser-treated titanium surfaces covered with silver that generate a electrical dipole to inhibit the oral bacteria accumulation. Two approaches were developed for that purpose. In one approach a pattern of different titanium dioxide thickness was produced on the titanium surface, using a Q-Switched Nd:YAG laser system operating at 1064 nm. The second approach was to incorporate silver particles on a laser textured titanium surface. The incorporation of the silver was performed by laser sintering and hot-pressing approaches. The anti-biofilm effect of the discs were tested against biofilms involving 14 different bacterial strains growth for 24 and 72 hr. The morphological aspects of the surfaces were evaluated by optical and field emission guns scanning electronical microscopy (FEGSEM) and therefore the wettability and roughness were also assessed. Physicochemical analyses revealed that the test surfaces were hydrophilic and moderately rough. The oxidized titanium surfaces showed no signs of antibacterial effects when compared to polished discs. However, the discs with silver revealed a decrease of accumulation of Porphyromonas gingivalis and Prevotella intermedia strains. Thus, the combination of Nd:YAG laser irradiation and hot-pressing was effective to produce silver-based patterns on titanium surfaces to inhibit the growth of pathogenic bacterial species. The laser parameters can be optimized to achieve different patterns, roughness, and thickness of the modified titanium layer regarding the type and region of the implant.

Discrepancies in periodontitis classification among dental practitioners with different educational backgrounds

Background

The 2018 classification of periodontal disease characterizes the disease with a multidimensional staging and grading system. The purpose of this multicenter study was to examine variations in periodontitis classification among dental practitioners with different postgraduate educational backgrounds at the University of Maryland School of Dentistry and the Loma Linda University School of Dentistry using the 2018 classification.

Methods

This cross-sectional observational study included two cohorts: dental practitioners with periodontal backgrounds (n₁ = 31) and those with other educational backgrounds (n₂ = 33). The survey instrument contained three periodontitis cases presented with the guideline of the 2018 classification and a questionnaire including closed and open-ended questions. The participants were asked to review each case and to fill out the questionnaire independently. Fisher’s exact test was conducted to examine the differences in responses between the two cohorts. Polychoric correlations were calculated to examine the relation between the level of familiarity with the 2018 classification and the accuracy of the classification.

Results

The distribution of item responses was significantly different between the two cohorts regarding only one item, grading for Case 1 (p = 0.01). No significant differences in accuracy between the two cohorts were observed except for two items, grading in Case 1 (p = 0.03) and staging in Case 3 (p = 0.04). There were no significant differences in risk factor identification for each case among the two cohorts (p = 1.00, Case 1; p = 0.22, Case 2). Staging in Case 3

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Conclusion

A fair level of agreement in periodontitis classification was observed among dental practitioners with different educational backgrounds when the 2018 classification was used. The periodontal cohort showed better agreement levels and partially better accuracy. Risk factor identification for periodontal disease was difficult regardless of the educational background.

Depression is related to edentulism and lack of functional dentition: An analysis of NHANES data, 2005-2016

OBJECTIVE

Depression and tooth loss are significant health problems that affect individuals' functionality and quality of life. Comorbidity between depression and oral diseases has been reported. The aim of this study was to investigate the association between depression and tooth loss in a US representative adult sample.

METHODS

This study included data from 22,532 adults ≥18 years by combining six 2-year cross-sectional cycles of the National Health and Nutrition Examination Survey (NHANES) administered between 2005 and 2016. Data were analyzed using descriptive statistics and multinomial logistic regression adjusted for gender, age, race/ethnicity, smoking, education, socioeconomic status, body mass index, diabetes, and alcohol intake.

RESULTS

Of the total sample, 4.5 percent were edentulous, 10.3 percent were lacking functional dentition (1-19 remaining teeth) and 85.2 percent had functional dentition (≥20 remaining teeth); among whom, the prevalence of depression was 12.4, 11.7, and 5.9 percent, respectively. Compared to individuals without depression, those with depression were more likely to be edentulous or lacking functional dentition versus having functional dentition (adjusted odds ratios (95% CI): 1.48 (1.16-1.89) and 1.43 (1.18-1.75), respectively).

CONCLUSIONS

Depression was associated with edentulism and a lack of functional dentition. Further longitudinal and interventional studies are needed to elucidate the nature and direction of the relationship between depression and tooth loss.

Association between high psychological distress and poor oral health-related quality of life (OHQoL) in Japanese community-dwelling people: the Nagasaki Islands Study

Background

We investigated the association between psychological distress and oral health status/oral health-related quality of life (OHQoL) in Japanese community-dwelling people.

Methods

We conducted a cross-sectional study using data from the Nagasaki Islands Study. A total of 1183 (455 men and 728 women) has been analyzed in this study. Psychological distress was measured using the Kessler Psychological Distress Scale (K6). Oral health status was measured by dental examination. The OHQoL was measured using the General Oral Health Assessment Index (GOHAI). We defined the total score of ≥5 points on the K6 as high psychological distress (high-K6 group).

Results

The multiple linear regression analysis to identify the GOHAI showed that gender, K6, the total number of teeth, the number of dental caries, and visiting a dental clinic within the past 6 months significantly associated with the GOHAI. Among all of these variables, high-K6 (≥ 5) was a substantial contributing factor of the GOHAI (β = − 0.23, 95% Cl − 2.31 to −1.41, p < 0.0001).

Conclusions

It is likely that the individual with high psychological distress was strongly related to poor OHQoL even in the general population.

Emergency and urgent dental visits among Medicaid enrollees from 2013 to 2017

Background

Better understanding of the frequency of dental emergencies and the procedures performed during those emergency visits can help providers, insurers, and policymakers understand workforce and care provision needs.

Methods

Procedures performed at an emergency dental encounter and in the encounter following that encounter are assessed. Emergency dental encounters are those with a CDT code of D0140, D0160, or D0170. Data was analyzed from the IBM Watson Medicaid Marketscan data from 2013 to 2017, a nationally representative dental and medical claims database from 13 deidentified states in the United States.

Result

Consistently over time, about 10% of all dental encounters are due to a dental emergency. 28% of emergency dental encounters had no other procedure performed during those encounters. When other procedures were performed during the encounter, the majority were diagnostic in nature, primarily radiographs. Among patients who returned to the dentists following an emergency visit, 43% returned for more definitive dental treatment, most within 30 days.

Conclusions

The majority of dental emergency encounters do not result in definitive treatment, rather patients often return to the dentist at a later date for that treatment. Where possible, dental providers could utilize teledental services to triage patients to appropriate care.

Inequalities in Untreated Root Caries and Affordability of Dental Services among Older American Adults

The growing geriatric population is facing numerous economic challenges and oral health changes. This study explores the relationship between affordability of dental care and untreated root caries among older American adults, and whether that relationship is independent of ethnicity and socioeconomic factors. Data from 1776 adults (65 years or older) who participated in the National Health and Nutrition Examination Survey (NHANES) were analyzed. The association between affordability of dental care and untreated root caries was assessed using logistic regression models. Findings indicated that untreated root caries occurred in 42.5% of those who could not afford dental care, and 14% of those who could afford dental care. Inability to afford dental care remained a statistically significant predictor of untreated root caries in the fully adjusted regression model (odds ratio 2.79, 95% confidence interval: 1.78, 4.39). Other statistically significant predictors were gender (male), infrequent dental visits, and current smoking. The study concludes that the inability to afford dental care was the strongest predictor of untreated root caries among older Americans. The findings highlight the problems with access to and use of much needed dental services by older adults. Policy reform should facilitate access to oral healthcare by providing an alternative coverage for dental care, or by alleviating the financial barrier imposed on older adults.

Risk Indicators of Urgent and Extensive Dental Treatment Needs in U.S. Air Force Recruits

INTRODUCTION

Dental Readiness Classifications (DRCs) enable the Military Health System to prioritize dental care in garrison, minimizing dental emergencies and mission degradation during deployments. Over half (52.4%) of 2008 military recruits presented with high-priority urgent needs classified as DRC3 upon initial dental examination and 18.1% required extensive treatment, needing 7 or more restorations, in order to achieve operational dental readiness. The purpose of this study is to identify risk indicators for urgent and extensive dental treatment needs in current U.S. Air Force (USAF) recruits so that Dental Corps leadership can target interventions to maximize oral health, prioritize resources, and reduce health expenditures in this patient population.

MATERIALS AND METHODS

A secondary data analysis was performed of deidentified survey and clinical exam data from the 2018 to 2019 USAF Recruit Oral Health Surveillance study conducted at Lackland Air Force Base from February 2018 to February 2019. Select demographic and self-reported variables were analyzed with two outcome variables: urgent (DRC3) and urgent and extensive (DRC3 + 7) dental treatment needs. Univariate log binomial regression was performed to determine relative risk of DRC3 and DRC3 + 7 by independent variable. The Uniformed Services University of the Health Sciences institutional review board approved the study as an exempt protocol.

RESULTS

Among the 1,335 recruits studied, the overall prevalence of urgent dental needs was 21.5%, whereas 5.5% of participants had both urgent and extensive needs. The study group included participants who were mostly male (69%), were non-Hispanic white (60%), aged 17 to 19 years (48%), were high school educated (47%), had private dental insurance coverage (50%) and self-reported: no need for dental care in the past year (65%), excellent or good condition of teeth (63%), were toothbrushing more than once a day (58%), and had daily consumption of one to three servings of sugary beverages (62%) and foods (69%). Statistically significant differences in relative risk for DRC3 were found for all independent variables except gender and education level. Risk indicators significant for DRC3 and DRC3 + 7 were aged 25 to 29 years; Other and Black race/ethnicity; Medicaid insurance; uninsured; self-reported fair, poor, or unsure current condition of teeth; and past year needed care but did not go (P < .05). The majority of DRC3 and DRC3 + 7 cases were in the small subset of recruits who self-reported fair, poor, or unknown current condition of teeth or need for dental care in the past year without a dental visit.

CONCLUSIONS

Among USAF recruits, oral health disparities are observed in certain groups. The study findings can inform targeted utilization of resources and interventions to efficiently optimize oral health and operational dental readiness and decrease dental expenditures. Additionally, a two-question screening tool is proposed to facilitate priority assignment for dental examination during boot camp. This tool has the potential to correctly identify nearly 90% of those with urgent and extensive dental treatment needs at half the typical workload.

Fissure caries inhibition with a CO2 9.3-μm short-pulsed laser-a randomized, single-blind, split-mouth controlled, 1-year clinical trial

OBJECTIVES

The objective of this randomized, single-blind, split-mouth controlled, clinical trial was to evaluate whether the use of a short-pulsed 9.3-μm CO₂ laser increases the caries resistance of occlusal pit and fissures in addition to fluoride therapy over 12 months.

MATERIALS AND METHODS

A total of 60 participants, average age 13.1 years, were enrolled. At baseline, second molars were randomized into test and control, and assessed by ICDAS, SOPROLIFE, and DIAGNOdent. An independent investigator irradiated test molars with a CO₂ laser (wavelength 9.3 μm, pulse duration 4 μs, pulse repetition rate 43 Hz, beam diameter 250 μm, average fluence 3.9 J/cm², 20 laser pulses per spot). Test molars received laser and fluoride treatment, control teeth fluoride alone. Fluoride varnish was applied at baseline and at 6 months. After 6 and 12 months, teeth were again assessed.

RESULTS

A total of 57 participants completed the 6-month and 51 the 12-month recall. Laser-treated surfaces showed very slight ICDAS improvements over time with ICDAS change - 1 in 11% and 8%, no changes (ICDAS change 0) in 68% and 67%, and slightly worsened (ICDAS change 1) in 19% and 24% at 6- and 12-month recalls, respectively, and worsened by two scores in 2% at both recall time points. Control teeth showed significantly higher ICDAS increases, with 47% and 25% showing ICDAS change 0, ICDAS change 1 in 49% and 55%, and ICDAS change 2 in 4% and 20% at 6- and 12-month recalls, respectively. Differences in ICDAS changes between the groups were statistically significant (P = 0.0002 and P < 0.0001; Wilcoxon's signed-rank test, exact). A total of 22% of the participants developed ICDAS 3 scores on the control teeth.

CONCLUSIONS

Microsecond short-pulsed 9.3-μm CO₂ laser irradiation markedly inhibits caries progression in pits and fissures in comparison with fluoride varnish alone.

CLINICAL RELEVANCE

The 9.3-μm CO₂ laser irradiation of pits and fissures enhances caries resistance.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT02357979.

Effect of Copayment on Dental Visits: A Regression Discontinuity Analysis

Despite their prevalence and burdens, oral diseases are neglected in universal health coverage. In Japan, a 30% copayment (out of pocket) by the user and a 70% contribution by Japan’s universal health insurance (JUHI) are required for dental and medical services. From the age of 70 y, an additional 10% is offered by JUHI (copayment, 20%; JUHI, 80%). This study aimed to investigate the effect of cost on dental service use among older adults under the current JUHI system. A regression discontinuity quasi-experimental method was used to investigate the causal effect of the JUHI discount policy on dental visits based on cross-sectional data. Data were derived from the 2016 Japan Gerontological Evaluation Study. This analysis contained 7,161 participants who used JUHI, were aged 68 to 73 y, and responded to questions regarding past dental visits. Analyses were controlled for age, sex, number of teeth, and equalized household income. Mean ± SD age was 72.1 ± 0.79 y for the discount-eligible group and 68.9 ± 0.78 y for the noneligible group. During the past 12 mo, significantly more discount-eligible participants had visited dental services than noneligible participants (66.0% vs. 62.1% for treatment visits, 57.7% vs. 53.1% for checkups). After controlling for covariates, the effect of discount eligibility was significant on dental treatment visits (odds ratio [OR], 1.36; 95% CI, 1.32 to 1.40) and dental checkups (OR, 1.49; 95% CI, 1.44 to 1.54) in the regression discontinuity analysis. Similar findings were observed in triangular kernel-weighted models (OR, 1.38 [95% CI, 1.34 to 1.44]; OR, 1.52 [95% CI, 1.47 to 1.56], respectively). JUHI copayment discount policy increases oral health service utilization among older Japanese. The price elasticity for dental checkup visits appears to be higher than for dental treatment visits. Hence, reforming the universal health coverage system to improve the affordability of relatively inexpensive preventive care could increase dental service utilization in Japan.

Modifications of emergency dental clinic protocols to combat COVID-19 transmission

During the COVID-19 pandemic, incidence rates for dental diseases will continue unabated. However, the intent to prevent the spread of this lethal respiratory disease will likely lead to reduced treatment access due to restrictions on population movements. These changes have the potential to increase dental-related emergency department visits and subsequently contribute to greater viral transmission. Moreover, dentists experience unique challenges with preventing transmission due to frequent aerosol-producing procedures. This paper presents reviews and protocols implemented by directors and residents at the Dental College of Georgia to manage a dental emergency clinic during the COVID-19 pandemic. The methods presented include committee-based prioritization of dental patients, a multilayered screening process, team rotations with social and temporal spacing, and modified treatment room protocols. These efforts aid in the reduction of viral transmission, conservation of personal protective equipment, and expand provider availability. These protocols transcend a university and hospital-based models and are applicable to private and corporate models.

Microbial biogeography and ecology of the mouth and implications for periodontal diseases

In humans, the composition of microbial communities differs among body sites and between habitats within a single site. Patterns of variation in the distribution of organisms across time and space are referred to as "biogeography." The human oral cavity is a critical observatory for exploring microbial biogeography because it is spatially structured, easily accessible, and its microbiota has been linked to the promotion of both health and disease. The biogeographic features of microbial communities residing in spatially distinct, but ecologically similar, environments on the human body, including the subgingival crevice, have not yet been adequately explored. The purpose of this paper is twofold. First, we seek to provide the dental community with a primer on biogeographic theory, highlighting its relevance to the study of the human oral cavity. We summarize what is known about the biogeographic variation of dental caries and periodontitis and postulate that disease occurrence reflects spatial patterning in the composition and structure of oral microbial communities. Second, we present a number of methods that investigators can use to test specific hypotheses using biogeographic theory. To anchor our discussion, we apply each method to a case study and examine the spatial variation of the human subgingival microbiota in 2 individuals. Our case study suggests that the composition of subgingival communities may conform to an anterior-to-posterior gradient within the oral cavity. The gradient appears to be structured by both deterministic and nondeterministic processes, although additional work is needed to confirm these findings. A better understanding of biogeographic patterns and processes will lead to improved efficacy of dental interventions targeting the oral microbiota.

Progressive myeloneuropathy with symptomatic anaemia

Hypocupremia is a rare and under-recognised cause of bone marrow dysplasia and myeloneuropathy. A 47-year-old Caucasian woman had progressive ascending peripheral neuropathy and gait ataxia over 3 months and fatigue, dyspnoea and unintentional weight loss over 8 months. She had profound macrocytic anaemia and neutropenia. Initial workup included normal serum vitamin B12 Bone marrow biopsy was suggestive of copper deficiency. Serum copper levels were later confirmed to be undetectable. The patient received oral copper repletion which resulted in complete normalisation of haematological abnormalities 16 weeks later. However, neurological deficits persisted. This case describes a delayed diagnosis of hypocupremia as initially suggested through invasive testing. Associating myeloneuropathy with cytopenia is imperative for accurate and prompt diagnosis of hypocupremia, which can be confirmed by serum analysis alone. Developing an accurate differential diagnosis can help prevent unnecessary procedures. Furthermore, initiating prompt copper repletion prevents further neurological impairment. Neurological deficits are often irreversible.

Assessing the Translation of Research and Innovation into Dental Practice

INTRODUCTION

Over the past 100 y, there have been an unprecedented number of innovations that have improved oral health and functioning. Variations in lag times between discovery and clinical adoption are related to dentist education, the clinical availability of technology, and the perceived value of an innovation.

OBJECTIVES

The purposes of this cross-sectional study were 1) catalogue research discoveries and innovations over the past 30 y and 2) from that list identify those which practicing dentists believe have maximally affected patient care.

METHODS

Thirty International Association for Dental Research leaders identified innovations over the past 30 y that have significantly affected dental care. The 30 most cited innovations were included in a questionnaire that was sent to a random sample of US dentists who graduated dental school during or before 1995 (before the recency of identified discoveries) and devoted ≥50% of their time to patient care. Eighty-two percent of respondents identified as general dentists and 18% as specialists. Respondents were asked to identify 5 to 7 items whose loss would have the most adverse effects on patient care.

RESULTS

The most cited advances were adhesive dental materials (74.5%), dental implants (71.9%), direct bonding systems (71.2%), dental loupes (54.7%), universal precautions for infection control (48.6%), and digital imaging (46.0%). There were differences in the ranking of responses between generalists and specialists. For the oral surgeons and periodontists (OMSPER, n = 51), top choices were dental implants (82%), cone beam computed tomography (CBCT) imaging (74%), regenerative dentistry and tissue engineering (68%), universal precautions (58%), digital imaging (56%), and dental loupes (48%).

CONCLUSIONS

There was agreement among generalists and specialists about the importance of dental implants, digital imaging, use of dental loupes, and universal precautions in improving patient care. However, generalists also cited the importance of adhesive dental materials and bonding, and OMSPER cited CBCT and biological-based tissue restoration as major advances.

KNOWLEDGE TRANSFER STATEMENT

Many advances in dental patient care capitalize on innovations and technologies that have emerged after dentists graduate from dental school. Adoption of new technologies is influenced by information acquired from professional journals, continuing education, industry marketing activities, and interactions with colleagues. The results of this study suggest that innovations that are directly related to clinical procedures were rated most impactful. Future research should consider cost-effectiveness and patient perceptions on the impact of innovations and technologies.

Extractions in Patients with Periodontal Diseases and Clinical Decision-Making Process

Objectives

To investigate the professional aspects and clinical and radiographic evidence that influences the decision for the extraction of teeth among periodontologists and general dentists.

Material and methods

The sample consisted of 150 (n=106 females and 44 males) dentists (n=103 general dentists and 47 periodontologists) that responded to a questionnaire designed to retrieve cross-sectional information related mainly to their level of training and time of experience in practice, as well as their personal decision for managing four patients with periodontal disease. Bivariate analyses were performed to test the association between the clinical decisions and the professional information collected from the dentists.

Results

In specific cases, periodontologists decided to maintain more teeth than general dentists (p<0.05). In other cases, dentists with more years of experience in practice decided to opt for more extractions (p<0.05). The level of periodontal disease (50-92%), poor oral hygiene (42.6-67.3%) and lack of alveolar bone structure (43.2-79.3%) were the most prevalent reasons behind the decision for extractions.

Conclusions

An advanced level of training in Dentistry, especially Periodontology, and more years of experience in practice may lead to more well-founded decisions on whether extracting teeth or not in case-specific scenarios.

Impact of Dental Diseases on Quality-Adjusted Life Expectancy in US Adults

Comparing the burden of dental conditions to other health outcomes provides useful insight for public policy. We aimed to estimate quality-adjusted life expectancy (QALE) loss due to dental conditions in the US adult population. Social inequalities in QALE loss by dental conditions were also examined. Data from 3 cross-sectional waves of the National Health and Nutrition Examination Survey (NHANES waves 2001 to 2002, 2003 to 2004, and 2011 to 2012) were pooled and analyzed. The average age of study participants ( n = 9,445) was 48.4 y. Disutility scores were derived from self-rated health and the numbers of physically unhealthy days, mentally unhealthy days, and days with activity limitation, employing a previously published algorithm. The associations between the disutility scores and the numbers of decayed teeth, missing teeth, and periodontitis were examined by multiple linear regression stratified by age groups (20–39, 40–59, and ≥60 y), adjusted for other covariates (age, sex, wave fixed effect, educational attainment, smoking, and diabetes). The QALE loss due to dental conditions at the age of 20 was estimated using life tables. Decayed and missing teeth, but not periodontitis, were associated with a larger disutility score. The coefficient for decayed teeth was larger among the older population, whereas that of missing teeth was smaller among them. The estimated QALE loss was 0.43 y (95% confidence interval [CI], 0.28–0.59), which reached 5.3% of QALE loss (8.15 y; 95% CI, 8.03–8.27) due to overall morbidity. There were clear social gradients in QALE loss by dental conditions across the life course, and people with high school or less education had 0.32 y larger QALE loss in total compared with people with college or more education. This study suggests that improvements in people’s dental health may yield substantial gains in population health and well-being. The necessity of more comprehensive public health strategies is highlighted.

Tooth loss among older adults according to poverty status in the United States from 1999 through 2004 and 2009 through 2014

BACKGROUND

As tooth loss decreases in an aging United States, retaining enough natural teeth for function is important for quality of life.

METHODS

The authors used data from the 1999 through 2004 and the 2009 through 2014 National Health and Nutrition Examination Surveys to assess changes in tooth loss in adults 50 years or older. The authors evaluated changes in edentulism, retaining all teeth, and having a functional dentition (21 or more natural teeth) according to poverty status.

RESULTS

Edentulism was lower in 2009 through 2014 than in 1999 through 2004 (11% versus 17%) for adults 50 years or older, but this decrease was not significant among the poor (people at < 100% of the federal poverty guideline; P > .05). Complete tooth retention improved from 14% to 21% between 1999 through 2004 and 2009 through 2014 for people 50 years or older (P < .05). Gains were attributable mostly to adults who were nonpoor (≥ 200% federal poverty guideline). More older adults had a functional dentition in 2009 through 2014 than in 1999 through 2004 (67% versus 55%; P < .05), although the increases generally were significant only for those not living in poverty.

CONCLUSIONS

Complete tooth loss has decreased by more than 75% for those aged 65 through 74 years over the past 5 decades in the United States. Improvements in tooth loss measures, such as edentulism and complete tooth retention, have been most significant among the nonpoor, whereas those who are poor have experienced fewer improvements.

PRACTICE IMPLICATIONS

An aging population is experiencing less edentulism and greater tooth retention, so older adults may need more regular oral health care and prevention services to address concerns such as root caries and periodontal disease.

Tooth loss is a complex measure of oral disease: Determinants and methodological considerations

OBJECTIVES

Counts of missing teeth or measures of incident tooth loss are gaining attention as a simple way to measure dental status in large population studies. We explore the meaning of these metrics and how missing teeth might influence other measures of dental status.

METHODS

An observational study was performed in 2 contrasting adult populations. In total, 62 522 adult participants were available with clinically assessed caries and periodontal indices from the Swedish arm of the Gene-Lifestyle Interactions and Dental Endpoints Study (GLIDE) and the Korea National Health and Nutrition Examination Survey (KNHANES) in the Republic of Korea. Longitudinal measures of tooth loss were available for 28 244 participants in GLIDE with median follow-up of 10.6 years.

RESULTS

In longitudinal analysis, hazard for tooth loss was associated with baseline dental status (previous tooth loss, periodontal status and caries status) and socio-demographic variables (age, smoking status and highest educational level). Analysis of cross-sectional data suggested that indices of caries exposure were not independent of periodontal status. The strength and direction of association varied between groups, even for measures specifically intended to avoid measuring tooth loss. Individuals with impaired periodontal health (community periodontal index [CPI] 3 or higher in any sextant) had higher standardized decayed and filled surfaces (DFS; number of DFS divided by total number of tooth surfaces) in GLIDE (incidence risk ratio [IRR] 1.05 [95% CI: 1.04, 1.07], but lower standardized DFS in KNHANES (IRR: 0.95 [0.92, 0.98]) than individuals with better periodontal health (CPI <3 in all sextants).

CONCLUSIONS

Incident tooth loss is a complex measure of dental disease, with multiple determinants. The relative importance of dental caries and periodontal disease as drivers of tooth loss differs between age groups. Measures of dental caries exposure are associated with periodontal status in the studied populations, and these associations can be population-specific. Consideration of the study-specific properties of these metrics may be required for valid inference in large population studies.

Dental status, salivary flow, and sociodemographic aspects in Sheehan Syndrome patients

Background

Sheehan’s syndrome (SS) is one of the leading causes of hypopituitarism in developing countries. It occurs after postpartum necrosis of the pituitary gland, and it is considered a significant public health problem. This paper, apparently unpublished, aimed to perform an analysis on oral aspects in patients with SS.

Material and Methods

A cross-sectional study was performed with 23 women diagnosed with SS at the Division of Endocrinology and Diabetes (Walter Cantídio University Hospital, Fortaleza, Brazil).

Results

Data on sociodemographic, dental and salivary flow aspects were collected through a clinical approach and a panoramic radiograph request. The mean age was 64 ± 11.5 years old, with the sample consisting mainly of married women (56.5%), socioeconomic class C2 or D / E (78.2%) and years of education up to 8 years (69.5%). The presence of horizontal bone loss (p<0.001) and bilateral pneumatization of the maxillary sinus (p=0.015) were significant data. The mean number of absent teeth considering all subjects was 23.17±9.7, being statistically significant (p<0.001). In relation to age, the mean number of missing teeth was higher in individuals over 65 years old (p=0.048). Reduced salivary flow was observed in 78.3% of the patients. In a bivariate analysis, considering the outcome variables “missing teeth” and “reduced salivary flow”, it was observed that economic class (p< 0.001), family income (0.037) and maxillary sinus pneumatization (0.032) were statistically significant.

Conclusions

In brief, patients with SS showed severe teeth loss, reduced salivary flow, and low educational status. This study addressed important aspects regarding oral findings in SS and highlighted the importance of researches in oral medicine.

Key words:Sheehan’s Syndrome, hypopituitarism, tooth loss, salivary flow.

Differential Misclassification of Disease under Partial-Mouth Sampling

Aim:

The effect of misclassification of a cluster-level dichotomous outcome (disease) due to partial-cluster sampling on its association with a dichotomous exposure is investigated.

Methods:

Disease (e.g., chronic periodontitis) is deemed to exist in a cluster (e.g., full mouth) when a condition of interest (e.g., pocket depth or clinical attachment loss exceeding an established threshold) is present in number and pattern across observations (e.g., tooth sites) in the cluster according to a specific criterion. When a subset of observations within each cluster is selected (i.e., partial-mouth sampling), specificity of disease is 100% (in the absence of site-level measurement error), whereas sensitivity is imperfect and generally unknown. Using conditional probability arguments, we investigate disease misclassification under partial-cluster sampling and its impact on the estimated disease-exposure association when the exposure is cluster level and measured without error.

Results:

When the probability of disease varies by exposure status, outcome misclassification at the cluster level is differential under partial-cluster sampling and depends on 1) the partial recording protocol, including the number of observations sampled and the particular sites selected in a cluster; 2) the joint probability structure of the condition within clusters; and 3) the criterion for disease. A numeric example demonstrates that disease-exposure odds ratios under partial-cluster random sampling can be biased in either direction (toward or away from the null) relative to gold-standard odds ratios under full-cluster sampling.

Conclusions:

In general, misclassification of disease is differential under partial-cluster sampling. In particular, sensitivity and negative predictive values depend on exposure status, which leads to biased inference.

Knowledge Transfer Statement:

Partial-mouth sampling causes disease misclassification probabilities, including sensitivity, to vary by exposure groups when disease prevalence differs between groups. As a result, disease-exposure associations may be under- or overestimated by standard analysis procedures for periodontal data relative to full-mouth estimates. Procedures that address bias are needed for partial-recording protocols.

How Many Dentists Are Needed in 2040: Executive Summary

Five background articles in Section 2 of the "Advancing Dental Education in the 21^st Century" project examined some of the factors likely to impact the number of dentists needed in 2040: 1) the oral health of the population, 2) changes in the utilization of dental services, 3) new technologies, 4) the growth of large capitated dental group practices, and 5) the demand for dental care. With this information, a sixth background article estimated the number of dentists needed in 2040 compared to the number expected if current trends continue. This executive summary provides an overview of findings from these six articles. The data indicate major improvements in oral health, especially in upper income groups that account for 65% of practice revenues. At the same time, per capita utilization of restorative and prosthetic services has declined dramatically. No major new technologies are likely to impact the need for dentists by 2040. In a large capitated group practice, full-time general dentists treated an average of 2,100 patients per year; solo general dentists averaged 1,350. Based on the examined factors, growth in demand for traditional forms of care may slow substantially, raising the potential for a surplus of dentists in 2040. If these trends continue, the key national policy issue then would be: should schools reduce the number of graduates before market forces require them to downsize or close, or are other alternatives available?

Estimating the Number of Dentists Needed in 2040

Numerous factors that underlie the need for dentists are undergoing significant changes. Three factors are especially important: 1) improvements in oral health; 2) lower expenditures per patient per year, giving dentists the incentive to treat more patients to maintain incomes that justify their investment in dental education and practice; and 3) dental schools' producing new dentists at a faster rate than the growth in the population. If these trends continue, there is likely to be a dentist surplus of between 32% and 110% by 2040. A major challenge for dental schools is to adjust the production of dentists before 2040 and not wait for market forces to reduce the surplus. Whether there will be a painful market-based solution to the problem, as there was in the 1980s, or whether a more orderly path can be found is one of the key challenges of the project "Advancing Dental Education in the 21^st Century," for which this article was written.