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1.  Pattern of occurrence and treatment of impacted teeth at the Muhimbili National Hospital, Dar es Salaam, Tanzania 
BMC Oral Health  2013;13:37.
Background
Impacted teeth predispose to periodontal disease and dental caries of adjacent teeth resulting in pain, discomfort and loss of function. This study analyzed the pattern of occurrence of impacted teeth, associated symptoms, treatment and complications of treatment in patients who presented at the Muhimbili National Hospital, Tanzania.
Method
This was a crossectional descriptive study which utilized notes and x rays of patients who were treated for impacted teeth at the Oral and Maxillofacial firm in Muhimbili National Hospital over five years, from January 2005 to August 2010. These records were retrieved and examined for the major complaint of the patient at presentation to hospital, demography, impacted tooth, type of impaction (for third molars), treatment offered and complications after treatment. Similar information was collected from all patients with impacted teeth attended in the same centre from 1st September 2010 to 31st August 2011.
Results
A total of 896 patients (496 males and 400 females) treated for complaints related to impacted teeth were recorded. The male to female ratio was 1.2:1, age range of 16 to 85 years and a mean age of 28.9 years (SD = 9.5).
Slightly more than 84% of the patients presented with mandibular third molar impactions. Most (44.7%) of these patients had an impacted lower right third molar followed by those presenting with a lower left third molar impaction (39.7%). In 1.3% of the patients all the four third molars were impacted. Sixty nine (7.7%) patients had impacted upper 3rd molars while 2% had impacted upper canines. Of the mandibular 3rd molar impactions 738 (76%) were mesio-angular type, 87 (8.9%) horizontal type and 69 (7.1%) disto-angular.
Patients presented with a variety of complaints. About 85% of the patients presented to hospital due to varying degrees of pain. In 4.9% the detection of the impacted tooth/teeth was coincidental after presenting to hospital for other reasons not related to the impaction.
Majority of the patients with impacted mandibular third molars had carious lesions on the impacted teeth, neighbouring tooth or both. Four hundred and five (45.2%) patients had a carious lesion on one of the impacted teeth while 201(22.4%) patients had a carious lesion on the adjacent second molar. In 122 (13.6%) patients both the impacted third molar and the adjacent second molar were carious. In twelve patients who presented with a main complaint of fracture of the angle of the mandible there was an associated impacted 3rd molar. Eight hundred and fifteen (91%) patients with impacted teeth were treated by surgical removal. Among these only 15 (1.8%) had complications that ranged from excessive swellings, trismus and severe pain post operatively. One patient was reported to have fracture of the angle of the mandible sustained during surgical removal of an impacted 48.
Conclusions
The majority of patients with impacted teeth were young with an almost equal sex distribution. The most commonly impacted teeth were mandibular third molars followed by the maxillary third molars. Patients with impacted teeth reported for health care predominantly because of pain due to dental caries or infection.
There is a need of creating appropriate programmes that would further raise peoples’ awareness to regular dental checkups so that appropriate measures are taken before complications arise.
doi:10.1186/1472-6831-13-37
PMCID: PMC3750328  PMID: 23914842
Impacted teeth; Pattern of occurrence; Muhimbili; Tanzania
2.  Impact of tooth loss related to number and position on oral health quality of life among adults 
Background
The objective of this study was to evaluate the impact of tooth loss on oral health-related quality of life (OHRQoL) in adults with emphasis on the number of teeth lost and their relative position in the mouth.
Methods
The study population was a cross-sectional household probability sample of 248, representing 149,635 20–64 year-old residents in Piracicaba-SP, Brazil. OHRQoL was measured using the OHIP-14. Socioeconomic, demographic, health literacy, dental services use data and clinical variables were collected. Oral examinations were performed using WHO criteria for caries diagnosis, using the DMFT index; that is, the sum of decayed, missing and filled teeth (DMFT). An ordinal scale for tooth loss, based on position and number of missing teeth, was the main explanatory variable. The total OHIP score was the outcome for negative binomial regression and OHIP prevalence was the outcome for logistic regression at 5% level. A hierarchical modeling approach was adopted according to conceptual model.
Results
OHIP score was 10.21 (SE 1.16) with 48.1% (n=115) reporting one or more impacts fairly/very often (OHIP prevalence). Significant prevalence rate ratios (PRRs) for OHIP severity were observed for those who had lost up to 12 teeth, including one or more anterior teeth (PRR=1.63, 95%CI 1.06–2.51), those who had lost 13–31 teeth (PRR=2.33, 95%CI 1.49–3.63), and the edentulous (PRR=2.66, 95%CI 1.55–4.57) compared with fully dentate adults. Other significant indicators included those who only sought dental care because of dental pain (PRR=1.67, 95%CI 1.11–2.51) or dental needs (PRR=1.84, 95%CI 1.24–2.71) and having untreated caries (PRR=1.57 95%CI 1.09–2.26). Tooth loss was not significantly associated with OHIP prevalence; instead using dental services due to dental pain (PR=2.43, 95%CI 1.01–5.82), having untreated caries (PR=3.96, 95%CI 1.85–8.51) and low income (PR=2.80, 95%CI 1.26–6.42) were significant risk indicators for reporting OHIP prevalence.
Conclusion
Our analyses showed OHRQoL gradients consistent with the number and position of teeth missing due to oral disease. These findings suggest that the quantity of teeth lost does not necessarily reflect the impact of tooth mortality on OHRQoL and that future studies should take this into consideration.
doi:10.1186/s12955-014-0165-5
PMCID: PMC4263115  PMID: 25433483
Adults; Oral health; Quality of life; OHIP14; Regression analysis
3.  Genome-wide association Scan of dental caries in the permanent dentition 
BMC Oral Health  2012;12:57.
Background
Over 90% of adults aged 20 years or older with permanent teeth have suffered from dental caries leading to pain, infection, or even tooth loss. Although caries prevalence has decreased over the past decade, there are still about 23% of dentate adults who have untreated carious lesions in the US. Dental caries is a complex disorder affected by both individual susceptibility and environmental factors. Approximately 35-55% of caries phenotypic variation in the permanent dentition is attributable to genes, though few specific caries genes have been identified. Therefore, we conducted the first genome-wide association study (GWAS) to identify genes affecting susceptibility to caries in adults.
Methods
Five independent cohorts were included in this study, totaling more than 7000 participants. For each participant, dental caries was assessed and genetic markers (single nucleotide polymorphisms, SNPs) were genotyped or imputed across the entire genome. Due to the heterogeneity among the five cohorts regarding age, genotyping platform, quality of dental caries assessment, and study design, we first conducted genome-wide association (GWA) analyses on each of the five independent cohorts separately. We then performed three meta-analyses to combine results for: (i) the comparatively younger, Appalachian cohorts (N = 1483) with well-assessed caries phenotype, (ii) the comparatively older, non-Appalachian cohorts (N = 5960) with inferior caries phenotypes, and (iii) all five cohorts (N = 7443). Top ranking genetic loci within and across meta-analyses were scrutinized for biologically plausible roles on caries.
Results
Different sets of genes were nominated across the three meta-analyses, especially between the younger and older age cohorts. In general, we identified several suggestive loci (P-value ≤ 10E-05) within or near genes with plausible biological roles for dental caries, including RPS6KA2 and PTK2B, involved in p38-depenedent MAPK signaling, and RHOU and FZD1, involved in the Wnt signaling cascade. Both of these pathways have been implicated in dental caries. ADMTS3 and ISL1 are involved in tooth development, and TLR2 is involved in immune response to oral pathogens.
Conclusions
As the first GWAS for dental caries in adults, this study nominated several novel caries genes for future study, which may lead to better understanding of cariogenesis, and ultimately, to improved disease predictions, prevention, and/or treatment.
doi:10.1186/1472-6831-12-57
PMCID: PMC3574042  PMID: 23259602
Dental caries; Genetics; Genome wide association; Permanent dentition; Genomics
4.  Periodontal Reasons for Tooth Extraction in a Group of Greek Army Personnel 
Background and aims
The aim of this study was to investigate the prevalence of permanent teeth extracted due to periodontal disease and its relation to age, military rank, and type of extracted teeth due to periodontal and non-periodontal reasons among a group of Greek Army personnel attending a military dental practice.
Materials and methods
Study population consisted of 509 officers, non-commissioned officers and soldiers, aged 18 to 44 years from a military dental hospital in Greece. The reasons for extractions of teeth for a period of two years were obtained, including aspects such as age, military rank and the type of teeth extracted due to periodontal and non-periodontal reasons. Data were analyzed using chi-squared test.
Results
The total number of extracted teeth was 1,231, of which 34.4% were extracted because of periodontal reasons, 32.2% for dental caries and 33.4% for other reasons. The average number of extracted teeth due to periodontal disease showed an increase with age. Maxillary and mandibular first and second molars were the most frequently extracted teeth due to periodontal reasons; however, the anterior teeth of both jaws with mobility (grade III), the same teeth with attach-ment loss (≥5.0 mm) and the posterior teeth of both jaws with furcation involvement (grade IV) were the most frequently extracted teeth due to periodontal reasons.
Conclusion
Although the goal of the WHO regarding the reduction of dental caries was accomplished, periodontal dis-ease was still the main cause of tooth extraction and showed an increase with age.
doi:10.5681/joddd.2011.012
PMCID: PMC3429994  PMID: 23019510
Non-commissioned officers; officers; periodontal disease; permanent teeth; tooth extraction
5.  Association between parity and dentition status among Japanese women: Japan public health center-based oral health study 
BMC Public Health  2013;13:993.
Background
Several studies have shown that parity is associated with oral health problems such as tooth loss and dental caries. In Japan, however, no studies have examined the association. The purpose of this study was to determine whether parity is related to dentition status, including the number of teeth present, dental caries and filled teeth, and the posterior occlusion, in a Japanese population by comparing women with men.
Methods
A total of 1,211 subjects, who participated both in the Japan Public Health Center-Based (JPHC) Study Cohort I in 1990 and the dental survey in 2005, were used for the study. Information on parity or number of children was collected from a self-completed questionnaire administered in 1990 for the JPHC Study Cohort I, and health behaviors and clinical dentition status were obtained from the dental survey in 2005. The association between parity or number of children and dentition status was analyzed, by both unadjusted-for and adjusted-for socio-demographic and health behavioral factors, using a generalized linear regression model.
Results
Parity is significantly related to the number of teeth present and n-FTUs (Functional Tooth Units of natural teeth), regardless of socio-demographic and health behavioral factors, in female subjects. The values of these variables had a significantly decreasing trend with the rise of parity: numbers of teeth present (p for trend = 0.046) and n-FTUs (p for trend = 0.026). No relationships between the number of children and dentition status were found in male subjects.
Conclusion
Higher-parity women are more likely to lose teeth, especially posterior occluding relations. These results suggest that measures to narrow the discrepancy by parity should be taken for promoting women’s oral health. Delivery of appropriate information and messages to pregnant women as well as enlightenment of oral health professionals about dental management of pregnant women may be an effective strategy.
doi:10.1186/1471-2458-13-993
PMCID: PMC4015217  PMID: 24144183
Parity; Dentition status; Dental caries; Periodontal disease; Oral health
6.  Prevalence and Reasons for Tooth Loss in a Sample from a Dental Clinic in Brazil 
Purpose. To evaluate the prevalence and reasons for teeth extractions in a sample from a dental clinic in Brazil. Methods. The prevalence of teeth mortality was analyzed by gender, age, tooth type and reasons for extraction on 800 teeth of 439 subjects, whose data was collected in clinical records in a convenience sample. Results. The groups with range from 35 to 44 years, 45 to 54 years and 55 to 64 years revealed significantly greater number of teeth extractions than other age groups (P < 0.0001). The anterior teeth loss increased significantly with aging, while the tooth mortality of premolar and molar were higher in younger people. The caries was the more prevalent reason for tooth mortality among young and adults up to 44 years old, while the periodontal disease was the main reason for extractions from 45 years old until range of 81 years (P < 0.0001). Conclusions. It can be suggested that some reasons for tooth loss were age-dependent, but the caries and the periodontal diseases were the main reasons for tooth mortality in this Brazilian sample.
doi:10.1155/2012/719750
PMCID: PMC3437633  PMID: 22973312
7.  Associations between smoking and tooth loss according to reason for tooth loss 
Background
Smoking is associated with tooth loss. However, smoking's relationship to the specific reason for tooth loss in postmenopausal women is unknown.
Methods
Postmenopausal women (n = 1,106) who joined a Women's Health Initiative ancillary study (The Buffalo OsteoPerio Study) underwent oral examinations for assessment of the number of missing teeth, as well as the self-reported reasons for tooth loss. The authors obtained information about smoking status via a self-administered questionnaire. The authors calculated odds ratios (ORs) and 95 percent confidence intervals (CIs) by means of logistic regression to assess smoking's association with overall tooth loss, as well as with tooth loss due to periodontal disease (PD) and with tooth loss due to caries.
Results
After adjusting for age, education, income, body mass index (BMI), history of diabetes diagnosis, calcium supplement use and dental visit frequency, the authors found that heavy smokers (≥ 26 pack-years) were significantly more likely to report having experienced tooth loss compared with never smokers (OR = 1.82; 95 percent CI, 1.10-3.00). Smoking status, packs smoked per day, years of smoking, pack-years and years since quitting smoking were significantly associated with tooth loss due to PD. For pack-years, the association for heavy smokers compared with that for never smokers was OR = 6.83 (95 percent CI, 3.40-13.72). The study results showed no significant associations between smoking and tooth loss due to caries.
Conclusions and Practical Implications
Smoking may be a major factor in tooth loss due to PD. However, smoking appears to be a less important factor in tooth loss due to caries. Further study is needed to explore the etiologies by which smoking is associated with different types of tooth loss. Dentists should counsel their patients about the impact of smoking on oral health, including the risk of tooth loss due to PD.
PMCID: PMC3842224  PMID: 23449901
Tooth loss; periodontal diseases; caries; smoking; menopause; women's health
8.  Dental caries and associated factors among primary school children in Bahir Dar city: a cross-sectional study 
BMC Research Notes  2014;7(1):949.
Background
Dental caries is the most common chronic infectious disease of childhood caused by the interaction of bacteria, mainly Streptococcus mutans and sugary foods on tooth enamel. This study aimed at determining the prevalence and associated factors of dental caries among primary school children at Bahir Dar city.
Methods
A school based cross-sectional study was conducted at Bahir Dar city from October 2013 to January 2014. Systematic random sampling technique was used to select the children. Structured questionnaire was used to interview children and/or parents to collect socio demographic variables. Clinical dental information obtained by experienced dentist using dental caries criteria set by World Health Organization. Binary and multiple logistic regression analysis were computed to investigate factors associated with dental caries.
Results
Of the 147 children, 82 (55.4%) were girls. Majority of the children (67.6%) cleaned their teeth using traditional method (small stick of wood made of a special type of plant). The proportion of children having dental caries was 32 (21.8%). Primary tooth decay accounted for 24 (75%) of dental caries. The proportion of missed teeth was 7 (4.8%). The overall proportion of toothache and dental plaque among school children were 40 (27.2%) and 99 (67.3%), respectively. Grade level of 1–4 (AOR = 3.9, CI = 1.49 -10.4), poor habit of tooth cleaning (AOR = 2.6, CI = 1.08 - 6.2), dental plaque (AOR = 5.3, CI = 1.6 - 17.7) and toothache (AOR = 6.3, CI = 2.4 – 15.4) were significantly associated with dental caries.
Conclusion
Dental caries is a common public health problem in school children associated with poor oral hygiene, dietary and dental visit habits. Therefore, prevention measures such as health education on oral hygiene, dietary habits and importance of dental visit are obligatory for children.
doi:10.1186/1756-0500-7-949
PMCID: PMC4307198  PMID: 25540044
Dental caries; Dental plaque; Children
9.  Family history and oral health: findings from the Dunedin Study 
Context
The effects of the oral health status of one generation on that of the next within families are unclear.
Objective
To determine whether parental oral health history is a risk factor for oral disease.
Methods
Oral examination and interview data were collected during the age-32 assessments in the Dunedin Study. Parental data were also collected on this occasion. The sample was divided into two familial-risk groups for caries/tooth loss (high risk and low risk) based on parents’ self-reported history of tooth loss at the age-32 assessment interview.
Main outcome measures
Probands’ dental caries and tooth loss status at age 32, together with lifelong dental caries trajectory (age 5–32).
Results
Caries/tooth-loss risk analysis was conducted for 640 proband-parents groups. Referent groups were the low-familial-risk groups. After controlling for confounding factors (sex, episodic use of dental services, socio-economic status and plaque trajectory), the prevalence ratio (PR) for having lost 1+ teeth by age 32 for the high-familial-risk group was 1.41 (95% confidence interval [CI] 1.05, 1.88) and the rate ratio for DMFS at age 32 was 1.41 (95% CI 1.24, 1.60). In the high-familial-risk group, the PR of following a high caries trajectory was 2.05 (95% CI 1.37, 3.06). Associations were strongest when information was available about both parents’ oral health. Nonetheless, when information was available for one parent only, associations were significant for some proband outcomes.
Conclusions
People with poor oral health tend to have parents with poor oral health. Family/parental history of oral health is a valid representation of the intricacies of the shared genetic and environmental factors that contribute to an individual’s oral health status. Associations were strongest when data from both parents can be obtained.
doi:10.1111/j.1600-0528.2011.00641.x
PMCID: PMC3270204  PMID: 22022823
oral health; family history; intergenerational; risk
10.  Analysis of Tooth Mortality Among Nigerian Children in a Tertiary Hospital Setting 
Background:
Tooth mortality is important in evaluating dental care as tooth loss is a reflection of cumulative effects of past disease and treatment practices.
Aim:
The aim of this study is to analyze the pattern of tooth mortality among pediatric dental patients treated at the University of Benin Teaching Hospital, Benin City, Nigeria.
Subjects and Methods:
This was a retrospective study of patients treated at the Pediatric dental clinic of the University of Benin Teaching Hospital, Benin City between June 2007 and April 2012. Patients’ age, sex, indication for extraction and type of tooth were reviewed. Data analysis in the form of frequency, percentages, cross tabulation, Chi-square statistics were performed using the statistical package for the social sciences (SPSS) (Chicago IL, USA) version 17.0.
Results:
A total of 712 patients between the ages 0 and 16 years were seen and 1039 extractions were performed. Tooth extraction was performed more among females 53.4% (380/712) and those aged 6-12 years 54.1% (384/712). About one-third 33.1% (236/712) of the patients had two or more teeth extraction. The deciduous teeth were more frequently extracted 65.2% (677/1039) with second molars being the most frequently extracted deciduous teeth and first molars being the most frequently extracted permanent teeth. Permanent third molar accounted for the 0.7% (7/1039) of the extracted teeth in this study. The extractions were done more on the lower arch and on the right side of the mouth. In this study, dental caries was the leading reason for extraction of the deciduous and permanent teeth. Neonatal teeth and supernumerary accounted for 0.9% (4/438) and 0.7% (2/289) of deciduous and permanent dentition extractions respectively.
Conclusion:
Dental caries was the leading reason for extraction in both deciduous and permanent dentitions with female patients aged 6-12 years receiving the most tooth/teeth extractions. Stakeholder in child health need to pay adequate attention to dental caries preventive approaches to enable the pediatric population reach adulthood with a healthier dentition.
doi:10.4103/2141-9248.133457
PMCID: PMC4071731  PMID: 24971206
Deciduous teeth; Extraction; Permanent teeth; Reasons
11.  The genetic basis of modularity in the development and evolution of the vertebrate dentition. 
The construction of organisms from units that develop under semi-autonomous genetic control (modules) has been proposed to be an important component of their ability to undergo adaptive phenotypic evolution. The organization of the vertebrate dentition as a system of repeated parts provides an opportunity to study the extent to which phenotypic modules, identified by their evolutionary independence from other such units, are related to modularity in the genetic control of development. The evolutionary history of vertebrates provides numerous examples of both correlated and independent evolution of groups of teeth. The dentition itself appears to be a module of the dermal exoskeleton, from which it has long been under independent genetic control. Region-specific tooth loss has been a common trend in vertebrate evolution. Novel deployment of teeth and reacquisition of lost teeth have also occurred, although less frequently. Tooth shape differences within the dentition may be discontinuous (referred to as heterodonty) or graded. The occurrence of homeotic changes in tooth shape provides evidence for the decoupling of tooth shape and location in the course of evolution. Potential mechanisms for region-specific evolutionary tooth loss are suggested by a number of mouse gene knockouts and human genetic dental anomalies, as well as a comparison between fully-developed and rudimentary teeth in the dentition of rodents. These mechanisms include loss of a tooth-type-specific initiation signal, alterations of the relative strength of inductive and inhibitory signals acting at the time of tooth initiation and the overall reduction in levels of proteins required for the development of all teeth. Ectopic expression of tooth initiation signals provides a potential mechanism for the novel deployment or reacquisition of teeth; a single instance is known of a gene whose ectopic expression in transgenic mice can lead to ectopic teeth. Differences in shape between incisor and molar teeth in the mouse have been proposed to be controlled by the region-specific expression of signalling molecules in the oral epithelium. These molecules induce the expression of transcription factors in the underlying jaw mesenchyme that may act as selectors of tooth type. It is speculated that shifts in the expression domains of the epithelial signalling molecules might be responsible for homeotic changes in tooth shape. The observation that these molecules are regionally restricted in the chicken, whose ancestors were not heterodont, suggests that mammalian heterodonty may have evolved through the use of patterning mechanisms already acting on skeletal elements of the jaws. In general, genetic and morphological approaches identify similar types of modules in the dentition, but the data are not yet sufficient to identify exact correspondences. It is speculated that modularity may be achieved by gene expression differences between teeth or by differences in the time of their development, causing mutations to have cumulative effects on later-developing teeth. The mammalian dentition, for which virtually all of the available developmental genetic data have been collected, represents a small subset of the dental diversity present in vertebrates as a whole. In particular, teleost fishes may have a much more extensive dentition. Extension of research on the genetic control of tooth development to this and other vertebrate groups has great potential to further the understanding of modularity in the dentition.
doi:10.1098/rstb.2001.0917
PMCID: PMC1088541  PMID: 11604128
12.  The Effect of a Needs-Related Caries Preventive Program in Children and Young Adults – Results after 20 Years 
BMC Oral Health  2006;6(Suppl 1):S7.
The risk for caries development in children varies significantly for different age groups, individuals, teeth, and surfaces. Thus from a cost-effectiveness point of view, caries preventive measures must be integrated and based on predicted risk from age group down to individual tooth surfaces. Based on this philosophy and experiences from continuously ongoing research on evaluating and reevaluating separate and integrated caries preventive measures, as well as methods for prediction of caries risk, a needs-related caries preventive program was introduced for all 0–19-year-olds in the county of Värmland, Sweden, in 1979. The goals for the subjects following the program from birth to the age of 19 years were:
1. To have no approximal restorations.
2. To have no occlusal amalgam restorations.
3. To have no approximal loss of periodontal attachment.
4. To motivate and encourage individuals to assume responsibility for their own oral health.
The effect of the program is evaluated once every year on almost 100% of all 3–19-year-olds in a computer-aided epidemiologic program from 1979. Most of the individualized preventive program was carried out by dental hygienists or prophy dental assistants at clinics in the elementary schools. During the 20-year period the percentage of caries-free 3-year-olds increased from 51% to 97%. In 1999 as many as 86% of the 12-year-olds were caries free. Caries incidence was reduced more than 90% in all age groups. More than 90% did not develop any new caries lesions in 1999. As a consequence, caries prevalence was dramatically reduced. In 12- and 19-year-olds, the mean number of Decayed and Filled Surfaces (DFS) per individual was reduced from 6 to 0.3 and from 23 to 2 respectively. In 19-year-olds the mean number of approximal DFS was <1, and only 0.5 had to be filled. The mean number of occlusal DFS was <1. Since 1995 we have not been allowed to use amalgam in 1–19-year-olds in Sweden. As an effect of our high quality plaque program, approximal attachment loss was prevented, and by efficient education in self-care based on self-diagnosis, needs-related self-care habits were established. Thus it can be concluded that nearly 100% of our goals had been achieved.
doi:10.1186/1472-6831-6-S1-S7
PMCID: PMC2147598  PMID: 16934124
13.  Tooth loss and periodontal disease predict poor cognitive function in older men 
Objectives
To determine if rates of tooth loss, periodontal disease progression and caries incidence predict cognitive decline in men.
Design
Prospective study.
Setting
Community-dwelling men enrolled in the VA Dental Longitudinal Study.
Participants
Five hundred ninety-seven dentate men, aged 28–70 years at the study baseline, who have been followed up to 32 years.
Measurements
Oral examinations were conducted approximately every 3 years. Periodontal disease measures included probing pocket depth and radiographic alveolar bone height. Participants underwent cognitive testing beginning in 1993. Low cognitive statuses were defined as <25 points or <90% of the age and education-specific median on the MiniMental State Examination, and < 10 points on a Spatial Copying Task.
Results
Each tooth lost per decade since the baseline dental examination increased the risks of low MiniMental score (HR= 1.09, 95% CI=1.01, 1.18) and low spatial copying score (HR=1.12, CI= 1.05, 1.18). Risks were elevated per additional tooth with progression of alveolar bone loss (spatial copying: HR=1.03, CI= 1.01, 1.06), probing pocket depth (MiniMental: HR=1.04, CI= 1.01, 1.09; spatial copying: HR=1.04, CI= 1.01, 1.06) and caries (spatial copying: HR=1.05, CI= 1.01, 1.08). Risks were consistently higher among men who were older than 45.5 years at baseline than in younger men.
Conclusion
Risk of cognitive decline in older men increases as more teeth are lost. Periodontal disease and caries, major reasons for tooth loss, are also related to cognitive decline.
doi:10.1111/j.1532-5415.2010.02788.x
PMCID: PMC3649065  PMID: 20398152
Tooth loss; Periodontal Diseases; Dental Caries. MiniMental State Examination; Cognitive Impairment
14.  A survey of oral health in a Sudanese population 
BMC Oral Health  2012;12:5.
Background
We aimed to assess the oral health status and risk factors for dental caries and periodontal disease among Sudanese adults resident in Khartoum State. To date, this information was not available to health policy planners in Sudan.
Methods
A descriptive population-based survey of Sudanese adults aged ≥ 16 years was conducted. After stratified sampling, 1,888 adult patients from public dental hospitals and dental health centres scattered across Khartoum State, including different ethnic groups present in Sudan, were examined in 2009-10. Data were collected using patient interviews and clinical examinations. Dental status was recorded using the DMFT index, community periodontal index (CPI), and a validated tooth wear index.
Results
Caries prevalence was high, with 87.7% of teeth examined having untreated decay. Periodontal disease increased in extent and severity with age. For 25.8% of adults, tooth wear was mild; 8.7% had moderate and 1% severe toothwear. Multivariate analysis revealed that decay was less prevalent in older age groups but more prevalent in southern tribes and frequent problem based attenders; western tribes and people with dry mouths who presented with less than18 sound, untreated natural teeth (SUNT). Older age groups were more likely to present with tooth wear; increasing age and gender were associated with having periodontal pocketing ≥ 4 mm.
Conclusions
The prevalence of untreated caries and periodontal disease was high in this population. There appear to be some barriers to restorative dental care, with frequent use of dental extractions to treat caries and limited use of restorative dentistry. Implementation of population-based strategies tailored to the circumstances of Sudanese population is important to improve oral health status in Sudan.
doi:10.1186/1472-6831-12-5
PMCID: PMC3311612  PMID: 22364514
15.  The association between dental and periodontal diseases and sickle cell disease. A pilot case-control study 
The Saudi Dental Journal  2014;27(1):40-43.
Objective
This is a pilot case-control study conducted to investigate the prevalence of dental caries and periodontal disease and examine the possible association between oral health deterioration and SCD severity in a sample of Saudi SCD patients residing in the city of Al-Qatif, Eastern Province, Saudi Arabia.
Materials and methods
Dental examination to determine the Decayed, Missing and Filled Teeth index (DMFT), Community Periodontal Index (CPI), and plaque index system were recorded for 33 SCD patients and 33 age and sex-matched controls in the Al-Qatif Central Hospital, Qatif, Saudi Arabia. Self-administered surveys used to assess socio-economic status; oral health behaviors for both SCD patients and controls were recorded. In addition, the disease severity index was established for all patients with SCD. SPSS data analysis software package version 18.0 was used for statistical analysis. Numerical variables were described as mean with a standard deviation.
Results
Decayed teeth were significantly more in individuals with ages ranging from 18 to 38 years with SCD compared to the control group (p = 0.036) due to oral hygiene negligence. The mean number of filled teeth was significantly lower in individuals with SCD when compared to the control group (p = 0.015) due to the lack of appropriate and timely treatment reflected in the survey responses of SCD patients as 15.2% only taking oral care during hospitalization. There were differences between the cases and controls in the known caries risk factors such as income level, flossing, and brushing habit. The DMFT, CPI, and plaque index systems did not differ significantly between the SCD patients and the control group.
Conclusion
Data suggest that patients with SCD have increased susceptibility to dental caries, with a higher prevalence of tooth decay and lower prevalence of filled teeth. Known caries risk factors influenced oral health more markedly than did factors related to SCD.
doi:10.1016/j.sdentj.2014.08.003
PMCID: PMC4273253  PMID: 25544813
Sickle cell disease; Dental caries; Periodontal
16.  Genetic Susceptibility to Dental Caries on Pit and Fissure and Smooth Surfaces 
Caries Research  2012;46(1):38-46.
Carious lesions are distributed nonuniformly across tooth surfaces of the complete dentition, suggesting that the effects of risk factors may be surface-specific. Whether genes differentially affect caries risk across tooth surfaces is unknown. We investigated the role of genetics on two classes of tooth surfaces, pit and fissure surfaces (PFS) and smooth surfaces (SMS), in more than 2,600 subjects from 740 families. Participants were examined for surface-level evidence of dental caries, and caries scores for permanent and/or primary teeth were generated separately for PFS and SMS. Heritability estimates (h2, i.e. the proportion of trait variation due to genes) of PFS and SMS caries scores were obtained using likelihood methods. The genetic correlations between PFS and SMS caries scores were calculated to assess the degree to which traits covary due to common genetic effects. Overall, the heritability of caries scores was similar for PFS (h2 = 19–53%; p < 0.001) and SMS (h2 = 17–42%; p < 0.001). Heritability of caries scores for both PFS and SMS in the primary dentition was greater than in the permanent dentition and total dentition. With one exception, the genetic correlation between PFS and SMS caries scores was not significantly different from 100%, indicating that (mostly) common genes are involved in the risk of caries for both surface types. Genetic correlation for the primary dentition dfs (decay + filled surfaces) was significantly less than 100% (p < 0.001), indicating that genetic factors may exert differential effects on caries risk in PFS versus SMS in the primary dentition.
doi:10.1159/000335099
PMCID: PMC3304515  PMID: 22286298
Dental caries; Genetic correlation; Genetics; Heritability; Permanent dentition; Pit and fissure surfaces; Primary dentition; Smooth surfaces
17.  Tooth loss patterns in older adults with special needs: a Minnesota cohort 
This study was conducted to detail tooth loss patterns in older adults with special needs. A total of 491 elderly subjects with special needs were retrospectively selected and followed during 10/1999-12/2006. Medical, dental, cognitive, and functional assessments were abstracted from dental records and used to predict risk of tooth loss. Tooth loss events were recorded for subjects during follow-up. Chi-squared tests were used to study the association between tooth loss and the selected risk factors. Logistic, poisson, and negative binomial regressions were developed to study tooth loss patterns. Overall, 27% of the subjects lost at least one tooth during follow-up. Fourteen subjects had tooth loss events per 100 person-years. Tooth loss pattern did not differ significantly among different special-needs subgroups (i.e. community-dwelling vs. long-term care, physically disabled vs. functionally independent). Special-needs subjects with three or more active dental conditions at arrival had more than twice the risk of losing teeth than those without any existing conditions. After adjusting other factors, the number of carious teeth or retained roots at arrival was a significant predictor of tooth loss for older adults with special needs (P=0.001). These findings indicate that appropriately managing active caries and associated conditions is important to prevent tooth loss for older adults with special needs.
doi:10.4248/IJOS11012
PMCID: PMC3469872  PMID: 21449213
tooth loss; elderly; special needs
18.  Dental caries prevalence, oral health knowledge and practice among indigenous Chepang school children of Nepal 
BMC Oral Health  2013;13:20.
Background
Chepang communities are one of the most deprived ethnic communities in Nepal. According to the National Pathfinder Survey, dental caries is a highly prevalent childhood disease in Nepal. There is no data concerning the prevalence of caries along with knowledge, attitude and oral hygiene practices among Chepang schoolchildren. The objectives of this study were to 1) record the prevalence of dental caries 2) report experience of dental pain 3) evaluate knowledge, attitude and preventive practices on oral health of primary Chepang schoolchildren.
Method
A cross sectional epidemiological study was conducted in 5 government Primary schools of remote Chandibhanjyang Village Development Committee (VDC) in Chitwan district. Ethical approval was taken from the Institutional Review Board within the Research Department of the Institute of Medicine (IOM) Tribhuvan University. Consent was obtained from parents for conducting clinical examination and administrating questionnaire. Permission was taken from the school principal in all schools. Data was collected using a pretested questionnaire on 131 schoolchildren aged 8-16-year- olds attending Grade 3–5. Clinical examination was conducted on 361 school children aged 5–16 –year-olds attending grade 1–5. Criteria set by the World Health Organization (1997) was used for caries diagnosis. The questionnaires, originally constructed in English and translated into Nepali were administered to the schoolchildren by the researchers. SPSS 11software was used for data analysis.
Results
Caries prevalence for 5–6 –year-old was above the goals recommended by WHO and Federation of Dentistry international (FDI) of less than 50% caries free children. Caries prevalence in 5-6-year-olds was 52% and 12-13-year-olds was 41%. The mean dmft/DMFT score of 5–6 –year-olds and 12 -13-year -olds was 1.59, 0.31 and 0.52, 0.84 respectively. The DMFT scores increased with age and the d/D component constituted almost the entire dmft/DMFT index. About 31% of 8-16-year-olds school children who participated in the survey reported having suffered from oral pain. Further, the need for treatment of decayed teeth was reported at 100%. About 76% children perceived teeth as an important component of general health and 75% reported it was required to eat. A total 93% children never visited a dentist or a health care service. Out of 56% children reporting cleaning their teeth daily, only 24% reported brushing their teeth twice daily. About 86% of the children reported using toothbrush and toothpaste to clean their teeth. Although 61% children reported to have received oral health education, 82% children did not know about fluoride and its benefit on dental health. About 50% children reported bacteria as the main cause of tooth decay and 23% as not brushing teeth for gingivitis. Frequency of sugar exposure was low; 75% of children reported eating sugar rich food once daily.
Conclusions
Caries prevalence of 5–6 –year- old Chepang school children is above the recommended target set by FDI/WHO. The study reported 31% schoolchildren aged 8-16-year old suffered oral pain and decayed component constituted almost the entire dmft/DMFT index. The brushing habit was reportedly low with only 24% of the children brushing twice daily. A nationwide scientifically proven, cost effective school based interventions is needed for prevention and control of caries in schoolchildren in Nepal.
doi:10.1186/1472-6831-13-20
PMCID: PMC3655880  PMID: 23672487
Dental caries; School children; Oral hygiene
19.  An observational cohort study on shortened dental arches—clinical course during a period of 27–35 years 
Clinical Oral Investigations  2012;17(3):859-866.
Objectives
The objective of this study was to investigate the clinical course of shortened dental arches (‘SDA group’) compared to SDAs plus removable denture prosthesis (‘SDA plus RDP group’) and complete dental arches (‘CDA group’, controls).
Materials and methods
Data (numbers of direct and indirect restorations, endodontic treatments, tooth loss and tooth replacements) were extracted from patient records of subjects attending the Nijmegen Dental School who previously participated in a cohort study on shortened dental arches with three to four posterior occluding pairs (POPs).
Results
Records of 35 % of the original cohort were retrievable. At the end of the follow-up (27.4 ± 7.1 years), 20 out of 23 SDA subjects still had SDA with 3–4 POPs compared to 6 out of 13 for SDA plus RDP subjects (follow-up 32.6 ± 7.3 years). Sixteen out of 23 CDA subjects still had CDA; none of them lost more than one POP (follow-up 35.0 ± 5.6 years). SDA group lost 67 teeth: 16 were not replaced, 16 were replaced by FDP and 35 teeth (lost in three subjects) replaced by RDP. Mean number of treatments per year in SDA subjects differed not significantly compared to CDA subjects except for indirect restorations in the upper jaw.
Conclusion
Shortened dental arches can last for 27 years and over. Clinical course in SDA plus RDP is unfavourable, especially when RDP-related interventions are taken into account.
Clinical relevance
The shortened dental arch concept seems to be a relevant approach from a cost-effective point of view. Replacement of absent posterior teeth by free-end RDP cannot be recommended.
doi:10.1007/s00784-012-0765-6
PMCID: PMC3607715  PMID: 22744163
Shortened dental arches; Complete dental arches; Cohort study; Removable denture prosthesis; Tooth loss; Clinical course
20.  Longevity of dental amalgam in comparison to composite materials 
Health political background
Caries is one of the most prevalent diseases worldwide. For (direct) restaurations of carious lesions, tooth-coloured composite materials are increasingly used. The compulsory health insurance pays for composite fillings in front teeth; in posterior teeth, patients have to bear the extra cost.
Scientific background
Amalgam is an alloy of mercury and other metals and has been used in dentistry for more than one hundred and fifty years. Composites consist of a resin matrix and chemically bonded fillers. They have been used for about fifty years in front teeth. Amalgam has a long longevity; the further development of composites has also shown improvements regarding their longevity.
Research questions
This HTA-report aims to evaluate the longevity (failure rate, median survival time (MST), median age) of direct amalgam fillings in comparison to direct composite fillings in permanent teeth from a medical and economical perspective and discusses the ethical, legal and social aspects of using these filling materials.
Methods
The systematic literature search yielded a total of 1,149 abstracts. After a two-step selection process based on defined criteria 25 publications remained to be assessed.
Results
The medical studies report a longer longevity for amalgam fillings than for composite fillings. However, the results of these studies show a large heterogeneity. No publication on the costs or the cost-effectiveness of amalgam and composite fillings exists for Germany. The economic analyses (NL, SWE, GB) report higher costs for composite fillings when longevity is assumed equal (for an observation period of five years) or longer for amalgam compared to composite fillings. These higher costs are due to the higher complexity of placing composite fillings.
Discussion
Due to different study designs and insufficient documentation of study details, a comparison of different studies on longevity of direct amalgam and composite fillings in posterior teeth is difficult. Apart from the difficulties in conducting a randomized, controlled long-term study comparing the longevity of direct fillings, the fact that composites and adhesives used in a study have often already been replaced by the next generation of the product at the time of study publication presents an additional problem. Not only the filling material, but also patient parameters and local, intraoral factors (e. g. localisation of the filling) as well as the treating dentist have an impact on the longevity of dental fillings. In evaluating economic studies, one has to refer to the heterogeneity of data on longevity in the medical evaluation. The only effect parameter used in the studies is longevity, other aspects (e. g. long-term functionality) are only referred to in discussions. Extensive counselling of patients regarding the selection of the appropriate filling material is important.
Conclusions
Amalgam fillings show a longer longevity than composite fillings. Two out of six systematic reviews conclude that the expected survival time of composite fillings can be comparable to amalgam fillings. However, these conclusions are based on the results of short-term studies which usually overestimate the longevity of filling materials. From an economic standpoint, amalgam is the more economic filling material compared to direct composite fillings in posterior teeth when considering longevity as the only result parameter. Other aspects than longevity need to be considered in individually choosing the appropriate dental filling material. For future studies aiming to compare the longevity of amalgam and composite fillings, a sufficient sample size and study period, preferably in the setting of a private dental practice, should be aimed for. An evaluation of the cost-effectiveness of amalgam and composite fillings should take the functionality of teeth over a longer time period into account, as well as patients’ preferences. The rapid development of composite materials and adhesives make short term revisions of these conclusions necessary.
PMCID: PMC3011298  PMID: 21289917
21.  Social Determinants of Tooth Loss 
Health Services Research  2003;38(6 Pt 2):1843-1862.
Objectives
To quantify racial and socioeconomic status (SES) disparities in oral health, as measured by tooth loss, and to determine the role of dental care use and other factors in explaining disparities.
Data Sources/Study Setting
The Florida Dental Care Study, comprising African Americans (AAs) and non-Hispanic whites 45 years old or older who had at least one tooth.
Study Design
We used a prospective cohort design. Relevant population characteristics were grouped by predisposing, enabling, and need variables. The key outcome was tooth loss, a leading measure of a population's oral health, looked at before and after entering the dental care system. Tooth-specific data were used to increase inferential power by relating the loss of individual teeth to the disease level on those teeth.
Data Collection Methods
In-person interviews and clinical examinations were done at baseline, 24, and 48 months, with telephone interviews every 6 months.
Principal Findings
African Americans and persons of lower SES reported more new dental symptoms, but were less likely to obtain dental care. When they did receive care, they were more likely to experience tooth loss and less likely to report that dentists had discussed alternative treatments with them. At the first stage of analysis, differences in disease severity and new symptoms explained tooth loss disparities. Racial and SES differences in attitudes toward tooth loss and dental care were not contributory. Because almost all tooth loss occurs by means of dental extraction, the total effects of race and SES on tooth loss were artificially minimized unless disparities in dental care use were taken into account.
Conclusions
Race and SES are strong determinants of tooth loss. African Americans and lower SES persons had fewer teeth at baseline and still lost more teeth after baseline. Tooth-specific case-mix adjustment appears, statistically, to explain social disparity variation in tooth loss. However, when social disparities in dental care use are taken into account, social disparities in tooth loss that are not directly due to clinical circumstance become evident. This is because AAs and lower SES persons are more likely to receive a dental extraction once they enter the dental care system, given the same disease extent and severity. This phenomenon underscores the importance of understanding how disparities in health care use, dental insurance coverage, and service receipt contribute to disparities in health. Absent such understanding, the total effects of race and SES on health can be underestimated.
doi:10.1111/j.1475-6773.2003.00205.x
PMCID: PMC1360976  PMID: 14727800
Tooth loss; health disparities; race; socioeconomic status
22.  Dental caries prevalence and treatment levels in Arizona preschool children. 
Public Health Reports  1997;112(4):319-331.
OBJECTIVES: To assess the prevalence of dental caries in a large group of preschool children, to determine the extent to which the children received dental treatment, to examine the association between demographic and socioeconomic factors and the prevalence of caries, and to compare these findings with those from previous studies of preschool populations in the United States. METHODS: Dental caries exams were performed on 5171 children ages 5 months through 4 years, and a parent or other caregiver was asked to complete a questionnaire giving information about the child and her or his household. The children were recruited from Head Start programs; Women, Infants, and Children (WIC) nutrition programs; health fairs; and day care centers in a representative sample of Arizona communities with populations of more than 1000 people. RESULTS: Of the 994 one-year-old children examined, 6.4% had caries, with a mean dmft (decayed, missing [extracted due to caries], and filled teeth) score of 0.18. Nearly 20% of the 2-year-olds had caries, with a mean dmft of 0.70. Thirty-five percent of the 3-year-olds had caries, with a mean dmft of 1.35, and 49% of the 4-year-olds had caries, with a mean dmft of 2.36. Children whose caregivers fell into the lowest education category had a mean dmft score three times higher than those with caregivers in the highest education category. Children with caregivers in the lowest income category had a mean dmft score four times higher than those with caregivers in the highest category. Children younger than age 3 had little evidence of dental treatment, and most of the children with caries in each age group had no filled or extracted teeth. CONCLUSIONS: The data show that dental caries is highly prevalent in this preschool population, with little of the disease being treated. Timing of diagnostic examinations and prevention strategies for preschool children need to be reconsidered, especially for children identified as having a high risk of caries.
PMCID: PMC1381972  PMID: 9258297
23.  Prevalence of dental caries among 12–14 year old children in Qatar 
The Saudi Dental Journal  2014;26(3):115-125.
Background
To ensure the oral health of a population, clinicians must deliver appropriate dental services, and local communities need to have access to dental care facilities. However, establishment of this infrastructure must be based on reliable information regarding disease prevalence and severity in the target population.
Objectives
The aims of this study were to measure the incidence of dental caries in school children aged 12–14 throughout Qatar, including the influence of socio-demographic factors.
Materials and methods
A cross-sectional study was conducted in Qatar from October 2011 to March 2012. A total of 2113 children aged 12–14 were randomly selected from 16 schools located in different geographic areas. Three calibrated examiners using World Health Organization (WHO) criteria to diagnose dental caries performed the clinical examinations. Data analyses were subsequently conducted.
Results
The mean decayed, missing, and filled teeth index values were respectively 4.62 (±3.2), 4.79 (±3.5), and 5.5 (±3.7), for 12, 13, and 14 year-old subjects. Caries prevalence was 85%. The mandibular incisors and canines were least affected by dental caries, while maxillary and mandibular molars exhibited the highest incidence of dental caries. Dental caries were affected by socio-demographic factors; significant differences were detected between female and male children, where more female children showed dental caries than male children. In addition, children residing in semi-urban areas showed more dental caries than in urban areas.
Conclusion
Results indicated that dental caries prevalence among school children in Qatar has reached critical levels, and is influenced by socio-demographic factors. The mean decayed, missing, and filled teeth values obtained in this study were the second highest detected in the Eastern Mediterranean region.
doi:10.1016/j.sdentj.2014.03.006
PMCID: PMC4095054  PMID: 25057232
Prevalence; Dental caries; DMFT index; School children; Qatar
24.  Cigarette smoking and tooth loss experience among young adults: a national record linkage study 
BMC Public Health  2007;7:313.
Background
Various factors affect tooth loss in older age including cigarette smoking; however, evidence regarding the association between smoking and tooth loss during young adulthood is limited. The present study examined the association between cigarette smoking and tooth loss experience among adults aged 20–39 years using linked data from two national databases in Japan.
Methods
Two databases of the National Nutrition Survey (NNS) and the Survey of Dental Diseases (SDD), which were conducted in 1999, were obtained from the Ministry of Health, Labor and Welfare with permission for analytical use. In the NNS, participants received physical examinations and were interviewed regarding dietary intake and health practices including cigarette smoking, whereas in the SDD, participants were asked about their frequency of daily brushing, and received oral examinations by certified dentists. Among 6,805 records electronically linked via household identification code, 1314 records of individuals aged 20 to 39 years were analyzed. The prevalence of 1+ tooth loss was compared among non-, former, and current smokers. Multiple logistic regression models were constructed including confounders: frequency of tooth brushing, body mass index, alcohol consumption, and intake of vitamins C and E.
Results
Smoking rates differed greatly in men (53.3%) and women (15.5%). The overall prevalence of tooth loss was 31.4% (31.8% men and 31.1% women). Tooth loss occurred more frequently among current smokers (40.6%) than former (23.1%) and non-smokers (27.9%). Current smoking showed a significant association with 1+ tooth loss in men (adjusted OR = 2.21 [1.40–3.50], P = 0.0007) and women (1.70 [1.13–2.55], P = 0.0111). A significant positive exposure-related relationship between cigarette smoking status and tooth loss was observed (P for trend < 0.0001 and 0.0004 in men and women, respectively). Current smoking was also associated with the prevalence of decayed teeth (1.67 [1.28–2.20], P = 0.0002).
Conclusion
An association between cigarette smoking and tooth loss was evident among young adults throughout Japan. Due to limitations of the available variables in the present databases, further studies including caries experience and its confounders should be conducted to examine whether smoking is a true risk of premature tooth loss in young adults.
doi:10.1186/1471-2458-7-313
PMCID: PMC2186324  PMID: 17976246
25.  The occurrence of dental caries is associated with atherosclerosis 
Clinics  2013;68(7):946-953.
OBJECTIVE:
Previous studies have suggested that marginal periodontitis is a risk factor for developing atherosclerosis. The objective of this study was to determine whether caries may also be associated with atherosclerosis.
METHODS:
The computed tomography data sets of 292 consecutive patients, 137 women and 155 men with a mean age of 54.1±17.3 years, were analyzed. Caries were quantified based on the number of decayed surfaces of all the teeth, and periodontitis was quantified on the basis of the horizontal bone loss in the jaw. The presence of chronic apical periodontitis (CAP) was assessed, and the aortic atherosclerotic burden was quantified using a calcium scoring method.
RESULTS:
The patients with <1 caries surfaces/tooth had a lower atherosclerotic burden (0.13±0.61 mL) than patients with ≥1 caries surfaces/tooth. The atherosclerotic burden was greater in patients with a higher number of lesions with pulpal involvement and more teeth with chronic apical periodontitis. In the logistical regression models, age (Wald 49.3), number of caries per tooth (Wald 26.4), periodontitis (Wald 8.6), and male gender (Wald 11) were found to be independent risk factors for atherosclerosis. In the linear regression analyses, age and the number of decayed surfaces per tooth were identified as influencing factors associated with a higher atherosclerotic burden, and the number of restorations per tooth was associated with a lower atherosclerotic burden.
CONCLUSION:
Dental caries, pulpal caries, and chronic apical periodontitis are associated positively, while restorations are associated inversely, with aortic atherosclerotic burden. Prospective studies are required to confirm these observations and answer the question of possible causality.
doi:10.6061/clinics/2013(07)10
PMCID: PMC3714742  PMID: 23917658
Dental Caries; Atherosclerosis; Risk Factors; Dental Restoration; Computed Tomography; Cardiovascular Diseases

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