To review population-based research into oral health related quality of life.
Narrative review of selected publications.
In the 1970s, there were two incentives to assess non-clinical aspects of health: 1) a desire to understand impacts of disease on individuals’ quality of life; 2) a search for population-level measures that might better quantify the impact of health care systems on populations. Dental researchers responded to those incentives, creating dozens of questionnaires that assess individuals’ ratings of subjective oral health and quality of life. This has been a boon for clinical dental research, for example, by showing marked improvements in subjective oral health in patients receiving implant-supported dentures. Also, health surveys show poorer subjective oral health among disadvantaged population groups. However, the same measures show only modest benefits of general dental care. Furthermore, several population surveys show that today’s young adults, who grew up with widespread exposure to preventive dental programs, have poorer subjective oral health than earlier generations that experienced unprecedented levels of oral disease. Yet to materialize is the hope that “socio-dental indicators” of subjective oral health might provide a meaningful metric to demonstrate population-level benefits of dental care. A fundamental limitation is that population health is a contextual measure, not merely the aggregated health status of individuals within the population.
While researchers have successfully broken with clinical dogma by assessing subjective dimensions of individuals’ oral health, they have failed to explicitly ask people to assess the oral health of the community in which they live.
oral health; quality of life; health surveys; epidemiology
The US National Health and Nutrition Examination Survey (NHANES 2003–2004) evaluated oral health quality of life for the first time using a previously untested subset of seven Oral Health Impact Profile (OHIP) questions, i.e. the NHANES-OHIP.
(i) To describe the impact of dental conditions on quality of life in the US adult population; (ii) to evaluate construct validity and adequacy of the NHANES-OHIP in NHANES 2003–2004 and a comparable Australian survey.
In the cross-sectional NHANES 2003–2004 survey of a nationally representative sample of US adults (n = 4907), prevalence was quantified as the proportion of adults who reported experiencing one or more impacts fairly often or very often within the past year. Construct validity was tested by comparing prevalence estimates across categories of sociodemographic, dental health and utilization characteristics known to vary in oral health. In 2002, Australian cross-sectional survey of a nationally representative sample of adults (n = 2644), adequacy of the NHANES-OHIP questions were tested with reference to a slightly modified version of the OHIP-14 questions.
NHANES-OHIP prevalence estimates were markedly similar in the United States (15.3%) and Australia (15.7%). In the US construct, validity was evidenced by higher NHANES-OHIP scores among groups with greater levels of tooth loss, perceived treatment need and problem-oriented visiting and with lack of private dental insurance and low income. In Australia, prevalence for the NHANES-OHIP closely resembled prevalence estimates of the modified OHIP-14. Both varied to a similar degree across levels of tooth loss, perceived treatment need, problem-oriented visiting, and private dental insurance and income, demonstrating adequacy of the NHANES-OHIP as a brief independent instrument.
There was acceptable construct validity and adequacy of the NHANES-OHIP questionnaire. In the United States, the impact of oral disease disproportionately affected disadvantaged groups, a finding that supports application of the US Healthy People 2010 major goals of improved quality of life and reduced health disparities.
adults; health policy; health surveys; NHANES; population groups
To determine whether participants of a dental practice-based research network (PBRN) differ in their level of oral health impact as measured by the Oral Health Impact Profile (OHIP) questionnaire.
A total of 2410 patients contributed 2432 OHIP measurements (median age = 43 years; interquartile range = 28) were enrolled in four dental studies. All participants completed the Oral Health Impact Profile (OHIP-14) during a baseline visit. The main outcome of the current study was the level of oral health impact, defined as follows: no impact (“Never” reported on all items); low (“Occasionally” or “Hardly ever” as the greatest frequency score reported on any item); and high (“Fairly often” or “Very often” as the greatest frequency reported on any item). Polychotomous logistic regression was used to develop a predictive model for the level of oral health impact considering the following predictors: patient’s age, gender, race, practice location, type of dentist, and number of years the enrolling dentist has been practicing.
A high level of oral health impacts was reported in 8% of the sample; almost a third (29%) of the sample reported a low level of impacts, and 63% had no oral health impacts. The prevalence of impacts differed significantly across protocols (P<0.001). Females were more likely to be in the high oral impact group than the no impact group compared to males (OR=1.46; 95% CI= 1.06–1.99). African-Americans were more likely to report high oral impacts when compared to other racial/ethnic groups (OR=2.11; 95% CI = 1.26–3.55). Protective effects for being in the high or in the low impact groups were observed among patients enrolled by a solo practice (P<0.001) or by more experienced dentists (P=0.01). A small but highly significant statistical association was obtained for patient age (P<0.001). In the multivariate model, patient’s age, practice size and gender were found to jointly be significant predictors of oral health impact level.
Patients’ subjective report of oral health impact in the clinical setting is of importance for their health. In the context of a dental PBRN, the report of oral health-related quality of life (OHRQoL) was different across four dental studies. The observed findings validate the differential impact that oral health has on the patients’ perception of OHRQoL particularly among specific groups. Similar investigations to elucidate the factors associated with patient’s report of quality of life are warranted.
Oral-Health Impact; OHRQoL; Dental PBRN; OHIP-14; Patient Reported Outcomes; Subjective Health
The effects of the oral health status of one generation on that of the next within families are unclear.
To determine whether parental oral health history is a risk factor for oral disease.
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).
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.
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.
oral health; family history; intergenerational; risk
Caries is a severe condition which disproportionately affects Latino children in the U.S. This study sought contextual understanding of urban, low-income Mexican-American mothers’ beliefs, perceptions, knowledge and behavior surrounding causes of caries.
In urban San José, CA, a qualitative study was conducted with a convenience sample of Mexican-American mothers of young children about their beliefs and knowledge about the causes of caries. Audio-taped in-depth interviews with open-ended questions, primarily in Spanish, were translated to English and then transcribed verbatim. Texts were independently read and thematically analyzed by two researchers.
Even while expressing uncertainty, all 48 mothers mentioned specific causes of caries, most frequently citing candy or juice consumption (85%), poor oral hygiene (65%) and use of the bottle (52%). Mothers rarely recognized cariogenic foods beyond candy, did not know or perform recommended oral hygiene routines, and demonstrated confusion and uncertainty about exactly how baby bottles are detrimental to teeth. Nearly half of these mothers also mentioned secondary cavity causes, such as genetics, lack of calcium, not going to the dentist, or lack of fluoride. Mothers did not mention the role of bacteria. While mothers recognize that oral hygiene can counteract the detrimental effects of candy consumption, they did not recognize its beneficial effects in other contexts. Nor did they know about other preventive activities.
Mothers recognized the three major important factors causing caries: sugar consumption, poor oral hygiene, and bottle use. However, their knowledge is limited in depth and specificity which restricts development of caries prevention behaviors. More comprehensive education is needed, including on caries prevention (oral hygiene) behaviors, which could lead to an increased sense of self-efficacy with respect to their children’s oral health.
Caries; Caries etiology; Mothers’ beliefs and knowledge; Mexican-American children; Qualitative research
Calibration studies are routinely performed to establish examiner reliability in clinical periodontal research. In these studies, each periodontal site is assessed in duplicate, enabling point and interval estimation of agreement measures. We show how these data can be used additionally to discover subgroups among the periodontal sites according to degree of agreement with true periodontal status and to identify factors associated with examiner bias.
A Bayesian hierarchical model is developed that, for all examiners, links the examiner’s recorded measurement with the site’s true periodontal status, allowing for site-specific examiner effects on the recorded measurement. These site-specific examiner effects are modeled as arising from a Dirichlet process mixture, which yields a small number (relative to the number of sites) of distinct effects for each examiner. Hence sites that share the same examiner effect form a subgroup for which that examiner exhibits consistent bias relative to truth. We fit this model to data from a pilot calibration study for probed pocket depth measurements and use the results to explore examiner-specific groupings of sites according to degree of agreement with true pocket depth. The discovered group assignments were then associated with characteristics of the site.
The Bayesian hierarchical modeling revealed that periodontal sites were grouped according to bias into three, two and two subgroups, respectively, for each of the three study examiners. The magnitude of the bias was associated with tooth position and true depth of the pocket.
Our Bayesian hierarchical model enhances the utility of data obtained from calibration studies for periodontal pocket depth by facilitating discovery of subgroups of sites according to examiner bias. The results indicate that targeting specific tooth locations and pocket depths during examiner training, uniquely for each examiner, may reduce bias in periodontal pocket depth measurements, thereby enhancing the quality of oral epidemiologic research.
This study examined the relationship between children’s perception of their OHRQOL and their perceptions of their dentofacial image, social anxiety, and self-concept as an assessment of the concurrent validity for the Child Oral Health Impact Profile (COHIP).
A nonrandom, consecutive sample of children, ages nine to 14 years, was recruited for this observational validation study. Participants had been accepted for treatment in the University of North Carolina Graduate Orthodontic clinic. Data were collected after gathering initial orthodontic records and prior to delivery of any fixed or removable orthodontic appliances. Participants completed the COHIP and standardized dimension-specific questionnaires with known psychometric properties designed to assess self-concept, social anxiety, and perception of facial image. Child assent with caregiver consent was obtained prior to data collection. Pearson’s correlations between each of the domains of the COHIP and the Dento-facial Image, the Social Anxiety Scale, and the self-concept domains of the Multidimensional Self Concept Scale (MSCS) were calculated. Criteria for support of concurrent validity was established based on directionality of expected relationships and strength of the observed correlation coefficient. Each correlation was assessed as meeting or not meeting the criteria. A one-tailed one sample Z-test was used to test the null hypothesis that 58% of the calculated correlations would meet the criteria (expected a priori) with an alterative that less than 58% would meet the criteria.
The average age of the 52 subjects enrolled was 11.8; 40% were male; and 85% were Caucasian. The hypothesis that 58% of the calculated correlations defined a priori as expected relationships would meet the criteria was supported by the data (P = 0.63). The perception of dentofacial appearance was positively correlated (range = 0.39 to 0.45; with all of the COHIP domains except for the School domain. Overall, the COHIP domains, particularly Self-Image and Social Emotional subscales, were positively correlated (0.32–0.52) with the MSCS self-concept domain scores, except Family Self-Concept. The COHIP domains, particularly Functional Well-being and Social Emotional subscales, were negatively correlated (−0.76 to −0.33) with the three Social Anxiety subscales that include both fear of negative evaluation and social avoidance.
The findings in this study lend support to the validity of the COHIP since 77% of the expected relationships between the domains of the COHIP and the domains of general, standardized dimension-specific instruments were observed. The decision to use condition-specific, dimension-specific, or general quality of life (QOL) measures is dependent on the purpose of the study. For investigations in children on the effect of dental treatments or in epidemiologic studies of an oral health outcome, the use of condition-specific QOL measures like the COHIP have the advantages of increased patient responsiveness since the assessment is focused on a specific condition, oral health, and increased sensitivity to treatment effects.
child oral health impact profile; facial image; Oral health-related quality of life; self-concept; social anxiety
Few studies have examined dentists' subjective ratings of importance of caries risk factors or tested whether dentists use this information in treatment planning. This study tested several hypotheses related to caries risk assessment and individualized caries prevention.
Data were collected as part of a questionnaire entitled “Assessment of Caries Diagnosis and Caries Treatment”, completed by 547 practitioners who belong to The Dental Practice-Based Research Network (DPBRN), a consortium of participating practices and dental organizations.
Sixty-nine percent of DPBRN dentists perform caries risk assessment on their patients. Recently-graduated dentists, dentists with busier practices, and those who believe a dentist can predict future caries were the most likely to use caries risk assessment. The association between caries risk assessment and individualized prevention was weaker than expected (r=.21). Dentists who perform caries risk assessment provide individualized caries prevention to 57% of their patients, compared to 42% for dentists who do not perform caries risk assessment. Based on their responses to radiographic and clinical scenarios in the questionnaire, dentists who use caries risk assessment appear to use this information in restorative decisions.
A substantial percentage of DPBRN dentists do not perform caries risk assessment, and there is not a strong linkage between its use and use of individualized preventive regimens for adult patients. More progress in implementation of current scientific evidence in this area is warranted.
This work proposes a revision of the 30 item Rapid Estimate of Adult Literacy in Dentistry (REALD-30), into a more efficient and easier-to-use two-stage scale. Using a sample of 1,405 individuals (primarily women) enrolled in a Special Supplemental Nutrition Program for Women, Infants, and Children (WIC), the present work utilizes principles of item response theory and multi-stage testing to revise the REALD-30 into a two-stage test of oral health literacy, named Two-Stage REALD or TS-REALD, which maximizes score precision at various levels of participant ability. Based on the participant’s score on the 5-item first-stage (i.e., routing test), one of three potential stage-two tests is administered: a 4-item Low Literacy test, a 6-item Average Literacy test, or a 3-item High Literacy test. The reliability of scores for the TS-REALD is greater than .85 for a wide range of ability. The TS-REALD was found to be predictive of perceived impact of oral conditions on well-being, after controlling for educational level, overall health, dental health, and a general health literacy measure. While containing approximately one-third of the items on the original scale, the TS-REALD was found to maintain similar psychometric qualities.
Dental Health Literacy; Dental Care; Oral Health Quality of Life; Health Literacy; Psychometrics
This pragmatic randomized trial evaluated the effectiveness of a tailored educational intervention on oral health behaviors and new untreated carious lesions in low-income African-American children in Detroit, Michigan.
Participating families were recruited in a longitudinal study of the determinants of dental caries in 1,021 randomly selected children (0–5 years) and their caregivers. The families were examined at baseline in 2002–04 (Wave I), 2004–05 (Wave II) and 2007 (Wave III). Prior to Wave II, the families were randomized into two educational groups. An interviewer trained in applying motivational interviewing principles (MI) reviewed the dental exam findings with caregivers assigned to the intervention group (MI+DVD) and engaged the caregiver in a dialogue on the importance of and potential actions for improving the child’s oral health. The interviewer and caregiver watched a special 15-minute DVD developed specifically for this project based on data collected at Wave I and focused on how the caregivers can “keep their children free from tooth decay”. After the MI session the caregivers developed their own preventive goals. Some families in this group chose not to develop goals and were offered the project-developed goals. The goals, if defined, were printed on glossy paper that included the child’s photograph. Families in the second group (DVD-only) were met by an interviewer, shown the DVD, and provided with the project’s recommended goals. Both groups of families received a copy of the DVD. Families in the MI+DVD group received booster calls within 6 months of the intervention. Both caregivers and the children were interviewed and examined after approximately 2 years (Wave III: 2007).
After 6-month of follow-up, caregivers receiving MI+DVD were more likely to report checking the child for “pre-cavities” and making sure the child brushes at bedtime. Evaluation of the final outcomes approximately 2 years later found that caregivers receiving the MI+DVD were still more likely to report making sure the child brushed at bedtime, yet were no more likely to make sure the child brushed twice per day. Despite differences in one of the reported behaviors, children whose caregivers received the motivational intervention did not have fewer new untreated lesions at the final evaluation.
This study found that a single motivational interviewing intervention may change some reported oral health behaviors, it failed to reduce the number of new untreated carious lesions.
Motivational Interviewing; Early Childhood Caries
The article reviews proportional and partial proportional odds regression for ordered categorical outcomes, such as patient-reported measures, that are frequently used in clinical research in dentistry.
The proportional odds regression model for ordinal data is a generalization of ordinary logistic regression for dichotomous responses. When the proportional odds assumption holds for some but not all of the covariates, the lesser known partial proportional odds model is shown to provide a useful extension.
The ordinal data models are illustrated for the analysis of repeated ordinal outcomes to determine whether the burden associated with sensory alteration following a bilateral sagittal split osteotomy procedure differed for those patients who were given opening exercises only following surgery and those who received sensory retraining exercises in conjunction with standard opening exercises.
Proportional and partial proportional odds models are broadly applicable to the analysis of cross-sectional and longitudinal ordinal data in dental research.
altered sensation; bilateral sagittal split; longitudinal ordinal data; orthognathic surgery; sensory retraining
Associations between dental conditions and overall health have been previously reported. Investigators have also shown significant inverse relationships between serum albumin (a general health status marker) and root caries. This relationship was explored among a study population of Gullah African Americans (who have a considerably lower level of non-African genetic admixture when compared to other African American populations) with type-2 diabetes (T2DM) and self-reported history of normal kidney function (N = 280).
Root caries indices were defined as total decayed and/or filled root surfaces. The coronal caries index [total decayed, missing, and/or filled coronal surfaces (DMFS)], level of glycemic control, total number of teeth, and other covariates were also evaluated. Logistic regression models were used to evaluate the associations between these factors and hypoalbuminemia (serum albumin concentrations <4 g/dl).
Serum albumin concentrations ranged 2.4–4.5 g/dl (mean = 3.8, SD = 0.3), with 70.4% exhibiting hypoalbuminemia. Root caries totals ranged 0–38 (mean = 1.3, SD = 4.5) surfaces decayed/filled, while total teeth ranged 1–28 (mean = 19.4, SD = 6.2). DMFS totals ranged 2–116 (mean = 55.2, SD = 28.0). We failed to detect significant associations for root caries; however, the final multivariable logistic regression models showed significant associations between hypoalbuminemia and total teeth [odds ratio (OR) = 0.93, P = 0.01], poor glycemic control (OR = 2.49, P < 0.01), elevated C-reactive protein (OR = 1.57, P < 0.01), glomerular filtration rates ≥60 (OR = 0.31, P = 0.03), and age (OR = 0.97, P = 0.03).
Previously reported inverse relationships between serum albumin and root caries were not evident in our study population. We propose that these null findings are because of the considerably lower level of root caries as well as other differing characteristics (including oral health status, the chronic presence of T2DM, and predominantly younger age) within our study population compared to these previously assessed groups.
diabetes; Gullah African Americans; root caries; serum albumin
The aim of this paper is to evaluate a new comprehensive scoring system for longitudinal studies using the International Caries Detection and Assessment System (ICDAS).
A sample of 638 children was examined in 2002–03 and again in 2007. Caries was assessed using the ICDAS criteria which assess six clinical stages of dental caries. Based on a transition matrix matching the baseline and follow-up ICDAS scores, we developed transition weights to best describe the progression, regression, or no progression nor regression of dental caries. Differential weights were assigned to transitions involved with non-cavitated, cavitated, filled, crowned, or missing lesions. This method (Transitional Scoring System (TSS)) differentiated biologically plausible reversals from those due to examiner’s misclassification. We computed and compared mean dmfs (decayed, missing, and filled tooth surfaces) increment scores including (dtmfs) or excluding the non-cavitated stage (dcmfs) from TSS and another adjustment method proposed by Beck (modified Beck’s method). The coefficients of variations (CV) of the two methods were also compared.
Mean dtmfs from TSS was slightly higher than that from modified Beck’s method. There was no difference in mean dcmfs between two methods. The ratios of CV indicated that the CV of TSS was significantly smaller than those from modified Beck’s method.
There were differences in caries increment scores between the two methods when we accounted for the transition of non-cavitated lesions. The evaluation of CV concluded that TSS was more efficient because it requires less sample size compared with the modified Beck’s method to detect a treatment effect. Both methods can be used to compute caries increments for populations with similar distribution of the dmfs scores to the sample used in this study.
This cross-sectional study assessed the use of caries preventive services by Northwest PRECEDENT dental network practitioners and compared the caries experience of patients who received such services in the past 12 months with those who had not.
An oral health survey was conducted on approximately 20 patients seen by each of 97 private practice dental practitioners in the network. Eligible patients (total of 1877 aged 3–92) were randomly assessed for the occurrence of one or more new caries lesions as well as having received the following preventive services within the past 12 months: fluoride varnish or gel, sealant in molar or premolar, and prophylaxis. Patients were stratified by gender and age (1–17 years old, 18–64 years old, and 65+ years old). Logistic regression was used to investigate the association between the practitioner characteristics and the use of preventive services, as well as the preventive services and the presence of a new caries lesion in the past 12 months.
The percent of patients in age category 1–17 years old / 18–64 years old / 65+ years old receiving each preventive treatment varied as follows: 95%/85%/81% for prophylaxis, 87%/24%/22% for fluoride, and 27%/2%/0% for sealant. There was a very limited association between the use of a specific preventive service and practitioner gender, and no significant association between use of services and practice location (rural, urban or suburban). There was a significant association between greater use of sealants for dentists with 0–15 years of practice experience as compared with those having more than 25 years of experience. For the 1–17 year old age group, males had about 1.7 times the odds of having a new lesion than females in the past 12 months, and patients receiving a sealant had 1.9 times the odds of having a new caries lesion. In the 18–64 year old group, receiving a prophylaxis in the past 12 months was significantly associated with lower odds for having a new lesion (odds ratio = 0.57).
This study reports that aside from prophylaxis, which more than 85% of the patients had received, about one-third of the patients overall received preventive services consisting of either sealants or some type of fluoride treatment in private dental practices in the Northwest PRECEDENT network.
While risk factors for tooth loss in adults have been identified, limited studies describing factors associated with incident tooth loss in postmenopausal women exist. This study assessed both clinical and non-clinical risk factors for incident tooth loss.
Postmenopausal women (N= 1,341) were recruited between 1997–2000 from 1847 eligible Observational Study participants of the Buffalo, NY center of the Women’s Health Initiative who had complete dental examinations to assess alveolar bone height, soft tissue attachment and general oral health, and completed questionnaires concerning demographics, general health, lifestyle and oral health (72.6% participation rate). Five years later (2002–2005), 1021 women (76.1%) repeated these examinations and questionnaires. Incident tooth loss was determined by oral examination
After an average 5.1 years of follow-up (SD, 0.38), a total of 323 teeth were lost in 293 women, resulting in 28.7% of women with incident loss of at least one tooth. In multivariable models, diabetes history, gum disease history, smoking, previous tooth loss, BMI and plaque index, baseline clinical measures including alveolar crestal height (ACH) (OR=1.22 per mm loss, 95% CI 1.11, 1.35), clinical attachment loss (CAL) (OR=1.13 per mm loss, 95% CI 1.05, 1.23) and pocket depth (PD) (OR=1.26 per mm loss, 95% CI 1.13, 1.41) were significant risk factors of incident tooth loss. In a community model that included no clinical measures, diabetes history (OR=2.45, 95% CI 1.26, 4.77), prior gum disease (OR=1.97, 95% CI 1.43, 2.70), ever smoking (OR=1.42, 95% CI 1,06, 1.89), number of teeth lost at baseline (OR=1.05 per tooth, 95% CI 1.02, 1.08) and BMI (OR=1.15 per 5 km/m2 increase, 95% CI 1.01, 1.33) were associated with an increased risk of incident tooth loss.
Clinical and questionnaire based models were found to provide similar risk estimates for incident tooth loss in postmenopausal women. These models identified high risk postmenopausal women where preventive strategies may be targeted.
Life course research considers not only the influences on health which act during the lifespan but it is also concerned with factors that act across generations. Rarely are genetics or environment solely responsible for producing individual variation; virtually all characteristics are the result of gene–environment interaction. An increasing interest in life course research and gene–environment interactions is reflected in greater awareness of the role of family history and intergenerational continuity in oral health as a practical, inexpensive approach to categorizing genetic risk for many common, preventable disorders of adulthood (including oral disease). Does the health status of one generation have an effect on that of the next? While researchers in recent years have begun to investigate the inter-generational associations between exposures and disease, little research has been carried out (to date) on the long-term biological, behavioural, psychological, social and environmental mechanisms that link oral health and oral disease risk to exposures acting across generations. This narrative review identifies studies which have contributed to highlighting some of the intergenerational factors influencing oral health. However, there is a need for a wider perspective on intergenerational continuity in oral health, along with a careful evaluation of the factors which contribute to the effect. A comprehensive investigation into the nature and extent of intergenerational transmission of oral health is required.
gene-environment interaction; intergenerational; life course; oral health
Self-report of oral health is an inexpensive approach to assessing an individual’s oral health status, but it is heavily influenced by personal views and usually differs from that of clinically determined oral health status. To assist researchers and clinicians in estimating oral health self-report, we summarize clinically determined oral health measures that can objectively measure oral health and evaluate the discrepancies between self-reported and clinically determined oral health status. We test hypotheses of trends across covariates, thereby creating optimal calibration models and tools that can adjust self-reported oral health to clinically determined standards.
Using National Health and Nutrition Examination Survey (NHANES) data, we examined the discrepancy between self-reported and clinically determined oral health. We evaluated the relationship between the degree of this discrepancy and possible factors contributing to this discrepancy, such as patient characteristics and general health condition. We used a regression approach to develop calibration models for self-reported oral health.
The relationship between self-reported and clinically determined oral health is complex. Generally, there is a discrepancy between the two that can best be calibrated by a model that includes general health condition, number of times a person has received health care, gender, age, education, and income.
The model we developed can be used to calibrate and adjust self-reported oral health status to that of clinically determined standards and for oral health screening of large populations in federal, state, and local programs, enabling great savings in resources used in dental care.
Oral health; calibration; nomogram; cross validation; bootstrap
To investigate whether the relationship between dental anxiety and referral for treatment under sedation is explained by attendance patterns and oral health.
Structural Equation Modeling was used on the covariance matrix of the covariates to test hypothesized inter-relationships. Subsequently, we modeled the probability of referral for treatment under sedation with a multiple logistic regression taking into account inter-relationships between the independent variables.
A direct significant association of referral with dental anxiety and attendance patterns was detected but not with oral health status. However, oral health and anxiety were highly correlated. Also signaled were correlations between age and education and between gender and bad past experience.
Referral for treatment under sedation appears to be motivated by both fear and irregular patterns of attendance. Coupled with behavioral treatments to address dental fear and attendance, sedation can part of comprehensive care where curative treatments are long or unpleasant for patients.
dental anxiety; structural equation modeling; logistic regression; utilization; sedation
To identify risk indicators that are associated with root caries incidence in published predictive risk models.
Abstracts (n=472) identified from a MEDLINE, EMBASE, and Cochrane registry search were screened independently by two investigators to exclude articles not in English (n=39), published prior to 1970 (none), or containing no information on either root caries incidence, risk indicators, or risk models (n=209). A full-article duplicate review of the remaining articles (n=224) selected those reporting predictive risk models based on original/primary longitudinal root caries incidence studies. The quality of the included articles was assessed based both on selected criteria of methodological standards for observational studies and on the statistical quality of the modeling strategy. Data from these included studies were extracted and compiled into evidence tables, which included information about the cohort location, incidence period, sample size, age of the study participants, risk indicators included in the model, root caries incidence, modeling strategy, significant risk indicators/predictors, and parameter estimates and statistical findings.
Thirteen articles were selected for data extraction. The overall quality of the included articles was poor to moderate. Root caries incidence ranged fro m 12%–77% (mean±SD=45%±17%); follow-up time of the published studies was ≤10 years (range=9; median=3); sample size ranged from 23–723 (mean±SD=264±203; median=261); person-years ranged from 23–1540 (mean±SD=760±556; median=746). Variables most frequently tested and significantly associated with root caries incidence were (times tested; % significant; directionality): baseline root caries (12; 58%; positive); number of teeth (7; 71%; 3 times positive, twice negative), and plaque index (4; 100%; positive). Ninety-two other clinical and non-clinical variables were tested: 27 were tested 3 times or more and were significant between 9% and 100% of the times tested; and 65 were tested but never significant.
The root caries incidence indicators/predictors most frequently reported were root caries prevalence at baseline, number of teeth, and plaque index. This finding can guide targeted root caries prevention. There was substantial variation among published models of root caries risk in terms of variable selection, sample size, cohort location, assessment methods, incidence periods, association directionality, and analytical techniques. Future studies should emphasize variables frequently tested and often significant, and validate existing models in independent databases.
To estimate the prevalence of tooth wear and to investigate factors associated with tooth wear in patients from general practices in the Northwest United States.
Data on the diagnosis and treatment of oral diseases during the previous year were collected in a survey with a systematic random sample of patients (n = 1530) visiting general dentists from the Northwest Practice-based REsearch Collaborative in Evidence-based DENTistry (PRECEDENT) (n = 80). Prevalence ratios (PRs) of moderate to severe occlusal and incisal tooth wear by patient characteristics were estimated using cluster-adjusted multiple binomial regression for adults (18+ years) and children/adolescents (3–17 years).
For adults, the mean number of teeth with wear facets was 5.4 [95% confidence interval (CI) = 4.6–6.2] and 51% of the adults had four or more teeth with wear. Participants 45–64 and 65+ years old were 1.3 (95% CI = 1.1–1.6) and 1.4 (95% CI = 1.1–1.8) times as likely to have 4+ teeth with moderate to severe wear facets as participants 18–44 years old. Adult males had a 20% (PR = 1.2; 95% CI = 1.1–1.4) higher prevalence of wear than adult females. Adults who were using, or had ever used occlusal splints had higher prevalence of tooth wear compared to those who never used such appliances (PR = 1.3; 95% CI = 1.0–1.5). Adults with any periodontal bone loss also had a 20% higher prevalence of wear than adults without periodontal disease (PR = 1.2; 95% CI = 1.0–1.4). For children/adolescents, the mean number of teeth with moderate to severe wear facets was 1.6 (95% CI = 0.9–2.6) and 31% of the children had one or more teeth with wear facets. The adjusted prevalence ratio of tooth wear (1+ teeth with wear facets) for boys was 1.6 times as high (95% CI = 1.1–2.4) as compared with girls. The prevalence of wear for children 12+ years old was 50% (PR = 0.5; 95% CI = 0.3–0.8) lower than that of children <12 years old. Angle’s class II was associated with higher tooth wear prevalence (PR = 1.8; 95% CI = 1.3–2.6) than class I. Children with posterior or anterior open bite had lower prevalence of wear than their counterparts (PR = 0.6; 95% CI = 0.3–1.0). No associations were observed between tooth wear and orthodontic treatment, missing teeth, and race/ethnicity.
Tooth wear is a prevalent condition in this population. Among adults, higher prevalences of tooth wear were observed among those who were older, males, had used occlusal splints and had periodontal disease. Among children, higher prevalences were associated with younger age, male gender, class II malocclusion and the absence of open bite. Submitted on behalf of the Northwest PRECEDENT network, with support from NIDCR grants DE016750 and DE016752.
dental practice-based research; malocclusion; Northwest PRECEDENT; tooth attrition
To identify factors that are significantly associated with dentists’ use of specific caries preventive agents in adult patients, and whether dentists who use one preventive agent are also more likely to use certain others.
Data were collected from 564 practitioners in The Dental Practice-Based Research Network, a multi-region consortium of participating practices and dental organizations.
In-office topical fluoride was the method most frequently used. Regarding at-home preventive agents, there was little difference in preference between non-prescription fluoride, prescription fluoride, or chlorhexidine rinse. Dentists who most frequently used caries prevention were also those who regularly perform caries risk assessment and individualize caries prevention at the patient level. Higher percentages of patients with dental insurance were significantly associated with more use of in-office prevention modalities. Female dentists and dentists with more-recent training were more likely to recommend preventive agents that are applied by the patient. Dentists who reported more-conservative decisions in clinical treatment scenarios were also more likely to use caries preventive agents. Groups of dentist who shared a common preference for certain preventive agents were identified. One group used preventive agents selectively, whereas the other groups predominately used either in-office or at-home fluorides.
Caries prevention is commonly used with adult patients. However, these results suggest that only a subset of dentists base preventive treatments on caries risk at the individual patient level.
To empirically test a multilevel conceptual model of children’s oral health incorporating 22 domains of children’s oral health across four levels: child, family, neighborhood and state.
The 2003 National Survey of Children’s Health, a module of the State and Local Area Integrated Telephone Survey conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics, is a nationally representative telephone survey of caregivers of children.
We examined child-, family-, neighborhood-, and state-level factors influencing parent’s report of children’s oral health using a multilevel logistic regression model, estimated for 26 736 children ages 1–5 years.
Factors operating at all four levels were associated with the likelihood that parents rated their children’s oral health as fair or poor, although most significant correlates are represented at the child or family level. Of 22 domains identified in our conceptual model, 15 domains contained factors significantly associated with young children’s oral health. At the state level, access to fluoridated water was significantly associated with favorable oral health for children.
Our results suggest that efforts to understand or improve children’s oral health should consider a multilevel approach that goes beyond solely child-level factors.
children’s oral health; multilevel modeling; multiple imputation
This study aimed to estimate the prevalence of orthodontic treatment in France among children and teenagers aged 8 to 18 years, by sex and by age, and to investigate the specific role of social and economic characteristics on use of orthodontic treatment.
We analysed data from the cross-sectional national health survey conducted in France in 2002–2003, which included a sample of 5988 children aged 8 to 18 years. All data were collected by interview including the question on orthodontic treatment. Other data used in our study were family social status and income, maternal educational attainment and place of birth, whether the child was covered by a supplementary health insurance and whether the residence was urban or rural. We also calculated the density of orthodontists in the district. Multivariate logistic regression analyses were used to study the relationships between these social and economic factors and orthodontic treatment.
The prevalence of orthodontic treatment was 14% of all children aged 8 to 18, 15% for girls, and 13% for boys, and 23% in the 12 to 15-year age group. Children were less likely to have orthodontic treatment when parents were service or sales workers compared with children whose parents were managers or professionals (aOR=0.50; 95%CI: [0.34;0.76]), when family income was in the lowest, compared with highest quartile (aOR=0,62; 95%CI: [0.45;0.85]), when children had no supplementary insurance compared with children covered by private insurance (aOR=0.53; 95%CI: [0.34;0.81]), or when they lived in rural compared with urban areas (aOR=0.70; 95%CI: [0.54;0.91]).
There are social inequalities in orthodontic treatment in France, associated mainly with social status, annual income, supplementary insurance, and the residence area.
Adolescent; Age Distribution; Child; Child, Preschool; Cross-Sectional Studies; Educational Status; Female; France; Health Status Disparities; Healthcare Disparities; Humans; Income; Insurance, Dental; Interviews as Topic; Logistic Models; Male; Multivariate Analysis; Orthodontics, Corrective; economics; statistics & numerical data; Questionnaires; Rural Population; Sex Distribution; Social Class; Urban Population
The CONSORT statement recommended that investigators should clearly report which key trial persons were blinded to treatment allocation and test for the success of blinding. Clinical researchers, however, more often than not overlook the assessment of the success of blinding. The severe under-reporting on the success of blinding may improve with awareness of existing quantitative methods. The two statistical methods, James' blinding index (BI) and Bang's BI, are currently available. Subjects could be asked to guess their treatment assignment, possibly with an option to express the degree of certainty. Assessments of blinding at various points may serve different purposes, i.e. to evaluate comparability between experimental versus control treatments before the trial by the third party; to examine further comparability and credibility of the control treatment and patients' expectation about treatment received in early stage of the trial, and to summarize the overall maintenance of the blinding success at the end of the trial. In this article, we review BIs and how to use these methods along with discussion of other issues in blinding assessment and reporting. We contend the two BIs that were independently developed but carry complementary properties would characterize blinding behaviours in clinical trials qualitatively as well as quantitatively, and may also shed some lights on the interpretation of the study findings. Finally we urge the Item 11b of the CONSORT statement to be revised to require the assessment/reporting of blinding success for all trials that adopt blinding schemes.
blinding index; methods; randomized controlled trials; standards