Twenty-four month incidence of root caries among a diverse group of adults.

OBJECTIVES: (1) Describe for a diverse sample the 24-month incidence of root caries, and (2) test its association with a broad range of clinical, behavioral, financial, and sociodemographic factors. METHODS: The Florida Dental Care Study was a cohort study of randomly selected subjects who had at least 1 tooth and were 45 years or older at baseline. In-person interviews and clinical examinations were conducted at baseline and 24 months, with 6-monthly telephone interviews between those times; 723 subjects participated for both examinations. A multinomial logistic regression was done to predict whether the subject was in one of four mutually exclusive groups [new root decay only (NDO); new root filling(s) only (NFO); both new decay and new filling(s) (BOTH), or had neither (NONE)]. RESULTS: Thirty-six percent of subjects had at least 1 new root decayed and/or filled surface (DFS); 17% were in the NDO group, 14% in the NFO group, and 5% in the BOTH group. When limited to participants who had a nonzero increment, the mean (SD) DFS was 2.7 (2.9). Baseline clinical condition (presence of root decay, root filling(s), coronal decay, noncarious root defects, number of teeth present, percent of teeth with at least 4 mm of attachment loss) was predictive of moving from the NONE group into the NDO, NFO, or BOTH groups. The addition of behavioral, financial, and sociodemographic factors improved model fit. For example, regular dental attenders were significantly more likely to move from the NONE group into the NFO group, but regular attendance was not associated with a lower probability of moving from the NONE group into the NDO or BOTH groups. CONCLUSIONS: Root caries is a substantive dental health problem in this diverse sample of adults. These analyses demonstrate the utility of disaggregating caries incidence into four mutually exclusive groups for predictive models.

Risk indicators of edentulism, partial tooth loss and prosthetic status among black and white middle-aged and older adults.

OBJECTIVES: To describe the prevalence and risk indicators of edentulism; to describe the frequencies of wearing removable dentures; to describe the prevalence and risk indicators of fixed prosthetic restorations; to test the hypothesis that fixed prosthetic restorations are most likely to have been placed in persons at lower risk for dental and periodontal diseases, and to test the hypothesis that, with dental disease, dental behaviors, dental attitudes and ability to afford crowns taken into account, blacks are less likely than whites to have received crowns. METHODS: The Florida Dental Care Study is a cohort study of subjects 45 years old or older. A telephone screening interview was done as a first stage to identify 5254 subjects who met eligibility requirements and who self-reported whether they were edentulous. In a second stage, a subsample of dentate subjects was contacted after they completed their telephone screening interview. Of these, 873 subjects completed a baseline in-person interview and dental examination. RESULTS: A total of 19% of first-stage subjects were edentulous. In a single multiple logistic regression, having a poorer self-rated level of general health was significantly associated with edentulism, as were being poor, older and white. Among the second-stage participants (all of whom were dentate), several prosthetic patterns were observed. For example, a total of 64% of maxillary full denture wearers reported wearing their denture all the time. Participants had also received numerous fixed prosthodontic services. The proportion of subjects with at least one crown varied widely by subject characteristics. CONCLUSIONS: A substantial percentage of non-ideal frequencies of wearing removable prostheses was reported, as were prosthesis-related soreness and broken prostheses. Although we expected and observed an association between having a fixed prosthetic crown and periodontal status, dental fillings, dental attitudes and financial resources, a residual association with race suggests that blacks are much less likely to receive prosthetic crowns. The several possible reasons for this circumstance warrant further investigation.

Delphi study to identify core competencies in geriatric dentistry.

The Delphi technique and an expert panel of general practitioners were used to identify geriatric dentistry core competencies--the necessary knowledge, skills, and values of new graduates to meet the oral health needs of older patients. Of the 74 dentists solicited, 50 dentists agreed to participate, and 40 dentists returned two questionnaires. Respondents were mostly male, white, in solo practice, with a mean age of 51.6 (SD 7.4) years. The first survey asked the participants to identify at least three topics in geriatric dentistry that they believed to be essential to a dental curriculum to graduate competent practitioners who can effectively treat older patients. The 45 unique responses were used in the second questionnaire that asked the practitioners to rate the importance of each topic for inclusion in a curriculum. For the 29 items describing skills, respondents indicated how often they performed the skill in their practices. Finally, the respondents considered all 45 items, and selected the five most crucial topics. Overall, participants achieved good consensus as to core knowledge, skills, and values needed to provide general dental care to older patients.

Restoration fractures, cusp fractures and root fragments in a diverse sample of adults: 24-month incidence.

BACKGROUND: There are few reports in the literature regarding estimates of the occurrence of tooth fractures. Most studies have assessed tooth fractures in people seeking dental care, which may underestimate the incidence of the problem. METHODS: This study sought to estimate the incidence and prevalence of cusp and restoration fractures, as well as root fragments in participants in the Florida Dental Care Study, a diverse representative sample of community-dwelling residents of four north Florida counties made up of people who seek dental care regularly and those who do not. Participants received a dental examination and an in person interview at baseline and at a 24-month follow-up session. RESULTS: At least 20 percent of the participants were diagnosed as having bulk restoration fractures, cusp fractures or root fragments at the baseline visit. At the 24-month follow-up session, 26 percent of the participants had at least one new occurrence of these problems. Of those subjects presenting with tooth fracture, 25 percent had multiple teeth affected. African-Americans and people who sought care on a problem-oriented basis experienced twice the rate of cusp fracture and a higher rate of root fragments as did those who sought care on a regular basis. These data represent consecutive prevalence estimates rather than the true incidence, in that fractures that occurred after baseline may have been treated in the intervening 24 months. Thus, these data represent "lower-bound" incidence estimates. CONCLUSIONS: These results suggest that restoration fractures, cusp fractures and root fragments are a significant dental health problem, and that selected segments of the population are at greater risk of developing these problems. CLINICAL IMPLICATIONS: These data are useful for dentists in understanding the magnitude of the problem and the potential progression of fractures and root fragments.

Twenty-four month coronal caries incidence: the role of dental care and race.

OBJECTIVES: To describe for a diverse sample of dentate middle-aged and older adults: (1) the 24-month incidence of coronal caries, and (2) its association with a broad range of clinical, behavioral, financial, attitudinal, and sociodemographic factors. METHODS: The Florida Dental Care Study is a prospective observational longitudinal cohort study of 873 persons who at baseline had at least 1 tooth and were 45 years or older. In-person interviews and clinical examinations were conducted at baseline and 24 months, with 6-monthly telephone interviews between those times. A multinomial logistic regression was done to predict whether a participant was in one of four mutually exclusive groups at the 24-month examination (new decay only [NDO]; new filling(s) only [NFO]; both new decay and filling(s) [BOTH]; or neither [NONE]). RESULTS: Only 33% of the 24-month participants were in the NONE group. There was no significant difference in caries incidence between regular attenders and problem-oriented attenders, regardless of whether teeth crowned at baseline, incident crowns, or incident root fragments were excluded. However, once differences in incident tooth loss and baseline clinical, behavioral, financial, and attitudinal differences were taken into account, regular attenders did appear to benefit by developing fewer coronal lesions and fewer dental symptoms than problem-oriented attenders. Baseline carious surfaces, filled surfaces, number of teeth, and bulk restoration fractures predicted caries incidence, but baseline cusp fractures did not. Persons with negative dental attitudes were more likely to be in the NDO and BOTH groups, and negative attitude toward brushing and flossing (but not their frequency) also predicted caries incidence. CONCLUSION: Certain baseline clinical conditions, approach to dental care, ability to pay for dental care, dental attitudes, race, and age group were predictive of coronal caries incidence, and regular attenders appeared to benefit from regular attendance.

Cultivating critical thinking in the clinical learning environment.

The dental education knowledge base suggests a lack of understanding and research about how to teach critical thinking skills in the clinical learning environment. The acquisition of critical thinking skills is essential to the development of future practitioners, yet difficult to measure quantitatively. This study used qualitative research methods to assess the frequency and nature of teaching critical thinking skills in the University of Florida College of Dentistry predoctoral student clinics. Thirteen faculty and forty-four students in six clinics (oral diagnosis/treatment planning, endodontics, periodontology, operative dentistry, prosthodontics, and emergency care/oral surgery) were observed by an independent evaluator. Critical thinking skills were infrequently taught, and teacher-dominated instruction predominated. The findings underscore the need for thoughtful curriculum planning prior to predoctoral clinical instruction and periodic appraisal of clinical instruction. Suggestions for improving critical thinking in the clinical learning environment are presented.

Tooth-specific and person-level predictors of 24-month tooth loss among older adults.

OBJECTIVES: To describe: (1) the 24-month incidence of tooth loss in a diverse sample of dentate adults; and (2) the clinical, attitudinal, behavioral, and sociodemographic correlates of tooth loss incidence. METHODS: The Florida Dental Care Study is a prospective longitudinal cohort study of persons who at baseline had at least one tooth, were 45 years or older, and who resided in north Florida. An in-person interview and clinical examination were conducted at baseline and 24-months after baseline, with 6-monthly telephone interviews between those times. A two-level hierarchical generalized linear regression (logit model) was used to quantify tooth-specific and person-level factors simultaneously. RESULTS: Of the 739 persons who attended for a 24-month examination, 24% lost one or more teeth during follow-up. Tooth loss was more common in persons with dental disease at baseline, incident dental signs or symptoms, those with negative attitudes toward dental care and dental health, those with limited financial resources, older adults, blacks, females, and problem-oriented users of dental care (as distinct from regular attenders). Although disease presence at baseline was a major factor associated with incident tooth loss, most diseased teeth were in fact still present 24 months after baseline. CONCLUSIONS: Other than periodontal attachment loss, severe tooth mobility, and dental caries, no single factor was a dominant predictor of tooth loss; instead, numerous factors made statistically significant but small contributions to variation in tooth loss. Tooth loss apparently is the result of complex interactions among dental disease, incident dental signs and symptoms, tendency to use dental care in response to specific dental problems, dental attitudes, and ability to afford non-extraction treatment alternatives.

An association between dentate status and hearing acuity.

Hearing improvement following dental treatment has been reported in case studies, yet few objective studies of this phenomenon have been conducted. To determine if a relationship exists between dentate status and hearing acuity, we conducted a retrospective study of elderly subjects enrolled in a health promotion clinical trial. Air-conduction pure tone average thresholds (PTA) administered to left and right ears at 500 Hz, 1000 Hz, 2000 Hz, 3000 Hz, 4000 Hz, and 6000 Hz were used to create six hearing outcome variables, and were compared between groups of subjects who either had 25 or more teeth (n = 182) or were edentulous (n = 43). Mean PTA thresholds were significantly greater (p < 0.05) in edentulous subjects for each hearing outcome variable, and differences between unadjusted group means ranged from 4.9 dB to 8.6 dB. Mean PTA thresholds adjusted for clinical factors known to affect hearing also indicated worse hearing acuity in the edentulous group. These pilot findings suggest an association between dentate status and hearing acuity.

Functional health and dental service use among older adults.

BACKGROUND: Although socioeconomic barriers to receiving adequate dental care have been well documented, physical frailty as a risk factor for not visiting the dentist has not been fully explored. This study prospectively examines the relationship between functional health and dental service use, taking into account sociodemographic characteristics, general and dental health status, and prior dental utilization behavior. METHODS: Data from a randomized trial of a comprehensive geriatric assessment and prevention program in community-dwelling adults age 75+ years living in Santa Monica, CA, collected between 1988 and 1993, were analyzed. A series of discrete-time proportional hazards models were used to assess the effects of functional status, sociodemographic characteristics, and general health and dental health measures on dental service use. RESULTS: Functional status was negatively associated with dental service use, and the conditional probability of a first visit to the dentist after baseline decreased over time. When additional measures of general health, dental health, and socioeconomic status were introduced, the effect of functional status was mitigated but remained significant. In the most fully specified model, which took dental visitation behavior prior to the beginning of the study into account, the effect of functional limitation remained significant. CONCLUSIONS: Even in this relatively well-educated group of older persons with higher than average dental service use, impaired functional status was associated with lower levels of dental service use over time.

Multidimensionality of oral health in dentate adults.

OBJECTIVES: An understanding of the validity and usefulness of self-reported measures (as distinct from clinically determined measures) of oral health is emerging. These self-reported measures include self-rated oral health (SROH). Three objectives were to: (1) describe self-rated oral health in dentate adults, (2) quantify associations between self-rated oral health and other measures of oral health (oral disease and tissue damage, pain and discomfort, functional limitation, and disadvantage), and (3) assess the construct validity of a model of oral health proposed herein. METHODS: The Florida Dental Care Study is a longitudinal study of oral health, which included at baseline 873 subjects who had at least one tooth, were 45 years or older, and who participated for an interview and clinical examination. RESULTS: The prevalence of self-rated oral health decrements was substantial; approximately one fourth of subjects reported their oral health as only fair or poor. Bivariate and multivariate results provided consistent evidence of the construct validity of the proposed model of oral health. Additionally, the salience of one measure of dental appearance suggests that persons may use esthetic cues when rating their oral health. CONCLUSIONS: The proposed multidimensional model of oral health has construct validity. Self-rated oral health is affected by oral disease and tissue damage, oral pain and discomfort, oral functional limitation, and oral disadvantage. These self-reported measures and the proposed model should provide useful information for dental care effectiveness research. General health status has been disaggregated into the "physical" and the "mental;" an additional separation into the "oral" aspects of health seems warranted.

Trends in predoctoral education in geriatric dentistry.

Historically, education in geriatric dentistry has been limited in both quantity and quality. More recently, a number of educational initiatives have been developed in response to the growing number of older adults and their changing oral health status and dental treatment needs. A survey of U.S. and Canadian dental schools examined curriculum trends and assessed the effectiveness of educational initiatives and the value of AADS/AoA geriatric dental curricular materials. All schools responded. Compared to previous reports, more schools had geriatric didactic course(s), clinical rotations, and faculty with geriatric dental training. Fifty-eight percent of dental schools support geriatric dentistry in their budgets. The primary barriers to program expansion continue to be the lack of trained faculty members, a crowded curriculum, and fiscal concerns.

Three-year changes in global oral health rating by elderly dentate adults.

The single item global rating is an economical way of summarizing the state of a person's oral health, and thus is a potentially valuable oral health outcome measure. This research describes the nature, magnitude, and direction of changes in oral health as measured by the global rating with the goal of furthering our understanding of older adults' oral health perceptions over time. Data from a randomized trial of a comprehensive geriatric assessment and prevention program in community-dwelling adults aged 75+ years living in Santa Monica, California, collected between 1988 and 1993 were analyzed. Descriptive techniques as well as a transition matrix were used to examine changes in the global rating and compare these changes to variation, over time, in two relevant measures: the Geriatric Oral Health Assessment Index (GOHAI) and self-reported need for dental treatment. The global rating varied over time and the changes were consistent with those measured by the GOHAI and self-reported treatment need. Whether the change in oral health as measured by the global rating is clinically meaningful, and what specific dental conditions account for these changes remain important topics for future investigation. However, the changes that occur in oral health ratings at the individual level are much more pronounced than the distribution of global rating at each point in time would suggest.

Oral disadvantage among dentate adults.

Oral disadvantage can be defined as the avoidance of certain daily activities because of decrements in oral health. These decrements include oral disease and tissue damage, pain, and functional limitation. The Florida Dental Care Study (FDCS) is a longitudinal study of changes in oral health, which included at baseline 873 subjects who had at least 1 tooth, were 45 years old or older, and who participated for an interview and clinical examination. Three objectives of the FDCS are: (1) to describe selected psychometric properties of the measurement of oral disadvantage; (2) to describe oral disadvantage in a diverse sample of dentate adults; and (3) to describe the relationship between disadvantage and other aspects of oral health, such as disease/tissue damage, pain, and functional limitation. The prevalence of oral disadvantage within the previous 6 months, using eight self-reported measures, ranged from 5% to 25%, depending upon the measure. Factor analysis suggested that oral disadvantage is best described as three factors: disadvantage due to (1) oral disease/tissue damage, (2) oral pain, and (3) oral functional limitation. Irregular dental attenders, poor persons, and blacks had the highest prevalence of oral disadvantage. Clinical measures of oral disease/tissue damage, self-reported measures of oral disease/tissue damage, oral pain, and oral functional limitation were strongly associated with the presence of oral disadvantage. In multivariate analyses that accounted for differences in clinical measures of disease/tissue damage, self-reported disease/tissue damage, oral pain, and oral functional limitation, females were more likely to report disadvantage due to disease/tissue damage, and middle-aged persons and irregular dental attenders were more likely to report oral disadvantage due to pain. In these same regressions, differences in disadvantage due to race, poverty status, socioeconomic status, and rural/urban area of residence were not evident. These results have implications regarding the use of oral disadvantage to assess the long-term effectiveness of dental care.

Behavioral risk indicators of attachment loss in adult Floridians.

This study investigated behavioral and sociodemographic risk indicators of attachment loss (AL) at baseline in subjects of the Florida Dental Care Study: 873 subjects with at least 1 tooth, and who were 45+ years or older, participated for an in-person interview and dental examination; 761 subjects were probed for AL. Calibrated examiners used a modified NIDR protocol from the 1985-86 Survey of US Employed Adults and Seniors. Results were weighted to reflect actual population proportions. 92% of subjects had at least 1 site of 4+ mm AL, and 35% had at least 1 severe site (7+ mm AL). In a single multivariate regression, not having a recent dental check-up, not using dental floss, being a current smoker, and being diabetic were significantly associated with a higher probability of having 1 or more severe sites. Blacks were less likely than whites to be regular users of dental care, use dental floss, and be non-smokers. Similar findings were found for low income adults and rural residents. Risk groups (low income, blacks, rural residents) were more likely to present with modifiable risk indicators for AL, suggesting the need for targeted interventions.

The sensitivity of the Geriatric Oral Health Assessment Index to dental care.

The sensitivity of the Geriatric Oral Health Assessment Index (GOHAI) to dental treatment was evaluated using data from a community-based oral health promotion project. Ninety-six subjects completed baseline and twenty-four-month follow-up interviews that included the GOHAI as well as other self-reported measures of oral health. Subjects were predominantly white, female, not currently married, with less than a high school education, and had average age of seventy-six years at baseline. Through the health promotion project, participants were offered low cost diagnostic and preventive services on a sliding fee basis. At twenty-four months, subjects' records were abstracted regarding the receipt of dental hygiene, transportation, emergency, diagnostic, restorative, and prosthodontic services. Subjects were also asked about dental expenditures in the previous year and the type of dental care received, regardless of the source of care. The mean change in GOHAI scores from baseline to the twenty-four-month interview was 2.2 (std. dev. 6.6) and ranged from -15 to 30. Findings suggest that the GOHAI is sensitive to the provision of dental care, although additional research is needed to understand the impact of various dental services on the individual items of the GOHAI, as well as the overall index score. The potential applications of self-reported oral health outcome measures such as the GOHAI in dental education are discussed.

Tobacco control activities in U.S. dental practices.

The authors surveyed general dentists, periodontists, pediatric dentists and dental hygienists in three U.S. geographical regions to estimate the percentage who practiced tobacco use cessation activities in their dental offices. A total of 1,746 dentists and 723 dental hygienists completed either a long or short version of a mailed survey or telephone interview. The authors found that tobacco cessation activities are not a routine part of dental practice and that tobacco control activities and training vary by dentist type and geographical region.

Root caries and root defects in urban and rural adults: the Florida Dental Care Study.

As part of the Florida Dental Care Study--a longitudinal study of risk factors for changes in dental health--the authors examined and interviewed 873 adults aged 45 years and older. During the examination, clinicians noted the number of teeth present and the participant's dental condition, including presence of root caries and fillings or noncarious defects on the roots. The interview was conducted to collect demographic and other information such as the adults' perceptions about dental care and their perceptions about their own dental health. The authors found that men, African-Americans, adults living in rural areas and those living in poverty were significantly more likely to have root caries than other participants. The data reported in this article will serve as baseline information for subsequent research.