Hazardous alcohol use and receipt of risk-reduction counseling among U.S. veterans of the wars in Iraq and Afghanistan.

OBJECTIVE: Military service in Afghanistan (Operation Enduring Freedom [OEF]) and Iraq (Operation Iraqi Freedom [OIF]) has been associated with high rates of mental health problems. Relatively little is known, however, about the prevalence of risky drinking among OEF/OIF veterans using U.S. Department of Veterans Affairs (VA) health care. This study examined the prevalence of hazardous alcohol use among OEF/OIF veterans and the incidence of alcohol risk-reduction counseling offered by VA providers. METHOD: A secondary analysis of data extracted from the VA outpatient Survey of Healthcare Experiences of Patients, a stratified random sample of VA clinic users from the fiscal year 2005 (October 1, 2004, to September 30, 2005), was conducted. The Alcohol Use Disorders Identification Test (AUDIT-C) was scored to assess hazardous drinking and possible alcohol use disorder (AUD). Patient report of alcohol counseling by a VA provider in the past year was queried for those with risky drinking behavior. The association of demographic variables with potentially hazardous alcohol use, alcohol use disorder, and receipt of alcohol risk-reduction counseling was estimated using logistic regression. RESULTS: Overall, 40% of the sample screened positive for potentially hazardous alcohol use, and 22% screened positive for possible AUD. Only 31% of those with hazardous drinking behavior, however, reported being counseled to cut back or to not drink alcohol. Higher AUDIT-C scores were associated with increased likelihood of risk-reduction counseling. Among patients reporting hazardous drinking, there was a trend for those with less education and lower income to be more likely to report receiving advice about their drinking. CONCLUSIONS: Hazardous alcohol use is prevalent among OEF/OIF veterans seeking VA health care. There is a need for increased vigilance and action to identify and counsel at-risk veterans in this population.

The impact of the 2004-2005 influenza vaccine shortage in the Veterans Health Administration.

BACKGROUND: The Veterans Health Administration (VHA) serves a population at high risk of influenza-related morbidity and mortality. The national public health response to the vaccine shortage of the 2004-2005 season resulted in prioritization of recipients and redistribution of available supply. OBJECTIVE: To characterize the impact of the 2004-2005 influenza vaccine shortage on vaccination among users of VHA facilities. DESIGN: Analysis using data from the cross-sectional VHA Survey of Healthcare Experiences of Patients. PARTICIPANTS: Outpatients seen in VHA clinics during the months September 2004-March 2005. MEASUREMENTS: Sociodemographics, vaccination prevalence, setting of vaccination, and reasons cited for not getting vaccinated. RESULTS: Influenza vaccination prevalence among VHA outpatients aged 50-64 was 56% and for those aged > or = 65 was 86%. Compared to the 2 previous seasons, this estimate was lower for patients age 50-64 but similar for patients > or = 65. After adjustment for patient characteristics, unvaccinated patients aged 50-64 were 8.3 (95% CI 6.0, 11.4) times as likely to cite that they were told they were not eligible for vaccination because of the national shortage compared to patients > or = 65. Regional VHA variation in vaccination receipt and shortage-related reasons for nonvaccination was small. CONCLUSIONS: The national influenza vaccine shortage of 2004-2005 primarily affected VHA users aged 50-64, consistent with the tiered prioritization guidance issued by the Centers for Disease Control and Prevention and Advisory Committee on Immunization Practices. Despite the shortage, vaccination prevalence among VHA users > or = 65 remained high.

Adequacy of training in oral cancer prevention and screening as self-assessed by physicians, nurse practitioners, and dental health professionals.

OBJECTIVE: To assess the educational preparedness of medical and dental professionals to reduce the burden of OPC through planning effective cancer control strategies such as reducing tobacco consumption, suggesting healthy lifestyle and diet, and performing early detection through screening examinations and appropriate follow-up. METHODS: Self-reported adequacy of training in oral and pharyngeal cancer (OPC) early intervention activities was compared among 4 health care provider groups in North Carolina. Pretested surveys were mailed to random samples of licensed professionals. RESULTS: Nearly all providers agreed that early detection improves 5-year survival rates from OPC. Compared with 567 medical providers (273 family physicians and 294 nurse practitioners), 1235 dental providers (584 dentists and 651 hygienists) were significantly less likely to feel adequately trained in tobacco and alcohol cessation and to palpate neck nodes, but were significantly more likely to feel adequately trained to perform oral cancer examinations. Among dental providers, those who felt they had adequate training in tobacco and alcohol cessation were significantly more likely to assess these risk factors on patient medical histories. CONCLUSIONS: Education is needed to prepare dental providers to undertake OPC prevention activities, whereas medical providers would benefit from enhanced oral examination skills to improve their performance in early detection.

Prevention and early detection of oral and pharyngeal cancer in veterans.

OBJECTIVES: To assess knowledge of oral and pharyngeal cancer (OPC) clinical signs and risk factors, the association between the risk factors and OPC, and the experience with OPC screening between newly diagnosed OPC patients and controls among a population of veterans in North Carolina. STUDY DESIGN: A case-control study with 31 OPC cases and 30 frequency-matched controls recruited from 2003 to 2004. Bivariate analysis using chi-square statistics and multivariate logistic regression was implemented to estimate the association with OPC. RESULTS: Only 34% of respondents knew 1 clinical sign and 4 or 5 risk factors for OPC. The lifetime accumulation of tobacco had a significant relationship with OPC (>20 pack-years; OR, 3.2; 95% CI, 1.01-10.3). Many respondents had not had an oral cancer examination within 3 years, mostly through ignorance. Most VA OPC patients were diagnosed by physicians, rather than by dentists. CONCLUSIONS: A considerable knowledge deficit on OPC was found among North Carolina veterans. Use of tobacco was a risk factor for OPC in this population.

The effects of periodontal therapy on vascular endothelial function: a pilot trial.

BACKGROUND: Chronic periodontal infection is associated with an increased risk of coronary heart disease. Although the mechanism responsible for the relationship between periodontal disease and cardiovascular events is not fully understood, it is hypothesized that the chronic inflammatory burden of periodontal disease may lead to impaired functioning of the vascular endothelium. METHODS: Twenty-two otherwise healthy adults with moderate to severe periodontitis who underwent complete mouth disinfection were evaluated to determine if periodontal therapy would result in improved endothelial function and a decrease in serum inflammatory markers. Subjects had measurements of periodontal disease severity, flow-mediated (endothelium-dependent), and nitroglycerin-mediated (endothelium-independent) dilation of the brachial artery, serum C-reactive protein (CRP) and interleukin 6 (IL-6), and serum total and high-density lipoprotein cholesterol levels on 2 baseline visits separated by 1 month and, again, 1 month after treatment. RESULTS: There were no significant changes in clinical periodontal measures, flow-mediated dilation, nitroglycerin-mediated dilation, CRP, IL-6, total cholesterol, or high-density lipoprotein cholesterol between the repeated baseline measurements. Periodontal treatment, however, resulted in significant improvements in periodontal pocketing, flow-mediated dilation, and serum IL-6, as well as a trend toward reduction in serum CRP; there were no significant changes in nitroglycerin-mediated dilation or in cholesterol levels. CONCLUSIONS: These results represent proof of concept that improvement in endothelial function, as measured by flow-mediated dilation of the brachial artery, may be possible through near-elimination of chronic oral infection and suggest that the conduct of a larger controlled trial is justified.

North Carolina dental hygienists' oral cancer knowledge and opinions: implications for education.

BACKGROUND: Appropriately trained dental hygienists can participate in oral cancer (OC) control. METHOD: We assessed knowledge of risk factors, diagnostic procedures, and opinions regarding OC education among 651 dental hygienists practicing in North Carolina using a mail survey. We constructed regression models of factors influencing high knowledge levels. RESULTS: Most correctly identified tobacco and alcohol use as OC risk factors, and 52% felt their knowledge of OC was current; however, we identified gaps. Diagnostic knowledge was highest for those who were recent graduates or received continuing education in the last 5 years; 96% were interested in future continuing education. CONCLUSION: Increased OC education content in dental hygiene curricula and training programs for practicing hygienists is needed to enhance early detection of OC.

North Carolina dental hygienists' assessment of patients' tobacco and alcohol use.

PURPOSE: North Carolina is the 11th most populous state and ranks 14th among all states in the age-adjusted mortality rate for oral and pharyngeal cancer (OPC). This study assessed North Carolina dental Hygienists' knowledge of tobacco and alcohol use as OPC risk factors, assessment practices of tobacco and alcohol use in patient medical histories, and opinions regarding tobacco and alcohol cessation education. Characteristics of dental hygienists who screen for tobacco and alcohol use in medical histories were also analyzed. METHODS: A 40-item survey was mailed to a simple random sample of 1,223 dental hygienists from a registry of 4,076 licensed in North Carolina. Data were included from 651 completed surveys, giving an effective response rate of 57%. RESULTS: Most respondents correctly identified tobacco and alcohol use as risk factors for OPC. A majority assessed patients' tobacco and alcohol use. Less than 10% assessed no tobacco factors, while nearly 42% assessed no alcohol factors. A number of background and practice characteristics were found to be positively associated with tobacco and alcohol screening in patient medical histories. A majority agreed or strongly agreed that dental hygienists should be trained to provide tobacco and alcohol cessation education to their patients; however, few felt trained to provide such education. CONCLUSION: Improvements in knowledge regarding tobacco and alcohol use as OPC risk factors are needed. Future interventions might include educational programs for currently practicing dental hygienists and increased tobacco and alcohol cessation education in the professional entry-level dental hygiene curricula.

Knowledge of oral cancer risk factors and diagnostic concepts among North Carolina dentists. Implications for diagnosis and referral.

BACKGROUND: Dentists play a critical role in the early detection of oral and pharyngeal cancer (OPC). The authors administered a survey that assessed the level of knowledge among dentists regarding risk factors and diagnostic concepts. METHODS: In 2002, the authors mailed a 38-item, pretested survey to a random sample of 1,115 licensed dentists practicing in North Carolina. Three-level (low, medium, high) composite index scores for knowledge of risk factors and diagnostic concepts were created using previously developed scales. The authors formulated multivariable models for risk factor and diagnostic knowledge indexes. RESULTS: Of the 584 respondents, only 181 (31 percent) had consistent medium-to-high levels of knowledge on both highly correlated indexes. Dentists who had higher risk factor and diagnostic knowledge scores were significantly (P < .05) more likely to have heard of one or more diagnostic aids (odds ratio [OR], 2.7), to have graduated from dental school within the previous 20 years (OR, 1.8) and to have performed biopsies or referred five or more patients with suspicious lesions per year (OR, 1.7 and 1.5, respectively) than were less-knowledgeable respondents. CONCLUSIONS: More education is needed in dental schools, postgraduate programs and continuing education programs to enhance dental professionals' knowledge of OPC risk factors and diagnostic concepts. Such programs should include information about adjunctive diagnostic aids. PRACTICE IMPLICATIONS: Greater knowledge of risk factors and diagnostic concepts may result in more frequent patient referrals, biopsy procedures or both, thus aiding in the early diagnosis and treatment of patients with OPC.

Incidence rates and trends for oral and pharyngeal cancer in North Carolina: 1990-1999.

This study describes the incidence of oral and pharyngeal cancer (OPC) in North Carolina (NC) from 1990 to 1999. OPC cases 1990-1999 from the NC Central Cancer Registry were included. Variables included date of diagnosis, county of residence, anatomical site, histology, age at diagnosis, sex, race, stage at diagnosis, grade, tumor behavior, and laterality. The overall average annual rate of OPC was 10.6 cases per 100,000 population. OPC incidence was highest for African-American males and for eastern NC; there was no significant trend in the overall annual incidence rate. Squamous cell carcinoma of the lip increased for white females and other oral cancers decreased among all females. With a few specific exceptions, NCCCR rates were similar to SEER rates. North Carolina continues to have substantial OPC incidence and substantial racial disparities persist.

Evidence for periodontitis as a tertiary vascular infection.

Periodontal infections create an oral wound that serves as a portal for the systemic dissemination of oral pathogens. Clinical assessments of periodontal disease that account for the number and severity of diseased periodontal sites and teeth; including measurements of pocketing, the degree of redness, inflammation and bleeding on probing, can all provide an estimate of the severity of the clinical condition. However, these clinical signs appear inadequate to completely characterize the size, patency and integrity of the periodontal lesion which serves as a portal for systemic exposure. Increasingly, measures of infectious exposure including systemic antibodies, inflammatory mediators and acute phase reactants serve as surrogates or biomarkers for periodontal disease that provide further insight into the linkages between periodontitis and atherogenesis. This review discusses the evidence for systemic inflammatory responses to oral organisms and the potential role of chronic vessel pathology as a manifestation of tertiary periodontal infections.

Periodontal disease is associated with renal insufficiency in the Atherosclerosis Risk In Communities (ARIC) study.

BACKGROUND: Periodontitis, a chronic bacterial infection of the oral cavity, is a novel risk factor for atherosclerotic cardiovascular disease (CVD). Given the numerous shared risk factors for CVD and chronic kidney disease (CKD), we hypothesized that periodontitis also is associated with renal insufficiency in the Dental Atherosclerosis Risk in Communities study. METHODS: We conducted a cross-sectional study of 5,537 middle-aged black and white men and women. Periodontitis was determined by using an independent clinically derived definition and categorized as healthy/gingivitis, initial, and severe. Renal insufficiency is defined as glomerular filtration rate (GFR) less than 60 mL/min/1.73 m2 . Multivariable logistic regression models were used to estimate odds ratios and 95% confidence intervals for renal insufficiency using healthy/gingivitis as the referent group. RESULTS: A total of 2,276 individuals had initial periodontitis, and 947 individuals had severe periodontal disease. One hundred ten individuals (2%) had a GFR less than 60 mL/min/1.73 m2 . Compared with healthy/gingivitis, initial and severe periodontal disease were associated with a GFR less than 60 mL/min/1.73 m2 (odds ratio, 2.00; 95% confidence interval, 1.23 to 3.24) for initial periodontal disease and an odds ratio of 2.14 for severe disease (95% confidence interval, 1.19 to 3.85) after adjustment for important risk factors for CVD and CKD. Sensitivity analysis showed that initial and severe periodontitis were each associated with an elevated serum creatinine level (men, >1.4 mg/dL [>124 micromol/L]; women, >1.2 mg/dL [>106 micromol/L]; odds ratio, 3.21; 95% confidence interval, 1.32 to 7.76 and odds ratio, 5.39; 95% confidence interval, 2.08 to 13.99, respectively). CONCLUSION: This is the first study to show an association of periodontal disease with prevalent renal insufficiency. A prospective study is necessary to determine the exact nature of the observed relationship.

Incidence of occlusal dental caries in asymptomatic third molars.

PURPOSE: We sought to determine the incidence of caries experience on the occlusal surface of asymptomatic third molars erupted to the occlusal plane and to examine the association between the prevalence of caries experience in third molars and other molars. PATIENTS AND METHODS: Clinical data were collected from healthy patients (ASA Class I, II) with asymptomatic third molars enrolled at 2 clinical centers in an institutional review board-approved clinical trial. All patients with at least one third molar at the occlusal plane and with data at baseline and from the most recent of at least 2 follow-up visits were compared in the analysis. At each visit, the presence or absence of caries experience on the occlusal surface of third molars and on any surface of the first and second molars was recorded during clinical and radiographic examinations. RESULTS: Median time between baseline and the most recent follow-up examination was 2.9 years (interquartile range, 1.6 to 4.0 years). Patients (N = 211) were more often female (55%) and white (79%). Median age at baseline was 26.6 years (interquartile range, 22.7 to 32.6 years). At baseline, 29% of patients were affected by third molar occlusal caries, increasing to 33% at follow-up. Older patients at baseline had more caries in a third molar than those younger than 25 years (43% versus 9%). However, patients who were younger at baseline were more likely to develop caries in third molars at follow-up (9% versus 19%). Mandibular third molars were affected more often than maxillary third molars: 25% versus 19% at baseline and 29% versus 22% at follow-up. At baseline and at follow-up, nearly all patients with third molar caries, 98% and 99%, also had caries in first/second molars. CONCLUSIONS: The 3-year caries incidence in third molars erupted to the occlusal plane was highest among younger patients and mandibular teeth. The presence of caries in first/second molars at baseline was highly predictive of the development of third molar caries during the ensuing 3 years.

Third molars associated with periodontal pathology in older Americans.

PURPOSE: The study goal was to assess the association between the presence of visible third molars and periodontal pathology in a community-dwelling sample of middle-aged and older adults. MATERIALS AND METHODS: Data were obtained between 1996 and 1999 on 6,793 persons aged 52 to 74 from the Dental ARIC Study, a substudy of the Atherosclerosis Risk in Communities Study. The main independent variable was presence or absence of third molars assessed visually, and the dependent variable was assessment of periodontal disease as measured by pocket depth of 5 mm or greater (PD5+). Periodontal measures included pocket depth, gingival recession, and attachment level on 6 sites per tooth on all remaining teeth. Second molars were compared for periodontal pathology based on the presence or absence of a visible third molar in the same quadrant. Associations were determined using odds ratios and 95% confidence intervals. Weighted multivariable models were fit using logistic regression, and variances were adjusted to account for the clustering of quadrants within persons with the use of SUDAAN (Research Triangle Institute, Research Triangle Park, NC). RESULTS: A visible third molar was associated with 1.5 times the odds of PD5+ on the adjacent second molar, while controlling for other factors associated with the presence of third molars and periodontal disease. Other factors positively associated with PD5+ in the model were male gender, older age, smoking, and irregular and episodic dental visits. CONCLUSIONS: The finding of more severe periodontal conditions associated with visible third molars in these middle-aged and older adults indicates that third molars may continue to have a negative impact on periodontal health well into later life. The relationship between third molars and periodontal disease pathogenesis deserves further study using longitudinal data.

Oral cancer knowledge and examination experiences among North Carolina adults.

OBJECTIVE: This study assesses knowledge of oral cancer risk factors, clinical signs, and oral cancer examination experience among North Carolina adults. METHODS: A statewide random digit dial, computer-assisted telephone interview was conducted in 2002. Data from 1,096 respondents, with a response rate of 62 percent, were poststratified to 2000 census data by sex, race, and age group to produce population-based estimates. Knowledge of one sign of oral cancer, four or more risk factors for oral cancer, and having ever had an oral cancer examination were compared in logistic regression models using normalized weights. RESULTS: Fourteen (95% confidence interval [CI] +/-2) percent of adults had never heard of oral or mouth cancer. Risk factor knowledge was high for 56 percent (95% CI+/-3) and associated in a logistic regression model with younger age, feeling personal factors cause cancer, and nonuse of snuff. One sign of oral cancer (sore/lesion, red or white patch in mouth, and bleeding in the mouth) was correctly identified by 53 percent (95% CI+/-3) with significantly more correct responses from younger people, nonsmokers, and some college education. Only 29 percent (95% CI+/-3) reported ever having had an oral cancer examination when this procedure was described. Most respondents reported exams performed by dentists. In a weighted logistic regression model, older age, being dentate, nonsmokers, alcohol users, and those with some college education were significantly more likely to report having ever had an oral cancer examination. CONCLUSIONS: Although there is moderate knowledge of signs and risk factors for oral cancer among North Carolina adults, knowledge deficits remain. Oral cancer examinations need to be increased, particularly among tobacco smokers.

Relationship of periodontal disease and tooth loss to prevalence of coronary heart disease.

BACKGROUND: Studies relating periodontal disease to coronary heart disease (CHD) have provided equivocal results using tooth loss and/or clinical signs of periodontal disease as measures of periodontal exposure. METHODS: The purpose of this cross-sectional study was to evaluate the relationship of tooth loss and periodontitis to prevalent CHD at the Atherosclerosis Risk in Communities (ARIC) visit 4 using both tooth loss and clinical signs of disease in a population-based sample of 8,363 men and women aged 52 to 75 years from four U.S. communities. Each subject participated in a complete periodontal examination, assessment of missing teeth, assessment of prevalent CHD, and a number of laboratory tests and questionnaires. High attachment loss was defined as > or = 10% of sites with attachment loss > 3 mm and high tooth loss was defined as fewer than 17 remaining teeth. RESULTS: Individuals with both high attachment loss and high tooth loss (odds ratio [OR] 1.5, 95% confidence interval [CI] 1.1 to 2.0) and edentulous individuals (OR 1.8, CI 1.4 to 2.4) had elevated odds of prevalent CHD compared to individuals with low attachment loss and low tooth loss, while controlling for a number of traditional risk factors for CHD. CONCLUSIONS: These results suggest that tooth loss and periodontal disease are associated with prevalent CHD, but only when both are present. The weaker relationships between periodontal disease and CHD that have been found among older adults may be due to older adults having fewer teeth. Future longitudinal studies should be designed to ascertain the cause of tooth loss during follow-up.

Third molars associated with periodontal pathology in the Third National Health and Nutrition Examination Survey.

PURPOSE: Assess the association between visible third molars (VTM) and periodontal pathology in Third National Health and Nutrition Examination Survey (NHANES III). MATERIALS AND METHODS: Data were obtained on 5,831 persons aged 18 to 34 from the NHANES III. Relevant to the present study was the presence of VTM and the assessment of periodontal disease in 2 randomly selected (1 maxillary and 1 mandibular) quadrants. Periodontal measures included gingival index, pocket depth, and attachment level on mesiobuccal and buccal sites on up to 7 teeth (excluding third molars) per quadrant. Second molars were compared for periodontal pathology based on the presence or absence of a VTM in the same quadrant. Associations were determined using odds ratios and 95% confidence intervals. Weighted multivariable models were fit using logistic regression, and variances were adjusted to account for the complex sampling design using SUDAAN (Research Triangle Institute, Research Triangle Park, NC). RESULTS: A VTM was associated with twice the odds of a probing depth 5+ mm (PD5+) on the adjacent second molar, while controlling for other factors associated with VTM and periodontal disease. Other factors positively associated with PD5+ in the model were age 25 to 34 years, smoking, and African American race. CONCLUSIONS: The finding of more severe periodontal conditions associated with VTM in these young adults indicates that third molars may have a negative impact on periodontal health. The relationship between third molars and periodontal disease pathogenesis deserves further study using longitudinal data.

Incidence of periodontal attachment loss over 5 years among older South Australians.

OBJECTIVES: This study described the 5-year incidence of periodontal attachment loss (ALOSS) among older Australians. MATERIAL AND METHOD: Clinical examination data were obtained at baseline and 5 years from participants in a cohort study of South Australians aged 60+. Periodontal measurements (gingival recession, GR; probing depth, PD) were made for each tooth at 3 sites. An incident case of ALOSS was identified as an individual having 2+ sites with 3+ mm ALOSS. RESULTS: Some 342 (42.7%) of the 801 individuals examined at baseline were re-examined after 5 years, contributing longitudinal data from a total of 15,522 sites (6102 in the maxilla and 9420 in the mandible). Most sites showed no change in either GR or PD. Using a threshold of 3+ mm for change, ALOSS occurred at 2.3% of mesiobuccal sites, 2.5% of buccal sites, and 3.4% of distolingual sites. Distolingual sites on molars showed the highest progression rates. The major component of ALOSS was increased GR. Overall, only 10.1% of the observed ALOSS was contributed by increases in PD. Nearly two-thirds of the sites that experienced ALOSS had <3 mm of ALOSS at baseline. The weighted 5-year incidence estimate for ALOSS was 43.2% (N=145), and was higher among diabetics or those who had lost 1+ teeth since baseline. Smoking was not a significant predictor. CONCLUSION: The rates and patterns of ALOSS among older South Australians are largely similar to those recently reported for North Carolinians. Most ALOSS in older people manifests as increases in GR, rather than PD. Diabetics should be targeted for intensive primary and secondary prevention of periodontal disease.

Relationship of clinical depression to periodontal treatment outcome.

BACKGROUND: Depression has been associated with periodontal disease; however, its relationship to periodontal treatment outcome (PTO) has not been investigated. METHODS: Data were obtained by chart abstraction and computer databases on 1,299 health maintenance organization (HMO) patients aged 30 to 64 who had concurrent medical, dental, and pharmacy benefits, and who had an initial periodontal examination during 1996, 1997, or 1998. Depression (yes/no) was the main independent variable and was determined by presence of any diagnosis code for depression on the patient record. PTO was determined by the difference in percent of sites with probing depth (PD) > or = 5 mm between the initial and 1-year post-treatment periodontal exams. Sub-median periodontal treatment outcome (SMPTO) was defined as a reduction in fewer than the median percent of sites (7.33%) with PD > or = 5 mm. Information on sociodemographics, periodontal therapy, calculus and plaque, number of remaining teeth, smoking, antidepressant medications, and diabetes were collected. RESULTS: A total of 697 patients had a periodontal exam at both baseline and follow-up. Of these, 12.2% had depression. In a multivariable logistic model, depression (odds ratio [OR] 2.16, 95% confidence interval [Cl] 1.12 to 4.16) and 4-month recall treatment (OR 2.34, Cl 1.46 to 3.75) were associated with SMPTO, while percent of sites at baseline with PD > or = 5 mm (OR 0.93, Cl 0.91 to 0.94), number of remaining teeth at baseline (OR 0.94, Cl 0.89 to 0.99), and number of teeth lost during the study period (OR 0.75, Cl 0.58 to 0.96) were negatively associated. Periodontal surgery, age, gender, smoking, plaque, calculus, diabetes, and antidepressant medication were not significant in the model. CONCLUSION: Clinical depression may have a negative effect on periodontal treatment outcome in this group model HMO population.