Bruce A. Dye

Risk Indicators for Periodontitis in US Adults: NHANES 2009 to 2012

BACKGROUNDnThrough the use of optimal surveillance measures and standard case definitions, it is now possible to more accurately determine population-average risk profiles for severe (SP) and non-severe periodontitis (NSP) in adults (aged 30 years and older) in the United States.nnnMETHODSnData from the 2009 to 2012 National Health and Nutrition Examination Survey were used, which, for the first time, used the gold standard full-mouth periodontitis surveillance protocol to classify severity of periodontitis following suggested Centers for Disease Control/American Academy of Periodontology case definitions. Probabilities of periodontitis by: 1) sociodemographics, 2) behavioral factors, and 3) comorbid conditions were assessed using prevalence ratios (PRs) estimated by predicted marginal probability from multivariable generalized logistic regression models. Analyses were further stratified by sex for each classification of periodontitis.nnnRESULTSnLikelihood of total periodontitis (TP) increased with age for overall and NSP relative to non-periodontitis. Compared with non-Hispanic whites, TP was more likely in Hispanics (adjusted [a]PR = 1.38; 95% confidence interval 95% CI: 1.26 to 1.52) and non-Hispanic blacks (aPR = 1.35; 95% CI: 1.22 to 1.50), whereas SP was most likely in non-Hispanic blacks (aPR = 1.82; 95% CI: 1.44 to 2.31). There was at least a 50% greater likelihood of TP in current smokers compared with non-smokers. In males, likelihood of TP in adults aged 65 years and older was greater (aPR = 2.07; 95% CI: 1.76 to 2.43) than adults aged 30 to 44 years. This probability was even greater in women (aPR = 3.15; 95% CI: 2.63 to 3.77). Likelihood of TP was higher in current smokers relative to non-smokers regardless of sex and periodontitis classification. TP was more likely in men with uncontrolled diabetes mellitus (DM) compared with adults without DM.nnnCONCLUSIONSnAssessment of risk profiles for periodontitis in adults in the United States based on gold standard periodontal measures show important differences by severity of disease and sex. Cigarette smoking, specifically current smoking, remains an important modifiable risk for all levels of periodontitis severity. Higher likelihood of TP in older adults and in males with uncontrolled DM is noteworthy. These findings could improve identification of target populations for effective public health interventions to improve periodontal health of adults in the United States.

Performance of a quality assurance program for assessing dental health in methamphetamine users

BackgroundSystematic characterization of the dental consequences of methamphetamine (MA) abuse presupposes a rigorous quality assurance (QA) program to ensure the credibility of the data collected and the scientific integrity and validity of the clinical study. In this report we describe and evaluate the performance of a quality assurance program implemented in a large cross-sectional study of the dental consequences of MA use.MethodsA large community sample of MA users was recruited over a 30xa0month period during 2011–13 and received comprehensive oral examinations and psychosocial assessments by site examiners based at two large community health centers in Los Angeles. National Health and Nutrition Examination Survey (NHANES) protocols for oral health assessments were utilized to characterize dental disease. Using NHANES oral health quality assurance guidelines, examiner reliability statistics such as Cohen’s Kappa coefficients and inter-class correlation coefficients were calculated to assess the magnitude of agreement between the site examiners and a reference examiner to ensure conformance and comparability with NHANES practices.ResultsApproximately 9xa0% (nu2009=u200949) of the enrolled 574 MA users received a repeat dental caries and periodontal examination conducted by the reference examiner. There was high concordance between the reference examiner and the site examiners for identification of untreated dental disease (Kappa statistic values: 0.57–0.75, percent agreement 83–88xa0%). For identification of untreated caries on at least 5 surfaces of anterior teeth, the Kappas ranged from 0.77 to 0.87, and percent agreement from 94 to 97xa0%. The intra-class coefficients (ICCs) ranged from 0.87 to 89 for attachment loss across all periodontal sites assessed and the ICCs ranged from 0.79 to 0.81 for pocket depth. For overall gingival recession, the ICCs ranged from 0.88 to 0.91. When Kappa was calculated based on the CDC/AAP case definitions for severe periodontitis, inter-examiner reliability for site examiners was low (Kappa 0.27–0.67).ConclusionOverall, the quality assurance program confirmed the procedural adherence of the quality of the data collected on the distribution of dental caries and periodontal disease in MA-users. Examiner concordance was higher for dental caries but lower for specific periodontal assessments.

Contemporary impact of tobacco use on periodontal disease in the USA

Periodontal disease (PD) is a common chronic disease that can be expensive to treat, and when untreated, can inflict significant morbidity and tooth loss. Growing evidence also links PD to higher risks of cancer, cardiovascular and other chronic diseases.nnCigarette smoking has been estimated to cause 8 million cases of PD in the USA or more than half of the 15 million cases of PD.1 However, these estimates are based on data from the third National Health and Nutrition Examination Survey (NHANES), conducted from 1988 to 1994. The prevalence of PD was underestimated in this survey because a partial mouth examination was utilised that included many fewer sites per tooth than currently recommended.2 Current prevalence estimates of PD in the USA are substantially higher, as they incorporate new population-based PD case definitions and full-mouth assessments.3 Equally important, previous estimates of the tobacco-induced PD burden failed to include the effects of non-cigarette tobacco products and environmental tobacco smoke (ETS). There have also …

Methamphetamine Users Have Increased Dental Disease: A Propensity Score Analysis

Methamphetamine (MA) users are assumed to have a high burden of tooth decay. Less clear is how the distribution and severity of dental caries in MA users differ from the general population. Using a covariate-balancing propensity score strategy, we investigated the differential effects of MA use on dental caries by comparing the patterns of decayed, missing, and filled teeth in a community sample of 571 MA users with a subset of 2,755 demographically similar control individuals selected from a National Health and Nutrition Examination Survey (NHANES) cohort. Recruited over a 2-y period with a stratified sampling protocol, the MA users underwent comprehensive dental examinations by 3 trained and calibrated dentists using NHANES protocols. Propensity scores were estimated with logistic regression based on background characteristics, and a subset of closely matched subjects was stratified into quintiles for comparisons. MA users were twice as likely to have untreated caries (odds ratio [OR] = 2.08; 95% confidence interval [95% CI]: 1.55 to 2.78) and 4 times more likely to have caries experience (OR = 4.06; 95% CI: 2.24 to 7.34) than the control group of NHANES participants. Additionally, MA users were twice as likely to have 2 more decayed, missing, or filled teeth (OR = 2.08; 95% CI: 1.29 to 2.79) than the NHANES participants. The differential involvement of the teeth surfaces in MA users was quite distinctive, with carious surface involvement being highest for the maxillary central incisors, followed by maxillary posterior premolars and molars. Users injecting MA had significantly higher rates of tooth decay compared with noninjectors (P = 0.04). Although MA users experienced decayed and missing dental surfaces more frequently than NHANES participants, NHANES participants had more restored surfaces, especially on molars. The high rates and distinctive patterns of dental caries observed could be used 1) to alert dentists to covert MA use in their patients and 2) as the basis for comprehensive management strategies.

Age‐dependent distribution of periodontitis in two countries: Findings from NHANES 2009 to 2014 and SHIP‐TREND 2008 to 2012

OBJECTIVEnWe used epidemiologic data of clinical periodontal status from two population-based samples in two countries, United States and Germany, to examine 1) the impact of age on the relative contribution of recession and pocketing on the distribution of clinical attachment loss, and 2) whether it is feasible to define age-dependent thresholds for severe periodontitis.nnnMETHODSnThe analytical sample was based on persons aged ≥30 and included 10,713 individuals in the United States, participants in NHANES 2009 to 2014, and 3,071 individuals in Pomerania, Germany, participants in the SHIP-Trend 2008 to 2012. NHANES used a full-mouth examination protocol to collect data on recession (R), pocket depth (PD) and clinical attachment loss (CAL) for six sites/tooth on a maximum of 28 teeth; SHIP-Trend used a half-mouth examination at four sites/tooth. In both samples, percentile distributions of mean CAL/person were generated for each 5-year age interval. Age-dependent thresholds defining the upper quintile of mean CAL were calculated for both samples. The topographic intraoral distribution of CAL and the relative contribution of R and PD on CAL was assessed.nnnRESULTSnMean CAL increased linearly with age in both samples and was higher in SHIP-Trend than NHANES across the age spectrum. In contrast, mean PD was constant across age groups in both populations. R contributed increasingly to CAL with age, especially after 45 to 49 years. Upper quintile mean CAL thresholds in NHANES werexa0<xa03xa0mm for ages up to 39 years, and under 3.58xa0mm in all other age groups. Corresponding values in SHIP-Trend were alsoxa0<xa03xa0mm in ages up to 39 years but increased linearly with age up to 7.21xa0mm for ages ≥75 years.nnnCONCLUSIONSnDespite substantial differences in the overall severity of attachment loss between the two samples, common patterns of CAL and of the relative contribution of R and PD to CAL with increasing age were identified. Although periodontitis severity may vary in different populations, empirical evidence-driven definitions of CAL thresholds signifying disproportionate severity of periodontitis by age are feasible.

Sample size for clinical trials.

The gold standard of study design in clinical investigation is the randomized controlled trial (RCT). Over the past 50 years, RCTs have come to be considered the primary source of evidence for the efficacy of newer therapeutic interventions (Matthews, 2006). The design of the trial varies with the phase of the clinical trial (I-IV) and is dependent on several statistical exercises. Typically, sample size calculation and statistical power are critical components of study design. n nThis article is protected by copyright. All rights reserved.

Significance and Implications of Patient-reported Xerostomia in Sjögren's Syndrome: Findings From the National Institutes of Health Cohort

Background Xerostomia is a chief complaint of patients with Sjögrens syndrome (SS). However, newer proposals for SS classification remove xerostomia and hyposalivation from the criteria list. Given these developments and the importance of patient-centered research outcomes, we sought to evaluate the utility of patient-reported xerostomia with implications for classification criteria, and clinical trials targeting SS treatment modalities. Methods A nested case-control study was designed within The National Institute of Dental and Craniofacial Research/National Institutes of Health (NIDCR/NIH) SS Cohort - one of the largest SS cohorts in the US. Clinical characteristics of those with and without xerostomia in SS and other salivary gland dysfunctions were compared. Several analytical methods were employed, including multivariable logistic regression modeling. Findings The NIDCR/NIH Sjögrens Syndrome Clinic has an open cohort with ongoing enrollment since 1984. This open cohort comprised of 2046 participants by August 27, 2015. Baseline data of 701 SS, 355 Sicca, and 247 ISS participants within the source cohort were analyzed. Xerostomia was highest among SS participants (87.4%, 95% CI: 84.8%–89.8%) compared to Sicca (72.4%, 95% CI: 67.4%–77.0%, p < 0.001) and ISS groups (38.1%, 95% CI: 32.0%–44.4%, p < 0.001). Those with xerostomia were more likely to have SS than Sicca/ISS (OR = 4.98, 95% CI: 3.78–6.56). The ability of xerostomia to screen for SS among those with salivary gland dysfunction was higher than screening for Sicca/ISS. Screening diagnostics of xerostomia were of greater utility compared to hyposalivation. After adjusting for confounding in multivariable modeling, SS participants with xerostomia were more likely to be White (Black/African Americans (OR: 0.40, 95% CI: 0.23–0.68, p-value = 0.001) and Asians (OR: 0.49, 95% CI: 0.25–0.96, p-value = 0.038) were less likely to have xerostomia compared to Whites), have dry eye symptoms for > 3 months (OR: 5.80, 95% CI: 3.62–9.28, p-value < 0.001), a lower Van Bijsterveld score (OR: 0.55, 95%CI: 0.34–0.90, p-value = 0.017), a lower stimulated salivary flow rate (OR: 1.67, 95% CI: 1.06–2.65, p-value = 0.028), a focus score of > 2 (OR: 1.92, 95% CI: 1.20–3.09, p-value = 0.007), and salivary gland swelling (OR: 49.39, 95% CI: 2.02–1206.30, p-value = 0.017). Age, gender, fatigue, pain, anxiety, and autoantibodies were not significantly associated with xerostomia. Interpretation Findings from this study indicate that patient-reported xerostomia is highly prevalent among SS patients and is associated with several clinical phenotypes of this complex syndrome, thereby making it an important indicator of SS. The evidence also suggests that xerostomia is not limited to low salivary flow but might be reflective of compositional changes of saliva. Consequently, these findings suggest the need to consider xerostomia in the development of SS classification criteria and in patient-centered outcomes research in SS intervention trials. This research was supported by the Intramural Research Program of the National Institutes of Health (NIH), National Institute of Dental and Craniofacial Research (NIDCR) Grant # DE000704-15. Dr. Baer is supported by RO1-DE-12354-15A1.

Oral health status of children in Los Angeles County and in the United States, 1999–2004

OBJECTIVEnTo ascertain and compare the oral health status and related sociodemographic risk indicators in children in Los Angeles (LA) County with children in the United States.nnnMETHODSnData from the National Health and Nutrition Examination Survey (NHANES) 1999-2004 were used to calculate prevalence estimates for children aged 2-13 years living in LA County and in the United States. Sociodemographic indicators were evaluated using multiple logistic regression modeling.nnnRESULTSnOverall, children in LA County were more likely to experience dental caries than children in the United States in 1999-2004. In the primary dentition, nearly 40% of preschool children residing in LA County had dental caries compared to 28% of same-age children in the United States. Among children aged 6-13, 44% living in LA County had dental caries in the permanent dentition compared to 27% in the United States. Mexican American children in LA County had higher caries experience in permanent teeth (but not in primary teeth) than US Mexican American children. Among children aged 6-9 years, there was no difference in the prevalence of dental sealants in permanent teeth between those living in LA County and in the United States. However, among children aged 10-13 years, dental sealants were more than twice as prevalent in US children (40.8%) than in LA County children (17.5%). Among LA County children, the adjusted odds of having caries experience or untreated dental caries in permanent teeth were not higher among children from lower income families than in lower income children in the United States.nnnCONCLUSIONSnChildren residing in LA County had less favorable oral health than children in the United States in 1999-2004. The usual sociodemographic caries risk indicators identified among children in the United States were not consistently observed among children in LA County. Unlike in the wider United States, poverty was not a risk indicator for dental caries in older children in LA County.

Elucidating the Role of Hyposalivation and Autoimmunity in Oral Candidiasis.

INTRODUCTIONnOral candidiasis (OC) is a potential oral complication in Sjögrens syndrome (SS). Some studies indicate that the low stimulated salivary flow and not low unstimulated salivary flow is associated with OC in SS, while others report that the underlying autoimmune disorders contribute to OC, based solely on correlation coefficients. Given the conflicting and limited existing evidence, we purposed to ascertain the role of both salivary gland dysfunction (hyposalivation based on unstimulated and stimulated flow rates) and autoimmunity (SS, other autoimmune disorders) in OC among those with SS, other salivary gland dysfunction, and non-salivary gland dysfunction controls (NSGD).nnnMETHODSnA nested case-control study was designed within a larger NIH/NIDCR cohort. Descriptive analyses, nonparametric tests, comparative analyses, and multivariate logistic regression analyses were undertaken.nnnRESULTSnData on 1526 subjects (701 SS, 247 ISS, 355 Sicca, and 223 NSGD) were obtained from the source cohort of 2046 and analyzed for this study. The median whole unstimulated salivary flow rate (WUS, mlxa015xa0min-1 ) was lower in SS (0.8, interquartile range (IQR) 1.8) compared to ISS (5.5, IQR: 5.2, Pxa0<xa00.001) and NSGD (3.8, IQR: 3.8, Pxa0<xa00.001) but comparable with that of Sicca (1.0, IQR: 1.5, Pxa0=xa00.777) participants. The median total stimulated salivary flow rate (TSS, mlxa015xa0min-1 ) was lowest in SS (7.0, IQR: 12.4, Pxa0<xa00.001) compared to other groups. Of the 45 OC cases in this cohort, 71.1% (nxa0=xa032) were from the SS group. The prevalence of OC was highest in the SS group (4.6%, Pxa0=xa00.008). SS group had twice the risk of OC than NSGD (ORxa0=xa02.2, 95%CI: 1.1-4.2, Pxa0=xa00.02) and Sicca (ORxa0=xa02.2, 95% CI: 1.0-4.8, Pxa0=xa00.03), adjusting for confounders; hyposalivation [WUS (ORxa0=xa05.1, 95%CI: 2.5-10.4, Pxa0<xa00.001), TSS (ORxa0=xa01.9, 95%CI: 1.0-3.5, Pxa0=xa00.04)], history of other autoimmune disorders (ORxa0=xa04.4, 95%CI: 1.7-11.3, Pxa0=xa00.002), medications for extraglandular manifestations (ORxa0=xa02.3, 95%CI: 1.1-4.9, Pxa0=xa00.03), and diabetes mellitus (4.2, 95%CI: 1.2-15.2, Pxa0=xa00.02) were independent predictors of OC; females had a lower risk than males (ORxa0=xa00.29, 95%CI: 0.13-0.67, Pxa0=xa00.004). Age, race, anti-SSA/SSB autoantibodies, focus score, other medications, anxiety, fatigue, cigarette smoking, alcohol, and caffeine use were not associated with oral candidiasis.nnnCONCLUSIONnSalivary gland dysfunction (hyposalivation with WUS being a stronger predictor than TSS) and autoimmunity (SS, other autoimmune disorders, medications, i.e., DMARDS) are both independent predictors of OC. Diabetes mellitus is an independent predictor of OC among those with salivary gland dysfunction. Our findings suggest that these independent predictors should be considered in the prevention and management of OC in this population.

Methamphetamine use and oral health-related quality of life

PurposeMethamphetamine (MA) is associated with adverse health effects, including the rampant tooth decay condition called “Meth Mouth.” However, the impact of MA use on oral health-related quality of life (OHRQOL) is unknown. This study assessed the relationship between MA use and self-reported OHRQOL.MethodsThis cross-sectional study uses information from 545 MA-using participants recruited from Los Angeles County, California. Dental examinations were performed by three calibrated dentists using National Health and Nutrition Examination Survey (NHANES) protocols. Data on socio-demographic, behavioral, and drug-use history were recorded using questionnaires. Participants were categorized as ‘light’ or ‘moderate/heavy’ users based on reported frequency of MA use in the past 30 days. Route of MA administration was categorized as ‘smoking’ or ‘other.’ Self-reported OHRQOL was based on the Oral Health Impact Profile scale.ResultsMajority of the participants were male (80.9%). Median age was 45.0xa0years (IQR-13.0). Median number of days of MA use was 10.0 (IQR-12.0). Smoking was the preferred route of MA use (70.2%). Root caries in ≥u20093 teeth were reported in 78% of MA users. More than half of the participants reported having painful aching in mouth, avoidance of particular food items, feeling embarrassed, and discomfort while eating in the last 12xa0months. In unadjusted logistic models, moderate/heavy MA users were more likely to report an affected sense of taste [ORu2009=u20091.58, 95% CI (1.10–2.27)] and avoidance of particular foods [ORu2009=u20091.45, 95% CI (1.02–2.01)] than light users. Among individuals preferring other MA administration routes, moderate/heavy MA users were 3.09 times as likely to report an affected sense of taste than light users [ORu2009=u20093.09, 95% CI (1.52−6.27)].ConclusionOral health and OHRQOL appear to be worse among Methamphetamine users than in the US general population.