Kathryn A. Atchison

ORAL HEALTH, HEALTH, AND HEALTH-RELATED QUALITY OF LIFE

Health-related quality of life is a multidimensional concept with five broad domains: opportunity/resilience, health perception, functional states, impairments/diseases, and duration of life. It addresses the tradeoff between how long and how well people live. The health-related quality of life approach has provided greater opportunity for investigation of the interrelations among oral health, health, and related outcomes. The inclusion of patient-driven measures, such as perceptions and functional status, is critical. Oral health-related quality of life measures are being developed and used in research on aging populations. Clinical measures of oral health, perceptions of general and oral well-being, and reported physical, social, and psychological functioning are independent, but correlated, components of overall oral health-related quality of life. An oral health-related quality of life approach benefits 1) clinical practitioners in selecting treatments and monitoring patient outcomes; 2) researchers in identifying determinants of health, tracking levels of health risk factors, and determining use of services in populations; and 3) policy-makers establishing program and institutional priorities, policies, and funding decisions. This overview indicates substantial value in pursuing several recommendations. A theoretical framework from which concepts, measures, and models can be derived must be developed to address oral health, oral health-related quality of life, health, and health-related quality of life. Oral health outcomes or states must be identified and classified along some continuum of impairment, function, disability, and opportunity. Indicators of appropriate concepts and domains must be adapted or established. Extended analyses on the relations among oral health, oral health-related quality of life, health, and health-related quality of life should be conducted with use of the Boston VA Normative Aging Study and other appropriate data sets.

Perceived Oral Health in a Diverse Sample

Measures of perceived oral health represent subjective, individual perspectives of ones health. One measure commonly used is the single-item perceived oral health rating: How would you rate your overall oral health? These analyses examine the associations among age, ethnicity, and perceived oral health within the context of a comprehensive battery of 21 predisposing, enabling, and need variables. The study compares the adult data from three United States research locations of the International Collaborative Study of Oral Health Outcomes (ICS-II). Only social survey data were used for this analysis. The multiple regression model explains over 30% of the variance in perceived oral health, with R squares ranging from 0.324 for Indian Health Service sites to 0.391 for San Antonio. The most important significant predictors include ethnic group, education, perceived general health status, being edentulous or not having a partial denture, having no oral pain, fewer oral symptoms, and having one or more dental visits. The predictors of positive perceived oral health for the diverse groups highlight interesting age and ethnic differences. The only universal predictor for the middle-aged adults was having fewer oral symptoms. For the older adults, being edentulous or not having a partial denture was the only universal predictor. The findings suggest that perceived oral health may be a useful outcome measure in dentistry because of its relation to predisposing sociodemographics and dental utilization.

Perceptions of the Natural Dentition in the Context of Multiple Variables

Perceived oral health status has been shown to be associated with a variety of single clinical and self-reported indicators of oral health and oral health-related behaviors. A behavioral model is utilized which hypothesizes that perceived condition of natural teeth is predicted by multiple factors, including individual demographic and enabling characteristics, other health perceptions and orientations, actual levels of diseases and conditions, and self-defined need for treatment. The data are from the clinical examination and adult questionnaire of Phase 1 (1988-1991) of the Third National Health and Nutrition Examination Survey, which is based on a stratified multistage probability sample to produce nationally representative data for the civilian, non-institutionalized US population. Multivariate hierarchical regressions were used to assess perceived condition of natural teeth in two groups of dentate adults (those with a dental visit during the past 12 months, and those with a less recent dental visit). Self-defined treatment need made a significant, non-trivial contribution after other variables had been controlled. In both subpopulation models, the perception of general health and epidemiological indicators of oral health status were also significant factors. Socio-economic indicators did not contribute significantly in either regression. Understanding components of overall perceptions of oral health moves us closer to understanding oral health behaviors and oral-health-related quality of life.

Conceptualizing oral health and oral health-related quality of life

This investigation considers oral health from a health-related quality of life perspective using a multidimensional concept representing a combination of impairment, function, perceptions, and/or opportunity. A subset of dentate individuals aged 18 and older from a national probability sample of the U.S. was selected for the reported analysis with data available from personal interviews, self-administered questionnaires, and oral examinations. Impairment was represented by clinically assessed active diseases and sequelae of diseases and self-reported acute symptoms. Other domains are represented by self-reported problems with function, perception of control over oral health, satisfaction with teeth, value attributed to oral health, and opportunity to obtain dental care. Principal components analysis with varimax rotation provided a structure to interpret four factors: accumulated oral neglect, self-perceived symptoms and problems, reparable oral diseases, and oral health values and priorities. Approximately 50% of the variance was explained by these four factors. Factor-based scores, envisioned as an index or summary measure representing the combination of variables identified in each factor, were used to assess potential validity. Whites had lower levels of accumulated oral neglect, fewer symptoms, and less reparable oral disease, but similar oral health values, than non-whites. Level of formal education was associated with each of the four factor-based scores. Age was directly associated with accumulated oral neglect, but the youngest age group had significantly more reparable oral diseases. Individuals with a dental visit in the past two years had considerably less accumulated oral neglect, fewer self-perceived problems, less reparable oral disease, and higher values of oral health than those without a dental visit in the past two years. Ordinary least square regressions were performed on each of the four factor-based scores using eight sociodemographic and economic variables. All four regression models were significant, with only the education variable being significant across all models. These analyses provide no evidence for one unique factor representing oral health. Rather, a conceptual framework for oral health appears to be represented by a set of reasonably independent components, including two groups of clinically assessed oral health, which together more fully represent oral health than any one single variable. Conceptualizing and measuring oral health multidimensionally leads us closer to examining it as part of general health.

Screening for oral health literacy in an urban dental clinic

OBJECTIVE Studies show that the average person fails to understand and use health care related materials to their full potential. The goal of this study was to evaluate a health literacy instrument based on the Rapid Estimate of Adult Literacy in Medicine (REALM) that incorporates dental and medical terms into one 84-item Rapid Estimate of Adult Literacy in Medicine and Dentistry (REALM-D) measure and determine its association with patient characteristics of a culturally diverse dental clinic population. METHODS An 84-item dental/medical health literacy word list and a 48-item health beliefs and attitudes survey was provided to a sample of 200 adult patients seeking treatment for the first time at an oral diagnosis clinic located in a large urban medical center in Los Angeles, California. RESULTS Of the total sample, 154 participants read all of list 1 correctly, 141 read list 2 correctly, and only 38 read list 3 correctly. Nonwhite participants had significantly lower REALM-D scores at each level of difficulty as well as the total scale score compared to white participants. Participants who reported English as not their main language had significantly lower REALM-D scores. REALM-D scores also varied significantly by level of education among participants where as level of education increased, oral health literacy increased. At a bivariate level, race, education, and English as a main language remain predictive of health literacy in a regression model. An interaction between education and English as a main language was significant. CONCLUSIONS The REALM-D is an effective instrument for use by medical and dental clinicians in detecting differences among people of different backgrounds and for whom English was not their primary language.

Dentition, Dental Health Habits, and Dementia: The Leisure World Cohort Study

To explore the association between dentition and dental health behaviors and incident dementia.

Patient-Related Predictors of Rehabilitation Use for Community-Dwelling Older Americans

To determine patient factors that predict use of physical or occupational therapy (PT/OT) services by elderly people.

Benzodiazepine Use in Older, Community-Dwelling Southern Californians: Prevalence and Clinical Correlates

OBJECTIVE: To determine the use of benzodiazepines (BZDs) in an older, community-dwelling sample and to examine the sociodemographic and clinical correlates of BZD use. DESIGN: A cross-sectional study of 1752 elderly people (aged ≥65 y) who completed a mailed medication survey and a telephone health status survey. PARTICIPANTS: Participants were invited to participate in a large Medicare demonstration project on prevention by their private physicians, who were also enrolled in the larger study. Participants had to be English-speaking, could not have dementia or a terminal illness, and had to give informed consent to participate in the study. MAIN OUTCOME MEASURES: Sociodemographic and health status variables that predicted BZD use were examined. Sociodemographic variables included age, gender, ethnicity, education, and income. Health status variables included functional status, with measures of mental, social, and physical health. Influenza immunization status was used as an indicator for preventive health services use and self-reported chronic illness was used as a measure of comorbidity. RESULTS: Twenty percent of the participants used BZDs at least twice in the past year. We found that those who used BZDs were more than twice as likely to take ten or more drugs, two-and-a-half times more likely to have difficulty falling asleep, and over twice as likely to be depressed. BZD users were also more likely to be white, to have a college education, and to have received a recent influenza shot, but were not more likely to be women when controlled for health status. CONCLUSIONS: Further clinical research should explore the relationship between BZD use among older patients and the BZD-associated adverse clinical factors we observed, as well as the association between multiple drug use and potential adverse outcomes in older BZD users.

Risk factors for fractures in older men and women: The Leisure World Cohort Study.

BACKGROUND Osteoporosis results in >1.5 million fractures in the United States each year, leading to substantial health care costs and loss of quality of life. One major gap in our knowledge is how to effectively identify individuals at risk of developing a fracture. OBJECTIVE We examined a population-based cohort for risk factors for fractures of the hip, wrist, and spine in men and women. METHODS The Leisure World Cohort Study was established between 1981 and 1985 when residents of a southern California retirement community completed a postal health survey. Multiple lifestyle, medical, attitudinal, and anthropomorphic factors were self-reported. Fractures were identified from 4 follow-up surveys, hospital discharge records, and death certificates. Fracture rates were determined separately for men and women. Cox proportional hazards regression was used to identify predictors of fracture. RESULTS Incident fractures of the hip (n = 1,227), wrist (n = 445), and spine (n = 729) incurred over the course of 2 decades were identified in the 13,978 residents surveyed. Mean (SD) age at entry was 74.9 (7.2) years for men and 73.7 (7.4) years for women. The most important risk factors for fracture were the same in men and women: age increased risk of hip and spine fractures (hazard ratio [HR] = 2.3-3.2 per 10 years) and history of fracture increased fracture risk at all 3 sites (HR = 1.4-3.2). In both men and women, glaucoma was a significant risk factor for hip fracture (HR = 1.9 and 1.3, respectively), and smoking was a risk factor for hip and spine fractures. Men and women with a positive mental attitude had fewer hip and spine fractures (HR = 0.7-0.9). High body mass index was protective at all 3 fracture sites in women (HR = 0.7-0.8), but those who used vitamin A supplements had increased rates of hip and wrist fracture (HR = 1.1 per 10,000 IU per day). CONCLUSIONS Attitude, lifestyle choices, and the presence of medical conditions may influence the rate of osteoporotic fracture in older women and men and may help identify individuals at high risk.

Impact of cone-beam computed tomography on orthodontic diagnosis and treatment planning.

INTRODUCTION In this study, we measured the impact of cone-beam computed tomography (CBCT) on orthodontic diagnosis and treatment planning. METHODS Participant orthodontists shown traditional orthodontic records for 6 patients were asked to provide a diagnostic problem list, a hypothetical treatment plan, and a clinical certainty. They then evaluated a CBCT scan for each patient and noted any changes, confirmations, or enhancements to their diagnosis and treatment plan. RESULTS The number of diagnosis and treatment plan changes varied widely by patient characteristics. The most frequently reported diagnosis and treatment plan changes occurred in patients with unerupted teeth, severe root resorption, or severe skeletal discrepancies. We found no benefit in terms of changes in treatment plan for patients when the reason for obtaining a CBCT scan was to examine for abnormalities of the temporomandibular joint or airway, or crowding. Orthodontic participants who own CBCT machines or use CBCT scans frequently in practice reported significantly more diagnosis and treatment plan changes and greater confidence after viewing the CBCT scans during the study. CONCLUSIONS The results of this study support obtaining a CBCT scan before orthodontic diagnosis and treatment planning when a patient has an unerupted tooth with delayed eruption or a questionable location, severe root resorption as diagnosed with a periapical or panoramic radiograph, or a severe skeletal discrepancy. We propose that CBCT scans should be ordered only when there is clear, specific, individual clinical justification.