Teresa A. Dolan

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.

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.

Coronal Caries, Root Fragments, and Restoration and Cusp Fractures in US Adults

The Florida Dental Care Study is a longitudinal study of changes in oral health that included at baseline 873 subjects (Ss) who had at least 1 tooth, were 45 years or older, and participated for an interview and examination. Forty-five percent of Ss had active coronal caries; 94% of the coronal carious surfaces were primary decay, and only 6% were secondary/recurrent. Ten percent of Ss had 1 or more root fragments, 16% of Ss had 1 or more teeth with restoration fractures, and 14% of Ss had 1 or more teeth with cusp fractures. Blacks, poor persons, and irregular attenders had more caries, root fragments, and cusp fractures, even though they had significantly fewer teeth. Blacks, poor persons, and irregular attenders were not at increased risk for restoration fractures, probably because fractures were associated with dental care use. These findings regarding caries and restorative treatment needs are consistent with a substantial burden in adult high-risk groups, and are relevant for dental primary health care policy.

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.

Geriatric Grand Rounds: Oral Diseases in Older Adults

In the case presented, a 65-year-old man with multiple dental, medical, and social problems benefited from interdisciplinary assessment and treatment. Despite his poor oral-health status and oral-health behaviors upon admission, patient education and dental therapy resulted in improved daily oral hygiene, elimination of oral diseases, and improved oral function. The overall quality of life of any individual, particularly an older one, can be enhanced through oral-disease prevention, health promotion, and, when indicated, dental therapy. This patient was treated in a hospital environment with a well-established team approach to geriatric care. However, regardless of the care setting, the physician can play a key role in improving the oral health status and quality of life of older adults by including an oral screening examination as part of the periodic comprehensive geriatric assessment, recognizing oral pathology, requesting dental consultations and encouraging appropriate dental service utilization.

Dental, visual, auditory and olfactory complications in Paget's disease of bone

OBJECTIVE: To determine the prevalence of dental problems in Pagets patients and in a control population without Pagets disease. The relationship of localization of bony involvement of Pagets disease with the prevalence of dental, auditory, visual, and smell changes is examined.

Professional education to meet the oral health needs of older adults and persons with disabilities.

A well-prepared dental workforce is critical to improving the oral health of special needs patients. This paper, originally presented at the National Coalition Consensus Conference: Oral Health of Vulnerable Older Adults and Persons with Disabilities, reviews and suggests opportunities to enhance the professional education of the dental workforce, including enhanced faculty training in gerontology, geriatrics and special patient care, and opportunities for improved curricula and team training both within the dental team and among the diverse group of health professional that often collaborate in the care of special needs patients. Other considerations include the creation of a specialty of Special Care Dentistry, and the effective use of dental team members in the care of special needs patients.

A Multidimensional Model for Analyzing Educational Processes.

We propose a multidimensional model that can be used to formulate a research agenda that aims to explore how innovations in teaching and instruction influence the science of learning within educational contexts. This model depicts the complexity of relationships between variables within: classrooms, the total school program, and inside and outside the institution that can impact student achievement. Measuring the success of schools and student outcomes cannot be determined solely by using a legislated school‐grading system test or achievement tests. To assert that the outcomes of such measures are indicators of the quality of teaching and learning is to ignore differences in classroom teaching within an institution.

A national imperative: Oral health services in Medicare

Harold C. Slavkin, DDS; for The Santa Fe Group D ental benefits are not included in Medicare despite the reality that more Americans are living well beyond their 65th birthdays. In the United States, 10,000 people turn 65 every day, which drives the increasing cohort of seniors. Today, the number of seniors—47 million—essentially will double by 2050 according to demographers, and there is no doubt that oral health and general well-being are inextricably bound together. Many conditions that plague the body are manifested in the mouth, a readily accessible vantage point from which to view the onset, progression, and management of numerous systemic diseases. Periodontal diseases are generated by microorganisms that readily can enter the general circulation and cause bacteremia, resulting in adverse systemic effects that can promote conditions such as atherosclerosis. Study investigators assert that adverse cardiovascular effects from periodontal diseases are due to a few highrisk oral microorganisms associated with the pathogenesis of atherosclerosis via increased lipoprotein concentrations, endothelial permeability, and binding of lipoproteins in the arterial intima. In this guest editorial we assert that oral bacteria influence the pathogenesis of atherosclerosis and a number of other chronic degenerative diseases. We argue that sufficient scientific and health economic evidence support providing oral health benefits to older adults through the Medicare mechanism. Oral chronic degenerative diseases, such as periodontal diseases, often cause tooth mobility and tooth loss and serve as a portal for microorganisms, their by-products, and host-generated inflammatory mediators to enter the bloodstream, and they are associated with conditions in other parts of the body—pulmonary disease, type 2 diabetes, and cardiovascular diseases. Furthermore, periodontal diseases share genetically determined risk factors with other chronic degenerative diseases with an inflammatory response such as ulcerative colitis, juvenile arthritis, and systemic lupus erythematosus. These conditions are associated closely with increased production of proinflammatory cytokines that serve as indicators of susceptibility to severe chronic degenerative diseases. The same cytokines expressed in inflammation in type 2 diabetes, cardiovascular diseases, and obesity also are expressed within periodontal diseases. It is now evident that there is a confounding relationship among oral infections, host inflammatory response, and host genetic characteristics. Major scientific discoveries support the thesis that oral health care begins during prenatal care and extends over the human life span. Authors of a number of reports highlight significant benefits of prevention interventions in early childhood and thereafter. Despite these advances, according to

Preparing the oral health workforce to effectively address public health challenges

In the decades prior to the recognition of Dental Public Health (DPH) as a specialty of dentistry by the American Dental Association (ADA), the US population faced significant oral health challenges. The ADA actively debated the role of the dental profession in improving the health of the public. Dental schools were responding to the William J. Gies’s report (1) to define dentistry as an essential component of higher education in the health professions. Dental professionals were beginning to establish a presence in the federal services and agencies, hospitals, and other institutional settings. The pressure to extend medical and dental care to a broader segment of the US population continued to increase. Public health was a relatively new venture for dental professionals in the 1940s and 1950s, and public health efforts were more likely to focus on ensuring access to clean water supplies and controlling devastating communicable diseases. That is not to say that oral health challenges did not exist. Extensive dental caries was common in the United States and most developed countries (2). Many children and adults were not able to afford dental care during the economic depression of the 1930s and dental needs reflected the accumulation of disease and the inability of patients to access needed services. One of the better known outcomes of these circumstances was the unexpected finding that about 8.8 percent of Army inductees were disqualified for service for dental reasons based on oral examinations conducted in 1940-41 (3). While access to care improved during the postdepression recovery, a Gallup poll conducted in 1950 indicated that 47 percent of the US adult population had had not seen a dentist for 2 years or more (4). Also, the discussions about the adequacy of the size and preparation of the dental workforce were actively debated, much as they are today. Also during the early 20th century, the role of the dental hygienist as a dental team member was becoming defined. Dr. Alfred Civilion Fones is credited with coining the term dental hygienist in 1913, although dental hygiene education and practice as well as the activities of dental nurses, for example, predate the use of this term and the acknowledgment of dental hygiene as a true college discipline (5). Fones also helped define the dental hygienist’s role in dental public health by developing curricula for hygienists working within the public school system of Bridgeport, Connecticut. While the role of the dental hygienist was being actively debated by national and state dental associations, population-leveland individual-focused preventive strategies were recognized as critical to improving oral health. By 1951, hygienists were licensed to practice in all states, the District of Columbia, Alaska, and Hawaii, but only four percent of dentists employed hygienists (6). The role of public health dentists and the core competencies of DPH practice were also being defined during this time. Dr. Easlick set about defining the field of DPH through a series of landmark workshops in Ann Arbor, Michigan, through the 1940s and 1950s. The results defined the scope of DPH practice and the necessary competencies for public health dentists. This work was seminal in many ways, and it led to the ADA’s recognition of DPH as a board-certified specialty of dentistry in 1950 (7). This began the critical recognition of DPH as a unique dental specialty, and the only specialty in the dental profession that focuses on dental and oral health issues in communities and populations rather than individuals. DPH units were established in virtually every state health department, and the Oral Health Unit in the World Health Organization was established in 1953. Pioneer public health dentists and oral epidemiologists developed the first index to measure the prevalence of caries and to begin the process to systematically study preventive and other strategies to reduce dental disease rates, among many other contributions to the improvement of oral health in the US and globally. It was not until the beginning of the 21st century that the first ever Oral Health in America: A Report of the Surgeon General (8) was published followed by the National Call to Action to Promote Oral Health (9). These publications alerted Americans to the importance of oral health in their daily lives and brought important attention to barriers that continue to hinder the ability of some Americans from attaining optimal oral health. One of four action items focused on the dental workforce and the need to enhance diversity, capacity, and flexibility. Around the same time, the Institute of Medicine’s report on The Future of the Public’s Health in the 21 Century (10) embraced the vision originally articulated by Healthy People 2000 (11) recognizing the importance of not only a governmental public health infrastructure as the backbone of the public health system, but also critical partners including academic institutions who train the health-care workers for the future. While the nation’s public health infrastructure and experts are critical elements in our national public health strategy, the health care delivery systems and the private practice commuJournal of Public Health Dentistry 75 (2015) S1–S3