The Transnational Tobacco Industry and Oral Health.

OBJECTIVE: All tobacco products carry established or probable adverse oral health effects. This study highlights several examples of actions by transnational tobacco corporations to obscure those effects, including several in which they were aided by the oral health community. METHODS: Information was derived primarily from a search of records in the Truth Tobacco Industry Documents Database, supplemented by other published material and the author's personal experiences. RESULTS: Tobacco companies attempted to interfere with oral cancer research and dissemination of its findings the 1950s and 1960s. Philip Morris, Inc. partnered with the American Dental Association's periodontal research centre until 1973 and the Council for Tobacco Research supported its dental student research program until 1972. Swedish Match funded much of the Swedish research on oral health effects of its smokeless tobacco products and helped foster the current "tobacco harm reduction" strategy. Electronic nicotine delivery devices are the current focus of that strategy, though data on oral health effects are sparse. CONCLUSIONS: The transnational tobacco industry has a long history of deception, corruption, and devastation, and oral health was no exception. Organized dentistry may have unwittingly aided and abetted the tobacco industry during a critical period of history.

Oral Health Effects of Combusted and Smokeless Tobacco Products.

The oral cavity is usually the first part of a consumer's body exposed to the constituents of tobacco products or their emissions. Consequently, the oral cavity is a frequent site for carcinogenic, microbial, immunologic, and clinical effects of tobacco use. This article summarizes 5 presentations on various aspects of oral health affected by combusted or noncombusted tobacco products from a recent conference, "Oral Health Effects of Tobacco Products: Science and Regulatory Policy," sponsored by the American Association for Dental Research and the Food and Drug Administration.

Evaluate, assess, treat: development and evaluation of the EAT framework to increase effective communication regarding sensitive oral-systemic health issues.

Oral healthcare providers are likely to encounter a number of sensitive oral/systemic health issues whilst interacting with patients. The purpose of the current study was to develop and evaluate a framework aimed at oral healthcare providers to engage in active secondary prevention of eating disorders (i.e. early detection of oral manifestations of disordered eating behaviours, patient approach and communication, patient-specific oral treatment, and referral to care) for patients presenting with signs of disordered eating behaviours. The EAT Framework was developed based on the Brief Motivational Interviewing (B-MI) conceptual framework and comprises three continuous steps: Evaluating, Assessing, and Treating. Using a group-randomized control design, 11 dental hygiene (DH) and seven dental (D) classes from eight institutions were randomized to either the intervention or control conditions. Both groups completed pre- and post-intervention assessments. Hierarchical linear models were conducted to measure the effects of the intervention whilst controlling for baseline levels. Statistically significant improvements from pre- to post-intervention were observed in the Intervention group compared with the Control group on knowledge of eating disorders and oral findings, skills-based knowledge, and self-efficacy (all P < 0.01). Effect sizes ranged from 0.57 to 0.95. No statistically significant differences in outcomes were observed by type of student. Although the EAT Framework was developed as part of a larger study on secondary prevention of eating disorders, the procedures and skills presented can be applied to other sensitive oral/systemic health issues. Because the EAT Framework was developed by translating B-MI principles and procedures, the framework can be easily adopted as a non-confrontational method for patient communication.

Association of Candida albicans and Cbp+ Streptococcus mutans with early childhood caries recurrence.

Early childhood caries (ECC) recurrence occurs in approximately 40% of treated cases within one year. The association of Streptococcus mutans and Candida albicans with the onset of ECC is well known. Also, S. mutans strains harboring collagen-binding proteins (Cbps) avidly bind to collagen-rich dentin and are linked to increased caries risk. Here, we investigated the presence of Cbp+ S. mutans and C. albicans in saliva and dental plaque of children with varying caries statuses, and their salivary microbiome. In this cross-sectional study, 143 children who were caries-free (n = 73), treated for ECC with no signs of recurrence after 6 months (n = 45), or treated for ECC and experiencing recurrence within 6 months following treatment (n = 25) were enrolled. Co-infection with C. albicans and S. mutans, especially Cbp+ S. mutans, was strongly associated with caries recurrence. Subjects of the recurrence group infected with Cbp+ S. mutans showed a greater burden of Candida spp. and of Mutans streptococci in dentin than those infected with Cbp- strains. Salivary microbiome analysis revealed that Streptococcus parasanguinis was overrepresented in the caries recurrence group. Our findings indicate that Cbp+ S. mutans and C. albicans are intimately associated with caries recurrence, contributing to the establishment of recalcitrant biofilms.

Design and statistical analysis of oral medicine studies: common pitfalls.

A growing number of articles are emerging in the medical and statistics literature that describe epidemiologic and statistical flaws of research studies. Many examples of these deficiencies are encountered in the oral, craniofacial, and dental literature. However, only a handful of methodologic articles have been published in the oral literature warning investigators of potential errors that may arise early in the study and that can irreparably bias the final results. In this study, we briefly review some of the most common pitfalls that our team of epidemiologists and statisticians has identified during the review of submitted or published manuscripts and research grant applications. We use practical examples from the oral medicine and dental literature to illustrate potential shortcomings in the design and analysis of research studies, and how these deficiencies may affect the results and their interpretation. A good study design is essential, because errors in the analysis can be corrected if the design was sound, but flaws in study design can lead to data that are not salvageable. We recommend consultation with an epidemiologist or a statistician during the planning phase of a research study to optimize study efficiency, minimize potential sources of bias, and document the analytic plan.

Dental and other health care visits among U.S. adults with diabetes.

OBJECTIVE: This study compared yearly dental visits of diabetic adults with those of nondiabetic adults. For adults with diabetes, we compared the frequency of past-year dental visits with past-year visits for diabetes care, dilated eye examinations, and foot examinations. RESEARCH DESIGN AND METHODS: We conducted a cross-sectional study using a sample of 105,718 dentate individuals aged > or =25 years, including 4,605 individuals with diabetes who participated in the 1995-1998 Behavioral Risk Factor Surveillance System in 38 states. RESULTS: Dentate adults (i.e., those with at least some natural teeth) with diabetes were less likely than those without diabetes to have seen a dentist within the preceding 12 months (65.8 vs. 73.1%, P = 0.0000). Adults with diabetes were less likely to have seen a dentist than to have seen a health care provider for diabetes care (86.3%); the percentage who saw a dentist was comparable with the percentage who had their feet examined (67.7%) or had a dilated eye examination (62.3%). The disparity in dental visits among racial or ethnic groups and among socioeconomic groups was greater than that for any other type of health care visit for subjects with diabetes. CONCLUSIONS: Promotion of oral health among diabetic patients may be necessary, particularly in Hispanic and African-American communities. Information on oral health complications should be included in clinical training programs. Oral and diabetes control programs in state health departments should collaborate to promote preventive dental services, and the oral examination should be listed as a component of continuous care in the American Diabetes Association's standards of medical care for diabetic patients.

Oral mucosal smokeless tobacco lesions among adolescents in the United States.

The presence of oral smokeless tobacco lesions among adolescents may be an early indicator of increased risk for oral cancers. Data from the 1986-1987 National Survey of Oral Health in US School Children were used to examine the cross-sectional relationship between the use of tobacco and alcohol and the presence of white or whitish oral soft-tissue lesions. The sample included 17,027 schoolchildren (aged 12 to 17 years) who provided information on the use of snuff, chewing tobacco, cigarettes, and alcohol and who received oral clinical examinations. Smokeless tobacco lesions were detected in 1.5% of students (projects to about 300,000 nationally), including 2.9% of males and 0.1% of females. These lesions were more prevalent among whites (2.0%) than among African-Americans (0.2%) or Hispanics (0.8%). Modeling with multivariate logistic regression revealed that, among white males, current snuff use was the strongest correlate of lesions [odds ratio (OR) = 18.4; 95% confidence interval (CI) = 8.5-39.8], followed by current chewing tobacco use [OR = 2.5; 95% CI = 1.3-5.0]. Lesions were strongly associated with duration, monthly frequency, and daily minutes of use of snuff and chewing tobacco. These data suggest that snuff may be a stronger risk factor than chewing tobacco for smokeless tobacco lesions, but the use of either of these forms of oral tobacco exhibits a dose-response relationship with the occurrence of lesions. We found little evidence that the use of alcohol or cigarettes may increase the risk of smokeless tobacco lesions. Preventing smokeless tobacco lesions and their possible malignant transformation may be best accomplished among adolescents by preventing the use of snuff and chewing tobacco.

Smoking-attributable periodontitis in the United States: findings from NHANES III. National Health and Nutrition Examination Survey.

BACKGROUND: The principal objectives of this study were to examine the relationship between cigarette smoking and periodontitis and to estimate the proportion of periodontitis in the United States adult population that is attributable to cigarette smoking. METHODS: Data were derived from the Third National Health and Nutrition Examination Survey, a nationally representative multipurpose health survey conducted in 1988 to 1994. Participants were interviewed about tobacco use and examined by dentists trained to use standardized clinical criteria. Analysis was limited to dentate persons aged > or =18 years with complete clinical periodontal data and information on tobacco use and important covariates (n = 12,329). Data were weighted to provide U.S. national estimates, and analyses accounted for the complex sample design. We defined periodontitis as the presence of > or =1 site with clinical periodontal attachment level > or =4 mm apical to the cemento-enamel junction and probing depth > or =4 mm. Current cigarette smokers were those who had smoked > or =100 cigarettes over their lifetime and smoked at the time of the interview; former smokers had smoked > or =100 cigarettes but did not currently smoke; and never smokers had not smoked > or =100 cigarettes in their lifetime. RESULTS: We found that 27.9% (95% confidence interval [CI]: +/-1.8%) of dentate adults were current smokers and 23.3% (95% CI: +/-1.2%) were former smokers. Overall, 9.2% (95% CI: +/-1.4%) of dentate adults met our case definition for periodontitis, which projects to about 15 million cases of periodontitis among U.S. adults. Modeling with multiple logistic regression revealed that current smokers were about 4 times as likely as persons who had never smoked to have periodontitis (prevalence odds ratio [ORp] = 3.97; 95% CI, 3.20-4.93), after adjusting for age, gender, race/ethnicity, education, and income:poverty ratio. Former smokers were more likely than persons who had never smoked to have periodontitis (ORp = 1.68; 95% CI, 1.31-2.17). Among current smokers, there was a dose-response relationship between cigarettes smoked per day and the odds of periodontitis (P <0.000001), ranging from ORp = 2.79 (95% CI, 1.90-4.10) for < or =9 cigarettes per day to ORp = 5.88 (95% CI, 4.03-8.58) for > or =31 cigarettes per day. Among former smokers, the odds of periodontitis declined with the number of years since quitting, from ORp = 3.22 (95% CI, 2.18-4.76) for 0 to 2 years to ORp = 1.15 (95% CI, 0.83-1.60) for > or =11 years. Applying standard epidemiologic formulas for the attributable fraction for the population, we calculated that 41.9% of periodontitis cases (6.4 million cases) in the U.S. adult population were attributable to current cigarette smoking and 10.9% (1.7 million cases) to former smoking. Among current smokers, 74.8% of their periodontitis was attributable to smoking. CONCLUSIONS: Based on findings from this study and numerous other reports, we conclude that smoking is a major risk factor for periodontitis and may be responsible for more than half of periodontitis cases among adults in the United States. A large proportion of adult periodontitis may be preventable through prevention and cessation of cigarette smoking.

Loss of periodontal attachment in HIV-seropositive military personnel.

The cross-sectional relationship between severe loss of periodontal attachment (LPA) and worsening immune status due to HIV infection was evaluated in 474 HIV-infected subjects (416 men, 58 women) aged 18 to 49 years who had been classified at stages 1 through 6 of the Walter Reed Army Institute of Research (WR) Staging Classification System. LPA was measured at four sites per tooth using a manual probe; severe LPA was defined as > or = 1 site/subject exhibiting > or = 5 mm LPA. Severe LPA was found in 94 (20%) of the subjects. Modeling with multiple logistic regression analysis revealed that WR stage and peripheral CD4+ lymphocyte cell counts were not significant independent predictors of severe LPA. Severe LPA was more common in subjects at WR stage 5 or 6 who exhibited oral candidiasis (OC), a marker of immune system damage, than in persons at those WR stages without OC (odds ratio = 7.85; 95% confidence interval (CI) = 1.94-31.81). After the analysis controlled for WR stage, younger subjects receiving AZT had greater odds of severe LPA than same-age subjects not taking the drug (e.g., odds ratio for subjects aged 30 years = 2.59; 95% CI = 1.22, 5.49). Other significant predictors in the model included male sex; retired military status; cigarette smoking; and presence of cratered, ulcerated, or necrotic interdental papillae. HIV-associated immune deficiency may be associated with localized severe LPA, but this may be an indirect association due to medication use, opportunistic infection, or other factors not captured by the WR staging system or peripheral CD4+ cell counts.(ABSTRACT TRUNCATED AT 250 WORDS)

Quantifying the diffused benefit from water fluoridation in the United States.

OBJECTIVE: To estimate the total contribution of water fluoridation to caries reduction by including the benefit from the diffusion of fluoride from fluoridated communities to surrounding nonfluoridated communities via the export of bottled beverages and processed foods. METHODS: We analyzed data from the 1986-87 NIDR Children's Survey for 18,507 school children aged 6-17 years who had at least one permanent tooth and for whom a complete fluoride exposure history could be created. To measure water fluoridation exposure, we generated continuous and categorical exposure variables. Years of fluoridation exposure (YFE-continuous) measured the number of years the child lived at residences receiving fluoridated water. Lifetime fluoridation exposure (LFE-categorical) was high if the child lived at residences receiving fluoridated water more than 50% of his life and low, otherwise. We summed the proportion of state population receiving fluoridated water times the number of years the child had lived in each state and then divided this value by the child's age to measure diffusion exposure (DE). We grouped DE into three levels: low (DE<=0.25), medium (0.25=0.55). For each level of DE, we compared the age-adjusted mean DMFS for high and low LFE. In addition we used linear regression to measure the association between DMFS and YFE while controlling for DE, age, exposures to other fluoride sources, and sociodemographic variables. Reported results are significant at P<0.05. RESULTS: Comparison of mean DMFS scores found that the direct benefit of water fluoridation (DMFS(LFE=low) - DMFS(LFE=high)) was 1.44 surfaces among low DE children and 0 among high DE children. The diffused benefit (DMFS(LFE=low, DE=low) - DMFS(LFE=low, DE=high)) was 1.23 surfaces. The regression results were similar and indicated that the direct benefit would be 1.44 fewer DMFS for low DE children and the indirect benefit would be 1.09 fewer DMFS for high DE children. CONCLUSION: Failure to account for the diffusion effect may result in an underestimation of the total benefit of water fluoridation, especially in high diffusion exposure regions.

An economic evaluation of community water fluoridation.

OBJECTIVE: The purpose of this research was to assess the local cost savings resulting from community water fluoridation, given current exposure levels to other fluoride sources. METHODS: Adopting a societal perspective and using a discount rate of 4 percent, we compared the annual per person cost of fluoridation with the cost of averted disease and productivity losses. The latter was the product of annual dental caries increment in nonfluoridated communities, fluoridation effectiveness, and the discounted lifetime cost of treating a carious tooth surface. We obtained or imputed all parameters from published studies and national surveys. We conducted one-way and three-way sensitivity analyses. RESULTS: With base-case assumptions, the annual per person cost savings resulting from fluoridation ranged from $15.95 in very small communities to $18.62 in large communities. Fluoridation was still cost saving for communities of any size if we allowed increment, effectiveness, or the discount rate to take on their worst-case values, individually. For simultaneous variation of variables, fluoridation was cost saving for all but very small communities. There, fluoridation was cost saving if the reduction in carious surfaces attributable to one year of fluoridation was at least 0.046. CONCLUSION: On the basis of the most current data available on the effectiveness and cost of fluoridation, caries increment, and the cost and longevity of dental restorations, we find that water fluoridation offers significant cost savings.

Adult dental visits in California: successes and challenges.

OBJECTIVES: This study sought to estimate and characterize the proportion of California adults who visited a dentist in the preceding year and to identify reasons for not going. METHODS: In 1995, 4,029 adults were interviewed by telephone as part of the California Behavioral Risk Factor Surveillance System. Items included recentness of a dental visit, dental insurance status, and number of teeth lost due to disease. Persons who had not seen a dentist within the preceding year were asked the main reason they had not gone. RESULTS: In 1995, 65.9% of adults reported visiting a dentist in the preceding twelve months. Use of dental services was greater among persons aged 35 years or older (70.4%) than among those aged 18-34 years (58.4%) and among those with dental insurance (74.9%) than those without (54.4%). Dental visits were less likely among adults living at or below 200 percent of the federal poverty level, those with less than a high school education, and the edentulous. Reasons most commonly cited for not seeing a dentist were no perceived reason to go (37.2%), cost (30.7%), and fear (9.2%). CONCLUSION: Substantial variation in use of dental services exists among California's adults. Achieving equity in access and opportunity for disease prevention in this state may require expanded dental insurance coverage and serious efforts in oral health promotion.

Dentistry's role in tobacco control.

BACKGROUND: Cigarette smoking remains the nation's leading preventable cause of premature mortality. Tobacco use also is responsible for 75 percent of deaths resulting from oral and pharyngeal cancer, more than one-half of the cases of periodontitis and numerous other oral health effects. METHODS: The author summarized the prevalence of tobacco use in the United States, evaluated recent literature on the status of tobacco control activities in dental schools and dental practice, and reviewed new guidelines on clinical and community-based interventions for tobacco use. RESULTS: Nearly 25 percent of adults and 35 percent of high-school students smoke cigarettes, and many use other forms of tobacco. More than one-half of adult smokers and nearly three-fourths of adolescents see a dentist each year. However, more than 40 percent of dentists do not routinely ask about tobacco use, and 60 percent do not routinely advise tobacco users to quit. Meanwhile, less than one-half of dental schools and dental hygiene programs provide clinical tobacco intervention services. CONCLUSIONS: At least 50 dental organizations have adopted policy statements about tobacco use, but much work needs to be done in translating those policy statements into action. Tobacco use remains prevalent in the United States, and dentistry has not yet maximized its efforts to reduce it. PRACTICE IMPLICATIONS: The recently issued U.S. Public Health Service guidelines on treating tobacco use and dependence provides evidence-based, practical methods for dentists and other primary care providers to incorporate into their practice. Because dentists and dental hygienists can be effective in treating tobacco use and dependence, the identification, documentation and treatment of every tobacco user they see need to become a routine practice in every dental office and clinic.

Chewing tobacco use and dental caries among U.S. men.

BACKGROUND: Chewing tobacco has high levels of sugars and may be cariogenic, but few studies have investigated such an association. This study examined the relationship between chewing tobacco use and dental caries among U.S. adult men. METHODS: Participants in the Third National Health and Nutrition Examination Survey conducted from 1988 to 1994 were interviewed about tobacco use and examined by dentists. The authors included in their analysis dentate men 18 years of age or older. They calculated the mean number of decayed or filled permanent teeth, or DFT, and decayed or filled coronal tooth surfaces, or DFS, as well as the mean number and percentage of decayed or filled root surfaces, or RDFS, and decayed root surfaces, or RDS, by tobacco-use status. They used multiple logistic regression to examine the association between chewing tobacco use and root-surface caries. RESULTS: Men who currently used only chewing tobacco had a higher adjusted mean number of DFT than did those who currently used only snuff, only cigarettes or more than one form of tobacco or who never used tobacco. Mean DFS also was higher among chewing tobacco users than among those who used only snuff, only cigarettes or more than one form of tobacco. Chewing tobacco users had a higher mean RDFS and RDS than did the users of other forms of tobacco or nonusers. Current users of chewing tobacco were more than four times as likely as those who never used tobacco to have one or more RDFS or RDS, with a dose-response relationship between number of packages used per week and odds of having root-surface caries. CONCLUSIONS: In addition to its established role as a carcinogen, chewing tobacco may be a risk factor in the development of root-surface caries and, to a lesser extent, coronal caries. This may be due to high sugar content, increased gingival recession and enhanced collagenase activity. CLINICAL IMPLICATIONS: Interventions by dentists and other members of the oral health care team to prevent tobacco use and help users quit can reduce the risk of developing oral and systemic disease.

Do dentists and physicians advise tobacco users to quit?

To examine dentists' and physicians' effectiveness in advising patients who use tobacco to quit, the authors estimated the percentages of smokers in the United States who visited a dentist or physician in the preceding year, the percentages of those who were advised by their health care provider to quit and the percentages of those who planned to quit smoking. They also estimated the percentage of smokeless tobacco users who were ever advised by their dentist or physician to quit. The results of the study indicate that dentists and physicians may not be maximizing their opportunities to advise their patients who use tobacco to quit, or they are not adequately communicating to their patients the importance of quitting.

Microcanals of dentin associated with maxillary primary anterior teeth.

PURPOSE: This study was performed to estimate the prevalence of giant dentin tubules or microcanals in primary maxillary anterior teeth. METHODS: One hundred sixty eight extracted or exfoliated primary maxillary anterior teeth were sectioned and examined by optical microscopy and image analysis. Differences in the proportion of teeth with microcanals among tooth types were tested by using the Pearson chi-square test. RESULTS: Microcanals, having the appearance of enlarged dentin tubules, were found in approximately 20% of primary central and lateral incisors, but were significantly less prevalent (3%) in primary cuspids. Microcanals occurred in a mesial distal axial plane and ran between the DEJ and the pulp chamber. When present they numbered between 1 and 43, with mean numbers of 20 and 16 in central and lateral incisors, respectively. The microcanals ranged in size between 5 and 70 microns, compared to normal dentin tubule diameters of approximately 1 micron. CONCLUSIONS: Microcanals are relatively common in primary maxillary incisors, but uncommon in primary cuspids. Additional work is needed to establish their prevalence in various teeth of both primary and permanent dentition.