Cluster Effects in a National Dental PBRN restorative study.

Items in clusters, such as patients of the same clinician or teeth within the same patient, tend to be more similar than items from different groups. This within-group similarity, represented by the intraclass correlation coefficient (ICC), reduces precision, yielding less statistical power and wider confidence intervals, compared with non-clustered samples of the same size. This must be considered in the design of studies including clusters. We present ICC estimates from a study of 7,826 restorations placed in previously unrestored tooth surfaces of 4,672 patients by 222 clinicians in the National Dental Practice-Based Research Network, as a resource for sample size planning in restorative studies. Our findings suggest that magnitudes of ICCs in practice-based research can be substantial. These can have large effects on precision and the power to detect treatment effects. Generally, we found relatively large ICCs for characteristics that are influenced by clinician choice (e.g., 0.36 for rubber dam use). ICCs for outcomes within individual patients, such as tooth surfaces affected by a caries lesion, tended to be smaller (from 0.03 to 0.15), but were still sufficiently large to substantially affect statistical power. Clustering should be taken into account in the design of oral health studies and derivation of statistical power estimates for these studies (ClinicalTrials.gov, NCT00847470).

Differences between reported and actual restored caries lesion depths: results from The Dental PBRN.

OBJECTIVE: The objectives of this research were to (1) quantify the discordance between the caries lesion depth at which dentists restored initial lesions during a clinical study ("actual depth") and the lesion depth that they reported during a hypothetical clinical scenario ("reported depth"); (2) test the hypothesis that certain practitioner, practice, patient, and caries lesion characteristics are significantly associated with this discordance. METHODS: Practitioner-investigators who perform restorative dentistry in their practices completed an enrollment questionnaire and participated in two consecutive studies on caries diagnosis and treatment. The first study was a survey asking about caries treatment. The second study collected data on restorations placed in routine clinical practice due to caries in patients over 19 years of age on occlusal surfaces only or proximal surfaces only. We report results on 2691 restorations placed by 205 dentists in 1930 patients with complete data. RESULTS: Discordance between actual depth and reported depth occurred in only about 2% of the restorations done due to proximal caries, but about 49% of the restorations done due to occlusal caries. Practice type, restorative material used and the diagnostic methods used were significantly associated with discordance. CONCLUSION: Dentists frequently restored occlusal caries at a shallower depth as compared to their reported depth, but the discordance was very small for proximal lesions. Discordance for occlusal caries was more common when radiographs were not taken or if a resin restoration was placed.

Predictors of change in satisfaction with chewing ability: a 24-month study of dentate adults.

People's satisfaction with chewing ability is not determined entirely by their mechanical chewing function. Instead, it is a complex measure that embraces broad physical, social and psychological components. Using data from the Florida Dental Care Study, a prospective longitudinal study of oral health and dental care, this current study aimed to identify the longitudinal relationships between changes in satisfaction with chewing ability and changes in other dimensions of oral health and oral health-related quality of life (OHRQoL). A multidimensional conceptual model of oral health and OHRQoL was applied to guide the analysis. Most dentate people were satisfied with their chewing ability. However, changes in satisfaction with chewing ability were common: nearly 11-22% of subjects experienced improved satisfaction, depending on the interval; while about 12-18% of subjects experienced deteriorated satisfaction by the end of the interval. Changes in satisfaction with chewing ability were significantly associated with changes in other aspects of oral health and OHRQoL. Onset of certain oral health problems/conditions or constantly having such problems was associated with a lower probability of reporting improvement in satisfaction and a higher probability of experiencing deterioration. In contrast, recovery from certain oral health problems/conditions or not having such problems was associated with a higher probability of improvement and a lower probability of deterioration.

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.

Coping with tooth pain: a qualitative study of lay management strategies and professional consultation.

This research analyzes transcripts of semi-structured interviews with patients presenting with tooth pain at a rural dental clinic in North Florida. The primary objectives are to identify the strategies patients use to manage their pain and to elucidate the decision-making process leading to the clinic visit. Although respondents understood that their condition was not self-limiting, only about one-half contacted the clinic within several days of the onset of their pain. Most tried one or more lay management strategies.

Evaluation for an observation effect in a prospective cohort study of oral health outcomes.

OBJECTIVES: Evaluation for changes in behavior due to research participants' knowledge that behavior is being observed (also referred to as a Hawthorne effect or reactivity) has received little attention in the dental literature. The Florida Dental Care Study, a prospective, non-randomized, longitudinal study of oral health outcomes, provides some inferential power to evaluate for an effect on dental care use due to participants' knowledge that this behavior was being observed. The purpose of this paper is to document that an observation effect can occur in dental studies, and to estimate its magnitude in four groups that were defined by their typical approach to dental care as stated at baseline: consistent regular attenders (CRAs); inconsistent regular attenders (IRAs); consistent problem-oriented attenders (CPOAs); and inconsistent problem-oriented attenders (IPOAs). METHODS: At baseline, 873 respondents with at least one natural tooth and who were 45 years of age or older participated for an interview and clinical dental examination. Respondents were asked about their dental care use in general and check-up use in particular at 6-month intervals over a period of 24 months. RESULTS: Dental care use in general and check-up use in particular varied across time points and across the four groups of the sample. There was some stimulation in dental care use for the sample overall, but by the 18-to-24-month period, use had returned to baseline levels. In a direction opposite from that hypothesized, results from the CRAs suggested decreased use of dental care over the course of the 24 months of observation. No consistent pattern was evident for the IRAs, CPOAs, or IPOAs. CONCLUSIONS: An observation effect was evident, but was modest in magnitude and differed within and between sub-groups of the sample. While self-selection into dental care user groups is an expected and desirable feature of this design, the size of the user/non-user groups was affected for some subgroups. We conclude that dental care studies with the potential for an observation effect should evaluate for this effect by distinguishing sub-groups of the sample based on their propensity (as stated at baseline) to use dental care. These differential effects across sub-groups should be taken into account as inferences are made.

Taking dental self-care to the extreme: 24-month incidence of dental self-extractions in the Florida Dental Care Study.

OBJECTIVE: A common response to health-related symptoms is to treat oneself in lieu of or prior to seeking formal health care. Among the more extreme forms of dental self-care is dental self-extraction. To our knowledge, no study of the incidence of this behavior has been conducted. The objective of this study was to determine if one form of dental self-care, dental self-extraction, is a real phenomenon, and if so, to determine its incidence. METHODS: The Florida Dental Care Study is a longitudinal study of changes in oral health, whose subjects participated for an interview and clinical examination at baseline and 24 months after baseline. RESULTS: Of the 739 persons who participated through 24 months 176 lost one or more teeth. Of these 176 persons, 13 (7%) extracted one or more of their own teeth. The clinical status at baseline of the self-extracted teeth was consistent with the ability to self-extract. CONCLUSION: The phenomenon of dental self-extraction is real and is not limited to residents of developing nations or geographically isolated areas. Because of the potential for prolonged bleeding or bacterial endocarditis in certain population groups, community health clinicians and officials should be cognizant of this behavior.

Dietary implications of oral health decrements among African-American and white older adults.

OBJECTIVE: Older African-Americans are at disproportionate risk of chronic, nutritionally-related diseases. To begin to understand factors that may contribute to the disproportionate prevalence of life-threatening illnesses among African-Americans, this study investigates ethnic differences in the prevalence of oral health decrements. DESIGN: The Florida Dental Care Study (FDCS), a longitudinal study of changes in the oral health of 873 subjects age 45+, was used to explore a broad range of oral health status differences between African-Americans and White adults in the United States. The FDCS consists of clinical and self-reported measures of oral health, sociodemographic information, and other indicators of oral functional status. RESULTS: The prevalence of oral health decrements in this sample using a broad range of clinical and self-reported measures was substantial. African-American elders were at a heightened risk of poor oral health profiles, including having fewer teeth and being more likely to have a carious surface, fractured cusp or incisal edge, severely mobile teeth and severe periodontal levels than their White counterparts. Furthermore, the African-American respondents in our sample were significantly more likely to report a lower self-rated oral health and functioning than their White counterparts. These findings persist regardless of poverty status or educational level, two factors commonly thought to confound racial differences in health outcomes. CONCLUSION: Our study provides evidence that the widespread prevalence of oral health decrements and accompanying functional disability among this sample of dentate older adults impacts their daily lives. Of particular concern is the oral heath status of older African-Americans who may be nutritionally vulnerable due, in part, to these oral health decrements and disabilities. We suggest enhancing the access of health services in order to prevent those oral health decrements that presumably undermine adequate dietary intake.

Multidimensionality of oral health in dentate adults.

OBJECTIVES: An understanding of the validity and usefulness of self-reported measures (as distinct from clinically determined measures) of oral health is emerging. These self-reported measures include self-rated oral health (SROH). Three objectives were to: (1) describe self-rated oral health in dentate adults, (2) quantify associations between self-rated oral health and other measures of oral health (oral disease and tissue damage, pain and discomfort, functional limitation, and disadvantage), and (3) assess the construct validity of a model of oral health proposed herein. METHODS: The Florida Dental Care Study is a longitudinal study of oral health, which included at baseline 873 subjects who had at least one tooth, were 45 years or older, and who participated for an interview and clinical examination. RESULTS: The prevalence of self-rated oral health decrements was substantial; approximately one fourth of subjects reported their oral health as only fair or poor. Bivariate and multivariate results provided consistent evidence of the construct validity of the proposed model of oral health. Additionally, the salience of one measure of dental appearance suggests that persons may use esthetic cues when rating their oral health. CONCLUSIONS: The proposed multidimensional model of oral health has construct validity. Self-rated oral health is affected by oral disease and tissue damage, oral pain and discomfort, oral functional limitation, and oral disadvantage. These self-reported measures and the proposed model should provide useful information for dental care effectiveness research. General health status has been disaggregated into the "physical" and the "mental;" an additional separation into the "oral" aspects of health seems warranted.

Behavioral risk indicators of attachment loss in adult Floridians.

This study investigated behavioral and sociodemographic risk indicators of attachment loss (AL) at baseline in subjects of the Florida Dental Care Study: 873 subjects with at least 1 tooth, and who were 45+ years or older, participated for an in-person interview and dental examination; 761 subjects were probed for AL. Calibrated examiners used a modified NIDR protocol from the 1985-86 Survey of US Employed Adults and Seniors. Results were weighted to reflect actual population proportions. 92% of subjects had at least 1 site of 4+ mm AL, and 35% had at least 1 severe site (7+ mm AL). In a single multivariate regression, not having a recent dental check-up, not using dental floss, being a current smoker, and being diabetic were significantly associated with a higher probability of having 1 or more severe sites. Blacks were less likely than whites to be regular users of dental care, use dental floss, and be non-smokers. Similar findings were found for low income adults and rural residents. Risk groups (low income, blacks, rural residents) were more likely to present with modifiable risk indicators for AL, suggesting the need for targeted interventions.

Race differences in the health of elders who live alone.

This investigation was initiated to determine whether older African Americans who live alone are in poorer health than their White counterparts who live under the same circumstances. Data on 5 measures of health were collected in telephone interviews with a stratified random sample of community-dwelling elders (n = 1,189). Analysis of weighted data indicate that there were fewer differences in health by race among older persons who lived alone compared to elders who lived with others. Where racial differences in health did exist among older adults who lived alone, the differences could only sometimes be accounted for by population composition factors that are known to influence health.

Dental health attitudes among dentate black and white adults.

OBJECTIVES: Blacks and poor persons share a greater burden of oral disease and are less likely to seek dental care on a regular basis. The role of dental attitudes and knowledge of services on this circumstance is unclear. The authors quantified group differences in dental attitudes and knowledge of services and related them to regularity of dental care use. METHODS: As part of the baseline phase of The Florida Dental Care Study, a longitudinal study of oral health, 873 respondents who had at least one tooth and who were 45 years or older participated for an interview and a clinical dental examination. Dental care use, seven dental attitudinal constructs, and knowledge of dental services were queried. RESULTS: Forty-five percent of respondents reported going to a dentist only when they have a problem, and 17% of respondents had not seen a dentist in more than 5 years. Ten percent of respondents reported that they had at least one permanent tooth removed by someone other than a dentist (typically, the respondent himself). Blacks and poor persons had more negative attitudes toward dental care and dental health and were less knowledgeable of dental services. Multivariate analyses suggested that dental attitudes were important to understanding the use of dental care services for this diverse group of adults, and that race and poverty contributed independently to dental care use even with dental attitudes taken into account. CONCLUSIONS: Dental attitudes contribute to race and poverty differences in dental care use among adults. The persistence of race and poverty effects with attitudes taken into account suggests that additional explanatory factors contribute as well. These differences may contribute to more prevalent and severe oral health decrements among the same adults who also are more likely to suffer from other health decrements.

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.

Perceived need for dental care in dentate older adults.

Previous studies have observed a substantial difference between need for dental care as determined by professional dental examiners (determined by disease presence) and that reported by potential dental patients (which may or may not be based on perceived disease presence). In this study of community-dwelling dentate older adults a substantial difference was also observed. To explore the role that factors other than disease presence may have in determining perceived current need for dental care, subjects were queried about their current oral signs, oral symptoms, psychosocial impacts from oral disease, and other factors hypothesised as affecting current need for dental care. When reporting perceived current need, subjects apparently were not responding to overall assessments of their dental health or periodontal health; rather, they were responding to specific oral signs and symptoms, and their effects. In a multivariate model, dental pain was most strongly associated with perceived need, followed by the psychosocial effects of oral diseases, reported presence of cavities, and reported presence of loose teeth. However, substantial percentages of persons reported oral signs, symptoms, and effects that would be judged professionally as sufficient for reporting a current need for dental treatment, yet did not report a need. With oral signs and symptoms accounted for, persons with less discretionary income and those who were less satisfied with their last dental visit were actually more likely to perceive a current need for dental care.(ABSTRACT TRUNCATED AT 250 WORDS)

Dental care use by U.S. veterans eligible for VA care.

Military veterans eligible for dental care in U.S. Department of Veterans Affairs (VA) facilities cooperated for a mailed survey about their dental care utilization. Subjects were selected because of their eligibility for continuing dental care in VA facilities at no monetary cost. However, only 48% reported the VA as their only or primary source of dental care; this allowed us the opportunity to compare dental care frequency by those who received dental care at no monetary cost with those who did not, as well as measure delivery system effects on dental care use. Consequently, we tested respondent-level and delivery system-level hypotheses regarding determinants of veterans' dental care use. Predisposing characteristics (dentate status, usual reason for dental visits, and the importance placed on dental care and oral health) were the strongest determinants of interval since last dental visit. Enabling determinants (current source of dental care, and having a regular source of care) were also significant, but measures of need for dental care (perceived oral health and perceived need for treatment) were not. More recent dental care use by veterans who used the VA delivery system as their source of dental care, even with dental care payment source and other determinants accounted for, suggests that the VA delivery system may have promoted more regular use compared to other systems.

Factors influencing the effectiveness of mailed health surveys.

The authors investigated sources of bias in health surveys by examining responses to their 1989 questionnaire mailed to 1,255 Massachusetts men who were eligible for dental care provided by the Department of Veterans Affairs. After a maximum of three mailings and one telephone call to nonrespondents, a total of 1,049 veterans had responded out of 1,228 finally determined to be eligible, a response rate of 85 percent. The investigators found that small differences in univariate estimates would have occurred had the field phase been terminated after the first mailing, which had a response rate of 61 percent. To evaluate multivariate distributions, they duplicated their previously published logistic regression model for sources of dental care, using only those who responded to the first and second mailings. Although model fits would have been substantively the same had the field phase been terminated after the first or the second mailings, analysis of parameter estimates and their statistical significances suggested bias that would have led to different substantive conclusions, in some instances. Another potential source of bias in surveys was found to be item omission. Fifty-eight percent of respondents answered all 46 survey questions, and 90 percent answered at least 91 percent of the questions. Fewer questions were answered by those whose responses were received last, but trends regarding missing data by age or education were not statistically significant. Although the survey using this methodology met all objectives, subject nonresponses, the ineligibility of potential respondents, item nonresponses, and skewed distributions of outcome variables combined to reduce the statistical power to detect differences among groups or to alter the analysis of the differences. These factors need to be planned for by investigators undertaking similar surveys.

An operational definition of the homebound.

Homebound status is a critical eligibility criterion for Medicare reimbursement of some home care services, yet little discussion has been undertaken to establish a valid definition of it. We propose an operational definition of homebound status, and we measure its validity for community-dwelling elderly in the Massachusetts Health Care Panel Study (MHCPS). The MHCPS is a longitudinal study of a cohort of elderly persons (N = 1,625), which began in 1974, with follow-up surveys in 1976, 1980, and 1985. Validity was measured by comparing responses from the operational measure to persons' responses to questions that we judged should be associated with a valid measure of homebound status. This construct validity method resulted in correlations that were significant and in the expected direction, and that suggested that this operational measure is a highly specific, moderately sensitive, valid measure. These results underscore the need for researchers investigating the homebound to discuss the validity and limitations of their homebound measures, and in what context these measures are useful.

Eligible veterans' choice between VA-covered and non-VA-covered dental care.

Veterans who were eligible for dental care in Department of Veterans Affairs (VA) facilities at no monetary cost responded to a mailed questionnaire. Seventy-one percent were aware that they were actually eligible for VA dental care. However, only 48 percent reported the VA as their only or primary source of dental care. Eligibility status, perceived quality of VA dental care, use of VA medical care, perception that one's income meets expenses, and perceived need for dental care were significant correlates of using the VA as one's current source of dental care. Level of formal education, perception that one's income meets expenses, transportation pattern, geographic distance from a VA facility, and eligibility status were significant correlates of using the VA as one's current medical care source. Research on VA utilization offers the opportunity to study issues of access to, and use of, a large public health care system whose patients largely receive care at no monetary cost. Veterans' use of VA dental and medical care is apparently influenced by a wide variety of factors, ranging from barriers to access to non-VA systems, to characteristics of the VA delivery system itself, to need for treatment.

Principles of surgical risk assessment of the elderly patient.

Treatment of the elderly will comprise increasingly higher proportions of practice time in the future, and issues regarding this treatment are more salient now than ever before. Because more elders are seeking treatment, surgeons need to be comfortable with assessing the potential risks associated with surgical procedures in their elderly patients, many of whom have multiple chronic diseases. Risks that need to be considered are those physiologic changes normal for aging, pathologic changes due to disease, and psychosocial changes that may occur with aging. This article assesses the contribution each of these changes makes to surgical risk, and discusses the principles of gerontology and geriatric medicine that are relevant to risk assessment.

Issues in financing dental care for the elderly.

The elderly make up an increasingly larger segment of the patient population in dental practices. This article reviews recent epidemiologic, demographic, and health services research, and concludes that significant segments of the elderly are at high risk for oral disease and/or limited access to dental treatment, and consequently warrant classification as high-risk groups for policy considerations. It then proposes policy options to the dental community and public decision makers. Oral care can be viewed as having three components. Two basic components are the primary care component--which includes diagnostic, preventive restorative, and periodontal care--and the acute care component--i.e., the treatment of oral pain, trauma, and infection. The third, rehabilitative component, has to do with the restoration of oral function, including prosthodontics and cosmetic dentistry. Viewing dental care in this perspective may help link funding for dental primary care services with that for other primary health services, and link restoration of function and improvement of quality of life with similar health services, like hearing, vision, and social services. In addition, approaching dental care policy makers on several levels--i.e., federal, state, and local--will contribute to our ability as a profession, in the decades ahead, to meet the oral health needs of more elders: including the frail, those at high risk for oral disease, and those with limited access to care.