Identification of yeast in chronic wounds using new pathogen-detection technologies.

OBJECTIVE: To evaluate the ability of two new diagnostic methods to detect and accurately identify yeast associated with chronic wound infections. METHOD: Fungal tag-encoded FLX amplicon pyrosequencing (fTEFAP), a universal fungal identification method, bacterial tag-encoded FLX amplicon pyrosequencing (bTEFAP), a universal bacterial identification method, and a new quantitative polymerase chain reaction (qPCR) wound pathogen panel were used to evaluate three chronic wounds suspected to contain yeast. RESULTS: Forty wound samples were analysed in addition to the three samples suspected of containing yeast. The qPCR panel, which targets Candida albicans, detected this yeast in two of the three wound samples. In contrast, fTEFAP detected yeast in each of the three samples: two showed Candida albicans and the third Candida parapsilosis. fTEFAP also identified a lower level of Candida tropicalis in one of the wounds that was positive for Candida albicans. The qPCR wound panel results were returned within two hours, while the fTEFAP results were returned within 24 hours. CONCLUSION: Two new molecular methods have been developed to aid wound pathogen diagnostics. The quantitative PCR wound panel is rapid but is limited to major wound-associated bacteria and yeasts. The universal fTEFAP and bTEFAP methods take 24 hours to return results but are able to detect the relative contribution of any bacteria of yeast in a chronic wound diagnostic sample. DECLARATION OF INTEREST: Southwest Regional Wound Care Center is a clinical wound-care provider seeking to improve the ability of wound care practitioners to help patients. The Research and Testing Laboratory develops molecular methods including fTEFAP, bTEFAP and the quantitative PCR wound panel.

Public policy and the market for dental services.

Social inequality in access to oral health care is a feature of countries with predominantly privately funded markets for dental services. Private markets for health care have inherent inefficiencies whereby sick and poor people have restricted access compared to their healthy and more affluent compatriots. In the future, access to dental care may worsen as trends in demography, disease and development come to bear on national oral healthcare systems. However, increasing public subsidies for the poor may not increase their access unless availability issues are resolved. Further, increasing public funding runs counter to policies that feature less government involvement in the economy, tax policy on private insurance premiums, tax reductions and, in some instances, free-trade agreements. We discuss these issues and provide international examples to illustrate the consequences of the differing public policies in oral health care. Subsidization of the poor by inclusion of dental care in social health insurance models appears to offer the most potential for equitable access. We further suggest that nations need to develop national systems capable of the surveillance of disease and human resources, and of the monitoring of appropriateness and efficiency of their oral healthcare delivery systems.

Chemotherapy effects on hepatoblastoma. A histological study.

The histopathological features of hepatoblastoma in 17 patients treated with preoperative chemotherapy were compared with those in 11 patients not subjected to chemotherapy during the same 11-year period. Tumor necrosis was more extensive in patients receiving preoperative chemotherapy. Two tumors, however, were apparently unaffected by chemotherapy. There was no obvious correlation between the extent of necrosis and the number of courses of chemotherapy. There also seems to be no evidence of preferential ablation of a particular morphological type of tumor. The most notable feature in cases treated with chemotherapy was the extensive presence of osteoid. Osteoid was present in 36% of untreated cases, occupying < 5% of the surface area, compared with 82% in the treated group. In seven cases, osteoid occupied > 40% of the surface area. This finding raises speculation about the role of chemotherapy in the maturation of tumors that have an inherent ability to differentiate. A long-term study is needed to clarify the prognostic significance of mature heterologous elements in hepatoblastoma.

Risk indicators and risk markers for periodontal disease experience in older adults living independently in Ontario, Canada.

This study examined risk indicators and risk markers for periodontal disease experience in 624 adults aged 50 years and over living independently in four communities in Ontario, Canada. The data were collected as part of the baseline phase of a longitudinal study of the oral health and treatment needs of this population. Periodontal disease experience was assessed in terms of attachment loss, measured at two sites on each remaining tooth. Bivariate and multivariate analyses were used to examine the relationship between a number of sociodemographic, general health, psychosocial, and oral health variables and three indicators of periodontal disease experience. These were: mean attachment loss, the proportion of sites examined with loss of 2 mm or more, and the probability of the subjects having severe disease, arbitrarily defined as a mean attachment loss in the upper 20th percentile of the distribution. Mean attachment loss was 2.95 mm (SD = 1.41 mm), and 76.6% of sites examined had loss of 2 mm or more. In bivariate analyses, the most consistent predictors of periodontal disease experience were: age, education, income, smoking, dental visiting, the number of remaining teeth, the number of decayed coronal surfaces, and the number of decayed root surfaces. In multivariate analyses, age, education, current smoking status, and the number of teeth had the most consistent independent effects. These data confirm the results of recent US studies indicating that periodontal disease experience is influenced by social and behavioral factors.

Prevalence of and factors associated with root decay in older adults in Canada.

We collected data on the oral health status and treatment needs of a random sample of persons aged 50 years and over. Data on root decay were obtained from the 183 subjects who were dentate. All remaining teeth were examined for root decay and restorations, whether root surfaces were affected by recession or not. Analysis was undertaken by case and root surface, with separate analyses of decayed (DS), and decayed and filled (DFS) root surfaces. One or more root surfaces with untreated decay were found in 37.2% of subjects, while one or more decayed or filled root surfaces were found in 56.8%. The mean number of decayed surfaces was 1.3 per person, and the mean number of decayed and filled root surfaces was 2.6. Multiple and logistic regression analyses showed that oral health variables were more important predictors of the presence and severity of root decay than demographic, general health, or dental care factors.

Incidence of and risk factors for tooth loss in a population of older Canadians.

Data on the incidence of tooth loss in community-dwelling older Canadians have not previously been reported. Since recent US studies of older adults were conducted in predominantly rural communities, their results may not be generalizable to Canada, where the majority of older adults live in major metropolitan or urban settings. This paper describes a study designed to estimate the incidence of tooth loss in older Canadians and to identify factors predictive of that loss. Using personal interviews and clinical examinations, we obtained baseline and three-year follow-up data from 491 dentate subjects. Overall, 23.2% lost one or more teeth between baseline and follow-up. Only six, or 1.2%, became edentulous. Twelve baseline factors were significantly associated with the probability of loss. However, in a logistic regression analysis, only five had significant independent effects. These were gender, marital status, self-rating of oral health status, the number of decayed root surfaces, and a mean periodontal attachment loss of 4 mm or more. The predictive ability of the model was poor, largely because tooth loss is a complex outcome which depends on decisions taken by dentists and patients. Since this decision-making process cannot be captured in epidemiological studies, observational studies are needed to cast further light on tooth loss in this population.

Risk factors for dental fluorosis in a fluoridated community.

We conducted a case-control study to determine the sources of fluoride which are particular risk factors to dental fluorosis. Cases and non-cases were identified by the screening of 8-, 9-, and 10-year-old schoolchildren in the fluoridated community of East York, Ontario. Parents were interviewed about the child's first five years of residence and about diet and preventive caries practices. The Mantel-Haenszel odds ratio and associated chi-square tests were used to assess the association of fluorosis with several potential sources, controlling for other sources of fluoride and mother's education. The prevalence of mild fluorosis [1-4 on the Thylstrup and Fejerskov (1978) Index] was 13%. Those who brushed their teeth before the age of 25 months had 11 times the odds of fluorosis compared with those beginning toothbrushing later; prolonged use of infant formula (greater than or equal to 13 months) was associated with 3.5 times the risk of fluorosis, compared with no, or shorter duration of, formula use. We estimate that these factors were responsible for 72% and 22%, respectively, of the cases in our population. Dental fluorosis is not a public health problem in East York, but parents should be advised to supervise toothbrushing by children under 2 years of age.

Oral health and family characteristics of children attending private or public dental clinics.

The City of North York Public Health Department (NYPHD) operates a school-based dental programme that provides preventive and treatment services to children according to evidence-based practice guidelines. This programme and private dental practices (PDP) represent the only sources of dental care for children in North York. The purpose of our study was to compare the oral health and family characteristics of clients from the NYPHD and PDP using a dental examination and a parent interview. Results showed that NYPHD and PDP clients had similar levels of fluorosis, calculus, and periodontal health, but NYPHD clients had experienced greater levels of decay. Clients of the NYPHD and PDP also had significantly different family characteristics, many of which were significantly associated with the presence of one or more decayed primary or permanent teeth. Multivariate logistic regression identified mother's immigration history, past caries experience, and parents' rationale for scheduling their child's dental appointments as the principle risk makers for dental decay. When compared with PDP clients, the NYPHD serves higher-needs children who otherwise might not receive care.

Differences in oral health status between institutionalized and non-institutionalized older adults.

Differences in oral health status between independent and institutionalized adults have been difficult to interpret because the latter population is typically older and has a higher proportion of women, confounding any association between institutionalization and disease levels. We undertook an analysis of oral disease amongst institutionalized (n = 149) and non-institutionalized (n = 246) samples of older adults randomly selected from the population in East York, Ontario. When the confounding effects of age and gender were controlled by constructing 67 matched pairs, institutionalized people were more than twice as likely to be edentulous (OR = 2.17, 95% CI = 1.09-4.29). This association was confirmed using data from all subjects in a logistic regression model. Analysis of covariance of data from dentate subjects revealed that the institutionalized seniors had fewer filled teeth (P less than 0.05, controlling for age and sex), but there were no statistically significant differences in the number of teeth which were missing, decayed, or requiring extraction. These findings suggest that antecedent, sociodemographic factors prior to institutionalization are responsible for the higher probability of oral disease in this group of older adults.

Observer agreement in the grading of oral epithelial dysplasia.

OBJECTIVES: To determine the extent of observer agreement in diagnosis of oral epithelial dysplasia (OED). Published studies of OED examiner agreement report relatively low agreement levels; however, these studies were limited by the methodologies employed. METHODS: For this study, 64 slides were each independently examined twice by three oral pathologists. Consistency was assessed by determining intra- and interexaminer agreement. Conformity was assessed by using the modal diagnosis as a gold standard. RESULTS: The group showed moderate interobserver agreement when grading the presence or absence of OED with a group-simple kappa (Ks) of 0.51 (95% CI = 0.42-0.61), and substantial agreement when using a 5-point ordinal scale with a group-weighted kappa (Kw) of 0.74 (95% CI = 0.64-0.85). The group showed fair to substantial intraexaminer agreement when assessing the presence or absence of OED, with Ks ranging from 0.22 to 0.78, and showing almost a perfect agreement using a 5-point ordinal scale, with Kw ranging from 0.82-0.96. Conformity with the comparison standard modal diagnosis was almost perfect, with pairwise Kw ranging from 0.81 to 0.92. CONCLUSION: Overall, there was substantial intra- and interobserver consistency and almost perfect conformity in the grading of OED. Appropriate statistical methods are necessary to determine the degree of observer agreement.

Income inequalities in oral health among older adults in four Ontario communities.

We used data from telephone interviews, personal interviews and clinical examinations to assess income inequalities in oral health among older adults living in four Ontario communities. Lower income groups had significantly higher rates of edentulism than upper income groups. In dentate subjects aged 50 to 64 years, significant associations were observed between income and 9 of 10 clinical, functional and subjective oral health indicators. Among those aged 65 years and over, associations were found for only 5 of these indicators. The data suggested that the association between income and clinical and functional measures of oral health was stronger among those aged 50 to 64 years, while the association between income and subjective indicators was stronger among those aged 65 years and over. No association was noted between income and oral health status among edentulous subjects. These observations are difficult to explain because of the cross-sectional nature of the study and the complexity of the processes which may lead to social inequalities in health. Nevertheless, the data do suggest the need for the targeting of oral health promotion programs and appropriate dental services at disadvantaged groups.

The response rate problem in oral health surveys of older adults in Ontario.

We undertook two surveys of older adults in Ontario to estimate the proportion in need of dental treatment. Because we expected low response rates, these studies were designed to assess 1) the effect of response enhancement strategies on participation, and 2) the extent of bias in estimates of treatment needs resulting from less than acceptable response rates. Our response enhancement strategies did not improve response rates substantially. In both surveys, there were significant differences in the characteristics of responders and nonresponders. Nevertheless, there was little difference in crude estimates of the prevalence of treatment needs and adjusted estimates taking account of non-response bias. We conclude that, while high response rates should always be the aim, low response rates do not necessarily compromise the results of descriptive epidemiological studies.

The oral health status and treatment needs of adults aged 65+ living independently in Ottawa-Carleton.

We report the findings from a dental survey of a random sample of 299 senior citizens living in Ottawa-Carleton. Those examined were younger, less likely to have a regular dentist, and more likely to have oro-facial pain, difficulty chewing, and to perceive a need to visit a dentist compared with those responding to the enrollment phone interview. Among the 65% of seniors who were dentate, 37% had dental decay; men and seniors with low incomes had more decay (p less than 0.05). Periodontal disease was worse among older seniors, men and poor seniors (p less than 0.05). One third of all seniors reported recent oro-facial pain, 50% had difficulty chewing foods and 30% reported some social impact resulting from their oral health. The resources required to treat the prevalent disorders were considerable and differences between dentate and edentulous people were negligible. Senior citizens expressed attitudes which indicate that they value dental health and would like help to achieve it.

Results of the socio-dental survey of people aged 50 and older living in East York, Ontario.

We determined the oral health status and treatment needs of the current and future elderly in East York and tested four enrollment strategies for community-based surveys. We selected our sample from the Municipal Composite Report and obtained the data using a multi-item questionnaire and a clinical examination. The examination protocol was based on World Health Organization (WHO) methodology but was expanded to provide tooth surface specific information. Of those contacted by telephone and repeated mailings, 35% participated. The sample appeared representative of the community as determined by a follow-up mail survey of non-respondents. 76% of those examined were dentate and 71% had visited the dentist within the last two years. Nonetheless, 27% had chewing impairment, 15% had discomfort with their teeth and 15% needed care urgently. Treatment needs were highest for the 187 dentate. They required 504 extractions or restorations and 113 denture services. Periodontal care for calculus and pockets was needed by 86% of the dentate. This report shows an apparent contradiction of high dental treatment needs remaining in the context of reported high care-seeking rates.

Economic issues in the development and use of practice guidelines: an application to resource allocation in dentistry.

In this paper, the extent to which practice guidelines using cost-effectiveness data can be used to inform programme decisions is analysed. In particular it is shown that guidelines aimed at informing individual patient-provider decisions are unable to reflect the economic concepts that are required to inform public decisions concerned with making best (i.e., most productive) use of the resources available to serve defined populations. The research on which practice guidelines are based represents an important but incomplete source of information for taking decisions about which clients to serve, with which services, and when in the disease process, in the context of provision of services to groups or populations. Moreover, the inappropriate use of 'individually focused' guidelines to inform 'collectively-focused' decisions can lead to more harm than good. An alternative approach for dealing with the difficult choices faced by decision makers involved in public programmes is identified. An illustration of the proposed approach is presented concerning the provision of pit and fissure sealants to children served by a public health clinic.

Developing evidence-based programme guidelines for children's dental care in a dental public health unit in Ontario, Canada.

The North York Public Health Department operates a school-based dental care programme. Dental care providers are expected to follow guidelines in order that the programme shall achieve the best outcomes for the clients served. A model is described by which published evidence informs the guideline development process. The process is considered to require knowledge of the epidemiology of dental disease in the target population; skills in collecting, critically appraising and summarising the scientific literature; working with internal and external advisory panels to write the guidelines; disseminating results and assessing both compliance and health outcomes. This work is one example of a larger trend to evidence-based health care.

Estimation of procedure times in a publicly funded dental programme.

For the purposes of planning and evaluation, knowing the time-costs associated with each dental procedure carried out in a publicly funded dental programme is very helpful. This knowledge, along with the expected or known benefits, also allows researchers to assess the efficacy of a dental procedure. However, only a few estimates of dental procedure times exist in the literature, and most of these focus on restorative treatments. The North York Public Health Department operates a school-based public dental programme, where each dental procedure carried out by a dentist or hygienist is entered into a dental management information system database, along with the date of the procedure and the hours worked by the provider on that date. Using these data and multiple regression analyses it was possible to estimate the average time required to carry out the most common procedures in North York's dental programme. These estimates were found to be similar to estimates published in the dental literature and very similar to estimates of the Ontario Dental Association. Thus, this method of calculating procedure times appears valid and may be very useful to managers of public dental programmes and public dental health researchers.

An index of chewing ability.

This study was carried out to develop and test an index of chewing ability suitable for epidemiologic surveys. Existing data on older adults living independently in East York, Ontario, were reanalyzed and the index was developed using techniques of scalogram analysis. Individuals were scored from 0 to 5 based on their self-reported ability to chew the most difficult of five foods. In this representative sample, 77 percent scored 5. The index has high predictive values when compared to two other questions on chewing ability in the survey. Among those with chewing disability (scoring 0 to 4), the odds ratio (OR) for being edentulous was 4.1 (95%) Cl = 2.1-8.3). No factor influenced chewing ability among the edentulous. Among the dentate, several clinical dental health status measures appeared to influence chewing ability. Logistic analysis identified the absence of functioning opposing pairs of natural posterior teeth, OR 5.6 (95% Cl = 2.21-14.39), and the need for urgent care, OR 23.7 (95% Cl = 1.05-6.95), as the most important.

Coronal and root decay experience in older adults in Ontario, Canada.

This paper describes the coronal and root caries experience of subjects aged 50 years and older living in four communities in Ontario, Canada. The data were obtained as part of a comprehensive epidemiologic study of the oral health and treatment needs of this population. Caries experience was defined as the number of decayed and filled coronal and root surfaces per subject. Of 907 subjects interviewed and clinically examined, 78.3 percent were dentate and retained a mean of 18.9 teeth. The mean number of coronal decayed and filled surfaces was 23.9; 95.6 percent of subjects had at least one coronal DFS. The mean number of decayed and filled root surfaces was 3.6; 70.9 percent had at least one root DFS. The percent D/DFS was 3.5 for coronal and 20.0 for root caries. In linear regression analysis the number of teeth, making regular preventive visits, being born in Canada, and educational status emerged as predictors of coronal DFS. Predictors of root DFS were the number of surfaces with recession, the number of coronal DFS, the number of teeth, age, sex, and smoking status. These variables accounted for 42 percent and 35 percent of the variance in the number of coronal and root DFS, respectively.

Periodontal attachment loss in independently living older adults in Ontario, Canada.

This paper describes the periodontal disease experience of a community-dwelling population aged 50 years and older, living in four communities in Ontario, Canada. The periodontal status of this population was assessed using attachment loss and the extent and severity index. Attachment loss was measured at two sites on each tooth using a pressure-sensitive periodontal probe. Complete periodontal data were obtained on 624 subjects. The mean number of sites per subject was 37.9. In line with recent US studies, the diagnostic threshold for a diseased or previously diseased site was set at 2 mm of loss. The overall mean attachment loss was 2.95 mm, with 19.7 percent of subjects having an overall mean attachment loss of 4.00 mm or more. The proportion of sites examined with loss of attachment of 2 mm or more was 77 percent. The severity of disease, defined as the average distance between the base of the sulcus or pocket and a point 1.00 mm apical to the cemento-enamel junction in sites with loss of 2 mm or more was 2.44 mm. These data indicate that the extent and severity of disease in this population were greater than that reported by some recent studies in the US. Taken together, the results of these studies suggest that there is some variation in the periodontal disease experience of population subgroups across North America.