Preconception Periodontitis and Risk of Spontaneous Abortion in a Prospective Cohort Study.

Few studies have evaluated the association between periodontitis and spontaneous abortion (SAB), and all had limitations. We used data from the Pregnancy Study Online (PRESTO), a prospective preconception cohort study of 3,444 pregnancy planners in the United States and Canada (2019-2022), to address this question. Participants provided self-reported data on periodontitis diagnosis, treatment, and symptoms of severity (i.e., loose teeth) via the enrollment questionnaire. SAB (pregnancy loss at <20 weeks' gestation) was assessed via bimonthly follow-up questionnaires. Participants contributed person-time from the date of a positive pregnancy test to the gestational week of SAB, loss to follow-up, or 20 weeks' gestation, whichever came first. We fitted Cox regression models with weeks of gestation as the time scale to estimate adjusted hazard ratios (HRs) and 95% confidence intervals (CIs), and we used inverse probability of treatment weighting to account for differential loss to follow-up. We used probabilistic quantitative bias analysis to estimate the magnitude and direction of the effect of exposure misclassification bias on results. In weighted multivariable models, we saw no appreciable association between preconception periodontitis diagnosis (HR = 0.97, 95% CI: 0.76, 1.23) or treatment (HR = 1.01, 95% CI: 0.79, 1.27) and SAB. A history of loose teeth was positively associated with SAB (HR = 1.38, 95% CI: 0.88, 2.14). Quantitative bias analysis indicated that our findings were biased towards the null but with considerable uncertainty in the bias-adjusted results.

Periodontitis is associated with an increased hazard of mortality in a longitudinal cohort study over 50 years.

AIM: To evaluate the association between periodontal disease and all-cause mortality in a longitudinal cohort study over 50 years. MATERIALS AND METHODS: Participants (N = 1156) in the Veterans Affairs Dental Longitudinal Study, aged 25-85 years at enrollment in 1968, received comprehensive medical and oral exams approximately every 3 years through 2007. Periodontal status was defined using person-level, mean whole-mouth radiographic alveolar bone loss (ABL) scores using a five-point Schei ruler, each unit representing 20% increments of ABL. Time-varying Cox regression models estimated hazard ratios (HRs) for the association between continuous and categorical ABL and mortality, adjusting for covariates. RESULTS: Each one-unit increase in mean ABL score was associated with a 14% increase in the hazard of mortality (adjusted HR = 1.14, 95% confidence interval [CI] 1.02, 1.27). When assessed categorically, HRs for average scores of 2 to <3 and 3 to ≤5 showed increasing associations with hazard of mortality, relative to 0 to <1 (adjusted HR = 1.17, 95% CI 0.94, 1.46; and HR = 1.65, 95% CI 0.94, 2.85, respectively). By contrast, we observed null associations for average scores of 1 to <2 relative to 0 to <1 (adjusted HR = 1.00, 95% CI 0.86, 1.17). CONCLUSIONS: Time-varying periodontal status assessed using radiographic ABL was positively associated with all-cause mortality even after confounder adjustment.

Health-based homophily in public housing developments.

Public housing residents in the United States face disproportionately high risks for disease, presenting an urgent need for interventions. Evidence suggests interventions leveraging social networks can be successful when relationships are homophilous, as this leads to pooling of risk behaviors among interconnected alters. Yet, we know little about networks of public housing residents. To assess the feasibility of network-based interventions, we investigate the incidence of health-based homophily in public housing developments in Boston, Massachusetts. Employing multilevel models (HLM), we find that respondents report their own health characteristics to be similar to their network partners on oral health, weight, and consumption of sugar-sweetened beverages and foods. We discuss the implications of our findings for health-based interventions in low-income communities.

Recruitment and Enrollment of Low-income, Minority Residents of Urban Public Housing into Research.

Research participation among vulnerable populations is often limited by the same socioeconomic factors that contribute to poor health. Identifying best practices for inclusion is critical to addressing health disparities. Urban public housing communities bear a disproportionate burden of chronic disease and may represent an opportunity to directly engage historically vulnerable populations in research designed to ultimately reduce that burden. We used mixed-method data to analyze recruitment effectiveness among a random sample of households (N = 380) across two public housing developments in Boston, MA who were approached for participation in a pre-COVID oral health study. Quantitative data from detailed recruitment tracking methods was analyzed to assess the relative efficiency of the methods employed. Field journals of study staff were qualitatively analyzed to identify community-specific recruitment barriers and facilitators. The participation rate among randomly sampled households was 28.6% (N = 131), with participation from primarily Hispanic (59.5%) or Black (26%) residents. Door-to-door knocking with response yielded the highest participation (44.8%), followed by responses to informational study flyers (31%). Primary barriers to enrollment included references to unemployment and employment variations, shift work, childcare responsibilities, time demands, and managing multiple appointments and social services. This study finds active, door-to-door knocking and return visits resolved barriers to participation, and reduced safety concerns and historic distrust. It's time to consider how best to adapt effective pre-COVID recruitment practices for utilization under current and future exposure conditions as effective recruitment of populations such as urban public housing residents into research is only becoming more important.

Exploring periodontitis misclassification mechanisms under partial-mouth protocols.

AIM: To investigate the sources of periodontitis misclassification under partial-mouth protocols (PMPs) and to explore possible approaches to enhancing protocol validity. MATERIALS AND METHODS: Using data from 10,680 adults with 244,999 teeth from the National Health and Nutrition Examination Survey, we compared tooth-, site-, and quadrant-specific periodontal parameters and case identification under full-mouth protocols and PMPs. Separately, we utilized population measures of tooth-specific periodontal severity to generate PMPs with tooth selection based on the population ranking of clinical severity and assessed the sensitivity of case identification. RESULTS: Symmetry of clinical severity was generally confirmed, with the exception of lingual inter-proximal sites, which yielded greater sensitivity in identifying periodontitis compared to buccal sites due to more severe pocketing and attachment loss on average. Misclassification of severe periodontitis occurred more frequently under commonly implemented PMPs compared to ranking-based selection of teeth, which yielded sensitivity estimates of 70.1%-79.4% with the selection of 8 teeth and reached 90% with the selection of only 14 teeth. CONCLUSIONS: Clinical symmetry and sources of periodontitis misclassification were confirmed. The proposed selection of teeth based on population rankings of clinical severity yielded optimal sensitivity estimates for the detection of severe periodontitis and may present a favourable alternative to current options.

A quantitative bias analysis to assess the impact of unmeasured confounding on associations between diabetes and periodontitis.

AIM: To investigate unmeasured confounding in bidirectional associations between periodontitis and diabetes using quantitative bias analysis. METHODS: Subsamples from the Veterans Affairs Dental Longitudinal Study were selected. Adjusted for known confounders, we used Cox proportional hazards models to estimate associations between pre-existing clinical periodontitis and incident Type II Diabetes (n = 672), and between pre-existing diabetes and incident severe periodontitis (n = 521), respectively. Hypothetical confounders were simulated into the dataset using Bernoulli trials based on pre-specified distributions of confounders within categories of each exposure and outcome. We calculated corrected hazard ratios (HR) over 10,000 bootstrapped samples. RESULTS: In models using periodontitis as the exposure and incident diabetes as the outcome, adjusted HR = 1.21 (95% CI: 0.64-2.30). Further adjustment for simulated confounders positively associated with periodontitis and diabetes greatly attenuated the association or explained it away entirely (HR = 1). In models using diabetes as the exposure and incident periodontitis as the outcome, adjusted HR = 1.35 (95% CI: 0.79-2.32). After further adjustment for simulated confounders, the lower bound of the simulation interval never reached the null value (HR ≥ 1.03). CONCLUSIONS: Presence of unmeasured confounding does not explain observed associations between pre-existing diabetes and incident periodontitis. However, presence of weak unmeasured confounding eliminated observed associations between pre-existing periodontitis and incident diabetes. These results clarify the bidirectional periodontitis-diabetes association.

Oxidative stress links periodontal inflammation and renal function.

AIMS: Patients with chronic kidney disease (CKD) are also susceptible to periodontitis. The causal link between periodontitis and CKD may be mediated via systemic inflammation/oxidative stress. Using structural equation modelling (SEM), this cross-sectional study aimed to explore the causal relationship between periodontal inflammation (PI) and renal function. MATERIALS AND METHODS: Baseline data on 770 patients with stage 3-5 (pre-dialysis) CKD from an ongoing cohort study were used. Detailed, bioclinical data on PI and renal function, as well as potential confounders and mediators of the relationship between the two, were collected. SEMs of increasing complexity were created to test the causal assumption that PI affects renal function and vice versa. RESULTS: Structural equation modelling confirmed the assumption that PI and renal function are causally linked, mediated by systemic oxidative stress. The magnitude of this effect was such that a 10% increase in PI resulted in a 3.0% decrease in renal function and a 10% decrease in renal function resulted in a 25% increase in PI. CONCLUSIONS: Periodontal inflammation represents an occult source of oxidative stress in patients with CKD. Further clinical studies are needed to confirm whether periodontal therapy, as a non-pharmacological approach to reducing systemic inflammatory/oxidative stress burden, can improve outcomes in CKD.

A measure development study of sugar-sweetened beverage-related knowledge, self-efficacy, and intention among urban, low-income adults.

BACKGROUND: Sugar-sweetened beverage (SSB) consumption is an important behavior that can influence individuals' risk for diabetes, obesity, and other chronic diseases. Nonetheless, there is a lack of valid measures to assess SSB-related constructs. Reliable and valid measures can help evaluate the efficacy of interventions designed to curb SSB consumption. Our aim was to develop a valid and reliable instrument to measure constructs related to SSB consumption in English and Spanish. METHODS: A cross-sectional survey was conducted among a convenience sample of 150 adult residents of public housing developments in Boston, Massachusetts between July of 2016 and January of 2017. All households from two public housing developments were approached by study staff to solicit participation via door-to-door knocking and posted flyers. We developed questions to measure three SSB-related constructs informed by the Social Cognitive Theory: SSB knowledge, and self-efficacy and intention to act on SSB consumption. The questions were pilot tested in the population, and then administered in-person by bilingual study staff in either English or Spanish. Interviews were conducted most often in the participant's home and less frequently within a community space. Item normality was assessed with descriptive statistics. Difficulty of knowledge items was assessed with percent correct. Construct validity of self-efficacy items was assessed using confirmatory factor analysis (CFA). A model was considered a good fit if confirmatory factor index (CFI) > 0.95, root mean square error of approximation (RMSEA) < 0.05, and standardized root mean square residual (RMSR) < 0.05. Pearson correlations with consumption scores assessed criterion validity, and intraclass correlation coefficients (ICC) assessed test-retest reliability. RESULTS: Of the eight knowledge items tested, only four items resulted in correct answers less than half of the time. CFA resulted in a 5-item scale with excellent fit indices (CFI = .99; RMSEA = .025: SRMR = .02) and Cronbach's (0.79), test-retest (ICC = 0.68), and significant correlation with intention and SSB consumption. Of the four intention items, one was significantly correlated with SSB consumption. CONCLUSIONS: This study provides evidence for the validity of key constructs related to SSB consumption for use in adults, which could provide important theory-based markers for program evaluations of SSB-related interventions.

The impact of periodontitis exposure misclassification bias from partial-mouth measurements on association with diabetes and cardiovascular disease.

AIM: To quantify exposure misclassification bias arising from use of partial-mouth protocols in studies of periodontitis-systemic disease associations. MATERIALS AND METHODS: Using data from 10,134 adults participating in the National Health and Nutrition Examination Survey, we classified periodontal status based on full-mouth clinical examinations and three commonly used partial-mouth protocols. Associations between periodontitis and self-reported diabetes and cardiovascular disease were evaluated under each protocol using adjusted logistic regression. Percent relative bias was calculated to evaluate magnitude and direction of bias. RESULTS: Misclassification primarily resulted in underestimation of associations, the extent of which depended on both the outcome under study and exposure severity. Bias due to misclassification of severe periodontitis was negligible for cardiovascular disease (0%-4.1%) compared to diabetes (177.7%-234.1%). In contrast, bias in moderate periodontitis associations was comparable across each outcome-diabetes (28.4%-39.5%) and cardiovascular disease (8.9%-46.7%). Results did not meaningfully change based on the partial-mouth protocol implemented. Stratified analyses showed increased bias among those with ≤15 teeth. Use of mean attachment loss as a continuous exposure resulted in minimal-to-no bias. CONCLUSIONS: Exposure misclassification bias due to use of partial-mouth protocols can yield inaccurate conclusions about periodontitis-systemic disease associations, the extent of which may depend on periodontitis classification and the association under study.

Simulation study of misclassification bias in association studies employing partial-mouth protocols.

AIM: To simulate the exposure misclassification bias potential in studies of perio-systemic disease associations due to the use of partial-mouth recording (PMR) protocols. METHODS: Using data from 640 participants in the Dental Longitudinal Study, we evaluated distributions of clinical periodontitis parameters to simulate hypothetical outcome probabilities using bootstrap sampling. Logistic regression models were fit using the hypothetical outcome as the dependent variable. Models were run for exposure classifications based on full-mouth recording (FMR) and PMR protocols over 10,000 repetitions. RESULTS: The impact of periodontitis exposure misclassification was dependent on periodontitis severity. Per cent relative bias for simulated ORs of size 1.5, 2 and 4 ranged from 0% to 30% for the effect of severe periodontitis. The magnitude and direction of the bias was dependent on the underlying distribution of the clinical parameters used in the simulation and the size of the association being estimated. Simulated effects of moderate periodontitis were consistently biased towards the null. CONCLUSION: Exposure misclassification bias occurring through the use of PMR protocols may be dependent on the sensitivity of the classification system applied. Using the CDC-AAP case definition, bias in the estimated effects of severe disease was small, on average. Whereas effects of moderate disease were underestimated to a larger degree.

Evaluating periodontal disease misclassification mechanisms under partial-mouth recording protocols.

AIM: To evaluate the assumptions underlying the use of partial-mouth recording (PMR) protocols and the associated mechanisms of potential misclassification of periodontal disease. METHODS: Using data from 640 participants in the VA Dental Longitudinal Study, we compared tooth-specific and site-specific clinical measures and calculated sensitivity and specificity of different PMR protocols by applying the Centers for Disease Control and Prevention in collaboration with the American Academy of Periodontology definitions for periodontitis as the full-mouth reference standard. Additionally, we evaluated alternative case definitions for PMR protocols that accounted for the reduction in numbers of teeth under observation. RESULTS: In this cohort, periodontitis presented as a generalized condition in that measures of clinical severity did not differ meaningfully according to site measured, oral quadrant or jaw. Sensitivity of disease classification under PMR protocols was a function of the number of teeth and sites under observation and the case definition applied. Sensitivity increased when case definitions were modified to account for the smaller number of teeth under observation with PMR protocols. However, specificity was reduced. CONCLUSIONS: Misclassification of periodontal disease by PMR protocols is not random, even if sites under observation are randomly selected. PMR protocols can be selected/modified to maximize sensitivity, but they do so at the expense of bias in mean measures of severity.

Using Storytelling to Address Oral Health Knowledge in American Indian and Alaska Native Communities.

INTRODUCTION: We conducted a qualitative analysis to evaluate the acceptability of using storytelling as a way to communicate oral health messages regarding early childhood caries (ECC) prevention in the American Indian and Alaska Native (AIAN) population. METHODS: A traditional story was developed and pilot tested among AIAN mothers residing in 3 tribal locations in northern California. Evaluations of the story content and acceptability followed a multistep process consisting of initial feedback from 4 key informants, a focus group of 7 AIAN mothers, and feedback from the Community Advisory Board. Upon story approval, 9 additional focus group sessions (N = 53 participants) were held with AIAN mothers following an oral telling of the story. RESULTS: Participants reported that the story was culturally appropriate and used relatable characters. Messages about oral health were considered to be valuable. Concerns arose about the oral-only delivery of the story, story content, length, story messages that conflicted with normative community values, and the intent to target audiences. Feedback by focus group participants raised some doubts about the relevance and frequency of storytelling in AIAN communities today. CONCLUSION: AIAN communities value the need for oral health messaging for community members. However, the acceptability of storytelling as a method for the messaging raises concerns, because the influence of modern technology and digital communications may weaken the acceptability of the oral tradition. Careful attention must be made to the delivery mode, content, and targeting with continual iterative feedback from community members to make these messages engaging, appropriate, relatable, and inclusive.

The basic research factors questionnaire for studying early childhood caries.

BACKGROUND: We describe development of the Early Childhood Caries (ECC) Basic Research Factors Questionnaire (BRFQ), a battery of measures assessing common potential predictors, mediators, and moderators of ECC. Individual-, family-, and community-level factors that are linked to oral health outcomes across at-risk populations are included. Developing standard measures of factors implicated in ECC has the potential to enhance our ability to understand mechanisms underlying successful prevention and to develop more effective interventions. METHODS: The Early Childhood Caries Collaborating Centers (EC4), funded by National Institute of Dental and Craniofacial Research, developed the BRFQ, which was used across four randomized trials to develop and test interventions for reducing ECC in at-risk populations. Forty-five investigators from across the centers and NIDCR were involved in the development process. Eight "measures working groups" identified relevant constructs and effective measurement approaches, which were then categorized as "essential" or "optional" common data elements (CDEs) for the EC4 projects. RESULTS: Essential CDEs include 88 items, with an additional 177 measures categorized as optional CDEs. Essential CDEs fell under the following domains: oral health knowledge, oral health behavior, utilization/insurance and cost, parent/caregiver dental self-efficacy, quality of life, caregiver and family characteristics, and child characteristics. CONCLUSIONS: The BRFQ makes available a battery of measures that support efforts to understand population risk factors for ECC and to compare oral health outcomes across populations at risk. The BRFQ development process may be useful to other clinical research networks and consortia developing CDEs in other health research fields. TRIAL REGISTRATION: All the trial that used the BRFQ were registered at Clinicaltrial.gov NCT01116726 , April 29, 2010; NCT01116739 , May 3, 2010; NCT01129440 , May 21, 2010; and NCT01205971 , September 19, 2010.

Validity of individual self-report oral health measures in assessing periodontitis for causal research applications.

BACKGROUND: Self-reported measures of periodontitis developed for use in population surveillance are increasingly used in causal research. Numerous studies evaluate the validity of these measures against clinical parameters of periodontitis, yet few include validation parameters outside of multivariable models. Individual item validity is necessary to adequately inform use of these measures in causal research. METHODS: We used data from the National Health and Nutrition Examination Survey 2011-2014 in which dentate participants completed full-mouth periodontal examinations (N = 6966). We evaluated six self-report questionnaire items related to periodontal disease status against periodontitis case definitions developed by the Centers for Disease Control and Prevention and American Academy of Periodontology (CDC-AAP). We estimated the sensitivity and specificity of individual items using severe and moderate-to-severe periodontitis classifications. We additionally combined items to evaluate the validity of joint measures. RESULTS: Sensitivity was highest when measures were evaluated against severe periodontitis. Self-rated oral health of fair/poor demonstrated the highest sensitivity for severe (0.60) and moderate-to-severe periodontitis (0.48). Specificity was highest when evaluated against moderate-to-severe periodontitis, with self-reported history of tooth mobility as the most specific measure (0.87 for severe disease; 0.92 for moderate-to-severe) followed by a history of bone loss (0.88 for severe; 0.91 for moderate-to-severe). Combining questions generally improved specificity at the expense of sensitivity. CONCLUSIONS: Our findings related to item-specific validity and the associated clinical profiles facilitate needed considerations for the use of self-reported measures of periodontitis in causal research. Additionally, item-specific validity can be used to inform assessments of misclassification bias within such investigations.

Methods to madness: The utility of complex systems science in a mad, mad world.

Existing methods in social [oral] epidemiology primarily utilize statistical models that assume static characteristics of individuals and environments. While useful, an over reliance on these methods in the social and behavioural sciences can unnecessarily limit perspective and progress as even the most advanced statistical methods cannot capture complex behaviour over time given that systems evolve, environments respond, and behaviours and beliefs crystalize or deteriorate based on a variety of social, environmental and access variables. The recent consensus statement on Future Directions for the Behavioral and Social Sciences in Oral Health acknowledges that dental, oral and craniofacial health emerge from the complex interplay of multiple factors at multiple levels over time and highlights the need for the incorporation of new and underutilized methodologies. Complex Systems Science offers a suite of tools and methodologies that are responsive to the generative mechanisms and processes that underlie population distributions of oral health and disease. Specifically, they assume intricate, dynamic interactions between individuals and groups, they facilitate the study and synthesis of interconnections between people (e.g. patients, healthcare providers and policy makers), how these change over time, any differences across settings, and provide an opportunity to guide future longitudinal data collection and intervention science more effectively. This paper aims to provide an introduction to foundational principles of complex systems, complex systems thinking, and methods found in complex systems science, including social network analysis, system dynamics models and agent-based models, and offers perspectives on the challenges faced and opportunities afforded in the incorporation of these methods into the population oral health sciences.

Perceived experiences of racism linked to dental fear and anxiety among Black women.

OBJECTIVES: Dental fear and anxiety are known determinants of delaying or avoiding dental care and vary considerably based on factors such as age and gender. However, little is known about dental fear and anxiety in racial/ethnic minority populations, which bear a disproportionate burden of poor oral health outcomes. Structural and social pathways responsible for producing these disparities are also understudied. Experiences of racism over the lifecourse may contribute to poor oral health outcomes through a pathway of dental fear and anxiety. This paper aimed to evaluate perceived experiences with racism, dental fear and anxiety, and the utilization of dental services, in the Black Women's Health Study (BWHS), a United States-based prospective cohort. METHODS: Analysis of prospective data obtained from a geographic subset of participants in the BWHS was conducted. In 2014, BWHS participants residing in Massachusetts responded to a mailed oral health questionnaire that included the Index of Dental Anxiety and Fear (IDAF-4C+) instrument (N = 484; 69% response rate). Previously collected demographic and health information, along with reported experiences of everyday and lifetime racism, obtained from national BWHS questionnaires between 1995 and 2009, were merged with the Massachusetts-based sub-sample. Associations between high dental anxiety (HDA) (mean IDAF-4C+ score ≥2.5 on the dental fear and anxiety module) and oral health outcomes and perceived racism and HDA were explored via prevalence ratios (PR) calculated using log-binomial regression models, including adjustment for potential confounders. RESULTS: Reported exposures to everyday racism occurred weekly on average for the top 25% of the sample, while 13% of participants reported exposure to multiple (n = 3) experiences of unfair treatment due to their race over their lifetime. HDA was prevalent among 17.8% of the sample and was significantly associated with indicators of poor oral health status. High exposures to everyday and lifetime experiences of racism were positively associated with HDA (PR = 1.08; 95% CI: 0.90, 1.58 and PR = 1.72; 95% CI: 1.03, 2.88, respectively). CONCLUSIONS: Significant associations between racism and HDA, and between HDA and poor oral health and reduced utilization of dental care were observed. Dental anxiety may be a pathway through which perceived experiences with racism may impact oral health outcomes.

Photo-Enhanced Health Promotion Messages to Target Reduction in Dietary Sugar among Residents of Public Housing.

Interventions intended to reduce the consumption of dietary sugars among those population groups demonstrating disproportionately greater and more frequent consumption of sugar-sweetened beverages and foods (SSBF) would benefit from intervention strategies that are tailored to population-specific barriers and facilitators. The objective of this study was to develop and evaluate the acceptability of photo-enhanced and theory-based health promotion messages that target the reduction in SSBF among adult residents of public housing developments, a population known for their high rates of chronic disease. Using the message development tool as a framework, we developed a series of 15 SSBF reduction messages, using an iterative process with community member input. We then evaluated the acceptability of the messages and compared three delivery mechanisms: print, text, and social media. We recruited participants who were residents of urban public housing developments, and who spoke either English or Spanish. A majority of participants identified as being of Hispanic ethnicity (73%). The message acceptability scoring did not appear to differ according to the assigned delivery mechanism, despite some imbalances in participants' characteristics across delivery mechanisms. The messages that targeted motivation were least likely to be accepted. In conclusion, our findings suggest that engaging members of the community at all phases of the development process was a feasible method to develop SSBF reduction messages with a high perceived acceptability.

Gastrointestinal distress as a potential mediator between stress and periodontal inflammation.

OBJECTIVES: Periodontal disease is multifactorial in its aetiology, which encompasses biopsychosocial contributors, including psychological stress. Gastrointestinal distress and dysbiosis have been associated with several chronic inflammatory diseases yet have rarely been investigated with respect to oral inflammation. Given the implications of gastrointestinal distress on extraintestinal inflammation, this study aimed to evaluate the potential role of such distress as a mediator between psychological stress and periodontal disease. METHODS: Utilizing a cross-sectional, nationwide sample of 828 adults in the USA generated via Amazon Mechanical Turk, we evaluated data collected from a series of validated self-report psychosocial questionnaires on stress, gut-specific anxiety around current gastrointestinal distress and periodontal disease, including periodontal disease subscales targeted at physiological and functional factors. Structural equation modelling was used to determine total, direct and indirect effects, while controlling for covariates. RESULTS: Psychological stress was associated with gastrointestinal distress (ß = .34) and self-reported periodontal disease (ß = .43). Gastrointestinal distress also was associated with self-reported periodontal disease (ß = .10). Gastrointestinal distress likewise mediated the relation between psychological stress and periodontal disease (ß = .03, p = .015). Given the multifactorial nature of periodontal disease(s), similar results were demonstrated using the subscales of the periodontal self-report measure. CONCLUSIONS: Associations exist between psychological stress and overall reports of periodontal disease as well as more specific physiological and functional components. Additionally, this study provided preliminary data supporting the potential mechanistic role that gastrointestinal distress plays in connecting the gut-brain and the gut-gum pathways.

Perceived racism associated with declines in self-rated oral health among U.S. Black women.

PURPOSE: Racial disparities in oral health are well-documented. Stress has been associated with both perceived racism and oral health, yet little research has directly investigated the association between perceived racism and oral health. METHODS: We used data from the Black Women's Health Study, a longitudinal cohort study that includes a geographically diverse sample of Black women across the United States. Perceived exposure to racism was assessed via two scales, one assessing lifetime exposure and one everyday exposure. Self-rated oral health was subsequently assessed over multiple time points. We used Cox proportional hazard models to calculate adjusted incidence rate ratios estimating the association between higher levels of perceived racism and incident "fair" or "poor" oral health, and explored potential effect measure modification using stratified models. RESULTS: The adjusted incidence rate ratios (n = 27,008) relating perceived racism to incident fair or poor oral health were 1.50 (95% confidence interval 1.35, 1.66) comparing the highest quartile of everyday racism to the lowest and 1.45 (95% confidence interval 1.31, 1.61) for the highest score of lifetime racism compared to the lowest. We did not see evidence of effect modification. CONCLUSIONS: Higher levels of perceived racism documented in 2009 were associated with declines in self-rated oral health from 2011 to 2019.