National Bone Health Alliance Bone Turnover Marker Project: current practices and the need for US harmonization, standardization, and common reference ranges.

UNLABELLED: This position paper reviews how the National Bone Health Alliance (NBHA) will execute a project to help assure health professionals of the clinical utility of bone turnover markers; the current clinical approaches concerning osteoporosis and the status and use of bone turnover markers in the USA; the rationale for focusing this effort around two specific bone turnover markers; the need to standardize bone marker sample collection procedures, reference ranges, and bone turnover marker assays in clinical laboratories; and the importance of harmonization for future research of bone turnover markers. INTRODUCTION: Osteoporosis is a major global health problem, with the prevalence and incidence of osteoporosis for at-risk populations estimated to be 44 million Americans. The potential of bone markers as an additional tool for health care professionals to improve patient outcomes and impact morbidity and mortality is crucial in providing better health care and addressing rising health care costs. This need to advance the field of bone turnover markers has been recognized by a number of organizations, including the International Osteoporosis Foundation (IOF), National Osteoporosis Foundation, International Federation of Clinical Chemistry, and Laboratory Medicine (IFCC), and the NBHA. METHODS: This position paper elucidates how this project will standardize bone turnover marker sample collection procedures in the USA, establish a USA reference range for one bone formation (serum procollagen type I N propeptide, s-PINP) and one bone resorption (serum C-terminal telopeptide of type I collagen, s-CTX) marker, and standardize bone turnover marker assays used in clinical laboratories. This effort will allow clinicians from the USA to have confidence in their use of bone turnover markers to help monitor osteoporosis treatment and assess future fracture risk. This project builds on the recommendations of the IOF/IFCC Bone Marker Standards Working Group by developing USA reference standards for s-PINP and s-CTX, the markers identified as most promising for use as reference markers. RESULTS: The goals of this project will be realized through the NBHA and will include its governmental, academic, for-profit, and non-profit sector stakeholders as well as major academic and commercial laboratories. Upon completion, a parallel effort will be pursued to make bone turnover marker measurements reliable and accepted by all health care professionals for facilitating treatment decisions and ultimately be reimbursed by all health insurance payers. CONCLUSIONS: Successful completion of this project will help assure health professionals from the USA of the clinical utility of bone turnover markers and ties in with the parallel effort of the IOF/IFCC to develop worldwide bone turnover reference ranges.

Dental caries in Quebec adults aged 35 to 44 years.

BACKGROUND: The purpose of this study was to assess the prevalence of dental caries in Quebec adults aged 35 to 44. METHODS: A stratified sample was used. The participation rate was 77% for the questionnaire and 44.5% for the oral examination. A total of 2,110 people were examined. The World Health Organization's caries criteria were used. Examiner agreement with gold standard dentist was excellent at the end of the nine-day training session (Kappa index > 0.8). RESULTS: The level of caries experience is very high in Quebec adults aged 35 to 44. Almost half of dental surfaces (65 of 148) have been affected. These surfaces are mostly missing (39.3) or filled (23.9). However, there were 1.8 decayed surfaces in need of treatment per adult, and more than half the people (55.5%) had no untreated decayed surfaces. Almost three-quarters of decayed surfaces were present in only 14% of the people; lower family income and lower education are risk factors. CONCLUSION: Comparison between Quebec and industrialized countries (United States, England and the Netherlands) shows that in adults 35 to 44, the mean number of decayed teeth is low (between 1.0 and 2.2) and the mean number of filled teeth is relatively similar (between 9.6 and 11.1); however, Quebec has a higher percentage than the United States of edentulous people. As well, in dentate adults, there are 1.6 times more missing teeth among Quebecers than among Americans.

Community periodontal index of treatment needs and prevalence of periodontal conditions.

BACKGROUND/AIMS: In 1977, the World Health Organization (WHO) proposed a new index, the community periodontal index of treatment needs (CPITN) to evaluate the periodontal treatment needs of populations. The aim of this study is to compare different approaches of recording and presenting the CPITN. METHODS: A sample of 2110 subjects aged 35-44 years were examined between September 1994 and July 1995, throughout the province of Quebec, Canada. For each tooth (3rd molars excluded), the presence of bleeding and calculus, the level of epithelial attachment, and the depth of periodontal pockets were measured. Periodontal pocket depths were measured from the edge of the free gingiva, at 2 sites (mesiovestibular and vestibular), as well as all around the tooth. RESULTS: Only 8.5% of adults had at least one tooth with a 6 mm or deeper periodontal pocket when probing on 2 sites, whereas if probing is done all around the tooth, this percentage is 2.5x higher (21.4%). The partial recording of pocket depths (10 index teeth recommended by WHO, or 2 quadrants chosen at random) resulted in an underestimation of the prevalence of subjects with at least one tooth with a periodontal pocket (CPITN score 3 and 4). Among subjects with at least one tooth with a 6 mm or deeper periodontal pocket, 12% were not detected with the 10 index teeth recording, and 25% go undetected with the measure on 2 quadrants. Finally, using the % of subjects with periodontal pockets overestimates the prevalence of deep pockets compared with using sextants. Indeed, close to 30.0% of sextants have no treatment needs, whereas only 5.2% of subjects are in this category. Similarly, 7.7% of sextants have at least one tooth with a 6 mm or deeper periodontal pocket, yet there are 3x more subjects in this category (21.4%).

Comparison between the DMF indices and two alternative composite indicators of dental health.

The DMFT and DMFS indices employed in the majority of oral epidemiological studies have several limitations. In response to this problem, Sheiham et al. (Community Dent Health 1987;4:407-14) proposed two alternative dental health indicators: the number of functioning teeth (hereafter referred to as FS-T) and tissue health (T-Health). Using data from an epidemiological study on the dental health status of adults aged 35-44 from Quebec (N=2110), this article compares the alternative indices with the conventional DMFT and DMFS indices. By comparing Pearson's correlation coefficient for the four indices in this study with the number of decayed, missing and filled surfaces, it is noted that the FS-T index bears the strongest correlation to the three variables. It is also the only index whose correlation coefficient is greater than 0.3 for each of the three DMFS components. A risk group was created for each index, composed of the 18% of people demonstrating the poorest index. The risk group's FS-T index results in an average of 4.3 decayed surfaces (compared with 2.6 for the DMFT), 92.7 missing surfaces (74.4 for the DMFT) and 9.0 filled surfaces (compared with 26.9 for the DMFT). Using linear regression analysis with each index as a dependent variable, and people's socio-demographic characteristics, regular use of dental services and perception of dental health as independent variables, it appears that the percentage of the explained variance (R2) is 21.2% for the FS-T index, 13.8% for the T-Health index, 12.3% for the DMFS index and only 7.6% for the DMFT index.

[Socioeconomic variables and the prevalence of dental caries in second and sixth grade Quebec children in 1989-90]. / Association des variables socio-economiques avec la prévalence de la carie dentaire chez les ecoliers québécois de deuxième et sixième année en 1989-1990.

OBJECTIVES: 1) To determine caries risk factors in second and sixth grade Quebec children; 2)To test multivariate models which identify children as belonging to a high prevalence group. METHODS: For the 1989-90 Santé Dentaire Québec survey, 2,291 second grade and 2,111 sixth grade school children responded to a questionnaire on their personal habits of hygiene and diet and underwent a clinical examination, while their parents answered a questionnaire regarding their family's socio-economic status. RESULTS: Statistics demonstrate a stronger link between socioeconomic variables and caries prevalence than demographic and sanitary factors. Children emerging from a high socioeconomic milieu have better dental health than children with low socioeconomic standing. The most effective model, However, registers a sensitivity of 65% and a specificity of 66%, revealing the inadequacy of statistical models to accurately identify children in the caries high prevalence group.

[Treatment cost savings with universal coverage of dental pit and fissure sealants in Québec]. / Coût des traitements épargnés avec une couverture universelle des agents de scellement de puits et sillons dentaires au Québec.

Approximately 95 per cent of caries or fillings in the first permanent molars of eight-year-old children are found on pit and fissure surfaces. In 17-year-old adolescents, these account for 68 per cent. This article evaluates two treatment approaches based on their respective cost: one that does not use sealants and one that uses sealants for pit and fissure surfaces and amalgam fillings for restorations involving other surfaces. Compared to the current situation in which sealants are rarely used, applying dental sealant to three out of four first permanent molars reduces the cost of treatment by 31 per cent. Therefore, pit and fissure sealants are recommended as a universal preventive measure for children. In the long run, this could generate savings of up to $7 million in the public and private sectors for each age group in Quebec.

Restorative treatments received by children covered by a universal, publicly financed, dental insurance plan.

OBJECTIVES: This study sought to identify risk markers associated with the provision of new restorations in children and to investigate whether the carious status of a tooth surface is associated with the restorative decisions of dentists. METHODS: A total of 911 schoolchildren in grades one, two, and three were randomly selected from the island of Montreal, Quebec, Canada. Dental examinations were carried out in 1990, 1991, and 1992. Tooth surfaces of first permanent molars were classified as sound, noncavitated, and cavitated. The carious status of a tooth was matched with restorative decisions reported to the insurance board. RESULTS: The presence of a carious cavity was a strong risk marker for placement of new restorations (odds rations > or = 4.11). After one year, less than 2 percent of sound tooth surfaces of first permanent molars were restored and about 21 percent of noncavitated tooth surfaces were restored. When new class I restorations placed in maxillary first permanent molars within 3-6 months after the baseline examination were evaluated, we found that between 73 percent and 86 percent of these new restorations were placed in sound or noncavitated tooth surfaces. A similar trend also was observed in mandibular first permanent molars. Poor agreement between epidemiologic diagnosis and restorative decisions was found. The restorative profile of dentists was a significant risk marker for placement of new restorations. CONCLUSION: The majority of new restorations in first permanent molars were placed in sound and noncavitated tooth surfaces because of the ubiquitous prevalence of these tooth surfaces and the validity problems of current caries diagnosis methods.

[Trends in the level of edentulism in Quebec between 1980 and 1993]. / Evolution de l'édentation au Québec entre 1980 et 1993.

Level of edentulism is a good indicator of a populations' bucco-dental health. Thus, the evolution of this phenomena enables us to seek any modification of adults' bucco-dental health. The percentage of adults in Quebec aged 18 and over who are completely edentulous decreased from 26 per cent in 1980 to 20 per cent in 1993. During the same period, the percentage of adults aged 18 and over who are only partially edentulous decreased from 18 per cent to 13 per cent. We note on one hand that this decrease is more prominent among younger adults and among anglophones and on the other hand that income and education are more strongly associated with edentulism in 1993 than in 1980. In 1980, individuals with lower levels of education were three times more edentulous (partially or totally) than those with higher levels of education (73 per cent versus 25 per cent). In 1993, this ratio increased to six times (72 per cent versus 12 per cent). It appears, therefore, that while edentulism has generally decreased in Quebec, it is more concentrated among certain high risk groups.

[Use of dental services and the percentage of persons possessing private dental insurance in Québec]. / Utilisation des services dentaires et pourcentage de personnes possédant une assurance dentaire privée au Québec.

The utilization of dental health services and the percentage of adult members of a private health dental insurance plan are generally lower in Quebec than in the other Canadian provinces. In this study, results of a telephone survey of a representative sample of Quebec adults aged 18 and over (N = 8,042) show that 58 per cent of interviewed individuals visited a dentist (53 per cent) or a denturologist (five per cent) during the 12 months preceeding the interview. A multivariate analysis indicates that the most strongly associated factors related to the utilization of dental health services are, in decreasing order, edentulousness, income and level of education. About one third (36 per cent) of those surveyed had dental insurance coverage. Age and income are the most strongly associated factors concerning the membership to a dental health insurance plan. Finally, among those with dental insurance coverage, 71 per cent had visited a dentist or a denturologist during the last 12 months compared to 51 per cent of those not insured.

Comparison of dental caries and oral hygiene indices for 13- to 14-year-old Quebec children between 1977 and 1989-1990.

A comparison of the principal dental health indices of 13- to 14-year-old Quebec school children between 1977 and 1989-1990 is reported. Data derive from a dental health survey of 1,093 Quebec school children in 1977 and from a province-wide probability sample of 1,342 children in 1989-1990. The most interesting conclusions are: the DMFT index for 13- to 14-year-old children dropped from 9.0 to 4.5; an improvement in the caries treatment level from 26 per cent to 90 per cent is noted; caries treatment needs decreased from 55 per cent to nine per cent; the mean number of extracted teeth per child dropped from a score of 1.6 to a score of 0.03; significant differences in the DMFT index between residential status no longer exist; and no improvement in the oral hygiene condition (OHIS index) is observed. In 1989-1990, 35 per cent of these adolescents had perfect periodontal health. For the others, the principal problems were bleeding gums and/or calculus.

Prevalence of non-cavitated and cavitated carious lesions in a random sample of 7-9-year-old schoolchildren in Montreal, Quebec.

This report describes the prevalence of non-cavitated and cavitated carious lesions in 911 randomly selected children in grades one through three on the Island of Montreal, Quebec, Canada. The criteria for diagnosis were developed for a longitudinal epidemiological study of restorative treatment decisions by dentists practising under a provincial dental insurance program for children. The intra- and inter-examiner reliability correlation coefficients of the two examiners were excellent (Kappa > or = 0.80). The most frequent carious lesion found in the examined children were non-cavitated carious lesions (incipient) within 1.5 of the gingival line on smooth tooth surfaces, and stained or non-cavitated carious lesions on pits and fissures. Out of 911 children in the study, 19.6% had sealants. Children whose parents completed a university education had a significantly lower prevalence of non-cavitated and cavitated carious lesions and fillings, and a significantly higher mean number of sealants than children whose parents had only primary school education. Education status of the parents was a significant risk marker of children with high caries experience and these children had a significantly higher mean number of non-cavitated carious lesions. This study has found that non-cavitated carious lesions are significantly more prevalent than cavitated carious lesions in children.

[Oral health of 15-year-old students living in non-fluoridated public school sectors on l'Ile de Montreal in 1987]. / Condition bucco-dentaire des écoliers de 15 ans des zones non fluorées du secteur scolaire public de l'Ile de Montréal en 1987.

Using data from a cross-sectional survey on 570 fifteen year old students living in non-fluoridated public school sectors on the Island of Montreal in 1987, the effect of terminating the restorative aspect of public dental health care insurance for twelve to fifteen year old students is examined. This study also highlights the level and quality of dental caries treatment on the twelve to fifteen year old group. The main point to be made is that there was an improvement in the DMFT index values of fourteen and fifteen year old students in metropolitan areas. In reality, fourteen year old children had a DMFT index of 6.45 in 1983-1984, while the fifteen year old children in the 06A region (non-fluoridated area) had a DMFT of 6.07 in 1987. Since the metropolitan fluoridated area had been eliminated from the results in 1987, it is quite obvious that the 6.07 result obtained overestimates the actual prevalence of dental caries in the metropolitan area in 1987. On the other hand, the progress which had been recorded between 1977 and 1984 by francophones in relation to anglophones was partially lost in 1987. Furthermore, this study has demonstrated that the prevalence and level of dental caries treatment are highly associated with the language spoken at home and also with the family's socio-economic status.

[The prevalence of malocclusion problems and orthodontic treatment needs in 13 and 14-year old Quebec school children in 1983-1984]. / La prévalence des problèmes de malocclusion et les besoins de traitements orthodontiques des écoliers québécois de 13 et 14 ans en 1983-1984.

This article details the problems related to occlusion of 13-14 year old Quebec students. The data was derived from a province wide probability sample of 1201 children in 1983-84 using Granger's Orthodontic Treatment Priority Index (TPI). The principal conclusion are: 32% of the children are in Angle's class II; 18% have an overjet of 5 mm and over; 50% have one or more teeth in minor or major displacement; treatment is mandatory or highly desirable for 13.7% and only 2.9% of the students are under treatment. The results are compared to 6 surveys of the same nature.