Feasibility of Collecting Saliva for Biological Verification of Tobacco Use Status in Dental Practices and Patients' Homes: Results from the National Dental PBRN.

OBJECTIVE: To evaluate the feasibility of collecting and analyzing saliva samples from dental practices and patients' homes for biochemical verification of tobacco use status. BASIC RESEARCH DESIGN: Sub-study within single-arm, multi-center, longitudinal clinical study. CLINICAL SETTING: Dental practices in the South Central region of the United States National Dental Practice-Based Research Network and patients' homes. PARTICIPANTS: Fifty-five patients recruited from 30 dental practices. INTERVENTIONS: Participants in the sub-study were instructed on saliva collection for cotinine analysis in dental practices where they enrolled in the primary study. Saliva was collected at the practices and then from patients' homes. MAIN OUTCOME MEASURES: Feasibility for dental practice collection was define as 80% of enrolled participants having analyzable samples. For patients' home collection, feasibility was defined as 70%. RESULTS: Forty-seven samples (i.e., 86% of those enrolled) collected in dental practices were analyzable. Twenty-one samples (i.e. 38% of those enrolled) collected in patients' homes were analyzable. CONCLUSIONS: Collecting saliva samples for cotinine analysis from dental practices, but not from patients' homes, was feasible. Dental practices may provide an advantageous setting for biochemically verifying tobacco use status as part of clinical trials for tobacco cessation.

Characteristics, detection methods and treatment of questionable occlusal carious lesions: findings from the national dental practice-based research network.

Questionable occlusal carious lesions (QOC) can be defined as an occlusal tooth surface with no cavitation and no radiographic radiolucencies, but caries is suspected due to roughness, surface opacities or staining. An earlier analysis of data from this study indicates 1/3 of patients have a QOC. The objective of this report has been to quantify the characteristics of these common lesions, the diagnostic aids used and the treatment of QOC. A total of 82 dentist and hygienist practitioner-investigators from the USA and Denmark in the National Dental Practice-Based Research Network participated. When consenting patients presented with a QOC, information was recorded about the patient, tooth, lesion and treatments. A total of 2,603 QOC from 1,732 patients were analyzed. The lesions were usually associated with a fissure, on molars, and varied from yellow to black in color. Half presented with a chalky luster and had a rough surface when examined with an explorer. There was an association between color and luster: 10% were chalky-light, 47% were shiny-dark and 42% were mixtures. A higher proportion of chalky than of shiny lesions were light (22 vs. 9%; p < 0.001). Lesions light in color were less common in adults than in pediatric patients (9 vs. 32%; p < 0.001). Lesions that were chalky and light were more common among pediatric than among adult patients (22 vs. 6%; p < 0.001). This is the first study to investigate characteristics of QOC in routine clinical practice. Clinicians commonly face this diagnostic uncertainty. Determining the characteristics of these lesions is relevant when making diagnostic and treatment decisions.

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 2 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 2,691 restorations placed by 205 dentists in 1,930 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.

The Evidence-practice Gap in Minimal Intervention Dentistry: An International Comparison Between Dentists in Japan and Brazil.

OBJECTIVES: This study was designed to: 1) evaluate and compare the evidence-practice gap (EPG) in minimal intervention dentistry (MID) in Japan and Brazil by measuring concordance between dentists' clinical practice and published evidence; and 2) identify dentists' factors associated with the EPG in both countries. METHODS: We performed a cross-sectional study using a web-delivered questionnaire among 136 Japanese and 110 Brazilian dentists. The questionnaire consisted of three questions concerning "restoration diagnosis and treatment," "deep caries diagnosis and treatment," and "caries risk assessment" regarding MID. A chi-square test was used to analyze differences in concordance among clinical practice and evidence from the literature between Japanese and Brazilian dentists. Logistic regression analyses were performed to analyze dentists' factors associated with overall concordance for all three questions. RESULTS: Overall concordance was significantly higher in Brazil (55%) than in Japan (38%) (p<0.01). Concerning how evidence was obtained, textbooks, nonacademic journals, and seminars and workshops were used as information sources more frequently by Japanese than Brazilian dentists (p<0.001), whereas scientific journal articles in English were used more frequently by Brazilian dentists (p<0.001). On logistic regression analysis, overall concordance was higher for Japanese dentists who frequently obtained evidence from scientific journal articles in English (p<0.05), whereas Brazilian dentists who frequently obtained evidence from the Internet were associated with lower overall concordance (p<0.05). CONCLUSIONS: Because overall concordance was significantly higher in Brazil than in Japan, Japan may have a greater EPG in MID practice. Specific characteristics of Japanese and Brazilian dentists showed significant associations with overall concordance.

Dental risk factors for osteonecrosis of the jaws: a CONDOR case-control study.

BACKGROUND: Reports of osteonecrosis of the jaw (ONJ) have associated this lesion to treatment with bisphosphonates (BPs) and dental procedures. In this study, we investigated the association of specific dental diagnoses and procedures with ONJ among patients with past BP use. METHODS: Dentists from three practice-based research networks provided ONJ cases and controls (1:3). Data gathered from patients and dental offices with two respective standard questionnaires included demographic, medical, pharmaceutical, and dental information. Diagnoses and procedures up to 3 years prior to ONJ (prior to interview for controls) were analyzed within risk strata, defined by BP use and cancer status, using interaction terms within conditional logistic regression models. RESULTS: We enrolled 191 ONJ cases and 573 controls from 119 dental offices. Among participants who had used only oral BP, extraction was the only dental risk factor for ONJ (odds ratio (OR) = 12, p = 0.01). Suppuration was also more prevalent in cases (18 %) than in controls (9 %), but not statistically significant (OR = 9, p = 0.06). Among participants who had not used either oral or IV BP (a majority of whom received radiation therapy to the head and neck), suppuration was the only dental risk factor for ONJ (prevalence = 34 % for cases and 8 % for controls; OR = 7, p = 0.01). The prevalence of extractions in this group was also higher, but not statistically significant (44 vs 10 %; OR = 3). Limited power precludes definitive findings among participants exposed to IV BP. CONCLUSIONS: Among patients taking oral BP, extraction was the only dental procedure associated with subsequent ONJ development CLINICAL RELEVANCE: Results of this study suggest that routine dental procedures are not associated with development of ONJ in patients exposed to BPs.

Causes of the Evidence-practice Gap and Its Association with the Effects of Minimal Intervention Dentistry Education to Clinicians.

OBJECTIVES: To identify causes of the evidence-practice gap (EPG) in dentistry in Japan and analyze whether these causes are associated with: (a) improvement of EPG in minimal intervention dentistry (MID) following an educational intervention and (b) specific dentist characteristics. METHODS: We conducted a mixed-methods questionnaire survey among 197 Japanese dentists that integrated both quantitative and qualitative data. Causative factors for the EPG identified in the quantitative survey were clarified by qualitative analysis. We measured the EPG in a baseline survey using an EPG measurement tool based on MID. To examine how feedback using the latest scientific evidence affected change in the EPG, we measured the EPG again immediately after feedback was provided to participating dentists. RESULTS: Qualitative analysis classified all dentists into one of four "EPG cause" groups, namely "evidence-", "dentist-", "patient-", and "health insurance system-related" causes. Quantitative analysis confirmed that improvement in the EPG following the feedback intervention was indeed associated with group classification. The highest concordance was found for the "evidence-related" group while the lowest concordance was in the "dentist-related" group (p=0.004). Concordance improved after evidence feedback in all groups but was lowest in the "dentist-related" group. More dentists reported practice busyness in the "dentist-related" group. CONCLUSIONS: In this study, we identified four groups of causes of EPG among Japanese dentists. The degree of concordance between evidence and clinical practice was the lowest in the "dentist-related" group, and the results of this study are expected to provide useful information for the development of intervention methods for closing the EPG in the future.

Root Canal Treatment Survival Analysis in National Dental PBRN Practices.

Few studies have examined the longevity of endodontically treated teeth in nonacademic clinical settings where most of the population receives its care. This study aimed to quantify the longevity of teeth treated endodontically in general dentistry practices and test the hypothesis that longevity significantly differed by the patient's age, gender, dental insurance, geographic region, and placement of a crown and/or other restoration soon after root canal treatment (RCT). This retrospective study used deidentified data of patients who underwent RCT of permanent teeth through October 2015 in 99 general dentistry practices in the National Dental Practice-Based Research Network (Network). The data set included 46,702 patients and 71,283 RCT permanent teeth. The Kaplan-Meier (product limit) estimator was performed to estimate survival rate after the first RCT performed on a specific tooth. The Cox proportional hazards model was done to account for patient- and tooth-specific covariates. The overall median survival time was 11.1 y; 26% of RCT teeth survived beyond 20 y. Tooth type, presence of dental insurance any time during dental care, placement of crown and/or receiving a filling soon after RCT, and Network region were significant predictors of survival time (P < 0.0001). Gender and age were not statistically significant predictors in univariable analysis, but in multivariable analyses, gender was significant after accounting for other variables. This study of Network practices geographically distributed across the United States observed shorter longevity of endodontically treated permanent teeth than in previous community-based studies. Also, having a crown placed following an RCT was associated with 5.3 y longer median survival time. Teeth that received a filling soon after the RCT before the crown was placed had a median survival time of 20.1 y compared to RCT teeth with only a crown (11.4 y), only a filling (11.2 y), or no filling and no crown (6.5 y).

Methods used by Dental Practice-based Research Network (DPBRN) dentists to diagnose dental caries.

OBJECTIVES: To (1) identify the methods that dentists in The Dental Practice-Based Research Network (DPBRN) use to diagnose dental caries; (2) quantify their frequency of use and (3) test the hypothesis that certain dentist and dental practice characteristics are significantly associated with their use. METHODS: A questionnaire about methods used for caries diagnosis was sent to DPBRN dentists who reported doing some restorative dentistry; 522 dentists participated. Questions included the use of dental radiographs, the dental explorer, laser fluorescence, air-drying and fiber-optic devices and magnification as used when diagnosing primary, secondary/recurrent or non-specific caries lesions. Variations on the frequency of their use were tested using multivariate analysis and Bonferroni tests. RESULTS: Overall, the dental explorer was the instrument most commonly used to detect primary occlusal caries and caries at the margins of existing restorations. In contrast, laser fluorescence was rarely used to help diagnose occlusal primary caries. For proximal caries, radiographs were used to help diagnose 75%­100% of lesions by 96% of the DPBRN dentists. Dentists who use radiographs most often to assess proximal surfaces of posterior teeth were significantly more likely to also report providing a higher percentage of patients with individualized caries prevention (p=.040) and seeing a higher percentage of pediatric patients (p=.001). CONCLUSION: The use of specific diagnostic methods varied substantially. The dental explorer and radiographs are still the most commonly used diagnostic methods..

Caries Diagnosis in Dental Practices: Results From Dentists in a Brazilian Community.

The aim of this study was to assess practices related to diagnosis of dental caries among dentists (n=217) from Araraquara, São Paulo State, Brazil. Data on sociodemographic information and practitioner characteristics were collected using a pretested questionnaire, and data on practices related to caries diagnosis were gathered by using a translated and culturally adapted questionnaire from the US National Dental Practice-Based Research Network. Descriptive statistics and regression analyses were used for data analysis. Respondents reported using in most of their patients radiographs (Rx) to diagnose proximal caries (59%), explorer (Ex) for the diagnosis of occlusal caries (64%) and on the margins of existing restorations (79%), as well as air jet (AJ) with drying (92%). Magnification (M) (25%), fiber optic transillumination (FOTI; 14%), and laser fluorescence (LF) (3%) were used in the minority of patients. Regression analysis revealed that the following dentists' characteristics were significantly associated (p<0.05) with the use of diagnostic methods on a greater percentage of their patients: advanced degree (Rx, FOTI), higher percentage of patients with individualized caries prevention (Rx, FOTI, M), more years since dental school graduation (Ex, M), and work in an exclusively private practice model (LF). In conclusion, most Brazilian dentists from Araraquara reported they most commonly use visual, tactile, and radiographic imaging for the diagnosis of dental caries. Some dentists' characteristics, such as time from dental school graduation and having a postgraduation course, were associated with the use of certain diagnostic methods.

Prescription Drug Monitoring Program Use: National Dental PBRN Results.

INTRODUCTION: The American Dental Association recommends that dentists use a prescription drug monitoring program (PDMP) prior to prescribing an opioid for acute pain management. OBJECTIVE: The objective of this study was to examine dentists' experiences using their state PDMP, as well as the impact that state-mandated registration policies, mandated use policies, and practice characteristics had on the frequency with which dentists used their PDMP. METHODS: We conducted a web-based cross-sectional survey among practicing dentist members of the National Dental Practice-Based Research Network ( n = 805). The survey assessed prescribing practices for pain management and implementation of risk mitigation strategies, including PDMP use. Survey data were linked with network Enrollment Questionnaire data to include practitioner demographics and practice characteristics. RESULTS: Nearly half of respondents ( n = 375, 46.6%) reported having never accessed a PDMP, with the most common reasons for nonaccess being lack of awareness ( n = 214, 57.1%) and lack of knowledge regarding registration and use ( n = 94, 25.1%). The majority of PDMP users reported the program to be very helpful (58.1%) or somewhat helpful (31.6%). Dentists reported that PDMP use most often did not change their intended prescribing behavior (40.2%), led them not to prescribe an opioid (33.5%), or led them to prescribe fewer opioid doses (25.5%). Presence of a mandated use policy was significantly associated with increased frequency of PDMP use across a variety of situations, including prior to 1) prescribing any opioid for pain management, 2) issuing refills, 3) prescribing to new patients, and 4) prescribing to patients deemed high risk. CONCLUSION: Findings suggest that the majority of dentists find PDMPs helpful in informing their opioid-prescribing practices. Whereas the existence of a state-mandated use policy is a consistent predictor of dentists' PDMP use, outreach and education efforts may overcome key barriers to use identified in this study. KNOWLEDGE TRANSFER STATEMENT: Findings from this national survey suggest that the majority of practicing dentists find PDMPs helpful in informing their opioid-prescribing practices; however, consistent PDMP use was not common. Whereas the existence of a state-mandated use policy is a consistent predictor of dentists' PDMP use, outreach and education efforts may overcome key barriers to use identified in this study.

Patient-Centered Dentinal Hypersensitivity Treatment Outcomes: Results from the National Dental PBRN.

Dentinal hypersensitivity (DH) can have a significant impact on oral health and functioning, and it is a clinical symptom commonly managed by dentists during routine clinical practice. DH symptoms are typically elicited by otherwise innocuous, nonpainful stimuli applied to exposed dentin (e.g., tactile stimuli, warming or cooling temperatures or air puffs). Treatment approaches have sought to directly target the dentinal pulp tissues or close dentinal tubules via dental office care and treatment services (fluoride varnishes, glutaraldehydes, bonding agents, sealants, oxalates, or lasers) or home care services (toothpastes or dentifrices containing fluoride or potassium nitrate compounds). The purpose of this prospective multicenter cohort study was to assess how community-based dentists from the National Dental Practice-Based Research Network (National Dental PBRN) manage DH and whether the effectiveness of DH treatments can be assessed in those settings. A total of 171 dentists recruited 1862 subjects with DH from their existing patients. Dentists then recommended and provided DH treatment as appropriate. Treatment choice was at the discretion of the dentists. Patients rated their DH pain at baseline and 1, 4, and 8 wk during the course of their treatments. They used pain intensity and unpleasantness visual analog scales and 4 labeled magnitude scales and rated their satisfaction with treatment after 8 wk. Patients were provided reminders postbaseline via email, texting, or voice mail. These patient-centered outcomes served as the principal measures for the assessment of treatment because treatments sought to alleviate DH symptoms. The patients with DH who reported pain reduction from dentist-provided treatments (glutaraldehyde/HEMA [hydroxyethyl methacrylate] compounds, oxalates, and bonding agents), dentists' advice and counseling regarding oral habits and diet, and patient-applied fluoride toothpaste reported a concomitant positive rating of satisfaction with DH treatments. The results from this study support the feasibility of engaging network practices to assess the effectiveness of clinical DH treatments. Knowledge Transfer Statement: National Dental PBRN dentists provide a range of procedures to treat dentinal hypersensitivity. In this large nonrandomized study designed to assess clinical care and to capture patient-reported outcomes, about 60% of patients reported improvement in pain. This study demonstrated the feasibility of engaging network dentists and their patients to assess treatment effectiveness. Future studies will explore the feasibility of imposing randomization and measuring patient compliance with treatment in the manner that this treatment is provided.

Judgment of the Quality of Restorative Care as Predictors of Restoration Retreatment: Findings from the National Dental PBRN.

The primary aim of this study was to test the hypothesis that a patient's subjective assessments of the dentist's technical competence, quality of care, and anticipated restoration longevity during a restorative visit are predictive of restoration outcome. This prospective cohort study involved 3,326 patients who received treatment for a defective restoration in a permanent tooth, participated in a baseline patient satisfaction survey, and returned for follow-up. Of the 4,400 restorations that were examined by 150 dentists, 266 (6%) received additional treatment after baseline. Reporting satisfaction with the technical skill of the dentist or quality of the dental work at baseline was not associated with retreatment after baseline. However, patients' views at baseline that the fee was reasonable (odds ratio [OR], 1.6) was associated with retreatment after baseline, whereas satisfaction at baseline with how long the filling would last (OR, 0.6) was associated with less retreatment. These findings suggest that retreatment occurs more often for patients who at baseline are satisfied with the cost or who at baseline have less confidence in the restoration. The authors found no associations between restoration retreatment and the patients' baseline evaluations of the technical skills of their dentists or perceptions of quality care. KNOWLEDGE TRANSFER STATEMENT: Dental patients' ratings of their dentist's skills were not related to a restoration needing retreatment. Patients focus on other aspects of the dental visit when making this judgment.

Orofacial pain symptom prevalence: selective sex differences in the elderly?

This study investigated sex differences in orofacial pain symptoms in a sample of elderly adults. Furthermore, differences across sex were tested on symptom continuity, overall duration, pain severity, activity reduction, and health care utilization, related to each specific symptom. Telephone interviews were conducted with a stratified random sample of community dwelling older (65+) north Floridians. A total of 5860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. Of the remaining households, 1636 completed the interview. Of the total sample, 17.4% reported experiencing at least one of the four target orofacial pain symptoms (jaw joint pain, face pain, oral sores, burning mouth) during the past year, suggesting that orofacial pain symptoms are common in older adults. Our findings for prevalence of each specific symptom (jaw joint pain, 7.7%; face pain, 6.9%; oral sores, 6.4%; toothache, 12.0%; burning mouth, 1.7%) are similar to those estimated by the 1989 National Health Interview Survey, for the US adult population. Consistent with other epidemiological and clinical studies, we found that females were more likely to report jaw joint pain and face pain than males. In contrast to clinical studies, no differences were found on subjective ratings of pain severity, for any symptom. Differences across sex were most likely to be reported for jaw joint pain related variables, suggesting undetermined sex-uniqueness for these symptoms. In contrast to previous studies, older females tended to report lower levels of health care utilization than older males. This is the first study to our knowledge that reports orofacial symptom-specific sex differences among the elderly.

Health care utilization by older adults in response to painful orofacial symptoms.

The purpose of this study was to determine which specific attributes of painful orofacial symptoms serve as predictors of health care utilization in a population based sample of elderly subjects. Furthermore, we documented patterns of health care utilization selection by type of health care provider. To our knowledge, these specific utilization patterns have never before been reported in the pain literature. Telephone interviews were conducted with a stratified random sample of 1636 community dwelling older (65+) north Floridians. A total of 5860 households were contacted and screened, with 75.3% participating to the point where their eligibility for the study could be determined. The percentage of subjects reporting health care utilization for a specific symptom ranged from 62 to 32%. One or more health care visits were reported by at least 50% of those reporting symptoms of toothache pain, facial pain, jaw joint pain and burning mouth in the past 12 months. These rates suggest that elderly individuals are willing and able to seek health care for painful orofacial symptoms. We found that pain intensity was the best predictor of whether an elderly individual utilized health care or not, which suggests that some pain intensity threshold may exist at which health care seeking behavior is initiated. The overall number of visits was not predicted by pain intensity but by other qualities more associated with time or level of dysfunction caused by the symptom. We also found that elderly adults, typically seek care for toothache from a dentist and from physicians for painful orofacial symptoms not associated with the teeth or mouth. These decisions regarding the selection of a health care professional may, in part, be a function of financial and insurance considerations, anatomical site and perception of the role of dentistry in orofacial care.

Tooth loss occurring at a place other than a health-care facility: 72-month incidence.

Dental care can occur within or outside the formal health-care system. We hypothesized that certain subject characteristics would partly explain one type of dental self-care, non-professional extractions. A representative sample of diverse groups of dentate adults was studied. In-person interviews and clinical examinations were conducted at baseline, 24, 48, and 72 months, with semi-annual telephone interviews in between. Of 699 participants, 291 (42%) reported loss of at least one tooth, of whom 42 (14% of those with tooth loss) reported having lost the tooth at a place other than a health-care facility. Ninety-four percent of non-professionally lost teeth were self-extracted; relatives extracted the remainder. Fifty-eight percent of these teeth were deliberately removed; the remainder came out while subjects were eating or brushing their teeth, or due to injury. Attachment loss and mobility at previous examination were consistent with the occurrence of non-professional extraction. The incidence magnitude was substantive and persistent throughout follow-up.

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.

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.

Determinants of dental care use in dentate adults: six-monthly use during a 24-month period in the Florida Dental Care Study.

The objective of this study is to describe for a diverse sample of dentate adults the incidence of dental care use and predisposing, enabling, and need correlates of that use. The Florida Dental Care Study (FDCS) is a prospective longitudinal cohort study of persons who at baseline had at least one natural tooth, were 45 years or older, and who resided in north Florida, U.S.A. An in-person interview and clinical dental examination were conducted at baseline and 24 months after baseline, with 6-monthly telephone interviews between those times. Seventy-seven percent of subjects reported one or more dental visits during the 24 months of follow-up. Six-monthly use ranged from 46% to 55%. Incident perceived need for care and certain incident self-reported oral signs and symptoms were strongly predictive of incident dental care use. Decrements in oral functional limitation, oral disadvantage, and self-rated oral health were predictive of less care bivariately, but were not salient in a multivariate model, with two notable exceptions: two measures related to esthetics. The conclusions are that certain measures of need (perceived need and specific self-reported signs and symptoms) were important predictors of incident dental care. However, persons with need as determined by direct clinical examination and persons with need as determined by self-reported decrements in the more distal measures of oral health (oral functional limitation, oral disadvantage, and self-rated oral health) were actually less likely to seek dental care. The salience of esthetics in predicting use is consistent with cross-sectional findings that dental esthetic cues are important to oral "health". Typical approach to care, dental attitudes, ability to pay for care, race, and sex were also important for understanding incident dental care use.

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.

Oral and maxillofacial surgical therapy for the older adult.

Older adults can present with a wide range of oral and maxillofacial diseases and conditions, and many of these are best treated surgically. One of the distinguishing features of geriatric surgery is the large percentage of older adults who have medical conditions that must be planned for perioperatively. Good communication between the surgeon and the primary care physician is important for this perioperative management. Orofacial infections, the most common of which are odontogenic in origin, require some form of surgical treatment and may or may not require treatment with antibiotics. Preprosthetic and reconstructive surgery may be necessary to treat the sequelae of oral and maxillofacial fractures, the sequelae of tooth loss, or surgical defects incurred during the treatment of cancer, osteomyelitis, osteoradionecrosis, or disorders of the TMJ.