Report of the EGOHID I Project. Selecting a coherent set of indicators for monitoring and evaluating oral health in Europe: criteria, methods and results from the EGOHID I project.

OBJECTIVES: The EGOHID I (European Global Oral Health Indicators Development) project started in 2002 under the European Health Monitoring Programme. The aim was to develop a set of indicators for monitoring and describing oral health morbidity and different facets of oral health care systems in Europe. The challenge was to define valid indicators that would cover common concerns and would have the same meaning throughout the different European health care systems. METHODS: EGOHID included i) a review of existing recommendations on oral health indicators, ii) a European study of the availability of national/or regional statistics to construct recommended indicators; iii) a consensus process using aggregation of preferences methods to select a list of essential indicators; iv) the production of a catalogue for information users, including descriptions for all indicators. RESULTS: A set of 40 indicators in oral public health were identified which, even though restricted to a minimal essential list, still addressed four key dimensions. The 40 indicators were described in four categories. Part A. indicators for monitoring the oral health of children and adolescents; Part B. indicators for monitoring the oral health of general population; Part C. indicators for monitoring oral health systems and Part D. indicators for monitoring oral health quality of life. This work has enabled a feasibility study (EGOHID II, which is now in progress), which is an essential part of an overall project, since it will allow Member States to evaluate their capability to use these indicators. CONCLUSIONS: The EGOHID 1 project was successful in identifying a set of 40 indicators which drew on and consolidated previous work. Consensus was achieved from a wide group of stakeholders on precise indicators in areas where uncertainty about appropriate indicators was high; some areas were also targeted for future development.

Food Consumption and Nutrient Intake in Relation to Denture Use in 55- to 84-Year-Old Men and Women -Results of a Population Based Survey.

OBJECTIVE: To study differences in consumption of foods and intake of nutrients attributable to denture status. DESIGN, SETTING AND PARTICIPANTS: Data from a cross-sectional, nationally representative Health 2000 Survey, subjects aged 55-84 years (n=2,241). MEASUREMENTS: Denture status (edentulous with full dentures, own dentition with removable dentures, own dentition with no removable dentures) was used as an explanatory variable. The consumption of foods and intake of nutrients was used as an outcome variable and was measured using a validated Food Frequency Questionnaire. RESULTS: Denture status associated with food choices. Full denture wearers consumed less vegetables (p = 0.013 among men and p = 0.001 among women) and fruits (p = 0.001 among women), more sugary products (p = 0.012 among men and p = 0.008 among women), and their balance in fatty acids was less favourable than among dentate participants. Among dentate participants, the differences between the two groups were small and statistically significant differences were seen mostly in women. CONCLUSIONS: Wearing full dentures appears to be associated with unhealthier food choices, lower consumption of some foodstuffs and lower intake of certain nutrients when compared to the food choices of dentate persons.

Pit and fissure sealants versus fluoride varnishes for preventing dental decay in children and adolescents.

BACKGROUND: The majority of the detected increment in dental caries is confined to pit and fissure surfaces of first molars. Application of pit and fissure sealants and topical fluorides are widely used procedures in the prevention of decay, and their effectiveness in caries prevention has been proved by systematic reviews. OBJECTIVES: The objective of this study was to compare the effectiveness of pit and fissure sealants with fluoride varnishes in the prevention of dental decay on occlusal surfaces. SEARCH STRATEGY: Electronic searching was performed on the following databases: the Cochrane Oral Health Group's Trials Register (last update November 2005), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 4), MEDLINE (from 1966 to December 2005), EMBASE (from 1974 to November 2004), SIGLE (from 1976 to December 2004), SCISEARCH, CAplus, INSPEC, JICST-EPLUS, NTIS, PASCAL (last update December 2004), DARE, NHS EED and HTA (last update November 2005). Reference lists from articles that fulfilled the inclusion criteria in this review and from review articles based on the search of MEDLINE were searched for additional relevant articles. Conference abstracts published as books or journals and handsearched by the Cochrane Oral Health Group were also included. SELECTION CRITERIA: The inclusion criteria for study selection were: random or quasi-random allocation study design; sealants versus fluoride varnish or sealants and fluoride varnish combination versus fluoride varnish alone; included studies included caries documentation on occlusal surfaces of permanent molars and the subjects were under 20 years of age. Both parallel and split-mouth study designs were accepted. The primary outcome of interest was the increment in the numbers of carious occlusal surfaces of premolars and molars. A study was excluded if sealants and fluoride varnish were not compared with each other. DATA COLLECTION AND ANALYSIS: Two review authors carried out the baseline searches, selecting the papers on the basis of the title, keywords and abstract and making decisions about the eligibility and data extractions. The same review authors assessed the methodological quality of all included studies: for example, the allocation concealment, blinding, and completeness of follow up. Authors of the studies were contacted for additional information. Risk ratios (RR) as effect estimates were calculated for the differences in whether surfaces were carious or not in the treatment groups, along with the appropriate standard errors and 95% confidence intervals (CI). No data could be combined or meta-analyses undertaken due to the clinical and methodological diversity between study designs. MAIN RESULTS: Four studies were eligible for inclusion in the review. Three of the four studies compared the effectiveness of sealants with fluoride varnish application, and one study compared the effectiveness of sealants and fluoride varnish combination with fluoride varnish alone. Results of two studies revealed the effectiveness of pit and fissure sealants to be statistically significantly higher than an application of fluoride varnish every 6 months in preventing occlusal decays of first molars at 23 months (RR 0.74, 95% CI 0.58 to 0.95) and at 9 years follow up (RR 0.48, 95% CI 0.29 to 0.79). One of these studies was classed as at low risk of bias, one of moderate to high risk. One small study at moderate to high risk of bias failed to find a statistically significant difference between sealants and fluoride varnishes. One study of low risk of bias found a statistically significant difference in favour of the sealants and fluoride varnish combination compared with merely fluoride varnish at 24 months follow up with RR 0.36 (95% CI 0.21 to 0.61). The age of children in the included studies was 5 to 9 years. Allocation concealment was classified adequate in two of these four studies. AUTHORS' CONCLUSIONS: There was some evidence of the superiority of pit and fissure sealants over fluoride varnish application in the prevention of occlusal decays. However, it remained unclear to what extent there is difference between the effectiveness of pit and fissure sealants and fluoride varnishes. Therefore, more high quality research is needed. No recommendations for the clinical practice could be given and the benefit of pit and fissure sealants and fluoride varnishes should be considered locally and individually.

Pit and fissure sealants for preventing dental decay in the permanent teeth of children and adolescents.

BACKGROUND: Fissure sealants used on occlusal tooth surfaces were introduced in the 1960s for protecting pits and fissures from dental caries. Although sealants have demonstrated to be effective in preventing caries, their efficacy may be related to the background caries prevalence in the population. OBJECTIVES: The primary objective of this review was to evaluate the caries prevention of resin based pit and fissure sealants and glass ionomer cements or sealants in children and adolescents. SEARCH STRATEGY: We searched the Cochrane Oral Health Group's Trials Register (last update December 2002), the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, Issue 4, 2002), MEDLINE via OVID (1966 to December 2002), EMBASE (1974 to February 2002), SCISEARCH, SIGLE, CAplus, INSPEC, JICST-EPLUS, NTIS, PASCAL (February 2002) and DARE, NHS EED, HTA (March 2002). Reference lists from included articles and review articles were searched for additional relevant articles. All relevant studies in most languages were considered and translated. SELECTION CRITERIA: Randomised or quasi-randomised controlled trials of at least 12 months in duration in which sealants were used for preventing caries in children and adolescents under 20 years of age were included. The primary outcome was the increment in the numbers of carious occlusal surfaces of premolars and molars. DATA COLLECTION AND ANALYSIS: In the first phase, two reviewers independently examined whether a given study was likely to be relevant on the basis of the title, key words and abstract. In the second phase, four of the reviewers independently classified studies to be included in final analyses. Study authors were contacted for additional information. In the split-mouth studies relative risk ratios were calculated for the paired differences of tooth surfaces being carious or not. In studies comparing resin based sealant with no treatment, fixed effect meta-analyses were used to combine the estimates of relative risk ratios. In one parallel group study, the mean DFS data as continuous data, the effect estimate being the difference in mean DFS, was calculated from data of occlusal surfaces of teeth included in the test and control groups. MAIN RESULTS: Eight trials were included in this review of which seven trials were split-mouth studies and one a parallel group study. Six studies provided data for comparing sealant with no treatment and three studies for comparing glass ionomers with resin based sealants. The overall effectiveness of resin based sealants in preventing dental decay on first molars was high. Based on five split-mouth studies with 5 to 10 year old children there were significant differences in favour of the second-generation resin sealant compared with no treatment with pooled relative risk values of 0.14, 0.24, 0.30, 0.43 at 12, 24, 36 and 48 to 54 months respectively. The reductions in caries therefore ranged from 86% at 12 months to 57% at 48 to 54 months. The 24 month parallel group study comparing second-generation resin sealant with control in 12 to 13 year old children found also significantly more caries in the control group children with DFS = 0.65 (95% CI 0.47 to 0.83). Allocation concealment was classified adequate in three of these six studies. However the information on background levels of caries in the population was insufficient to conduct further analyses to estimate the effectiveness of resin based sealants related to baseline caries prevalence. Only one study provided data for the comparison between glass ionomer sealant and control. Based on this, there is not enough information to say whether ionomer sealants are effective, or not. The results of three studies comparing resin sealants with glass ionomer sealants were conflicting and the meta-analyses were not carried out. REVIEWERS' CONCLUSIONS: Sealing with resin based sealants is a recommended procedure to prevent caries of the occlusal surfaces of permanent molars. However, we recommend that the caries prevalence level of both individuals and the population should be taken into account. In practice, the benefit of sealing should be considered locally and specified guidelines for clinicians should be used. The methodological quality of published studies concerning pit and fissure sealants was poorer than expected.

Changes in epidemiologic pattern of dental caries in cohorts of schoolchildren in Espoo, Finland, during a 3-year period.

The purpose of the present study was to establish the distribution of need for treatment of dental caries and also to evaluate the changes in the distribution of DMFT scores in cohorts of schoolchildren aged 7-15 yr. There was a decrease in the proportion of children with high DMFT scores during the study period. The difference was most pronounced at the age of 13 yr. Polarization of the DMFT scores was most obvious at 10 yr, but was also seen at 13 yr. The proportion of patients at risk of caries differs from one age group to another.

Caries and fillings in the permanent dentition of cohorts of schoolchildren in Espoo, Finland.

The purpose of the study was to analyze longitudinally the timing of enamel caries and, thereafter, fillings in occlusal, proximal and smooth surfaces of the permanent dentition of cohorts of schoolchildren initially 7, 10, 13, and 15 yr old. Altogether 228 children were examined annually during a 3-year period. Enamel and dentin caries affected on an average less than 15% of the occlusal surfaces in the first molars and at most 4% of the premolars; fillings proved to be the main determinant of the DF-scores for occlusal surfaces. On the other hand, decay was the main determinant of DF-scores on the proximal surfaces of the molars for at least 6 yr after eruption. The results indicate that in the 1970s some overtreatment of occlusal caries may have occurred, whereas indications for fillings on proximal surfaces were more accurate. The reduction in the number of extractions and fillings during the late 1970s resulted in a considerable decrease in the DMF scores. The decrease on DMF scores appears to have been due only to a minor extent to the decrease in caries. Thus, there was a decline in DMF scores rather than a decline in the prevalence of caries during this period.

Self-reported gingivitis and bleeding gums among adolescents in Helsinki.

The purpose of this descriptive cross-sectional community based investigation was to analyze the relationship between professionally measured and perceived gingival health in a sample of 1217 adolescents (age 14.0 +/- 0.7 yr). The responses to two questionnaire items relating to self-reporting of "gingivitis" ("inflammation of gums" in Finnish) and "bleeding from gums" are reported along with Community Periodontal Index of Treatment Needs (CPITN), percentage of bleeding sites (BOP%) and modified Papillary Bleeding Index (PBI) scores. It was found that current or past "gingivitis" was less often reported than "bleeding from gums" by this sample and that responses to both items exhibited low levels of agreement with the clinical measures. The results suggest that the self-reporting of gingival health may be useful in monitoring the gingival health of populations but does not have sufficient validity for screening individuals for gingivitis as defined by dental professionals. Furthermore, it is suggested that the term "bleeding from gums" rather than "gingivitis" should be used during clinical or group oral health promotion.

Gingival recession in schoolchildren at 7, 12 and 17 years of age in Espoo, Finland.

The present study was undertaken in response to a growing concern among clinicians about an increase in gingival recession among children and adolescents. Groups of 50 boys and 50 girls aged respectively 7, 12, and 17 yr were examined at Espoo Health Centre in 1983. Gingival recession was measured on the facial and lingual aspects of all permanent teeth. Whenever the gingival margin was located on root cementum, the distance from the gingival margin to the enamel border was measured to the nearest 0.5 mm. Recession was categorized as "slight" (0.5 or 1 mm) or "extensive" (1.5-3.5 mm). The prevalence of gingival recession was 5% at 7 yr, 39% at 12 yr, and 74% at 17 yr of age. More girls than boys had recession in the two youngest age groups. At 17 yr recession was equally common in both sexes and both "slight" and "extensive" recession was most often recorded on facial surfaces of first molars, premolars and canines. The alarmingly high prevalence of gingival recession at young age warrants further study of both the reasons and the consequences of early cementum exposure.

Periodontal treatment needs in populations under 20 years of age in Espoo, Finland and Chiangmai, Thailand.

The aim of this study was to assess the periodontal treatment needs at under 20 yr of age in the affluent area of Espoo, Finland, offering comprehensive public dental health care, as compared to a less advantaged area in Chiangmai, Thailand. In Espoo, 50 girls and 50 boys were examined in each age group of 7, 12 and 17 yr. In Chiangmai equal numbers of girls and boys were examined to obtain a group of 89 subjects aged 18.5 + 0.6 yr. According to the Community Periodontal Index of Treatment Needs (CPITN) the need of scaling increased in Espoo from 6% of the 7-yr-olds to 39% of the 17-yr-olds. Moderate pocketing (4-5 mm) occurred in one subject at age 12 and in three subjects at age 17. In Chiangmai, deep pockets (6 mm and over) were recorded for 1%, moderate pockets for a total of 44%, and dental calculus as the highest treatment need indicator in the remaining 55%, indicating a need for professional treatment in 100% of the group examined. The mean number of sextants requiring scaling was 0.6 per person at age 17 in Espoo as compared to 4.5 at 18.5 yr of age in Chiangmai. Three or more healthy sextants per subject were recorded for 47% of the 17-yr-olds in Espoo and for only 6% of the 18.5-yr-olds in Chiangmai. It was concluded that already at young age vast differences occur between periodontal treatment needs in industrialized and developing countries.

Edentulism among Finnish adults of working age, 1978-1997.

OBJECTIVES: The dental health of Finnish children and young adults has improved considerably during the last 25 years. At the same time, there are still middle-aged or elderly individuals who have lost some or all of their teeth, since extractions were commonly used as a treatment for dental infections during earlier decades. The aim of the present study was to analyze changes of the prevalence of and risk indicators for edentulism among Finnish adults of working age (15-64 years) from 1978 to 1997. METHODS: The National Public Health Institute has, since 1978, conducted annual surveys concerning health behavior among the Finnish adult population. The data were collected through a mailed questionnaire including questions on the number of missing teeth. Sample sizes varied from 5000 to 6000 and the response rates from 70% to 85%. RESULTS: The dental status profile of the Finnish adult population has changed considerably since 1978. The prevalence of edentulism decreased from 14% to 6% during the study years. At the same time, the number of persons with complete dentition increased from 60% to 80%. The decrease in edentulism was obvious in both sexes, but the change was more remarkable among women. In 1997, the difference between the sexes had almost disappeared. The differences between regional and educational groups were still marked in 1997. Belonging to a certain birth cohort appeared to be the major factor affecting the percentage of edentulous subjects. In 1978 risk indicators of total tooth loss included age, gender, length of education, geographical area, urbanization, marital status, and medication for headache. In 1997 risk indicators included age, length of education, geographical area, history of smoking, and perceived status of health. CONCLUSIONS: The number of totally edentulous working-age persons is rapidly decreasing in Finland. Edentulism was strongly associated with birth cohorts and is apparently accumulating in a diminishing group of people. Relevant factors that were strongly associated with edentulousness did not vary considerably between the study years.

Smart Habit Xylitol campaign, a new approach in oral health promotion.

A national 'Smart Habit' Xylitol campaign was organised in Finland in autumn 1992. The aim of the campaign was to increase consumption of xylitol chewing gum in 13-year-old school children, to promote their oral health. The campaign was conducted in elementary schools in the form of a quiz and lesson related to xylitol. Seventh form children from schools in 12 local health authority areas in 10 provinces took part in the campaign. Six thousand seven hundred children were involved. Data were collected with a series of three separate postal questionnaires. The study group consisted of 1,281 children exposed to the campaign. A control group was formed from 1,227 children in the same provinces not exposed to it. Questionnaires were distributed before and after the campaign. A third one was sent out a month later. A high number of the children had consumed xylitol chewing gum even before the campaign. The majority of the respondents reported no changes in consumption of xylitol chewing gum after meals in the first two questionnaires. The results showed that the consumption of xylitol chewing gum after meals increased more in the group exposed to the campaign than in the control group (P = 0.002). Girls in the study group increased their consumption of xylitol chewing gum more than boys (P = 0.016). Also an increase in the daily use of xylitol chewing gum was achieved by the campaign; differences between the study and the control group being significant (P < 0.05). Even though there was knowledge about the beneficial properties of xylitol beforehand, an increase in knowledge was achieved by the campaign. There seems to be potential for positive oral health promotion by means of this type of xylitol campaign.

Self-reported dental health, treatment need and attendance among older adults in two areas of Finland.

OBJECTIVE: The purpose of the study was to assess differences in dental health, need for care and attendance among older adults in two areas of Finland with contrasting socio-cultural and economic backgrounds. A further aim was to analyse and compare the determinants of oral health and dental visiting patterns. BASIC RESEARCH DESIGN AND PARTICIPANTS: FINRISK senior survey was conducted by the National Public Health Institute in the two areas in 1997. Data were collected through a postal questionnaire, a health examination and an interview, which included questions of number of extracted teeth, dental treatment need and utilisation. The sample consisted of 1,500 persons, 250 women and 500 men aged 65-74 years in both areas; the response rate was 86%. RESULTS: Forty-one per cent of the respondents reported having lost all their teeth and 44% had visited a dentist during the past year. Differences between the areas concerning both dental health and attendance were considerable. Respondents living in North Karelia had lost more teeth and visited a dentist more seldom than respondents in the Helsinki region. Risk indicators for the number of extracted teeth differed between the areas, while determinants for the dental attendance during the previous year were almost identical. The major predictors for a dental visit during the previous year were number of teeth and household income. Self-perceived need for dental care was minor. Functional capacity, medically compromising diagnoses or medication did not play any apparent role in dental attendance. CONCLUSIONS: The number of teeth together with income are the principal determinants for dental visits among older persons in Finland.

Use of the CPITN in populations under 20 years of age.

The aim of this study was to find the optimal approach to the use of the Community Periodontal Index of Treatment Needs (CPITN) in age groups under 20 years of age in which the presence of false pockets around erupting teeth has caused confusion. Fifty boys and fifty girls in each age group of 7-, 12- and 17 years were selected at random from among young patients attending for regular dental care. To allow detailed analysis, CPITN recordings were made for each tooth instead of per sextant. The 4-5 mm pockets were divided into true pathologic pockets requiring scaling and improved oral hygiene; false pockets with bleeding after gentle probing and thus needing improved oral hygiene only; and false pockets with no treatment need. Comparisons of periodontal treatment needs per sextant were made after basing the CPITN code number on examination of all teeth in the sextant, of the CPITN epidemiological index teeth (17, 16; 11; 26, 27; 37, 36; 31; 46, 47), and of teeth 16, 11, 26, 36, 31, 46. Incomplete eruption even of first molars and maxillary central incisors was frequently observed at age 7 whereas at ages 12 and 17 the presence of false pockets was most frequent around mandibular and maxillary second molars. It is suggested that in populations under 20 years of age CPITN recordings should be based on examination of teeth 16, 11, 26, 36, 31, 46.(ABSTRACT TRUNCATED AT 250 WORDS)

Use of CPITN cross-tabulations--a research perspective.

In earlier years, studies on the epidemiology of periodontal disease were often reported in the form of mean scores for the population studied. Use of the WHO recommended Community Periodontal Index of Treatment Needs (CPITN) has given important additional information, particularly about the distribution of indicators of current periodontal disease within various age groups of the population. In the analysis of survey data, the use of CPITN cross-tabulations has been found particularly promising for the assessment of both preventive and therapeutic needs. For example, in Finnish schoolchildren the proportion of subjects with two or more sextants scoring Code 2 for calculus increased from 0 per cent at age 7 to 5 per cent at age 12 and 9 per cent at age 17 years. In the same population, 0 per cent at 7, 1 per cent at 12, and 4 per cent at 17 years of age had one or more pockets measuring more than 3 mm. In another population, comprising dentate adults from rural Finland, the prevalence of Code 4 for 6 mm or deeper pockets increased from 1 per cent at age 25 to 6 per cent at age 35, 18 per cent at age 50, and 27 per cent at 65 years of age. An important additional observation was that a total of 58 per cent of those who had one or more Code 4's, had their advanced periodontal disease confined to only one sextant. The latter finding may prove useful when deciding between partial and full mouth examinations in future epidemiological studies.

Self-assessed bleeding and plaque as methods for improving gingival health in adolescents.

The aim of this longitudinal study was to compare the effectiveness, in terms of cognitive and clinical changes, of two oral self-care promoting interventions based on a self-assessment of bleeding from gums or of presence of plaque. Adolescent students (age 14.0 + 0.7 years) from two health districts in Helsinki, Finland, participated in this one-year study. The self-assessment of bleeding group (n = 172) recorded bleeding during tooth brushing and inter-proximal cleaning with toothpicks on a single session. The self-assessment of plaque group (n = 156) recorded the presence of plaque with disclosing dye. Both programmes resulted in comparable clinical improvement in bleeding on probing over 9 months. Increased awareness of gingivitis was associated with clinical improvement. The subjects' socio-economic background, baseline gingival health status and age were statistically significantly associated with gingival health improvement during the follow-up. The results support earlier reports on self-assessment and suggest that both self-assessment approaches are beneficial for promoting gingival health in adolescents.

Video as a medium of oral health education for children with mental handicaps.

This study assessed the usefulness, appropriateness, and relevance of a video as an oral health education medium for children with mental handicaps and for preschool groups where children with mental handicaps and healthy children are taught together. The evaluated video was designed for children with mental handicaps but was also recommended for integrated groups. Forty children with mental handicaps from four special education classes and two nursery school groups, 151 normal children from 11 nursery school groups, and the teachers of these classes and groups evaluated the material. The assessment of the material's value was based on the teachers' records of their experiences with the material, their records of the children's opinions and discussions about the material, and their records of drawing interviews with the children. Based on the evaluation, it is apparent that, when used by trained teachers, professionally made videos designed for children with mental handicaps can be useful and valuable aids in educating children of different levels of mental and social development about oral health. Integrated groups need videos featuring both children with mental handicaps and normal role models and with a diversity of contents that will interest and challenge both types of audiences.E.