Using subjective oral health status indicators to screen for dental care needs in older adults

A study was undertaken to assess the ability of a number of subjective oral health status indicators to identify community-dwelling older adults who need dental treatment. The indicators consisted of a single-item self-rating of treatment need, a 15-item psychosocial impact index and the 49-item Oral Health Impact Profile (OHIP). Data for the study were collected as part of an oral health survey of Canadians aged 50 years and over. The associations between these subjective indicators and clinically defined dental treatment needs were assessed using statistics for determining the predictive power of a diagnostic test. Although there were statistically significant associations between the subjective and clinical measures, values for statistics such as sensitivity, positive predictive values and positive likelihood ratios were low. Although the measures did not perform well as screening tests, they did identify a sub-group of individuals whose clinical conditions impacted significantly on daily life and who would probably benefit the most from dental treatment. In this respect, the subjective measures assessed here can themselves be interpreted as indicators of need which complement conventional clinical measures of needs for dental care.     

Unmet needs as sociomedical indicators

This paper discusses the Meharry Medical College Study of Unmet Needs designed to measure the effectiveness of alternative health care delivery systems: (a) comprehensive care with broad outreach, (b) comprehensive care with limited outreach, and (c) traditional care. Unmet needs are defined as the differences between services judged necessary to deal appropriately with health problems and services actually received. The central hypothesis is that comprehensive health programs will be more effective than traditional care in reducing unmet needs. Unmet needs are viewed as measures of program outcome and are one of several types of sociomedical indicators which use factors other than biomedical or biological states as measures of outcome. The distinction is made between unmet needs are discussed and the relatively limited focus of these is contrasted with the more comprehensive Meharry approach. Household interviews and clinical examinations provide the data base for deriving professional judgements of unmet needs in the medical, dental, nursing, and social services areas. The Meharry work suggests several areas in which further work on unmet needs would be useful.     

Multidimensionality of oral health in dentate adults

OBJECTIVES: An understanding of the validity and usefulness of self-reported measures (as distinct from clinically determined measures) of oral health is emerging. These self-reported measures include self-rated oral health (SROH). Three objectives were to: (1) describe self-rated oral health in dentate adults, (2) quantify associations between self-rated oral health and other measures of oral health (oral disease and tissue damage, pain and discomfort, functional limitation, and disadvantage), and (3) assess the construct validity of a model of oral health proposed herein. METHODS: The Florida Dental Care Study is a longitudinal study of oral health, which included at baseline 873 subjects who had at least one tooth, were 45 years or older, and who participated for an interview and clinical examination. RESULTS: The prevalence of self-rated oral health decrements was substantial; approximately one fourth of subjects reported their oral health as only fair or poor. Bivariate and multivariate results provided consistent evidence of the construct validity of the proposed model of oral health. Additionally, the salience of one measure of dental appearance suggests that persons may use esthetic cues when rating their oral health. CONCLUSIONS: The proposed multidimensional model of oral health has construct validity. Self-rated oral health is affected by oral disease and tissue damage, oral pain and discomfort, oral functional limitation, and oral disadvantage. These self-reported measures and the proposed model should provide useful information for dental care effectiveness research. General health status has been disaggregated into the "physical" and the "mental;" an additional separation into the "oral" aspects of health seems warranted.     

A classification of sociomedical health indicators: perspectives for health administrators and health planners

The conceptualization and operationalization of measures of health status are considered. Health indicators are conceived as a subset of social indicators, and therefore, as any social indicator, they are viewed as derivative from social issues. The interrelationships of different frames of reference for defining and measuring health that have accompained three distinct health problem patterns in the United States are viewed from a developmental perspective. Mortality and morbidity rates, the traditional health indicators, by themselves no longer serve to assess health status in developed nations. Their deficiencies as indicators serve as background for a classification schema for sociomedical health status indicators that relates health definition frames of reference, measures of health status, and health problems. The role of a group of health indicators-sociomedical heath indicators-in the current formulation of health status measures is assessed.     

Subjectively reported oral health status in an adult population

This study describes the subjectively reported oral health status of an adult population aged 18 yr and over. The study used measures of the functional, social and psychological impact of oral disorders, originally developed for surveys of older adults, and aimed to determine whether or not they were sensitive to the oral health concerns of younger adults. It compared four age groups (18-29 yr; 30-49 yr; 50-64 yr; 65 yr and over) in terms of the following subjective oral health indicators: ability to chew, problems speaking, oral and facial pain; other oral symptoms; problems eating; problems with communication-social relations; limitations in activities of daily living and worry and concern. The initial hypothesis that few younger subjects would report the kinds of problems documented by these indicators was not supported. On all measures except ability to chew, younger subjects were as likely to be compromised by oral conditions as older subjects.     

Continuous improvement of oral health in Europe

The oral health action programmes of the WHO Regional Office for Europe (WHO/EURO) comply with the overall European Health Policy and targets for the improvement of health in Europe by the year 2000 (HFA2000) and focus on promotive and preventive care approaches primarily at the community level. Various activities, including the development of guidelines for local action projects, have been established to support WHO/EURO's Member States in initiating preventive oral health care system and introducing the concept of continuous quality development in oral health care. The main focus for Countries of Central and Eastern Europe (CCEE) is to formulate national goals for oral health and to further develop oral health services in the region. Collection of national data using agreed European quality indicators for oral health will form the basis of appropriate monitoring and development of technologies to improve oral health care services and the oral health status at large. The WHO/EURO action programmes aim to implement oral disease prevention and health promotion activities. Guidelines have been established to support individual Member States who intend to establish community-based programmes in accordance with scientifically sound principles and methods. The ORATEL Project (Telematic System for Quality Assurance in Oral Health Care) is part of the Commission of European Communities (CEC) strategy for harmonization and standardization in health care (CEC) Programme for advanced informatics in medicine--AIM/CEC) and ORATEL is the only AIM/CEC project related to oral health. The ORATEL Project aims to improve the oral health status in the European Region through use of appropriate computerized information systems. The Project will support management and administration of dental clinics and will be an integral part of a quality assurance system to promote a standardized level of quality in the field. Its advanced educational and decision-support tools can be used by professionals at all levels of the system. ORATEL possesses tools for aggregating and transmitting data upwards for monitoring and evaluation purposes at local, national and supranational administrative levels.     

Validity of two methods for assessing oral health status of populations

OBJECTIVE: This investigation assessed two methods for estimating epidemiologic indicators of oral health status among children: (1) a visual-only screening, performed independently by a dental hygienist and a registered nurse; and (2) a parent- or guardian-completed questionnaire. The indicators included dichotomous variables measuring dental caries and treatment needs, presence of sealants, injuries to the anterior teeth, and dental fluorosis. METHODS: Following training and calibration, data were collected over an eight-day period in April 1994 among 632 elementary schoolchildren (aged 5 to 12 years) in Monticello, Georgia. Both screening and questionnaire findings were compared pairwise with results from visual-tactile examinations done by a dentist. Validity, represented by sensitivity, specificity, and predictive values, was assessed for screening results from the dental hygienist, the nurse, and the parent-completed questionnaire. RESULTS: Validity was high for screening for caries and treatment needs (> 90% for sensitivity, specificity, and predictive values in a sample having 30% to 40% prevalence). Less valid data--mainly an effect of false negatives--were obtained for fluorosis, injuries, and presence of sealants. No significant difference in validity was observed between the nurse and the dental hygienist. One-third of respondents to the questionnaire did not know if their children needed fillings (a proxy for untreated decay) or had received sealants; only knowledge of restorations was comparable to results from screening. Intraexaminer reliability for the two screeners ranged from 85 to 100 for percent agreement and 0.70 to 0.93 for kappa scores. CONCLUSIONS: Screening by dental hygienists or nurses can provide valid data for surveillance of dental caries and treatment needs. Training for visual assessment of fluorosis and injuries must be improved to diminish the proportion of false negatives. A parent-completed questionnaire is less effective than visual screening for evaluating oral health status in children.     

Oral hygiene for children: a look at what we must have and what we should do

Numerous reports show the state of oral health in children from many parts of the world. They indicate that dental caries and periodontal disease in children are common and not under proper control and that there is a high prevalence of dentofacial anomalies requiring early treatment. What we must have in relation to oral hygiene for children are manpower, materials and health education. These needs are analysed in detail. What we do is described for three groups of children: preschool, school and adolescent and young adult. Six common factors for all children carrying out oral hygiene are outlined under the following headings: (a) increasing the resistance of the tooth by the use of fluorides, (b) the control of plaque, (c) correct nutrition, (d) dental health education, (e) early recognition of major disorders of the orofacial complex and (f) regular visits to the dentist and his auxiliary help. What we should be doing for each group is discussed. Finally, some thought about the future way to dental health are presented in which it is suggested that the computer revolution "will have an overwhelming and comprehensive impact on every human being on earth in every aspect of his or her life' (Evans, 1979). The question is asked and discussed whether the dental profession is preparing for this revolution and the great changes that will come in our methods of education, clinical practice, research and education. The paper ends with the proposal that now is the time for organized dentistry to examine its policies in relation to education, clinical practice, research and administration so as to produce a primary dental health service available to total populations in the countries of the world.     

Culture, dental professionals and oral health values in multicultural societies: measuring cultural factors in geriatric oral health research and education

Culture has significant impacts upon professional practice and patient health behaviours, especially in multicultural societies. This paper introduces the concept of culture and examines how it may be of importance to dental health professionals. Using the Dental Impact Profile and other dental social science measures, dental researchers and students can be engaged in studying cultural values and characteristics as a way of dealing with cultural differences.     

Fourth ventricular entrapment caused by rostrocaudal herniation following shunt malfunction

The aim of this study was to assess differences in dental health between socioeconomic and ethnic groups in a cohort of 5-yr-old children born in 1982 and in a cohort of 11-yr-old children born in 1976. A further aim was to evaluate the putative role of dental behaviors as intervening factors between ethnicity and maternal education on the one hand and caries experience on the other. A secondary analysis was performed on data collected in a study monitoring the oral health of youths covered by public health insurance (Ziekenfonds) in the Netherlands. The results showed both ethnicity and maternal education to be indicators of caries risk in the primary dentition. For caries in the permanent dentition, only maternal education could be identified as a risk indicator. Dental behaviors were related to caries experience as well as to ethnicity and maternal education, though the evidence for the role of these dental behaviors as intervening factors was weak. It is concluded that the validity and reliability of the behavioral measurements might be questionable and that the mechanism underlying the differences in caries experience between the various groups is still little understood.     

Patterns of class inequality in health through the lifespan: class gradients at 15, 35 and 55 years in the west of Scotland

Data confirming the existence of social inequalities in health have continued to accumulate since the Black Report reported class inequalities across a broad range of causes of mortality, with an increasing emphasis on indicators of morbidity and current health status. Although evidence of continuing inequalities mounts, elucidation of underlying mechanisms generating and maintaining such inequalities has been more elusive, and much of the debate has oscillated from the very broad to the very specific. In this paper, the class patterning of a range of non-fatal indicators of health are modelled in an attempt to outline first the adequacy of models of linear relationships for this range of measures, and secondly, the extent to which these are generalizable across a series of age/sex subgroups and across different domains of health. Data are presented here for representative community samples of men and women in adolescence, early- and late-midlife. While orderly relationships between social class and health were seen for the majority of the measures considered; the detailed patterns show considerable diversity. Thus for some aspects of health, notably height (itself often heralded as a broad indicator of health and early life experience), common class gradients were observed for both sexes at each of the stages of the life course examined. For others (notably mental health and presence of chronic illness), gradients were evident in later life but not in adolescence. Others still showed sex but not age differences in class patterning (typically measures of body shape), or no clear patterns (notably blood pressure and consultations with general practitioners). The current analysis draws attention to the consistency of gradients in early- and late-midlife, which are apparent despite the marked increase in the burden of poorer health which manifests between these life stages for almost all indicators of health (an exception being mental health). The challenges which this presents for understanding the mechanisms and processes which have been candidate explanations for social inequalities in health are discussed.     

The effect of social and personal factors on the utilisation of dental services in Glasgow, Scotland

This study examined potential mediators of dental attendance among two distinct adult populations who lived in contrasting social environments (deprived and affluent). The aim of the study was to describe and quantify the effect of both the potentially modifiable and the fixed factors which influence use of dental services. A two-stage weighted random sampling technique was used to select 863 participants who were interviewed. Of these participants, 372 lived in 'affluent' areas and 491 in 'deprived' areas. The 45 minute interview explored many aspects of oral health, and related behaviour and attitudes. The results showed a highly significant association between social deprivation and reported dental attendance (P < 0.001). Social environment was also significantly related to asymptomatic dental attendance. Deprived respondents' dental behaviours were significantly affected by life events and yet structural/organisational barriers to attendance had a significantly greater impact on the affluent population's dental visiting patterns than they did on the deprived population's. A regression model indicated that the best predictors of dental attendance were social environment, dental anxiety, perceptions about denture wearers and the value placed upon restored teeth. The study suggests that the barriers to dental attendance experienced by deprived populations are not easily modifiable, but belong instead to a group which relate to the socio-political agenda. The study also demonstrates the importance of accurate and regularly updated community registers for use in population based health services research.     

African trypanosome infections in mice that lack the interferon-gamma receptor gene: nitric oxide-dependent and -independent suppression of T-cell proliferative responses and the development of anaemia

This paper presents an analysis of the main policy and organisational issues confronting dental health systems in Japan and Australia. Using the changes in the epidemiology of dental disease (the oral disease which still affects much of public dental health planning) as evidence of fundamental differences in the dental health systems of the two countries, the analysis seeks to illuminate, first, the structures and processes in both nations to review and implement changes to educational practices and workforce planning and, second, the constraints on each nation's capability to respond quickly and appropriately to the changing dental health needs. It is argued that Japan's ability to rapidly change its oral health outcomes, its dental educational system and its traditional workforce structure and service-mix, is more constrained than appears to be the case in the Australian dental system. The major barriers to Japan's ability to change appear to lie in both its traditional cultural decision-making processes and in a series of specific health and educational structures which place high reliance on a private educational system for health providers, a national insurance system which rewards treatment under a fee-for-service reimbursement scheme and the lack of a formal, transparent, infra-structure for planning health priorities. Barriers to Australia achieving culturally appropriate oral health outcomes for the next century appear more related to whether national unity in goal setting and implementation strategies can be achieved. The constraints in Australia are related to its federal system and to the low priority given to financing public dental services.     

Common pediatric dental problems

Physicians who provide primary care for children have a unique position to provide diagnostic, triage, educational, and preventive dental care for patients. Several papers have been published regarding primary pediatricians' participation in the preventive dental health care of their patients. One publication, a survey of physicians in Alabama focusing on physicians' overall awareness of dental issues, concluded that most physicians believe they have a role in the oral health of their patients, yet most were not aware of the American Academy of Pediatric Dentistry's recommendations. Most physicians report that they routinely perform oral examinations during physical examinations of children and deliver preventive, oral information by the age of 6 months or earlier; however, most recommend that infants' first visit should be at 3 years of age, not at the time of first-tooth eruption as the authors recommend. Furthermore, many primary care physicians do not talk about oral health during prenatal counseling. Many physicians understand the preventive advantages of fluoride, yet most do not prescribe vitamin combinations that contain fluoride. If an understanding of the aforementioned issues of dental care, as well as aspects of preventive care in infants and children, become more uniform among primary care physicians, the prevention-based practice of pediatric dentistry will become much more successful, and children and adults will enjoy better dental health.     

Emergency medicine and the development of the Food and Drug Administration''s final rule on informed consent and waiver of informed consent in emergency research circumstances

The quality of dental unit water is of considerable importance since patients and dental staff are regularly exposed to water and aerosols generated from the dental unit. The unique feature of dental chair water lines is the capacity for rapid development of a biofilm on the dental water supply lines combined with the generation of potentially contaminated aerosols. The biofilm, which is derived from bacteria in the incoming water and is intrinsically resistant to most biocides, then becomes the primary reservoir for continued contamination of the system. Dental water may become heavily contaminated with opportunistic respiratory pathogens such as Legionella and Mycobacterium spp. The significance of such exposure to patients and the dental team is discussed. There is at the present time, no evidence of a widespread public health problem from exposure to dental unit water. Nevertheless, the goal of infection control is to minimise the risk from exposure to potential pathogens and to create a safe working environment in which to treat patients. This paper evaluates the range of currently available infection control methods and prevention strategies which are designed to reduce the impact of the biofilm on dental water contamination, and are suitable for use in general practice. Bacterial load in dental unit water can be kept at or below recommended guidelines for drinking water (less than 200 colony forming units/ml) using a combination of readily available measures and strict adherence to maintenance protocols. Sterile water should be employed for all surgical treatments.     

Preparing for the "silver age of dentistry"

Providing oral health care to older adults will be a challenging and rewarding part of dental practice in the years ahead. It will include understanding normal aging, appreciation of the pathophysiology of chronic diseases experienced by many elderly, and application of key principles of pharmacology in care of patients receiving medications for treatment of these diseases. It will involve an understanding of the interaction of systemic conditions with oral health status, adequate diagnosis of oral disease, and appropriate rational treatment planning with a strong emphasis on preventive dentistry. It will include care provided in nursing homes or during housecalls for the homebound. Dentist-geriatricians will be working with teams of healthcare professionals that include physicians, dentists, podiatrists, ophthalmologists, nurses, social workers, nutritionists, pharmacists, and occupational and physical therapists. Above all, the team will provide skilled compassionate care, which is always good business!     

Comparing measures of health inequality

Several methods are available to measure social inequalities in health. This paper discusses the advantages and disadvantages of different approaches, in particular the odds ratio, the slope and alpha. These methods are illustrated using data from subjects in the 1958 British birth cohort. The inequality measures are compared using health status at ages 23 and 33. Six health indicators are examined, including self-rated health, limiting long-standing illness, psychological health, respiratory symptoms, asthma and obesity. Two social indicators are compared, namely class at birth and educational qualifications. Conclusions do not differ substantially using the three methods for measuring inequality. However, consistent differences were evident between the measures of social position, with greater inequalities apparent for educational qualifications. Choice of social indicator therefore appears to be of primary importance in measuring health inequality.     

Cell behavior and signal molecule involvement in a case study of malignant histiocytosis: a negative model of morphine as an immunoregulator

OBJECTIVE: This paper identifies specific data items for use by state and local agencies in a maternal and child oral health needs assessment model. METHODS: A modified Delphi approach was used to develop consensus on items for inclusion in the data set and their relative importance. Initially, 31 data items were chosen from several national sources. All state dental directors, along with other selected administrators and advisory committee members for this process, were asked to categorize each of the data items as core (essential), important but optional, or of lesser importance. Short comments about each data item were accepted, as were additions to the list of data items. Two rounds of comments were held. RESULTS: Eleven data items/types of information were selected as core items to be included in all needs assessments. All but one of these items were determined by the scores of the respondents. The advisory committee strongly recommended that at least one core item relate to the public's perception of oral health. Some differences in perceived importance of several items existed among the state dental directors, local dental directors, and the advisory committee. Twenty-one items were identified as being important, but optional, and seven were considered less than important and not included in the model data set. CONCLUSIONS: A modified Delphi approach facilitated the development of core and optional data items for a model oral health needs assessment. This model has potential for a common reporting mechanism so that states and local dental programs can share data.     

The importance of quality of life research for health care reform in the USA and the future of public health

Quality of life research data have significant implications for the social and public policy in the USA as it can be used to evaluate the cost-effectiveness of various permutations of treatment as well as the 'human effectiveness' of health care system restructuring. The USA spends more on health care per capita than any other industrialized nation, yet on major health indicators, such as infant mortality rate, this expenditure is not related to beneficial effects on the community. When epidemiological and quality of life data drive national health care planning, improved approaches to the management of health service delivery may become apparent. Ultimately only the patient or consumer can determine if a particular treatment is successful; the same may be true for health care reform.