Understanding and utilizing qualitative research.
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Dental Research↗
Biomedical subjects
K A Atchison
Publications and source records attributed to K A Atchison.
Efficacy of FDA guidelines for prescribing radiographs to detect dental and intraosseous conditions.
OBJECTIVES: This study compared the FDA guidelines for ordering dental radiographs to a conventional full-mouth examination for the detection of intraosseous disease and conditions affecting teeth other than caries. STUDY DESIGN: We examined 490 patients and selected posterior bite-wing and periapical views as indicated by the patient's signs or symptoms. We compared the radiographic findings with the use of this selected set of radiographs to those from a full-mouth set of radiographs to determine the rates of missed disease when the FDA guidelines were used. RESULTS: The most commonly missed intraosseous findings were osteosclerosis, unerupted teeth, periapical radiolucencies, and primary root tips. Periapical radiolucencies that were most probably periapical cemental dysplasia were missed in six patients. The most commonly missed dental findings were resorbed roots and pulp stones. Three instances of dens in dente were missed. CONCLUSIONS: When we used the FDA guidelines, the number of missed intraosseous and dental conditions was small and most likely inconsequential given the range of variability in dental diagnosis and treatment.
Adolescent↗
Oral health, health, and health-related quality of life.
Health-related quality of life is a multidimensional concept with five broad domains: opportunity/resilience, health perception, functional states, impairments/diseases, and duration of life. It addresses the tradeoff between how long and how well people live. The health-related quality of life approach has provided greater opportunity for investigation of the interrelations among oral health, health, and related outcomes. The inclusion of patient-driven measures, such as perceptions and functional status, is critical. Oral health-related quality of life measures are being developed and used in research on aging populations. Clinical measures of oral health, perceptions of general and oral well-being, and reported physical, social, and psychological functioning are independent, but correlated, components of overall oral health-related quality of life. An oral health-related quality of life approach benefits 1) clinical practitioners in selecting treatments and monitoring patient outcomes; 2) researchers in identifying determinants of health, tracking levels of health risk factors, and determining use of services in populations; and 3) policy-makers establishing program and institutional priorities, policies, and funding decisions. This overview indicates substantial value in pursuing several recommendations. A theoretical framework from which concepts, measures, and models can be derived must be developed to address oral health, oral health-related quality of life, health, and health-related quality of life. Oral health outcomes or states must be identified and classified along some continuum of impairment, function, disability, and opportunity. Indicators of appropriate concepts and domains must be adapted or established. Extended analyses on the relations among oral health, oral health-related quality of life, health, and health-related quality of life should be conducted with use of the Boston VA Normative Aging Study and other appropriate data sets.
Activities of Daily Living↗
Jaw function status in an elderly community sample.
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Activities of Daily Living↗
Factors affecting self-ratings of oral health.
OBJECTIVES: The purpose of this study is to determine the relationship of self-rated oral health to a comprehensive battery of clinical, sociodemographic, physical health, and mental health measures in a well-elderly urban population. METHODS: Results are based on telephone interviews and clinical assessments of 550 subjects over 65 years of age participating in a Los Angeles-based Medicare project during 1990. Subjects were mostly female, white (89%), with above-average income. RESULTS: Findings show that: (1) the DMF measure is not as strongly related to self-rated oral health as was a single measure of missing teeth; (2) the major predictors of self-rated oral health were "worry about teeth" and "appearance of teeth" followed by total missing teeth, race, education, and depression scores; and (3) self-rated general health is related to self-rated oral health. CONCLUSION: Self-rated oral health may be, for older adults, a better measure of "health" than of "morbidity".
Aged↗
Efficacy of the FDA selection criteria for radiographic assessment of the periodontium.
The diagnosis of periodontitis is generally made on the basis of a clinical examination supported by radiographic evidence of bone loss. Recent guidelines promulgated by the US Food and Drug Administration recommend that periapical radiographs be ordered on the basis of clinical signs and symptoms indicating the probable presence of disease. This study evaluated the effectiveness of the FDA Guidelines for ordering radiographs for new adult dental patients as related to assessment of the periodontal condition of the patient. We examined 490 patients and determined the periapicals needed to supplement the posterior bitewings based upon the patient's clinical findings. We measured the reduction in the number of radiographs ordered as well as the extent of missed alveolar and furcation bone loss resulting from the use of the selected set of radiographs compared with a complete set. Four hundred thirty-three subjects had at least one clinical sign of periodontitis present in their mouths, and 264 demonstrated radiographic evidence of alveolar bone loss. Of the 460 subjects on whom periodontal probing was conducted, two-thirds demonstrated periodontal probing depths in excess of 3 mm; almost half showed evidence of bleeding upon probing. Individuals with clinical signs of periodontitis had, on average, 10 periapicals ordered--more than twice the number as those with no sign of periodontitis. Of the 2,415 teeth with radiographic findings of proximal or furcal bone loss, 152 sites of bone loss (6%) were missed when the selected set of films plus the posterior bitewings was used.
Adolescent↗
Clinical and historical predictors of dental caries on radiographs.
This report evaluates the efficacy of the clinical predictors of caries proposed in the USA FDA guidelines for prescribing dental radiographs. The clinical findings that best associate with the presence of any caries where a history of pain, a defective restoration, unusual calcification, and an abutment tooth for a fixed or removable prosthesis. There is a group of measures of periodontal disease that were also weakly associated with the presence of caries. The best predictors of caries extending into the dentin were the presence of clinically defective restorations, a history of pain, and signs of periodontal disease. Proximal lesions are likely to appear on teeth with defective restorations, unusual calcification or large or deep restorations. The best predictors of radiographic root caries are periodontal findings such as furcation involvement, increased mobility, a history of periodontal therapy and gingival recession. While the specificities for these findings were generally high, the sensitivities and positive predictive values were usually under 50%, and often much lower. Thus these clinical findings cannot successfully be used as exclusive criteria for ordering radiographs for caries detection. Because caries is found fairly frequently, and because we are unable to identify tooth-specific criteria with clinically useful sensitivity and specificity values, these data support the FDA panel recommendation of bitewing examinations for all new patients and at periodic intervals for recall patients.
Confidence Intervals↗
Assessing the FDA guidelines for ordering dental radiographs.
In 1988, the U.S. Food and Drug Administration issued guidelines to help dentists reduce the amount of X-ray exposure to patients without reducing the quality of care. This study assesses the efficacy of those guidelines. The authors examined 490 patients and ordered radiographs as indicated by the FDA guidelines. Using the guidelines, they ordered a mean of 9.7 radiographs out of a 17-film series, a reduction of 43 percent compared with a full-mouth series. The authors conclude that dentists can reduce a patient's exposure to X-rays by using these guidelines with a low level of missed radiographic findings, most of which would have no effect on the patient's treatment.
Adolescent↗
Managed care and dentistry: promises and problems.
At its inception in the mid-1950s, managed care held a number of promises for dental care providers and dental patients. Sometime during the development of managed care, however, many programs lost sight of the importance of provider equity. Using data from current programs, the authors contrast the original promises with the realities of managed care in dentistry.
Capitation Fee↗
Efficacy of FDA guidelines for ordering radiographs for caries detection.
This study evaluated the effect on caries diagnosis of using the Food and Drug Administration (FDA) guidelines for ordering radiographs on a sample of new adult patients seeking general dental care at a dental school clinic. These guidelines recommend posterior bitewing views accompanied by supplemental periapical views as indicated by the patient's clinical signs or symptoms. We compared the findings from the use of this protocol to those from a full-mouth set of radiographs made on the same new patient. We examined 490 patients and ordered periapical radiographs in accordance with the FDA guidelines, namely, when there was some clinical sign or symptom suggesting the need for radiographs. A full-mouth set of radiographs was obtained, and both the full and selected sets were evaluated separately. We found that 95% of our patients had one or more carious lesions, with an average of 5.7 carious teeth per patient. Of the 2808 carious teeth detected in the study, 1949 (69%) were found radiographically and 1564 (56%) were found clinically. Indeed, 1244 (44%) of the carious teeth were detected only by radiographic examination. Use of the FDA guidelines resulted in a 43% reduction in the number of radiographs ordered. Reduction in the number of images made on patients resulted in failure to detect 93 lesions (3.3%) located on 88 teeth in 11.4% of the study patients. Most of the missed lesions (2.9%) were radiographically confined to the enamel of anterior maxillary teeth. Only 36 of the missed lesions (1.6% of all radiographic lesions) extended into the dentin. We believe that this number is very small and most likely inconsequential compared with the considerable diversity among dentists regarding radiographic detection of caries, as well as the diversity of opinion regarding the indications for restorative treatment.
Adolescent↗
Measuring oral health status: theoretical and methodological challenges.
Development of oral health status indexes poses a set of theoretical and methodological challenges. Although the amount of work done on oral health indexes is far less that that done on general health indexes, to date those developed share many of the same theorectical assumptions. For the most part they have shared the dominant biomedical paradigm and the underlying theory of illness. These theories significantly influence both the instruments developed to measure oral health and the methods of measurement adopted. More recently alternative, holistic theories of illness have been proposed and there has been a shift from instruments focused on the provider to those focused on the patient and a move from objective to subjective measures of oral health. Furthermore the relationship between oral health and general health has received insufficient attention. The paper examines the relationship between the theories of illness, methods of measurement, and oral health indexes and suggests that other holistic, patient centered, paradigms, using qualitative methods, should also be considered in the construction or oral health indexes.
Attitude to Health↗
The relationship between dental utilization and preventive participation among a well-elderly sample.
Previous studies have shown that dental utilization by older people is lower than for the general population. This study hypothesizes that an elder's tendency toward participating in preventive health activities may be an important factor in explaining the likelihood of accessing the dentist. Subjects included 1,911 older individuals who enrolled in the UCLA Medicare Screening and Health Promotion Trial. All were interviewed about their utilization of preventive health services and participation in preventive behaviors. A recent dental visit was positively associated with all sociodemographic variables examined except age and sex. It was also related to health status questions and utilization of the preventive health services and health behaviors studied. Logistic regression analysis showed that both summary preventive health behavior and preventive service utilization variables were important factors in explaining a recent dental visit (model chi-square = 221.4, P = .001) along with income, not having a removable prosthesis, and perceiving the need for dental care. This study showed that dental utilization is related to older people's participation in other preventive activities. When in contact with older people, health care professionals should consider current oral and general preventive health status and encourage appropriate referral for preventive activities.
Age Factors↗
The standard of care: an ethical responsibility of public health dentistry.
Wide variation in the diagnosis and treatment of dental problems is indicative of the lack of a standard of care to guide the practitioner and to protect the public. Examples of questionable dental practices are described to illustrate how the public may be overtreated, overcharged, and put at risk of iatrogenic injury, practices that are no longer valid in light of current knowledge of dental diseases and their treatment. Public health dentistry traditionally concerns itself with community preventive, educational, and curative programs. It also has the ethical responsibility--the moral duty and obligation--to recognize and contend with paternalistic professional behavior that, intentionally or otherwise, violates the public trust, and to promote systems that will improve access, quality, and financing of dentistry for everyone.
Codes of Ethics↗
Comparison of oral health ratings by dentists and dentate elders.
Previous studies suggest a discrepancy between the way dentists and patients measure oral health. The purpose of this study was to determine the relationship between a dentist's rating of an older dentate person's oral health and the patient self-rating using a single-item indicator, and to compare the clinical (i.e., number of teeth, caries, etc.) and subjective (problems with function, pain, etc.) factors that influence the rating. The study sample consisted of 776 older dentate people. Results showed that dentists judged subjects' oral health significantly more positively than the self-ratings. Approximately 30 percent of the elders rated their oral health identically to the dentist and half rated their oral health lower than the dentist. Bivariate comparisons showed that similar clinical and subjective variables were associated with the dentist and patient ratings. Multiple regression findings, however, highlighted differences in the factors that influenced the ratings. In addition, the proportion of variance accounted for by the clinical factors as opposed to the subjective factors was greater for the dentist rating (R2 = .28 of .33) than the subject self-rating (R2 = .18 of .43).
Age Factors↗
Radiographic secondary caries prevalence in teeth with clinically defective restorations.
Decisions to replace existing restorations are often based on clinical findings of margin discrepancies and other restoration defects. Previous studies have suggested that such findings do not correlate well with the actual presence of secondary caries, and that treatment should be deferred until caries is clinically or radiographically evident. The purpose of this study was to assess the frequency with which clinically defective restorations are associated with radiographic secondary caries. As part of a study to assess the efficacy of guidelines for the ordering of dental radiographs, 6285 restored teeth in 490 subjects were examined clinically and radiographically by three calibrated investigators. Specific criteria were used to determine whether restorations were intact or defective. Of the total, 822 teeth (13%) were judged to have clinically defective restorations. Of these, 113 teeth (14%) had radiographic secondary caries. Of the 5463 teeth with intact restorations, 5% had radiographic secondary caries. We found that the likelihood of radiographic secondary caries was nearly three-fold higher for defective restorations than for intact restorations. The large percentage (86%) of defective restorations with no radiographic secondary caries suggests, however, that replacement of all defective restorations due to risk of secondary caries may constitute overtreatment. The use of defective restoration status and presence of radiographic secondary caries as a combined criterion for replacement may potentially reduce such overtreatment. The prevalence of secondary caries under defective restorations should be determined clinically so that the usefulness of combining the criteria of defective restoration with those of radiographic secondary caries can be evaluated.
Analysis of Variance↗
Benzodiazepine use in older, community-dwelling southern Californians: prevalence and clinical correlates.
OBJECTIVE: To determine the use of benzodiazepines (BZDs) in an older, community-dwelling sample and to examine the sociodemographic and clinical correlates of BZD use. DESIGN: A cross-sectional study of 1752 elderly people (aged > or = 65 y) who completed a mailed medication survey and a telephone health status survey. PARTICIPANTS: Participants were invited to participate in a large Medicare demonstration project on prevention by their private physicians, who were also enrolled in the larger study. Participants had to be English-speaking, could not have dementia or a terminal illness, and had to give informed consent to participate in the study. MAIN OUTCOME MEASURES: Sociodemographic and health status variables that predicted BZD use were examined. Sociodemographic variables included age, gender, ethnicity, education, and income. Health status variables included functional status, with measures of mental, social, and physical health. Influenza immunization status was used as an indicator for preventive health services use and self-reported chronic illness was used as a measure of comorbidity. RESULTS: Twenty percent of the participants used BZDs at least twice in the past year. We found that those who used BZDs were more than twice as likely to take ten or more drugs, two-and-a-half times more likely to have difficulty falling asleep, and over twice as likely to be depressed. BZD users were also more likely to be white, to have a college education, and to have received a recent influenza shot, but were not more likely to be women when controlled for health status. CONCLUSIONS: Further clinical research should explore the relationship between BZD use among older patients and the BZD-associated adverse clinical factors we observed, as well as the association between multiple drug use and potential adverse outcomes in older BZD users.
Aged↗
Implications of access, utilization and need for oral health care by the non-institutionalized and institutionalized elderly on the dental delivery system.
Oral health is integral to an older adult's general health and quality of life, and basic oral health services are an essential component of primary health care. The elderly should receive special consideration in terms of their oral health care needs since they: 1) may have unique problems accessing the health care delivery system; 2) experience different patterns and prevalence rates of oral diseases; and 3) may have characteristics that affect the amount and types of dental treatment and the method by which it is performed. Older adults are maintaining their natural teeth into their later years, and epidemiologic trends suggest the increasing need for dental services by older adults. Yet dental utilization rates are lower for older adults than for younger age groups, and barriers to care include the cost of dental care, the lack of perceived need for care, transportation problems, and fear. Oral diseases and impairments are most commonly experienced by those segments of society least able to obtain dental care. Economically and socially disadvantaged older adults and the physically impaired are more likely to experience tooth loss and edentulism, untreated dental decay and periodontal diseases. Adults over the age of 65 years have the lowest proportion of dental expenses reimbursed by private dental insurance (10 percent), and the highest percentage of out-of-pocket dental expenses (79 percent), as compared to all other age groups. Of the two largest public programs, Medicare does not pay for most dental services, and Medicaid (Title XIX), does not offer dental benefits for adults in most states. Although the majority of older adults live independently in the community, there is a growing number of elders with special needs that require long term care either at home or in an institution. These frail and functionally dependent elders have significant dental needs, and experience greater barriers to receiving dental care as compared to the independent elderly. Additional research is needed to accurately characterize the oral health status and needs of the growing number of homebound and institutionalized elders. This will be of growing importance with the emergence of the vast array of home health care services available to older adults, and the changing emphasis on home care often seen as the preferred and lower cost alternative to nursing home care.
Aged↗
An algorithm for ordering pretreatment orthodontic radiographs.
A study was conducted to identify selection criteria for ordering pretreatment orthodontic radiographs. Thirty-nine orthodontists evaluated six test cases. They provided information on the rationale for ordering each specific radiograph and the impact of the radiograph on the diagnosis and treatment plan. Skeletal relationship of the jaws was the most common indication for a radiograph request, followed by root formation/length and molar position or development. Of the radiographs, 16% produced a change in diagnosis, and 20% produced a change in treatment plans. The criteria specified for the radiographs, their impact, and relevant information in the literature were used to develop an algorithm or set of decision rules that, when tested on the six test cases, resulted in a 36% reduction in the total number of radiographs.
Airway Obstruction↗