Veterans Affairs Dental Longitudinal Study Research Articles

Marginal clustered multistate models for longitudinal progressive processes with informative cluster size

AbstractInformative cluster size (ICS) is a phenomenon where cluster size is related to the outcome. While multistate models can be applied to characterize the unit‐level transition process for clustered interval‐censored data, there is a research gap addressing ICS within this framework. We propose two extensions of multistate model that account for ICS to make marginal inference: one by incorporating within‐cluster resampling and another by constructing cluster‐weighted score functions. We evaluate the performances of the proposed methods through simulation studies and apply them to the Veterans Affairs Dental Longitudinal Study (VADLS) to understand the effect of risk factors on periodontal disease progression. ICS occurs frequently in dental data, particularly in the study of periodontal disease, as people with fewer teeth due to the disease are more susceptible to disease progression. According to the simulation results, the mean estimates of the parameters obtained from the proposed methods are close to the true values, but methods that ignore ICS can lead to substantial bias. Our proposed methods for clustered multistate model are able to appropriately take ICS into account when making marginal inference of a typical unit from a randomly sampled cluster.

Modelling time-varying risk factors of tooth loss: Results from joint model compared with extended Cox regression model.

To illustrate the use of joint models (JMs) for longitudinal and survival data in estimating risk factors of tooth loss as a function of time-varying endogenous periodontal biomarkers (probing pocket depth [PPD], alveolar bone loss [ABL] and mobility [MOB]). We used data from the Veterans Affairs Dental Longitudinal Study, a longitudinal cohort study of over 30 years of follow-up. We compared the results from the JM with those from the extended Cox regression model which assumes that the time-varying covariates are exogenous. Our results showed that PPD is an important risk factor of tooth loss, but each model produced different estimates of the hazard. In the tooth-level analysis, based on the JM, the hazard of tooth loss increased by 4.57 (95% confidence interval [CI]: 2.13-8.50) times for a 1-mm increase in maximum PPD, whereas based on the extended Cox model, the hazard of tooth loss increased by 1.60 (95% CI: 1.37-1.87) times. JMs can incorporate time-varying periodontal biomarkers to estimate the hazard of tooth loss. As JMs are not commonly used in oral health research, we provide a comprehensive set of R codes and an example dataset to implement the method.

Periodontitis is associated with an increased hazard of mortality in a longitudinal cohort study over 50 years.

To evaluate the association between periodontal disease and all-cause mortality in a longitudinal cohort study over 50 years. Participants (N= 1156) in the Veterans Affairs Dental Longitudinal Study, aged 25-85 years at enrollment in 1968, received comprehensive medical and oral exams approximately every 3 years through 2007. Periodontal status was defined using person-level, mean whole-mouth radiographic alveolar bone loss (ABL) scores using a five-point Schei ruler, each unit representing 20% increments of ABL. Time-varying Cox regression models estimated hazard ratios (HRs) for the association between continuous and categorical ABL and mortality, adjusting for covariates. Each one-unit increase in mean ABL score was associated with a 14% increase in the hazard of mortality (adjusted HR=1.14, 95% confidence interval [CI] 1.02, 1.27). When assessed categorically, HRs for average scores of 2 to <3 and 3 to ≤5 showed increasing associations with hazard of mortality, relative to 0 to <1 (adjusted HR=1.17, 95% CI 0.94, 1.46; and HR=1.65, 95% CI 0.94, 2.85, respectively). By contrast, we observed null associations for average scores of 1 to <2 relative to 0 to <1 (adjusted HR=1.00, 95% CI 0.86, 1.17). Time-varying periodontal status assessed using radiographic ABL was positively associated with all-cause mortality even after confounder adjustment.

Accounting for drop-out using inverse probability censoring weights in longitudinal clustered data with informative cluster size

Periodontal disease is a serious gum infection impacting half of the U.S. adult population that may lead to loss of teeth. Using standard marginal models to study the association between patient-level predictors and tooth-level outcomes can lead to biased estimates because the independence assumption between the outcome (periodontal disease) and cluster size (number of teeth per patient) is violated. Specifically, the baseline number of teeth of a patient is informative. In this setting a cluster-weighted generalized estimating equations (CWGEE) approach can be used to obtain unbiased marginal inference from data with informative cluster size (ICS). However, in many longitudinal studies of dental health, including the Veterans Affairs Dental Longitudinal Study, the rate of tooth-loss or tooth drop-out over time is also informative, creating a missing at random data mechanism. Here, we propose a novel modeling approach that incorporates the technique of inverse probability censoring weights into CWGEE with binary outcomes to account for ICS and informative drop-out over time. In an extensive simulation study we demonstrate that results obtained from our proposed method yield lower bias and excellent coverage probability, compared to those obtained from traditional methods which do not account for ICS or drop-out.

Edentulism is associated with increased risk of all-cause mortality in adult men

BackgroundPrior reports of positive associations between edentulism and all-cause mortality have been limited by onetime assessments of edentulism and inadequate control of known confounding variables. The authors aimed to assess the association between edentulism and mortality using a longitudinal clinical oral health cohort. MethodsThe authors used data from the Department of Veterans Affairs Dental Longitudinal Study, an ongoing, closed-panel cohort study from 1968 through 2019 (N = 1,229). Dentition status was evaluated through triennial clinical examinations. Mortality was assessed via the National Death Registry. The authors used Cox regression models to estimate the association between edentulism and all-cause mortality after covariate adjustment. Furthermore, the authors calculated propensity scores and assessed hazard ratios (HRs) in a trimmed, matched, and inverse probability weighted sample. ResultsParticipants who were edentulous (N = 112) had 1.24 (95% CI, 1.00 to 1.55) times the hazard of all-cause mortality compared with those who were nonedentulous, after adjustment with time-varying covariates. Use of propensity scores in the model resulted in slightly elevated HRs compared with the standard Cox model, regardless of propensity score method; adjusted HRs were 1.35 (95% CI, 1.01 to 1.80) after matching, 1.26 (95% CI, 1.00 to 1.59) after trimming, and 1.29 (95% CI, 1.18 to 1.42) after inverse probability weighting. ConclusionsEdentulism was associated with an increased risk of all-cause mortality in a cohort that captured incident edentulism. This association was consistent after multiple methods to account for confounding. Practical ImplicationsThe findings of this study suggest that edentulism is associated with an increase in risk of mortality, after accounting for salient confounding variables using multiple approaches. Efforts to improve equitable access to tooth-preserving treatments are critical.

A quantitative bias analysis to assess the impact of unmeasured confounding on associations between diabetes and periodontitis.

To investigate unmeasured confounding in bidirectional associations between periodontitis and diabetes using quantitative bias analysis. Subsamples from the Veterans Affairs Dental Longitudinal Study were selected. Adjusted for known confounders, we used Cox proportional hazards models to estimate associations between pre-existing clinical periodontitis and incident Type II Diabetes (n=672), and between pre-existing diabetes and incident severe periodontitis (n=521), respectively. Hypothetical confounders were simulated into the dataset using Bernoulli trials based on pre-specified distributions of confounders within categories of each exposure and outcome. We calculated corrected hazard ratios (HR) over 10,000 bootstrapped samples. In models using periodontitis as the exposure and incident diabetes as the outcome, adjusted HR=1.21 (95% CI: 0.64-2.30). Further adjustment for simulated confounders positively associated with periodontitis and diabetes greatly attenuated the association or explained it away entirely (HR=1). In models using diabetes as the exposure and incident periodontitis as the outcome, adjusted HR=1.35 (95% CI: 0.79-2.32). After further adjustment for simulated confounders, the lower bound of the simulation interval never reached the null value (HR≥1.03). Presence of unmeasured confounding does not explain observed associations between pre-existing diabetes and incident periodontitis. However, presence of weak unmeasured confounding eliminated observed associations between pre-existing periodontitis and incident diabetes. These results clarify the bidirectional periodontitis-diabetes association.

Marginal analysis of multiple outcomes with informative cluster size.

In surveillance studies of periodontal disease, the relationship between disease and other health and socioeconomic conditions is of key interest. To determine whether a patient has periodontal disease, multiple clinical measurements (eg, clinical attachment loss, alveolar bone loss, and tooth mobility) are taken at the tooth-level. Researchers often create a composite outcome from these measurements or analyze each outcome separately. Moreover, patients have varying number of teeth, with those who are more prone to the disease having fewer teeth compared to those with good oral health. Such dependence between the outcome of interest and cluster size (number of teeth) is called informative cluster size and results obtained from fitting conventional marginal models can be biased. We propose a novel method to jointly analyze multiple correlated binary outcomes for clustered data with informative cluster size using the class of generalized estimating equations (GEE) with cluster-specific weights. We compare our proposed multivariate outcome cluster-weighted GEE results to those from the convectional GEE using the baseline data from Veterans Affairs Dental Longitudinal Study. In an extensive simulation study, we show that our proposed method yields estimates with minimal relative biases and excellent coverage probabilities.

Marginal analysis of ordinal clustered longitudinal data with informative cluster size.

The issue of informative cluster size (ICS) often arises in the analysis of dental data. ICS describes a situation where the outcome of interest is related to cluster size. Much of the work on modeling marginal inference in longitudinal studies with potential ICS has focused on continuous outcomes. However, periodontal disease outcomes, including clinical attachment loss, are often assessed using ordinal scoring systems. In addition, participants may lose teeth over the course of the study due to advancing disease status. Here we develop longitudinal cluster-weighted generalized estimating equations (CWGEE) to model the association of ordinal clustered longitudinal outcomes with participant-level health-related covariates, including metabolic syndrome and smoking status, and potentially decreasing cluster size due to tooth-loss, by fitting a proportional odds logistic regression model. The within-teeth correlation coefficient over time is estimated using the two-stage quasi-least squares method. The motivation for our work stems from the Department of Veterans Affairs Dental Longitudinal Study in which participants regularly received general and oral health examinations. In an extensive simulation study, we compare results obtained from CWGEE with various working correlation structures to those obtained from conventional GEE which does not account for ICS. Our proposed method yields results with very low bias and excellent coverage probability in contrast to a conventional generalized estimating equations approach.

Incisor malalignment and the risk of periodontal disease progression.

The objective of this study was to investigate the association between incisor crowding, irregularity, and periodontal disease progression in the anterior teeth. Data collected over 35years from men enrolled in the Veterans Affairs Dental Longitudinal Study included information concerning pocket depth and alveolar bone loss. Plaster casts of the maxillary (n=400) and mandibular (n=408) arches were available for baseline measurements. Periodontal disease in the anterior teeth was defined as per arch sum of pathologic pocket depth and sum of teeth with any alveolar bone loss in the anterior sextants. Incisor malalignment status was defined by the anterior tooth size-arch length discrepancy index and Little's Irregularity Index. Adjusted mixed effects linear models computed the beta (β) estimates and 95% confidence intervals (95% CI) of the amounts of change in periodontal disease outcomes by the level of malalignment. In the anterior maxillary arch, crowding and spacing were significantly associated with an increased per-arch sum of pathologic pocket depth (β, 0.70mm; 95% CI, 0.20-1.21, and β, 0.49mm; 95% CI, 0.06-0.91, respectively). In the anterior mandibular arch, incisor crowding and irregularity were significantly associated with an increased per-arch sum of pathologic pocket depth (mild crowding: β, 0.47mm; 95% CI, 0.01-0.93; severe irregularity: β, 0.94mm; 95% CI, 0.50-1.38), and the sum number of teeth with alveolar bone loss (mild and moderate-to-severe crowding: β, 0.45 teeth; 95% CI, 0.08-0.82; and β, 0.45 teeth; 95% CI, 0.13-0.83, respectively; moderate irregularity: β, 0.34 teeth; 95% CI, 0.06-0.62). Certain incisor malalignment traits (ie, maxillary incisor crowding, maxillary incisor spacing, mandibular incisor mild crowding, mandibular incisor moderate-to-severe crowding, mandibular incisor moderate irregularity, and mandibular incisor severe irregularity) are associated with significant periodontal disease progression.

Influence of Obesity on Periodontitis Progression Is Conditional on Interleukin-1 Inflammatory Genetic Variation.

This study evaluates whether specific patterns of interleukin (IL)-1 gene variants, known to affect periodontitis severity, influence the previously reported association between obesity and subsequent periodontitis progression in a longitudinal database. The study population included 292 men (aged 29 to 64 years at entry) from the Veterans Affairs Dental Longitudinal Study from whom DNA and dental and anthropometric endpoints were collected during multiple examinations (approximately every 3 years for up to 27 years). Key variables assessed included: 1) periodontitis; 2) body mass index; 3) waist circumference to height (WHTR) ratio for central adiposity; 4) age; 5) smoking; 6) glucose tolerance; and 7) two previously reported versions of IL-1 genetic patterns associated with periodontitis severity and progression. Disease progression was determined using predefined criteria that used a combination of change in classification of disease severity based on alveolar bone loss and tooth loss during follow-up. Extended Cox regression analyses were used to estimate hazards of experiencing periodontal disease progression with or without adjustments for appropriate covariates. In hazard ratio analyses, men with WHTR >50% at baseline and positive for either IL-1 genotype version were at significantly higher risk (two-fold) for disease progression (P for interaction = 0.04). Participants positive for IL-1 genotype version 2 exhibited earlier progression (fewer years from baseline to first incidence of progression) than those who were negative (P = 0.02, adjusted for age and smoking). In this longitudinally monitored male population, observed effect of baseline central adiposity on future periodontitis progression is conditional on proinflammatory IL-1 genetic variations.

Metabolic Syndrome and Periodontal Disease Progression in Men

Metabolic syndrome, a cluster of 3 or more risk factors for cardiovascular disease, is associated with periodontal disease, but few studies have been prospective in design. This study’s aim was to determine whether metabolic syndrome predicts tooth loss and worsening of periodontal disease in a cohort of 760 men in the Department of Veterans Affairs Dental Longitudinal Study and Normative Aging Study who were followed up to 33 y from 1981 to 2013. Systolic and diastolic blood pressures were measured with a standard mercury sphygmomanometer. Waist circumference was measured in units of 0.1 cm following a normal expiration. Fasting blood samples were measured in duplicate for glucose, triglyceride, and high-density lipoprotein. Calibrated periodontists served as dental examiners. Periodontal outcome events on each tooth were defined as progression to predefined threshold levels of probing pocket depth (≥5 mm), clinical attachment loss (≥5 mm), mobility (≥0.5 mm), and alveolar bone loss (≥40% of the distance from the cementoenamel junction to the root apex, on radiographs). Hazards ratios (95% confidence intervals) of tooth loss or a periodontitis event were estimated from tooth-level extended Cox proportional hazards regression models that accounted for clustering of teeth within individuals and used time-dependent status of metabolic syndrome. Covariates included age, education, smoking status, plaque level, and initial level of the appropriate periodontal disease measure. Metabolic syndrome as defined by the International Diabetes Federation increased the hazards of tooth loss (1.39; 1.08 to 1.79), pocket depth ≥5 mm (1.37; 1.14 to 1.65), clinical attachment loss ≥5 mm (1.19; 1.00 to 1.41), alveolar bone loss ≥40% (1.25; 1.00 to 1.56), and tooth mobility ≥0.5 mm (1.43; 1.07 to 1.89). The number of positive metabolic syndrome conditions was also associated with each of these outcomes. These findings suggest that the metabolic disturbances that comprise the metabolic syndrome may play a role in the development or worsening of periodontitis.

In Obese Teens, Are Blood Pressure &amp; Periodontal Disease Linked?

Research Article| September 01 2015 In Obese Teens, Are Blood Pressure & Periodontal Disease Linked? AAP Grand Rounds (2015) 34 (3): 33. https://doi.org/10.1542/gr.34-3-33 Views Icon Views Article contents Figures & tables Video Audio Supplementary Data Peer Review Share Icon Share Facebook Twitter LinkedIn MailTo Tools Icon Tools Get Permissions Cite Icon Cite Search Site Citation In Obese Teens, Are Blood Pressure & Periodontal Disease Linked?. AAP Grand Rounds September 2015; 34 (3): 33. https://doi.org/10.1542/gr.34-3-33 Download citation file: Ris (Zotero) Reference Manager EasyBib Bookends Mendeley Papers EndNote RefWorks BibTex toolbar search toolbar search search input Search input auto suggest filter your search All PublicationsAll JournalsAAP Grand RoundsPediatricsHospital PediatricsPediatrics In ReviewNeoReviewsAAP NewsAll AAP Sites Search Advanced Search Topics: obesity, periodontal diseases, blood pressure Source: Zeigler CC, Wondimu B, Marcus C, et al. Pathological periodontal pockets are associated with raised diastolic blood pressure in obese adolescents. BMC Oral Health. 2015; 15(1): 41; doi: https://doi.org/10.1186/s12903-015-0026-6Google Scholar Investigators from the Karolinska Institutet in Stockholm, Sweden conducted a cross-sectional study of obese adolescents to assess the association between periodontal disease and blood pressure. Participants were recruited from the National Childhood Obesity Center at Karolinska University Hospital, and were eligible if they were 12–18 years of age, not a smoker, had not taken systemic antibiotics in the past 3 months, and were not undergoing orthodontic treatment. The primary independent variable of interest was periodontal disease. This was determined by the presence of pathological periodontal pockets (PD) ≥4mm on dental examination indicating the presence of an abnormal depth of the gingival sulcus where the gingival tissue contacts the tooth. The primary outcome was diastolic blood pressure (DBP), measured manually in the sitting position and expressed as the mean of 2 separate readings. Additional variables collected included body mass index (BMI), gender, age, medications, dietary habits, parents’ education, and mother’s country of birth. Gingival inflammation was also measured by dental examination based on bleeding on probing (BOP). Lastly, fasting blood samples were obtained to measure factors known to be associated with periodontal disease, obesity, or blood pressure, including total cholesterol, high density lipoprotein, thyroid stimulating hormone (TSH), c-reactive protein (CRP), monocyte chemoattractant protein-1 (MCP-1), interleukin (IL)-1b, 6 and 8, and leptin. Among the 75 participants enrolled, 14 had PDs ≥4 mm. The DBP among participants with PDs ≥4 mm was 7 points higher than the DBP among participants without pathologic PDs (74 mmHg vs 67 mmHg, respectively; P = .008). After adjusting for BMI, age, gender, mother’s country of birth, BOP, IL-6, IL-8, leptin, MCP-1, TSH, and total cholesterol, PDs ≥4 mm remained significantly associated with DBP (P = .006). The investigators conclude that there is an association between periodontal disease and DBP among obese adolescents. Dr Slayton has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device. Periodontal disease is a chronic inflammatory disease that involves interaction between pathogenic bacteria and the host’s immune system resulting in gingivitis and alveolar bone loss.1 Loss of alveolar bone leads to partial or complete loss of teeth. Obesity is a common, chronic condition that has been linked to periodontal disease in recent studies.2,3 In a 20-year Department of Veterans Affairs Dental Longitudinal Study, it was found that rapid weight gain, waist circumference and increases in arm fat were associated with more periodontitis and periodontitis progression in men.2 The results of a second longitudinal study of men indicated that there was a greater risk for periodontal disease associated with waist circumference and waist to hip measurements and that participants with a BMI ≥30 kg/m2 were at significantly greater risk for... You do not currently have access to this content.

Coffee Consumption and Periodontal Disease in Males

Coffee is a major dietary source of antioxidants as well as of other anti-inflammatory factors. Given the beneficial role of such factors in periodontal disease, whether coffee intake is associated with periodontal disease in adult males was explored. Existing data collected by a prospective, closed-panel cohort study of aging and oral health in adult males was used. Participants included the 1,152 dentate males in the Veterans Affairs (VA) Dental Longitudinal Study who presented for comprehensive medical and dental examinations from 1968 to 1998. Mean age at baseline was 48 years; males were followed for up to 30 years. Participants are not VA patients; rather, they receive their medical and dental care in the private sector. Periodontal status was assessed by probing depth (PD), bleeding on probing, and radiographic alveolar bone loss (ABL), measured on intraoral periapical radiographs with a modified Schei ruler method. Moderate-to-severe periodontal disease was defined as cumulative numbers of teeth exhibiting PD ≥4 mm or ABL ≥40%. Coffee intake was obtained from participant self-reports using the Cornell Medical Index and food frequency questionnaires. Multivariate repeated-measures generalized linear models estimated mean number of teeth with moderate-to-severe disease at each examination by coffee intake level. It was found that higher coffee consumption was associated with a small but significant reduction in number of teeth with periodontal bone loss. No evidence was found that coffee consumption was harmful to periodontal health. Coffee consumption may be protective against periodontal bone loss in adult males.

Retained Asymptomatic Third Molars and Risk for Second Molar Pathology

Prophylactic extraction of unerupted asymptomatic third molars is the most common oral surgery procedure in the United States. However, limited evidence exists to justify its costs and associated morbidity. We analyzed data collected over 25 years from 416 adult men enrolled in the Veterans Affairs Dental Longitudinal Study to evaluate the association of retained asymptomatic third molars with risk of adjacent second molar pathology (caries and/or periodontitis), based on third molar status (i.e., absent, erupted, or unerupted). Unerupted molars were further categorized as either “soft tissue” or “bony” impacted. We found that the lowest prevalence and incidence of second molar pathology occurred when the adjacent third molar was absent. The presence of a third molar that was soft tissue impacted increased the risk of incident second molar pathology 4.88-fold (95% confidence interval: 2.62, 9.08). Having an erupted or “bony” impacted third molar increased the risk of incident second molar pathology by 1.74 (95% confidence interval: 1.34, 2.25) and 2.16 (95% confidence interval: 1.56, 2.99), respectively. The retention of third molars is associated with increased risk of second molar pathology in middle-aged and older adult men.

Vitamin D and Periodontal Health in Older Men

Vitamin D, an anti-inflammatory mediator, has potential benefits for physical and oral health. Although it is produced endogenously, some individuals have a greater need for dietary and supplemental sources. This repeated-measures cross-sectional study assessed associations between total vitamin D intake and periodontal health in older men. Participants were 562 members of the Department of Veterans Affairs Dental Longitudinal Study, mean age 62.9 years, who were examined 1 to 4 times between 1986 and 1998. A calibrated examiner measured probing pocket depth (PPD) and attachment loss (AL) on each tooth. Alveolar bone loss (ABL) was determined from radiographs. Severe periodontal disease was defined as PPD ≥ 5 mm on ≥ 1 tooth and AL ≥ 6 mm at ≥ 2 sites (not on same tooth), and moderate-to-severe alveolar bone loss as ABL ≥ 40% at ≥ 3 sites. Generalized estimating equations were used to compute the odds ratios (OR) and 95% confidence intervals (95% CI) of having periodontal disease by level of vitamin D intake. Total vitamin D intake ≥ 800 IU was associated with lower odds of severe periodontal disease (OR = 0.67, 95% CI = 0.55-0.81) and moderate-to-severe ABL (OR = 0.54, 95% CI = 0.30-0.96) relative to intake < 400 IU/day. Vitamin D intake may protect against periodontal disease progression.

High‐Fiber Foods Reduce Periodontal Disease Progression in Men Aged 65 and Older: The Veterans Affairs Normative Aging Study/Dental Longitudinal Study

To determine whether foods that are good to excellent sources of fiber reduce periodontal disease progression in men. Prospective, observational study. Greater Boston, Massachusetts, metropolitan area. Six hundred twenty-five community-dwelling men participating in the Department of Veterans Affairs Dental Longitudinal Study. Dental and physical examinations were conducted every 3 to 5 years. Diet was assessed using food frequency questionnaires (FFQs). Mean follow-up was 15 years (range: 2-24 years). Periodontal disease progression on each tooth was defined as alveolar bone loss (ABL) advancement of 40% or more, probing pocket depth (PPD) of 2 mm or more, or tooth loss. Good and excellent fiber sources provided 2.5 g or more of fiber per serving. Multivariate proportional hazards regression estimated hazard ratios (HRs) and 95% confidence intervals (CIs) of periodontal disease progression and tooth loss in relation to fiber sources, stratified according to age younger than 65 versus 65 and older, and controlled for smoking, body mass index, calculus, baseline periodontal disease level, caries, education, exercise, carotene, thiamin and caffeine intake, and tooth brushing. In men aged 65 and older, each serving of good to excellent sources of total fiber was associated with lower risk of ABL progression (HR = 0.76, 95% CI = 0.60-0.95) and tooth loss (HR = 0.72, 95% CI = 0.53-0.97). Of the different food groups, only fruits that were good to excellent sources of fiber were associated with lower risk of progression of ABL (HR = 0.86 per serving, 95% CI = 0.78-0.95), PPD (HR = 0.95, 95% CI = 0.91-0.99), and tooth loss (HR = 0.88, 95% CI = 0.78-0.99). No significant associations were seen in men younger than 65. Benefits of higher intake of high-fiber foods, especially fruits, on slowing periodontal disease progression are most evident in men aged 65 and older.

Association of Endodontic Involvement with Tooth Loss in the Veterans Affairs Dental Longitudinal Study

Introduction The effect of endodontic involvement on tooth loss has not been quantified, so the present study aimed to assess this relationship after controlling for other relevant risk factors for tooth loss. Methods We analyzed data from 791 participants (18,798 teeth) in the Veterans Affairs Dental Longitudinal Study. Potential tooth-level and person-level covariates were fitted into marginal proportional hazards models, including both apical radiolucencies (AR) and root canal therapy (RCT) status as time-dependent variables. Survival curves were plotted for teeth according to their AR and RCT status. Results Both current AR and RCT status were associated with increased risk of tooth loss ( P < .01), after controlling for baseline levels of periodontal disease, caries, tooth type, number of proximal contacts, number of teeth, age, education, and smoking history. Root canal filled (RCF) teeth seemed to have better survival than non-RCF teeth among teeth with AR but worse survival than non-RCF teeth among teeth without AR. Conclusions Endodontic involvement was associated with tooth loss, controlling for other potential risk factors. Additional prospective studies are needed to provide better evidence as to the impact of endodontic involvement on tooth loss.

Association of Endodontic Involvement with Tooth Loss in the Veterans Affairs Dental Longitudinal Study

Association of Endodontic Involvement with Tooth Loss in the Veterans Affairs Dental Longitudinal Study

Periodontitis Severity Plus Risk as a Tooth Loss Predictor

Tooth loss can be a consequence of the natural history of periodontitis. Stratification of periodontitis severity, risk, and tooth loss exists within the United States adult population, and tooth loss correlates to severity and risk. We evaluated the loss of teeth for a periodontitis-affected population categorized by the combination of severity and risk in which the subjects predominantly did not receive periodontal treatment. The clinical records of 523 subjects enrolled in the Veterans Affairs Dental Longitudinal Study, covering a period of 15 years, were used. Disease severity, risk level, and the number of teeth lost for each subject were determined. A stepwise regression analysis showed that disease and risk scores predicted mean tooth loss rate. The P value for the disease score was <0.0005, and the P value for the risk score was 0.001. The ordinal logistic regression model showed that disease (P = 0.002) and risk scores (P = 0.000) were significantly associated with the probability of subjects losing a specific number of teeth. Tooth loss is more precisely and accurately predicted by the combination of risk score and periodontal disease score than by either score alone. The combined scores may be a surrogate variable for periodontal status. Because the scores are derived from routine clinical measurements, they may be useful for population surveillance and dynamics, practice management, patient care decisions, practice-based research, and the determination of treatment effectiveness and the factors required for successful treatment, resulting in improved oral health and higher clinician productivity and income.

Extension and Density of Root Fillings and Postoperative Apical Radiolucencies in the Veterans Affairs Dental Longitudinal Study

We evaluated the association between radiographically assessed extension and density of root canal fillings and postoperative apical radiolucencies (ARs) by using data from 288 participants in the Veterans Affairs Dental Longitudinal Study. Study subjects were not Veterans Affairs patients; all received their medical and dental care in the private sector. Generalized estimating equations were used to account for multiple teeth within subjects and to control for covariates of interest. Defective root filling density was associated with increased odds of postoperative AR among teeth with no preoperative AR (odds ratio, 3.0; 95% confidence interval [CI], 1.3–7.1), although preoperative AR was the strongest risk factor for postoperative AR (odds ratio, 29.2; 95% CI, 13.6–63.0 among teeth with ideal density). Compared with well-extended root fillings, neither overextended nor underextended root fillings separately were related to postoperative AR, but when those 2 categories were collapsed into one poorly extended category, poor extension was related to postoperative AR (odds ratio, 1.8; 95% CI, 1.1–3.2).