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Ahmadinia AR, Rahebi D, Mohammadi M, Ghelichi-Ghojogh M, Jafari A, Esmaielzadeh F, Rajabi A. Association between type 2 diabetes (T2D) and tooth loss: a systematic review and meta-analysis. BMC Endocr Disord 2022; 22:100. [PMID: 35418054 PMCID: PMC9006550 DOI: 10.1186/s12902-022-01012-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 04/01/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Several studies have assessed the relationship between type 2 diabetes (T2D) and tooth loss; however, results have been inconsistent. Therefore, the present systematic review and meta-analysis of observational studies was designed to examine the association between T2D and tooth loss. METHODS This systematic review and meta-analysis was conducted based on Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) Guideline. We searched all the relevant studies in international databases of Scopus, PubMed, ProQuest, Web of Science, Cochrane Library, and Google scholar search engine until February 2022. The heterogeneity of the studies was calculated using the I2 index. Measure of effect and 95% confidence interval (CI) were extracted from each study. The results of the study were analyzed using the random effects model. RESULTS In the present study, 22 eligible studies were included. Meta-analysis of unadjusted and adjusted results showed that T2D significantly increased the risk of tooth loss, and Odds Ratio (OR) unadjusted was 1.87 (95% CI: 1.62-2.13, p < 0.001), and OR adjusted was 1.20 (95% CI: 1.10-1.30, p < 0.001), respectively. Subgroup analysis based on study design for adjusted OR indicated that in the cohort study (OR: 1.29, 95% CI: 1.07-1.51), in the cross-sectional study (OR: 1.15, 95% CI: 1.06-1.23), and in the case-control study (OR: 5.10, 95% CI: 1.01-9.18) there was a significant association between T2D and tooth loss. Other subgroups analyses showed consistent results and no publication bias existed. CONCLUSIONS The findings suggest that T2D is associated with increased risk of tooth loss. This conclusion may provide useful evidence for correlated clinical researches.
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Affiliation(s)
- Amir Reza Ahmadinia
- Dental Research Center, School of Dentistry Golestan University of Medical Sciences, Gorgan, Iran
| | - Donya Rahebi
- Dental Research Center, School of Dentistry Golestan University of Medical Sciences, Gorgan, Iran
| | - Masoud Mohammadi
- Research Center of Gastroenterology and Hepatology, Golestan University of Medical Sciences, Gorgan, Iran
| | - Mousa Ghelichi-Ghojogh
- Department of Health Management and Social Development Research Center, Golestan University of Medical Sciences, Gorgan, Iran
| | - Alireza Jafari
- Department of Health Education and Health Promotion, School of Health, Social Development and Health Promotion Research Center, Gonabad University of Medical Sciences, Gonabad, Iran
| | - Firooz Esmaielzadeh
- School of Nursing and Allied Medical Sciences, Maragheh University of Medical Sciences, Maragheh, Iran
| | - Abdolhalim Rajabi
- Dental Research Center, School of Dentistry Golestan University of Medical Sciences, Gorgan, Iran
- Health Management and Social Development Research Center, Faculty of Health, Golestan University of Medical Sciences, Gorgan, Iran
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Glycemic control and number of natural teeth: analysis of cross-sectional Japanese employment-based dental insurance claims and medical check-up data. Diabetol Int 2021; 13:244-252. [DOI: 10.1007/s13340-021-00533-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Accepted: 08/16/2021] [Indexed: 02/08/2023]
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Borgnakke WS, Poudel P. Diabetes and Oral Health: Summary of Current Scientific Evidence for Why Transdisciplinary Collaboration Is Needed. FRONTIERS IN DENTAL MEDICINE 2021. [DOI: 10.3389/fdmed.2021.709831] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
This Perspective provides a brief summary of the scientific evidence for the often two-way links between hyperglycemia, including manifest diabetes mellitus (DM), and oral health. It delivers in a nutshell examples of current scientific evidence for the following oral manifestations of hyperglycemia, along with any available evidence for effect in the opposite direction: periodontal diseases, caries/periapical periodontitis, tooth loss, peri-implantitis, dry mouth (xerostomia/hyposalivation), dysbiosis in the oral microbiome, candidiasis, taste disturbances, burning mouth syndrome, cancer, traumatic ulcers, infections of oral wounds, delayed wound healing, melanin pigmentation, fissured tongue, benign migratory glossitis (geographic tongue), temporomandibular disorders, and osteonecrosis of the jaw. Evidence for effects on quality of life will also be reported. This condensed overview delivers the rationale and sets the stage for the urgent need for delivery of oral and general health care in patient-centered transdisciplinary collaboration for early detection and management of both hyperglycemia and oral diseases to improve quality of life.
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Varis H, Hagnäs M, Mikkola I, Nordström T, Puukka K, Taanila A, Keinänen-Kiukaanniemi S. Parental separation and offspring morbidity in adulthood: a descriptive study of the Northern Finland Birth Cohort 1966. Scand J Public Health 2021; 50:601-612. [PMID: 34030537 DOI: 10.1177/14034948211014296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Aims: Rates of parental separation have increased dramatically in recent decades. We evaluated the association of individuals' childhood family structure with their somatic health over 46 years of follow-up. Methods: Data were drawn from the Northern Finland Birth Cohort, an ongoing project in which 12,058 participants born in 1966 have been followed from their 24th gestational week. Based on information supplied at age 14 years, family structure was categorised as 'single-parent family' and 'two-parent family'. The anthropometric information, data from blood samples and medical history were collected from postal questionnaires and clinical examinations routinely performed at the ages of 31 and 46 years. Results: The study population comprised a total of 10,895 individuals; 85% (n=9253) were offspring of two-parent families and 15% (n=1642) of single-parent families. Type 2 diabetes (P=0.032) or prediabetes (P=0.007), psychoactive drug problems (P<0.001) and sexually transmitted diseases (P<0.001) were more common in the single-parent family group than in the participants from two-parent families. In addition, among men back diseases (P=0.002), and among women hypertension (P=0.003) and ovary infection (P=0.024) were more frequent in individuals affected by parental death than in those from two-parent families. Conclusions: Our results indicate the association of childhood family structure with offspring morbidity during 46 years' follow-up. The lifetime morbidity was observed to be higher among offspring from a single-parent family compared to two-parent family offspring. Public and scientific concern about the consequences of parental separation on the offspring' health exist, therefore support from healthcare professionals and society is warranted.
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Affiliation(s)
- Heidi Varis
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Rovaniemi Health Centre, Rovaniemi, Finland
| | - Maria Hagnäs
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Rovaniemi Health Centre, Rovaniemi, Finland.,Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy.,Diabetes and Obesity Unit, Garibaldi Hospital, Catania, Italy
| | | | - Tanja Nordström
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Infrastructure for Population Studies, University of Oulu, Oulu, Finland
| | | | - Anja Taanila
- Center for Life Course Health Research, University of Oulu, Oulu, Finland
| | - Sirkka Keinänen-Kiukaanniemi
- Center for Life Course Health Research, University of Oulu, Oulu, Finland.,Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,Unit of Primary Care, Oulu University Hospital, Oulu, Finland.,Healthcare and Social Services of Selänne, Pyhäjärvi, Finland
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5
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Weijdijk LPM, Ziukaite L, Van der Weijden GAF, Bakker EWP, Slot DE. The risk of tooth loss in patients with diabetes: A systematic review and meta-analysis. Int J Dent Hyg 2021; 20:145-166. [PMID: 33973353 PMCID: PMC9291053 DOI: 10.1111/idh.12512] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Revised: 04/09/2021] [Accepted: 05/05/2021] [Indexed: 01/02/2023]
Abstract
Aim The aim of this systematic review was to comprehensively and critically summarize and synthesize the risk of losing teeth among with diabetes mellitus (DM) compared to those without DM, as established in observational studies. Materials and methods MEDLINE‐PubMed and Cochrane databases were searched through a period from their inception through October 2020 to identify eligible studies. Papers that primarily evaluate the number of teeth in DM patients compared to non‐DM individuals were included. A descriptive analysis of the selected studies was conducted, and when feasible, a meta‐analysis was performed. The quality of the studies was assessed. Results A total of 1087 references were generated, and screening of the papers resulted in 10 eligible publications. A descriptive analysis demonstrated that six of these studies indicate a significantly higher risk of tooth loss in DM patients. This was confirmed by the meta‐analysis risk ratio of 1.63 95% CI (1.33; 2.00, p < 0.00001). Subgroup analysis illustrates that this is irrespective of the risk‐of‐bias assessment. The higher risk of tooth loss in DM patients was also higher when only DM type II patients or studies with a cross‐sectional design were considered. Patients with a poor DM control status presented a significantly increased risk of tooth loss. When the data were separated by the world continent where the study was performed, Asia and South America had numerically higher risks and a 95% CI that did not overlap with Europe and North America. Conclusion There is moderate certainty for a small but significantly higher risk of tooth loss in DM patients as compared to those without DM.
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Affiliation(s)
- Lotte P M Weijdijk
- Department of Oral and Maxillofacial Surgery, Amsterdam UMC and Academic Center for Dentistry Amsterdam (ACTA), ACTA is a joint venture between the Faculty of Dentistry of the University of Amsterdam and the Faculty of Dentistry of the Vrije Universiteit Amsterdam, Amsterdam, The Netherlands.,Clinic for Dentistry, Dental Care Utrecht (DCU), Utrecht, The Netherlands.,Department of Periodontology, Academic Center for Dentistry Amsterdam (ACTA), ACTA is a joint venture between the Faculty of Dentistry of the University of Amsterdam and the Faculty of Dentistry of the Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Laura Ziukaite
- Department of Periodontology, Academic Center for Dentistry Amsterdam (ACTA), ACTA is a joint venture between the Faculty of Dentistry of the University of Amsterdam and the Faculty of Dentistry of the Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - G A Fridus Van der Weijden
- Department of Periodontology, Academic Center for Dentistry Amsterdam (ACTA), ACTA is a joint venture between the Faculty of Dentistry of the University of Amsterdam and the Faculty of Dentistry of the Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Eric W P Bakker
- Division Clinical Methods and Public Health Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Dagmar Else Slot
- Department of Periodontology, Academic Center for Dentistry Amsterdam (ACTA), ACTA is a joint venture between the Faculty of Dentistry of the University of Amsterdam and the Faculty of Dentistry of the Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
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Abstract
Evidence increasingly demonstrates that prediabetes is a toxic state, as well as a risk factor for diabetes, and is associated with pathophysiological changes in several tissues and organs. Unfortunately, use of available evidence-based treatments for prediabetes is low. This review seeks to explain why prediabetes must be viewed and treated as a serious pathological entity in its own right. It offers an overview of the pathophysiology and complications of prediabetes and describes how this condition can be reversed if all treatment avenues are deployed early in its course.
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Affiliation(s)
| | - Fatima Bello
- Ahmadu Bello University Teaching Hospital Zaria, Kaduna, Nigeria
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Taguchi A, Nagai K, Ideno Y, Kurabayashi T, Hayashi K. Parity and Number of Teeth in Japanese Women: Results from the Japan Nurses' Health Study. WOMEN'S HEALTH REPORTS (NEW ROCHELLE, N.Y.) 2020; 1:366-374. [PMID: 33786501 PMCID: PMC7784744 DOI: 10.1089/whr.2020.0066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Accepted: 07/06/2020] [Indexed: 06/12/2023]
Abstract
Background: Parity is thought to be associated with a decreased number of teeth present in women. However, educational level and social status, which are particularly significant risk factors for loss of teeth, have been heterogeneous in previous observations. This cross-sectional survey aimed to clarify the associations of parity with the risk of having <20 teeth in Japanese female nurses participating in the Japan Nurses' Health Study (JNHS). Methods: In the third follow-up questionnaire of the JNHS, 11,299 women aged 27-82 years participated in this study. The number of participants according to age range was 7,225 (63.9%) aged <50 years and 4,074 (36.1%) aged ≥50 years. Information on parity and risk factors for loss of teeth was collected through a baseline questionnaire and then a follow-up questionnaire. Multivariate logistic regression analysis was used to calculate the adjusted odds ratio (OR) and 95% confidence interval (CI) of having <20 teeth according to parity category. Results: Participants ≥50 years who had experienced three or more deliveries had a significantly higher risk of having <20 teeth than those who had not experienced delivery (OR = 1.59, 95% CI = 1.14-2.20), although this finding was not observed in participants <50 years. In addition to parity, age and current smoking may be independent risk factors for having <20 teeth in Japanese nurses. Conclusions: Higher-parity female nurses ≥50 years may be more likely to lose teeth than those who have not experienced delivery.
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Affiliation(s)
- Akira Taguchi
- Department of Oral and Maxillofacial Radiology, School of Dentistry, Matsumoto Dental University, Shiojiri, Japan
- Department of Hard Tissue Research, Graduate School of Oral Medicine, Matsumoto Dental University, Shiojiri, Japan
| | - Kazue Nagai
- School of Health Sciences, Gunma University, Maebashi, Japan
| | - Yuki Ideno
- Gunma University Center for Mathematics and Data Science, Maebashi, Japan
| | - Takumi Kurabayashi
- Department of Obstetrics and Gynecology, Niigata City General Hospital, Niigata, Japan
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Association between metabolic syndrome and tooth loss: A systematic review and meta-analysis. J Am Dent Assoc 2019; 150:1027-1039.e7. [PMID: 31761016 DOI: 10.1016/j.adaj.2019.07.023] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Revised: 07/14/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The authors conducted a systematic review and meta-analysis to verify the existence and level of scientific evidence concerning the association between metabolic syndrome (MetS), as the main exposure, and tooth loss (TL), as the outcome. TYPES OF STUDIES REVIEWED Through electronic databases and partially through gray literature, the authors identified observational studies in adults. The authors used no date or language restrictions. The authors evaluated the studies' methodological quality by using the Newcastle-Ottawa Scale. The authors conducted a random-effects model meta-analysis. The authors assessed the quality of evidence by using the Grading of Recommendations Assessment, Development and Evaluation criteria. RESULTS Twelve studies met the eligibility criteria, and 9 were retained for the meta-analysis. Most were cross-sectional studies with good methodological quality. Participants with MetS had fewer teeth (standardized mean difference, -2.77; 95% confidence interval, -4.56 to -0.98) and an increased likelihood of lacking functional dentition (odds ratio, 2.37; 95% confidence interval, 1.89 to 2.96) than did those without MetS. The overall quality of evidence was very low. CONCLUSIONS AND PRACTICAL IMPLICATIONS Better-conducted longitudinal studies are necessary to establish a causal relationship between MetS and TL to inform the best strategies to prevent TL in populations with MetS.
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9
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Borgnakke WS. IDF Diabetes Atlas: Diabetes and oral health - A two-way relationship of clinical importance. Diabetes Res Clin Pract 2019; 157:107839. [PMID: 31520714 DOI: 10.1016/j.diabres.2019.107839] [Citation(s) in RCA: 54] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Accepted: 09/06/2019] [Indexed: 12/22/2022]
Abstract
The current scientific evidence for the bi-directional associations between oral health and diabetes is summarized. The universal biologic mechanisms and demographic and behavioral risk drivers underlying these associations in both directions are also described. Dysglycemia, even slightly elevated blood sugar levels, adversely affects oral health, manifesting itself in several oral diseases and conditions. In the opposite direction, any oral infection with its subsequent local and systemic inflammatory responses adversely affects blood glucose levels. Moreover, painful, mobile, or missing teeth may lead to intake of soft food items representing a sub-optimal diet and hence poor nutrition, and thereby contribute to incident type 2 diabetes or to poorer glucose control in existing diabetes. Treatment of inflammation related oral conditions, such as non-surgical periodontal treatment and extraction of infected teeth, can lead to a clinically significant decrease in blood glucose levels. Attention to infectious oral diseases and referral to dental care professionals for treatment can therefore be an important novel tool for medical care professionals in preventing and managing diabetes mellitus. Dental professionals can detect unrecognized potential dysglycemia and refer for medical examination. Such interprofessional, patient centered care may contribute to improved health, wellbeing, and quality of life in people with diabetes.
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Affiliation(s)
- Wenche S Borgnakke
- Department of Periodontics and Oral Medicine, University of Michigan School of Dentistry, 1011 North University Avenue Rm# 3060, Ann Arbor, MI 48109-1078, USA.
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Fouda SM, Gad MM, El Tantawi M, Virtanen JI, Sipila K, Raustia A. Influence of tooth loss on mandibular morphology: A cone-beam computed tomography study. J Clin Exp Dent 2019; 11:e814-e819. [PMID: 31636874 PMCID: PMC6797444 DOI: 10.4317/jced.55879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2019] [Accepted: 08/23/2019] [Indexed: 11/22/2022] Open
Abstract
Background Tooth loss adversely affects patients’ health and psychosocial wellbeing. In addition, it changes mandibular morphology. Objective: To evaluate the effect of tooth loss, age, and gender on mandibular morphology. Material and Methods Cone-beam computed tomographic (CBCT) scans of 101 patients were examined to measure the gonial angle (GA), ramus height (RH) and condylar height (CH). Patients’ age, gender, and dental status were recorded. Repeated measures analysis of variance (ANOVA) was used to assess the impact of gender, age, and tooth loss on the GA, RH and CH. The mean measurements of the GA, RH and CH were compared between dentate/edentulous patients after splitting by gender. Results The GA was larger in edentulous patients compared to dentate ones, in females than in males, and in older than in younger. RH on the right side was significantly longer than on the left side (P< 0.0001), and also longer in males and younger patients. CH was shorter in younger than in older patients and in dentate than in edentulous patients. Conclusions Tooth loss is associated with changes in mandibular morphology and its prevention would avoid these irreversible changes. Key words:Tooth loss, mandibular morphology, Cone-Beam computed tomography, gender, age.
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Affiliation(s)
- Shaimaa-Mohamed Fouda
- MSc. Lecturer, Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Mohammed M Gad
- MSc. Lecturer, Department of Substitutive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Maha El Tantawi
- Professor, Department of Preventive Dental Sciences, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Jorma I Virtanen
- PhD. Adjunct Professor, Department of Community Dentistry, Faculty of Medicine, University of Turku, 20014 Turku, Finland.,PhD. Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland
| | - Kirsi Sipila
- PhD. Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,PhD. Professor, Research Unit of Oral Health Sciences, Prosthetic Dentistry and Stomatognathic Physiology, Faculty of Medicine, University of Oulu, P.O. Box 5281, 90014 Oulu, Finland
| | - Aune Raustia
- PhD. Medical Research Center Oulu, Oulu University Hospital and University of Oulu, Oulu, Finland.,PhD. Professor, Research Unit of Oral Health Sciences, Prosthetic Dentistry and Stomatognathic Physiology, Faculty of Medicine, University of Oulu, P.O. Box 5281, 90014 Oulu, Finland
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Similä T, Nieminen P, Virtanen JI. Validity of self-reported number of teeth in middle-aged Finnish adults: the Northern Finland Birth Cohort Study 1966. BMC Oral Health 2018; 18:210. [PMID: 30538003 PMCID: PMC6290517 DOI: 10.1186/s12903-018-0666-4] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/16/2018] [Indexed: 11/22/2022] Open
Abstract
Background We examined the validity of self-reported number of teeth in middle-aged adults by using representative cohort data to compare corresponding self-reported and clinical values. Methods This validity study is part of the representative 46-year-old follow-up of the Northern Finland Birth Cohort 1966 (NFBC1966) Study. Mailed questionnaires (n = 5950) requested information on self-reported number of teeth and background variables (education, tooth brushing and smoking), while clinical oral health examinations (n = 1891) assessed the number of teeth (the ‘gold standard’). The main analyses compared the self-reported and clinical values for the number of teeth in 1669 participants. Scatterplot and Bland-Altman plot served for visual analyses, and alternative correlation coefficients (Pearson, Spearman, intraclass) for numerical comparisons separately for men and women, with stratification according to background variables. Results The clinical assessment revealed that the mean value for the number of teeth was 27.46 (SD = 2.38), while the corresponding value based on self-reported information was 27.48 (SD = 2.78). According to the Bland-Altman plot, the mean difference between the clinical and self-reported values was − 0.02 (95% limits of agreement, LoA: − 3.37 to 3.32). The observed ranges of intraclass correlation coefficients (ICC) among men and women were 0.72 to 0.95 and 0.72 to 0.85, respectively, depending on the background variables. Conclusions Self-reported number of teeth in middle-aged Finnish adults agreed closely with the corresponding clinical measure.
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Affiliation(s)
- Toni Similä
- Research Unit of Oral Health Sciences, Faculty of Medicine, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland. .,Medical Research Center Oulu, Oulu University Hospital, P.O. Box 5000, 90029, Oulu, Finland.
| | - Pentti Nieminen
- Medical Informatics and Data Analysis Research Group, University of Oulu, P.O. Box 5000, 90014, Oulu, Finland
| | - Jorma I Virtanen
- Medical Research Center Oulu, Oulu University Hospital, P.O. Box 5000, 90029, Oulu, Finland.,Institute of Dentistry, University of Turku, 20014, Turku, Finland
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