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Tooth Loss Occurring at a Place Other than a Health-care Facility: 72-month Incidence

¹ Department of Diagnostic Sciences, School of Dentistry, University of Alabama at Birmingham, SDB Room 109, 1530 3rd Avenue South, Birmingham, AL 35294-0007;
² Department of Health Services Administration, School of Health Professions, University of Florida; and
³ Department of Biostatistics, School of Public Health, University of Alabama at Birmingham;

*corresponding author, ghg{at}uab.edu

	ABSTRACT

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Dental care can occur within or outside the formal health-care system. We hypothesized that certain subject characteristics would partly explain one type of dental self-care, non-professional extractions. A representative sample of diverse groups of dentate adults was studied. In-person interviews and clinical examinations were conducted at baseline, 24, 48, and 72 months, with semi-annual telephone interviews in between. Of 699 participants, 291 (42%) reported loss of at least one tooth, of whom 42 (14% of those with tooth loss) reported having lost the tooth at a place other than a health-care facility. Ninety-four percent of non-professionally lost teeth were self-extracted; relatives extracted the remainder. Fifty-eight percent of these teeth were deliberately removed; the remainder came out while subjects were eating or brushing their teeth, or due to injury. Attachment loss and mobility at previous examination were consistent with the occurrence of non-professional extraction. The incidence magnitude was substantive and persistent throughout follow-up.

KEY WORDS: tooth loss • self-care • incidence • longitudinal studies

	INTRODUCTION

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Instead of seeking care in the formal health-care system, many persons commonly treat themselves in some manner (e.g., Kronenfeld and Wasner, 1982; Murray and Rubel, 1992; Stoller et al., 1993). This response is so common that the majority of health-related symptoms are actually evaluated and treated outside the formal health-care system (e.g., Dean, 1986; Eisenberg et al., 1993). Examples of self-treatment include the use of non-prescription or over-the-counter medications, the use of appliances or home-made remedies, changes in activity or diet, consultation of lay sources for information, or the initiation of psychological or spiritual interventions. Research on self-care specific to oral health has emphasized oral hygiene habits, the use of dental devices or products, changes in dietary habits, and reports of actual self-treatment (e.g., Clancy and Dixon, 1989; Payne and Locker, 1992; Shirley, 1994; Moss, 1995).

During questionnaire development for the Florida Dental Care Study (FDCS), a longitudinal study of oral health and dental care, we received anecdotal reports of the existence of a certain type of dental self-care (self-extraction). This led us to query tooth loss that might have occurred at a place other than a health-care facility, hereafter referred to as "non-professional" tooth loss. Our report from the first 24 months of the study documented that the phenomenon of non-professional loss is indeed real (Gilbert et al., 1998a). Building upon previous work (Gilbert et al., 1997b, 1998a,b, 2000), we adapted to the dental self-care context a health-care utilization model (Andersen and Newman, 1973; Andersen, 1995). In this model, utilization results from characteristics of the population and the health-care delivery system. Population characteristics can be summarized by three groups: predisposing, enabling, and need (PEN) characteristics. Predisposing characteristics exist prior to disease. Enabling characteristics affect one's ability to access the health-care system, such as income or health insurance. Need variables reflect illness levels. Because self-care can act as a substitute for health care, we tested not only whether PEN variables significantly predicted non-professional extractions, but also whether they acted in directions opposite their effects on dental care use (directions which are discussed in Gilbert et al., 1998b). Our objective here is to quantify the 72-month incidence of non-professional tooth loss, to describe fully the circumstances surrounding this tooth loss, including the characteristics of teeth lost and the characteristics of persons who lost them, and to document whether loss was due to self-extraction only or due to extraction by relatives as well.

	METHODS

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Sample Development
Data were derived from the FDCS. Sampling methodology is described in an earlier publication (Gilbert et al., 1997a). Briefly, however, the 873 subjects who participated resulted in a representative sample of the population of interest, which was defined as persons 45 years old or older, who had a telephone, did not reside in an institutional setting, resided in one of four counties in Florida, could engage in a coherent telephone conversation, and had at least one tooth. This sample had an "interval since last dental visit" at baseline that was very similar to National Health Interview Survey (NHIS) data, and conclusions drawn from the FDCS and the NHIS regarding sociodemographic determinants of dental care interval were the same (Gilbert et al., 1997a). Additionally, the percentage of the sample that had one or more dental visits in the first two years of the study, 77%, was very similar to the figure, 75%, among the comparable group of 1989 NHIS respondents (Bloom et al., 1992; Gilbert et al., 1998b). Human subjects participated after providing informed consent to a protocol that was reviewed and approved by the Institutional Review Board.

Data-gathering Stages and Attrition
Subjects participated for an in-person interview and clinical examination at baseline, 24, 48, and 72 mos (Table 1). These events were followed by telephone interviews at 6, 12, 18, 30, 36, 42, 54, 60, and 66 mos following baseline. By the end of the study at 72 mos, 665 persons (un-weighted n; weighted n = 699) remained in the study. To evaluate the potential for bias as a result of subject attrition, we compared characteristics of those who participated for a 72-month interview with characteristics of those who did not. The mean (SD) number of teeth present at baseline among 72-month participants was 22.3 (7.0); for non-participants, it was 20.9 (7.6) (ANOVA; p < 0.02). At baseline, the percentage of the sample who reported having had non-professional loss at some point during adulthood was 10%; had the sample been limited at baseline to persons who ultimately participated at 72 mos, that figure would have been 8%. Therefore, the incidence figures in this report are likely an underestimate.

At baseline, participants were asked to describe their "approach to dental care" as: (1) "I never go to a dentist"; (2) "I go to a dentist when I have a problem or when I know that I need to get something fixed"; (3) "I go to a dentist occasionally, whether or not I have a problem"; or (4) "I go to a dentist regularly". Persons who responded #1 or #2 were classified as "problem-oriented attenders" (POAs). Those who responded #3 or #4 were classified as "regular attenders".

Clinical Examination Criteria
We have previously described the examination protocol, diagnostic criteria, and examiner reliability (e.g., Gilbert et al., 1996). Briefly, however, the examination recorded the presence and location of remaining teeth, root fragments (missing more than 3/4 of the anatomic crown), bulk restoration fractures, fractured teeth, severe root defects, teeth that were severely mobile (non-physiologic occluso-apical movement or more than 2 mm bucco-lingual movement), and worst site per tooth in terms of periodontal attachment level.

Statistical Methods
Results were weighted by sampling proportions to reflect the counties studied, with a proportional fitting algorithm that minimized variance inflation due to sample design effects (Gilbert et al., 1997a). Analyses were done with the use of SAS (SAS Institute, 2000). For regression analysis, we adopted a stepwise technique, because we had multiple measures of each of the PEN constructs. We used a less stringent criterion for statistical significance, p < 0.10. We first tested all seven need variables in Table 2, retaining only the three that met the p < 0.10 criterion (which appear in Table 3). Predisposing variables were next included with the need variables retained from the first step, and only one predisposing variable met the p < 0.10 criterion (approach to dental care). The next step included the retained predisposing and enabling variables, along with one of the enabling variables. Because the enabling variables had an expected and confirmed overlap (Gilbert et al., 1998b), only one enabling variable was tested at a time. None of the enabling variables met the p < 0.10 criterion.

	RESULTS

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Although cumulative self-reported tooth loss was 42%, as determined by direct clinical examination it was 44%. Once limited to the 665 persons who also participated in a 72-month clinical examination, cumulative self-reported incidence was still under-reported at 41%. Five persons reported incident non-professional tooth loss, but did not participate in a subsequent clinical examination because they were unavailable, unwilling, or were lost to follow-up. Therefore, the missing teeth could not be confirmed clinically and were not included in calculations.

Eight persons also reported one non-professionally lost tooth each, but subsequent clinical examination showed no tooth loss. In each instance, the reported teeth had intact clinical crowns at a previous examination but, at the examination after the self-reported loss, were found to exist as root fragments with the clinical crown missing.

Previous Clinical Characteristics of Teeth Lost Non-professionally
Characteristics of teeth that were non-professionally lost were determined from the most recent previous examination. A total of 76 teeth from 41 persons had clinically verified loss. Seventy-six percent (n = 58) of these teeth were severely mobile at the most recent previous examination. Fifty-nine of these 76 teeth were assessed for attachment loss at the most recent previous examination; mean (SD) attachment loss was 10.6 (3.0) mm, with a range of 5 to 19 mm. Thirty-four (46%) of the 76 teeth were anterior teeth; the remainder were posterior.

Circumstances Surrounding Non-professional Tooth Loss
Almost all (94%) non-professionally lost teeth were self-extracted. Relatives (spouse, nephew, or grandson) extracted the remainder. Fifty-eight percent of teeth were deliberately removed, by means of fingers (76%), string or nylon (13%), pliers (5%), napkin (3%), or Q-tip^® (3%). The remainder (42%) came out while subjects were eating or brushing their teeth, or due to injury. For 11% of the non-professionally removed teeth, participants reported that they became inebriated beforehand.

Characteristics of Persons Who Had Non-professional Tooth Loss
Persons with non-professional loss during follow-up were more likely at baseline to have had severe attachment loss, a severely mobile tooth, active dental decay, a cusp or incisal edge fracture, or a root fragment (Table 2). These persons were also more likely at baseline to have been POAs, African-American, males, non-high-school graduates, and with fewer financial resources. Attachment loss, tooth mobility, root fragment status, and POA status each independently predicted non-professional loss (Table 3).

Persons who lost teeth during follow-up, but who had no non-professional loss, had more dental visits during follow-up (mean [SD] of 12.0 [8.0] visits), compared with 4.4 (4.0) visits among persons who lost at least one tooth non-professionally (Wilcoxon rank-sum test; p < 0.001). Of the 12 six-month follow-up intervals, persons who lost teeth but who had no non-professional loss had at least one visit during a mean (SD) of 5.9 (3.4) intervals, compared with 2.1 (1.8) intervals among persons who lost at least one tooth non-professionally (Wilcoxon rank-sum test; p < 0.001).

Persons with at least one non-professionally lost tooth during follow-up reported having lost a mean (SD) of 2.7 (2.1) teeth non-professionally. However, these same persons also reported a mean (SD) of 3.8 (5.1) teeth extracted by a dentist; this compares with 3.5 (3.8) teeth among persons who lost teeth during follow-up, but who lost all these teeth in a dental office (Wilcoxon rank-sum test; p = 0.69).

	DISCUSSION

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The findings from this population-based sample of adults suggest that tooth loss incidence occurring at a place other than in a health-care facility is substantive, on the order of 14% of all persons who experienced tooth loss. This incidence magnitude is salient for two reasons: its potential for harm, and its contribution to our understanding of the role of self-care in the daily lives of diverse groups of adults.

These findings parallel findings in the general medical literature. When an individual decides to seek health care, he/she often goes outside the mainstream health-care system. For example, 34% of adults reported using one or more "unconventional" therapies, generally used as adjuncts to conventional medical therapy instead of being a replacement for it (Eisenberg et al., 1993). "Unconventional" medicine was defined as medical interventions not taught widely at medical schools. Researchers have begun to incorporate indicators of lay treatment strategies into studies of illness behavior (e.g., McElroy and Jezewksi, 2000; Stoller et al., 2002). One study (Stoller et al., 1994) found that about 2% of persons recommended self-treatments that a panel of clinicians considered "definitely harmful", while about 71% mentioned treatments judged "conditionally harmful". Given potential for prolonged bleeding or clinically significant bacteremia, we would place non-professional tooth loss in the "conditionally harmful" category. Fleming and colleagues (1984) found that more self-care, as measured by the use of non-prescribed home treatment, was associated with less use of formal medical care. They concluded that self-care acted as a substitute for formal services, rather than as a supplement to or stimulus to formal service use. The phenomenon of non-professional tooth loss clearly falls into this category.

Studies of illness behavior have often not taken into account the social context, a context that could affect access to resources, expectations regarding social roles, and knowledge about health. Nonetheless, at least with regard to this one type of dental self-care, a type that we would consider one of the more extreme forms of self-treatment, sociodemographic circumstance had no direct effect on non-professional loss (Table 3). Instead, disease and approach to dental care were the strong predictors of non-professional tooth loss. Our expectation before baseline was that non-professional loss would be a phenomenon limited to a tiny fraction of geographically isolated residents in the three non-metropolitan counties in the FDCS. As shown in Table 2, this was not the case. However, we have showed, in the FDCS sample, that area of residence and other sociodemographic variables are strongly associated with disease level and approach to dental care (Gilbert et al., 1997b,c, 1998b). Therefore, sociodemographic circumstance can be viewed as having an effect, albeit indirect, on non-professional loss.

Even with key clinical characteristics taken into account, "approach to dental care" makes an additional contribution to our understanding of dental self-care (Table 3). From a public health perspective, the role of approach to care has been pervasive and consistent throughout findings from the FDCS. We have showed that POAs have a high prevalence of dental disease and decrements in dental-health-related quality of life (Gilbert et al., 1996, 1997b,c, 1998c). Indeed, this was the reason for our early interest in self-care behavior, especially among POAs. POAs are at further disadvantage, because they have fewer financial resources available to afford dental services, place a lower emphasis on dental hygiene behaviors, have more negative dental attitudes, experience a higher use of tobacco products, have lower dental care utilization rates, and place a lower value on dental health and dental care. Based on this report, they are at an even further dental health disadvantage due to non-professional tooth loss.

	ACKNOWLEDGMENTS

 
This investigation was supported in part by USPHS Research Grants DE-11020, DE-12457, and DE-14164 from the National Institute of Dental and Craniofacial Research, National Institutes of Health, Bethesda, MD 20892. The opinions and assertions contained herein are those of the authors and are not to be construed as necessarily representing the views of the universities or the National Institutes of Health. An Internet Home Page devoted to details about the FDCS, including full questionnaire content, test/re-test interview, and examiner reliabilities, can be found at http://nersp.nerdc.ufl.edu/~gilbert/ (formerly at http://www.nerdc.ufl.edu/~gilbert/).

Received January 7, 2002; Last revision July 9, 2002; Accepted September 6, 2002

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