|Year : 2019 | Volume
| Issue : 2 | Page : 231-237
|Regular dental scaling associated with decreased tooth loss in the middle-aged and elderly in Korea: A 3-year prospective longitudinal study
Ga Yeong Lee1, Sang Baek Koh2, Nam Hee Kim3
1 Department of Dental Hygiene, Graduate School, Yonsei University, Seoul, Korea
2 Department of Preventive Medicine, Wonju College of Medicine, Yonsei University, Wonju, Korea
3 Department of Dental Hygiene, Wonju College of Medicine, Yonsei University, Wonju, Korea
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|Date of Web Publication||29-May-2019|
| Abstract|| |
Context: Tooth loss exacerbates the deterioration of physical function and induces illness. Numerous studies have identified the risk factors for tooth loss, and several have identified an association of tooth loss with sociodemographic factors, general health status, and lifestyle. Aims: The objective of the present cohort study was to elucidate the relationship between regular dental scaling and tooth loss in middle-aged and elderly individuals in Korea. Settings and Design: The study was 3-year prospective longitudinal study and conducted in Wonju-si of South Korea. Methods: In total, 557 subjects (219 men, 338 women; 40–75 years) were included in our 3-year follow-up survey (2010–2014). Data from the Korean Genome and Epidemiology Study on Atherosclerosis Risk of Rural Areas in the Korean General Population (KOGES-ARIRANG) were used. All subjects underwent an oral examination and face-to-face interview for taking oral health behavior, sociodemographic status, and the utilization of dental service. Statistical Analysis Used: Logistic regression analysis was used to determine the effects of regular dental scaling on tooth loss after adjusting for history of oral examinations and dental visits, oral health behavior, and sociodemographic status. Results: In total, 263 subjects (47.2%) experienced a loss of one or more teeth during the 3-year period, and lost a mean of 1.54 ± 2.53 teeth. The incidence of tooth loss was 1.87 (1.03–3.38) times higher in participants who did not undergo dental scaling during the 3-year period than in those who regularly received dental scaling. Conclusions: This study showed the potential causal relationship between tooth loss and regular dental scaling for preventing oral disease. Further study is needed to consolidate the evidence that regular dental scaling is effective in preventing tooth loss.
Keywords: Cohort studies, community dentistry, dental scaling, preventive dentistry, tooth loss
|How to cite this article:|
Lee GY, Koh SB, Kim NH. Regular dental scaling associated with decreased tooth loss in the middle-aged and elderly in Korea: A 3-year prospective longitudinal study. Indian J Dent Res 2019;30:231-7
|How to cite this URL:|
Lee GY, Koh SB, Kim NH. Regular dental scaling associated with decreased tooth loss in the middle-aged and elderly in Korea: A 3-year prospective longitudinal study. Indian J Dent Res [serial online] 2019 [cited 2020 Feb 23];30:231-7. Available from: http://www.ijdr.in/text.asp?2019/30/2/231/259229
| Introduction|| |
Periodontal disease is one of the most common oral health problems among elderly individuals worldwide. Apart from its contribution to the quality of life in the elderly population, oral health also influences their daily activities and social interactions. The final result of oral disease is tooth loss. Tooth loss in older individuals results in discomfort during mastication and adversely affects social interactions by impairing the pronunciation of words. In particular, tooth loss can impair physical and cognitive function. Further, loss of teeth may result in general debilitation and illness, leading to poor quality of life and increasing morbidity and mortality.,,
Dental prostheses, such as dentures and implants, prevent malnutrition by restoring masticatory function and significantly improve the quality of life of affected patients. However, prostheses provide inferior masticatory function compared with natural teeth; therefore, the quality of life is comparatively worse in patients with dental prostheses than in those with natural dentition., Therefore, the prevention of tooth loss is critically important.
The paradigm of health care has changed to focus on prevention rather than treatment. In this regard, it is important to characterize the associated risk factors to establish appropriate disease prevention strategies. An understanding of this association will provide a much-needed foundation for encouraging preventive oral health care and clearly demonstrate the importance of preventive oral healthcare policy implications.
However, elderly patients typically prioritize their general health and other life-threatening illnesses and pay relatively less attention to their oral health. Furthermore, among elderly patients, the use of preventive oral health care such as regular dental scaling, dental check-up, and fluoride application is lower compared with that of major dental treatment procedures.
Recently, the national health insurance benefits in Korea have been expanded to provide universal coverage to all residents in an effort to reduce the financial burden of oral disease. Particularly, preventive dental care including dental scaling to prevent periodontal disease, as well as items for restoration of oral function such as dentures and implants are now considered national health insurance benefit items, making them easily accessible and decreasing oral health disparity associated with socioeconomic status.
Dental scaling, which is instrumentation of the crown or root surface to eliminate calculus, dental biofilm, and stains, is used as preventive dental care for clients with healthy gingiva or gingivitis.,, Dental professionals recommend clients receive dental scaling regularly. Removing dental plaque and calculus deposits may help reduce gingival bleeding and inflammation, thereby reducing gum disease, and ultimately, tooth loss. It has been shown that supportive periodontal therapy after active periodontal treatment is effective at preventing tooth loss in patients with periodontal diseases.,, Although previous studies have shown that regular dental scaling can prevent atrial fibrillation and cardiovascular diseases, such as myocardial infarction and stroke, it still remains unclear whether receiving regular dental scaling for gingival health can prevent tooth loss. Since the causal relationship between preventative dental scaling and tooth loss remains to be elucidated, it is not known whether it is advisable to recommend regular dental scaling to prevent tooth loss in middle-aged and elderly individuals.
Therefore, the objective of this study was to determine the relationship between regular dental scaling and tooth loss by conducting a 3-year prospective longitudinal study of middle-aged and elderly individuals in Korea.
| Methods|| |
Study design and subjects
The study design was a 3-year prospective longitudinal study using data from the Korean Genome and Epidemiology Study on Atherosclerosis Risk of Rural Areas in the Korean General Population (KOGES-ARIRANG). The KOGES-ARIRANG was a community-based prospective cohort study conducted by the Korean Centers for Disease Control and Prevention. For baseline recruitment, the KOGES-ARIRANG study invited all adults aged 40 years and older who resided in rural Wonju in South Korea to participate. Eligible participants were asked to volunteer through on-site invitation, mailed letters, telephone calls, media campaign, or community leader-mediated conferences.
In this study, inclusion criteria were those who were 40–75 years of age in the baseline year and those who participated in oral examinations and face-to-face interview in both baseline year and follow year. Exclusion criteria were those who did not have a tooth in the baseline year (N = 35). The analysis was performed with the exception of data that did not meet the reliability criterion (N = 296) and outlier data from which more than nine teeth were extracted during the three years (N = 11). The final sample for the study was a 557-person (219 men and 338 women) cohort group [Figure 1].
The study protocol was approved by the Institutional Review Board of Yonsei Wonju Christian Hospital in accordance with the World Medical Association Declaration of Helsinki (CR105024-026). All participants provided written informed consent.
All participants underwent an oral examination to count the number of teeth by well-trained dental hygienists. The frequency of dental scaling, oral examinations and dental visits, oral health behavior, and the sociodemographic characteristics were determined based on face-to-face interview.
To test reliability, 20% of the participants were randomly selected 2–4 weeks after the survey and interviewed using the same questions to evaluate test–retest reliability; the kappa value was 0.967.
The main outcome variable of this study was defined as the loss of more than one tooth occurring during the 3-year period after baseline. Tooth loss was measured by subtracting the number of teeth in the follow year from the number of teeth in the baseline year. The main independent variable was the frequency of dental scaling within 3 years. The covariate variables were frequency of oral examinations and dental visits, oral health behavior, and sociodemographic variables.
The frequency of dental scaling was determined from the responses to the question, “If you visited a dental clinic within the last 3 years, what services have you received?” The subjects were provided with the following list: oral examination (only an oral examination, no other treatment, or preventive care); dental scaling; other dental treatments (such as, periodontal, restorative, endodontic, or prosthetic treatment, or dental implantation); and “not sure.” If the subjects answered, “dental scaling,” this study considered that the subjects received dental scaling.
Oral health behaviors included daily tooth brushing and use of dental floss or an interdental brush. Sociodemographic variables included age, sex, educational level, marital status, and cohabitation status.
Accumulation variables were used to estimate the relationship between tooth loss and the participants' independent and covariate variables because these variables can change easily. These included the frequency of dental scaling, oral examinations, and dental visits; oral health behavior; and the marital and cohabitation status.
The dental scaling variable was classified as “Regular,” “Irregular,” or “Never.” For these variables, a “Regular” rating was assigned to subjects who received dental scaling in both the baseline and follow-up years. An “Irregular” rating was assigned to subjects who received dental scaling in the baseline year, but not in the follow-up year, or vice-versa. A “Never” rating was assigned to subjects who did not receive dental scaling in either the baseline or follow-up years. The dental visit and oral examination variables were classified in the same manner as the dental scaling variable.
The oral health behavior variables were classified as “Good,” “Moderate,” and “Poor.” For these variables, a “Good” rating was assigned to subjects who brushed their teeth more than twice per day and used dental floss or an interdental brush. A “Moderate” rating was assigned to subjects who met the conditions for a “Good” rating in 1 year, but a “Poor” rating in the other year (e.g., brushed their teeth more than twice a day during the baseline year, but less than once per day during the follow-up year, or vice-versa). A “Poor” rating was assigned to subjects who did not meet these conditions in both the baseline and follow-up years.
The marital and cohabitation status variables were classified in the same manner as the other variables.
A case-crossover analysis was performed to determine differences in the distribution of tooth loss associated with the independent and covariate variables. Logistic regression analysis was performed to identify the risk of the independent variable for loss of more than one tooth and risk ratios and 95% confidence intervals (CIs) were calculated. A crude model and adjusted model were used to identify independent and covariate variables associated with tooth loss. Using the crude model, the magnitude of the effect of each independent and covariate variable on tooth loss was identified. An adjusted model was used to determine the effects of regular dental scaling on tooth loss after adjusting for covariate variables. All statistical analyses were performed using SPSS 20.0 for Windows (SPSS Inc., Chicago, IL, USA), and a P value < 0.05 was considered statistically significant.
| Results|| |
Of the 557 participants, 263 (47.2%) experienced tooth loss during the 3-year follow-up period. The mean and standard deviation of lost teeth per patient was 1.54 ± 2.53. The range of lost teeth was 0–19. With regard to dental scaling, 81 participants (14.5%) underwent regular dental scaling and 291 (52.2%) did not receive any dental scaling in both the baseline and follow-up years. Thirty-one participants (5.6%) had regular oral examinations and 301 (54.0%) had regular dental visits. With regard to the surveyed oral health behaviors, 463 participants (83.1%) consistently brushed their teeth at least twice daily and 136 (24.4%) maintained the use of dental floss or an interdental brush [Table 1].
|Table 1: Distribution of independent variables at the baseline and follow-up year|
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Differences in tooth loss according to regular dental scaling and covariates
During the follow-up period, tooth loss was higher in participants that did not receive dental scaling than in those who received dental scaling regularly [P < 0.05; [Table 2]. In addition, tooth loss was higher in participants with negative oral behavior than in those who consistently practiced daily tooth brushing and use of oral hygiene devices [P < 0.05; [Table 2]. However, there was no significant difference among participants stratified by oral examination and dental visits.
|Table 2: Differences in tooth loss according to covariates and independent variables after follow-up 3 years|
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Tooth loss occurred more in men than in women (P < 0.05); a loss of ≥1 tooth occurred in 115 men (52.5%) and 148 women (43.8%). Tooth loss increased with age (P < 0.001); 36 participants (69.2%) aged ≥70 years lost teeth, compared with 30 participants (31.6%) aged 40–49 years.
Tooth loss was also more frequent in individuals with a lower education level (P < 0.001); 113 participants (59.5%) with tooth loss had an elementary school education or less, while 98 (37.0%) had a high school education or more. There was no significant difference in tooth loss among participants stratified by marital and cohabitation status over the 3-year study period.
Logistic regression analysis for risk factors of tooth loss
Logistic regression analysis revealed frequency of dental scaling and dental visits, age, and education level as significant predictors of tooth loss in the adjusted model. After adjustment for sociodemographic factors, oral health behavior, oral examination, and dental visits as covariate variables, we found that the incidence of tooth loss was 1.87 (CI: 1.03–3.38) higher in participants who did not receive scaling during the 3-year period than in those who received scaling regularly [Table 3].
|Table 3: Logistic regression analysis of factors affecting tooth loss according to independent variable|
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The results showed that the risk ratio for tooth loss in participants aged 60–69 and ≥70 years was 2.57 (CI: 1.45–4.57) and 2.96 (CI: 1.32–6.61), respectively, while that in participants with an elementary school or lower education was 1.76 (CI: 1.10–2.81) times higher than that observed in participants with higher education [Table 3].
| Discussion|| |
Dental plaque control is considered a positive oral health behavior for the maintenance of good oral health. Oral health professionals recommend regular dental scaling to prevent periodontal disease, a major cause of tooth loss. Supportive periodontal therapy such as dental scaling after active periodontal therapy such as surgery is effective in preventing periodontal disease and tooth loss. However, it remains unknown whether oral health behaviors such as dental scaling without surgical periodontal therapy are effective in preventing tooth loss in the general population. The purpose of this study was to clarify whether regular dental scaling can prevent tooth loss by using 3-year follow-up data from a cohort of middle-aged and elderly individuals in Korea.
Tooth loss was 1.87 times higher in participants who did not undergo scaling within the 3-year period than in those who consistently underwent scaling after adjusting for the frequency of oral examinations and dental visits, oral health behavior, and sociodemographic characteristics such as sex, age, education level, and marital and cohabitation status. Meanwhile, the participants who visited a dental clinic lost significantly more teeth than those who did not. However, there was no significant association between tooth loss and the frequency of tooth brushing, use of oral hygiene devices, or oral examinations.
Why did participants who visited dental clinics lose more teeth than participants who did not? After middle age, most dental visits are focused on prosthetic treatment and tooth extraction due to periodontal disease. The participants of this study were middle-aged or elderly individuals and presumably visited a dental clinic for prosthetic treatment or tooth extraction. Dental care utilization has a strong association with oral health outcomes, such as the number of decayed, missing, and filled teeth. However, the causal relationship between dental visits and tooth loss is unclear, because the frequency of dental visits depends on dental needs and demands. This point should be evaluated and discussed in future longitudinal cohort studies.
The findings of our study, which is not undergoing regular dental scaling, are associated with increased tooth loss and support the results of previous studies. Although the need and demand for dental scaling is reportedly associated with socioeconomic factors — such as low education levels, low income, employment as a service and sales worker, and employment as a manual worker — after adjustment for sociodemographics in this study, it was evident that regular dental scaling is associated with a lower incidence of tooth loss. This finding is similar to that of previous studies showing that supportive periodontal care after surgical periodontal therapy can prevent tooth loss.,, This result suggests that scaling, which is known as a method of preventing periodontal disease, is directly related to tooth loss, since tooth loss is more frequently caused by periodontal disease than by dental caries or trauma in the middle-aged people.
Nonsurgical periodontal therapy includes dental biofilm removal and control, supragingival and subgingival scaling, root planing, and adjunctive treatments such as chemotherapy; the basic objective is the restoration of periodontal health. Dental scaling is different from nonsurgical periodontal therapy. In other words, dental scaling is a preventive, rather than curative, approach to periodontal disease and tooth loss.
Since 2013, dental scaling has been covered by the national health insurance in Korea in an effort to decrease the burden of oral disease and oral health disparity in association with socioeconomic status. This national health insurance policy has increased dental care utilization in adults, who are more likely to demand dental treatment beyond dental scaling. With the improved health care coverage, economic barriers could be lowered and professional oral care could be extended to a wider population. Clear evidence of the effects of dental scaling on tooth loss could have very important healthcare policy implications.
This study had notable limitations. First, it was conducted using face-to-face interviews, which may have led to interviewer bias. However, the validity of reported oral health behaviors is considered to be better compared with that of clinical assessments in community-based samples. Second, participants answered questions on the basis of their memory; therefore, recall bias cannot be ruled out. Third, this study only considered sociodemographic and oral health behavior, and other known risk factors for tooth loss, including periodontal disease at baseline year; systemic diseases such as diabetes, cardiovascular disease, and metabolic syndrome; and general health and lifestyle factors, such as smoking and drinking, were not considered. Further studies with long-term follow-up periods should be required to examine how the prevalence and management of chronic diseases, particularly during middle age, and changes in health practices contribute to tooth loss in old age.
Nevertheless, this study showed the potential causal relationship between tooth loss and regular dental scaling for preventing oral disease. In further studies, more concrete evidence of the clinical outcomes of regular dental scaling for preventing periodontal disease, including the impact on tooth loss, could have important implications for the utility and effect of universal national insurance coverage.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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Prof. Nam Hee Kim
20 Ilsan-Ro, Wonju Gangwondo 26426
Source of Support: None, Conflict of Interest: None
[Table 1], [Table 2], [Table 3]
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