Social science study end points
A paper questionnaire is completed by the subjects at the investigation centre before clinical examination. The questionnaires were also used from previous DMS studies to ensure comparisons. Further, the questionnaires are designed according to the specific age cohorts. The interviewers provide the subjects with support with this as appropriate. The basic points of the social science survey component with general question parameters are: general perception of oral health, self-efficacy regarding oral health, cognitive attitude regarding monitoring of dental health, snacks between meals, oral hygiene habits/prosthesis hygiene, past periodontal treatment and regular supportive periodontal care, utilization of dental services, loyalty to dentist, subjective satisfaction with dental prosthesis, subjective morbidity status, questions on childhood and course of life, care status, wearing behavior of removable prosthesis, tobacco/alcohol consumption, social demographics, place of residence, and place of birth (if Germany, federal state; otherwise country). For the first time, the sense of coherence scale (SOC-13 [
18]) is incorporated to obtain information between health, stress, and coping. The SOC scale consists of three dimensions: comprehensibility, manageability, and meaningfulness.
Particular issues arise among the old olds. As well as being significantly shortened, the foci of the questions for this age group are specific perception of oral health, general perception of health, utilization pattern/care pattern of dental services, subjective satisfaction with dental prosthesis, utilization pattern/care pattern of medical services, perceptions of oral pain, disabled status and degree of disability, care status and care context, any assistance needs for housekeeping, wearing behavior of removable prosthesis, survey on age-specific diet and food intake, general mobility status, reduced social demographics, place of residence, and place of birth (if Germany, then federal state; otherwise country).
Clinical study end points
Clinical examinations are applied to the subjects in different age cohorts according to Table
1. The course of clinical examinations is carried out according to the following order:
Table 1
DMS V clinical examinations according to age cohorts
Oral mucosa lesions | | X | X | X |
Tooth-specific findings | X | X | X | X |
Tooth surface-specific findings | X | X | X | X |
Molar incisor hypomineralization | X | | | |
Dental erosions | X | X | X | X |
Dental caries | X | X | X | X |
Root caries | | X | X | X |
Periodontal index teeth recording | | X (90%) | X (90%) | |
Periodontal full-mouth recording | | X (10%) | X (10%) | X |
Gingivitis | X | | | |
Prosthodontics | | X | X | X |
Oral functional capability | | | | X |
Oral mucosa lesions Examination of the oral mucosa is carried out with two dental mirrors in all subjects ≥ 35 years. Partial dentures are removed if present. The following forms of oral lesions are recorded: carcinoma, leukoplakia, erythroplakia, lichen planus, candida, smoker’s keratosis, prosthesis-related changes, other changes. The lesion size is not recorded. Selection of oral mucosa lesions is based on the recommendations of the WHO [
19,
20]. The localization of the lesions is captured using a coding model based on Roed-Petersen and Renstrup [
21]. Where findings are present, a photograph of the lesion is taken for a systematic expert diagnostic verification.
Tooth-specific findings Tooth-specific findings are obtained for all teeth including third molars. At the beginning of the examination, each subject is asked whether she/he has a removable prosthesis or any implants. The following findings are recorded: extracted teeth due to caries, not replaced; missing, non-replaced teeth, missing for reasons other than caries; full crown; partial crown (at least one cusp covered); anchor crown (bridge anchor, telescopic crown, crown anchored to bar, root caps); pontic (fixed prosthesis); replaced tooth (removable prosthesis); implant (with prosthetic restoration).
Tooth surface-specific findings In the surface-specific examination, an assessment is performed of five surfaces per posterior tooth (premolars and molars) and four surfaces per anterior tooth (incisors and canines). An assessment is performed in teeth, which have been erupted into the oral cavity at least beyond the equator. The following findings are recorded on surface level: initial caries (for details see below); carious lesions (for details see below); secondary caries (for details see below); fissure sealants; dental restorations (the restoration material is not recorded).
Molar incisor hypomineralization Special interest shall be put on recording teeth showing signs of molar incisor hypomineralization (MIH). This kind of developmental tooth defect with hitherto unknown aetiology is by definition restricted to incisors and molars, although other teeth can show the same characteristics. For documentation, the MIH index according to the European Academy of Paediatric Dentistry is used [
22]. Each tooth is assessed using the MIH code definitions: Code 1: limited demarcated opacities; mildest form of MIH, no surface loss; generally, whitish or yellowish, occasionally also brownish discolored areas can be identified as a result of the disordered mineralization. Opacities smaller than 1 mm are not recorded. Code 2: posteruptive, localized enamel cracks. Code 3: posteruptive enamel breakdown, large scale. Code 4: atypical restorations. Code 5: extraction due to MIH. Code 6: tooth has not erupted.
Dental erosions Erosions are measured according to the basic erosive wear examination (BEWE) [
23]. The most severe finding of a sextant is registered. Typical for erosive findings is a bowel-shaped appearance rounded at the margins. The defects are typically more extensive in width that in depth. BEWE case definitions are as follows: Code 0: no erosion: Code 1: initial loss of surface structures (e. g. shine, perikymata). Code 2: clinically manifest defect, loss of tooth structure over less than 50% of the tooth surface. Code 3: clinically manifest defect, loss of tooth structure over more than 50% of the tooth surface. This estimation of the percentage of the surface affected is based on the most severely affected tooth surface per tooth. The involvement of dentine, which generally occurs from degree two or three, is not named as a graduation criterion.
Dental and root caries To assess dental caries the DMF index is used [
24]. This index covers teeth and/or tooth surfaces which are decayed, filled or extracted due to caries. If this assessment is carried out for each tooth surface, adding together the affected tooth surfaces results in the DMFS sum score (S = surfaces). By assessing the findings on tooth level, the DMFT sum score can be calculated (T = teeth). If at least one tooth surface is carious or filled, the whole tooth is classified as a DMF tooth. The D component (D = decayed) stands for tooth or surface destroyed by caries, M (M = missing) for tooth or surfaces extracted due to destruction by caries, and F (F = filled) for a filled tooth or surface due to caries. Coronally, the caries findings are examined visually and not through exploration with a dental probe according to WHO recommendations for epidemiological field studies [
25]. This study only uses a blunt periodontal probe to assess sealings or restoration defects. Only clearly diagnosable carious lesions are recorded. With proximal surfaces, the contact with the neighboring tooth frequently makes it difficult to conclusively detect carious lesions. In these cases, the dental investigators are urged to note a defect, where there are typical signs of a proximal lesion shining through. As a general principle, the primary carious surface in each case is recorded as defective. Adjacent areas are also considered as carious if the defect clearly extends to these. Dental restorations are registered in each case where the reason for their presence cannot be be assumed to be other than a carious defect. If both a carious lesion and a dental restoration are present on a tooth surface, the assessment is differentiated on the basis of the degree of severity of the caries. In case of extension of the carious lesion into dentine this surface is classified as carious. In case of initial lesions or carious lesions limited to enamel, however, this is not included in the findings but rather the dental restoration is recorded.
Initial carious lesions are recorded separately, distinguishing between active and inactive lesions. Active initial carious lesions are defined to show a white, rough, and lackluster surface. Inactive initial carious lesions are defined as to present a smooth and glossy surface.
Root caries is examined both as prevalence recording and according to the root caries index (RCI) [
26]. A root is assessed as carious if it is possible to establish cavity formation with or without softening. If caries on a root appears to be a continuation of extended crown caries not extending more than 2 mm onto the adjacent root area, no caries finding is noted for the root. In the event of major defects to the root, however, stand-alone root caries is assumed, and this is recorded. For root caries, a distinction is drawn between active and inactive lesions. A brown (yellow, reddish to brown) root surface with varying substance loss and a soft to leathery texture (tactile examination using a blunt probe), usually plaque-covered, is considered as active root caries. Inactive root caries is noted if the substance loss is accompanied by a dark brown to black root surface and hard surface, usually plaque-free. Root surfaces, filled to improve the aesthetic appearance, according to information provided by the subject, are not recorded as filled. Likewise, no dental restoration is recorded if coronal restorations extend up to 2 mm onto roots, as it is assumed that the defect, which was the basis for this restoration, was crown caries. In case of a major restoration to the root, on the other hand, this is recorded as root filling.
In order to be able to calculate the RCI representing the percentage of filled and carious root surfaces relative to the number of exposed root surfaces, healthy but exposed root surfaces are also recorded.
Periodontal diseases The periodontal assessment is performed on the basis of the previous DMS IV, but current developments in epidemiological assessments are taken into consideration [
27]. In adults and young olds, all the findings are obtained from the following index teeth [
28]: 17, 16, 11, 24, 26, 27, 37, 36, 31, 44, 46, and 47. If there is a missing index tooth, a substitute tooth from the same tooth group is used for the assessment. This means that if 16 and 17 are missing, 18 is used. If 24 is missing, 25 is used, if 11 is missing, 21 is used for assessment. If 21 is also missing, other teeth should be used instead in the following order of priority: 12, 22, 13, 23. If all the substitute teeth from the same tooth group are missing, no evaluation is performed.
In the adult and young olds age cohort, 10% of the subjects are examined using a six-point full-mouth periodontal recording based on a random algorithm process. Because in old olds, it is expected that there will be a reduced natural dentition, a six-point full-mouth periodontal recording is carried out throughout. The 10% subsample approach constitutes a scientific comprise in periodontal epidemiology by determining a so-called inflation factor to correct the periodontal epidemiological underestimation accompanied with the index tooth-specific approach and, on the other hand, to keep the time required for periodontal measurement within acceptable limits [
27,
29].
The periodontal pocket probing depth and recession is ascertained using a WHO probe (PCP 11.5B, HuFriedy, Tuttlingen) and is noted with one millimeter increments. The values are up rounded mathematically. The maximum probing pressure is 0.2 N. Making contact with the tooth, the WHO periodontal probe is inserted parallelly to the tooth axis into the sulcus or pocket and the distance from the gingival margin to the sulcus base or pocket base is determined at the following measurement sites per index tooth: mesial-vestibular, medial-vestibular, distal-oral. Entry into the DentaSoft V software is performed to an accuracy of one millimeter.
Gingival recession (resp. hyperplasia) is also determined using the WHO probe and is ascertained at the same sites as the measurement of the periodontal pocket probing depth. The cement-enamel junction (CEJ) serves as a coronal reference point for gingival recession measurement [
30]. In the event of a visible CEJ, the distance between CEJ and the gingival margin is measured to an accuracy of one millimeter as a positive value. If the gingival margin is positioned coronally to the CEJ, it is detected by using the probe tilted outwards by approximately 45° and carefully moving the probe in an upward and downward direction and it is noted with a minus value. If the CEJ is not discernible due to a dental restoration or a crown, then it should be determined arbitrarily on the basis of the anatomy of the neighboring teeth. If it cannot be determined due to extensive prosthetic provision, the gingival recession (resp. hyperplasia) cannot be documented. Attachment loss is calculated as the sum of periodontal pocket probing depth and gingival recession.
Gingivitis In children, the papilla bleeding index (PBI) is determined instead of the above described periodontal measurement as advanced periodontal disease is not expected in this age cohort [
31]. Papilla bleeding is provoked using a WHO probe by gentle probing the sulcus of the mesial and distal papilla. The stroking pressure is at maximum of 0.2 N. One-off gentle probing from the papilla base up to the papilla tip is performed. The probing begins on the distal-vestibular site on tooth 16 and is continued until the mesial-vestibular site on tooth 11. Subsequently, the extent of any bleeding is immediately assessed. This is followed by measurement and evaluation in the second quadrant orally. A similar approach is taken from the vestibular side in the third quadrant and again orally in the fourth quadrant. The PBI scale is as follows: Code 0: no bleeding. Code 1: appearance of one bleeding point. Code 2: appearance of different isolated bleeding points on less than half of the coated length. Code 3: the interdental triangle fills with blood shortly after probing. Code 4: severe bleeding from the papilla region.
Prosthodontics Most prosthetic findings, such as crowns or bridge works, emerge from the tooth-specific findings at the beginning of the clinical examination. At this point, the type of denture is registered. The type of denture, separately for upper and lower jaw, is recorded as follows: resin partial denture with curved retention elements, model cast denture, combined denture with complex anchorage (telescopic, bar, attachment denture, hybrid denture excl. anchorage element on root caps), full denture. For each denture in the upper and lower jaw, information is recorded about the wearing behavior. Sporadic wearing (to look better in company or similar) is rated as non-wearing.
Index of oral functional capability A four-level index of oral functional capability (IOFC) is measured in old olds. The determination of IOFC is a dental investigator’s estimation [
32]. The IOFC consists of three dimensions: treatment potential level, oral hygiene ability, and personal responsibility.
The treatment potential level refers to whether dental treatment may performed consistent with treating healthy subjects, or if there should be certain limitations be expected due to decreased capability (for example number and length of appointments, diagnostic options, medical risk factors, medication, type of dental treatment concept). Neither the financial situation nor the dental status of the subject has any impact on the determination of the treatment potential level. When assessing the oral hygiene ability, the question must be answered whether the subject can participate in an individual prophylactic dental treatment and whether the subject has the motor function and cognitive skills to understand the instructions on oral hygiene and implement these in her/his daily oral and denture hygiene regime. Personal responsibility refers to the subject ability to decide on the one hand to seek dental services and on the other hand to individually organize this visit. The index of oral functional capability is calculated in a four point capability level scale: normal, slightly reduced, considerably reduced, and none.