Study of Health in Pomerania (SHIP): a Health Survey in an East German Region

Epidemiology

Study of Health in Pomerania (SHIP): A health survey in an East German region. Objectives and design of the oral health section

Elke Hensel, Prof Dr Med DentVDietmar Gesch, Dr Med DentVReiner Biffar, Prof Dr Med Dent^/ Olaf Bernhardt, Dr Med Deni-TThomas Kocfier, Prof Dr Med DenfVChrisfian Splieth, PhD, Dr Med DenfV Gabriele Born, Dr Ing'/Ulrich John, Prof Dr PhiP

The goai ol the Study of Health in Pomerania ¡SHIP) was to estimate the prevalence ol diseases, identify potential risk factors in a defined region in northeast Germany, and examine the particular living situation of this population after the reunification ol East and West Germany. One of the main concerns ol the SHIP design is the analysis of the relationships between dental, medical, social, and environmentally and be- haviorally determined health tactors. SHIP is a cross-seotional study (clinical findings and sociologie interviews). The sample was drawn in two steps; Thirty-two communities in the region were selected, and within these communities, a simple random sample was drawn from residence registries, stratified by gender and age. The final sample included 4,310 males and females, aged 20 to 79 years.This is equivalent tc a participation rate of 68.87a. Data collection was completed in May 2001. The data collecticn and items comprised four parts: oral health examination, medical examination, health-related interview, and a health- and risk-factor-related questionnaire. The oral health examination included the teeth, periodontium, oral mueosa, morphology and function ofthe craniomandiPular system, and prosthodontics. The medical examination included biood pressure measurements; electrocardiography; echocardiography; carotid, thy- roid, and liver ultrasound examinations; neurologic screening; and blood and urine sampling. The computer-assisted interview consisted of questions on symptoms of disease, utilization of medical and dental services, self-assessment of general and oral health, health behavior and knowledge, and socioeconomic variables. The self-administered questionnaire comprised housing conditions, social network, work conditions, subjective well-being, and individual consequences of the German reunification. (Quiniessence Int 2003:34:370-378)

Key words: general health, Germany, health behavior, health examination and investigaticn survey, oral health, prevalence, socioeconomic factors

he background of the Study of Health in 'Associate Professor, Department of Orthodontics, Denial Schooi, TPomerania (SHIP) is the need for population- University of Greifswald, Greifswald, Germany. based health surveys encompassing a broad spectrum Âssistant Professor, Department of Orthodontics, Denial School, of health and lifestyle factors. Particularly in Germany, University of Gieifswald, Greifswald, Germany. most population studies focus on single diseases and 3p;ofesso( and iHead, Deparimeni of Prosthodontpcs, Dental Sohooi, University ot Greifswald, Greitswald, Germany. their risk markers: In medicine, this is most frequently 'Assistant Professor, Department of Operative Dentistry, Dental Schooi, cardiovascular disease, and in dentistry, most fre- University of Greifswaid, Greifswaid, Gerrnany quently coronal caries and its consequences. Âssociate Professor, Unit of Periodontoiogy, Dental Schooi, University ot The design of SHIP is complex, allowing multiple Greifswaid, Greifswald, Germany. anaiyses in terms of comorbidity and risk combina- Âssociate Professor, Department of Operative Dentistry, Dental Schooi, tions for crucial health problems, in addition to the University of Greifswald, Greifswald. Germany, prevalence estimations of diseases determining mor- 'Assistant Professor, institute ot Epidemioiogy and Social Medicine. bidity among adults in Vorpommern (West Pomer- University of Greitswald, Greifswald, Germany. ania) in northeastern Germany. In tbe future, the re- 'Professor and Head, Institute of Epidemiology and Social Medicine, sults of SHIP will be supplemented by cohort, University of Greifswald, Greitswaid, Germany. case-control, and intervention studies. The pilot pbase Reprint requests: Dr Thomas Kocher, Zentrum für Zahn-. Mund-, und Kieferheilkunde, Ernst-fulorilz-Aindt-Universität Greifswald, Rotgerber- of a SHIP follow-up study started at the beginning of siraße 8, t74e7 Greifswald, Germany, E-mail: [email protected] 2002, preparing the way for incidence estimations.

370 Volume 34, Number 5, 2003 • Hensei et al

The overall design of SHIP, its general objectives, and lected communities, subjects were drawn at random medical contents have been publisbed in a previous from ofl^icial inhabitant data files-wbicb include insti- report,^ Tbis report focuses on the design and objec- tutionalized persons-proportional to the population tives of tbe oral beaitb section of SHIP, size of eacb community and stratified by age and gender. Since tbere was just a proportion of 1,6% nonGerman citizens in the population, only individu- RESEARCH OBJECTIVES AND STUDY DESIGN als with German citizenship and main residence in the study area were included. From the entire study popu- The oral health section pursued the foiiowing research lation of 212,157 inbabitants, 7,008 subjects were goals: sampled, with 292 persons of each gender in each of the 12 five-yearag e strata. This sample size was calcu- • To determine current age- and gender-related preva- lated on the basis of pre-existing prevalence data, ' lences of oral diseases in persons aged 20 to 79 years Tbe collection of personal data was supported by (crown caries, root caries, periodontal disease, dis- the residents' registration offices. The sampling proce- eases of the oral mucosa, dysgnathic conditions and dure followed strict data security protocols. The initial orofacial deformities, tooth loss, prosthetic status, sample size of 7,008 persons was reduced by 741 neu- craniomandibular dysfunctions) tral dropouts (126 had died and 615 had moved • To coEect population-based information on the self- away). Five additionai participants were also classified assessment of oral health and esthetics, satisfaction as neutral dropouts due to severe medical problems with oral health, oral care habits, locus-of-control for that did not allow for an oral examination, oral health, utilization of dental services and atten- A response rate of 70% was intended. Given this, dance patterns, satisfaction with dental care, percep- the sample was 2,15% of the 20- to 79-year-old popu- don of para- and dysfunctions, and problems and pain lation in the region, Tbe overall response rate was in tbe craniomandibular system (dental interview) 68,8% (n = 4,310), With exclusion of the oldest age • To test for correlations between clinical variables group (70-F), a mean response rate of 71,2û,'b was at- and behavioral and socioeconomic variables tained (Figs 1 and 2), • To test for correlations between dental and medical Reasons given by 1,683 nonresponders (839 men, morbidity, including a genetic examination 844 women) for declining to participate in the study • To identify potential risk indicators for caries, perio- were recorded. In tbe younger age groups, the pre- dontitis, tooth loss, and craniomandibular dysfunc- dominant reasons given by both men and women tions were "no time" and "not interested," With increasing • To modify health programs based on the results and age, the frequency of the answers "adequate medical use the data in follow-up, case-control, and inter- care," "health reasons," and "fear of the results" also vention studies. increased. The latter two reasons were most frequently given by women in the oldest age group. Sample and study area Oral health data collection procedure and criteria A sample of 7,008 women and men aged 20 to 79 years was drawn from the cities of Greifswald, Stralsund, and The criteria for the oral-bealth data collection and ex- Anklam, and from 29 communities in tbe surrounding amination procedures had been developed in collabo- region, which is part of West Pomerania (2,024 km^), ration with local, national, and international experts the most northeasterly region of Germany, on the and tested during three pilot phases, Baltic Sea at the north and the Polish border in tbe A detailed description of procedures and criteria east. West Pomerania makes up tbe northeastern part for collecting medical data has been published by of Mecklenburg-Vorpommern, one of tbe 16 federal Jobn et al,^ German states, Mecklenburg-Vorpommern is, with 79 Data collection began in October 1997 and ended inhabitants/Ion^, the state with the lowest population in May 2001, density in Germany (For comparison: Germany has an The oral beaitb examinations included the teetb, average of 229 inhabitants/km'),' periodontium, oral mucosa, morpbology (alignment Tbe sample selection was carried out in two steps. and occlusion of teeth) and function of the cran- First, of tbe tbree districts in the region, the three iomandibular system, and prostbodontics (Table 1). cities (17,076 to 65,977 inhabitants) and 12 towns Additionally, an online interview was conducted with (1,516 to 3,044 inhabitants) were selected, and of the questions about knowledge relevant for the mainte- small towns (less than 1,500 inhabitants), 17 out of 97 nance of oral health, the self-assessment of oral health, were drawn at random. Second, from each of the se- utilization of dental services, pain and dysfunctions in

•fi IntprnatJonal 371 Hensel et ai

recorded from all teeth except the third moiars (64 TABLE 1 Oral health items examined in SHIP risk surfaces). Oral health item Parameters Enamel caries, dentin caries, fillings, secondary Caries caries, and missing teeth were registered by surface. Coronai Decayed, missed, filled teeth ¡DMF-T) The decayed, missing, and filled surface {DMFS) index Decayed, missed, filled surfaces and decayed, missing, and filled tooth {DMFT) index were calculated according to World Health Organi- Dental root Root Caries index (RCI)' zation {WHO) criteria." Test evaluations in the pilot Periodontium Piaque Index, Bieeding Index, probing depth, attachment ioss. gingivai recession. phases and while the study was ongoing showed no furcation invoiuement,"•'•"'•'^ Community statistically relevant right-left differences, meaning the Periodontal index (CPI]^"'^ half-mouth method presents a realisfic view of caries Orai mucosa Findings recorded according to 1tie prevalence (Fig 3). Cerman Cancer Reiief Manuai'''^ Function ot cranio- Tooth Wear Index," classification of dyna- Root caries. Root caries was defined as cementum- mandibular system mic occlusion, parameters of craniomandi- dentin caries and recorded in a full-mouth manner, ex- buiar dysfunction,"^^" Dysfunction lnde>!'*" cluding the third molars. The diagnostic criteria were Orthodontics Alignment and occlusion of teetb. softening of or lesions in the cementum or root dentin graded recording of individuai symtoms^'-^^ and fillings in the root area, as proposed by the Prosthodontics Fixed and removable dentures, design and mater ials'-^'^"-'^ WHO." Discolorations without softening were not judged as carious, nor were brushing or wedge-shaped Tlie eiamination parameters were defined in an examiner's handbook anfl were entered online into a compiiteri!ed dala base. defects. In addifion, gingival recessions were recorded Mean time required per participant lo collect data was 35 min (SD = 13.0). in order to calculate the root caries index.' Periodontium. All periodontal findings were registered according to the half-mouth method (quadrants 1 and 4, or quadrants 2 and 3). In all examinations, the periodontal probe PCP" was used (graduated at 3 mm, 6 mm, 8 mm, 11 mm). Probing depth, gingival re- the craniomandibular system, perception and evalua- cession, and attachment level were taken for all teeth tion of signs of periodontal disease, and perception of {except third molars) in the test quadrants. Measure- parafunctions. ments were taken distobuccally, mesiobuccally, mid- At the same visit as the oral examinations, a stan- buccally, and midpalatally or midlingually. Further, all dardized interview of 21 questions was conducted, first molars in the maxilla and mandible were checked and the data entered online. for furcation involvement, which was then registered The examinations were conducted by dentists who by degree of involvement. were trained und certified in cariology, periodontoi- Visual inspection and probing determined the pres- ogy, orthodontics, prosthodonties, and gnathology, ence or absence of plaque and calculus on test teeth 1, and the interviews were conducted by trained and cer- 3, and 6 in the test quadrants, and the relative fre- tified dental assistants. quency of presence or absenee was calculated per par- A data entry program was used by a trained dental ticipant, if a test tooth was missing, the distal adjacent assistant during the examination and investigation. tooth was examined instead. The examination parameters were defined in an ex- Orai mucosa. The examination included all areas aminer's handbook and were entered online into a of the oral eavity-also the tongue and lips-and was computerized data base. conducted according to the manual of the German The time required per participant to collect data Cancer Association, entitled "Early diagnosis of neo- was 35 min on average {SD = 13.0). plasmas in the maxillofacial area by the praeticing Al! examinafions were conducted in the dental ex- dentist."'^ The seated patient was examined with two amination room with professional illumination and oral mirrors. If suspicious alterations were discovered, without the use of a saliva ejector or air ¡et Two ex- fhe participant was informed immediately and advised aminer teams worked simultaneously in the examina- to seek help at a specialized cHnic. tion centers in Greifswald and Stralsund. Signs and symptoms of craniomandlbuiar disor- Below, some of the items of the oral health exami- ders. The clinical analysis of function included pain nation are briefiy explained. upon pressure to the masticatory muscles and joints; Coronal caries. From the coronal area, findings deviations, defiections, and limitations during mouth were obtained visually and with a periodontal probe opening; and the occurrence of pain and/or discom- {PCP 11, Hu Friedy) in a half-mouth design on the fort upon defined movements or palpation. The col- right or left side in alternate pafients. Findings were lected data also allowed the calculation of the

372 Volume 34, Number 5, 2003 Hensel el a[

Fig 1 Female partioipatory behavior in SHIP by age group. O Respondents D Nonrespondents

114 129 14/ 131 1ti9 358

361 399 396 430 354 253

20-29 30-39 40-^9 50-59 60-69 70+

Age group

Fig 2 Male pariioipatory behavior in SiHIPby age group. D Respondents D Nonresponderts

- 164 154 182 162 14U 187 -

- —

311 347 356 378 404 321

Fig 3 Box plots of DMFS number (maxi- mal score 64) recorded in a half-mouth design (right vs left]. No signlUcant differ- ence between sides was found (P = .07, Mann-Whitney test).

1,893 1,895 1/4 (right) 2/3 (ieft) Quadrant

373 • Hensel et al

Helkimo dysfunction index"'* and axis 1 of the • Training of SHIP dentists by the appropriate special- Researcft Diagnostic Criteria for tetnporomandibular ists from the University of Greifswald Dental disorders (RDC),-' In addition, the occurrence of cer- School/Dental Clinic, Double examinations were vical wedge-shaped defects and occiusal tooth wear conducted of patients and students of the dental was registered by means of a tooth-wear index,'' The school using the SHIP data sheets. The standard of tooth-guided dynamic occlusion was examined with reference was the respective specialist, and training 8 pm shimstock foil in an occiusal range of 3 mm to was conducted in the subdisciplines: cariology, peri- the right and left in laterotrusion, and the protrusion odontology, orthodontics, functional diagnostics, likewise examined up to incisai edge contact of the in- and prosthodontics. The training duration was a cisors or maximally to a protrusion extent of 5 mm. total of 4 to 8 weeks. After introductory instruction All tooth contacts and balance and hyperbalancc con- with slides, double collection of data from patients tacts during these movements were registered. with much rarer oral mucosa findings and root Orthodontics, The collection of orthodontic data Is caries was conducted throughout the training pe- sometimes limited by the number of teeth already miss- riod; on these two topics and functional diagnostics, ing. In SHIP, orthodontic status was considered not diagnostic seminars were continually held. Eight recordable when three or more teeth per sextant were SHIP dentists were involved over the entire exami- already missing in two or more sextants of dentition nation period, (two anterior and four posterior tooth regions}, regard- • Simultaneous training of three dental assistants (to less of whether or not the gaps bore prosthetic restora- document findings, carry out interviews, prepare tions. Third molars were not included in the evaluation. workplace, conduct hygiene regimen). The occiusai status was registered according to Angle's classification-' in the canine and first molar areas (neu- As a result of this preparatory phase, the sequence tral, distal-premolar width, distal 1 premolar width, of steps in data collection, the data sheets, and the mesial). The following symptoms were individually manual were optimized. recorded (graded either as present or absent): frontal For all tooth-related examinations, findings from and lateral crowding, ectopic position of canines, the prosthetic examination sheet, recorded at the be- widely spaced teeth without tooth loss, frontal and lat- ginning of the clinical exam, were used to check the eral crossbite, buccal nonocclusion, excessive overjet plausibility of later entries. Index calculations were and overbite, edge-to-edge bite, open bite, reversed in- added to the analysis program. cisal step, and retruded position of maxillary incisors, All SHIP examination and interview items and self- Prosthodontics. The collection of prosthetic data answered questionnaires were tested in three pilot was designed as a ftill-mouth examination, including phases (testing of examination items, sampling proce- the registration of tooth-loss rate for the entire denti- dure, complete examination inciuding time analyses, tion. The parameters of the examination were type participants' acceptance of the program as a whole). and extent of prosthetic restorations, materials used (especially for occiusai restorations), type of anchor- Certification age, number and location of implants, and the date of the most recent prosthetic treatment. This examina- The certification of SHIP dentists, which consisted of tion design enabled prevalence estimations, determi- double examinations of 10 test participants for the nation of degree of prosthetic restoration, and most sections cariology, periodontology, prosthodontics, importantly, analyses of relationship to other oral and functional diagnostics, took place before the ac- health and socioeeonomic factors. tual start of the data collection period. In the field of oral mucosa diseases, a series of 70 slides of the diseases to be recorded in the SHIP program was shown QUALITY ASSURANCE AND QUALITY CONTROL twice several days apart in different sequences for diagnosis. The standard of reference consisted of the The SHIP quality assurance and control measures written diagnoses of the specialists. In orthodontics, were conducted in two phases: the study preparatory 30 model pairs with complex dysgnathic symptoms phase and the data collection phase. had to be evaluated twice, several days apart. Here, The following steps were carried out in the prepara- too, the standard of reference consisted of the special- tory phase : ist's diagnosis. Further similar certification took place later in the study. However, the number of test partici- • Creation of data sheets for all parts of the oral exam- pants examined was reduced to five. ination and the interview, and production of a de- The quality of data collection and entry of the den- tailed manual for examiners and interviewers. tal interview data was tested with tape recordings, to

374 Volume 34, Number 5, 2003 • Hensel et al

Fig 4 Quarter-year bOK plots of average attachment loss over entire observation period ol SHIP. The median is not subjecl to any large tiuctuations, with the exoep- tion of the fourth quarter of ihe year 2000. Figure 5 sfiows that in this quarter, much younger participants were examined, which makes the deviation plausibie " = outliBfs. • = extreme values.

= 15B 230 406 305 355 403 389 296 326 281 168 104 52 52 44 1997 Kl 1998(1-4) t999(1-4) 2000 (t^] 2001(1,2) Quarters of years (appearing seguentiaily)

Fig 5 Ages of SHIP participants examined per quarter year. The median does not exhibit any large fluctuations, with the exception of the tourtli quarter of the year 2000, in whioh a much younger age group was examined. This wiii be re- tlected in all age-dependent oral parameters.

N-158 230 406 305 355 4Q3 389 29B 326 231 158 104 52 52 44 1997(4)1998(1^) 1999(1-4) 2000(1-4) 2001(1,2) Quarters of years (appearing sequentially)

which the participants had given informed consent. tested in a similar fashion (1,217 single entries per par- Only 11.6% of the participants refused to be tape ticipant). For every 18 controlled-tape recordings per recorded. Every 10th interview, computer and tape dental assistant, only one entry error was found. data were checked for agreement and against the manual for correct conduction of the interview. Certification resuits During the entire course of the study, the dental assistants conducting interviews made an average of 0.05 For coronal caries (DMF-S number, 128 individual mistakes per interview (minimum 0.0; maximum 0.3), items per test person), there was a Cohen-Kappa^^ in- This result is based on 427 controlled interviews. The traexaminer reliability coefficient of 0,9 to 1.0; the in- entry quality of the clinical oral and denial data was terexaminer reliability was 0.93 to 0.96.

Q..:.... 375 • Hensei et al

Categories of attachment loss (mm) a 0-3 D4-6 BT-Ö «9+ 2,6 2 2 1,3 1.2 2.9 1,8 1,2 1,0 2,0

8,6 8,5 18,3 80 Ï3,O 22,3 34,2 7,t 4,0 2T,5 JSá a' 60 nJ ,Q. •1 40 39 8 70.3 70,0 78,2 o7.1 75,6 76,8 75,7 72.0 D.

t 2 3 4 5 6 7 8 Tota (991] 927) (346) (378) 228) (157) 262) 280) (3,56 3)

Fig 6 Examiner-related representation of relative trequency ot tiie different categories ot attaofiment loss on a site basis. The number ol participants examined (N) is gi^ien after the observer number (1 to 8). The column at Ihe tar right depicts the relative frequencies in liie total study sample.

Certification resulted in excellent reliabiliti', Tbis is showed a range of kappa values from 0.68 to 0,91 and also true of tbe prostbetic examinations in terms of interexaminer reliability varied from 0,53 to 0,74, For the full-moutb recording of tooth loss rate (MT), and tootb-guided dynamic occlusion measurements, kappa also the certification results for oral mucosa diseases, values for intraexaminer reliability ranged from 0,62 to Tbe test results for the 30 orthodontic model pairs 0,88 and for interexaminer reliability from 0,58 to 0,79, sbow examiner-related differences, but all are in tbe With tbe test-patient group, higb examiner reliability marked to strong reliability range (Coben-Kappa 0,66 to was reacbed for root caries and diseases of the oral mu- 0.81) in terms of both intra-and extraexatitiner reliability. cosa. As the prevalence of these findings was relatively Attachment loss is one of the best indicators to low, additional diagnostic training for these diseases characterize periodontal beaith status. Double exatni- and functional parameters was conducted in seminars nations (full moutb, 4-point measurement) of four pe- with suitable patients and photograpbic material. riodontally diseased test patients yielded an intraclass As of the study's start, all oral examination metbods correlation"'^ of 0,82 to 0,91 per examiner, and tbe remained uncbanged. Quality assurance and control interrater correlation was 0,84, during the study period comprised semiannual interim Interobserver variability for diagnosing signs of analyses, renewed certifications, and specialist semi- craniomandibular disorders was assessed in five cali- nars. These interim evaluations checked for implausi- bration sessions using a total of 22 volunteers (7 of ble examiner differences, itnplausibilities and trends in them with functional complaints). For the measure- the different items, frequency of entering "data not ment of the vertical ¡aw movements in the final cali- collectible," undefined missing entries, and examiner bration, an intraclass correlation coefficient of 0,95 for differences of tbe mean examination time (see Figs 4 all examiners was found. Kappa values for detceting to 6 for attacbment loss). tenderness of tbe masticatory muscles and tbe tem- Results of quality management as a wbole were re- poromandibular joint during palpation varied from ported semiannually to an external Data Safety and 0,53 to 0,63 comparing all examiners witb one as a Monitoring Committee (DSMC), in written form and standard of reference. In detecting joint sounds, the presented in separate worksbops (8 DSMC reports final calibration session delivered kappa values from during tbe course of the study). 0.71 to 1.0 in comparing all examiners with a standard By mid-October 2000, SHIP bad examined 4,142 of reference. study participants (DSMC report No. 7), This total data Fourteen dentate volunteers were examined twice pool was cbecked for undefined missings and data out- for the reproducibility of cervical wedge-shaped defects side tbe plausibility areas for tbe eigbt data sheets and and occlusal wear facets, Intraexaminer reliability the sheet containing personal identification information.

376 Volume 34, Number 5, 2003 • Hensel et al

Incorrect data sets on the nine sheets resulted with REFERENCES a relative frequency of 0.0% to 0.9%. The frequency of faulty single items per examination sheet fluctuated be- 1. John U, Greiner B, Hensel E, et al. Study of heaifh iti tween 0.0% and O.Wo (undefined missings, implausihie Pomerania (SHIP): A health examinatioti survey in ati east German region: Objectives and design, Soz,-Präventivmed- single items). Data collecfion was completed in May izin 2001;46;186-194. 2001, with a total of 4,510 study participants. 2. Statistisches Bundesamt. Statistisches |ahrbuch 1997. The measures deseribed here contributed to quality [Statistical Yearbook 1997J Stuttgart: Metzler-Pocschel assurance in an epidetniologic study, but their com- 1997. plexity also demanded adequate consideration during 3. Eitiwag J, Keß K, Reich E. Oral Health in Germany: Diag- the planning phase. nostic Criteria and Data Recording Manual. Köln: Deut- scher Ärzte-Verlag, 1992. 4. Micheelis W, Bauch J. Mundgesundheitszustand und -ver- halten in Westdeutschland. Ergebtiisse des nationalen IDZ- OUTLOOK Survey 1989. ¡Oral health status and oral health behavior in West Germany, results of the national lDZ survey]. Köln; The SHIP is a representative cross-sectional study of Deutscher Ärzte-Verlag, 1991, the adult population of the Vorpommern region in 5. Micheelis W, Bauch J. Mundgesundheitszustand und -ver- Germany. It realizes an interdisciplinary pool of data halten in Ostdeutschland. Ergebnisse des IDZ-Ergänzungs- from the fields of medicine, dentistry, and the social survey 1992. [Oral health status and oral health behavior in East Germany, results of the 1992 IDZ supplementary sur- sciences. Data checking and editing has been com- vey|. Köln; Deutscher Ärzte-Vcdag, 1993. pleted, and the data analysis began in 2001. 6. Micheeiis W, Reich E. Dritte Deutsche Mu nd gesund he its- Based on the medical, dental, and socioeconomic Studie (DMS III) Ergebnisse, Trends, Prob 1 emanalysen auf data from the study, the autfiors expect that a complex der Grundlage bevöllierungsreprasentativer Stichproben in regional health diagnosis and mulfiple eontext anaiy- Deutschland 1997, [Third German Oral Health Study (DMS III): Results, Trends, Problem Analyses Based on Popu- ses between examination items can be processed. The lationally Representative Samples in Germany 1997]. Köln: use of the results in case-control and intervention Deutscher Ärzte-Verlag, 1999. studies and in cooperation with other projects is possi- 7. Application of the International Classification of Diseases ble. The pilot phase for a 5-year follow-up of SHIP to Dentistry and Stomatology (lCD - DA¡, ed 3. Geneva, began in 2002. Switzerland. World Health Organization, 1995. 8. Oral Health Surveys: Basic Methods, ed 4. Geneva, Switzerland: World Health Organization, 1997. ACKNOWLEDGMENTS 9. Katz RV, Hazen SP, Chilton NW, Murrmia RD. Prevalence and intraorai distribution of root caries in an adult population. Caries Res 1982;16;265-271. The authors would like to Ihank Dr Amje Hartell. Dr Georg Meyer, Dr Wolfgang Sümnig, Dr Almiiih Wenetiadis, Dr Christian Schwahn, 10. Badersten A, Nilveus R. Egelberg ]. Reproducibility of prob- Dr Jan Lüdemann, and Dr Sybille Sauer (Dental School, University ing attachment level measurements. ¡ Clin Periodontoi of Greifswald. Greifswald. Germany); Dr Eberhard Greiser (Bremen 1984;J 1:475-485. Institute for Prevention Research and Social Medicine, Bremen, 11. Fleiss [L. Measuring agreement between two judges on the Germany); Dr tjrsula Haertel (Human Studies Center, University of presence or absence of a trait Biometrics 1975 ;31:651-659, Munich, Munich, Germany); Dr Hans-Wemer Hcnse (Institute of 12. Fleiss JL, Mann J, Paik M, Goultchin J, Chilton NW. A study Epidemiology and Social Medicine. Univer.sity of Muenster, of inter- and intra-examiner rcliahility of pocket depth and Muenster. Germany I; and Dr Johannes Haerting (Institute of Medical attachment level. J Periodontal Res 1991;26;122-128. Epidemiology, Biometry, and Medical Informatics. University of 13. Grossi SG, Duniord RG, Ho A, Koch G, Machtei EE, Halle-Winenberg, Halle, Germany) for their help in conducting the Genco RJ. Sources of error for periodontal probing mea- stndy and assistance in writing this puper. surements. J Periodontal Res 1996;31;330-336. This work is part of the Community Medicine Research net 14. Cutress TW, Ainamo J, Sardo-Infirri J. The community (CMR) of the University of Greifswald, Germany, which is ñinded by periodontal index of treatment needs (CPITN) procedure the Federal Ministry of Education and Research (grant No. ZZ9603], for population groups and individuals. Int Dent J 1987;37: the Ministry of Cultural Affairs, and the Social Ministry of the Federal 222-233. State of Mecklenburg-VoTpommem, The CMR encompasses several research projects ihai share data of the popuiùtion-based Study of 15. Holmgren CJ, Corbet EF, Relationship between periodontal Health in Pomerania (SHIP; www.niedizin.uni-greifswald.de/cm). parameters and CPITN scores. Community Dent Oral Epidemiol 1990;18;322-323.

377 • Hensel et al - ADVANCED 16. Reichart P, Schulz P, Walz Ch, et al. Früherkennung von Neubildungen im Kiefer-Gesichtsbereich durch den prak- REMOVABLE PARTIAL DENTURES tizierenden Zahnarzt. [Early diagnosis of neoplasmas in the maxiilofacial area by the practicing dentist]. Bonn: lames S, Brudvik, DDS, FACP Deutsche Krebshilfe, 1993, 17 Helkimo M. Studies on function and dysfunction of the masticatory system, 11, Itidex for anamncatic arid clitiical dys- his book is the first to set standards of care for function and occlusal state. Swed Dent J 1974;67:I01-121, Tthe comprehensive management of the partial- IS, Helkimo M, Epidemiological surveys of dysfunclion of the ly edentulous patient who requires some fonn of masticatory system. Oral Sei Rev 1976;7:54-69. removable restoration. It is written for graduate 19, Hugoson A, Bergendal T, Eldeldt A, Helldmo M, Prevalence prosthodontic students and general practitioners and severity of incisai and occlusal tooth wear in an adult Swedish population. Acta Odontol Scand 1988;46:255-265. who are ready to take a more sophisticated look at 20. Okeson P], Orofacial Pain. Guidelines for Assessment, this treatment modality. To produce the state-of- Diagnosis, and Management, Chicago: Quintessence, 1996: the-art retnovahle partial denture, readers are chal- 23-24, lenged to use the same treatment-planning consid- 21. Angle EH, Classification of malocdusion. Dent Cosmos erations they would for the fixed partial denture- 1899:41:248-264, soft tissne management, caries control, periodontai 22. Klink-Heckmann U, Bredy E. Kieferorthopädie, 3. Auflage support, orthodontic therapy, and implant place- [Orthodontics, ed 3], Heidelberg: JA Barth Leipzig, 1990: ment—and to direct the laboratory phases and con- 97-98,131-206, trol the critical steps in design and construction. 23. Schmuth G, Kieferorthopädie I, Praxis der Zahnheilkunde 11, ed 3, [Orthodontics I. The Practice of Dentistry, ed 3], This tnonograph guides readers step hy step from München: Urban & Schwarzenberg, 1994:39-40, patient evaluation to completion of the state-of- 24, Eichner K, Über die Gruppeneinteilung der Lückengebisse the-art remov- fur die Prothetik, [Grouping of partially edentulous arches able partial den- in prosthetics). Dtsch Zahnàrztl Z 1955;10:1831-1834, ture, with supple- 25, Kerschbaum T, Micheelis W, Fischbach H, von Thun P, mentary chapters Prothetische Versorgung in der BRD. Eine bevöl- on repairs, preci- kerungsrepräsentative Untersuchung bei 35 - 54 ¡ährigen, [Prosthetic care in the FRG, A populationally representative sion attachments, survey of 35- to 5't-year-olds]. Dtsch Zahnärzti Z 1994; ADVANCED Special prosthe- 49:990-994, REMOVABLE ses, and use of 26, Kerschbaum T, Micheelis W, Fischbach H. Prothetische PARTIAL implants. Versorgung in Ostdeutschland - Eine bevölkerungsrepräsen- tative Untersuchung bei 35 - 54 jährigen. [Prosthetic care in DENTURES fomier East Germany, A popuiationally representative survey of 35- to 54-year-olds]. Dtsch Zahnärzti Z 1996;51:452-455, 27. Dworkin SF, Le Resche L, Research diagnostic criteria for temporomandibular disorders: Review, criteria, examina- 168 pages; tions and specifications, critique. J Craniomandib Diaord 132 iliustrations; ISBN 0-86715-351-2; 1992;6:301-355. US$4S 28, Fleiss JL, Statisticai Methods for Rates and Proportions, ed 2, New York: Wiley & Sons, 1981, Contents 1. Patient Evaluation, Diagnosis, and Treatment Planning 2. Removable Partial Denture Design 3. Mouth Preparation 4. Final Impressions and Master Casts 5. Laboratory Construction ofthe Framework 6. Establishing the Tooth-Frame Relationship 7. Completioti of the Removable Partial Denture 6, Repairs, Additions, and Relines 9, Special Prostheses 10, Precision Attachments 11, Implants for Removable Partial Dentures

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