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SAFETY FIRST
COMMENTARIES
neuroscientists have demonstrated that specific elements (number of interrelated ideas, complexity of written language) in early adulthood writing samples (medical school admission essays) can be used to predict the development of cognitive impairment in later life in men and women, thus confirming this construct.4 It is, therefore, just as plausible to suggest that some components of neurodegenerative disease, which takes decades to develop fully, may have precipitated the severe dental disease by hampering afflicted individuals from following routine oral hygiene procedures over a significant portion of their lifetime.5 Arthur H. Friedlander, DMD Associate Chief of Staff Director of Graduate Medical Education VA Greater Los Angeles Healthcare System and Professor-in-Residence Oral and Maxillofacial Surgery UCLA Dental School and Director, Quality Assurance Hospital Dental Service Ronald Reagan University at California Medical Center Los Angeles 1. The ARIC investigators. The Atherosclerosis Risk in Communities (ARIC) study: design and objectives. Am J Epidemiol 1989;129(4): 687-702. 2. Stein PS, Desrosiers M, Donegan SJ, Yepes JF, Kryscio RJ. Tooth loss, dementia and neuropathology in the Nun Study. JADA 2007;138(10):1314-1322. 3. Snowdon DA, Kemper SJ, Mortimer JA, Greiner LH, Wekstein DR, Markesbery WR. Linguistic ability in early life and cognitive function and Alzheimer’s disease in late life: findings from the Nun Study. JAMA 1996;275(7):528-532. 4. Engelman M, Agree EM, Meoni LA, Klag MJ. Propositional density and cognitive function in later life: findings from the Precursors Study (published online ahead of print Sept. 13, 2010). J Gerontol B Psychol Sci Soc Sci 2010;65(6):706-711. doi:10.1093/geronb/gbq064. 5. Friedlander AH, Jarvik LF. The dental management of the patient with dementia. Oral Surg Oral Med Oral Pathol 1987;64(5):549-553.
Authors’ response: We wish to thank Dr. Friedlander for his comments regarding our investigation of cognitive function and oral health in the Atherosclerosis Risk in Com-
munities (ARIC) study. Specifically, he proposes that early stages of neurodegenerative diseases, occurring years before ARIC participants enrolled in the study, might have hampered oral hygiene, thereby precipitating oral disease. He cites findings from the Nun Study in which “idea density,” a measure of linguistic ability assessed at 22 years of age, was correlated with low cognitive test scores and neuropathologically confirmed Alzheimer disease later in life.1 In that study, participants were 75 to 91 years old at their first cognitive assessment, yielding measures of impaired memory function that were related to low idea density earlier in life.1,2 In contrast, ARIC participants completed their first cognitive assessment at a younger age (age range: 47 to 70 years). A previous ARIC study reported that changes in cognitive function over the sixyear interval (between 1990-1992 and 1996-1998) were minimal.3 In our separate study, we found that a six-year cognitive decline in both memory and executive function was associated with an increased likelihood of complete tooth loss, an indicator of past dental disease. We also found that greater decline in executive function, although not memory function, was associated with infrequent tooth brushing, gingival inflammation or greater plaque deposit, but the associations were relatively weak.4 We are aware of the possibility that low cognitive ability in early life contributes to adverse oral health by hampering oral hygiene. Furthermore, low cognitive ability in early life may limit education achievement and income, thus impairing selfcare, leading to poor oral health.5 However, in our study, cognitive ability was not measured in young adulthood. Therefore, impacts of cognitive trajectories on lifetime oral hygiene procedures remain speculative and, as we conclude in our article, it is plausible that causal mechanisms operate in both directions.
Gary D. Slade, DPH, PhD Professor Supawadee Naorungroj, DDS, MS, PhD Research Assistant Department of Dental Ecology School of Dentistry University of North Carolina at Chapel Hill 1. Snowdon DA, Kemper SJ, Mortimer JA, Greiner LH, Wekstein DR, Markesbery WR. Linguistic ability in early life and cognitive function and Alzheimer’s disease in late life: findings from the Nun Study. JAMA 1996;275(7):528-532. 2. Riley KP, Snowdon DA, Desrosiers MA, Markesbery WR. Early life linguistic ability, late life cognitive function, and neuropathology: findings from the Nun Study. Neurobiol Aging 2005;26(3):341-347. 3. Knopman D, Boland LL, Mosley T, et al. Cardiovascular risk factors and cognitive decline in middle-aged adults. Neurology 2001;56(1):42-48. 4. Naorungroj S, Slade GD, Beck JD, et al. Cognitive decline and oral health in middleaged adults in the ARIC study (published online ahead of print July 19, 2013). J Dent Res 2013;92(9):795-801. doi:10.1177/0022034513497960. 5. Sabbah W, Watt RG, Sheiham A, Tsakos G. The role of cognitive ability in socio-economic inequalities in oral health. J Dent Res 2009; 88(4):351-355.
SAFETY FIRST
Ms. Kathy Eklund and Dr. Donald Marianos’ December guest editorial, “Providing a Safe Environment for Dental Care in an Era of Infectious Diseases” (JADA 2013;144[12]:13301332), highlights an issue for dentists that must be continually addressed. In most settings in the United States and in the world, all of the Centers for Disease Control and Prevention and Organization for Safety, Asepsis and Prevention recommendations can be followed. The issue is meticulous vigilance. However, many American Dental Association–member dentists travel to remote locations to provide volunteer dental treatment. In some locations, electricity is not available and autoclaves are not present. What methods of sterilization are being used? What recommendations can researchers give us as options? Our ADA promotes volunteering; please give us some practical, effective alternatives to an autoclave.
JADA 145(4)
John Reed, DMD New Wilmington, Pa.
http://jada.ada.org April 2014
327
neuroscientists have demonstrated that specific elements (number of interrelated ideas, complexity of written language) in early adulthood writing samples (medical school admission essays) can be used to predict the development of cognitive impairment in later life in men and women, thus confirming this construct.4 It is, therefore, just as plausible to suggest that some components of neurodegenerative disease, which takes decades to develop fully, may have precipitated the severe dental disease by hampering afflicted individuals from following routine oral hygiene procedures over a significant portion of their lifetime.5 Arthur H. Friedlander, DMD Associate Chief of Staff Director of Graduate Medical Education VA Greater Los Angeles Healthcare System and Professor-in-Residence Oral and Maxillofacial Surgery UCLA Dental School and Director, Quality Assurance Hospital Dental Service Ronald Reagan University at California Medical Center Los Angeles 1. The ARIC investigators. The Atherosclerosis Risk in Communities (ARIC) study: design and objectives. Am J Epidemiol 1989;129(4): 687-702. 2. Stein PS, Desrosiers M, Donegan SJ, Yepes JF, Kryscio RJ. Tooth loss, dementia and neuropathology in the Nun Study. JADA 2007;138(10):1314-1322. 3. Snowdon DA, Kemper SJ, Mortimer JA, Greiner LH, Wekstein DR, Markesbery WR. Linguistic ability in early life and cognitive function and Alzheimer’s disease in late life: findings from the Nun Study. JAMA 1996;275(7):528-532. 4. Engelman M, Agree EM, Meoni LA, Klag MJ. Propositional density and cognitive function in later life: findings from the Precursors Study (published online ahead of print Sept. 13, 2010). J Gerontol B Psychol Sci Soc Sci 2010;65(6):706-711. doi:10.1093/geronb/gbq064. 5. Friedlander AH, Jarvik LF. The dental management of the patient with dementia. Oral Surg Oral Med Oral Pathol 1987;64(5):549-553.
Authors’ response: We wish to thank Dr. Friedlander for his comments regarding our investigation of cognitive function and oral health in the Atherosclerosis Risk in Com-
munities (ARIC) study. Specifically, he proposes that early stages of neurodegenerative diseases, occurring years before ARIC participants enrolled in the study, might have hampered oral hygiene, thereby precipitating oral disease. He cites findings from the Nun Study in which “idea density,” a measure of linguistic ability assessed at 22 years of age, was correlated with low cognitive test scores and neuropathologically confirmed Alzheimer disease later in life.1 In that study, participants were 75 to 91 years old at their first cognitive assessment, yielding measures of impaired memory function that were related to low idea density earlier in life.1,2 In contrast, ARIC participants completed their first cognitive assessment at a younger age (age range: 47 to 70 years). A previous ARIC study reported that changes in cognitive function over the sixyear interval (between 1990-1992 and 1996-1998) were minimal.3 In our separate study, we found that a six-year cognitive decline in both memory and executive function was associated with an increased likelihood of complete tooth loss, an indicator of past dental disease. We also found that greater decline in executive function, although not memory function, was associated with infrequent tooth brushing, gingival inflammation or greater plaque deposit, but the associations were relatively weak.4 We are aware of the possibility that low cognitive ability in early life contributes to adverse oral health by hampering oral hygiene. Furthermore, low cognitive ability in early life may limit education achievement and income, thus impairing selfcare, leading to poor oral health.5 However, in our study, cognitive ability was not measured in young adulthood. Therefore, impacts of cognitive trajectories on lifetime oral hygiene procedures remain speculative and, as we conclude in our article, it is plausible that causal mechanisms operate in both directions.
Gary D. Slade, DPH, PhD Professor Supawadee Naorungroj, DDS, MS, PhD Research Assistant Department of Dental Ecology School of Dentistry University of North Carolina at Chapel Hill 1. Snowdon DA, Kemper SJ, Mortimer JA, Greiner LH, Wekstein DR, Markesbery WR. Linguistic ability in early life and cognitive function and Alzheimer’s disease in late life: findings from the Nun Study. JAMA 1996;275(7):528-532. 2. Riley KP, Snowdon DA, Desrosiers MA, Markesbery WR. Early life linguistic ability, late life cognitive function, and neuropathology: findings from the Nun Study. Neurobiol Aging 2005;26(3):341-347. 3. Knopman D, Boland LL, Mosley T, et al. Cardiovascular risk factors and cognitive decline in middle-aged adults. Neurology 2001;56(1):42-48. 4. Naorungroj S, Slade GD, Beck JD, et al. Cognitive decline and oral health in middleaged adults in the ARIC study (published online ahead of print July 19, 2013). J Dent Res 2013;92(9):795-801. doi:10.1177/0022034513497960. 5. Sabbah W, Watt RG, Sheiham A, Tsakos G. The role of cognitive ability in socio-economic inequalities in oral health. J Dent Res 2009; 88(4):351-355.
SAFETY FIRST
Ms. Kathy Eklund and Dr. Donald Marianos’ December guest editorial, “Providing a Safe Environment for Dental Care in an Era of Infectious Diseases” (JADA 2013;144[12]:13301332), highlights an issue for dentists that must be continually addressed. In most settings in the United States and in the world, all of the Centers for Disease Control and Prevention and Organization for Safety, Asepsis and Prevention recommendations can be followed. The issue is meticulous vigilance. However, many American Dental Association–member dentists travel to remote locations to provide volunteer dental treatment. In some locations, electricity is not available and autoclaves are not present. What methods of sterilization are being used? What recommendations can researchers give us as options? Our ADA promotes volunteering; please give us some practical, effective alternatives to an autoclave.
JADA 145(4)
John Reed, DMD New Wilmington, Pa.
http://jada.ada.org April 2014
327