Methodological considerations concerning the development of oral dental erosion indexes : literature survey , validity and reliability Within the context of preventing non-communicable diseases , the World Health Report -LRB- 2002 -RRB- and the WHO Global Oral Health Program -LRB- 2003 -RRB- put forward a new strategy of disease prevention and health promotion . Greater emphasis is placed on developing global policies in oral health promotion and oral disease prevention . The Decayed , Missing , Filled Teeth -LRB- DMFT -RRB- index does not meet new challenges in the field of oral health . Dental erosion seems to be a growing problem , and in some countries , an increase in erosion of teeth is associated with an increase in the consumption of beverages containing acids . Therefore , within a revision of the WHO Oral Health Surveys Basic Methods , new oral disease patterns , e.g. dental erosion , have to be taken into account . Within the last 20 years , many studies on dental erosion have been carried out and published . There has been a rapid growth in the number of indexes quantifying dental erosion process in different age groups . However , these indexes are not comparable . This article discusses quality criteria which an index intended for assessing tooth erosion should possess . Introduction Within the context of preventing non-communicable diseases , the World Health Report -LRB- 2002 -RRB- and the WHO Global Oral Health Program -LRB- 2003 -RRB- put forward a new strategy of disease prevention and health promotion -LSB- 52 -RSB- . The main orientation of the WHO Oral Health Program -LRB- 2003 -RRB- is that oral health is integral , essential and interrelated to general health and a determinant factor for quality of life . Proper oral health care reduce the burden of disease as well as premature mortality . Risk factors for oral diseases are common with cardiovascular diseases , diabetes , cancer and chronic obstructive pulmonary diseases . The actual WHO Global Oral Health Program focuses on priority action areas as : `` Diet , nutrition and oral health '' , `` Oral health and fluorides '' , `` Tobacco and oral health '' , `` School children '' , `` Elderly people '' and `` Oral health services '' . Nutrition affects oral health in many ways , e.g. dental erosion . To minimize the occurrence of dental erosion which is particularly related to acidic beverages , the WHO/FAO -LRB- Food and Agricultural Organization of the UN -RRB- recommends -LRB- within their recently published Global Strategy on Diet , Physical Activity and Health -RRB- a reduction in the amount and frequency of intake of soft drinks and juices . WHO recommends that the Ministries of Health should ensure that the mechanisms for intersectorial collaboration are strengthened . Strategies include taxation and pricing , food labeling , school lunch policies and nutrition programs . This WHO Programme is elaborated for all countries of the World . The Regional Offices of WHO play an important role in the improvement of oral health within risk factor approach in disease prevention and health promotion . Therefore , the Global Oral Health Programme will help to achieve greater equity in oral health . But to evaluate the Global Oral Health Programme , we need suitable and validated indicators and indexes -LSB- 52 -RSB- . There is currently only one global oral health index to measure oral health . It is the Decayed , Missing , Filled Teeth -LRB- DMFT -RRB- index . According to the WHO Oral Health Data Bank in the year 2000 from 184 countries , 68 % had a DMFT index less than 3 -LSB- 52 -RSB- . Up to now , there is only the DMFT index for 12-year-old children in the Health for all 21 Database -LRB- www.euro.who.int : HFA-21 DB , downloaded June 13 , 2007 -RRB- . The European Commission launched from 2003 to 2005 the EU-Project : European Global Oral Health Indicators coordinated by the Université Claude Bernard de Lyon , to support European Member States in their efforts to reduce the toll of morbidity , disability related to oral health diseases and especially -LSB- 18 -RSB- : To identify indicators of oral health , of critical oral health care , its quality of care and of essential health resourcesTo strengthen the ability at the local , national and regional levels to measure , compare and determine the effects of oral health services and use of resourcesTo identify indicators of oral health -LRB- problems , determinants and risk factors related to lifestyle -RRB- of critical oral health careTo identify the types of data generation and management problems within the Health Information SystemTo identify principles for guiding the selection and use of oral health indicatorsTo identify a set of core indicators for oral healthTo review the recent oral health-indicator selection efforts In total , 66 indicators are proposed , but no indicator for dental erosion is considered -LSB- 18 -RSB- . Therefore up to now , the only international reference in the area of oral health is the DMFT index . The European Commission assesses the quality of oral health data as inadequate for planning , implementation , management and evaluation . The number of internationally recommended indicators complicates the national selection of indicators and the comparability of indicators and indexes -LSB- 18 -RSB- . The statements of the European Global Oral Health Indicators Report coincide with the experience in the field of development and using of different erosion indexes . Therefore , it would be necessary to strengthen the international alliance of dentists , epidemiologists , statisticians and other scientists and politicians , to develop an adequate oral health indicators set , i.e. as a subset or user-window of the ECHI-Database -LRB- European Community Health Indicators-Database -RRB- and within the Oral Databank of the WHO and to develop an internationally agreed and accepted erosion index . Societies around the world today are increasingly witnessing significant changes in diets and lifestyles which have an impact on oral health . Dental erosion seems to be a growing problem , and in some countries , an increase in erosion of teeth is associated with a higher consumption of beverages containing acids -LSB- 52 -RSB- . Within a revision of the WHO Oral Health Surveys Basic Methods , new oral disease patterns , e.g. dental erosion , have to be taken into account -LSB- 52 -RSB- . The WHO urges the development of methodologies and approaches for evaluating the effectiveness of community oral health programs focusing on health promotion and disease prevention . Additionally , the formulation of new WHO oral health goals up to the year 2020 have been initiated -LSB- 52 -RSB- . Most indexes use different clinical examination standards for measuring tooth erosion especially in preschool - and schoolchildren -LSB- 25 -RSB- . Such examination standards could be : -- The full mouth or partial recording -- The examination of primary and/or of only permanent teeth -- The examination of all surfaces or partial recording of surfaces On this basis , a lot of indexes for the clinical diagnosis of erosive tooth wear have been proposed , which are more or less modifications of combinations of the index published by Eccles -LSB- 17 -RSB- or Smith and Knight -LSB- 48 -RSB- . The most cited examples of Erosion Indexes developed during the last 20 years are -LSB- adopted from 20 -RSB- : -- The Smith and Knight Tooth Wear Index -LRB- TWI -RRB- -LRB- 1984 -RRB- -LSB- 48 -RSB- -- The Eccle 's Index -LRB- 1979 -RRB- -LSB- 17 -RSB- -- UK National Survey of Children 's Dental Health Index -LRB- 1999/2003 -RRB- -LSB- 35 -RSB- -- Erosion Index according to Lussi -LRB- 1996 -RRB- -LSB- 33 -RSB- -- Modified scoring system of Linkosalo and Markkanen -LRB- 1985 -RRB- -LSB- 19 -RSB- -- Aine Index 1993 -LSB- 1 -RSB- -- The Larsen and Westergaard Index -LRB- 2000 -RRB- -LSB- 30 -RSB- -- The O'Sullivan Index -LRB- 2000 -RRB- -LSB- 39 -RSB- Recently , the question has arisen how reliable and valid current diagnostic criteria and data on erosion are . The indexes developed and used during the last 20 years are not comparable ; a gold standard does not exist , and validation studies have not had the effect of identifying an index that could be used as a standard for assessing tooth erosion . The following questions should be answered to advance the definition and assessment of tooth erosion : -- Which erosion indexes are mostly used in the scientific literature ? -- Which quality criteria should indexes possess ? -- What differences exist between individual - and population-based erosion indexes ? Finally in the discussion , we will debate whether it is possible to involve erosion indexes into Health Indicator Sets and into International Classification of Diseases -LRB- ICD ; e.g. ECHI , HFA21 , country databases on oral Health , ICD-11 -RRB- . Erosion index in the scientific literature A literature analysis with regard to erosion indexes for the period 2000 -- 2006 was carried out . For this purpose , a Medline research was done considering mesh terms and keywords `` tooth erosion '' and `` dental erosion '' in connection with `` index '' . All human studies published in English found by this search strategy were analyzed for the erosion indexes used . In the literature analyses , a total of 1,380 articles were found with regard to the mesh terms and keywords `` tooth erosion '' or `` dental erosion '' . Approximately 326,112 articles were found with regard to the mesh term and keyword `` index '' . The conjunction of both revealed a total of 91 articles . From these articles , 40 were excluded as they were published before the year 2000 , three were excluded because they were not English-language publications , eight studies were not included as no humans were involved , and one review was excluded . In total , 40 publications were considered in the literature review . Of 22 publications , 14 cross sectional studies were found in children , and 18 publications/cross sectional studies were found in adults . The erosion indexes used are presented in Tables 1 and 2 for children and adults , respectively . In children , the UK children dental health survey index -LSB- 35 -RSB- was used in four studies , the O'Sullivan Index -LSB- 39 -RSB- in three , an index developed in 1993 by Aine et al. -LSB- 1 -RSB- was used in two studies , and the Smith and Knight TWI -LSB- 48 -RSB- in one study . However , in most studies -LRB- n = 4 -RRB- , differently designed erosion indexes were considered . In adults , the Smith and Knight TWI -LSB- 48 -RSB- was used in most studies -LRB- n = 10 -RRB- followed by the Eccle 's Index -LSB- 17 -RSB- -LRB- n = 2 -RRB- , Lussi Index -LSB- 33 -RSB- -LRB- n = 1 -RRB- , UK adult dental health survey index -LRB- n = 1 -RRB- and an index developed by Schweizer-Hirt et al. 1978 -LSB- 47 -RSB- . In one study , the method for estimating the tooth erosion was not mentioned . Table 1Used dental erosion indexes in human cross-sectional studies for children found in Medline from the years 2000 -- 2006Aim of the studynStudy populationReferred indexSourceErosive tooth wear463Kindergarten , 3 - to 5-year-old childrenO'Sullivan IndexWiegand et al. -LSB- 54 -RSB- Dental erosion15311-year-oldsO ' Sullivan IndexCaglar et al. -LSB- 10 -RSB- Prevalence of dental erosion499School setting ; 12-year-old childrenO'Sullivan IndexPeres et al. -LSB- 43 -RSB- Prevalence of dental erosion1 ,949 Preschool children ; 3 - to 5-year-old childrenUK Children dental health survey indexLuo et al. -LSB- 32 -RSB- Prevalence of dental erosion8326 - and 12-year-old school childrenOwn erosion indexTruin et al. -LSB- 50 -RSB- SES and ethnicity and oral health1 ,753 Random sample of 12 - and 14-year-old childrenUK Children dental health survey indexDugmore and Rock -LSB- 16 -RSB- Accuracy and reproducibility of school dental screening570Primary-school childrenNew index was developedHetherington and White -LSB- 24 -RSB- Prevalence of and risk factors for dental erosion95Children and adultsOwn erosion indexJohansson et al. -LSB- 28 -RSB- Oral health and gastro-oesophageal reflux52Children with gastro-oesophageal reflux diseaseAine IndexLinnett et al. -LSB- 31 -RSB- Asthma and dental erosion418Random Sample of 14-year-old childrenSmith and Knight TWIAl-Dlaigan et al. -LSB- 2 -RSB- Prevalence of dental erosionOral health and gastro-oesophageal reflux37Children with gastro-oesophageal reflux diseaseAine IndexDahshan et al. -LSB- 15 -RSB- Prevalence of dental erosions987Preschool children , 2 - to 5-year-old childrenUK Children dental health survey indexAl-Malik et al. -LSB- 4 -RSB- Oral health of children with clefts914 - , 8 - , and 12-year-old childrenUK Children dental health survey indexChapple and Nunn -LSB- 11 -RSB- Dental erosion and consumption of oranges1,01012-year-old childrenOwn erosion indexKünzel et al. -LSB- 29 -RSB- Table 2Used dental erosion indexes in human cross-sectional studies for adults found in Medline from the years 2000 -- 2006Aim of the studynStudy populationRefered indexSourceTooth survey -LRB- surface ? -RRB- check ! loss155Patients attending a dental hospitalUK Adult dental health survey indexRafeek et al. -LSB- 44 -RSB- Tooth wear among psychiatric patients143Psychiatric patientsSmith and Knight TWIAl-Hiyasat et al. -LSB- 3 -RSB- Tooth wear in elderly690Local survey , elderlyEccles IndexTaiwo et al. -LSB- 49 -RSB- Tooth surface in winemakers36WinemakersSchweizer-Hirt et al. 1978Chikte et al. -LSB- 12 -RSB- Workplace and dental erosion20Silicon workersOwn erosion indexJohansson et al. -LSB- 27 -RSB- Oral and dental health34Inpatients in treatment of alcohol disordersNo information givenAraujo et al. -LSB- 6 -RSB- Dental erosion and gastro-oesophageal reflux?Patients with gastro-oesophageal reflux diseaseSmith and Knight TWIMoazzez et al. -LSB- 36 -RSB- Prevalence of dental erosion18 ,555 Permanent dentitionSmith and Knight TWIBorcic et al. -LSB- 9 -RSB- Dental erosion and gastro-oesophageal reflux253Patients with gastro-oesophageal reflux diseaseEccles IndexMunoz et al. -LSB- 37 -RSB- Monitoring of tooth wear500Patients referred for a variety of restorative procecduresSmith and Knight TWIBartlett -LSB- 7 -RSB- Risk factors of tooth wear506Patients attending a dental hospitalSmith and Knight TWIChuajedong et al. -LSB- 13 -RSB- Sport drinks and dental erosion304AthletesLussi IndexMathew et al. -LSB- 34 -RSB- Prevalence of tooth wear126Patients attending a dental hospitalSmith and Knight TWIOginni and Olusile -LSB- 41 -RSB- Recreational drug and tooth surface loss13Undergraduate studentsSmith and Knight TWINixon et al. -LSB- 38 -RSB- Risk factors for dental erosion10Male military Saudi inducteesOwn erosion indexJohansson et al. -LSB- 28 -RSB- Oral health status of workers68Workers exposed to acid fumesSmith and Knight TWIAmin et al. -LSB- 5 -RSB- Methamphetamine and tooth wear43Methamphetamine usersSmith and Knight TWIRichards and Brofeldt -LSB- 45 -RSB- Dental erosion and gastro-oesophageal reflux20Patients with gastro-oesophageal reflux diseaseSmith and Knight TWIGregory-Head et al. -LSB- 21 -RSB- Quality criteria of indexes for measuring tooth erosion Instruments or indexes for measuring a construct of interest -- quality of life or intelligence , mental health status or tooth erosion -- should possess certain quality characteristics . Otherwise , the scientific value of the obtained results is questionable -LSB- 8 -RSB- . Important quality characteristics are validity and reliability as well as sensitivity and specificity , which will be explained in the following paragraphs . The validity of an instrument indicates to what extent it measures what it is supposed to measure . There are different -- partly overlapping -- types of validity which emphasize different aspects -LSB- 42 -RSB- . The most important types are content , construct , and criterion validity which will be explained in the following paragraphs . Content validity describes whether all aspects , which are relevant to grasp the construct of interest , have been considered adequately . For example , a test that is supposed to measure the ability to calculate should not be restricted only to addition and subtraction but include all basic arithmetic operations . In our context , e. g. the erosion of surfaces of all teeth has to be considered , not only the erosion of incisors . The extent to which an instrument possesses content validity can not be determined numerically . It is solely based upon the subjective meaning of established experts -LSB- 8 , 23 -RSB- . Therefore , a major step in developing a new instrument is a thorough discussion of which aspects should be included . The optimal method to validate a newly developed instrument is the comparison with a so-called gold standard , which measures the same construct . A gold standard is `` the method , procedure or measurement that is widely accepted as being the best available '' -LSB- 46 -RSB- . The so-called criterion validity is high if the results of the new instrument and the gold standard are highly correlated . For example , a thermometer might serve as a gold standard for self-reported temperature -LSB- 23 -RSB- . However , because a gold standard is seldom available , construct validity is of major importance -LSB- 8 -RSB- . Construct validity is subdivided into convergent and discriminant validity . There is convergent validity if the results obtained by the new instrument are correlated with the results of an established instruments that measures similar aspects . If , for example , results of a new instrument for measuring physical health are correlated with the results of an established instrument which measures activity of daily living , convergent validity is indicated -LSB- 8 -RSB- . Or in our context : if the results of a tooth-wear index is correlated with tooth-erosion index , convergent validity is indicated . On the other hand , an instrument possesses discriminant validity if the results of this instrument are not too highly correlated with the results of an established instrument that measures a different construct . For example , results of an instrument for measuring mental health should not be too highly correlated with an instrument for measuring physical function -LSB- 23 -RSB- . With regard to teeth , a high correlation between tooth erosion and wedge-shaped defects might indicate insufficient discriminant validity . Both convergent and discriminant validity have to be given for a complete confirmation of construct validity . The reliability of an instrument indicates how precise it is able to measure , independent of whether it really measures what it is supposed to -LRB- this is a question of validity -RRB- -LSB- 42 -RSB- . There are different aspects of reliability . For our purposes , inter-examiner reliability and intra-examiner reliability are important . Inter-examiner reliability can be determined if two or more dentists -LRB- the `` examiner '' -RRB- assess dental erosion of a number of patients independently of each other -LSB- 14 -RSB- . Roughly spoken , the more often the examiners agree in their assessment , the higher the inter-examiner reliability . Intra-examiner reliability or test -- retest reliability can be determined if each dentist rates dental erosion of a group of patients twice -LSB- 23 -RSB- . The period of time between the two assessments should be fairly long , otherwise the examiners may be overly consistent because they remember their former ratings . On the other hand , if the time interval between the two assessments is too long , changes in the erosion status might bias the reliability estimates . The more often the assessments at the two points in time concerning each examiner are identical , the higher the intra-examiner reliability . A widespread index to calculate the degree of agreement is Cohen 's Kappa -LSB- 14 -RSB- , which `` is now fairly well disseminated as one of the standard summary statistics used in the medical literature '' -LSB- 22 -RSB- . The calculation of Kappa is based on the percentage of agreement which is adjusted for agreement expected by chance . The sensitivity of an instrument indicates its ability to detect -- in our case -- dental erosion . In contrast , an instrument with high specificity is able to indicate no dental erosion if dental erosion is not present . Both assessment of sensitivity and specificity require the comparison with a gold standard . Comparing a new instrument that is supposed to detect dental erosion with an instrument that is known to be able to detect dental erosion , i.e. a gold-standard instrument , can yield one of the four following outcomes : -LRB- 1 -RRB- dental erosion is indicated by the new instrument if there is in fact dental erosion -LRB- correct positive -RRB- , -LRB- 2 -RRB- dental erosion is indicated if there is no dental erosion -LRB- false positive -RRB- , -LRB- 3 -RRB- dental erosion is not indicated if there is dental erosion -LRB- false negative -RRB- and -LRB- 4 -RRB- dental erosion is not indicated if there is no dental erosion -LRB- correct negative -RRB- . The degree of sensitivity is calculated by dividing the frequency of correct positive results by the sum of correct positive and false negative results , while the degree of specificity is determined by dividing the frequency of correct negative results by the sum of correct negative and false positive results -LSB- 46 -RSB- . Individual versus population-based erosion indexes An individual-based index should fulfill other criteria than a population-based index . The first should allow assessment of the full truth of the construct `` tooth erosion '' . Therefore , a very good individual-based erosion index should nearly be a gold-standard instrument . Using a population-based erosion index , the individual assessment should take less time to allow an assessment in big population samples . Therefore , for practical reasons , a population-based erosion index is often a short form of an individual-based index . However , a good population-based erosion index should possess very high validity as well as high reliability . Discussion There is no common sense in the usage of the above-mentioned erosion indexes . A wide range of different forms and indexes was used in the last 6 years . Therefore , comparability between different studies was not given , and meta-analyses were not possible . If anything , it can be stated that for adults , the Smith and Knight TWI -LSB- 48 -RSB- has been widely used in most Medline-cited cross-sectional studies . For children , there is no index that is most used . However , the literature analysis is limited . Only one search strategy was used . Some articles which do not use the mentioned key words or mesh headings might not be included in the analysis . However , the results presented help to get a first view on the different indexes on tooth erosion cited in the last 6 years . In all these indexes , the criteria to record the grading for erosion differed -LSB- 26 -RSB- . Most of the indexes used are based on the clinical severity of erosion , focusing on accessible teeth but not all -LSB- 29 -RSB- . For example , the structure of the Smith and Knight TWI is shown in Table 3 . However , this index is made for scoring tooth wear in general irrespective of its predominant aetiology . It is only a system for quantifying and grading the amount of tissue loss but does not include diagnostic criteria for erosion . The UK National Survey of Children 's Dental Health Index was a modified version of the Smith and Knight TWI assessing only buccal or palatal surfaces of maxillary incisors and added erosion criteria . However , while using the first index , the conclusion was drawn that the figures might not be completely accurate -LSB- 40 -RSB- . The next version focused on erosion of the palatal surface of at least one maxillary anterior tooth with the majority of surfaces having dentin involvement -LSB- 29 -RSB- . To date , literature assessing the prevalence of erosion has been published from different countries . Erosion was recorded using various indexes . In addition , selection criteria of study populations , sampling techniques and considered age groups differed . The prevalence of dental erosion of different studies is therefore difficult and nearly impossible to compare -LSB- 29 -RSB- . Table 3Smith and Knight Tooth Wear Index -LSB- 48 -RSB- ScoreSurfaceCriterion0B/L/O / I/CNo loss of surface characteristic , no loss of contour1B/L/O / I/CLoss of enamel surface characteristics , minimal loss of contour2B/L/OLoss of enamel exposing dentine for less than one third of the surfaceILoss of enamel just exposing dentineCDefect less then 1 mm deep3B/L/OLoss of enamel exposing dentine for more than one third of surfaceILoss of enamel and substantial loss of dentine not exposing secondary dentine or pulpCDefect 1 -- 2 mm deep4B/L/OComplete loss of enamel , or pulp exposure , or exposure of secondary dentineIPulp exposure or exposure of secondary dentineCDefect more than 2 mm deep , or pulp exposure , or exposure of secondary dentineB Buccal or labial , L lingual or palatal , O occlusal , I incisal , C cervical A good index is characterized by a conducted validation study . For those indexes for which a validation study has not been conducted so far , that should be made up to check whether they possess the quality criteria as described above . In a validation study , it is not only the validity of an index that is examined but also aspects of reliability as well . Intra-examiner and inter-examiner reliability should be checked . That is done quite easily as described in `` Quality criteria of indexes for measuring tooth erosion '' . At the beginning of the study , it has to be considered how many patients and how many examiners respectively have to be involved . This is because the number of patients and examiners should be as small as possible for practical and economic reasons . On the other hand , the number of patients and examiners has to be sufficiently high because otherwise a certain degree of reliability , which actually exists , might be overlooked . Therefore , solid sample-size calculations should be conducted with the help of an experienced statistician . So far , there is no consensus concerning a gold-standard instrument . However , a gold standard is important for comparison . Otherwise , criterion validity can not be checked . If one attempts to develop a gold-standard instrument , the first step would be a thorough discussion of which aspects of the construct `` tooth erosion '' have to be included . This should be conducted by established experts to ensure content validity . When the instrument is constructed , inter-examiner reliability and intra-examiner reliability can be examined as described above . However , this should be done not only in a national but in an international context . A gold-standard instrument would explain the full truth of the construct `` tooth erosion '' . Nevertheless , the measurement procedure in general takes a long time . It is not possible to deal with such a comprehensive assessment instrument in a population-based study design . Therefore , more simple assessment instruments should be available . These assessment instruments should fulfill the following qualifications : -LRB- a -RRB- a validation study should be available where all quality criteria of the assessment instrument were tested and -LRB- b -RRB- the instrument should be used in other scientific studies , too . If the population-based short version of an assessment instrument and the gold-standard instrument are measuring the same construct , and when both conditions are fulfilled , calibration studies might be possible . Calibration refers to a process in which values from one method are quantitatively related to values from a superior , gold-standard method . The aim of such an analysis is to ensure that the measurement uncertainty is known and is consistent with the required measurement capability . In a so-called calibration study , known data on the observed relationship between an independent variable of the population-based short version of the assessment instrument and the dependent variable of the gold-standard instrument are used to make estimates of other `` true '' values of the independent variable from new observations of the gold standard . One of the prospective targets ought to be the inclusion of indexes on dental health prevention especially of an internationally agreed `` erosion index '' into the existing Health Indicator Sets . These would be the Health for All Database of the WHO -LRB- HFA21 -RRB- , The European Community Health Indicator Set -LRB- ECHI -RRB- , Country Databases on Oral Health and the inclusion of Dental Erosion into the International Classification of Diseases and Health-Related Problems . In April 2007 , the World Health Organization announced plans to revise the ICD-10 , in other words , to prepare for ICD-11 . Within the actual ICD-10 , there exists two codes for Dental Diseases : `` K02 '' for Caries and `` K03 '' for `` Other diseases of hard tissues of teeth '' including with `` K03 .2 -- Erosion of teeth . '' On the four-digit level , we find the following different diagnoses presented in Table 4 . Table 4Code description for K03 .2 -- Erosion of teeth -LRB- ICD 10 code -RRB- -LSB- 51 -RSB- ICD 10 codeDescriptionK03 .2 Erosion of teethK03 .20 Occupational erosion of teethK03 .21 Erosion of teeth due to persistent regurgitating or vomitingK03 .22 Erosion of teeth due to dietK03 .23 Erosion of teeth due to drugs and medicamentsK03 .24 Idiopathic erosion of teethK03 .28 Other specified erosion of teethK03 .29 Erosion of teeth , unspecified The Updating and Revision Committee proposes major changes like addition of new codes or deletion of codes and developed submission guidelines . Therefore , it would be possible to check critically if the codes for dentistry within the Application of the International Classification of Diseases to Dentistry and Stomatology are adequate to future developments or have to be replaced or completed -LSB- 53 -RSB- . Conclusion Further efforts have to be made in the development of an internationally agreed index which is able to assess dental erosion with as much reliability and validity as possible . Current recommendations of the WHO and the European Union and health task forces within countries and Dental Associations should be used to develop and to discuss the concept of tooth erosion and the development of a unified erosion index .

O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O 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O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B O O O O O O O O O B I O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O B I O O O O O O O O O O O O O B I O O O O O O O O O O O B I O O O O O B O O O O O O O O O B O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O B O O O O B O O B O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O B O O O O O B O O O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O B O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O B O O O O O O O O O O O O O O B I O O O O O O O O O B O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O B O O O O O O O B O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O B O O O O O O O B O O O O O O B O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B O O O O O O O O B O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O B O

tooth erosion
gold standard
index
validity
reliability


Sick

leave

and

work

disability

in

patients

with

early

arthritis

We

studied

the

occurrence

of

sick

leave

and

work

disability

the

presence

of

workplace

adaptations

and

the

usage

of

professional

guidance

related

to

working

problems

in

patients

with

early

arthritis

Inclusion

criteria

were

arthritis

symptoms

of

less

than

years

duration

and

a

paid

job

at

the

time

of

diagnosis

Assessments

were

done

in

connection

with

an

early

arthritis

clinic

-LRB-

EAC

-RRB-

at

entry

into

the

cohort

and

months

thereafter

by

means

of

a

questionnaire

comprising

questions

on

sick

leave

-LRB-

absenteeism

from

work

reported

to

the

employer

-RRB-

work

disability

-LRB-

receiving

a

full

or

partial

work

disability

pension

-RRB-

unemployment

work

adaptations

and

professional

guidance

related

to

working

problems

Fifty-seven

of

the

participants

-LRB-

-RRB-

had

an

arthritis

symptom

duration

of

months

The

number

of

patients

with

sick

leave

due

to

arthritis

in

the

past

months

decreased

from

-LRB-

-RRB-

at

study

entry

to

-LRB-

-RRB-

after

months

of

follow-up

The

number

of

patients

receiving

a

work

disability

pension

increased

from

-LRB-

-RRB-

at

study

entry

to

-LRB-

-RRB-

after

months

of

follow-up

-LRB-

partial

and

full

-RRB-

Sick

leave

in

the

months

before

study

entry

appeared

to

be

the

most

important

predictor

of

the

institution

or

increase

in

a

work

disability

pension

-LRB-

odds

ratio

CI

-RRB-

Between

study

entry

and

follow-up

the

number

of

patients

with

workplace

adaptations

increased

from

-LRB-

-RRB-

to

-LRB-

-RRB-

whereas

the

number

of

patients

receiving

vocational

guidance

decreased

from

-LRB-

-RRB-

to

-LRB-

-RRB-

In

patients

with

early

arthritis

and

a

paid

job

arthritis-related

sick

leave

was

common

and

occurred

in

part

before

patients

entered

the

EAC

and

a

diagnosis

was

made

About

of

the

patients

became

permanently

work

disabled

with

partial

work

disability

being

more

common

than

full

work

disability

Considerable

proportions

of

patients

received

workplace

adaptations

and

professional

guidance

with

working

problems

Introduction

Rheumatoid

arthritis

-LRB-

RA

-RRB-

and

other

chronic

inflammatory

rheumatic

diseases

are

disabling

conditions

that

affect

the

lives

of

individual

patients

in

many

ways

The

prevalence

of

work

disability

is

high

among

patients

with

RA

-LSB-

-RSB-

as

well

as

other

forms

of

chronic

arthritis

such

as

ankylosing

spondylitis

-LSB-

-RSB-

systemic

lupus

erythematosus

-LSB-

-RSB-

and

to

a

lesser

extent

psoriatic

arthritis

-LSB-

-RSB-

In

RA

patients

it

was

found

that

most

work

disability

develops

rapidly

after

onset

-LSB-

-RSB-

with

recent

studies

showing

work

disability

rates

among

RA

patients

year

after

diagnosis

vary

between

and

-LSB-

-RSB-

So

far

research

has

focussed

mainly

on

permanent

work

disability

and

its

determinants

-LSB-

-RSB-

Over

the

recent

years

the

interest

in

sick

leave

which

is

considered

to

precede

permanent

work

disability

in

chronic

arthritis

is

increasing

In

cross-sectional

studies

in

early

RA

-LRB-

disease

duration

years

-RRB-

the

proportions

of

patients

on

sick

leave

varied

from

-LSB-

-RSB-

whereas

in

follow-up

studies

of

the

patients

reported

sick

leave

over

a

period

of

year

-LSB-

-RSB-

Until

now

the

number

of

studies

on

work

disability

and

sick

leave

in

early

arthritis

is

confined

to

the

situation

after

diagnosis

with

no

data

being

available

on

the

occurrence

of

sick

leave

or

permanent

work

disability

in

the

preceding

period

In

addition

little

is

known

about

the

extent

of

adaptations

to

the

work

place

or

guidance

by

health

professionals

in

these

early

stages

of

the

disease

The

aim

of

this

study

was

therefore

to

describe

the

occurrence

of

sick

leave

and

permanent

work

disability

and

its

predictors

in

the

very

early

phases

of

the

disease

Moreover

this

study

aimed

to

describe

the

provision

of

adaptations

to

the

workplace

and

professional

guidance

in

patients

with

chronic

arthritis

Materials

and

methods

Patients

This

work

disability

study

was

originally

designed

as

a

multicenter

study

including

the

Leiden

University

Medical

Center

-LRB-

LUMC

-RRB-

Leiden

the

Haga-Leyenburg

Teaching

Hospital

and

Bronovo

Hospital

The

Hague

and

the

Reinier

de

Graaf

Hospital

Delft

The

Netherlands

We

aimed

to

recruit

patients

in

connection

with

two

cohorts

the

early

arthritis

clinic

-LSB-

-RSB-

-LRB-

EAC

LUMC

patients

only

-RRB-

and

the

BeSt

study

-LSB-

-RSB-

-LRB-

LUMC

Haga-Leyenburg

Teaching

Hospital

Bronovo

Hospital

and

Reinier

de

Graaf

Gasthuis

-RRB-

BeSt

is

an

abbreviation

of

treatment

strategies

-LRB-

in

Dutch

BehandelStrategieën

-RRB-

for

RA

with

four

drug

treatment

strategies

all

aimed

at

achieving

low

disease

activity

being

compared

in

patients

with

early

active

RA

-LSB-

-RSB-

The

Medical

Ethics

Committees

of

all

three

participating

hospitals

approved

the

protocol

of

this

additional

work

disability

study

Due

to

logistical

problems

the

actual

recruitment

of

patients

in

the

period

has

only

been

carried

out

in

connection

with

the

EAC

in

the

LUMC

The

EAC

is

a

facility

aimed

at

early

diagnosis

and

treatment

of

arthritis

including

all

patients

suffering

from

arthritis

in

one

or

more

joints

an

arthritis

symptom

duration

of

less

than

years

and

not

being

diagnosed

with

gout

chondrocalcinosis

or

traumatic

arthritis

or

a

serious

disease

other

than

a

rheumatic

condition

General

practitioners

are

requested

to

refer

patients

with

suspected

arthritis

as

soon

as

possible

all

patients

can

be

seen

within

weeks

after

referral

-LSB-

-RSB-

Only

patients

who

had

a

paid

job

months

before

the

first

visit

in

connection

with

the

EAC

were

included

On

average

a

definite

diagnosis

was

made

within

weeks

after

the

first

visit

in

connection

with

the

EAC

At

the

time

the

present

study

was

conducted

patients

who

were

diagnosed

with

RA

were

promptly

treated

with

either

methotrexate

or

salazopyrine

RA

patients

fulfilling

the

inclusion

criteria

for

the

BeSt

study

-LSB-

RA

according

to

the

American

College

of

Rheumatology

formerly

American

Rheumatism

Association

criteria

-LSB-

-RSB-

a

disease

duration

of

less

than

years

aged

years

or

older

and

active

disease

indicated

by

of

swollen

joints

of

tender

joints

and

at

least

one

of

the

following

two

criteria

an

erythrocyte

sedimentation

rate

-LRB-

ESR

-RRB-

of

mm/h

or

a

global

health

score

of

mm

on

a

mm

visual

analogue

scale

-LRB-

VAS

-RRB-

where

best

and

worst

-RSB-

were

randomized

to

four

treatment

groups

These

groups

included

sequential

monotherapy

-LRB-

group

-RRB-

step-up

combination

therapy

-LRB-

group

-RRB-

initial

combination

therapy

with

tapered

high-dose

prednisone

-LRB-

group

-RRB-

or

initial

combination

therapy

with

infliximab

-LRB-

group

-RRB-

For

patients

failing

on

their

medication

the

study

protocol

prescribed

a

number

of

subsequent

treatment

steps

-LSB-

-RSB-

All

patients

included

in

the

work

disability

study

gave

written

informed

consent

Assessment

methods

Assessments

were

done

at

study

entry

-LRB-

at

study

inclusion

of

the

EAC

cohort

-RRB-

and

after

months

of

follow-up

Basic

sociodemographic

and

clinical

data

were

obtained

from

the

baseline

assessments

of

the

EAC

whereas

data

on

the

working

situation

and

mental

health

were

gathered

by

means

of

additional

questionnaires

Sociodemographic

and

clinical

characteristics

Sociodemographic

variables

included

age

sex

status

of

living

-LRB-

living

with

a

partner

yes/no

-RRB-

and

education

level

divided

into

three

categories

primary

education

-LRB-

years

-RRB-

secondary

education

-LRB-

years

-RRB-

and

higher

vocational

education

university

-LRB-

years

or

more

-RRB-

Disease

activity

was

measured

by

means

of

-LRB-

a

-RRB-

the

ESR

-LRB-

mm/h

-RRB-

-LRB-

b

-RRB-

the

Ritchie

score

concerning

pain

in

selected

joints

on

a

scale

of

-LRB-

no

pain

and

worst

pain

-RRB-

with

the

final

score

ranging

from

-LSB-

-RSB-

and

-LRB-

c

-RRB-

the

patient

's

global

assessment

of

disease

activity

pain

and

fatigue

on

three

separate

VAS

All

VAS

were

cm

horizontal

lines

with

the

anchors

on

the

left

being

no

disease

activity

no

pain

and

no

fatigue

whereas

the

anchors

on

the

right

were

the

worst

imaginable

disease

activity

severe

pain

and

severe

fatigue

Physical

functioning

was

measured

by

the

Health

Assessment

Questionnaire

-LRB-

HAQ

-RRB-

The

HAQ

is

a

questionnaire

comprising

eight

domains

of

activities

of

daily

living

with

the

final

score

ranging

from

-LRB-

no

disability

-RRB-

to

-LRB-

severe

disability

-RRB-

-LSB-

-RSB-

Anxiety

and

depression

were

measured

by

means

of

a

Dutch

version

of

the

Hospital

Anxiety

and

Depression

Scale

-LRB-

HADS

-RRB-

-LSB-

-RSB-

The

higher

the

scores

on

the

anxiety

or

depression

scales

the

more

anxious

or

depressed

the

subject

is

-LRB-

range

per

scale

-RRB-

Job

characteristics

sick

leave

work

disability

work

adaptations

and

guidance

with

working

problems

Current

occupation

was

grouped

into

four

categories

-LRB-

-RRB-

predominantly

mental

demands

and

absence

of

physical

demands

-LRB-

-RRB-

a

combination

of

physical

and

mental

effort

-LRB-

-RRB-

light

physical

demands

and

-LRB-

-RRB-

heavy

physical

demands

-LSB-

-RSB-

Sick

leave

was

defined

as

absenteeism

with

a

duration

of

weeks

or

more

related

to

the

arthritic

complaints

and

reported

to

the

employer

At

the

time

the

study

was

conducted

in

the

Dutch

social

security

regulations

the

maximum

duration

of

sick

leave

was

year

and

sick

leave

could

be

either

complete

-LRB-

reported

sick

for

all

hours

that

one

is

engaged

-RRB-

or

partial

-LRB-

reported

sick

for

part

of

the

hours

that

one

is

engaged

-RRB-

The

duration

of

sick

leave

in

the

months

before

study

entry

and

year

thereafter

was

divided

into

four

categories

-LRB-

-RRB-

weeks

-LRB-

-RRB-

months

-LRB-

-RRB-

months

-LRB-

-RRB-

months

and

-LRB-

-RRB-

months

Permanent

work

disability

was

defined

as

receiving

a

complete

or

partial

work

disability

pension

related

to

the

rheumatic

disease

In

the

Dutch

social

security

regulations

a

partial

work

disability

pension

in

combination

with

a

part-time

job

is

common

In

this

situation

sick

leave

may

occur

during

the

hours

active

at

work

The

presence

of

material

or

immaterial

adaptations

at

the

workplace

-LRB-

including

adapted

tools

adapted

furniture

reduction

in

tasks

or

duties

help

of

colleagues

flexible

working

hours

opportunities

for

more

breaks

less

working

hours

or

reduced

work

pace

-RRB-

was

recorded

Reduced

working

hours

were

only

considered

as

an

adaptation

at

work

when

this

adaptation

did

not

pertain

to

official

incomplete

sick

leave

Guidance

with

working

problems

was

recorded

by

means

of

a

question

concerning

the

receipt

of

help

in

maintaining

the

job

Health

professionals

listed

for

giving

help

were

the

rheumatologist

occupational

physician

general

practitioner

social

worker

physical

therapist

occupational

therapist

or

nurse

In

addition

it

was

registered

whether

patients

received

support

from

their

employer

and/or

colleagues

Satisfaction

with

the

received

guidance

was

recorded

In

addition

patients

were

asked

by

whom

they

would

have

liked

to

be

helped

more

Background

information

on

sick

leave

and

work

disability

Background

information

on

sick

leave

and

work

disability

in

the

Dutch

population

in

the

period

the

study

was

conducted

was

derived

from

the

Internet

site

of

the

Dutch

Central

Bureau

of

Statistics

Statistical

analysis

Data

entry

was

performed

using

Microsoft

Office

Access

Statistical

analyses

were

executed

using

SPSS

for

Windows

Continuous

variables

were

presented

as

medians

with

ranges

and

categorical

variables

as

number

and

percentages

Comparisons

of

the

median

age

and

the

sex

distribution

of

patients

included

in

the

study

and

all

other

patients

of

years

or

younger

who

entered

the

EAC

cohort

in

the

study

period

were

done

by

means

of

the

Mann

Whitney

U

and

chi-square

test

respectively

Proportions

of

patients

being

on

sick

leave

or

receiving

a

work

disability

pension

at

study

entry

and

after

months

of

follow-up

were

compared

using

McNemar

tests

for

paired

comparisons

of

categorical

data

whereas

the

average

numbers

of

hours

per

week

patients

were

working

were

compared

by

means

of

the

Wilcoxon

signed

rank

test

These

analyses

were

repeated

excluding

all

patients

with

a

symptom

duration

months

at

study

entry

Sociodemographic

disease

and

job

characteristics

in

the

group

of

patients

in

whom

the

working

situation

deteriorated

after

months

of

follow-up

-LRB-

defined

as

being

entitled

a

partial

or

full

work

disability

pension

for

the

first

time

or

changing

from

a

partial

to

a

full

work

disability

pension

-RRB-

and

in

the

group

of

patients

in

whom

the

working

situation

remained

stable

or

improved

-LRB-

defined

as

receiving

no

disability

pension

or

the

same

partial

work

disability

pension

at

either

time

point

of

changing

from

a

partial

work

disability

pension

to

no

disability

pension

-RRB-

were

compared

by

Mann

Whitney

U

and

chi-square

tests

Then

a

multivariate

backward

logistic

regression

analysis

on

predictors

of

deterioration

of

the

working

status

was

performed

Only

variables

that

showed

a

significant

difference

in

the

above-mentioned

analysis

-LRB-

p

values

-RRB-

were

entered

as

independent

variables

in

logistic

regression

analysis

The

numbers

of

patients

receiving

adaptations

in

the

workplace

or

vocational

guidance

in

the

past

year

at

study

entry

and

after

months

of

follow

up

were

compared

by

the

McNemar

test

whereas

the

median

total

numbers

of

workplace

adaptations

per

patient

at

both

time

points

were

compared

by

means

of

the

Wilcoxon

signed

rank

test

Results

In

the

study

period

in

total

patients

entered

the

EAC

cohort

One

hundred

and

five

of

these

patients

-LRB-

-RRB-

were

older

than

years

From

the

remaining

patients

patients

-LRB-

-RRB-

were

found

eligible

and

willing

to

participate

The

reasons

for

not

being

included

were

not

recorded

on

the

individual

level

A

group

of

patients

was

not

eligible

for

the

study

because

they

were

not

having

a

paid

job

months

before

the

first

visit

in

connection

with

the

EAC

cohort

In

addition

a

number

of

patients

were

eligible

but

declined

participation

and

some

patients

were

not

invited

because

of

logistic

reasons

Twelve

of

the

initially

included

patients

were

excluded

within

weeks

after

enrollment

because

a

diagnosis

of

gout

chondrocalcinosis

sarcoidosis

or

a

non-rheumatic

disease

was

confirmed

after

additional

diagnostic

procedures

so

that

they

did

not

meet

the

inclusion

criteria

for

the

EAC

The

patients

included

in

the

study

were

younger

-LRB-

median

age

years

range

-RRB-

than

the

patients

in

the

EAC

cohort

aged

years

or

less

who

were

not

included

-LRB-

median

age

years

range

p

-RRB-

Moreover

the

proportion

of

female

patients

was

lower

in

the

included

patients

-LRB-

-RRB-

than

in

the

patients

who

were

not

included

-LRB-

p

-RRB-

Sociodemographic

and

disease

characteristics

including

physical

and

mental

function

of

the

included

patients

are

shown

in

Table

In

total

patients

were

recruited

from

the

EAC

cohort

Thirty-nine

patients

-LRB-

-RRB-

had

definite

RA

patients

-LRB-

-RRB-

had

probable

RA

-LRB-

-RRB-

had

psoriatic

arthritis

-LRB-

-RRB-

had

spondylarthropathy

and

-LRB-

-RRB-

had

unclassified

arthritis

with

the

arthritis

still

being

unclassified

after

months

of

follow-up

Twelve

of

the

patients

with

definite

RA

also

participated

in

the

BeSt

study

two

were

randomized

to

treatment

group

three

to

treatment

group

five

to

treatment

group

and

two

to

treatment

group

Table

and

disease

characteristics

of

patients

with

early

arthritisCharacteristicsn

-LRB-

-RRB-

Sociodemographic

characteristics

Age

in

years

median

-LRB-

range

-RRB-

-LRB-

-RRB-

Female

patients

n

-LRB-

-RRB-

-LRB-

-RRB-

Living

with

partner/family

n

-LRB-

-RRB-

-LRB-

-RRB-

Educational

level

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Disease

characteristics

Diagnosis

n

-LRB-

-RRB-

RA

-LRB-

definite

-RRB-

-LRB-

-RRB-

RA

-LRB-

probable

-RRB-

-LRB-

-RRB-

Psoriatic

-LRB-

-RRB-

Arthritis

-LRB-

-RRB-

-LRB-

-RRB-

Duration

of

arthritis

symptoms

in

years

median

-LRB-

range

-RRB-

-LRB-

-RRB-

VAS

cm

median

-LRB-

range

-RRB-

Disease

activity

-LRB-

-RRB-

Pain

-LRB-

-RRB-

Fatigue

-LRB-

-RRB-

ESR

in

mm/hr

median

-LRB-

range

-RRB-

-LRB-

-RRB-

Ritchie

index

-LRB-

-RRB-

median

-LRB-

range

-RRB-

-LRB-

-RRB-

HAQ

-LRB-

-RRB-

median

-LRB-

range

-RRB-

-LRB-

-RRB-

HADS

anxiety

median

-LRB-

range

-RRB-

-LRB-

-RRB-

HADS

depression

median

-LRB-

range

-RRB-

-LRB-

-RRB-

In

total

patients

-LRB-

-RRB-

had

a

symptom

duration

of

year

patients

-LRB-

-RRB-

had

a

symptom

duration

between

months

and

year

and

patients

-LRB-

-RRB-

had

a

symptom

duration

of

months

Overall

disease

activity

was

moderate

with

the

median

VAS

disease

activity

score

being

-LRB-

range

-RRB-

cm

the

median

ESR

-LRB-

range

-RRB-

mm/h

and

the

median

Ritchie

score

being

-LRB-

-RRB-

Data

on

the

working

status

are

presented

in

Table

Patients

were

distributed

fairly

evenly

over

the

four

job

categories

Table

status

in

patients

with

early

arthritis

Study

entryFollow-up

-LRB-

months

-RRB-

p

valueaJob

characteristics

Occupational

category

n

-LRB-

-RRB-

Mental

-LRB-

-RRB-

Mixed

mental/physical

-LRB-

-RRB-

Light

physical

-LRB-

-RRB-

Heavy

physical

-LRB-

-RRB-

Hours

of

work

per

week

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Full-time

employment

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Sick

leave

Current

sick

leave

n

-LRB-

-RRB-

-LRB-

-RRB-

Sick

leave

for

the

past

months

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Extent

of

sick

leave

n

-LRB-

-RRB-

Complete

sick

-LRB-

-RRB-

-LRB-

-RRB-

Partial

sick

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Duration

of

sick

leave

for

the

past

months

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Work

disability

Work

disability

pension

Complete

or

partial

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Complete

n

-LRB-

-RRB-

-LRB-

-RRB-

Partial

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

ap

value

of

Wilcoxon

signed

rank

test

or

McNemar

where

appropriate.bOnly

patients

who

did

not

start

to

receive

a

work

disability

pension

or

an

extension

of

a

work

disability

pension

were

considered

At

study

entry

patients

-LRB-

-RRB-

were

currently

on

sick

leave

In

The

Netherlands

in

the

period

the

average

proportion

of

persons

on

sick

leave

in

the

working

population

ranged

between

and

depending

on

the

branch

-LRB-

public

service

or

industry

-RRB-

-LSB-

-RSB-

Twenty-eight

patients

reported

sick

leave

over

the

past

months

whereas

after

months

follow-up

patients

reported

sick

leave

in

the

preceding

period

This

difference

was

mainly

accounted

for

by

a

decrease

in

the

number

of

patients

reporting

sick

leave

for

periods

of

months

In

total

patients

-LRB-

-RRB-

reported

sick

leave

in

either

months

before

study

entry

or

months

thereafter

Of

the

patients

who

reported

sick

leave

due

to

arthritis

in

the

past

months

with

a

specific

duration

at

study

entry

were

partially

or

fully

work

disabled

after

months

of

follow

up

reported

long-term

sick

leave

-LRB-

months

-RRB-

reported

short-term

sick

leave

-LRB-

weeks

-RRB-

and

reported

no

sick

leave

due

to

arthritis

Five

patients

-LRB-

-RRB-

received

a

partial

disability

pension

at

study

entry

In

two

of

these

patients

this

entitlement

was

extended

to

a

full

work

disability

pension

after

months

whereas

in

the

other

three

patients

the

disability

pension

remained

unchanged

In

addition

eight

patients

-LRB-

-RRB-

started

receiving

a

work

disability

pension

in

the

follow-up

period

-LRB-

one

patient

a

full

disability

pension

and

seven

a

partial

disability

pension

-RRB-

In

The

Netherlands

the

average

proportion

of

employees

in

the

working

age

range

-LRB-

years

-RRB-

becoming

work

disabled

over

a

period

of

year

ranged

between

and

in

the

period

the

study

was

conducted

-LRB-

-RRB-

of

the

patients

became

unemployed

during

follow-up

A

repetition

of

the

analyses

excluding

the

six

patients

with

a

symptom

duration

of

year

showed

similar

results

-LRB-

data

no

shown

-RRB-

Table

shows

sociodemographic

disease

and

job

characteristics

of

patients

in

whom

the

work

status

deteriorated

-LRB-

institution

or

extension

of

work

disability

pension

-RRB-

and

of

patients

in

whom

the

working

situation

improved

or

remained

stable

In

the

patients

in

whom

the

work

status

deteriorated

the

proportions

of

patients

with

a

diagnosis

of

definite

RA

the

occurrence

of

sick

leave

in

the

previous

months

and

a

duration

of

sick

leave

weeks

were

significantly

higher

than

in

the

group

of

patients

in

whom

the

working

status

remained

stable

Moreover

patients

in

whom

the

working

status

deteriorated

had

a

significantly

higher

VAS

disease

activity

compared

to

patients

in

whom

the

working

status

remained

stable

or

improved

Table

of

working

statusa

in

months

follow

up

in

patients

with

early

arthritis

More

work

disability

n

work

-LRB-

dis

-RRB-

ability

n

valuebSociodemographic

characteristics

Age

years

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Female

patients

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Educational

level

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Disease

characteristics

Diagnosis

n

-LRB-

-RRB-

RA

-LRB-

definite

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

RA

-LRB-

probable

-RRB-

-LRB-

-RRB-

Arthritis

-LRB-

-RRB-

-LRB-

-RRB-

Psoriatic

-LRB-

-RRB-

-LRB-

-RRB-

Duration

of

symptoms

years

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

VAS

cm

median

-LRB-

range

-RRB-

Disease

activity

-LRB-

-RRB-

-LRB-

-RRB-

Pain

-LRB-

-RRB-

-LRB-

-RRB-

Fatigue

-LRB-

-RRB-

-LRB-

-RRB-

Disease

activity

ESR

mm/h

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Ritchie

index

-LRB-

-RRB-

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Physical

and

mental

functioning

HAQ

-LRB-

-RRB-

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

HADS

anxiety

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

HADS

depression

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Job

characteristics

Current

occupational

category

n

-LRB-

-RRB-

Mental

-LRB-

-RRB-

-LRB-

-RRB-

Mixed

mental/physical

-LRB-

-RRB-

-LRB-

-RRB-

Light

physical

-LRB-

-RRB-

-LRB-

-RRB-

Heavy

physical

-LRB-

-RRB-

-LRB-

-RRB-

Sick

leave

related

to

arthritis

months

before

study

entry

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Duration

of

sick

leave

related

to

arthritis

in

months

before

study

entry

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

aDeterioration

of

work

status

defined

as

starting

to

receive

a

work

disability

pension

or

altering

from

a

partial

to

a

full

work

disability

pension

after

months

of

follow-up

bp

value

of

Mann

Whitney

U

test

or

chi-square

where

appropriate

In

the

multivariate

logistic

regression

analysis

the

occurrence

of

sick

leave

in

months

before

study

entry

was

found

to

be

the

only

significant

predictor

of

deterioration

of

the

working

situation

-LRB-

odds

ratio

CI

-RRB-

The

presence

of

material

and

immaterial

adaptations

at

the

workplace

is

shown

in

Table

The

number

of

patients

in

whom

the

workplace

was

adapted

increased

from

-LRB-

-RRB-

at

baseline

to

patients

-LRB-

-RRB-

after

year

follow-up

The

numbers

of

patients

using

adapted

tools

or

furniture

flexible

time-management

or

performing

different

tasks

increased

significantly

with

time

Moreover

the

average

number

of

workplace

adaptations

per

patient

increased

significantly

Table

of

material

and

immaterial

adaptations

at

the

workplace

in

patients

with

early

arthritis

Study

entry

n

-LRB-

months

-RRB-

n

valueaNo

of

patients

with

adaptations

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

No

of

adaptations

per

personb

median

-LRB-

range

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Types

of

adaptations

Adapted

tools/furniture

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Different

tasks

-LRB-

extra

education

-RRB-

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Reduction

of

tasks/duties

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Help

of

colleagues

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Flexible

working

hours

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Flexible

time-management

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Less

working

hours

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Reduced

work

pace

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

ap

value

of

McNemar

test

or

Wilcoxon

signed

rank

test

where

appropriate.bOnly

considering

patients

with

one

or

more

adaptations

Table

shows

the

guidance

of

other

persons

with

the

aim

of

the

maintenance

of

the

paid

job

At

study

entry

patients

-LRB-

-RRB-

and

in

the

follow-up

period

patients

-LRB-

-RRB-

received

professional

guidance

with

the

rheumatologist

general

practitioner

and

physical

therapist

being

the

most

frequently

mentioned

health

care

professionals

The

proportions

of

patients

being

satisfied

with

the

guidance

were

the

lowest

for

the

occupational

physician

Employers

and/or

colleagues

provided

help

in

one

third

of

patients

for

the

large

majority

of

patients

to

their

satisfaction

Table

of

and

satisfaction

with

professional

guidance

and

help

of

employers/colleagues

with

respect

to

arthritis-related

problems

at

work

in

patients

with

early

arthritis

Study

entryFollow-up

-LRB-

months

-RRB-

UsageSatisfactionUsageSatisfactionRheumatologist

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

General

practitioner

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Physiotherapist

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Occupational

physician

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Social

worker

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Clinical

nurse

specialist

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Occupational

therapist

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

Employer/colleagues

n

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

-LRB-

-RRB-

All

values

expressed

as

numbers

-LRB-

-RRB-

Thirteen

patients

-LRB-

-RRB-

would

have

liked

to

have

more

guidance

with

problems

at

work

especially

from

their

rheumatologist

a

nurse

specialized

in

rheumatology

or

from

their

employer

Discussion

This

study

in

patients

with

early

chronic

arthritis

shows

that

about

half

of

the

patients

reported

arthritis-related

sick

leave

and

became

permanently

work

disabled

over

a

period

year

before

and

year

after

entering

an

EAC

cohort

Partial

work

disability

was

more

common

than

full

work

disability

and

sick

leave

appeared

to

be

its

most

important

predictor

In

addition

work

place

adaptations

professional

guidance

and

help

from

employer

and/or

colleagues

were

common

in

this

population

With

respect

to

the

occurrence

of

sick

leave

our

results

are

in

accordance

with

those

of

previous

follow-up

studies

in

patients

with

early

arthritis

where

sick

leave

rates

of

over

a

period

of

year

were

reported

-LSB-

-RSB-

As

in

our

study

of

the

patients

had

a

disease

duration

of

less

than

months

our

data

on

the

occurrence

of

sick

leave

in

the

months

before

study

entry

suggest

that

in

a

considerable

proportion

of

patients

sick

leave

may

occur

before

they

enter

an

EAC

and

a

diagnosis

of

arthritis

has

been

made

In

our

study

the

occurrence

of

sick

leave

decreased

with

time

a

finding

that

can

not

be

completely

interpreted

as

a

positive

observation

as

it

was

in

part

explained

by

patients

on

sick

leave

becoming

permanently

work

disabled

-LRB-

Table

-RRB-

Table

situation

after

months

of

follow-up

in

patients

with

early

arthritis

who

reported

sick

leave

at

study

entry

-LRB-

in

one

patient

the

duration

of

sick

leave

was

unknown

-RRB-

Study

entryFollow-upDuration

of

sick

leavePartial

work

disabilityFull

work

disabilitySick

leave

weeksSick

leave

monthsSick

leave

monthsNo

sick

weeks

-LRB-

n

-RRB-

months

-LRB-

n

-RRB-

months

-LRB-

n

-RRB-

In

our

study

of

the

patients

were

permanently

work

disabled

after

years

of

follow-up

This

figure

is

in

the

same

range

or

somewhat

more

favourable

than

work

disability

rates

found

in

previous

studies

in

patients

with

early

RA

-LSB-

-RSB-

In

fact

our

results

may

even

be

more

favourable

as

work

disability

was

partial

in

the

majority

of

patients

whereas

in

other

studies

only

complete

job

loss

was

considered

It

should

be

noted

however

that

our

study

concerned

various

forms

of

chronic

arthritis

and

a

deterioration

of

the

working

situation

appeared

to

be

more

frequent

among

patients

with

a

diagnosis

of

definite

RA

than

in

patients

with

other

forms

of

arthritis

Our

results

are

in

concordance

with

the

observation

that

the

incidence

of

permanent

work

disability

among

RA

and

AS

patients

appears

to

be

declining

over

the

last

decades

most

probably

related

to

new

developments

in

pharmacological

therapy

-LSB-

-RSB-

Indeed

the

patients

included

in

our

study

were

promptly

treated

with

the

medical

treatment

for

the

patients

with

RA

consisting

of

either

monotherapy

with

methotrexate

or

salazopyrine

or

treatment

according

to

the

BeSt

protocol

-LSB-

-RSB-

In

this

study

the

duration

of

symptoms

varied

among

patients

so

that

not

all

patients

were

at

equal

risk

of

developing

sick

leave

or

work

disability

The

impact

of

the

symptom

duration

may

however

be

limited

as

one

of

our

analyses

showed

that

symptom

duration

had

no

effect

on

the

development

of

more

work

disability

in

the

follow-up

period

of

months

In

this

study

no

control

group

was

used

for

comparison

Data

from

the

Dutch

Central

Bureau

of

Statistics

-LRB-

-RRB-

indicate

that

there

is

a

considerable

background

risk

of

sick

leave

and

work

disability

in

the

general

population

However

as

in

this

study

patients

were

explicitly

asked

to

report

sick

leave

and

work

disability

due

to

arthritis

it

is

doubtful

whether

this

background

risk

needs

to

be

taken

into

account

It

appeared

that

sick

leave

and

work

disability

rates

among

patients

with

early

arthritis

were

considerably

higher

than

those

in

the

general

population

however

for

valid

comparisons

a

separate

study

with

similar

registration

methods

among

patients

with

early

arthritis

and

the

general

population

is

needed

With

respect

to

the

determinants

of

work

disability

similar

to

studies

in

RA

-LSB-

-RSB-

disease

severity

was

in

general

higher

and

physical

and

psychological

functioning

worse

among

patients

in

whom

the

working

status

deteriorated

than

in

those

in

whom

the

working

status

remained

stable

The

fact

that

the

association

of

some

measures

of

disease

severity

or

physical

or

psychological

functioning

with

changes

in

the

working

status

did

not

reach

statistical

significance

may

have

been

due

to

the

relatively

small

sample

size

of

this

study

Moreover

our

finding

that

the

occurrence

of

sick

leave

in

the

months

before

study

entry

was

associated

with

a

deterioration

of

the

working

situation

is

in

concordance

with

the

results

of

another

study

by

our

group

among

another

group

of

patients

with

various

form

of

chronic

arthritis

-LSB-

-RSB-

The

results

of

both

studies

underscore

the

importance

of

the

recognition

of

sick

leave

as

a

risk

factor

for

work

disability

in

patients

with

chronic

arthritis

Previously

it

has

been

questioned

whether

rheumatologists

do

sufficiently

recognize

patients

working

problems

-LSB-

-RSB-

of

which

sick

leave

could

be

considered

as

one

of

its

manifestations

Apart

from

paying

attention

to

the

presence

of

sick

leave

the

use

of

instruments

that

have

been

specifically

developed

for

the

identification

of

those

individuals

with

chronic

arthritis

having

difficulties

at

work

could

be

helpful

because

by

using

these

tools

working

problems

could

be

recognized

in

earlier

stages

Examples

of

those

instruments

are

the

RA-Work

Instability

Scale

-LSB-

-RSB-

and

the

Work

Limitations

Questionnaire

-LSB-

-RSB-

In

addition

Detaille

et

al.

-LSB-

-RSB-

showed

which

issues

are

important

from

the

patients

perspective

and

recommended

a

topic

list

for

various

health

professionals

to

use

during

consultations

So

far

these

instruments

are

only

partly

validated

have

been

mainly

used

in

studies

and

are

not

developed

to

be

applied

at

the

individual

level

At

present

valid

and

brief

questionnaires

specifically

designed

for

clinical

practice

are

not

yet

available

It

is

however

conceivable

that

simply

asking

patients

about

working

problems

or

sick

leave

is

another

sensitive

method

to

identify

patients

at

risk

of

work

disability

The

results

of

this

study

show

that

over

a

period

of

years

in

of

the

patients

the

work

situation

was

adapted

about

received

help

from

the

employer

or

colleagues

and

of

patients

received

professional

guidance

to

maintain

their

job

With

respect

to

the

implementation

of

work

place

adaptations

and

help

from

the

employer

or

colleagues

these

figures

are

in

line

with

those

of

a

recent

study

in

early

RA

patients

-LSB-

-RSB-

In

that

study

it

was

demonstrated

that

support

and

help

of

co-workers

employer

help

shortened

work

days

new

skills

and

a

modified

work

station

or

equipment

were

among

the

work-related

factors

that

significantly

ameliorated

work

ability

With

respect

to

professional

guidance

a

recent

study

in

Dutch

employing

RA

patients

with

a

short

disease

duration

found

that

according

to

the

patients

the

mobilization

of

health

care

professionals

would

help

them

tackle

their

threats

to

work

ability

-LSB-

-RSB-

In

our

study

patients

were

generally

very

appreciative

of

help

concerning

their

working

problems

with

the

lowest

proportions

of

patients

being

satisfied

obtained

for

the

occupational

physician

In

The

Netherlands

the

importance

of

the

role

of

occupational

physician

in

the

maintenance

of

a

paid

job

in

patients

with

chronic

diseases

is

generally

recognized

However

in

a

previous

study

the

communication

between

occupational

physicians

and

rheumatologists

was

found

to

be

hampered

-LSB-

-RSB-

factor

that

could

have

contributed

to

the

relatively

low

satisfaction

scores

A

limitation

of

the

present

study

may

be

that

the

total

number

of

patients

was

relatively

low

and

various

types

of

chronic

arthritis

were

included

hampering

conclusions

about

specific

diagnosis

groups

Moreover

in

this

study

about

of

all

patients

in

the

working

age

range

-LRB-

years

-RRB-

who

entered

the

EAC

participated

in

the

work

disability

study

This

proportion

is

significantly

lower

than

the

percentages

of

patients

with

a

paid

job

at

symptom

onset

in

similar

age

groups

in

early

RA

cohorts

with

frequencies

ranging

between

and

-LSB-

-RSB-

As

the

sociodemographic

and

clinical

characteristics

of

the

non-participants

were

not

systematically

gathered

it

remains

unclear

to

what

extent

the

population

included

in

this

study

differs

from

all

patients

with

early

arthritis

who

have

a

paid

job

at

symptom

onset

Given

the

probability

of

selection

bias

our

results

have

to

be

interpreted

with

care

In

conclusion

this

study

in

patients

with

early

chronic

arthritis

and

a

paid

job

showed

that

the

occurrence

of

arthritis-related

sick

leave

before

and

directly

after

a

diagnosis

is

made

is

substantial

In

contrast

full

permanent

work

disability

developed

in

a

relatively

small

minority

Work

place

adaptations

professional

guidance

and

help

from

employers

or

colleagues

to

maintain

a

paid

job

were

fairly

common

Future

research

should

aim

at

the

detection

of

patients

at

risk

for

the

development

of

sick

leave

and

permanent

work

disability

as

well

as

the

optimization

of

the

process

of

vocational

guidance

B I O B I O O O O B O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O B O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B I O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B I O B I O O B O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O B O O O O O O O B O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O B I O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O B I O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O B O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O B O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O B I O O O O O O O O O O O O O O O O O O B I O B I O O B O O O O O O O O O O O O O O O O O O B I O B I O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O B I O O O O O B I O O O O B O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O B I O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O O B I O O B I O O O O O O O O O O O O O

occupational health
vocational rehabilitation