Oral and maxillofacial surgical therapy for the older adult

Older adults can present with a wide range of oral and maxillofacial diseases and conditions, and many of these are best treated surgically. One of the distinguishing features of geriatric surgery is the large percentage of older adults who have medical conditions that must be planned for perioperatively. Good communication between the surgeon and the primary care physician is important for this perioperative management. Orofacial infections, the most common of which are odontogenic in origin, require some form of surgical treatment and may or may not require treatment with antibiotics. Preprosthetic and reconstructive surgery may be necessary to treat the sequelae of oral and maxillofacial fractures, the sequelae of tooth loss, or surgical defects incurred during the treatment of cancer, osteomyelitis, osteoradionecrosis, or disorders of the TMJ.

Periodontal status of older Floridians attending senior activity centers

Older adults attending senior activity centers in Florida cooperated for a questionnaire and an oral examination. The 671 ambulatory dentate seniors in this report had a mean of 17.0 teeth. The mean attachment loss was 3.5 mm from the cementoenamel junction (CEJ), and the mean pocket depth was 2.1 mm. 24% of the sample had at least 1 site with attachment loss of 7 or more mm; the majority of these persons had only 1 or 2 severely-involved sites. The extent and severity index of attachment loss (2 mm or more threshold) was (88%, 3.7 mm). Use of pocket depths alone would have substantially underestimated prevalence of periodontitis in this older sample. Sites with severe attachment loss were typically not accompanied by severe pockets. Evidence of a history of moderate disease in this cross-sectional study was prevalent (62% of persons had a maximum attachment loss of 4-6 mm), as was evidence of a history of severe disease (24% had at least 1 site with attachment loss of 7 mm or more).

An operational definition of the homebound

Homebound status is a critical eligibility criterion for Medicare reimbursement of some home care services, yet little discussion has been undertaken to establish a valid definition of it. We propose an operational definition of homebound status, and we measure its validity for community-dwelling elderly in the Massachusetts Health Care Panel Study (MHCPS). The MHCPS is a longitudinal study of a cohort of elderly persons (N = 1,625), which began in 1974, with follow-up surveys in 1976, 1980, and 1985. Validity was measured by comparing responses from the operational measure to persons' responses to questions that we judged should be associated with a valid measure of homebound status. This construct validity method resulted in correlations that were significant and in the expected direction, and that suggested that this operational measure is a highly specific, moderately sensitive, valid measure. These results underscore the need for researchers investigating the homebound to discuss the validity and limitations of their homebound measures, and in what context these measures are useful.

Factors influencing the effectiveness of mailed health surveys

The authors investigated sources of bias in health surveys by examining responses to their 1989 questionnaire mailed to 1,255 Massachusetts men who were eligible for dental care provided by the Department of Veterans Affairs. After a maximum of three mailings and one telephone call to nonrespondents, a total of 1,049 veterans had responded out of 1,228 finally determined to be eligible, a response rate of 85 percent. The investigators found that small differences in univariate estimates would have occurred had the field phase been terminated after the first mailing, which had a response rate of 61 percent. To evaluate multivariate distributions, they duplicated their previously published logistic regression model for sources of dental care, using only those who responded to the first and second mailings. Although model fits would have been substantively the same had the field phase been terminated after the first or the second mailings, analysis of parameter estimates and their statistical significances suggested bias that would have led to different substantive conclusions, in some instances. Another potential source of bias in surveys was found to be item omission. Fifty-eight percent of respondents answered all 46 survey questions, and 90 percent answered at least 91 percent of the questions. Fewer questions were answered by those whose responses were received last, but trends regarding missing data by age or education were not statistically significant. Although the survey using this methodology met all objectives, subject nonresponses, the ineligibility of potential respondents, item nonresponses, and skewed distributions of outcome variables combined to reduce the statistical power to detect differences among groups or to alter the analysis of the differences. These factors need to be planned for by investigators undertaking similar surveys.

Tooth loss and caries prevalence in older Floridians attending senior activity centers

Older adults attending 14 senior activity centers in six countries of Florida cooperated for a questionnaire and an oral examination. The mean age was 76.5 yr, and about one-third were 80 yr or older. One-third of the dentate persons had dental caries. Most of the carious lesions were on the crown, not the root, and most of the decay was primary, not recurrent. Most of the persons with a need for caries treatment were likely to seek dental care; however, the majority of carious surfaces were in persons who reported being infrequent users of care. These results from ambulatory older adults suggest that older adults have significant caries treatment needs, and provide support for the view that the treatment of older U.S. adults may grow in the coming decades.

Predictors of older adults' longitudinal dental care use. Ten-year results

Our purpose was to identify factors predictive of reported dental care use by elders (65+) over a ten-year period in Massachusetts. The Massachusetts Health Care Panel Study began in 1974-75 (wave 1) as a statewide survey of 1625 noninstitutionalized elders. Wave 2 occurred in 1976, wave 3 in 1980, and wave 4 in 1985. The 540 persons who participated in all four waves are the subject of this report. The remainder either died, entered nursing home, or were lost to follow-up. This longitudinal design permits analysis of cohort, aging, and period effects. The outcome variables were self-reported dental care use within two years, or more than two years, as reported at waves 1, 3, and 4. Wave 2 was excluded because less than two years had elapsed since the previous wave. To identify factors predictive of reported use, we used a generalization of the logistic regression model that included a random effect term, which accounts for repeated measures being made on the same subjects. Covariates in the model were dentate status, education, income, cohort, sex, martial status, and time. The variable "time" served as a measure of aging/period effects. Persons were grouped into four birth cohorts. Before adjusting for other covariates, cohort was significantly associated with dental care use, but was not so in the full multivariate model. Dentate status, education, and income were significant predictors of use. The cohort effect was explained by dentate status, education, and income. Time was not significant, indicating no aging/period effects in this ten-year period, or that their net effect was zero.

Principles of surgical risk assessment of the elderly patient

Treatment of the elderly will comprise increasingly higher proportions of practice time in the future, and issues regarding this treatment are more salient now than ever before. Because more elders are seeking treatment, surgeons need to be comfortable with assessing the potential risks associated with surgical procedures in their elderly patients, many of whom have multiple chronic diseases. Risks that need to be considered are those physiologic changes normal for aging, pathologic changes due to disease, and psychosocial changes that may occur with aging. This article assesses the contribution each of these changes makes to surgical risk, and discusses the principles of gerontology and geriatric medicine that are relevant to risk assessment.

Issues in financing dental care for the elderly

The elderly make up an increasingly larger segment of the patient population in dental practices. This article reviews recent epidemiologic, demographic, and health services research, and concludes that significant segments of the elderly are at high risk for oral disease and/or limited access to dental treatment, and consequently warrant classification as high-risk groups for policy considerations. It then proposes policy options to the dental community and public decision makers. Oral care can be viewed as having three components. Two basic components are the primary care component--which includes diagnostic, preventive restorative, and periodontal care--and the acute care component--i.e., the treatment of oral pain, trauma, and infection. The third, rehabilitative component, has to do with the restoration of oral function, including prosthodontics and cosmetic dentistry. Viewing dental care in this perspective may help link funding for dental primary care services with that for other primary health services, and link restoration of function and improvement of quality of life with similar health services, like hearing, vision, and social services. In addition, approaching dental care policy makers on several levels--i.e., federal, state, and local--will contribute to our ability as a profession, in the decades ahead, to meet the oral health needs of more elders: including the frail, those at high risk for oral disease, and those with limited access to care.

'Ageism' in dental care delivery

Older adults will comprise increasingly higher proportions of dentists' practice time in the future, and issues regarding their treatment are more salient now than ever before. Psychosocial issues and attitudes toward treating older patients are among the most important of these. Ageism, defined as negative attitudes or prejudice toward older adults, has implications in dental care delivery. It can be manifested by the attitudes that older people have toward their own aging process, by those who provide their health care, and by society. This article proposes a more appropriate definition of ageism, and discusses the forms ageism can take in the dental care setting.

Phenytoin sensitivity of fibroblasts as the basis for susceptibility to gingival enlargement

A side effect of long-term administration of the anti-epileptic drug phenytoin is overgrowth of the connective tissues surrounding the teeth. In this in vitro study of protein and collagen synthesis by diploid fibroblasts from 17 nonepileptic young persons with healthy gingivae, only seven strains of cells responded to phenytoin in culture medium. Because not all phenytoin-treated individuals develop gingival overgrowth, we suggest that susceptibility is predicated upon the presence of a (genetically determined) phenytoin-sensitive subpopulation of gingival fibroblasts. The concept of the participation of sensitive cell subpopulations in other connective tissue disorders is supported by these findings.