Oral health care among nursing home residents in Avon

OBJECTIVE

To assess personal oral health care standards among frail, elderly and infirm nursing home residents prior to developing and evaluating a health promotion intervention.

DESIGN

Descriptive survey, interview and clinical data.

SETTING

22 randomly selected nursing homes in the Bristol area.

METHOD

412 residents with denture(s) and/or natural teeth, and giving informed consent to the study were interviewed about dental attendance and current dental problems. A clinical examination assessed levels of oral and denture hygiene, denture-related stomatitis, gingivitis, calculus and root caries.

RESULTS

Less than half the subjects (mean age 84.5 years) were ambulant. Over 70% had not seen a dentist for over 5 years, and 22% reported a current dental problem. Among denture wearers, 82% were unable to clean their dentures; staff cleaned dentures for 64%. Denture-related stomatitis affected 33%, and unhygienic dentures were worn by 95% of subjects. Among dentate subjects (mean number of teeth 11.6), 75% were unable to clean their teeth yet none received regular assistance. On average, two-thirds of each tooth surface were covered in plaque. Gingivitis was moderately severe. Calculus was present in 82% of subjects and root caries in 63% of subjects.

CONCLUSIONS

Most residents required help with oral health care but many did not receive it. Residents' levels of plaque and associated dental disease were high. Staff did not effectively perform oral health care appropriate to residents' needs. Further research to evaluate an oral health care training programme for care staff is planned.

Candida albicans strain differentiation in complete denture wearers

Strain differentiation of 66 clinical isolates of Candida albicans obtained from healthy dentate and complete denture wearers was performed. Resistogram method based on differences in the resistance of C. albicans isolates to sodium selenite, boric acid, cetrimide, sodium periodate and silver nitrate was used for strain differentiation. Of the 32 potential strains that can be distinguished, 14 different resistogram strains of C. albicans were found among the 66 isolates tested. Strain-C--was the most predominant (24.3% of total isolates), while strain A-CDE was the least predominant (1.5%). The results showed no particular association of certain strains with Candida infections in complete denture wearers. Sensitivity to antifungal agents showed that isolates from different strains were most sensitive to amphotericin B and nystatin and least sensitive to miconazole.

Effects of an oral health program on the occurrence of oral candidosis in a long-term care facility

OBJECTIVES

The aim was to evaluate the effectiveness of a preventive oral health program on the prevalence of oral candidosis in 237 frail or dependent residents in a long-term care facility. Half of the residents were included in an experimental group which benefited from a preventive oral hygiene program including instruction of the carers and implementation of a recall program for professional oral hygiene care.

METHODS

Intraoral examinations and yeast cultures from the oral mucosa and the fitting denture surface were carried out at baseline and 18 months later. The outgrowth of yeast was estimated on Oricult-N dip slides using the scale: no growth; 1-20 colonies; 21-100 colonies; >100 colonies.

RESULTS

At baseline (n = 237) and at 18 months (n = 159) the experimental and the control groups were similar with regard to the residents' distribution by age, sex, dental and prosthetic status and prevalence of denture stomatitis. The 78 residents lost had the same baseline characteristics as the survivors, except for being older. In the experimental group the severity of the inflammation of the palate decreased (P = 0.005) as well as the prevalence of glossitis (P = 0.005). At baseline high yeast scores from the mucosa (>20) were observed in about 50% of the residents in the experimental as well as the control group. At 18 months this figure was 23.4% for the experimental and 48.7% for the control group (P = 0.001). There was also a reduction of the number of residents with positive cultures and the denture yeast scores at 18 months in the experimental group (P = 0.05).

CONCLUSIONS

This study has shown that the preventive program was effective in reducing the colonization of the oral mucosa and dentures by Candida and thereby improving the health of the oral mucosa.

[Non-Hodgkin lymphoma of the maxilla. Report of a case]

Lymphomas are primitive neoplasias of the lympho-reticular system and are classified into two principal categories: Hodgkin's lymphoma (HL) and Non-Hodgkin's Lymphoma (NHL) each classified into low, medium and high grades, according to their clinical and cytological characteristics. The treatment and prognosis of such neoplasias vary according to the distribution of the illness and to the moment of initial diagnosis. In NHL, treatment depends prevalently on the histological subtype. Over the last few years it has been possible to associate to defined nosographic entities a characteristic phenotype, and to formulate a phenotypical classification of chronic lymphoproliferating illnesses. The classification of the Working Formulation subdivides lymphomas into groups of increasing malignancy. In histological sections, non-Hodgkins lymphomas are relatively homogeneous, uniformly cellular and dominated by malign lymphocytes. The symptomatology of NHL can vary according to the different location. The clinical manifestation of NHL can be in the form of swelling or ulceration. In contrast with lymphonodal lymphoma, in which the spread through blood to distant lymphonodal regions or extra lymphonodal areas is rapid, the extra lymphonodal ones show a clinical course of illness comparable with those of carcinomas. The authors present the case of a 89 year-old patient with an ulcerated, non painful swelling in the upper right alveolar maxillary region, showing slow development, soft consistency and indefinite edges; this lesion did not affected the normal physiological functions of the stomatognathic apparatus, thus explaining why the patient had noticed the appearance of the process two years prior to the visit but had not reported it. The pathological case-history shows traumas at the site of the lesions due to dentures. At the moment of the visit, the ortopathomographic examination of the upper and lower dental arch shows the presence of a lesion in the right maxillary region, radiographically opaque, with ill-defined margins and signs of continuity with the homolateral maxillary sinus.

A clinical evaluation of 76 implant-supported superstructures in the composite grafted maxilla

The aim of the study was to evaluate the material behaviour and nature of implant-supported superstructures in function. A total of 37 overdentures, 26 fixed partial and 13 fixed full dentures with a mean lifetime of 40 months were clinically evaluated in relation to damage, occlusion and articulation, parafunction, retentive devices, hygiene and speech problems. In general 70% of all superstructures were damaged. Fixed partial dentures were significantly less damaged than overdentures and fixed full dentures (P<0.001). A significant high percentage of newly gained parafunction was found (P<0.05).

Clinical complications of osseointegrated implants

STATEMENT OF PROBLEM

There is no comprehensive review of the literature that identifies the complications reported in clinical dental implant studies.

PURPOSE

This article attempted to determine the types of complications that have been reported and to provide data regarding their frequency.

METHODS

All available clinical studies from 1981 to 1997, published in English or with English abstract, that presented success/failure data regarding implant treatment were evaluated to determine the types of reported complications and to quantify implant loss as it relates to type of prosthesis, arch, time, implant length, and bone quality.

RESULTS

Greater implant loss occurred with overdentures than with other types of prostheses. There was greater loss in the maxilla than mandible with fixed complete dentures and overdentures, whereas little arch difference was noted with fixed partial dentures. Implant loss increased with short implants and poor bone quality. The time of implant loss (preprosthetic vs postprosthetic) varied with type of prosthesis. Surgical complications included neurosensory disturbance, hematoma, mandibular fracture, hemorrhage, and tooth devitalization. Initial and long-term marginal bone changes were identified. Peri-implant soft tissue complications included dehiscence, fistulas, and gingival inflammation/proliferation. Mechanical complications were screw loosening/fracture, implant fractures, framework, resin base and veneering material fractures, opposing prosthesis fractures, and overdenture mechanical retention problems. Some studies also presented phonetic and esthetic complications.

CONCLUSIONS

Although the literature presents considerable information on implant complications, variations in study design and reporting procedures limited the available data and therefore precluded proper analysis of certain complications.

Associations between self-assessed masticatory ability, nutritional status, prosthetic status and salivary flow rate in hospitalized elders

OBJECTIVES

To compare the association between self-assessed masticatory ability and nutritional status with general health status, salivary flow and dental/prosthetic status.

DESIGN

A questionnaire and a cross-sectional clinical investigation combined with a measurement of salivary flow rates.

SUBJECTS AND METHODS

A cohort of 99 elderly, non-psychiatric patients in a geriatric hospital; clinical examination to determine dental and prosthetic status, oral health and whole unstimulated (USFR) and stimulated (SSFR) salivary flow rates, examination of anthropometric measures, serum albumin level and body mass index (BMI); questionnaire designed to produce yes or no answers related to masticatory function, nutritional status, appetite and prosthesis function; mini mental score examination (MMES).

MAIN OUTCOME MEASURES

USFR, SSFR, BMI, anthropometric measures and serum albumin level; complaints related to appetite and xerostomia.

RESULTS

Mean age of the 99 patients was 82.5 +/- 4.04 with a MMES of > 21; 50% with malnutrition of severe or intermediate degree, and 86% with moderately or severely reduced serum albumin concentration; 55% reported recent loss of appetite and 52% had symptoms of oral dryness. Recent loss of appetite was associated with reduced serum albumin and complaints of dry mouth and lack of appetite was associated with BMI < 21, 10% weight loss during the preceding 6 months, SSFR < or = 0.5 ml min-1 and wearing dentures. Complaints on poor retention of the maxillary denture were associated with recent weight loss and SSFR < or = 0.5 ml min-1.

CONCLUSIONS

Malnutrition in hospitalized elders is primarily associated with recent loss or lack of appetite whereas complaints related to dentures are associated with poor denture quality.

Factors associated with the presence of denture related stomatitis in complete denture wearers: a preliminary investigation

Various factors have been associated with the presence of denture related stomatitis. These include local factors such as continuous denture wear, trauma from dentures and poor denture hygiene Systemic factors, use of various pharmacological agents and smoking have also been implicated. This investigation involved history taking and examination of 250 patients attending Guy's Hospital for the construction of complete dentures. No association was found between systemic factors, use of pharmacological agents or smoking and the presence of denture related stomatitis. Night wear of complete dentures was found to be significantly associated with the prevalence of denture related stomatitis.

Relationship of masticatory mandibular movements to masticatory performance of dentate adults: a method study

This study evaluated a sieve method for measuring masticatory performance and determined the associations between masticatory performance and masticatory mandibular movements. Ten dentate adults and three complete denture-wearing subjects participated in the study. The masticatory performance indices for these subjects were determined after a 10 s masticatory sequence and another sequence that ended at the swallowing threshold. Almond was used as the test food and almond fragments were sized using a standard 0.65 mm square size brass wire sieve. Masticatory mandibular movements were simultaneously recorded by an optoelectronic device. The reproducibility of the masticatory performance tests was good (r = 0.98 and 0.82 for the 10 s and swallowing threshold test indices, respectively). The masticatory performance indices were markedly different between dentate and denture-wearing subjects. The 10 s masticatory performance index in the dentate subjects, showed moderate to rather strong correlation with all parameters of mandibular velocity (r = 0.6-0.7). The 10 s index also showed a strong negative correlation to the duration of the occlusal level phase and the total duration of the chewing cycle (r = -0.7 to -0.8) in the dentate subjects. This study confirms that masticatory performance levels are relatively stable and associated with the efficacy of specific masticatory mandibular movement parameters.

The aetiology, diagnosis and management of denture stomatitis

This article examines the evidence for the aetiology, diagnosis and management of denture stomatitis. Extensive reviews of the literature using the Index to Dental Literature, references in relevant publications and computerised databases were employed. Microbiological confirmation of implicated Candida infection should be sought before prescribing antifungal drugs.

[Changes in the biological and immunologic parameters in the oral cavity of the aged. Review]

Senescence is the effect of the immune system incapacity to see "self" and "non-self"; timo-involution induced down-regulation of immunoregulatory -T and B-lymphocytes. Immunosenescence mutations in oral cavity are examined. Even the oral ecosystem presents disorders in quality and quantity of the bacterial plaque and a different immune response. Age senescence is particularly evident in the masticatory apparatus, in fact the dental tissues have remarkable morpho-structural physiological changes; the epithelial, connective and osseous tissues of the periodontium have structural age changes related to the collagen synthesis and physical properties, with an increase of the stroma and a decrease of cell population. The osseous tissue presents cellular atrophy, sclerosis, osteoporosis and is undergoing a continuous structural remodelling; the oral mucous membranes show a thinning of epithelium and an increase of the stroma related to the parenchyma. Specific individual changes could be appraised in the involution of stomatognathic apparatus, more than an indefinite reduction of the performances.

Evaluation of an optical instrument for objective assessment of oral mucosal erythema

This study evaluated the sensitivity and reproducibility of an optical instrument, the Erythema Meter, for quantifying erythema of palatal mucosa. The instrument is based on the principle that haemoglobin in the vasculature selectively absorbs green light but has little effect on red light and allows derivation of an 'erythema index'. Non-clinical investigations were carried out by taking a series of Erythema Meter readings from each colour block on a red check-standard used by graphic artists for colour reproduction. For clinical assessment, 20 dentate patients with healthy palatal mucosa and 40 complete denture wearers (20 with denture stomatitis and 20 with healthy palatal mucosa) were enrolled, and palatal erythema determined both visually and using the Erythema Meter. Two weeks later the Erythema Meter readings for the 40 patients with healthy palatal mucosa were repeated, to allow assessment of the reproducibility of the Erythema Meter scores. The median erythema index was 12 (range 2-38) for dentate patients with healthy palatal mucosa and 5 (range 0-29) for denture wearers with healthy palatal mucosa. For denture stomatitis patients the median erythema index was 95 (range 36-117). The overall reproducibility coefficient was 88%. Visual scoring correlated poorly with the Erythema Meter scores for those with moderate degrees of erythema. The Erythema Meter provides an objective and reproducible means of measuring the degree of erythema of the palatal mucosa.

Inflammatory papillary hyperplasia: supraperiosteal excision by the blade-loop technique

Inflammatory papillary hyperplasia (IPH) is a benign, irreversible, persistent, and usually painless lesion of the oral mucosa that is the result of epithelial proliferation. Many surgical methods of treatment have proven to be not totally satisfactory in case of surgery, completeness of tissue removal, healing time, or patient comfort in the postoperative period. A relatively simple and effective procedure is proposed for the supraperiosteal excision of this lesion from the palate, using a razor blade cutting element and handle, called the blade-loop knife, or the Paquette knife handle. The blade-loop technique minimizes trauma and results in a short and comfortable postoperative period.

A multicenter survey of amalgam fillings and subjective complaints in non-selected patients in the dental practice

The aims of this study were to examine whether there is a difference in symptoms between patients with amalgam fillings and patients without such restorations, to investigate the relationship between particular symptoms and the number of amalgam filled surfaces, and the differences in symptoms between patients with and without removal of amalgam fillings. Data from 6744 consecutive patients in 34 dental offices located throughout Germany were documented. Patients completed a questionnaire answering 48 items, and the current oral findings in the patients were registered. The analysis was restricted to 4,787 patients aged 21 to 60 yr because of special dental conditions in children and elderly persons. The study did not show any significant correlation between the intensity of complaints or particular groups of symptoms and the number of amalgam-filled surfaces. A higher number of symptoms as well as a higher intensity of symptoms were found in patients before amalgam removal compared to the remaining patients. The question remains open whether or not there may be a certain kind of relationship between the complaints and amalgam fillings in individual patients.

Candida-associated denture stomatitis. Aetiology and management: a review. Part 2. Oral diseases caused by Candida species

Certain systemic conditions and/or defects in the immune system may predispose the host to oral candidal infection and the commonest form of oral candidosis is candida-associated denture stomatitis. Until recently there has been controversy concerning the aetiology of the disease. Although some earlier investigators linked denture stomatitis with trauma or bacterial infection, others had isolated Candida albicans from the mouths of patients with the condition. Current studies indicate that denture stomatitis lesions are associated with the detection of candida species while other factors such as denture hygiene, trauma, systemic diseases and deficiencies of the immune system may be involved.

Perceptions of complete dentures by prospective implant patients

PURPOSE

The purpose of this study was to facilitate the recognition of denture patients who are unable to adapt to conventional dentures and who are likely to benefit from treatment using implant-supported prostheses.

MATERIALS AND METHODS

Sixty-nine patients who where referred for postgraduate prosthetic treatment at Wits Dental School completed a self-report inventory of items related to their dentures in current use. Conventional dentures were fabricated for all subjects. Those patients who could not adapt to conventional complete denture treatment were referred for treatment with implant-supported prostheses provided that they conformed with the recommended criteria for this treatment modality.

RESULTS

Analysis of the inventory of pretreatment denture complaints yielded variables that differentiated between the group who remained with conventional dentures and the group that was referred for implants. Significant variables were the period that a mandibular denture was used before new dentures were requested (P = 0.025); the period that a maxillary denture was used before further treatment was sought (P = 0.03); the discarding of a mandibular denture (P = 0.035); and pain complaints related to maxillary dentures (P = 0.045). A logistic regression model was used to compare the clinical division of the sample with that determined by the mathematic model. Sixty-six percent of the subjects who accepted conventional treatment and 69% of implant patients corresponded for both classifications.

CONCLUSION

The authors conclude that pretreatment denture complaints can be used diagnostic aids for evaluating patients who are likely to benefit from implant-supported prostheses.

Construction faults, age, gender, and relative medical health: factors associated with complaints in complete denture patients

STATEMENT OF PROBLEM

Many practitioners will experience a situation, whereby a patient with newly fabricated complete dentures continues to experience difficulty in adapting to them. This can lead to a protracted period of discouraging "adjustment appointments" that may not result in the eventual resolution of the problem. Therefore it is often concluded that there is some patient factor, either age, gender, medical, or psychologic status that is hindering the success of treatment.

PURPOSE

This study examined a group of 100 patients who experienced ongoing difficulties with their new complete dentures, to determine possible underlying causes.

MATERIAL AND METHODS

A retrospective study was conducted with information derived from patient records. All patients were treated by the same prosthodontist after having been referred specifically for their denture problems. Information regarding patient age, gender, medical and psychological histories, and information pertaining to the dentures at the time of presentation was derived from patient records.

RESULTS

Statistical analysis comparing age, gender, and medical and psychologic status with the number or type of patient complaint failed to show any significant relationships. Significant relationships were observed when denture design faults or the condition of a patient's mucosa were compared with patient complaints.

CONCLUSIONS

This study suggests that in most instances, complete denture patients present with complaints only when there is a real design fault or a tissue problem.

The traditional therapeutic paradigm: complete denture therapy

The art and science of complete dentures for oral restoration has been espoused and debated for over a century. A tradition of clinical mentoring has passed this prosthodontic trust through time to create an educational cycle where the pupil ultimately became the tutor for yet another pupil. Today's clinical techniques and judgments are an amalgamation of these original prosthodontic philosophies. This article will bring forward some procedures for the fabrication of complete dentures for the scrutiny of their scientific bases. Scrutiny does not imply that aspects of therapy not proved in studies of rigorous scientific design are untruths. However, it is incumbent that those aspects of denture therapy regarded as "public domain" by the corpus of the profession be analyzed. It is also incumbent that possible costly or harmful aspects of denture therapy be identified. There is a paucity of "procedural research" in clinical investigations; research that involves performing an invasive or clinician-intensive procedure. This article also discusses the difficulties in performing procedural research as a means of understanding its importance, but also realizing the reasons that this type of research is not prevalent in the dental and health professional literature. The most common types of investigations used to evaluate patient acceptance and function of dentures will also be discussed.

Clinical morbidity and sequelae of treatment with complete dentures

Wearing complete dentures may have adverse effects on the health of both the oral and the denture-supporting tissues. This article is a review of selected literature on the sequelae of treatment with complete dentures in the specific areas of residual ridge resorption, mucosal reactions, burning mouth syndrome, temporomandibular disorders, and patient satisfaction. Recent literature found with a Medline search from 1952 to 1996 is included in this review. Residual ridge resorption is an inevitable consequence of tooth loss and denture wearing, with no dominant causative factor having been found. Mucosal reactions have a multifactorial cause, most of which can be easily treated. Most patients are satisfied with their complete dentures. Correlations between anatomic conditions and denture quality and patient satisfaction are weak. Psychologic factors seem to be extremely important in the acceptance of and adaptation to removable dentures. There are still no reliable methods to predict the outcome of complete denture treatment and there are many problems related to treatment with complete dentures. Although the prevalence of an edentulous condition is decreasing, the great number of edentulous people warrants the continuing efforts of basic and clinical research on removable partial dentures. Complete denture prosthodontics will remain an important part of dental education and practice. In addition to clinical and technical skills, insight into patient behavior and psychology and communication techniques are also necessary.

The association of yeasts and denture stomatitis with behavioral and biologic factors

OBJECTIVES

This study describes the association of yeasts and denture stomatitis with behavioral and biologic factors.

STUDY DESIGN

Seven hundred eighty 55-year-old citizens of Oulu, Finland, were examined clinically; 452 of them had complete dentures. Salivary yeasts and lactobacillus counts were detected through the use of Oricult-N and Dentocult-LB dip-slide techniques. Lifestyle factors were measured by means of questions concerning physical activity, tobacco smoking, alcohol consumption, and dietary habits. Other background variables used in cross-tabulations and logistic regression analysis were unstimulated salivary secretion rate, retention of denture, oral hygiene, gender, and socioeconomic status.

RESULTS

The prevalence of denture stomatitis was greater among subjects with an unhealthy lifestyle, subjects with higher lactobacillus counts, and subjects with poor oral hygiene. Salivary secretion rate and smoking were associated with the presence of yeasts, but general lifestyle measures were not.

CONCLUSION

The presence of yeasts tended to be associated with biologic factors, but behavioral factors reflecting lifestyle may be more important in the development of denture stomatitis.

The effect of diet on the bearing mucosa during adjustment to new complete dentures: a pilot study

PURPOSE

This pilot study investigated the reliability of the conventional prosthodontic wisdom that a modified diet ameliorates soreness during the adjustment to new complete dentures. Tissue ulceration of the bearing mucosa served as the indicator of patient soreness as a function of diet.

MATERIAL AND METHODS

Fourteen men were randomly assigned to two equal treatment groups. One group consumed a consistency-gradated diet and the other (control) ate as they wished. New complete dentures were fabricated for both groups by the same provider, technician, materials, and method; the study was double-blinded. Tissue ulceration was assessed and totaled for the 10 days after denture placement, constituting a soreness score.

RESULTS

Data analysis identified a significant difference in soreness scores between dietary groups (p < 0.05). Wearing time had a significant inverse relation to soreness (p < 0.05) in this study. A host of potential explanatory variables of clinical interest failed to relate significantly to the outcome of soreness.

CONCLUSIONS

The results of this study indicated that a consistency-gradated diet had a significant effect in diminishing tissue ulceration during the immediate postplacement period for this group of men. Potentially, these findings could contribute to enhanced quality of care and to the more efficient allocation of provider-based resources.

Home relines and residual ridge resorption

Two cases of patients who have relined their complete dentures with home-applied materials in an attempt to improve the denture stability are discussed. The resultant damage to the residual tissues is described. A review of the literature on the effects of home relines leads to suggestions for the regular review of patients who wear complete dentures.

Effect of complete denture renewal on oral health--a survey of 42 patients

The effect of complete denture renewal on oral health was evaluated both subjectively and clinically at follow-up 30 months (range 19-36 months) after completion of treatment in 42 edentulous patients (31 women and 11 men, aged 34-76 years) treated by dental students during 1989-1992. Ninety per cent of the patients were satisfied with the new appearance of their dentures and 71% with the way they functioned. When comparing the base data and results from follow-up it seems that general health and medication, anatomical circumstances, salivary flow rates and denture wearing habits in edentulous subjects do not change significantly over a few years. The main effects of denture renewal are seen in patient satisfaction, and clinically in the improved condition of oral mucosa and better fit and acceptable occlusion of dentures.