Public health issues in geriatric dentistry in the United States

Towards an operational definition of oral frailty: A e-Delphi study

OBJECTIVES

Building upon our recently developed conceptual definition of oral frailty (the age-related functional decline of orofacial structures), this e-Delphi study aims to develop an operational definition of oral frailty by identifying its components.

METHODS

We used a modified e-Delphi study to reach a consensus among international experts on the components of oral frailty. Twelve out of fifteen invited experts in the field of gerodontology participated. Experts responded to three rounds of an online 5-point scale questionnaire of components to be included or excluded from the operational definition of oral frailty. After each round, scores and rationales were shared with all experts, after which they could revise their position. A consensus was reached when at least 70% of the experts agreed on whether or not a component should be included in the operational definition of oral frailty.

RESULTS

The experts achieved a high level of agreement (80 - 100%) on including eight components of oral frailty and excluding nineteen. The operational definition of oral frailty should include the following components: 1) difficulty eating hard or tough foods, 2) inability to chew all types of foods, 3) decreased ability to swallow solid foods, 4) decreased ability to swallow liquids, 5) overall poor swallowing function, 6) impaired tongue movement, 7) speech or phonatory disorders, and 8) hyposalivation or xerostomia.

CONCLUSION

This e-Delphi study provided eight components that make up the operational definition of oral frailty. These components are the foundation for the next stage, which involves developing an oral frailty assessment tool.

Interprofessional collaboration utilizing oral health therapists in nursing homes: Perceptions of oral health therapists and nursing home staff in Singapore

INTRODUCTION

Oral health therapists (OHTs) have the potential to increase the access to oral care for elderly residents in nursing homes (NHs).

AIMS

To evaluate the perceptions of NH staff and OHTs regarding the barriers and enablers toward oral care provision for elderly NH residents, and their perceptions toward interprofessional collaboration through the utilization of OHTs in NHs.

METHODOLOGY

Electronic surveys were completed by 231 direct care and 15 managerial staff from 15 NHs, and 103 OHTs. Factors influencing oral care provision, and aspects of awareness, capabilities, and willingness/interest toward collaboration were evaluated.

RESULTS

The OHTs and NH staff reported mutually positive responses toward interprofessional collaboration. The most frequently reported barriers by the NH staff were the lack of regular support from dental health professionals and inadequate knowledge and skills. The OHTs expressed willingness and competence in assisting the NH staff, but lacked regulatory and educational support.

CONCLUSION

OHTs have the potential to address the barriers faced by the NH staff, if adequately supported through policy and education. Oral health promotion in intermediate and long-term care sectors should take into account this potential for interprofessional collaboration through greater utilization of the skill-set of OHTs.

Oral Health, Diabetes, and Inflammation: Effects of Oral Hygiene Behaviour

INTRODUCTION

The aim of this research was to assess the association between inflammation and oral health and diabetes, as well as the mediating role of oral hygiene practice in this association.

METHODS

Data were from the 2009-2010 National Health and Nutrition Examination Survey. The analytical sample consisted of 2,191 respondents aged 50 and older. Poor oral health was clinically defined by significant tooth loss (STL) and periodontal disease (PD). Diabetes mellitus (DM) was determined by glycemic levels. The outcome variable was serum C-reactive protein (CRP) level, dichotomised as ≥1 mg/dL (elevated CRP) vs <1 mg/dL (not elevated CRP). Two path models, one using STL and DM as the independent variable, the other using PD and DM as the independent variable, were estimated to assess the direct effects of having poor oral health and DM on elevated CRP and the mediating effects of dental flossing.

RESULTS

In path model 1, individuals having both STL and DM (adjusted odds ratio [AOR], 1.92; 95% confidence interval [CI], 1.30-2.82) or having STL alone (AOR, 2.30; 95% CI, 1.68-3.15) were more likely to have elevated CRP than those with neither STL nor DM; dental flossing (AOR, 0.92, 95% CI, 0.88-0.96) was associated with lower risk of elevated CRP. In path model 2, no significant association was found between having both PD and DM and elevated CRP; dental flossing (AOR, 0.91; 95% CI:, 0.86-0.94) was associated with lower risk of elevated CRP.

CONCLUSIONS

Findings from this study highlight the importance of improving oral health and oral hygiene practice to mitigate inflammation. Further research is needed to assess the longer-term effects of reducing inflammation.

Treatment planning considerations in the older adult with periodontal disease

Periodontal health in the elderly is influenced by numerous factors, including systemic conditions, patient compliance, age-associated changes, and restorative procedures. The numerous comorbidities seen in the elderly necessitate individualized approaches for treatment planning. In this paper, we review how age, comorbidities, oral hygiene, and restorative dental procedures collectively influence the treatment and management of the periodontium in the elderly. The elderly population is predicted to double in 30 years, which will have an economic impact the dental profession needs to plan for. Preventative and noninvasive treatment, supportive periodontal therapy, and patient-specific maintenance plans are imperative to maintaining oral health in the older population. Multiple coexisting changes, including xerostomia, altered wound healing, altered bone physiology, altered microbiome, and diminished plaque control, can add complexity to periodontal management. Considerations of the patient's general health, the selected periodontal treatment plan, and the selected completed restorative procedures need to be considered. The influence of caries, fixed prosthodontics, partial dentures, shortened dental arch, and implant therapy can have unintended impacts on periodontal health in the elderly. Adverse periodontal outcomes in the elderly can be minimized by carefully assessing the patient's medical history, impact of medications, functional needs, properly finishing and contouring restorations to avoid plaque accumulation, and designing restorations to allow access for hygiene. Partial dentures can be a source of plaque accumulation leading to periodontal disease, caries, and recession around abutment teeth. A shortened dental arch should be considered as a functional and cost-effective alternative to partial dentures. With dental implants, the patient's tissue phenotype, keratinized tissue quantity, risk of peri-implantitis, and patient access for maintaining adequate oral hygiene are all important to consider. Implant risk-assessment tools show promise by providing a systematic approach for early diagnosis to avoid future complications.

Relationship between Er,Cr:YSGG laser power and surface roughness of lased radicular dentin

Background: This study sought to assess the effect of Er,Cr:YSGG laser power on the surface roughness of lased radicular dentin using atomic force microscopy (AFM).

Methods: Fifteen human radicular dentin samples were randomly divided into five groups: one control (G1, intact) and four experimental groups treated with 0.25W (G2), 0.5W (G3), 0.75W (G4) and 1W (G5) powers of Er,Cr:YSGG laser (2.78µm) at a repetition rate of 20 Hz, with a 600-µm-diameter sapphire tip. After irradiation, surface topography was analyzed by AFM using a Si probe in tapping mode. Quantitative information concerning the arithmetic average roughness (Ra) and quadratic mean roughness (Rq) was obtained from three 5×5µm areas of each sample. The data were analyzed using one-way ANOVA (P<0.05).

Results: The Ra and Rq values increased in G2 and G5 and decreased in G3 and G4 groups compared to the control group. The maximum Ra and Rq values were noted in G5, which were significantly higher than the corresponding values in G3 (P<0.05).

Conclusion: No direct correlation was found between Er,Cr:YSGG laser power and surface roughness of lased radicular dentin. Laser therapy with a mean power of 0.5W and 1W caused the lowest and highest surface roughness, respectively.

Empathy in Dentistry: How Attitudes and Interaction With Older Adults Make a Difference

The development of empathy and positive attitudes are essential elements of professional education. This study explored the nature of empathy and its association with attitudes about, and exposure to older patients in a sample of dental students. Students completed an adapted version of the Jefferson Scale of Physician Empathy (JSPE), the Aging Semantic Differential (ASD) and answered questions about their exposure to older people. Factor analysis was used to identify four factors: (1) Empathy is Valuable, (2) Empathy is Demonstrated, (3) Empathy is not Influential, and (4) Empathy is Difficult to Accomplish. Higher empathy scores were related to the ASD subscale attitude of acceptability of aging and to greater exposure to older adults outside of clinical practice. There were no demographic predictors of higher empathy scores.

Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues

Objective

The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia.

Methods

A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS).

Results

The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without.

Conclusions

Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia.

Clinical relevance

The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.

Mediation Effect of Oral Hygiene on the Relationship Between Cognitive Function and Oral Health in Older Adults

Poor oral health is a common problem among older adults in general and particularly among those with cognitive impairment. The current study was conducted to (a) explore direct and indirect relationships between cognitive function and oral health outcomes and (b) test the mediating effect of oral hygiene on the relationship between cognitive function and oral health. The current study used data from 327 community-dwelling older adults in West Virginia who completed an oral health evaluation, comprehensive cognitive assessment, and questionnaire about oral hygiene. Structure equation modeling was used to test for mediation. Results showed that more severe cognitive impairment was related to poorer oral health outcomes and less frequent tooth brushing and flossing. Tooth brushing serves as a mediator between cognitive impairment and oral health outcome. The current study suggests regular tooth brushing is a promising intervention to maintain oral health among individuals with cognitive impairment. [Journal of Gerontological Nursing, 42(5), 30-37.].

Detection and proportion of very early dental caries in independent living older adults

BACKGROUND AND OBJECTIVES

Dental caries is an important healthcare challenge in adults over 65 years of age. Integration of oral health screening into non-dental primary care practice may improve access to preventive dental care for vulnerable populations such as the elderly. Such integration would require easy, fast, and accurate early caries detection tools. Primary goal of this study was to evaluate the diagnostic performance of optical coherence tomography (OCT) imaging for detecting very early caries in the elderly living in community-based settings. The International Caries Detection and Assessment System (ICDAS) served as gold standard. Secondary goal of this study was to provide baseline prevalence data of very early caries lesions in independent living adults aged 65+ years.

MATERIALS AND METHODS

Seventy-two subjects were recruited from three sites in Southern California: a retirement community, a senior health fair, and a convalescent hospital. Clinical examination was performed using the ICDAS visual criteria and this was followed by OCT imaging. The two-dimensional OCT images (B-scan) were analyzed with simple software. Locations with a log of back-scattered light intensity (BSLI) below 2.9 were scored as sound, and areas equaling or exceeding 2.9 BSLI were considered carious. Diagnostic performance of OCT imaging was compared with ICDAS score.

RESULTS

OCT-based diagnosis demonstrated very good sensitivity (95.1%) and good specificity (85.8%). 54.7% of dentate subjects had at least one tooth with very early coronal caries.

CONCLUSIONS

Early coronal decay is prevalent in the unrestored pits and fissures of coronal surfaces of teeth in independent living adults aged 65+ years. Though OCT imaging coupled with a simple diagnostic algorithm can accurately detect areas of very early caries in community-based settings, existing devices are expensive and not well-suited for use by non-dental health care providers. Simple, inexpensive, fast, and accurate tools for early caries detection by field health care providers working in non-traditional settings are urgently needed to support inter-professional dental health management.

Oral health disparity in older adults: dental decay and tooth loss

Progress has been made in reducing dental caries and edentulism in older adults, but disparities continue to exist related to race, ethnicity, socioeconomic level, and sex. Lack of training in treating medically complex patients, economic factors including absence of coverage for oral health services in Medicare and as a required service for adults in Medicaid, and attitudinal issues on the part of patients, caregivers, and providers contribute to barriers to care for older adults. In addition to the impact of oral health on overall health, oral health impacts quality of life and social and employment opportunities.

The first-choice standard of care for an edentulous mandible: a Delphi method survey of academic prosthodontists in the United States

BACKGROUND

In 2002 and 2009, two consensus statements-one from a symposium in Canada and one from England-were issued that recommended that the first-choice standard of care for an edentulous mandible should be the two implant-retained mandibular overdenture (IRMOD). The authors conducted a survey to determine if, in 2011, U.S. academic prosthodontic experts' opinions were aligned with those in the two consensus statements.

METHODS

The authors administered a Delphi method survey to an expert panel of 16 nationally representative academic prosthodontists to determine if there is consensus on the first-choice standard of care for an edentulous mandible between the IRMOD and a conventional mandibular complete denture (CD). Consensus agreement was defined as a 70 percent agreement level among the panelists.

RESULTS

The panel attained consensus favoring the IRMOD for nine of the 10 parameters assessed-retention, stability, speech, masticatory efficiency, comfort while eating soft foods and hard foods, confidence in intimate situations, satisfaction and self-esteem. The exception was esthetics for which only a majority (51-69 percent) favored the IRMOD.

CONCLUSIONS

The panelists reached consensus that they would recommend an IRMOD instead of a CD as the first-choice standard of care for patients who are healthy or have mild systemic disease, but not for patients with severe systemic disease.

CLINICAL IMPLICATIONS

Surveyed academic prosthodontists recommend an IRMOD as the first choice standard of care when restoring an edentulous mandible of a healthy patient or a patient with mild systemic disease.

A model for dental practice in the 21st century

The dental profession is responsible for the prevention, diagnosis, and treatment of diseases and disorders of the oral cavity and related structures. Although the majority of the US population receives excellent oral health care, a significant portion is unable to access regular care. Along with proposals to develop midlevel providers, the scope of practice for dentists needs to be reconceptualized and expanded. A broad number of primary health care activities may be conducted in the dental office, such as screening for hypertension, diabetes mellitus, and dermatopathology; smoking prevention and cessation activities; and obesity interventions. More than 70% of adults saw a dentist in the past year, which represents an unrealized opportunity to improve both oral health and general health.

The Copenhagen Oral Health Senior Cohort: design, population and dental health

BACKGROUND

  In order to study the way old age influence oral health, the Copenhagen Oral Health Senior Cohort (COHS) has been established.

OBJECTIVES

  To describe the design, measurement procedures, and baseline values for COHS including spatial distribution of restorations and dental caries as well as reasons for non-participation.

MATERIALS AND METHODS

  Seven hundred and eighty-three individuals aged 65 years or older, from a total of 1918 invited elderly people, underwent an interview regarding oral health-related behaviour and a clinical oral examination including measurement of unstimulated whole saliva flow rate.

RESULTS

  Twelve percent of the COHS was edentulous. The number of dental restorations was higher for women compared to men; however, men had more caries than women. Coronal caries was most frequent on mesial and distal surfaces and on the maxillary incisors and canines; root caries was most frequent on labial surfaces and evenly distributed within the dentition. Only 41% of all invited elderly people accepted the invitation, with old age and poor health being the primary reasons for non-participation.

CONCLUSION

  The baseline values for COHS show that a substantial proportion of the participants had retained a natural dentition and that dental caries was prevalent with the anterior maxillary teeth being most affected.

Cost as a barrier to dental care among people with disabilities: a report from the Florida behavioral risk factor surveillance system

Many individuals who have disabilities or complex health conditions do not have adequate access to comprehensive oral health care. An examination of the literature indicates a variety of contributing factors. This study reports on cost of care as a barrier to oral health care. Data from the 2007 Florida Behavioral Risk Factor Surveillance System (BRFSS) were used (n = 33,777). Respondents who reported activity limitation or the use of special equipment were considered to have a disability. Lack of access to dental care due to cost during the past year was assessed. More individuals with a disability reported not seeing a dentist due to cost versus people without disabilities (30% vs. 16%). After adjusting for confounding variables, Floridians with disabilities were 60% more likely to report cost as a barrier to dental care (OR = 1.60, 95% CI 1.32-1.94). Cost of dental care is an access to oral health barrier for Floridians with disabilities. Improving access to dental care for this population will require consideration of financial issues.

Acid tolerance mechanisms utilized by Streptococcus mutans

Since its discovery in 1924 by J Clarke, Streptococcus mutans has been the focus of rigorous research efforts due to its involvement in caries initiation and progression. Its ability to ferment a range of dietary carbohydrates can rapidly drop the external environmental pH, thereby making dental plaque inhabitable to many competing species and can ultimately lead to tooth decay. Acid production by this oral pathogen would prove suicidal if not for its remarkable ability to withstand the acid onslaught by utilizing a wide variety of highly evolved acid-tolerance mechanisms. The elucidation of these mechanisms will be discussed, serving as the focus of this review.