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Geddis-Regan A, Abley C, Exley C, Wassall R. Dentists' Approaches to Treatment Decision-Making for People with Dementia: A Qualitative Study. JDR Clin Trans Res 2024; 9:221-230. [PMID: 37775967 DOI: 10.1177/23800844231199385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION Globally, the number of people living with dementia (PLwD) is projected to increase substantially. Dentists will encounter an increasing number of PLwD retaining natural teeth who need dental care. Dental treatment planning can be complex for PLwD as both oral diseases and dental treatment can be detrimental to patients' oral and social function and comfort. In addition, patients may lack the capacity to make decisions about their treatment, posing further challenges for dentists. OBJECTIVE This study aimed to explore dentists' approach to treatment decision-making with or for PLwD. METHODS Semistructured one-to-one interviews were completed with 22 dentists between April 2020 and March 2021. Data generation and analysis followed the principles of constructivist grounded theory with data being collected and analyzed simultaneously using a maximum variation sample. Interviews were recorded, transcribed verbatim, and then analyzed, leading to a theoretical understanding of how dentists approach treatment decisions for PLwD. RESULTS Four data categories describe dentists' approaches to treatment decision-making for PLwD. Dentists sought to provide individualized care for PLwD. However, they described planning care based on risk-benefit analyses that primarily considered biomedical factors and generic assumptions. There was an underemphasis on the psychological or social implications of dental care or its delivery. Furthermore, while some dentists attempted to involve patients in treatment decisions, they reported fewer attempts to identify the views and preferences of PLwD identified as lacking decisional capacity. In this scenario, dentists reported leading the decision-making process with little regard for patients' known or identified preferences and minimal involvement of PLwD's family. CONCLUSIONS Dentists acknowledge the complexity in treatment decision-making for PLwD yet focused heavily on biomedical considerations, with an underemphasis on individuals' preferences and autonomy. Considering psychosocial aspects of care alongside biomedical factors is essential to support holistic person-centered care for this growing patient cohort. KNOWLEDGE TRANSFER STATEMENT This study highlighted that dentists may only be considering biomedical aspects of care when considering what treatment is appropriate for people living with dementia. When making or supporting treatment decisions, dentists should explore patients' preferences and actively consider relevant psychosocial factors. These can be actively identified through considered discussions with patients as well as their family members. Gathering this information should support more person-centered and value-concordant decision-making for people living with dementia.
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Affiliation(s)
- A Geddis-Regan
- University Dental Hospital of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - C Abley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - C Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - R Wassall
- School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Dental Hospital, Newcastle upon Tyne, UK
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Tanaka K, Tominaga T, Kikutani T, Sakuda T, Tomida H, Tanaka Y, Mizukoshi A, Ichikawa Y, Ozeki M, Takahashi N, Tamura F. Oral status of older adults receiving home medical care: A cross-sectional study. Geriatr Gerontol Int 2024. [PMID: 38830832 DOI: 10.1111/ggi.14917] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2024] [Revised: 04/19/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024]
Abstract
AIM This study examined the oral status and the presence of teeth requiring treatment among older adults receiving home medical care. METHODS This cross-sectional study was conducted at a Japanese dental clinic specializing in geriatric treatment. We recruited older adults receiving home medical care in the community who had begun to receive domiciliary dental care. The Japanese version of the Oral Health Assessment Tool (OHAT-J), as well as the presence of teeth requiring extraction and the need for assistance in maintaining oral hygiene were used to evaluate the participants' oral health and its association with other items. RESULTS Ninety-three participants (44 male and 49 female, median age: 87.0 years) were surveyed. The median OHAT-J score was 6. The duration since the previous dental visit was 23 months. Sixty-two (73.8%) of 84 participants with ≥1 natural tooth had severe caries or teeth with severe mobility that required extraction. Logistic analysis revealed that requiring assistance in maintaining oral hygiene, mild dementia, severe dementia, and depression were significantly associated with an OHAT score of ≥6. CONCLUSIONS Older adults receiving home medical care had poor oral health, with approximately 70% of them requiring tooth extraction. The need for assistance in maintaining oral hygiene and poor mental status contribute to poor oral health. Geriatr Gerontol Int 2024; ••: ••-••.
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Affiliation(s)
- Kumi Tanaka
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
- Division of Rehabilitation for Speech and Swallowing Disorders, The Nippon Dental University, Tokyo, Japan
| | | | - Takeshi Kikutani
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
- Division of Rehabilitation for Speech and Swallowing Disorders, The Nippon Dental University, Tokyo, Japan
| | - Taeko Sakuda
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
| | - Hiroko Tomida
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
| | - Yuko Tanaka
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
| | - Arato Mizukoshi
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
| | - Yoko Ichikawa
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
- Division of Rehabilitation for Speech and Swallowing Disorders, The Nippon Dental University, Tokyo, Japan
| | - Maiko Ozeki
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
| | - Noriaki Takahashi
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
- Division of Rehabilitation for Speech and Swallowing Disorders, The Nippon Dental University, Tokyo, Japan
| | - Fumiyo Tamura
- The Nippon Dental University, Tama Oral Rehabilitation Clinic, Tokyo, Japan
- Division of Rehabilitation for Speech and Swallowing Disorders, The Nippon Dental University, Tokyo, Japan
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Geddis-Regan A, Wassall RR, Abley C, Exley C. Exploring dental treatment decision-making experiences of people living with dementia and family carers. Gerodontology 2024; 41:83-93. [PMID: 37036039 DOI: 10.1111/ger.12687] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION People living with dementia can have complex dental care needs. Dentists and patients should make treatment decisions together, yet some people living with dementia may be unable to make their own decisions about their dental care. Dental treatment decision-making and patients' experiences of this process have not been comprehensively researched. OBJECTIVE This study aimed to explore the dental treatment decision-making perspectives and experiences of people living with dementia and their family members. METHODS Semi-structured interviews were undertaken with 8 people living with dementia and 17 family caregivers. A constructivist grounded theory approach was adopted, using a maximum variation sample. Qualitative data collection and analysis occurred concurrently. Data underwent initial open coding followed by more focused coding, supported by reflexive memo writing, which supported data categorisation. RESULTS People living with dementia reported wanting to be understood as unique individuals with specific needs. All participants described wanting to be actively involved in dental treatment decisions. However, many felt that they were insufficiently involved in treatment decision-making. This perceived underinvolvement meant that some people living with dementia and family members felt the treatment outcomes they sought were neither discussed nor considered. CONCLUSION People living with dementia and carers had specific expectations of dental care yet felt passive in decision-making despite their desire to be involved in this process. Dentists should seek to actively establish patients' preferences, regardless of mental capacity and consider these in discussions and decisions about dental treatment.
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Affiliation(s)
- Andrew Geddis-Regan
- School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle Dental Centre, Carlisle, UK
| | - Rebecca R Wassall
- School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
- Newcastle Dental Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Clare Abley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
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Davies R, Doshi M. Prevention of oral diseases for the older person (Part 1). Br Dent J 2024; 236:35-41. [PMID: 38225311 DOI: 10.1038/s41415-023-6610-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2024]
Abstract
Older adults often experience poorer levels of oral health than younger adults, especially if they have become dependent on a third party to support their daily oral care routine. However, the deterioration of oral health does not need to be a part of the ageing process. Most oral diseases are largely preventable with the daily removal of dental plaque that forms on teeth and dentures, using a fluoride toothpaste, eating a healthy diet and reducing any tobacco consumption. The dental team have a duty of care to ensure that older people receive evidence-based oral health preventative advice tailored to the individual, taking into account individual risk factors that can increase with age. This can include the clinical application of topical fluoride and minimally invasive dentistry. Older people at an increased risk of poor oral health include those with cognitive conditions, physical impairments and certain medical conditions. Care home residents face particular barriers to attaining a satisfactory standard of oral care which are discussed herein. Good oral health preventative routines must be established early after the diagnosis of progressive chronic conditions and will help to prevent the need for dental intervention later in life when treatment can be more difficult to tolerate. Inclusion of oral health prevention within health policy and legislation is necessary to improve the oral health for older people living in all health and care settings.
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Affiliation(s)
| | - Mili Doshi
- Dental and Maxillofacial, Surrey and Sussex Healthcare NHS Trust, Surrey, United Kingdom.
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Langley J, Wassall R, Geddis-Regan A, Watson S, Verey A, McKenna G, Brocklehurst P, Tsakos G. Putting guidelines into practice: Using co-design to develop a complex intervention based on NG48 to enable care staff to provide daily oral care to older people living in care homes. Gerodontology 2023; 40:112-126. [PMID: 35288971 DOI: 10.1111/ger.12629] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2021] [Revised: 12/13/2021] [Accepted: 02/13/2022] [Indexed: 02/03/2023]
Abstract
OBJECTIVES (1) Explore the challenges of providing daily oral care in care homes; (2) understand oral care practices provided by care home staff; (3) co-design practical resources supporting care home staff in these activities. METHODS Three Sheffield care homes were identified via the "ENRICH Research Ready Care Home Network," and three to six staff per site were recruited as co-design partners. Design researchers led three co-design workshops exploring care home staff's experiences of providing daily oral care, including challenges, coping strategies and the role of current guidelines. New resources were prototyped to support the use of guidelines in practice. The design researchers developed final resources to enable the use of these guidelines in-practice-in-context. FINDINGS Care home staff operate under time and resource constraints. The proportion of residents with dementia and other neurodegenerative conditions is rapidly increasing. Care home staff face challenges when residents adopt "refusal behaviours" and balancing daily oral care needs with resident and carer safety becomes complex. Care home staff have developed many coping strategies to navigate "refusal behaviours." Supporting resources need to "fit" within the complexities of practice-in-context. CONCLUSIONS The provision of daily oral care practices in care homes is complex and challenging. The co-design process revealed care home staff have a "library" of context-specific practical knowledge and coping strategies. This study offers insights into the process of making guidelines usable for professionals in their contexts of practice, exploring the agenda of implementing evidence-based guidelines.
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Affiliation(s)
- Joe Langley
- Lab4Living, Sheffield Hallam University, Sheffield, UK
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Li L, Zhang Q, Yang D, Yang S, Zhao Y, Jiang M, Wang X, Zhao L, Liu Q, Lu Z, Zhou X, Gan Y, Wu C. Tooth loss and the risk of cognitive decline and dementia: A meta-analysis of cohort studies. Front Neurol 2023; 14:1103052. [PMID: 37139053 PMCID: PMC10150074 DOI: 10.3389/fneur.2023.1103052] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Accepted: 03/13/2023] [Indexed: 05/05/2023] Open
Abstract
Introduction Epidemiological studies have shown that tooth loss may be associated with an increased risk of cognitive decline and dementia. However, some results do not show a significant association. Therefore, we performed a meta-analysis to evaluate this association. Methods Relevant cohort studies were searched in PubMed, Embase, Web of Science (up to May 2022), and the reference lists of retrieved articles. The pooled relative risk (RR) and 95% confidence intervals were computed using a random-effects model (CI). Heterogeneity was evaluated using the I 2 statistic. Publication bias was evaluated using the Begg's and Egger's tests. Results Eighteen cohort studies met the inclusion criteria. Original studies with 356,297 participants with an average follow-up of 8.6 years (ranging from 2 to 20 years) were included in this study. The pooled RRs of tooth loss on dementia and cognitive decline were 1.15 (95% CI: 1.10-1.20; P < 0.01, I 2 = 67.4%) and 1.20 (95% CI: 1.14-1.26; P = 0.04, I 2 = 42.3%), respectively. The results of the subgroup analysis showed an increased association between tooth loss and Alzheimer's disease (AD) (RR = 1.12, 95% CI: 1.02-1.23) and vascular dementia (VaD) (RR = 1.25, 95% CI: 1.06-1.47). The results of the subgroup analysis also showed that pooled RRs varied by geographic location, sex, use of dentures, number of teeth or edentulous status, dental assessment, and follow-up duration. None of the Begg's and Egger's tests or funnel plots showed evidence of publication bias. Discussion Tooth loss is associated with a significantly increased risk of cognitive decline and dementia, suggesting that adequate natural teeth are important for cognitive function in older adults. The likely mechanisms mostly suggested include nutrition, inflammation, and neural feedback, especially deficiency of several nutrients like vitamin D.
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Affiliation(s)
- Liqing Li
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Qi Zhang
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Di Yang
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Ganzhou, Jiangxi, China
- School of Public Health and Health Management, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Sule Yang
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Yulan Zhao
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Min Jiang
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Xiaofang Wang
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Ling Zhao
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Qi Liu
- Research Center of Health Policy and Innovation, Jiangxi Science and Technology Normal University, Nanchang, Jiangxi, China
| | - Zuxun Lu
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Xiaogang Zhou
- School of Economics and Management, East China Jiaotong University, Nanchang, Jiangxi, China
| | - Yong Gan
- School of Public Health, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Chunmei Wu
- Key Laboratory of Prevention and Treatment of Cardiovascular and Cerebrovascular Diseases of Ministry of Education, Gannan Medical University, Ganzhou, Jiangxi, China
- School of Public Health and Health Management, Gannan Medical University, Ganzhou, Jiangxi, China
- *Correspondence: Chunmei Wu
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Dziedzic A. Is Periodontitis Associated with Age-Related Cognitive Impairment? The Systematic Review, Confounders Assessment and Meta-Analysis of Clinical Studies. Int J Mol Sci 2022; 23:15320. [PMID: 36499656 PMCID: PMC9739281 DOI: 10.3390/ijms232315320] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 11/27/2022] [Accepted: 11/29/2022] [Indexed: 12/12/2022] Open
Abstract
It has been suggested that molecular pathological mechanisms responsible for periodontitis can be linked with biochemical alterations in neurodegenerative disorders. Hypothetically, chronic systemic inflammation as a response to periodontitis plays a role in the etiology of cognitive impairment. This study aimed to determine whether periodontitis (PDS) is a risk factor for age-related cognitive impairment (ACI) based on evidence of clinical studies. A comprehensive, structured systematic review of existing data adhering to the Preferred Reporting Items for Systematic Review and Meta Analyses (PRISMA) guidelines was carried out. Five electronic databases, PubMed, Embase, Scopus, Web of Science, and Cochrane, were searched for key terms published in peer-reviewed journals until January 2021. The Newcastle-Ottawa scale was used to assess the quality of studies and risk of bias. The primary and residual confounders were explored and evaluated. A meta-analysis synthesizing quantitative data was carried out using a random-effects model. Seventeen clinical studies were identified, including 14 cohort, one cross-sectional, and two case-control studies. Study samples ranged from 85 to 262,349 subjects, with follow-up between 2 and 32 years, and age above 45 years, except for two studies. The findings of studies suggesting the PDS-ACI relationship revealed substantial differences in design and methods. A noticeable variation related to the treatment of confounders was observed. Quality assessment unveiled a moderate quality of evidence and risk of bias. The subgroups meta-analysis and pooled sensitivity analysis of results from seven eligible studies demonstrated overall that the presence of PDS is associated with an increased risk of incidence of cognitive impairment (OR = 1.36, 95% CI 1.03-1.79), particularly dementia (OR = 1.39, 95% CI 1.02-1.88) and Alzheimer's disease (OR = 1.03 95% CI 0.98-1.07)). However, a considerable heterogeneity of synthesized data (I2 = 96%) and potential publication bias might affect obtained results. While there is a moderate statistical association between periodontitis and dementia, as well as Alzheimer's disease, the risk of bias in the evidence prevents conclusions being drawn about the role of periodontitis as a risk factor for age-related cognitive impairment.
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Affiliation(s)
- Arkadiusz Dziedzic
- Department of Conservative Dentistry with Endodontics, Medical University of Silesia, 40-055 Katowice, Poland
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Barry BJ, McConnell ES, Duea SR, Blodgett NP. A Standardized Positive Physical Approach to Improve Oral Hygiene for Nursing Home Residents With Alzheimer's Disease and Related Dementias. J Gerontol Nurs 2022; 48:15-20. [DOI: 10.3928/00989134-20221003-07] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Tan ECK, Lexomboon D, Häbel H, Fastbom J, Eriksdotter M, Johnell K, Sandborgh-Englund G. Validating a model for medication-related dental outcomes in older people. Oral Dis 2022; 28:1697-1704. [PMID: 33780083 DOI: 10.1111/odi.13864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2021] [Revised: 03/07/2021] [Accepted: 03/24/2021] [Indexed: 01/23/2023]
Abstract
OBJECTIVES To externally validate a model for medication-related dental outcomes in (a) a general older population with dementia and (b) a matched population without dementia. SUBJECTS AND METHODS This validation study used population-based data from seven Swedish national registers (2008-2017). Individuals aged 60+ with dementia were matched to those without dementia on age, gender, and county of residence at the date of diagnosis (index date). The exposure was continuous use of xerogenic medications during the 3-year period before index date. The primary outcome was the number of tooth extraction and restorative procedures within 3 years after index date. RESULTS A total of 334,220 individuals were included in the final sample. In the dementia cohort, the use of urological drugs (incidence rate ratio [IRR] 1.08, 95% CI 1.03-1.13), respiratory medicines (IRR 1.10, 95% CI 1.04-1.17), and proton-pump inhibitors (IRR 1.09, 95% CI 1.05-1.13) was associated with the primary outcome. In the non-dementia cohort, respiratory medicines (IRR 1.03, CI 1.00-1.05), proton-pump inhibitors (IRR 1.06, CI 1.04-1.08), opioids (IRR 1.05, CI 1.03-1.07), and antidepressants (IRR 1.06, CI 1.04-1.08) were associated with the primary outcome. CONCLUSIONS Although there were differences in prescription patterns, the model performed similarly in both those with and without dementia.
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Affiliation(s)
- Edwin C K Tan
- Faculty of Medicine and Health, School of Pharmacy, The University of Sydney, Sydney, NSW, Australia
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
- Faculty of Pharmacy and Pharmaceutical Sciences, Centre for Medicine Use and Safety, Monash University, Parkville, Vic., Australia
| | | | - Henrike Häbel
- Unit of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Fastbom
- Department of Neurobiology, Care Sciences and Society, Aging Research Center, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Maria Eriksdotter
- Department of Neurobiology, Care Sciences and Society, Division of Clinical Geriatrics, Karolinska Institutet, Huddinge, Sweden
- Theme Aging, Karolinska University Hospital, Huddinge, Sweden
| | - Kristina Johnell
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Gunilla Sandborgh-Englund
- Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
- Academic Center for Geriatric Dentistry, Stockholm, Sweden
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Yamamoto‐Kuramoto K, Kiuchi S, Kusama T, Kondo K, Takeuchi K, Osaka K, Aida J. Subjective cognitive complaints and dental clinic visits: A cross‐sectional study from the Japan Gerontological Evaluation Study. Geriatr Gerontol Int 2022; 22:773-778. [DOI: 10.1111/ggi.14455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 07/04/2022] [Accepted: 07/14/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Kinumi Yamamoto‐Kuramoto
- Department of International and Community Oral Health Tohoku University Graduate School of Dentistry Sendai Japan
| | - Sakura Kiuchi
- Department of International and Community Oral Health Tohoku University Graduate School of Dentistry Sendai Japan
- Frontier Research Institute for Interdisciplinary Sciences Tohoku University Sendai Japan
| | - Taro Kusama
- Department of International and Community Oral Health Tohoku University Graduate School of Dentistry Sendai Japan
- Division of Regional Community Development, Liaison Center for Innovative Dentistry Tohoku University Graduate School of Dentistry Sendai Japan
| | - Katsunori Kondo
- Department of Social Preventive Medical Sciences, Center for Preventive Medical Sciences Chiba University Chiba Japan
- Department of Gerontological Evaluation, Center for Gerontology and Social Science National Center for Geriatrics and Gerontology Obu Japan
| | - Kenji Takeuchi
- Department of International and Community Oral Health Tohoku University Graduate School of Dentistry Sendai Japan
- Division of Regional Community Development, Liaison Center for Innovative Dentistry Tohoku University Graduate School of Dentistry Sendai Japan
| | - Ken Osaka
- Department of International and Community Oral Health Tohoku University Graduate School of Dentistry Sendai Japan
| | - Jun Aida
- Department of Oral Health Promotion, Graduate School of Medical and Dental Sciences Tokyo Medical and Dental University Tokyo Japan
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Somsak K, Tangwongchai S, Komin O, Maes M. Oral exercises significantly improve oral functions in people with mild and moderate dementia: a randomized controlled study. J Oral Rehabil 2022; 49:616-626. [PMID: 35274344 DOI: 10.1111/joor.13317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 02/02/2022] [Accepted: 03/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND There have been no standard protocols of oral exercises for maintaining and improving oral function for people with dementia. OBJECTIVE This study aimed to determine the effects of home-based oral exercises on the oral function of people with mild to moderate dementia. METHODS Twenty-two participants at King Chulalongkorn Memorial Hospital were randomly assigned to exercise group (n = 11) or control group (n = 11). The exercise group was instructed to do three home-based oral exercises, consisting of tongue-strengthening, oral diadochokinesis (ODK), and mouth-opening exercises, for 3 months, while the control group received advice on oral health care. The maximum tongue pressure (MTP) was the primary outcome. MTP, ODK rates of /pa/, /ta/, /ka/, modified water swallowing test (MWST), and oral moisture were measured at baseline, and after 1, 2, and 3 months of training. The generalized estimating equation analysis was used to evaluate the effects of oral exercises on the oral function. RESULTS The MTP and all ODK rates in the exercise group were significantly increased after 3 months of training. There were significant interaction effects between time and intervention in MTP and all ODK rates. No significant interaction effects between time and intervention in oral moisture were found. The MWST scores in both groups did not change through the end of study and no adverse effects were reported. CONCLUSION Home-based oral exercises were found to be effective for improving tongue strength and tongue-lip motor function in people with mild to moderate dementia.
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Affiliation(s)
- Kwanrutai Somsak
- Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Sookjaroen Tangwongchai
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cognitive Impairment and Dementia Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Orapin Komin
- Department of Prosthodontics, Faculty of Dentistry, Chulalongkorn University, Bangkok, Thailand
| | - Michael Maes
- Department of Psychiatry, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Cognitive Impairment and Dementia Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Department of Psychiatry, Medical University Plovdiv, Plovdiv, Bulgaria.,IMPACT Research Center, Deakin University, Geelong, Australia
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Ethnicity, Social, and Clinical Risk Factors to Tooth Loss among Older Adults in the U.S., NHANES 2011-2018. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:ijerph19042382. [PMID: 35206567 PMCID: PMC8875070 DOI: 10.3390/ijerph19042382] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 02/01/2022] [Accepted: 02/10/2022] [Indexed: 11/19/2022]
Abstract
Background. Many older adults suffer from poor oral health, including tooth loss, and disparities among racial/ethnic and socially disadvantaged populations continue to exist. Methods. Data were obtained from the National Health and Nutrition Examination Survey among the adult population in the U.S. The prevalence of edentulism and multiple regression models were conducted on 15,821 adults, including Asians, Blacks, Hispanics, Whites, and others to assess the relationships between tooth loss and their predictors. Results. The prevalence of complete tooth loss increased with age from 0.7% for ages 20–44 to 20.2% for ages 65 and over. There are disparities in complete tooth loss regarding race/ethnicity, with the highest percentages (9%) among Whites and Blacks and the lowest percentages among Asians (3%) and Hispanics (4%). After adjusting for predictors, their impact on tooth loss was not consistent within racial/ethnic groups, as Asians had more tooth loss from Model 1 (β = −1.974, p < 0.0001) to Model 5 (β = −1.1705, p < 0.0001). Conclusion. Tooth loss was significantly higher among older adults and racial/ethnic groups even after controlling for other predictors among a nationally representative sample. The findings point to the fact that subgroup-tailored preventions are necessary.
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Kc S, Aulakh M, Curtis S, Scambler S, Gallagher JE. Perspectives of community-dwelling older adults with dementia and their carers regarding their oral health practices and care: rapid review. BDJ Open 2021; 7:36. [PMID: 34811365 PMCID: PMC8608883 DOI: 10.1038/s41405-021-00091-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 09/13/2021] [Accepted: 09/29/2021] [Indexed: 12/29/2022] Open
Abstract
AIM To review evidence on oral health practices, beliefs/views and experiences of community-dwelling older adults living with dementia, including their carers. MATERIALS AND METHODS A search of key terms across six databases including Pubmed, Web of Science and OVID (Embase, MEDLINE [R] and PsycINFO) and Google Scholar was conducted, supplemented by reference screening. The Mixed Methods Appraisal Tool (MMAT) 2018 was used to assess the methodological quality. RESULTS Eighteen studies reported across 19 papers were included in the review. Papers largely focused on normative needs (n = 13), whilst also reporting oral health-related experiences (n = 2), practices (n = 7), and beliefs/views (n = 9), of community dwellers with dementia. Generally, people living with dementia presented with poor oral and dental health, the exception being one study where dental care was integrated with memory clinic services. Maintenance of oral health focused only on toothbrushing. Overall, people living with dementia have reduced capacity for self-performed oral hygiene and high reliance on caregivers. There was a paucity of evidence on their perceptions of oral health and quality of life, the findings of which were equivocal, with weak evidence suggesting possible difficulty in identifying and communicating their needs. Experiences of accessing dental care, when explored, appear to be system dependent. CONCLUSION There was limited research evidence on oral health-related practices, beliefs/views and experiences of people with dementia. Recommendations for future research are presented.
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Affiliation(s)
- S Kc
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Denmark Hill Campus, Bessemer Road, London, SE5 9RS, UK
| | - M Aulakh
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Denmark Hill Campus, Bessemer Road, London, SE5 9RS, UK
| | - S Curtis
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Denmark Hill Campus, Bessemer Road, London, SE5 9RS, UK
| | - S Scambler
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Denmark Hill Campus, Bessemer Road, London, SE5 9RS, UK
| | - J E Gallagher
- Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, Denmark Hill Campus, Bessemer Road, London, SE5 9RS, UK.
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14
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Schwahn C, Frenzel S, Holtfreter B, Van der Auwera S, Pink C, Bülow R, Friedrich N, Völzke H, Biffar R, Kocher T, Grabe HJ. Effect of periodontal treatment on preclinical Alzheimer's disease-Results of a trial emulation approach. Alzheimers Dement 2021; 18:127-141. [PMID: 34050719 DOI: 10.1002/alz.12378] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 04/20/2021] [Accepted: 04/20/2021] [Indexed: 12/27/2022]
Abstract
INTRODUCTION We investigated the relationship between periodontal treatment and pre-clinical Alzheimer's disease (AD). METHODS In this quasi-experimental design, 177 periodontally treated patients from the "Greifswald Approach to Individualized Medicine" cohort, which used the same protocols as the population-based Study of Health in Pomerania TREND (SHIP-TREND), and 409 untreated subjects from SHIP-TREND were analyzed. Subjects were younger than 60 years at the magnetic resonance imaging examination, with a median observation period of 7.3 years. Imaging markers for brain atrophy in late-onset AD and brain aging were used as the outcomes. RESULTS Robust to sensitivity analyses, periodontal treatment had a favorable effect on AD-related brain atrophy (-0.41; 95% confidence interval: -0.70 to -0.12; P = .0051), which corresponds to a shift from the 50th to the 37th percentile of the outcome distribution. For brain aging, the treatment effect was uncertain. CONCLUSION Periodontitis is related to pre-clinical AD in our population.
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Affiliation(s)
- Christian Schwahn
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, Dental School, University Medicine Greifswald, Greifswald, Germany
| | - Stefan Frenzel
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany
| | - Birte Holtfreter
- Unit of Periodontology, Department of Restorative Dentistry, Periodontology, Endodontology, and Pediatric and Preventive Dentistry, Dental School, University Medicine Greifswald, Greifswald, Germany
| | - Sandra Van der Auwera
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany.,German Centre for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
| | - Christiane Pink
- Unit of Periodontology, Department of Restorative Dentistry, Periodontology, Endodontology, and Pediatric and Preventive Dentistry, Dental School, University Medicine Greifswald, Greifswald, Germany
| | - Robin Bülow
- Department of Diagnostic Radiology and Neuroradiology, University Medicine Greifswald, Greifswald, Germany
| | - Nele Friedrich
- Institute of Clinical Chemistry and Laboratory Medicine, University Medicine Greifswald, Greifswald, Germany.,DZHK (German Center for Cardiovascular Research), Greifswald, Germany
| | - Henry Völzke
- DZHK (German Center for Cardiovascular Research), Greifswald, Germany.,Institute for Community Medicine, University Medicine Greifswald, Greifswald, Germany
| | - Reiner Biffar
- Department of Prosthetic Dentistry, Gerodontology and Biomaterials, Dental School, University Medicine Greifswald, Greifswald, Germany
| | - Thomas Kocher
- Unit of Periodontology, Department of Restorative Dentistry, Periodontology, Endodontology, and Pediatric and Preventive Dentistry, Dental School, University Medicine Greifswald, Greifswald, Germany
| | - Hans Jörgen Grabe
- Department of Psychiatry and Psychotherapy, University Medicine Greifswald, Greifswald, Germany.,German Centre for Neurodegenerative Diseases (DZNE), Site Rostock/Greifswald, Greifswald, Germany
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15
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Sun XN, Zhou JB, Li N. Poor Oral Health in Patients with Schizophrenia: a Meta-Analysis of Case-Control Studies. Psychiatr Q 2021; 92:135-145. [PMID: 32483766 DOI: 10.1007/s11126-020-09752-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Patients with schizophrenia have high rates of comorbid physical illness, but there has been less attention to dental diseases in these patients. This meta-analysis of case-control studies systematically examined the oral health in patients with schizophrenia. Case-control studies comparing the oral health in patients with schizophrenia and healthy controls were screened and identified. Standardized mean difference (SMD) with its 95% confidence interval (CI) was calculated using RevMan version 5.3. Three case-control studies comprising 306 patients with schizophrenia and 306 healthy controls were included in this meta-analysis. All studies were rated as "high quality". Patients with schizophrenia had significantly higher scores of decayed, missing and filled teeth (SMD = 0.83, 95%CI: 0.57, 1.09, p < 0.001; I2 = 51%), missing teeth (SMD = 0.79, 95%CI: 0.59, 0.98, p < 0.001; I2 = 19%), and decayed teeth (SMD = 0.89, 95%CI: 0.24, 1.54, p = 0.008; I2 = 92%) when compared to healthy controls. Similarly, patients with schizophrenia had significantly lower filled teeth scores (SMD = -0.76, 95%CI: -1.44, -0.09, p = 0.03; I2 = 93%) when compared to healthy controls. This meta-analysis found that patients with schizophrenia were likely to have worse oral health when compared to healthy controls.
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Affiliation(s)
- Xiao-Ni Sun
- Dental Department, Ningbo Yinzhou People's Hospital Community, Zhejiang, 315040, China.
| | - Jian-Bo Zhou
- Dental Department, Ningbo Yinzhou People's Hospital Community, Zhejiang, 315040, China
| | - Na Li
- Dental Department, Ningbo Yinzhou People's Hospital Community, Zhejiang, 315040, China
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16
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Floden AM, Sohrabi M, Nookala S, Cao JJ, Combs CK. Salivary Aβ Secretion and Altered Oral Microbiome in Mouse Models of AD. Curr Alzheimer Res 2021; 17:1133-1144. [PMID: 33463464 PMCID: PMC8122496 DOI: 10.2174/1567205018666210119151952] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 10/24/2020] [Accepted: 12/21/2020] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta amyloid (Aβ) peptide containing plaque aggregations in the brain are a hallmark of Alzheimer's Disease (AD). However, Aβ is produced by cell types outside of the brain suggesting that the peptide may serve a broad physiologic purpose. OBJECTIVE Based upon our prior work documenting expression of amyloid β precursor protein (APP) in intestinal epithelium we hypothesized that salivary epithelium might also express APP and be a source of Aβ. METHODS To begin testing this idea, we compared human age-matched control and AD salivary glands to C57BL/6 wild type, AppNL-G-F , and APP/PS1 mice. RESULTS Both male and female AD, AppNL-G-F , and APP/PS1 glands demonstrated robust APP and Aβ immunoreactivity. Female AppNL-G-F mice had significantly higher levels of pilocarpine stimulated Aβ 1-42 compared to both wild type and APP/PS1 mice. No differences in male salivary Aβ levels were detected. No significant differences in total pilocarpine stimulated saliva volumes were observed in any group. Both male and female AppNL-G-F but not APP/PS1 mice demonstrated significant differences in oral microbiome phylum and genus abundance compared to wild type mice. Male, but not female, APP/PS1 and AppNL-G-F mice had significantly thinner molar enamel compared to their wild type counterparts. CONCLUSION These data support the idea that oral microbiome changes exist during AD in addition to changes in salivary Aβ and oral health.
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Affiliation(s)
- Angela M Floden
- Department of Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58202-9037, United States
| | - Mona Sohrabi
- Department of Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58202-9037, United States
| | - Suba Nookala
- Department of Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58202-9037, United States
| | - Jay J Cao
- USDA, Agricultural Research Service, Grand Forks Human Nutrition Research Center, Grand Forks, ND, United States
| | - Colin K Combs
- Department of Biomedical Sciences, University of North Dakota School of Medicine and Health Sciences, Grand Forks, ND 58202-9037, United States
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17
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Lin CS, Lin HH, Fann SW, Lee WJ, Hsu ML, Wang SJ, Fuh JL. Association between tooth loss and gray matter volume in cognitive impairment. Brain Imaging Behav 2021; 14:396-407. [PMID: 32170642 DOI: 10.1007/s11682-020-00267-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Previous studies have reported an association between tooth loss and gray matter volume (GMV) in healthy adults. The study aims to elucidate the link between tooth loss, brain volume differences, and cognitive impairment by investigating the total and regional differences in GMV associated with tooth loss in older people with and without cognitive impairment. Forty older participants with mild cognitive impairment or Alzheimer's disease [the cognitive impairment (CI) group] and 30 age- and sex-matched healthy participants [the control (CON) group] received T1-weighted magnetic resonance imaging scans and assessments of oral functions, including masticatory performance (MP) and the number of missing teeth (NMT). Voxel-based morphometry was used to assess the total and regional GMV, including that of the medial temporal lobe and motor-related areas. (A) When the total intracranial volume and age were controlled for, an increased MP was associated with a larger GMV in the premotor cortex in the CON group. (B) In the CI group, an increased NMT was significantly correlated with smaller regional GMV of the bilateral primary motor cortex and the premotor cortex. (C) In the CI group, but not the CON group, an increased NMT was associated with both smaller total GMV and regional GMV of the left medial temporal lobe, including the left hippocampus and parahippocampus. Tooth loss may be preferentially related to the structural differences in the medial temporal lobe in cognitively impaired older people. Further research is required to understand the mechanisms of the relationships.
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Affiliation(s)
- Chia-Shu Lin
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei City, Taiwan.,Institute of Brain Science, National Yang-Ming University, Taipei City, Taiwan.,Brain Research Center, National Yang-Ming University, Taipei City, Taiwan
| | - Hsiao-Han Lin
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei City, Taiwan
| | - Shin-Woei Fann
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan, 122
| | - Wei-Ju Lee
- Neurological Institute, Taichung Veterans General Hospital, Taichung, Taiwan.,Faculty of Medicine, National Yang-Ming University, Taipei City, Taiwan
| | - Ming-Lun Hsu
- Department of Dentistry, School of Dentistry, National Yang-Ming University, Taipei City, Taiwan
| | - Shuu-Jiun Wang
- Brain Research Center, National Yang-Ming University, Taipei City, Taiwan. .,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan, 122. .,Faculty of Medicine, National Yang-Ming University, Taipei City, Taiwan.
| | - Jong-Ling Fuh
- Brain Research Center, National Yang-Ming University, Taipei City, Taiwan. .,Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei City, Taiwan, 122. .,Faculty of Medicine, National Yang-Ming University, Taipei City, Taiwan.
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18
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Konishi M, Kakimoto N. Relationship between oral and nutritional status of older residents with severe dementia in an aged care nursing home. Gerodontology 2020; 38:179-184. [PMID: 33247489 DOI: 10.1111/ger.12512] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2020] [Revised: 08/24/2020] [Accepted: 11/07/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE The aim of this study was to investigate the relationships between the oral and nutritional status of older residents with dementia in an aged care nursing home. BACKGROUND Insufficient oral evaluation and care due to refusal of treatment in older people with dementia may cause deterioration in oral and nutritional status. MATERIALS AND METHODS The subjects were 123 older residents with dementia who had been admitted to an aged care nursing home. Oral condition and body mass index (BMI) as a measure of nutritional status were investigated, and the results for the mild and severe dementia groups were compared. BMI was compared by the food consistency between the mild and severe dementia groups. RESULTS In the severe dementia group, fewer older adults had removable dentures and many had no molar occlusion. The rate of subjects who had refused oral care by the caregivers was significantly higher in the severe dementia group than in the mild dementia group. In the severe dementia group, the BMI of those having texture-modified foods was significantly lower than those having a normal diet. The BMI of subjects without molar occlusion and with a history of cerebrovascular disease was significantly lower in the severe dementia group. CONCLUSIONS The BMI of subjects in the severe dementia group having texture-modified food was significantly lower than that of those with a normal diet. The BMI of subjects in the severe dementia group without molar occlusion was significantly lower than those with molar occlusion.
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Affiliation(s)
- Masaru Konishi
- Department of Oral and Maxillofacial Radiology, Hiroshima University Hospital, Hiroshima, Japan.,Department of Oral and Maxillofacial Surgery, Tango Furusato Hospital, Kyotango, Kyoto, Japan
| | - Naoya Kakimoto
- Department of Oral and Maxillofacial Radiology, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima, Japan
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19
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Demmer RT, Norby FL, Lakshminarayan K, Walker KA, Pankow JS, Folsom AR, Mosley T, Beck J, Lutsey PL. Periodontal disease and incident dementia: The Atherosclerosis Risk in Communities Study (ARIC). Neurology 2020; 95:e1660-e1671. [PMID: 32727837 DOI: 10.1212/wnl.0000000000010312] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 04/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To test the hypothesis that periodontal disease would be associated with increased risk for dementia and mild cognitive impairment (MCI) by assessing dementia/MCI outcomes after a baseline periodontal examination. METHODS Participants enrolled in the Atherosclerosis Risk in Communities study with a clinical periodontal examination (or edentulous participants) at visit 4 (1996-1998; mean ± SD age 63 ± 6 years, 55% female, 21% black) and adjudicated dementia outcomes through 2016 were included (n = 8,275). A subgroup of 4,559 participants had adjudicated dementia and MCI assessments at visit 5 (2011-2013). Participants received a full-mouth periodontal examination and were classified into periodontal profile classes (PPCs) based on the severity and extent of gingival inflammation and attachment loss. MCI and dementia were determined via neurocognitive testing, neurological examination and history, informant interviews, and brain MRI in a subset. Cox proportional hazards models regressed incident dementia on PPCs. Relative risk regression models were used for the composite of MCI/dementia. RESULTS The cumulative incidence and incidence density of dementia during follow-up (average 18.4 years) were 19% (n = 1,569) and 11.8 cases per 1,000 person-years. Multivariable adjusted hazard ratios for incident dementia among participants with severe PPC or edentulism (vs periodontal healthy) were 1.22 (95% confidence interval [CI] 1.01-1.47) and 1.21 (95% CI 0.99-1.48), respectively. For the combined dementia/MCI outcome, adjusted risk ratios among participants with mild/intermediate PPC, severe PPC, or edentulism (vs periodontal healthy) were 1.22 (95% CI 1.00-1.48), 1.15 (95% CI 0.88-1.51), and 1.90 (95% CI 1.40-2.58). Results were stronger among younger (≤62 years) participants (p for interaction = 0.02). CONCLUSION Periodontal disease was modestly associated with incident MCI and dementia in a community-based cohort of black and white participants.
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Affiliation(s)
- Ryan T Demmer
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill.
| | - Faye L Norby
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - Kamakshi Lakshminarayan
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - Keenan A Walker
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - James S Pankow
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - Aaron R Folsom
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - Thomas Mosley
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - Jim Beck
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
| | - Pamela L Lutsey
- From the Division of Epidemiology and Community Health (R.T.D., F.L.N., K.L., J.S.P., A.R.F., P.L.L.), School of Public Health, University of Minnesota, Minneapolis; Department of Epidemiology (R.T.D.), Mailman School of Public Health, Columbia University, New York, NY; Department of Neurology (K.A.W.), Johns Hopkins School of Medicine, Baltimore, MD; Department of Medicine (T.M.), University of Mississippi Medical Center, Jackson; and Division of Comprehensive Oral Health-Periodontology (J.B.), Adams School of Dentistry, University of North Carolina at Chapel Hill
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20
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Kamer AR, Craig RG, Niederman R, Fortea J, de Leon MJ. Periodontal disease as a possible cause for Alzheimer's disease. Periodontol 2000 2020; 83:242-271. [PMID: 32385876 DOI: 10.1111/prd.12327] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 06/23/2019] [Indexed: 12/13/2022]
Abstract
Approximately 47 million people worldwide have been diagnosed with dementia, 60%-80% of whom have dementia of the Alzheimer's disease type. Unfortunately, there is no cure in sight. Defining modifiable risk factors for Alzheimer's disease may have a significant impact on its prevalence. An increasing body of evidence suggests that chronic inflammation and microbial dysbiosis are risk factors for Alzheimer's disease. Periodontal disease is a chronic inflammatory disease that develops in response to response to microbial dysbiosis. Many studies have shown an association between periodontal disease and Alzheimer's disease. The intent of this paper was to review the existing literature and determine, using the Bradford Hill criteria, whether periodontal disease is causally related to Alzheimer's disease.
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Affiliation(s)
- Angela R Kamer
- Department of Periodontology and Implant Dentistry, New York University, College of Dentistry, New York, New York, USA
| | - Ronald G Craig
- Department of Periodontology and Implant Dentistry, New York University, College of Dentistry, New York, New York, USA.,Department of Basic Sciences and Craniofacial Biology, New York University, College of Dentistry, New York, New York, USA
| | - Richard Niederman
- Department of Epidemiology and Health Promotion, New York University, College of Dentistry, New York, New York, USA
| | - Juan Fortea
- Alzheimer Down Unit, Department of Neurology, Hospital de la Santa Creu i Sant Pau- Biomedical Research Institute Sant Pau- Universitat Autònoma de Barcelona and Barcelona Down Medical Center, Fundació Catalana Síndrome de Down, Barcelona, Spain.,Alzheimer's Disease and Other Cognitive Disorders Unit, Neurology Service, Hospital Clínic, Barcelona, Spain
| | - Mony J de Leon
- Department of Radiology, Brain Health Imaging Institute, Weill Cornell Medicine, New York, New York, USA
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21
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Kerr K, Curl C, Geddis-Regan A. The Impact of Dementia on Oral Health and Dental Care, Part 1: Setting the Scene for Dental Care Provision. Prim Dent J 2020; 9:24-30. [PMID: 32643568 DOI: 10.1177/2050168420923861] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
There are over 850,000 people living with dementia in the UK and this figure is expected to rise to over a million by 2021. Increasingly, oral healthcare professionals in primary care will see more patients affected by dementia at varying stages of the disease, and it is therefore crucial that they have a basic understanding of the disease and how these patients can be managed in a primary care environment. The first article in this series of two provides a definition of dementia and describes the symptoms of the disease along with the key issues related to oral health, such as oral pain. Oral pain can have far reaching consequences, but identifying it can be problematic, particularly in the latter stages of the disease. This article will therefore cover how to diagnose pain in patients with dementia. Information is also provided about how to make dental surgeries more 'dementia friendly'.
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Affiliation(s)
- Kathryn Kerr
- Health Education England Regional Dental Adviser Workforce Transformation and Continuing Registration, Thames Valley and Wessex
| | - Charlotte Curl
- Consultant in Special Care Dentistry, Dental Care Group, King's College Hospital NHS Foundation Trust, London, UK
| | - Andrew Geddis-Regan
- NIHR Doctoral Research Fellow, Specialist in Special Care Dentistry, School of Dental Sciences, Newcastle University
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22
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Matsumura M, Shigeishi H, Su CY, Nishimura R, Ohta K, Sugiyama M. High Rate of Oral Candida Detection in Dependent Japanese Older People. Geriatrics (Basel) 2020; 5:geriatrics5010021. [PMID: 32213908 PMCID: PMC7151096 DOI: 10.3390/geriatrics5010021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2020] [Revised: 03/18/2020] [Accepted: 03/22/2020] [Indexed: 12/11/2022] Open
Abstract
The aim of this study was to clarify the association between oral Candida detection and the dependency status of older people. This study included 31 older people aged ≥70 years who had a certified need for long-term care or support and received care in a local day care center; it also included 27 independent older patients aged ≥70 years who visited Hiroshima University Hospital. Oral Candida was detected by a polymerase chain reaction using swab samples from the tongue surface. Oral moisture was significantly reduced in dependent older people, compared with independent older people (p = 0.003). There was a weak negative relationship between numbers of bacteria and levels of oral moisture (Spearman's rank correlation coefficient; R = -0.29, p = 0.01). Dependent older people exhibited a significantly higher rate of Candida albicans detection (35.5%) compared with independent older people (11.1%). Dependent older people also exhibited a higher rate of concurrent detection of both C. albicans and Candida glabrata (32.3%) compared with independent older people (11.1%), but this difference was not statistically significant. Thus, dependent older people may be more susceptible to oral C. albicans infection, compared with independent older people. Good oral hygiene is necessary to prevent oral Candida infection in dependent older people.
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Affiliation(s)
- Mari Matsumura
- Department of Public Oral Health, Program of Oral Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.M.); (K.O.); (M.S.)
| | - Hideo Shigeishi
- Department of Public Oral Health, Program of Oral Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.M.); (K.O.); (M.S.)
- Correspondence: ; Tel.: +81-82-257-5945; Fax: +81-82-257-5945
| | - Cheng-Yih Su
- Department of Oral Health Management, Program of Oral Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan;
| | - Rumi Nishimura
- Department of Oral Epidemiology, Program of Oral Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan;
| | - Kouji Ohta
- Department of Public Oral Health, Program of Oral Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.M.); (K.O.); (M.S.)
| | - Masaru Sugiyama
- Department of Public Oral Health, Program of Oral Health Sciences, Graduate School of Biomedical and Health Sciences, Hiroshima University, Hiroshima 734-8553, Japan; (M.M.); (K.O.); (M.S.)
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Gao SS, Chen KJ, Duangthip D, Lo ECM, Chu CH. The Oral Health Status of Chinese Elderly People with and without Dementia: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:ijerph17061913. [PMID: 32183484 PMCID: PMC7143847 DOI: 10.3390/ijerph17061913] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 03/13/2020] [Accepted: 03/14/2020] [Indexed: 01/08/2023]
Abstract
Objective: The objective of this study was to compare the caries, periodontal status, and toothbrushing practices of Chinese elderly people with and without dementia. Methods: This cross-sectional study recruited Chinese people aged 65 years or over attending daycare centers in Hong Kong. The participants’ dementia status was identified from their medical record. Their demographic information and toothbrushing practices were obtained through a questionnaire survey. Caries experience, periodontal status, and oral hygiene were measured using the Decayed, Missing, and Filled Teeth (DMFT) Index, Community Periodontal Index, and Visible Plaque Index (VPI), respectively. The case matching process, using the propensity score, was conducted to match the participants in dementia and nondementia groups. The chi-square test and t-test were conducted for analysis. Results: A total of 341 elderly people participated in this study. After case matching by gender and age, 129 participants with dementia were matched with 99 participants without dementia. The mean age and mean DMFT of the dementia group versus the nondementia group were 80.9 ± 7.5 vs. 79.4 ± 6.7 (p = 0.428) and 22.5 ± 7.9 vs. 19.2 ± 9.3 (p = 0.041), respectively. There was no significant difference of periodontal status observed. The VPI of dementia and nondementia groups were 77% and 63%, respectively (p = 0.027). Though they had no difference in frequency of toothbrushing, more dementia participants encountered difficulties in toothbrushing than those without dementia (57% vs. 8%, p < 0.001). Conclusion: Compared with elderly people without dementia, Chinese elderly people with dementia had more caries experience and poorer oral hygiene in Hong Kong. They were more likely to have difficulty in performing toothbrushing.
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Factors Contributing to the Preferred Method of Feeding in End-Stage Dementia: A Scoping Review. Dysphagia 2019; 35:616-629. [DOI: 10.1007/s00455-019-10072-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2018] [Accepted: 10/09/2019] [Indexed: 10/25/2022]
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25
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Aging and Oral Care: An Observational Study of Characteristics and Prevalence of Oral Diseases in an Italian Cohort. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2019; 16:ijerph16193763. [PMID: 31591317 PMCID: PMC6801690 DOI: 10.3390/ijerph16193763] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 12/17/2022]
Abstract
Background: Poor oral health is a common condition in patients suffering from dementia. Several aspects of this systemic pathology contribute to causing oral problems: cognitive impairment, behavior disorders, communication and, motor skills deterioration, low levels of cooperation and medical-nursing staff incompetency in the dental field. Objectives: The objectives of this study were to evaluate the prevalence and the characteristics of oral pathology in a demented elderly population, as well as to check the association between the different degree of dementia and the oral health condition of each patient. Materials and Methods: In this observational study (with cross-sectional design) two groups of elderly patients suffering from dementia, living in two different residential care institutions were recruited. The diagnosis of dementia of each included patient was performed using the Clinical Dementia Rating Scale. In order to evaluate the oral health condition of the included subjects, each patient underwent a physical examination of the oral cavity, during which different clinical parameters were analyzed (number of remaining teeth, oral mucosa, periodontal tissues, bone crests). To each parameter, a score was assigned. Spearman’s Rho test was used. Results: Regarding the prevalence of oral pathology in elderly suffering from dementia, it emerged that 20.58% of the included patients had mucosal lesions and/or new mucosal formations (in most cases undiagnosed and therefore untreated). The prevalence of periodontal disease was equal to 82.35% and a marked clinically detectable reabsorption of bone crests was found in almost all patients (88.23%). 24.13% of patients, who underwent the oral examination, had totally edentulous maxillae and/or with retained roots, without prosthetic rehabilitations. The correlation index r showed the presence of a linear correlation (inverse relationship) between the degree of dementia and the state of health of the oral cavity of each patient. Conclusions: Several factors contribute to poor oral health in the elderly suffering from dementia: cognitive functions deterioration, behavioral disorders and inadequate medical-staff nursing training on oral hygiene. This study also demonstrated that the lower the dementia degree is, the lower tends to be the oral health status. In order to guarantee a complete assistance to these patients, residential care institutions should include in their healthcare program specific dental protocols.
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Weintraub JA, Zimmerman S, Ward K, Wretman CJ, Sloane PD, Stearns SC, Poole P, Preisser JS. Improving Nursing Home Residents' Oral Hygiene: Results of a Cluster Randomized Intervention Trial. J Am Med Dir Assoc 2018; 19:1086-1091. [PMID: 30471800 PMCID: PMC6396648 DOI: 10.1016/j.jamda.2018.09.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Revised: 09/26/2018] [Accepted: 09/27/2018] [Indexed: 12/20/2022]
Abstract
OBJECTIVE A 2-year cluster randomized trial of Mouth Care Without a Battle (MCWB) was conducted in nursing homes (NHs) to determine if recommended mouth care practices provided by NH staff could improve residents' oral hygiene and denture outcomes. DESIGN Cluster randomized trial of NHs. SETTING AND PARTICIPANTS Seven MCWB NHs and 6 control NHs. A total of 219 NH residents completed baseline and 24-month oral examinations and, if applicable, denture assessments (control = 98, intervention = 121). INTERVENTION The intervention consisted of training NH staff in the MCWB protocol, and providing support in its use for 2 years. MEASURES Descriptive data from the Minimum Data Set and clinical oral health assessments: the Plaque Index for Long-Term Care (range 0‒3), the Gingival Index for Long-Term Care (range 0‒4), and the Denture Plaque Index (range 0‒4), with lower scores indicating better oral health. RESULTS There were no significant demographic or health differences between groups at baseline. Residents' mean age (standard deviation) was 77.8 years (13.5), 71% were female, and 49% had cognitive impairment. At 24 months, there were significant improvements in oral and denture hygiene in the intervention group compared with control (all P < .05) with mean changes in indices that were 0.44 (Plaque Index for Long-Term Care), 0.55 (Gingival Index for Long-Term Care), and 0.67 (Denture Plaque Index) points lower in intervention NHs than control NHs. CONCLUSIONS AND IMPLICATIONS FOR PRACTICE Training NH staff to attend to residents' oral hygiene and denture care had a sustained, favorable impact on residents' oral and denture hygiene after 24 months compared with usual care. The protocol, MCWB, can be used by direct caregivers to improve the oral hygiene and denture care of NH residents.
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Affiliation(s)
- Jane A Weintraub
- School of Dentistry, University of North Carolina at Chapel Hill, Chapel Hill, NC; Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC.
| | - Sheryl Zimmerman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; School of Social Work, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Kimberly Ward
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Christopher J Wretman
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Philip D Sloane
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC; Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sally C Stearns
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC; The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Patricia Poole
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - John S Preisser
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
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27
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Delwel S, Scherder EJA, Perez RSGM, Hertogh CMPM, Maier AB, Lobbezoo F. Oral function of older people with mild cognitive impairment or dementia. J Oral Rehabil 2018; 45:990-997. [DOI: 10.1111/joor.12708] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 07/31/2018] [Accepted: 08/15/2018] [Indexed: 01/19/2023]
Affiliation(s)
- Suzanne Delwel
- Department of Oral Kinesiology; Academic Centre for Dentistry Amsterdam (ACTA); University of Amsterdam and Vrije Universiteit Amsterdam; Amsterdam The Netherlands
- Department of Clinical Neuropsychology; Faculty of Behavioral and Movement Sciences; Vrije Universiteit Amsterdam; Amsterdam The Netherlands
| | - Erik J. A. Scherder
- Department of Clinical Neuropsychology; Faculty of Behavioral and Movement Sciences; Vrije Universiteit Amsterdam; Amsterdam The Netherlands
| | - Roberto S. G. M. Perez
- Department of Anesthesiology; Amsterdam Public Health Research Institute; VU University Medical Center; Amsterdam The Netherlands
| | - Cees M. P. M. Hertogh
- Department of Elderly Care Medicine; Faculty of Medicine; VU University Medical Center Amsterdam; Amsterdam The Netherlands
| | - Andrea B. Maier
- Department of Medicine and Aged Care @AgeMelbourne; The Royal Melbourne Hospital; University of Melbourne; Melbourne Australia
- Department of Human Movement Sciences @AgeAmsterdam; Faculty of Behavioural and Movement Sciences; Amsterdam Movement Sciences; Vrije Universiteit; Amsterdam The Netherlands
| | - Frank Lobbezoo
- Department of Oral Kinesiology; Academic Centre for Dentistry Amsterdam (ACTA); University of Amsterdam and Vrije Universiteit Amsterdam; Amsterdam The Netherlands
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