Indicators for root caries in Danish persons with recently diagnosed Alzheimer's disease

doi: 10.1111/j.1741‐2358.2011.00560.x
Indicators for root caries in Danish persons with recently diagnosed Alzheimer’s disease Objective: To identify indicators of root caries among persons with newly diagnosed Alzheimer’s disease (AD). Background: Few studies have investigated dental caries in older adults with AD. Previously we found that persons with AD had significantly more root caries compared to persons with dementia other than AD. Methods: Participants were recruited from two university hospital clinics in Copenhagen, Denmark. A team of neurologists/geriatricians carried out the diagnostic screening. The study included an interview, oral examination and medical records. Results: We evaluated potential indicators of root decay across subjects with 3+ decayed surfaces vs. <3 decayed surfaces. Variables associated with increased odds of root caries were age over 80 years, 2+ decayed coronal surfaces and 5+ filled root surfaces. Among the social variables, living with someone was associated with a nearly 70% reduction in the odds of having 3+ surfaces of untreated caries. Discussion: Root caries is highly prevalent among individuals with new AD and there is still a strong need for active assessment of and attention to oral problems in persons with AD. Our findings document that recently diagnosed AD cases with multiple coronal caries lesions are at elevated risk of having more root caries. Also persons 81+ years and those with multiple root fillings are more likely to have numerous untreated root lesions.     

Clinical and behavioural risk indicators for root caries in older people

Objective: To investigate the clinical and behavioural factors indicating root caries risk among older people. Desing: Cross sectional clinical and interview data from the National Diet and Nutrition Survey (aged 65 years and over) in Great Britain. Logistic regression models of the prevalence of root caries and linear regression models of the extent of root caries were constructed to quantify the role of a range of clinical and behavioural risk indicators, including sugars intake. Setting: A national sample of older British adults, free‐living and institutionalised. Participants: 462 dentate adults aged 65 years or over. Results: Nine or more intakes of sugars per day more than doubled the odds of root caries being present (OR 2.2–2.4). Other clinical and behavioural factors affecting root caries included wearing a partial denture in the presence of heavy plaque deposits (OR 2.1–2.6) and infrequent tooth brushing (OR 2.8 – 4.1). Linear regression models showed that, amongst those that had root caries, sucking sweets in the presence of a dry mouth, poor hygiene, partial dentures and living in an institution contributed to the extent of root caries, as measured by the RCI(d). Conclusions: Of the factors open to possible clinical or behavioural intervention, frequent sugars intake, poor hygiene and partial dentures were all associated with large increases in risk.     

Prosthetic crowns and other clinical risk indicators of caries among old-old Swedish adults: findings from the KEOHS Project. Kungsholmen Elders Oral Health Study

Objectives: The Kungsholmen Elders Oral Health Study (KEOHS) evaluated the oral health status of generally healthy, community‐dwelling persons over the age of 80 living in Kungsholmen, Sweden. This paper explored possible clinical risk indicators of coronal and root caries among the KEOHS subjects. Design: In this cross‐sectional study, dentate KEOHS subjects received a caries assessment using defined visual, tactile criteria. Setting: Examinations were carried out in two local clinics by standardized examiners. Subjects: One hundred twenty‐nine dentate persons were examined. Main Outcome Measures: The examination identified decayed and filled surfaces, prosthetic crowns, and missing teeth. Results: More root than coronal surfaces had untreated decay, and secondary root caries contributed the greatest number of decayed surfaces. Ninety percent of the examined dentate subjects had at least one prosthetic crown. Root surfaces exposed to crown margins were more likely to have caries than root surfaces not so exposed, particularly among women. The presence of untreated coronal caries (yes/no) was positively associated with having untreated root caries and an intermediate number (14–20) of teeth, but inversely associated with having 4+ prosthetic crowns. Active root caries (yes/no) was positively associated with having untreated coronal caries, 14–20 teeth, and 4+ prosthetic crowns. Nearly 20% of identified root lesions were present at or below the gingival margin, and most (88%) were secondary caries associated with crown margins (65%) or other restorations (23%). Conclusions: Our findings suggest that some dental characteristics, including the presence of prosthetic crowns, are risk indicators for the presence of untreated coronal and root caries.     

Trends in Oral Disease and Health1

Geriatric dentistry researchers are building a basic knowledge basic pertaining to the oral health status of older adults. Important findings on the prevalence of disease that run counter to “conventional wisdom” surrounding the oral health of older adults are that edentulism is decreasing, that both coronal and root caries are prevalent, that serious periodontal disease is not as prevalent as thought, that chronological age is not strongly associated with disease in older adults, and that oral lesions, especially those related to dentures, are prevalent. An important finding has been that the majority of disease seems to occur in a minority of the population. While the prevalence of oral diseases have been shown to be associated with water fluoridation, systemic diseases, use of medications, social and behavioral factors, and a variety of other oral conditions, there is only preliminary information on the incidence of disease and actual risk factors. The data available on the incidence of disease come from a study of community-dwelling older adults in Iowa, and these data generally confirm the prevalence results. Coronal and root caries are active in this older population with caries being the best predictor of tooth loss. Furthermore, most disease occurs in a high risk group. Multivariate models predicting people at highest risk for root and coronal caries implicate stress and anxiety, use of tobacco, and recent onset of illness as risk factors. In addition, preliminary results indicate that some dental conditions may be predictive of general health status.     

Oral glucose clearance in nonagenarians in relation to functional capacity,medication and oral variables

Objectives: To study oral sugar (glucose) clearance and to examine some factors which were believed to either influence or be dependent upon oral glucose clearance. Design: Cross-sectional, clinical study with analysis of records. Setting: Göteborg gerontological and geriatric population studies, Göteborg University, Sweden. Subjects: 71 community-dwelling individuals, 27 men and 44 women, of a representative sample of 260 92-year-old persons. Intervention and Main outcome measures : Glucose concentration was measured in saliva after chewing of a glucose tablet and the clearance was assessed by three different variables: (i) the initial salivary glucose concentration, (ii) the area under the curve (AUC) and (iii) the clearance time. Results: The glucose clearance showed a wide inter-individual variation, which could be explained partly by differences in oral state, chewing time, stimulated salivary secretion rate and medication use. A positive correlation was found between the clearance variables and the number of lactobacilli and mutans streptococci in saliva and the percentage of untreated root caries lesions of the total number of exposed root surfaces. Conclusions : A slow oral sugar clearance is more common among 92-year-olds than younger adults earlier reported in other studies, particularly in those who have uncompensated functional impairments and a high medication history. A decreased oral glucose clearance was associated with high counts of salivary lactobacilli and mutans streptococci and a high proportion of untreated root caries lesions.     

Caries and periodontal disease of the elderly in Pomerania, Germany: results of the Study of Health in Pomerania

Objective: The aim of this study was to describe the oral health status of older adults living in north‐eastern Germany. Materials and Methods: Representative samples of adults aged 60 years or older were examined as part of Study of the Health in Pomerania, a cross‐sectional, population‐based study. Data on 1446 subjects aged 60–79 years were evaluated for coronal caries using the decayed/missing/filled teeth (DMFT) index, root caries using the root caries index (RCI), calculus, plaque, bleeding on probing, pocket depth and attachment loss. Results: The prevalence of edentulousness varied from 16% in the 60–65‐year‐old group to 30% in the 75–79‐year‐old group, whereas the median number of remaining natural teeth per subject varied from 14 in the youngest age group (60–65 years) to one in the oldest (75–79 years). Among subjects aged 60–69 years, a quarter (26%) of the teeth examined had coronal restoration against 17% in the oldest age group (70–79 years). Coronal caries was found in 2% of the teeth in both age groups. Among teeth with gingival recession, 6% had fillings on root surfaces and 2% had root caries, irrespective of age. In all, 11% of the subjects had at least one untreated coronal lesion and 27% had at least one untreated root caries lesion. Plaque score, calculus score and bleeding on probing were higher in the oldest age group (70–79 years). The prevalence of periodontal disease expressed as the presence of at least one periodontal pocket of 4 mm and more, was higher in men and among the younger subjects (men aged 60–69 years: 85% vs. 71% in 70–79‐year‐old men; women aged 60–69 years: 71% vs. 62% in 70–79‐year‐olds). The prevalence of attachment loss of 3 mm or more followed a similar pattern. Conclusions: It seems therefore that in this population, the major oral health concern is related to caries and the small number of teeth retained among the dentate subjects.     

Methodological Issues Relative to the Quantification of Root Surface Caries1

The purpose of this study was to assess the effect upon the quantification of root surface caries (RSC) of (1) the separation of the disease into its discrete clinical phases, (2) the confounding caused by the presence of restored abraded surfaces, and (3) the decision rule formulated for dealing with lesions and restorations which involve both crown and root. It was found that the apparent prevalence of RSC varied widely depending upon arbitrary decisions as to what stages of the disease were included in the measurement scheme. The addition of restorations (confined to the root) greatly enlarged the various disease measures, but probably also introduced some degree of error since there are several indications from the data and the clinical patterns of affected surfaces which suggest that some of the restored surfaces were formerly abraded rather than carious. The inclusion of lesions and restorations involving both root and crown produced another conspicuous increment in all disease measures, which is a cause for concern given that these components are included in some studies and ignored in others. These findings serve as the basis for several recommendations for future prevalence and incidence studies of RSC.     

Dental Caries in the Elderly

Studies in the United States and other countries have shown that there is continued caries activity with advancing age. These studies, however, do not elaborate on the nature of the dental caries nor its anatomical location on the tooth. It has been assumed that dental caries occur on the coronal portion of retained teeth and that recurrent decay around existing restorations represents the major form of the disease. In addition to continued coronal caries activity in adults, the problem of carious lesions occurring on the exposed roots of teeth has been identified in a number of recent surveys. The exposure of the root surface to the oral cavity is a consequence of the apical migration of the periodontal attachment through periodontal disease and dental treatment which renders this part of the tooth at risk of the dental caries process. However, there are several distinct differences between coronal and root caries. The continued occurrence of coronal caries in adults and the projected increase m the prevalence of root caries suggests an expanded role for the restorative and preventive services for the older adult patient. Although the techniques relating to coronal caries are well-established, those relating to root caries are just beginning to be explored and developed. Many of the principles, materials and philosophies which have proved to be effective for coronal caries are not equally efficacious when the tooth root is involved. This area represents a fertile field for research and development in the older adult patient.     

Salivary levels of mutans streptococci associated with restorations: a case-control study

Our aim was to estimate whether restorative therapy with amalgam and composite resin could decrease salivary mutans streptococcal level, thus also decreasing the risk for other caries development. We selected a case group of 93 children with detectable salivary mutans levels (i.e., at least 1x10(4) cfu/ml), and a control group (n=93 subjects) with undetectable levels. Children had the same age (12 years), no extracted teeth, crowns, temporary fillings, and restorations other than amalgam and composite resin, and the two groups had similar gender distribution. We clinically examined children and recorded active caries, restorations and oral hygiene level by means of gingival bleeding on probing; we also investigated sucrose intake at breakfast. The case group had statistically significant higher prevalence of restorations (36.6% vs. 18.3%), active caries (44.1% vs. 12.9%), and bad oral hygiene (84.9% vs. 68.8%) than the control group. However, the logistic regression analysis showed that presence of active caries was the only significant variable associated with mutans streptococci (OR=4.0; p=0.0002), while the effects of sucrose intake and of restorations were marginally significant. This apparent contrast between statistical analyses was due to the concomitant presence, in children with detectable mutans streptococci level, of restorations and decayed teeth at the same time, and, on the basis of the multivariate analysis, presence of mutans streptococci in these children was explained by the presence of active caries, more than restorations.     

Tooth loss and caries prevalence in very old Swedish people: the relationship to cognitive function and functional ability

Objective: To analyse whether cognitive function and functional ability are related to oral health among community‐dwelling older people over the age of 80 years. Background: This cross‐sectional study is based on the Kungsholmen Elders Oral Health Survey (KEOHS). The study included oral examinations carried out in two local clinics by standardised examiners and interviews using structured questionnaires. Materials and Methods: Altogether 159 individuals were included in this study. Coronal caries and root caries were assessed using the National Institute of Dental and Craniofacial Research (NIDCR) diagnostic criteria. Cognitive function was assessed by the Mini‐Mental State Examination (MMSE) index and functional ability was assessed by a global measure of self‐reported changes. Results: Older adults with a low MMSE score (≤23) tended to have a higher risk of coronal caries than those with higher scores. Participants with mild cognitive decline (MMSE = 24–26) and with a decrease in functional ability had a significantly higher risk of root caries. These associations changed little when adjusted by the covariates. In addition, people with a low MMSE (0–23) had a four times higher risk of not using dental services regularly. This result was unchanged after adjusting for the variables studied. Conclusions: This study revealed associations between the cognitive and functional status of the individual and aspects of oral health, that may contribute to a deeper understanding of the background of oral health status in older adults.     

The Clinical Profiles of Individuals With and Without Root Surface Caries1

As part of a collaborative multidisciplinary investigation of root surface caries (RSC), 273 subjects (median age = 57) were clinically evaluated for coronal caries, debris, calculus, gingivitis, periodontal pocketing, recession, abrasion, as well as RSC. The entire study group was divided into three subgroups: (1) subjects whose exposed root surface were without lesions or restorations (non-diseased individuals, n= 43); (2) subjects whose exposed root surfaces had one or more lesions and may or may not have had restorations (diseased individuals, n= 110); (3) subjects with one or more restorations but no lesions, since it was not known whether these restorations were preceded by RSC or abrasion the disease status of these individuals was unclear (n= 120). A comparison of Subgroup 1 (unequivocally non-diseased) and Subgroup 2 (unequivocally diseased) revealed that subjects without RSC had more teeth, less coronal caries, less recession, less debris, less calculus, less gingivitis, and more abrasion. We infer that the common factor underlying most if not all of the subgroup differences is oral hygiene which must therefore be a major disease determinant.     

Epidemiology of root caries

Many epidemiological studies have been conducted on a variety of populations. Unfortunately, comparison of the prevalence data, and to a lesser degree of the incidence data, between the various studies is of little use due to the lack of standardised diagnostic criteria, reporting methods and population diversity. In the few incidence studies which have been conducted around 30–40% of people developed root caries, although many adults in the population appear to have been affected by root caries. Many risk factors associated with the occurrence of root caries have been identified and these include oral, medical, mental, behavioural and psychosocial conditions.     

The Epidemiology of Dental Diseases in the Elderly1

This paper summarizes and evaluates epidemiologic evidence on adult dental conditions with a focus on older adults. Information is presented on coronal caries; root caries; loss of teeth, attrition, abrasion, and erosion; periodontal diseases; and oral cancer. The author concludes that the oral health status of the elderly in the United States is essentially unknown. There are no recent, representative population base studies of oral conditions in the elderly. Studies of prevalence or incidence of oral diseases typically include few elderly persons or describe a select group of elderly who are at high risk. Furthermore, it is not really known whether the incidence and prevalence of coronal caries or root caries is actually increasing or is part of a cohort effect. While oral cancers have been shown to increase with age, there is no information as to whether their incidence rates are increasing. While, clinically, there are indications that attrition, abrasion and erosion are characteristics that are more likely to be seen in older adults, there is no information about their distribution in the population. There is evidence that loss of teeth is decreasing but nothing is known about the patterning of that loss. As for periodontal diseases, much work is needed to identify various syndromes that may be distinguished by their distribution in the population as well as determining whether periodontitis is a condition responsible for a majority of tooth loss or just the majority of tooth loss in a small high risk group. In addition, some suggestions are presented for future directions of research in this area.     

Epidemiology of Root Caries1

Over a dozen studies have been conducted on the prevalence of and factors associated with root caries, yet our knowledge of this disease process remains limited. This is due, in large part, to a lack of consistency of reporting among the studies undertaken and the wide spectrum of population groups investigated. Nevertheless, the occurrence of root caries is between 20 and 40 percent in healthy, urban adults. Certain population groups such as the institutionalized elderly and patients with periodontal disease tend to exhibit much larger prevalence rates. New root caries develops slowly and tends to be concentrated in a few individuals, usually on the buccal and proximal surfaces of teeth. It is generally accepted that only roots with gingival recession are susceptible to root caries and that age, sex, oral hygiene, diet, saliva, systemic fluoride and previous carious experience have been shown to be associated factors. The next wave of investigations of root canes should focus on testing hypotheses relating to causation so that efficacious preventive and treatment procedures can be developed.     

Relationship between root caries and cardiac dysrhythmia

doi: 10.1111/j.1741‐2358.2010.00367.x
Relationship between root caries and cardiac dysrythmia Background: Cardiac dysrhythmia are frequently found in the elderly population because of conduction system disease and ageing. Recent reports have suggested that dental caries and periodontal disease are predictors of coronary heart events. However, this hypothesis remains largely unproven. Objective: This study investigated the relationship between root caries and cardiac dysrhythmia in an elderly population. Subjects and methods: Among 600 subjects, 233 who were dentate at baseline underwent a baseline examination and subsequent annual investigations, including an oral examination and a 12‐lead electrocardiogram, for a 4‐year period. Analysis of covariance (ancova) was used to assess the number of sites with root caries between subjects with mean C‐reactive protein (CRP) serum level of <3.0 mg/l and those with the mean CRP serum level ≥3.0 mg/l. Logistic regression analysis was performed to assess relationship between root caries and cardiac dysrhythmia. Results: A high mean CRP serum level group had a significantly higher number of sites with root caries than a low CRP group (p < 0.001). Number of sites with root caries events was significantly associated with cardiac dysrhythmia among non‐smokers (odds ratio, 5.84; p = 0.040). These results suggest that root caries is related to the incidence of dysrhythmias in non‐smokers. Conclusions: We conclude that non‐smoking elders with root caries lesions are at an elevated risk for dysrhythmias.     

Impact of socio-demographic variables, oral hygiene practices, oral habits and diet on dental caries experience of Indian elderly: a community-based study

A number of factors influence the caries experience and the pattern of restorative care especially in the older age group. Objective: To evaluate the dental caries experience and restorative treatment needs of an elderly Indian population and to study the impact of socio‐demographic variables, oral hygiene practices, oral habits and dietary practices on them. Design: A community‐based study. Setting: An urban area in the south zone of Delhi and a cluster of four villages in its neighbourhood. Subjects: A total of 1240 elderly subjects, 716 urban and 524 rural, were included in the study. Results: Of the 1052 dentate elderly subjects, 676 (64.2%) had decayed teeth (66.7% root caries and 33.3% coronal caries), 69 (6.6%) had filled teeth and 17 (1.6%) had recurrent decay. Restorations were indicated in 233 (22.2%) subjects, endodontic treatment in 51 (4.8%) and extractions in 424 (40.3%). Urban–rural differences in caries experience were statistically significant. Multivariate regression analysis showed that dental caries was associated with literacy level, oral hygiene practices, oral health perception and diet, while previous restorative treatment was correlated only with location (urban–rural) and presence or absence of systemic diseases. Conclusion: Dental caries prevalence was high amongst the studied elderly population and significant differences were observed in those living in a rural compared with an urban setting. Only a small percentage of elderly had evidence of previous restorative treatment whereas their unmet treatment need was significant.     

Caries experience in existing and new nursing home residents in Adelaide,Australia

Objectives: The Adelaide Dental Study of Nursing Homes was instigated to provide comprehensive information concerning oral disease experience, incidence and increments in a random sample of those older South Australians residing in Adelaide nursing homes. Methods: This paper presents caries experience results for existing and new nursing home residents, and caries incidence and increments for existing residents, from dental inspections conducted at the baseline and one‐year data collections. Results: The residents in this study were very functionally dependent, medically compromised, cognitively impaired and behaviourally difficult older adults, the great majority of whom had moderate to severe cognitive impairment. Residents gave their carers many complex and challenging behavioural problems during oral hygiene care provision. Existing and new residents had similar dental history, oral hygiene, and socio‐detnographic characteristics, and similar cognitive, medical, functional, and nutritional status. Oral disease experience was high in both existing and new residents. There were no significant differences between existing and new residents for their dentate status, tooth status, coronal caries experience, or root caries experience, with the exceptions that new residents had significantly greater mean number of teeth, more filled coronal and root surfaces, and also new residents had significantly fewer decayed retained roots. Large numbers of tooth surfaces were covered in plaque and debris that negated more precise assessment of caries. The existing residents had caries increments on both coronal (2.5 surfaces) and root surfaces (1.0 surfaces) over the one‐year period. Coronal caries incidence was 64% and root caries incidence was 49% of existing residents. Conclusions: Oral disease experience was high in both existing and new residents. There were few significant differences between existing and new residents’ oral health status. New residents were being admitted to nursing homes with a compromised oral health status. Coronal and root caries increments and incidence were high for existing residents over the one‐year period.     

Dental status and dental caries in 85-year-old Danes

Objectives: This study reports findings on the dental status and the prevalence of dental caries among a group of 85‐year‐old Danes from the Glostrup 1914 Cohort, Denmark. The purpose of the study was to analyse whether caries experience was related to number of teeth and to indicators of functional ability and cognitive function. Methods: A total of 191 individuals (78 men and 113 women) participated in a cross‐sectional population study conducted in 2000. Using mobile dental equipment, a clinical oral examination and an interview were administered to all participants in their homes. Functional ability was measured by the Mob‐H scale and cognitive function was assessed by the Mini‐Mental State Examination. Results: Fifty‐nine per cent of the participants had their own natural teeth and for the dentate participants, the mean number of teeth was 13 (range 1–27). A high prevalence of active caries on coronal and root surfaces was observed. Older adults with few natural teeth had a higher prevalence of active coronal and root caries and a higher unmet treatment need than older adults with many teeth. Further, the study showed that 85‐year‐old persons with reduced functional ability and cognitive impairment tended to have more active caries than 85‐year‐olds with no impairment. Conclusions: A substantial proportion of 85‐year‐old individuals had retained a natural dentition; however, active dental caries is a problem of concern among the most elderly.     

The effectiveness of 10% chlorhexidine varnish treatment on dental caries incidence in adults with dry mouth

Objectives: This study compared a 10% chlorhexidine varnish treatment with placebo and sham treatments for preventing dental caries in adult patients with xerostomia (dry mouth). Design: The study was a multicentred, randomized, parallel group, double blind, placebo‐controlled clinical trial. Setting: All examinations and procedures were performed at Tuft's University, Boston, MA, the University of British Columbia, Vancouver, BC or the University of Western Ontario, London, ON. Subjects: Subjects were adults with recent or current dental caries experience, high salivary levels of cariogenic microorganisms and low salivary flow rates. Results: 236 subjects completed at least one post‐treatment examination. There were 697 new carious lesions diagnosed, 446 (64%) located on coronal surfaces and 251 (36%) located on root surfaces. The mean attack rate was 0.23 surfaces/100 surfaces at risk. A treatment difference observed between the Active and Placebo groups was statistically significant for root caries increment (p=.02) and total caries increment (p=.03). A treatment difference observed between the Active and Sham groups was not statistically significant for coronal, root or total caries increment. Analysis of variance of treatment group differences was performed using mutans streptococci counts, salivary flow rates, age, sex, caries prevalence, medications, time to first event and early withdrawal as co‐variables. These factors did not meaningfully alter the findings. Conclusions: The difference between the 10% chlorhexidine varnish and placebo treatments is considered to be highly clinically significant for root caries increment (41% reduction) and for total caries increment (25% reduction) but only for coronal caries increment (14%).     

Oral disease experience of older adults seeking oral health services

doi:10.1111/j.1741‐2358.2009.00311.x
Oral disease experience of older adults seeking oral health services Objective: The objective of this investigation was to describe the dental disease (dental caries and alveolar bone loss) experience in a sample of community‐dwelling older adults who regularly utilize dental services in New York City. Background: Public financing for dental care directed at older adults in the United States is minimal. Improved preventive methods, primarily the use of fluorides, have resulted in declines in tooth loss, and concomitant increase in risk for dental diseases among older adults. While the oral disease burden in institutionalized elderly and those unable to access services is well‐documented, the dental care needs of older adults who access dental services are not well documented. Materials and Methods: Radiographic and record review were used to determine prevalence of dental caries, alveolar bone loss, frequency of service utilization, and medical status in this cross‐sectional investigation of a sample of older adults (N = 200) using dental services at Columbia University College of Dental Medicine. Results: Only 9% of the sample was completely edentulous, the mean DMFT was 19.9 and mean alveolar bone loss was 3.6 mm. Missing and Decayed Teeth accounted for 57.8% and 6.5% of the total caries burden respectively. Missing Teeth and alveolar bone loss increased with increasing age, but there was no increase in Decayed Teeth. Conclusions: While access to and utilization of dental services may result in improved tooth retention, older adults who use dental services continue to have dental care needs, especially periodontal care needs.