The Yad Sarah geriatric dental clinic, a different model

Introduction: There are not sufficient dental services for elderly people around the world. Yad Sarah is an Israel‐wide network of volunteers aiding sick, elderly, isolated and housebound people with an array of services aimed at making home care possible. It provides medical and social services to more than 380 000 elderly persons per year and in addition, lends medical equipment free of charge, has day rehabilitation centres, legal aid council for seniors, provides transportation for the disabled, meal deliveries and geriatric dental services. Materials and methods: The latter are equipped with five dental units (one mobile unit) and a dental laboratory. During the 5 years from 2000 to 2004 the dental services provided dental care for 3890 elderly patients with the main clinic located in Jerusalem. Patients pay an average of 70% of the cost price of their dental care, with the difference being subsidised by Yad Sarah. Of the 515 patients who applied for treatment in 2004, 54% possessed natural teeth in both jaws, 28% were fully edentulous, 12% were edentulous in the maxilla and 6% were edentulous in the mandible. Females applied for dental treatment more often than the male population. Older patients (75–101 years old) required oral care at their homes or at old age residences, more frequently than the younger age groups (60–74 years old). Conclusion: Dental treatment was administered by 70 volunteer dental surgeons, two certified dental hygienists and dental hygienist students. The clinical staff was provided with a comprehensive in‐service training in geriatric dentistry during the 3‐year service learning period. A survey in 2004 showed that 83% of the selected patients were satisfied, compared with 14% who were not. The reasons for satisfaction were, mainly, the personal relationship with the attending staff (41%) and the professional ability of the dental team (46%).     

Care Needs of the Elderly Treated at a Dental School1

Increased longevity and recently intensified emphasis on gerodontology mandate that dental students'exposure to clinical care of the elderly be enhanced. The extent to which individual students can be exposed to geriatric dental care depends on the availability of elderly patients to dental school clinics and the treatment needs of these patients. The purposes of this study were (1) to determine the dental treatment needs of geriatric patients who seek care at a dental school, and (2) to ascertain if differences exist between the needs of older versus relatively young geriatric patients. Data collected on 128 elderly patients during a three month period indicate that 57% of the aged were either edentulous at examination or treatment planned to become edentulous and receive two full dentures. The remaining 43% were treatment planned to remain dentulous and receive therapies other than full upper and lower dentures. More older geriatric patients required full dentures than their younger cohorts. More young elderly required prophylaxes, scalings, root planing therapy, dental restorations, and partial dentures. Additional to their denture requirements, aged patients appear to have sufficient non-prosthetic needs to allow for meaningful gerodontic experience by students.     

Professional Dental Care for Patients with Dementia

Individuals with dementia present a significant challenge to the dental professional. The dental professional must meet the special needs of the patient with dementia with patience and a variety of non-traditional skills, including treatment planning with caregivers and nonverbal communication to reassure disoriented patients. The goals of dental care for the patient with dementia are to restore and maintain oral health and prevent progression of oral disease. Because of the degenerative nature of dementia, the first dental visit for a patient with dementia may represent the patient's best cognitive functioning level. For this reason, the dental treatment plan should aim to restore oral function quickly and to institute an intensive preventive program. Practical guidelines for preventive diagnostic, and restorative care are provided. To illustrate these points, two cases are presented.     

An eye for a tooth

Objective: To propose a possible link between dental extraction and intra‐ocular complications. Background: Several publications in medical literature describe intra‐ocular complications after different dental procedures. Results: Retinal detachment and vitreous hemorrhage following dental extraction with an appropriate anesthesia. Conclusion: Systemic complications following dental treatments should not be neglected and proper medical treatment must be provided as soon as possible.     

牙科焦虑症治疗方法综述

牙科焦虑症主要是对疼痛的恐惧、对未知的恐惧、对机体受到伤害的恐惧等因素导致的焦虑症状。临床中80%的口腔疾病患者都对治疗心存恐惧,因此在很大程度上不能配合医生的治疗甚至逃避治疗。随着生活水平的不断提高,人们要求在舒适的心理环境中接受治疗,因此牙科焦虑症就成为口腔医护工作者必须面对的问题。治疗牙科焦虑症的方法主要分为行为学,药理学和有机放松法三个大类,在实际使用的过程当中往往是各种方法配合使用,而不是单一使用。随着人们研究的逐步深入,提出的具体治疗方法也越来越多,本文就牙科焦虑症目前所使用的治疗方法做详细的介绍及分类,帮助口腔医护工作人员理清治疗思路,为正确的诊断、干预和治疗牙科焦虑症提供治疗方法。     

Historical perspectives on the clinical development of bisphosphonates in the treatment of bone diseases

Bisphosphonates (formerly termed diphosphonates) were first synthesized in the late 1800s; however, their clinical use has been relatively recent. The bisphosphonates' affinity for hydroxyapatite crystal surface led Procter and Gamble to test these compounds in dental, then medical applications. With key input from university researchers, this led to the medical use of the first bisphosphonate, etidronate disodium in 1968 to treat a young patient with myositis ossificans progressiva. Further clinical research led to widespread medical application for the bisphosphonate class including use as a diagnostic in radionuclide bone imaging agents, treatment of osteoporosis, Paget's disease of bone, hypercalcemia of malignancy and metastatic bone disease. The historical development of bisphosphonates provides an excellent example of how observations and knowledge obtained at the basic science level were applied and successfully tested in the clinic. The end result of these efforts has provided health care professionals with diagnostic and therapeutic tools to improve the lives of patients.     

CAD/CAM treatment for the elderly--a case report

doi: 10.1111/j.1741‐2358.2011.00521.x CAD/CAM treatment for the elderly – a case report Background: When elderly develop signs and symptoms of Alzheimer’s disease they lose their independence and neglect dental hygiene. Dentists are increasingly confronted by seniors who are in need but who have limited access to dental care. Caretakers and family are also often confronted with behaviour problems besides the dental problems. Objective: To report the importance of shorter and lower impact treatment for seniors when caretakers and family are confronted with a behavioural problem in addition to the dental problem. Materials and methods: In this case report, the oral management of a patient with Alzheimer’s disease was described using chairside computer‐aided design/computer‐aided manufacturing (CAD/CAM) technology while constructing a bonded bridge. Discussion: The case report emphasises the importance of interaction with the patient and added a treatment method for patients with limited cognitive skills who become easily agitated or aggressive. Conclusion: The fabrication of a full ceramic bonded bridge utilising the Cerec 3D chairside CAD/CAM technology in an Alzheimer patient has been shown to be a feasible, precise, aesthetic and durable solution. It added a technique for intervening with patients with limited tolerance for dental procedures, which improves the quality of life of both patient and family.     

Oral implants in dependent elderly persons: blessing or burden?

doi:10.1111/j.1741‐2358.2009.00314.x
Oral implants in dependent elderly persons: blessing or burden? Background: Implant‐supported (partial) dentures may raise problems in patients who have become dependent on others for daily oral health care. Dental hygienists and general dental practitioners, as well as care providers, volunteer aiders and even health care insurance companies, should anticipate the growing demand for specific oral health care for patients provided with implant‐supported (partial) dentures. Objective: To report three cases of dependent patients and to present recommendations to prevent or resolve implant‐related oral problems. Materials and methods: The three case reports are demonstrating that implant insertion in (dependent) elderly people needs careful consideration. Discussion: When considering implant treatment, some questions should be raised: (1) Is the treatment appropriate in contributing to the patient’s well‐being and quality of life? (2) Is the treatment the most suitable treatment? (3) Does the treatment integrate with the patient’s oral health care plan? (4) Is the patient sufficiently cooperative? (5) Is the patient supported by a well‐functioning oral (self) care assisting network? (6) Is it possible for the patient to regular see an oral health care professional and is oral health care easily accessible in cases of an emergency? Conclusion: Dependent elderly people can benefit from oral implants, providing that adequate oral health care and aftercare can be provided. When indicated, removal of the anchorage structure is easily performed by putting the implants to sleep. All implant patients should be provided with an ‘implant passport’. Regular information and instruction for care providers about the oral condition of the patient are essential.     

Compliance by physicians with the 1978 Ontario Mental Health Act.

In a survey of 102 patients admitted involuntarily to a psychiatric hospital, a statement of potential danger, required by law, was found to be provided on all the committal forms. Closer enquiry suggested that although 89% of these patients were admitted involuntarily in accordance with strict legal requirements the legal justification for involuntary admission was questionable in 11 cases. Of these 11 admissions, 10 were thought to be warranted if medical considerations were given priority and on humane grounds. For 6 of the 10 patients treatment was clearly beneficial. One patient suffered hardships as a result of his involuntary admission that were not compensated for by any likelihood that he could have benefited medically from psychiatric care. Apparently humane considerations and the possibility that a mentally ill person could benefit from treatment led to some committals that were legally uncertain. It is concluded that the Mental Health Act should be revised to take account of such situations.     

An Introduction to a Symposium in Geriatric Dentistry: Issues in Gerontology

The papers in this collection address geriatric dentistry at a time when society is rapidly becoming older. More than ever before, all dental care providers must understand the special needs of elderly patients and the unique biological features of the aged person that affect the diagnosis and prognosis of oral pathology. Attitudes about aging in the elderly must be discussed within the context of the health care setting so we can address the needs for social change, particularly in the dental and medical professions. This symposium brings together a series of papers on topics that are being researched in geriatric dentistry. The topics are diverse, including methods to finance dental care, psychiatric considerations, temporomandibular joint dysfunction, prosthodontics, artificial saliva and nutritional factors, immunology and the new frontiers in dental science, periodontal disease and oral cancer. And as an epilogue to our theme, a dentist with a primarily geriatric practice reflects on the difficulties and the rewards of the elderly patient. Improving the quality of life is the goal of aging research and to investigate aging legitimately we must ask in a systematic manner, what is aging? In this introduction, we discuss briefly the several theories of aging that are guiding research efforts.     

Oral health care for frail elderly people: actual state and opinions of dentists towards a well-organised community approach

Objective: This study was undertaken to provide an analysis of the actual oral heath care for frail elderly people living in different settings and to explore opinions of dentists towards new concepts in developing a community approach. Method: Data were collected from a sample of 101 dentists (15%) in the county of Antwerp using a self‐administered 30‐item questionnaire including questions about age, gender, education, organisational aspects of dental surgery, questions concerning dentists’ own contribution to oral healthcare services for frail elderly people and statements concerning opinions and attitude toward the organisation of oral health care for frail elderly people. At the same time, qualitative data were collected from focus group sessions with all participating dentists. Non‐parametric analysis was used to explore possible relationships between opinion and possible explanatory variables. Results: Half of the dentists offered dental services to residential or nursing homes (mean number of treatments a year: 5.4) and at home (mean number of treatments a year: 2.4). Prosthetic treatments such as relieving denture pressure points, repairing, rebasing and making new dentures were carried out in 77.4% and 76.7% of the cases in residential or nursing homes and at home respectively. Extractions were carried out in 16% and 18.6% of the cases in both living situations respectively. The main reasons for dentists refusing domiciliary oral health care were the absence of dental equipment (63%), lack of time (19%), with 11% convincing the patients to be treated in their dental surgery. Analysis showed different opinions of dentists depending on age, gender and university of education; however, statistically significant differences were only found by age. Conclusion: The older the dentist, the greater the tendency to refuse domiciliary oral healthcare services. The younger dentists were reluctant to cooperate in the provision of oral health care in a structured community approach.     

Continuing dental care for Highlands elderly: current practice and attitudes of dental practitioners and home supervisors

Objective : To investigate current practice and attitudes of Highland dentists and home supervisors to continued dental care of elderly residents. Methods : A cross‐sectional questionnaire was designed to survey the current practice and attitudes of Highland dentists and residential care supervisors in their provision of dental care for the elderly at home and in long stay accommodation. Results : The response rate was 94% of dentists and 79% of homes. Despite 86% of dentists providing domiciliary care and 93% of homes transport to a surgery, no more than a quarter of residents had had contact with a dentist in the previous year. The distribution of residents varied with dependant individuals living in nursing units and the least dependant in residential homes. Only 1% of all residents were totally bed bound. Domiciliary patients were less likely to receive continuing care compared with those seen in a surgery and 75% of homes had to initiate dental care. In terms of patient referral, the majority of GDPs would refer uncooperative patients, salaried dentists would refer those with complex medical histories and community dentists would refer those requiring complex treatments. A dental assessment was undertaken in 46% of homes and 81% of these kept a record of dental care. Conclusion : This study highlights the need for a co‐ordinated, seamless continuing dental care service, tailored to the actual needs of the elderly individuals it is designed to serve, particularly in a remote and rural area.     

A 5‐year follow‐up of older adults residing in long‐term care facilities: utilisation of a comprehensive dental programme

Objective: This study will compare the clinical outcomes of 139 elders residing in long‐term care (LTC) who received dental treatment with those who did not receive care under a comprehensive dental programme over 5 years. Background: Numerous studies have documented very poor oral health and limited access to dental care among frail older adults residing in LTC facilities. The University of British Columbia and Providence Healthcare developed a comprehensive dental programme to serve elderly LTC residents within seven Vancouver hospitals. Since 2002, the Geriatric Dentistry Programme has provided annual oral health assessments and access to comprehensive dental care. Material and methods: A comprehensive oral health assessment was provided using CODE (an index of Clinical Oral Disorders in Elders). A change in oral health status (improvement or worsening) was evaluated by measuring CODE scores including caries and periodontal condition, and other aspects of the dentition. Results: Eighty‐three residents received dental treatment of some form over the 5 years, while 56 did not receive any treatment beyond an annual examination. The percentage of residents initially recommended for treatment in 2002 was 97%, which declined to 70–73% after the 3rd year. The percentage of residents treated increased after the first year and remained at 56–72% thereafter. The comparison between CODE scores from baseline and 5 years later showed an improvement for those receiving care (p = 0.02, χ² = 7.9, df = 2). Conclusion: Within the limitations of this study, residents who did consent and receive care showed an improvement in their oral health status after 5 years.     

Medical home care services for the housebound elderly.

In our health jurisdiction the proportion of elderly people is more than double the national average, and there is a severe shortage of both home care services and long-term care beds. To help the many elderly housebound people without primary medical care we initiated a medical services home care program. The goals were patient identification, clinical assessment, medical and social stabilization, matching of the housebound patient with a nearby family physician willing and able to provide home care and provision of a backup service to the physician for consultation and help in arranging admission to hospital if necessary. In the program''s first 2 years 105 patients were enrolled; the average age was 78.9 years. More than 50% were widowed, single, separated or divorced, over 25% lived alone, and more than 40% had no children living in the city. In almost one-third of the cases there had never been a primary care physician, and in another third the physician refused to do home visits. Before becoming housebound 15% had been seeing only specialists. Each patient had an average of 3.2 active medical problems and was functionally quite dependent. Thirty-five of the patients were surveyed after 1 year: 24 (69%) were still at home, and only 1 (3%) was in a long-term care institution; 83% were satisfied with the care provided, and 79% felt secure that their health needs were being met. One-third of the patients or their families said that it was not easy to reach the physician when necessary. We recommend that programs similar to ours be set up in health jurisdictions with a high proportion of elderly people. To recruit and retain cooperative physicians hospital geriatric services must be willing to provide educational, consultative and administrative support.     

Daily nurse requirements planning based on simulation of patient flows

Nurses account for approximately 50 % of total hospital budgets and their allocation to medical units and shifts can significantly affect the quality of care provided to patients. The adoption of flexible shift schedules and the assessment of actual nursing time can enable sensible resource planning, balancing the quality of care with efficiency in resource use. Starting from the concept that nurse requirements are triggered by patient needs, which are stochastic in nature both for clinical activities and their duration, this paper proposes an innovative Nurse Requirement Planning model grounded on the concept of the clinical pathway (the “standard” sequence of diagnostic, therapeutic and care activities a patient with certain pathology should undertake over time) with its inner routing probability and patient dependence on nurses, which can be correlated to the time needed to perform nursing tasks. In merging and modelling these two aspects, the method summarizes the best features of acuity-quality and timed-task/activity techniques, well known although not usually applied for reasons of demands on clinicians’ time. Instead, in this paper, for each shift of the day, hospital management is enabled to choose the optimal number of nurses to meet actual requirements according to a desired service level and personnel saturation by means of a tool that simulates the patient flow in a medical unit based on automatic data retrieval from hospital databases. The validation and verification of the proposal were undertaken in a stroke unit.     

自闭症儿童口腔正畸治疗中系统性心理预防与干预的作用

目的:评估系统性心理预防及干预在自闭症儿童口腔疾病治疗中的作用。方法:将在我医院进行正畸治疗的40例12~16岁自闭症患者按着随机分配分为对照组与实验组,每组各20例。在正畸治疗过程中,对照组实施常规心理行为预防及干预,包括:治疗前的基础准备、治疗过程中注意事项、治疗后康复方案及辅助治疗等。而对于实验组,除了实施常规的行为预防及干预外,还进行系统性心理行为预防及干预,包括:语言疏导、健康教育、辅助矫正、生命体征监测、肢体语言演示等。结果:实验组和控制组的孩子们能够完成正畸治疗,自闭症儿童治疗配合的的程度,听话依从性,显著高于对照组(P0.01),两组之间蛀牙数和牙龈指数存在差异(P0.05)。结论:系统性行为预防及干预能够提高自闭症儿童的配合合作的程度及医嘱依从性,值得在口腔正畸科门诊自闭症儿童患者中推广。     

Geriatric dentistry--meet the need

Geriatric dentistry or gerodontics is the delivery of dental care to older adults involving the diagnosis, prevention, and treatment of problems associated with normal ageing and age-related diseases as part of an inter-disciplinary team with other health care professionals. Geriatric health is an ignored and under-explored area worldwide. Oral health reflects overall well being for the elderly population. Conversely, elderly patients are more predisposed to oral conditions due to age-related systemic diseases and functional changes. The major barriers to practising geriatric dentistry are the lack of trained faculty members, a crowded curriculum and monetary concerns. For successful treatment, the practitioner must adopt a humanitarian approach and develop a better understanding of the feelings and attitudes of the elderly. Prevention and early intervention strategies must be formulated to reduce the risk of oral diseases in this population. In future, dental professionals must have a proper understanding of the magnitude of the services to be provided to the elderly. This could only be realised through an education programme in geriatric dentistry, which should be started without further delay. This article hence sets out the objectives, needs, present scenario, strategies and types of dental treatment required by the elderly population.     

A Physician's Perspective on the Incorporation of Pictograms as a Supplement to Medical Instructions in Chile: A Pilot Study

Introduction and objectivesCurrent models of health care are progressively migrating to more participatory models, where for treatment to achieve results that last over time, there must be effective communication between the patient, his or her caregivers, and health professionals. Although the use of pictograms in the context of medical instructions has been widely studied, in our country, there are no studies about their usefulness, or which set of symbols should be used by the systems. This work aims to present the first step towards the development of platforms that automatically suggest pictograms to supplement medical instructions for primary care settings in Chile.Materials and methodsIn this pilot study, we collected and analyzed the physicians' opinions on the selection of medical instructions that later will automatically be supplemented by the software that is under construction. We designed an expert validation survey using a set of 66 medical instructions with pictograms. This survey provided three rating options for each medical instruction: Not necessary (supplementing the instruction with a pictogram does not carry any value), Useful (supplementing the instruction with a pictogram may help patients to understand and remember the instruction), and Essential (supplementing the instruction with a pictogram is essential). Seventy-one physicians responded to the survey.Results22 out of 66 medical instructions were considered “essential” by >=51% of the experts, and 12 of the 66 were considered to be “useful but not essential” by >=51% of the experts.ConclusionResults of our survey validate the potential use of pictograms as a complement to better comprehension of medical instructions in our country.