Psychiatric Problems Affecting Dental Care of the Elderly1

The author reviews the major psychiatric disorders that can affect the dental care of the aged. Depression and dementia are the most common problems in the upper age groups. Other less frequent disorders include paranoid states, anxiety states, and alcohol abuse. All of these illnesses have both symptomatic and specific treatments so that a thorough evaluation and aggressive treatment plan should be pursued when psychiatric symptoms present in any elderly patient. Their treatment can have a considerable influence on the patient's dental care. Ageism, orality, preventive dentistry, xerostomia and periodontal disease are discussed in the context of these psychiatric illnesses of the aged.     

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.     

Oral health care issues in aged care facilities in Western Australia: resident and family caregiver views

Objective: To investigate resident and family perceptions and attitudes towards oral health care and access to dental services for aged care facility residents. Method: Focus groups and individual interviews with residents and family caregivers were conducted at aged care facilities in the Perth Metropolitan Area, Western Australia. Results: There were 30 participants from twelve aged care facilities (21 residents and nine family caregivers). Five focus groups comprising both residents and family caregivers were conducted in addition to three face‐to‐face interviews with residents. Both groups considered oral health very important to overall health and quality of life. Family caregivers noted a lack of dental check‐ups and specialised professional oral care, particularly in high‐care facilities. Low care residents were more likely to have regular dental check‐ups or dental treatment and off‐site dental visits were straightforward due to their mobility and family member assistance. Family caregivers noted time limitations and lack of expertise in oral health care amongst staff in high‐care facilities, and the challenges of maintaining oral care for residents with poor mobility or cognitive impairment. It was considered important that staff and management liaise with family caregivers and family members in provision of oral care. Conclusion: Regular oral care, assessment and treatment were considered limited, particularly for residents in high care. There is a need for comprehensive, ongoing oral health programmes involving appropriately trained and empathetic dental health professionals and staff to improve oral health care in Perth’s aged care facilities.     

The role of anti‐PAc (361–386) peptide SIgA antibody in professional oral hygiene of the elderly

Objective: Measurement of salivary IgA antibody (PAc‐peptide antibody, PPA) to amino acid residues 361–386 of Streptococcus mutans PAc, which possess a multiple binding motif to various HLA‐DR molecules and a B‐cell epitope that recognises the inhibiting antibody to S. mutans, is an indicator for the population numbers of mutans streptococci (MS) in human saliva. The purpose of this study was to clarify the role of PPA in infection control of MS after professional oral hygiene care. Materials and methods: Thirty‐nine dependently living institutionalised elderly subjects (75.9 ± 7.5 years; 10 males, 29 females) participated in the study. The measurements of PPA, MS, total streptococci (TS) and lactobacilli (LB) were performed by ELISA and culture techniques from saliva, plaque and tongue samples from the elderly. Results: After treatment using professional oral care, the numbers of MS decreased significantly at 6 months in saliva and tongue samples from the group not having PPA in comparison with the primary data; whereas in the PPA‐detected group, a significant decrease in MS number was shown immediately following professional care at 1–12 months in all samples. There was little difference in the numbers of LB at any of the time points. The numbers of TS decreased rapidly in PPA‐not detected group in comparison with the PPA‐detected group. Conclusion: PPA may be more effective for controlling MS number in the oral cavity after professional treatment. The measurement of PPA may be used for preventive instruction to dental caries at the chair side in the clinical setting.     

A study on the effects of short-, medium- and long-term professional oral care in elderly persons requiring long-term nursing care at a chronic or maintenance stage of illness

Objective: The purpose of the present study is to clarify the frequency of provision of effective professional oral care by dental health workers in order to improve the oral hygiene state of elderly persons requiring long‐term care. Methods: In 105 patients requiring long‐term nursing care, 55 subjects with positive oral Candida albicans were divided into five groups according to the frequency of oral care intervention at intervals of 1, 2, 3, 4 and 6 weeks. The effects of professional oral care on the improvement of the oral hygiene state were investigated taking the frequency and duration of care into consideration. Results: The results showed that oral hygienic condition could be improved by performing professional oral care at intervals of 1 week for 12 consecutive weeks, and the improved condition could be maintained when professional oral care was continued at intervals of 1 week thereafter. Conclusion: It is necessary to continue professional oral care at intervals of 1 week for 12 consecutive weeks and at intervals of 2 weeks for more than 20 weeks. The oral hygiene state could be improved by professional intervention at intervals of three or four weeks in long‐term oral care, but this was limited to subjects whose Functional Independence Measure (FIM) scores were higher than 3.     

Behind the screens: care staff observations on delivery of oral health care in nursing homes

Objective: To identify qualitatively carer staff attitudes, practices and clinical comments related to oral health care of functionally dependent nursing home clients. Design: Open-ended questions included in a longer quantitative questionnaire. Setting: 22 randomly selected nursing homes in the Bristol area. Subjects: 416 carers employed in these homes. Results: The majority of carers thought that clients had a right to good oral health, accepted the carers' role in helping clients with oral and denture hygiene, but recognised that oral health care provision was deficient. However, some carers believed oral health care to be solely the clients' responsibility despite high disability levels. Main barriers to providing oral health care were low prioritisation of oral health by nursing management, lack of co-operation from cognitively impaired clients, and lack of training. Carers were critical of homes' lack of arrangements for routine professional dental cheeks, lack of commitment to staff training, low standards of oral health care by colleagues, and lack of provision of oral hygiene aids and cleansing materials for clients. Many responses indicated ways in which nursing home oral health care could be improved. Carers reported contrasting experiences of dental treatment, and deplored recent decreased availability of subsidised dental care. Conclusions: Carers' generally positive attitudes towards clients' oral health care should encourage health educators. Insights gained from qualitative data can help to identify the less obvious causes for poor oral care delivery, which can then be addressed in education and training initiatives in nursing home settings.     

Arresting rampant dental caries with silver diamine fluoride in a young teenager suffering from chronic oral graft versus host disease post-bone marrow transplantation: a case report

Background

Rampant caries is an advanced and severe dental disease that affects multiple teeth. This case describes the management of rampant caries in a young teenager suffering from chronic oral graft versus host disease after allogeneic bone marrow transplantation.

Case presentation

A 14-year-old Chinese boy suffering from β–thalassemia major was referred to the dental clinic for the management of rampant dental caries. An oral examination revealed pale conjunctiva, bruising of lips, and depapillation of tongue indicating an underlying condition of anemia. The poor oral condition due to topical and systemic immunosuppressants was seriously aggravated, and rampant caries developed rapidly, affecting all newly erupted, permanent teeth. The teeth were hypersensitive and halitosis was apparent. Strategies for oral health education and diet modification were given to the patient. Xylitol chewing gum was used to stimulate saliva flow to promote remineralization of teeth. Silver diamine fluoride was topically applied to arrest rampant caries and to relieve pain from hypersensitivity. Carious teeth with pulpal involvement were endodontically treated. Stainless steel crowns were provided on molars to restore chewing function, and polycarbonate crowns were placed on premolars, upper canines and incisors.

Conclusion

This case report demonstrates success in treating a young teenager with severe rampant dental decay by contemporary caries control and preventive strategy.     

Factors That Drive Dentists towards or Away from Dental Caries Preventive Measures: Systematic Review and Metasummary

Background

Dental caries is a serious public health concern. The high cost of dental treatment can be avoided by effective preventive measures, which are dependent on dentists’ adherence. This study aimed to evaluate the factors that drive dentists towards or away from dental caries preventive measures.

Methods and Findings

This systematic review was registered in PROSPERO (CRD42012002235). Several databases as well as the reference lists and citations of the included publications were searched according to PRISMA guidelines, yielding 18,276 titles and abstracts, which were assessed to determine study eligibility. Seven qualitative studies and 41 surveys (36,501 participants) remained after data extraction and interpretation. A total of 43 findings were abstracted from the reports and were grouped together into 6 categories that were judged to be topically similar: education and training, personal beliefs, work conditions, remuneration, gender, place of residence and patients. The main findings for adherence based on their calculated frequency effect sizes (ES) were teamwork (21%) and post-graduation (12%), while for non-adherence were biologicism (27%), and remuneration for preventive procedures (25%). Intensity ES were also calculated and demonstrated low prevalence of the findings. Quality assessment of the studies demonstrated that the methodological quality, particularly of surveys, varied widely among studies.

Conclusions

Despite the questionable quality of the included reports, the evidence that emerged seems to indicate that further education and training coupled with a fairer pay scheme would be a reasonable approach to change the balance in favor of the provision of dental caries preventive measures by dentists. The results of this review could be of value in the planning and decision making processes aimed at encouraging changes in professional dental practice that could result in the improvement of the oral health care provided to the population in general.     

Oral status among seniors in nine nursing homes in Styria,Austria

doi:10.1111/j.1741‐2358.2009.00281.x
Oral status among seniors in nine nursing homes in Styria, Austria Objective: To investigate the oral state in participants cared for in residences for senior citizens in Styria, Austria. Materials and methods: Four hundred and nine participants in Styria from nine homes for senior citizens were examined employing parameters in accordance with those of Folstein’s Mini Mental Status (MMS), DMFT, basic periodontal examination, the modified oral hygiene index, pain experienced during the preceding year, the subjective and objective need for treatment, and also requirements involving surgical and prosthetic treatment. Furthermore, the habitual methods of maintaining oral hygiene were examined establishing by whom this was carried out – whether by the patient, the nurse, or by patient and nurse together. Results: Four hundred and nine participants were examined, 48.3% were found to have retained on average 4.9 of their own teeth while 69% were fitted with dentures; however, 81% of the participants required prosthetic treatment. 28.9% of the participants had experienced acute dental pain during the preceding year and surgical treatment was found to be necessary in 47.7% of those with original teeth. Eighty‐four per cent of the participants showed acute inflammation of the periodontium while the state of oral hygiene, measured on a scale of 0–4, reached an average of 2.43. Oral hygiene was carried out by the nurses in only 7.46% of the cases which showed an average MMS measurement of 18. Conclusion: The results compared with those reported in other recent surveys and our data show an urgent need in Austria to improve the standards in dental care for the hospitalised elderly. Regular dental checks, carried out in the actual home by a dental surgeon should be introduced, whilst the nursing staff should be made fully aware of the problems caused by insufficient oral care and receive regular support from specialised oral hygiene assistants. The results of this survey also suggest that nursing staff should be equipped with simple instruments in order to judge to the extent to which the patient is capable of carrying out oral care independently and then according to the results to supplement this with additional care.     

The perceived importance of appearance and oral function,comfort and health for severely demented persons rated by relatives,nursing staff and hospital dentists

Dental health is an aspect of the quality of life. Oral treatment goals for, the severely demented and the benefits of oral treatment are complex issues. Severely demented people can neither express their wishes nor make rational decisions about oral care. Acting “in the best interests” of a demented person who refuses or does not understand the purpose of treatment depends on what perspective and treatment priorities the advocate has. For oral treatment of a demented person the advocate may be a relative, a member of the ward staff or a hospital dentist. In a structured interview, the relatives of demented patients in a Stockholm hospital and members of the nursing staff were asked to rate the importance of goals for dental care. These ratings were also recorded for hospital dentists. In this study there was agreement on the importance of freedom from oral pain and fear of aspiration. Nursing personnel gave priority to aspects of good care such as being able to chew and enjoy eating. Relatives were also concerned with social behaviour and communication such as fresh breath, normal speech, and normal appearance. The ratings by the hospital dentists were generally lower which might reflect professional awareness of the limitations of treatment success implied by cognitive impairment.     

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%).     

Ethical dilemmas in early detection of dementia. An inventory of moral intuitions in practice

In this article we present an inventory of the moral intuitions of the health care workers who work in the field of early detection of dementia. The effects of pharmacological treatment and professional care and support may improve when dementia is detected in an early stage. Furthermore, the patient (and his family) can prepare themselves for the period to come. Health care workers recognize moral problems and tensions concerning early detection that are related to the question whether persons will benefit from knowledge in an earlier stage of dementia, because this knowledge can be a heavy burden. We asked general practitioners, home care workers, employees of the so-called 'Memory clinic' and specialists, what ethical intuitions they recognize in practice. They mentioned the following questions: when are health care professionals allowed to take initiative, is causing worries and concerns problematic, and should a diagnosis always to be told? We conclude after a first analysis that many moral questions derive from the fact that many health care professionals lack knowledge of the wishes and interests of the elderly. At the same time they try to justify their actions on the (presupposed) consent of the elderly person. We suggest that the general norm 'only act when the patient wants to be helped' in health care should also apply to detection of dementia, although it should not be taken too strictly. Another justification for early detection can be found in the benefits for the elderly people, when their wishes are no longer expressed.     

Understanding the ‘epidemic’ of complete tooth loss among older New Zealanders

doi:10.1111/j.1741‐2358.2009.00306.x
Understanding the ‘epidemic’ of complete tooth loss among older New Zealanders Objective: The aim of this study was to obtain a deeper understanding of the social factors driving New Zealand’s historic ‘epidemic of edentulism’ and how they operated. Method: In‐depth, semi‐structured interviews with 31 older New Zealanders were analysed using applied grounded theory. Results: Universal factors present in the data were: (a) the way in which New Zealand society accepted and indeed encouraged edentulism without stigma for those who had a ‘sub‐optimal’ natural dentition; (b) how the predominant patterns of dental care utilisation (symptomatic and extraction‐based) were often strongly influenced by economic and social disadvantage; and (c) the way in which lay and professional worldviews relating to ‘calcium theory’ and dental caries were fundamental in decisions relating to the transition to edentulism. Major influences were rural isolation, the importance of professional authority and how patient‐initiated transitions to edentulism were ultimately facilitated by an accommodating profession. Conclusion: The combined effects of geography, economics, the dental care system and the professional culture of the day, in the context of contemporary (flawed) understandings of oral disease, appear to have been the key drivers. These were supported (in turn) by a widespread acceptance by the profession and society alike of the extraction/denture philosophy in dealing with oral disease.     

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.     

Cast titanium overlay denture for a geriatric patient with a reduced vertical dimension

An older patient reporting to the dental surgery for his/her dental treatment is becoming a common occurrence. Improved oral hygiene has meant that teeth are retained for a longer time, along with the potential problems of attrition, decreased vertical dimension, temporomandibular joint discomfort/strain, and poor aesthetics. The case in question is that of a 65-year-old male patient who had severe attrition in the lower arch, temporomandibular joint pain and reduced vertical dimension. The maxillary arch had previously been restored with a fixed partial prosthesis. For restoration of the lower teeth, a removable cast titanium overlay denture was fabricated incorporating an increased vertical dimension. Porcelain facings were placed to restore the aesthetics of the anterior teeth. The titanium was cast in a semi-automatic electric arc, pressure type casting machine. A titanium overlay denture with porcelain facing on the anterior teeth may provide a means of restoring a patient's concerns regarding aesthetics and function.     

Oral health related to demographic features in Bosnian children aged six

The main aim of this paper is to present epidemiological indicators of oral health among six-year olds in Bosnia and Herzegovina (BH) and to analyze values of dmft index and dental treatment needs in order to identify differences in parts of the country. Another aim is to identify the needs from the public oral health care system in Bosnia and Herzegovina related to early permanent dentition by analyzing the condition of first permanent molars (FPM) as an indicator of oral health of permanent dentition. Survey was carried out in 2004 in 8 cantons of the Federation of BH (FBH) and in the Republic of Srpska (RS). Final sample included 560 participants aged six (mean 6.2, SD +/- 0.87). One dental team clinically examined all participants according to WHO methodology and criteria. The parameters used were: dmft index, DMFT index of first permanent molars (FPM), presence of sealants and treatment needs. A questionnaire about oral health habits had been administered. Dmft was 6.71 in that the d-component constituted the major part of the index. DMFT index of FPM was 0.61 (SD +/- 1.08). Percentage of caries free participants aged 6 was 6.8%. Average number of FPM with fissure sealants in BH was 0.25 (SD +/- 0.78). Significant demographic differences in dmft index, DMFT FPM and treatment needs were identified. Most participants (48.5%) had their first dental visit between the ages of five and seven. National oral health goal for Bosnia and Herzegovina should be to develop and implement disease prevention programs based on education of both parents and dental practitioners. It is necessary to improve access to dental care and shift focus from curative to preventive procedures. It is also necessary to set real goals for improvement of oral health which can be achieved within a desired time frame, as well as to precisely define measures to be taken.     

Dental Management of the Geriatric Head and Neck Cancer Patient1

The geriatric patient presenting with cancer of the head and neck region constitutes slightly less than half of all oral cancers diagnosed. Cancers of this region are generally treated with surgery, radiation, chemotherapy or combinations of these three. These patients not only present with special problems due to their age but also with challenging ones resulting from treatment of their disease. The dentist plays an important role in evaluating the patient's oral health and providing necessary services prior to any curative treatment. The dental diagnosis and treatment protocol practiced at Memorial Hospital are discussed for each therapeutic modality along with the measures taken for follow up care.     

A Review of Probiotic Therapy in Preventive Dental Practice

Probiotics have been widely publicized in the general press and the consumer media. Knowledge of the existence of “probiotics” is commonplace, and the effectiveness of probiotic therapy has been well reported in the medical literature. However, even though most published dental studies have reported positive results, the dental profession has not yet accepted the use of probiotic therapy as an adjunct for preventive dental care. This review article discusses published and current research into the applications of probiotics along with diagnostic testing of the oral biofilm. Probiotic therapy appears to be generally safe and effective in modifying with beneficial bacteria the oral biofilm and thereby reducing the effects of pathogenic oral bacteria. In this review, some examples of current oral probiotic research are discussed along with reference to the potential application of diagnostic testing of the oral biofilm for the presence of oral pathogens as a precursor to initiation of specific probiotic therapy. Dental professionals should be actively investigating this potentially very useful therapeutic measure for the benefit of their patients.