Prevention and management of periodontal diseases and dental caries in the older adults.

As a result of aging populations, in the future, dental practitioners will be caring for more older adults than ever before. These older adults, especially in developed countries, will demand a greater number of dental services, driven by increased tooth retention and an expectation of excellent oral healthcare throughout the life course. Further, the global rise in the prevalence and incidence of chronic diseases will increase the risk and/or severity of oral diseases and add a layer of complexity to the management of oral diseases in older adults. More older adults will be at a higher risk of periodontal disease and root caries as a result of reduced tooth loss and edentulism. This article reviews information on periodontitis and root caries, oral diseases which reflect the cumulative risk of the individual, and which are best addressed through prevention. Oral healthcare providers must embrace the concept of lifelong emphasis on prevention, as well as participation as active members of a healthcare team which provides healthcare for older adults in various settings (eg, hospital/clinic-based care, community-based settings, and long-term care facilities). National guidelines that address oral health are being considered by some countries, and if these are implemented they will increase the accessibility to oral health for older adults. In parallel to this, revisions of existing older adult insurance schemes (eg, the inclusion of routine oral healthcare in the US Medicare program) would promote the maintenance of a functional dentition that is pain-free and conducive to general health. The opportunity exists to implement a holistic approach to oral health that will align oral health with general health and emphasize that true health can only be achieved with the inclusion of oral health.

Better-quality diet is associated with lower odds of severe periodontitis in US Hispanics/Latinos.

AIM: We investigated the cross-sectional association between diet quality and severe periodontitis in a sample of diverse Hispanics from the Hispanic Community Health Study/Study of Latinos. MATERIALS AND METHODS: A total of 13,920 Hispanic/Latinos aged 18-74 years of different heritages underwent a full-mouth oral examination and completed two 24-hr dietary recalls during 2008-2011. Severe periodontitis was defined as having ≥30% tooth sites with clinical attachment loss ≥5 mm. Diet quality was assessed using the Alternative Healthy Eating Index (AHEI-2010). We evaluated the association of diet quality with severe periodontitis adjusting for age, sex, nativity status, income, education, last dental visit, current insurance, cigarette smoking, diabetes, and energy intake. RESULTS: Relative to those at the lowest quartile of diet quality, individuals at the highest quartile had significantly lower odds of severe periodontitis (adjusted OR = 0.57, 95% CI: 0.39-0.82), with evidence of a dose-response relationship across AHEI quartiles. Among AHEI-2010 components, higher consumption of whole grains and fruits, and lower consumption of red/processed meats were associated with lower odds of severe periodontitis. CONCLUSION: Better-quality diet was associated with lower prevalence of severe periodontitis although the causal pathways need to be clarified in future work.

Geriatric periodontology: how the need to care for the aging population can influence the future of the dental profession.

The world's population is aging, and it has been estimated that by 2050, the number of people 65 years of age and older will reach 1.5 billion. The aging population will be affected by noncommunicable chronic diseases, including diabetes mellitus, cardiovascular disease and cognitive impairment. This important demographic shift includes a reduction in tooth loss/edentulism, particularly in older adults of the developed countries in North America, western Europe and north-east Asia. Therefore, in the future, dental providers will be required to care for an expanded number of older adults who have retained teeth and are medically complex. As the linkage of oral disease and systemic disease has focused on the relationship of periodontitis and noncommunicable chronic diseases, a broad review of 'geriatric periodontology' is both timely and important. This volume of Periodontology 2000 covers a range of subjects under this heading. Included are the demographics of an aging world; the effect of aging on stem cell function in the periodontium; the periodontal microbiota associated with aging; the host response in the periodontium of aging individuals; an analysis of the prevalence of periodontitis in the USA on a national, state-wide and community basis; differentiation of physiologic oral aging from disease; treatment of periodontal disease in older adults; implant therapy for older patients; oral disease and the frailty syndrome; the relationship of tooth loss to longevity and life expectancy; and the relationship of periodontal disease to noncommunicable chronic diseases. Although 'geriatric dentistry' is not a recognized specialty in dentistry, and 'geriatric periodontology' is a descriptive title, the subject of this volume of Periodontology 2000 is critical to the future of clinical dentistry, dental public health and dental research. Any comprehensive focus on older patients can only be accomplished with an emphasis on interprofessional education and practice. If embraced, this shift will allow the dental profession to be more closely aligned with the larger health-care environment, and can improve both oral health and health outcomes for patients seen in the dental office.

Tooth loss as a predictor of shortened longevity: exploring the hypothesis.

Many factors contribute to human tooth loss, including oral hygiene practices, trauma, smoking, health status, socio-economic status and individual preferences. Loss of teeth impairs quality-of-life measures, including the eating of most foods that require full masticatory function. A recent study of centenarians found that at age 65-74 years, those who lived to be 100 had a lower rate of edentulism than did younger members of their birth cohort at ages 65-74 years. Oral health was consistent with compression of morbidity toward the end of life. This article explores the hypothesis that factors associated with oral disease and noncommunicable diseases may increase the risk of tooth loss and lead to diminished longevity as a result of multifactorial interactions. It specifically addresses two critical questions. The first is: 'Can we conclude that the number of teeth in aging humans can affect longevity and life expectancy?' The answer is yes. The second is: 'Is tooth loss a predictor of shortened longevity?' Again, the answer is yes. Edentulism and partial edentulism are discussed as a disability, and how the philosophy/belief systems of dental providers and patients toward retaining teeth influences the outcome of tooth loss is also examined. Osteoporosis and cognitive impairment provide examples of modifying risk factors.

The aging mouth: differentiating normal aging from disease.

Aging is the physiologic change that occurs over time. In humans, this change occurs at different rates and are related to lifestyle, environment and genetics. It can be challenging to differentiate normal aging from disease. In the oral cavity, with increasing age the teeth demonstrate wearing of the enamel, chipping and fracture lines, and a darker color. The pulp chamber and canals are reduced in size as a result of the deposition of secondary dentin. Coronal or root caries, however, represent disease. A limited amount of periodontal attachment loss occurs in association with aging, usually manifesting as recession on the buccal surface of teeth. Severe periodontitis occurs in 10.5-12% of the population, with the peak incidence being observed at 35-40 years of age. Changes to the mucosal tissue that occur with age include reduced wound-healing capacity. However, environmental factors, such as smoking, dramatically increase the risk of mucosal pathology. Reduced salivary gland function is often seen in association with medication usage, as well as with disorders such as diabetes mellitus. Both medication use and chronic disorders are more common in older adults. Masticatory function is of particular importance for older adults. Maintenance of a nutritionally complete diet is important for avoiding sarcopenia and the frailty syndrome. Successful oral aging is associated with adequate function and comfort. A reduced, but functional, dentition of 20 teeth in occlusion has been proposed as a measure of successful oral aging. Healthy oral aging is important to healthy aging from both biological and social perspectives.

Cost-Effectiveness Analysis of Dental Sealants versus Fluoride Varnish in a School-Based Setting.

While sealants are more effective than fluoride varnish in reducing the development of new carious lesions on occlusal surfaces, and a course of treatment requires fewer clinical visits, they are more expensive per application. This analysis assessed which treatment is more cost-effective. We estimate the costs of sealants and fluoride varnish over a 4-year period in a school-based setting, and compare this to existing estimates of the relative benefits in terms of caries reduction to calculate the relative cost-effectiveness of these two preventive treatments. In our base case scenario, varnish is more cost-effective in preventing caries. Allowing for caries benefits to nonocclusal surfaces further improves the cost-effectiveness of varnish. Although we found that varnish is more cost-effective, the results are context specific. Sealants become equally cost-effective if a dental hygienist applies the sealants instead of a dentist, while varnish becomes increasingly cost-effective when making comparisons outside of a traditional dental clinic setting.

A New Practice Approach for Oral Health Professionals.

UNLABELLED: The oral health care paradigm presented here would broaden oral health services to include primary health care activities focusing on risk reduction and chronic disease screening. BACKGROUND AND PURPOSE: Changes in our nation's health care delivery system, shifting patient demographics, and availability of new health insurance programs have resulted in exploration of new practice models of health care delivery. Chronic diseases require coordinated care efforts over decades of a patient's life. Oral health professionals will be part of that care. METHODS: The practice model for this article was developed in the context of an academic medical center that promotes oral health care professionals as health care providers through interprofessional education. The combined experiences of the authors, including a diabetes predictive model for oral health settings, the efficacy and effectiveness of human immunodeficiency virus screening in a dental setting, the feasibility of using a decision support tool for tobacco cessation, and the effectiveness of integrating oral health education with comprehensive health services for people living with human immunodeficiency virus, have contributed to this concept. CONCLUSIONS: Prevention is increasingly recognized as a cost-effective means of reducing chronic disease burdens. To be effective, health promotion activities that encourage healthy living and early detection need to occur in a variety of health care settings. Oral health professionals represent an underutilized group of health care providers that can contribute to improved health of populations living with chronic diseases by broadening their scope of practice to include primary health screenings and tailored health promotion activities.

A community-based oral public health approach to promote health equity.

OBJECTIVES: We explored the interrelationships among diabetes, hypertension, and missing teeth among underserved racial/ethnic minority elders. METHODS: Self-reported sociodemographic characteristics and information about health and health care were provided by community-dwelling ElderSmile participants, aged 50 years and older, who took part in community-based oral health education and completed a screening questionnaire at senior centers in Manhattan, New York, from 2010 to 2012. RESULTS: Multivariable models (both binary and ordinal logistic regression) were consistent, in that both older age and Medicaid coverage were important covariates when self-reported diabetes and self-reported hypertension were included, along with an interaction term between self-reported diabetes and self-reported hypertension. CONCLUSIONS: An oral public health approach conceptualized as the intersection of 3 domains-dentistry, medicine, and public health-might prove useful in place-based assessment and delivery of services to underserved older adults. Further, an ordinal logit model that considers levels of missing teeth might allow for more informative and interpretable results than a binary logit model.

Six-month outcomes in dental patients identified with hyperglycaemia: a randomized clinical trial.

AIM: To assess an approach to improving behavioural and glycaemic outcomes in dental patients who present with diabetes risk factors and previously unrecognized hyperglycaemia. METHODS: We randomized 101 individuals identified with potential diabetes or pre-diabetes into two interventions. In the basic/control intervention, participants were informed about their diabetes risk factors and blood test result, and advised to see a physician. In the enhanced/test intervention, patients received a detailed explanation of findings and their implications, a written report for the physician, and were contacted at 2 and 4 months to inquire whether medical follow-up had occurred. At a 6-month re-evaluation, outcome measures included visit to physician, positive lifestyle changes and reduction in HbA1c. RESULTS: Seventy-three subjects returned for the 6-month visit. The two intervention groups did not significantly differ in any of the outcome variables. Eighty-four percent of subjects reported having visited a physician post-randomization, and 49% reported at least one positive lifestyle change as a result of our intervention. In subjects identified with potential diabetes (baseline HbA1c ≥ 6.5%), HbA1c was reduced 1.46 ± 0.28% compared to baseline (p < 0.01). CONCLUSION: Diabetes risk assessment and education by dental professionals of affected individuals unaware of their status may contribute to improved patient outcomes.

Periodontal findings in individuals with newly identified pre-diabetes or diabetes mellitus.

AIM: To assess the periodontal status and number of missing teeth in patients with newly identified pre-diabetes or diabetes mellitus. METHODS: A total of 1097 subjects with previously undiagnosed diabetes were available for study, and were categorized into normoglycaemic, potentially pre-diabetes or potentially diabetes groups based on a point-of-care (POC) HbA1c test. RESULTS: In fully adjusted models, significant differences were observed between all groups for the per cent of teeth with at least one site with a probing depth of ≥5 mm. For bleeding on probing, there were significant differences between diabetes and pre-diabetes (p = 0.001), and between diabetes and normoglycaemic groups (p = 0.002). For missing teeth, there were significant differences between the pre-diabetes and normoglycaemic groups (p = 0.034), and the diabetes and normoglycaemic groups (p = 0.004). CONCLUSIONS: Individuals with previously unidentified pre-diabetes demonstrate a level of periodontal destruction between that observed for normoglycaemic individuals and persons with diabetes. These data emphasize the association of oral findings to dysglycaemia, and suggest that periodontal disease and tooth loss can be early complications of diabetes mellitus.

Inclusion of Dental Services in Medicare to Improve Oral and General Health for Older Americans.

Poor oral health negatively impacts overall health, quality of life and well-being. Increasing evidence suggests that provision of basic dental care for elderly Americans would improve outcomes for a variety of systemic diseases and reduce the overall cost of health care. As a result, recent changes have been implemented to include some dental benefits in the Medicare program. This article outlines evidence, rationale and approaches required for inclusion of dental benefits for more Americans through the Medicare program. Improving access to dental services through Medicare to help prevent and manage common chronic diseases is an important step towards integration of dental care with general healthcare to improve the overall health, quality of life, and well-being for many older Americans.

Integrating oral and general health screening at senior centers for minority elders.

Racial/ethnic and socioeconomic disparities regarding untreated oral disease exist for older adults, and poor oral health diminishes quality of life. The ElderSmile program integrated screening for diabetes and hypertension into its community-based oral health activities at senior centers in northern Manhattan. The program found a willingness among minority seniors (aged ≥ 50 years) to be screened for primary care sensitive conditions by dental professionals and a high level of unrecognized disease (7.8% and 24.6% of ElderSmile participants had positive screening results for previously undiagnosed diabetes and hypertension, respectively). Dental professionals may screen for primary care-sensitive conditions and refer patients to health care providers for definitive diagnosis and treatment. The ElderSmile program is a replicable model for community-based oral and general health screening.

Inflammatory biomarkers in saliva: assessing the strength of association of diabetes mellitus and periodontal status with the oral inflammatory burden.

AIM: To determine the strength of association of type 2 diabetes mellitus and periodontal disease with the oral inflammatory burden, as assessed by markers of inflammation in saliva. MATERIAL AND METHODS: Unstimulated saliva samples were collected from 192 subjects with or without type 2 diabetes. ß-glucuronidase (ßG) was measured via a fluorometric array and interlukin-1ß (IL-1ß) via enzyme-linked immunosorbent assay. The concentration of both mediators was evaluated in relationship to clinical parameters, severity of periodontal disease and diabetes status. RESULTS: Regression analysis demonstrated that diabetes and periodontal disease was independently and positively correlated with increased concentration of ßG in saliva (p < 0.001). Moreover, the relative association of periodontal disease with the level of ßG in saliva was greater than the strength of association of the diabetic status. IL-1ß concentration in saliva was primarily associated with the severity of periodontal disease (p < 0.01), but not the presence of diabetes (p = 0.50). CONCLUSIONS: This study examined the nature of the inflammatory response in the oral cavity as assessed by inflammatory markers in saliva. Both periodontal disease and diabetes mellitus were independently associated with the oral inflammatory burden, in which the effect of periodontal disease was more pronounced.

Tooth loss and dental caries in community-dwelling older adults in northern Manhattan.

OBJECTIVE: To examine tooth loss and dental caries by sociodemographic characteristics from community-based oral health examinations conducted by dentists in northern Manhattan. BACKGROUND: The ElderSmile programme of the Columbia University College of Dental Medicine serves older adults with varying functional capacities across settings. This report is focused on relatively mobile, socially engaged participants who live in the impoverished communities of Harlem and Washington Heights/Inwood in northern Manhattan, New York City. MATERIALS AND METHODS: Self-reported sociodemographic characteristics and health and health care information were provided by community-dwelling ElderSmile participants aged 65 years and older who took part in community-based oral health education and completed a screening questionnaire. Oral health examinations were conducted by trained dentists in partnering prevention centres among ElderSmile participants who agreed to be clinically screened (90.8%). RESULTS: The dental caries experience of ElderSmile participants varied significantly by sociodemographic predictors and smoking history. After adjustment in a multivariable logistic regression model, older age, non-Hispanic Black and Hispanic race/ethnicity, and a history of current or former smoking were important predictors of edentulism. CONCLUSION: Provision of oral health screenings in community-based settings may result in opportunities to intervene before oral disease is severe, leading to improved oral health for older adults.

The dilemma of different dental degrees: DDS and DMD.

Although the Doctor of Dental Surgery (DDS) evolved from the surgical and the Doctor of Medicine in Dentistry (DMD) from the medical (DMD) roots of the dental profession, dental schools in the US currently award both degrees, verified as equivalent by finding no differences between them in standards of admissions, accreditation, or state licensure requirements while continuing to be subjectively perceived as different enough to create professional and public confusion. In contrast, Doctors of Osteopathy (DOs) and Doctors of Medicine (MDs) are both objectively and subjectively perceived as different in philosophy and healthcare training while objectively passing similar examinations to be licensed as physicians. Following from the history of both dental degrees and their implications for training and dental practice, the objective of this manuscript is to update the scientific, socio-political, and professional reasons for awarding only the DMD for future graduates while continuing to recognize the contributions of DDS graduates to oral healthcare. Working with the American Dental Association (ADA), American Dental Education Association (ADEA), and dental school librarians, a historical review was undertaken of the establishment of two doctoral degrees for dentists in the United States, including beliefs and attitudes of faculty and local dentists at the times of initiation or change in degrees awarded. Among the current 68 dental schools in the United States, there are approximately equal numbers of DDS- and DMD-granting schools. Except for some Harvard physicians, some of whom practiced dentistry, who wanted dentistry to be a specialty of medicine and the unexpected, serendipitous substitution of "medicine" for "surgery" which could not be translated into required Latin in 1867, all dental schools would have awarded only the DDS degree. Now, with the ongoing reorganization of the healthcare workforce in the United States, a single degree with broader healthcare connotations of the DMD will facilitate the integration of dentistry with overall healthcare, without changing the fundamental oral healthcare responsibilities of both DDS and DMD graduates.

Spending on emergency care due to nontraumatic dental conditions in the United States, 1996 through 2016.

BACKGROUND: Emergency department (ED) use for oral health care is a growing problem in the United States. The objective of the study was to describe spending on ED visits due to nontraumatic dental conditions (NTDCs) in the United States and to quantify changes in spending and its drivers. METHODS: Spending estimates for ED visits due to NTDCs according to type of payer were analyzed for the period from 1996 through 2016 and estimates about the drivers of change were analyzed for the period from 1996 through 2013. NTDCs included caries, periodontitis, edentulism, and other oral disorders. Estimates were calculated according to age, sex, and type of payer (that is, public, private, and out of pocket), adjusted for inflation, and expressed in 2016 US dollars. The estimate of expenses was decomposed into 5 drivers for the period from 1996 through 2013 (that is, population, aging, prevalence of oral disorders, service use, and service price and intensity). RESULTS: The total change in spending from 1996 through 2016 amounted to $540 million, an increase of 216%. The drivers of changes in spending from 1996 through 2013 were price and intensity ($360 million), service use ($220 million), and population size ($68 million). CONCLUSIONS: Spending on ED visits due to NTDCs more than tripled during the study period, with price and intensity representing the main drivers. This increase was primarily in adults and paid via the public sector. PRACTICAL IMPLICATIONS: Possible solutions include strengthening the oral health care safety net, especially for the most vulnerable populations.

A model for dental practice in the 21st century.

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

A summary of the 2010 Dunning Symposium: the practice of dentistry for the 21st century.

The 15th Dunning Symposium was held on November 29 and 30, 2010 in conjunction with the Greater New York Dental meeting in New York City. Since the first symposium in 1981, the symposia have addressed major issues in the field of dentistry that impact on the oral health of the public. The theme for this symposium dealt with how the practice of dentistry would emerge given healthcare reform legislation, opportunities for dentists to become more engaged in the primary care of patients, trends in dental education, and the addition of a mid-level practitioner. The audience, consisting of dental school deans and leaders in state and national dental associations, completed a pre-symposium questionnaire to gauge their opinions on key issues and then, after the presentations, participated in breakout sessions that discussed the implications of the presentations. This paper is a summary of the Dunning Symposium.