Barriers and Facilitators to integrate Oral Health care for Older Adults in General (Basic) Care in East Netherlands. Part 2 Functional Integration.

OBJECTIVE: to synthesise a framework of barriers and facilitators in the functional integration of oral health care (OHC) into general health care for frail older adults at macro (system), meso (organisation and interprofessional integration) and micro (clinical practice) levels. BACKGROUND: Identification of these barriers and facilitators is expected to promote better and more appropriate care. METHODS: For this qualitative study, comprising 41 participants, representatives of 10 different groups of (professional) care providers, and OHC receivers (home-dwelling and nursing-home patients) were interviewed. Transcripts of the in-depth, topic-guided interviews were thematically analysed. In a subsequent workshop with 52 stakeholders, results and interpretations were discussed and refined. RESULTS: Two themes were identified: (1) compartmentalised care systems and (2) poor interprofessional and communication infrastructure. Barriers related to (1) included lack of integrative policies and compartmentalised healthcare education (macro level); poor embedding of OHC in care procedures, instruments and guidelines (meso level); and poor interprofessional skills (micro level). Barriers related to (2) included poor financial incentives for collaborative practices (macro level) and badly connected ICT systems (meso level). Identified facilitators included integration of an OHC professional into care teams, and interdisciplinary consultations (meso level); and integration of OHC in individual care plans (micro level). CONCLUSION: In The Netherlands, OHC for older people is at best poorly integrated into general care practices. Barriers and facilitators are interconnected across macro-, meso- and micro levels and between normative and functional domains and are mainly related to compartmentalisation at all levels and to poor interprofessional and communication infrastructure.

[What promotes and hinders integration of oral care in general care? Part 1. Vision, attitude and culture]. / Wat bevordert en belemmert integratie van mondzorg in de algemene zorg? Deel 1. Visie, houding en cultuur.

To identify facilitators and barriers to integrate oral health care into general healthcare for frail elderly, 41 participants from 10 different groups of (professional) caregivers and care-recipients (residents living at home and nursing home patients) in the east of the Netherlands were interviewed. They were asked about normative integration (vision, attitude, culture) at the macro (system), meso (organizational and interprofessional), and micro (patient care) level. After thematic analysis of the interviews, the results were refined on the basis of a workshop with 52 stakeholders. Subsequently, two main themes were identified: 1. a compartmentalized care culture in which oral healthcare and general healthcare are seen as two separate domains; 2. prioritization, awareness, and attitude towards oral healthcare integration. Barriers to integration are: low political attention (macro level); unclear responsibilities, hierarchical relationships, and lack of vision (meso level); poor awareness and low prioritization by healthcare providers and patients (micro level). Leadership (meso level), a supportive personality of individual caregivers, and ownership of patients (micro level) promote integration.

[What promotes and hinders integration of oral care in general care? Part 2. Policy, organization, implementation]. / Wat bevordert en belemmert integratie van mondzorg in de algemene zorg? Deel 2. Beleid, organisatie, uitvoering.

To identify facilitators and barriers to integrate oral healthcare into general healthcare for frail elderly, 41 participants from 10 different groups of (professional) caregivers and recipients (residents living at home and nursing home patients) in the east of the Netherlands were interviewed. They were asked about functional integration at the macro (system), meso (organizational and interprofessional) and micro (patient care) level. After thematic analysis of the interviews, the results were refined on the basis of a workshop with 52 stakeholders. Subsequently, two main themes for functional factors were identified: 1. compartmentalized care systems and 2. deficient interprofessional and communication infrastructure. Barriers to integration are lack of integrative policies, compartmentalized education (macro level), poor embedding of oral healthcare in healthcare procedures and diagnostic tools, poor communication systems (meso level) and poor interprofessional skills (micro level). The integration of oral healthcare providers in care teams, agenda-setting during interdisciplinary consultations (meso level) and integration of oral care and care in individual care plans (micro level) promote integration. Oral healthcare for the elderly is poorly integrated in general care in the Netherlands.

[A PhD completed. The shortened dental arch and quality of life]. / Serie: Hora est. Verkorte tandboog en levenskwaliteit.

The question addressed by this doctoral research was whether the concept of the shortened dental arch has become an obsolete treatment therapy. To answer this question, a systematic review of literature concerning the oral health related quality of life of people with a shortened dental arch was carried out, a questionnaire among people with and without a shortened dental arch was employed to determine the longevity and clinical outcomes of shortened dental arches and finally, semi-structured interviews were conducted to assess perceptions and attitudes regarding absent molars and prostheses. The conclusion is that in certain situations the shortened dental arch concept is still valid. Patients with a shortened dental arch experience an oral health related quality of life comparable to people with a full dental arch and a shortened dental arch can function well for up to 30 years or more. During the joint decision-making process about whether to apply the shortened dental arch concept, it is important to address the underlying issues involved in having or treating a shortened dental arch.

[The (putative) pathological impact of fibromyalgia on the orofacial system]. / De (vermeende) pathologische invloed van fibromyalgie op het orofaciale systeem.

Fibromyalgia is a syndrome without apparent aetiology, characterised by pain, fatigue, memory disorders, mood disorders, and sleep disturbances. The syndrome is considered to be one of the rheumatic diseases. In the general population, the prevalence varies from 2 to 8%, with a women-men ratio of about 2:1. Suspicion of fibromyalgia arises when a patient has pain at multiple locations that cannot be attributed to trauma or inflammation, and when the pain is especially musculoskeletal. Primary management includes explaining the syndrome and offering reassurance. In addition, one can also attempt to increase mobility, avoid overloading, and improve physical condition and the level of activity, and to activate problem-solving skills. Subsequently, behavioural therapy and pharmacotherapy may be considered. The most important manifestations of fibromyalgia in the orofacial and occlusal system seem to be temporomandibular dysfunction, headache, xerostomia, hyposalivation, burning mouth and dysgeusia. However, with respect to the precise relation of fibromyalgia with the orofacial system, much needs to be elucidated.

[The impact of frailty on the oral care behaviour and dental service use of elderly people]. / De invloed van kwetsbaarheid op mondzorggedrag en tandartsbezoek van ouderen.

In order to explore how the level of frailty and various frailty factors affect the dental service use and oral self-care behaviour of frail elderly people, 51 frail elderly people were interviewed. Additional information on age, gender, living situation, prosthetic status, self-reported health and oral health, chronic diseases and an index for frailty was collected. A thematic qualitative analysis of the collected data reveals that frail elders maintain long-established oral hygiene routines as long as possible to sustain a sense of self-worth. When burdened by severe health complaints they discontinue visits to the dentist first and oral hygiene routines subsequently. A loss of confidence in the results of dental service use, the trivializing of complaints and a diminishing sense of the importance of oral health play a role in these developments. Frail elderly people also experience psychological and social barriers to oral healthcare and dental service use when they are institutionalized.

[Dissertations 25 year after date 41. Older people's adaptability]. / Proefschriften 25 jaar na dato 41. Aanpassingsvermogen van ouderen.

In 1990, the thesis 'Removable complete dentures in older people, an issue dealing with adaptability?' was published. Among other things, this thesis aimed at finding a method of measuring older people's adaptability to removable complete dentures. Its conclusion was that a subscale of the "Beoordelingsschaal voor Oudere Patiënten" (Rating scale for older patients) had predictive value. Subsequently, only a few research projects on this topic have been carried out. They dealt with demonstrated adaptation achieved after treatment, the realised adaptation. The results were disappointing. Ever since the availability of endosseous oral implants, research into adaptability to conventional removable complete dentures seems less relevant. During the last decades, inquiries into a method of measuring treatment effectiveness has focused on older people's quality of life and general health condition. However, to assess with respect to oral health care an older person's general health condition and load-taking capacity adequately, some experience is indispensable.

[Prosthetic replacement of missing teeth. Indications for fixed and removable dental prostheses]. / Prothetische vervanging van afwezige gebitselementen. Indicaties voor vaste en uitneembare prothetische constructies.

Prosthetic replacement of missing teeth aims to improve health. This can be achieved by improving the patient's well-being and quality of life and by restoring the biological balance in terms ofocclusal and mandibular stability in the occlusal and the orofacial system. In occlusal systems with a complete anterior region and 'satisfactory' premolar and molar regions, prosthetic replacement of missing teeth is not indicated generally. In case ofa restricted number of missing teeth in the anterior region and/or a not 'satisfactory' premolar region, fixed dental prostheses may be indicated. In case of an incomplete anterior region and no 'satisfactory'premolar as well as molar regions, removable dental prostheses are usually indicated. These guidelines are presented in the absence of sufficient scientific evidence. Therefore, in clinical decision making, the question whether prosthetic replacement of missing teeth is sensible, and if so, by which type of dental prosthesis, can only be answered after a dialogue with mutual respect between care provider and patient.

[Single- and multi-unit fixed dental prostheses in relation to the occlusal system]. / Kronen en bruggen in relatie tot het occlusiesysteem.

Occlusion concepts based on functional aspects offer more solid ground in the diagnostic process and in the treatment of (reduced) dentitions than morphologically and mechanically oriented occlusion concepts. Nevertheless, for occlusal reconstruction morphologically oriented guidelines are necessary. These guidelines are based on the border movements and positions of the mandible in the orofacial system, and on the location and modelling of the occlusal contacts in the occlusal system. The modelling of single- and multi-unit fixed dental prostheses must harmonize with the occlusal system. Moreover, an important feature is the relation of the anterior teeth which enables mutually protected occlusion. Characteristics of a healthy orofacial and occlusal system are: absence of pathology, perceived sufficient oral functions, variability inform and function, and adaptive capacity. When designing single- or multiunit fixed dental prostheses, a pragmatic starting point is to maintain the existing occlusion and the existing speech pattern unless arguments can be provided for alterations. The occlusal design should aim at optimizing oral functions, such as mandibular and occlusal stability.

[Single and multi-teeth fixed prostheses--functions and types]. / Kronen en bruggen-- functies en typen.

A single fixed prosthesis replaces parts of a tooth. However, a single fixed prosthesis may also be implant supported and in such a case it replaces in combination with the oral implant an entire tooth. A multi-teeth fixed prosthesis replaces 1 or more teeth using pontics and can be fixed on teeth, oral implants, or both. Materials applied are metal, metal fused with porcelain, and ceramic. After indicating a fixed prosthesis, the intended function is determining the appropriate type. Intended functions of single fixed prosthesis are: improvement of aesthetics, limitation of tooth fracture, acting as an abutment tooth for a removable metal frame partial denture, and splinting of mobile teeth. In addition, single fixed prostheses may be characterized by the number of replaced tooth surfaces and by the peripheral extension of the tooth preparation. The intended functions of a multi-teeth fixed prosthesis are improvement of aesthetics, chewing function, and occlusal as well as mandibular stability. Specific types of fixed prosthesis are used as temporary restorations and in case of evaluating preliminary treatments preceding a final treatment.

[Quality of life associated with tooth loss and tooth replacement]. / Levenskwaliteit bij verlies en vervanging van gebitselementen.

Tooth loss leads, depending on the number and location of missing teeth, to a certain degree of loss of function. This loss of function might lead to an impairment of oral health-related quality of life. The literature provides fairly strong evidence that tooth loss is associated with impaired oral health-related quality of life. The locations where teeth are missing and the distribution in the tooth arch of the teeth that still remain have an effect on the degree to which oral health-related quality of life is impaired. These findings are independent of the context and the measurement instrument used. With respect to tooth replacement no direct evidence exists concerning which type of replacement for which cases of tooth reduction have the largest positive effect. Research in this area is still in its infancy.

[Pain after cementation of cast restorations]. / Pijn na het cementeren van een gegoten restauratie.

Some patients experience pain after cementation of a cast restoration on a vital tooth. Limited data are available on the prevalence of this pain. In many cases the pain disappears within two weeks. The major cause of the pain might be attributed to more permeability of the dentine after preparation. Consequently, bacteria have free access towards the pulp. With respect to the cement, it is more likely that microleakage after cementation will be the cause of pulpal problems than toxicity of the cement. In order to prevent pain, the use of a desensitizer (a primer or a bonding) can be considered. However, use of a desensitizer in combination with some cements, can reduce the retention of a cast restoration. More important than the use of a desensitizer seem precautions during the procedures of preparing the restoration, like using sufficient cooling water and preventing a tooth from dehydration.

Occlusion and Temporomandibular Function among Subjects with Mandibular Distal Extension Removable Partial Dentures.

Objective. To quantify effects on occlusion and temporomandibular function of mandibular distal extension removable partial dentures in shortened dental arches. Methods. Subjects wearing mandibular extension removable partial dentures (n = 25) were compared with subjects with shortened dental arches without extension (n = 74) and with subjects who had worn a mandibular extension removable partial denture in the past (n = 19). Subjects with complete dentitions (n = 72) were controls. Data were collected at baseline and at 3-, 6-, and 9-year observations. Results. Occlusal activity in terms of reported awareness of bruxism and occlusal tooth wear of lower anterior teeth did not differ significantly between the groups. In contrast, occlusal tooth wear of premolars in shortened dental arches with or without extension dentures was significantly higher than in the controls. Differences amongst groups with respect to signs and symptoms related to temporomandibular disorders were not found. Occlusal support of the dentures did not influence anterior spatial relationship. Occlusal contacts of the denture teeth decreased from 70% for second premolars via 50% for first molars, to 30% for second molars. Conclusions. Mandibular distal extension removable partial dentures in moderate shortened dental arches had no effects on occlusion and temporomandibular function.