Public health issues in geriatric dentistry in the United States.

The aging United States population living in the new millennium has dental needs that are very different and more complex than those experienced by previous older adult cohorts during the twentieth century. The type of dental care to be provided for older Americans goes way beyond emergency care, extractions and denture care. Dental caries is still clearly a public health problem for subgroups of older Americans, such as those of lower socioeconomic status, with dementia, who are homebound and who are institutionalized. These are also the subgroups experiencing greater barriers to accessing dental care. Stakeholders, including dental professionals and the dental benefits industry, need to work together to develop innovative dental financing programs that will increase older Americans access to dental care.

Treatment planning concepts for the ageing patient.

There is an ageing imperative in Australia as in many other industrialized nations, and these populations are extremely heterogeneous. In young adults, the factors which influence decision making for oral health care are whether the patient has the will, the time or the finances to pay for care, while for clinicians, the decisions are whether they have the skill and the resources to carry out the treatment plan. For older adults, the decision making includes all of the previous identified factors, but they are now complicated by the patient's medical and medication problems, the side effects of the medications they are taking, their cognitive status as well as the cumulative effects of a lifetime of physiological, traumatic and iatrogenic effects on the dentition and the oral cavity. The decision-making process which has evolved has been called many names, from cost-effective care to minimal invasive dentistry to rational dental care. Fundamentally, they are similar. Rational dental care has been defined as the process of decision making, which develops a treatment plan that is in the best interest of the patient after evaluating all of the modifying factors. This article will discuss the various concepts, and the strengths and weaknesses of some of these systems. It will also illustrate some of the clinical problems as there is very little evidence-based data to support any of these concepts. However, treatment planning is still an art, which can only be carried out for an individual and not a group, and the result must serve the needs of the patient and enhance the quality of his or her life.

An in vitro evaluation of the prevention of caries on overdenture abutments.

Teeth prepared as overdenture abutments are susceptible to caries, and it has been shown that brushing by itself is not sufficient to prevent this process. This study evaluated the preventive effect of a remineralization gel which has a low fluoride concentration and compared its effects with those of a phosphate fluoride gel (Karigel), which has a much higher concentration of fluoride. Twenty extracted anterior teeth from patients aged 50 to 70 years were prepared as for overdenture abutments. Each tooth was sectioned into three fragments. An acidified gel system was used to produce artificial caries lesions on the occlusal and root surfaces of each fragment. One fragment of each tooth was treated with the remineralizing gel, the second fragment with a high-fluoride gel, and the third fragment served as the control. Ten teeth were removed at two weeks and again at four weeks, and were sectioned and prepared for histological examination. The depth of the lesions was measured from standardized photomicrographs by means of a sonic digitizer. The conclusions were: (1) Lesions on the occlusal tended to be deeper than those on the root surfaces at four weeks but not at two weeks; and (2) the high-fluoride gel was more protective than the low-fluoride remineralizing solution at both time periods on the occlusal but not on the root surface.

An in vitro evaluation of artificial caries-like lesions on restored overdenture abutments.

An acidified dialyzed gelatin gel system was used to determine the caries resistance of a variety of restorative materials used to obturate the canal orifice of overdenture abutment teeth. The restorative materials used were Tytin, Tytin + Copalite, P30 + Scotchbond, Fuji Ionomer-Type II, and Miracle Mix. Polarized light microscopy and microradiography were used to examine the caries-like lesions adjacent to the restorations. The lesions formed in the Fuji Ionomer-Type II and Miracle Mix groups appeared arrested at the wall adjacent to the restoration, and did not penetrate apically down the wall as did those associated with the other restorative materials. The mean depths of lesions adjacent to Fuji Ionomer-Type II and Miracle Mix restorations were significantly less than those of Tytin, Tytin + Copalite, or P30 + Scotchbond.

Histopathology of the initial lesion of the root surface: an in vitro study.

An acidified gel system was used to produce artificial caries lesions in root surfaces. Radiopaque surface layers were found with 47% of the lesions. Demineralized bodies of the lesion and mineralized zones of banding were seen in all lesions when examined by microradiography. Cementum and dentin seemed to respond to the acid attack in a similar manner. Although artificial root lesions did not simulate natural root caries entirely, the acidified gel system resulted in a reproducible method that might give insight into initial lesion formation on root surfaces. This technique may be used for studying the physico-chemical process involved in the demineralization of root surfaces and for testing the effects of various agents in the prevention of root caries.

Depth of penetration of in vitro root surface lesions.

An acidified gel system was used to produce artificial caries lesions in root surfaces and in enamel. The teeth were exposed to the gel system for two weeks and four weeks, after which the lesions were examined by polarized light microscopy and photographed by standardized techniques. The depths of penetration of the lesions were measured from these standardized photomicrographs. The lesions in root surfaces were deeper than those in enamel for all teeth. After two but not four weeks of exposure in the gel system, the lesions in the root surfaces of anterior teeth were deeper than those in pre-molars.

Oral care for the homebound and institutionalized.

Most patients who are homebound or in LTC facilities have multiple health problems that require the cooperation of many different types of providers. Dentists have a specific role in this process because they can improve the quality of life for the elderly by keeping them free of oral infection, restoring their dentition so they can enjoy eating, and restoring facial esthetics. It should be apparent that dental care for these patients is a complicated process. There are many considerations in prescribing the type of treatment needed by each patient. These include the patient's life span, medical history, drug history, mental status, mobility status, neuromuscular coordination, dental status, previous dental experience, dental expectations, and economic status. This information must be gathered by the dentist from the patient, the family, the nursing staff, and the patient's physician. Furthermore, the dentist also must assess the facilities and equipment available to carry out oral health care. Only after such considerations can a dental treatment plan evolve that is appropriate for the individual concerned. Dental care for one patient may be no treatment whatsoever, whereas a different patient in the same institution may require the most technologically sophisticated care that dentistry has to offer. Finally, the following circumstances should suggest that a homebound or institutionalized patient needs an urgent oral/dental evaluation: General Signs and Symptoms; Orofacial pain, Visible oral infection, Difficulty chewing food, Halitosis/dry burning mouth, Visible oral soft tissue lesions (white, red, or ulcerated). Tooth-related signs and symptoms; Visible dental decay, Loose or mobile teeth, Bleeding or sore gums. Denture-related Signs and Symptoms; Loose, ill-fitting, or worn dentures, Missing denture teeth, Home repairs attempted.

Measurement of the interface between bone and immediate endosseous implants: a pilot study in dogs.

This study developed methodology to evaluate the healing of 15 IMZ implants placed in the sockets of freshly extracted mandibular premolars in three adult mongrel dogs. Six surgical sites were prepared in each animal and one site was left as a control. Porous hydroxyapatite was placed around the top half of two implants in each animal; one implant was also covered with polytetrafluoroethylene membrane. All implants were covered with a mucoperiosteal flap and sutured closed. Upon animal sacrifice, the mandibles were retrieved for block dissection and the blocks were embedded in plastic. Serial longitudinal wafers were ground to 50 to 100 microns and stained. Standard photomicrographs were taken so that tracings of the implant-bone interface could be measured on a sonic digitizer. The mean percent amount of bone to plasma-sprayed portion of the implant on the longitudinal sections was 47.9% +/- 5.2% with a range of 17.4% to 84.7%. The horizontal sections were measured at 53.5% +/- 3.7% with a range of 0.0% to 100%. This pilot study suggests that IMZ implants placed in fresh extraction sockets can achieve a degree of intimate contact with bone; however, wide variation in the implant-to-bone interface was found even in the same specimen.

Caries: a problem in an overdenture population.

A series of 254 patients who had their overdentures constructed at a University clinic from 1973 to 1985 were followed longitudinally. This paper reports on the caries experience in the abutment teeth of these patients. The mean age of the patients at the time of insertion of the dentures was 58.6 yr. The overall rate for new caries was 6.5% of the abutment teeth per year. The highest rate for the maxilla was 15.4%, which occurred during the 5th yr, and in the mandible it was 11.0%, which occurred in the 4th yr. A regression model was developed to profile individuals susceptible to caries. The Logistic Regression model identified a list of predictor variables which included frequency of brushing, use of home fluoride, and disease and drug effect. However, discriminant function analysis showed that although specificity was very high (98.5%), sensitivity was very low (7.9%). Therefore, this model was unable to predict persons who would be at high risk for caries.

A comparison of patient satisfaction and dentist evaluation of overdenture therapy.

It has been argued that the retention of some teeth in the jaws as overdenture abutments prevents negative feelings about the loss of natural teeth. This study set out to evaluate how satisfied a group of patients were with wearing overdentures, and to compare their subjective evaluations with those of a dentist using objective criteria to examine the prostheses. A questionnaire was developed using questions adapted from several other studies. It was pretested, modified and used on all patients who were members of a longitudinal study of overdentures that started in 1974, and who returned on recall. At the end of 9 months, 101 subjects had completed the questionnaire and examination. The mean age of the patients was 65.9 years with an age range of 35 to 88 years. There were 68 men and 33 women in this study and 62 of them were satisfied with their dentures; 33 were satisfied, but felt they had some faults. Only 6 were unhappy about wearing the overdentures. The average length of time the dentures had been worn was 6.9 years, with a range of 1 to 15 years. The most frequent complaints were loss of retention (65.4%) and discomfort (62.2%) of the mandibular dentures. A number of correlations were evaluated and some significant relationships were found between dentist and patient evaluation of the dentures. The best predictor of patient satisfaction with denture wearing was the patient's perception of retention and appearance. In the maxilla the patient's ability to chew and the dentist's evaluation of occlusion were also significant predictors. In the mandible the only other factors apart from retention and appearance were patient comfort and age.

Dental status of the institutionalized elderly population of Edinburgh.

A randomly selected population of 442 persons in Edinburgh was interviewed and examined. Although 71 % of the sample required treatment, only 52 % were physically and mentally able to benefit from treatment. Thirty percent of the sample were able to use public transport to attend a dentist, 66 % would require cars and ambulance transport and 4 % were bedridden and would require domiciliary dental services. Twenty-one percent of the sample had thought about seeking dental treatment, while only 25 % had heard how to claim exemption from or help towards dental charges. Edentulousness was present in 91 % of the sample, only 41 persons having remaining natural teeth. Seventy-three percent were wearing dentures which required adjustment or replacement, but only 39 % thought their dentures were unsatisfactory. In 58 % of the patients the oral tissues were so deformed or resorbed that the prosthodontic treatment needed would be complex and require special skills. Half of the sample had some form of denture-induced pathology which required either conservative or surgical treatment.

Managing and treating the atrophic mandible.

Changes in age and disease patterns suggest that in the near future complete denture wearers will be older and have worn dentures for a longer time, but will also be more physically fragile. Some diagnostic issues related to support problems for mandibular complete dentures are evaluated and treatment modes suggested.

Evaluating the longevity of restorative materials that seal the root canals of overdenture abutments.

Researchers have not established which restorative materials are most appropriate to seal the root canals of overdenture abutments. The author evaluated the longevity of a spherical amalgam, a composite resin and a glass ionomer in 123 patients. Results of this study showed a significant difference between the glass ionomer and the other two materials with regard to the time from placement to replacement of the restorations.

Use of teeth with a poor prognosis in cleft palate prosthodontics.

Patients who have unoperated or incomplete closure of their clefts and who have only a few teeth of poor prognosis remaining are a challenge to the prosthodontist. Two cases have been presented to illustrate treatment techniques that can be used for such patients.

The acrylic removable partial denture.

Some aspects of acrylic partial dentures have been reviewed. The spoon denture, the Every design, and the Lam design have been discussed and suggestions made for their construction and use for patients with specific problems.

Eliminating office architectural barriers to dental care of the elderly and handicapped.

Methods by which the most common architectural barriers to dental care for the elderly and handicapped can be overcome are described. Some physiological and medical conditions that necessitate special provisions in location and design of the office management of patients have been described. The consequences of accessibility have been discussed and suggestions for management of elderly and handicapped patients are presented.

The old-old dental patient: the challenge of clinical decision-making.

As the U.S. geriatric population grows older, dentists should recognize the need to carefully consider age-related concerns that influence clinical decision-making. The authors discuss several prevalent problems typically found in "old-old" patients and propose a model for determining the appropriate extent of dental care for them.

The unique oral health needs of an aging population.

Over the last century, the number and percentage of older adults has increased dramatically. In the last 30 years, the percentage of older edentulous adults has declined significantly but the total number is expected to remain constant at 9 million until the year 2020. The increasing number of and percentage of dentate adults will have more teeth at risk for caries and periodontal disease. Many of these adults will have multiple medical problems and be taking various pharmacotherapies which will complicate oral disease and its treatment. New concepts in prevention of oral disease will be required, as will more accurate diagnostic procedures, especially to identify the at-risk older adults.

Epidemiology of dental caries. A broad review.

There is evidence from many sources that dental caries is an ancient disease; it has been found all over the world in skulls from the time humans replaced hunting with agriculture as the main source of food for survival. This article examines the epidemiology of dental caries with a specific focus on the twentieth century and high-risk groups.