DENTAL PATIENT-REPORTED OUTCOMES IN GERIATRIC DENTISTRY : A call for clinical translation.

As the proportion of older adults in the world population increases, there is an increasing need to provide adequate dental care for this very heterogeneous group of individuals. The relationship between oral and systemic health, the impact of medication on oral health, and the influence of accessibility to dental care and other social and environmental factors shape the provision of dental care for older adults more than in children, younger, and middle-aged adults. However, while dental care for older adults is shaped by these factors and is often different from the care for other adults, what matters to older dental patients does not differ from what matters to dental patients in general. The four dimensions of oral health-related quality of life (OHRQoL)-Oral Function, Orofacial Pain, Orofacial Appearance, and Psychosocial Impact-capture dental patients' suffering from oral disorders. OHRQoL questionnaires can be used to assess this impact and to achieve results that are compatible with adults in general. More than in other age groups, cognitive impairments or dementia limit the usefulness of questionnaires or interviews for oral health impact assessment. In these situations, family members or caregivers can assess the patient's oral health impact, and oral health care providers need to rely more on physical oral health characteristics for clinical decision-making than in other dental patients. While the tools to measure oral health impact change, the targets for dental care stay the same. Prevention and reduction of functional, painful, aesthetical, and broader psychosocial impact related to oral disorders are the central tasks for geriatric dentistry as they are for dentistry in general. The aim of the manuscript is to highlight the importance of patient-reported outcome measures in geriatric dentistry, addressing challenges and opportunities for their application.

The teaching of geriatric dentistry in South Korean dental schools.

OBJECTIVE: The purpose of this study was to investigate the curriculum of geriatric dentistry for undergraduates in Korean dental schools. BACKGROUND: For development purposes, it was necessary to compare geriatric dentistry education programmes in South Korea to programmes in the United States and Europe. METHODS: The most recent curriculum and related information on geriatric dentistry at the undergraduate level in all 11 dental schools in South Korea were collected by both official letter and e-mail. A symposium for gathering expert opinions to improve geriatric dentistry education in South Korea was also held. The collected data were analysed, and the expert opinions at the symposium were summarised. RESULTS: Six of 11 schools had a didactic course as compulsory and three schools as elective. The course was usually conducted as a form of integrated lectures, and the level of standardisation of lecture content was very low. There were no topics for older people who cannot access dental clinics due to functional frailty or disability. No dental school-affiliated hospitals had an independent department for geriatric dentistry. No schools provided clinical teaching for geriatric dentistry. There were no outreach programmes for geriatric dentistry. CONCLUSIONS: The educational curriculum for geriatric dentistry in South Korea was insufficient to cope with social and demographic changes. Curriculum content should include clinical practice education and needs to be focused on frail and dependent older adult patients. An essential educational curriculum and core competency for geriatric dentistry should be prepared.

Impact of the COVID-19 pandemic on the University of British Columbia Geriatric Dentistry Program: Clinical education and service.

BACKGROUND AND OBJECTIVE: In Canada, the COVID-19 pandemic was associated with significant morbidity and mortality in older adults, particularly those in long-term care (LTC). Access to oral health services was limited during the pandemic due to public health restrictions. The aim of this paper was to describe the impact of the pandemic on the clinical education and service of the University of British Columbia (UBC) Geriatric Dentistry Program (GDP), which provides care to LTC residents. METHODS: Data were collected from UBC GDP AxiUm dental software records, including number of dental appointments in 2019 and 2020. Data on revenue in 2019 and 2020 based on clinical production were collected through financial summary reports. Data on the number of educational rotations were collected from summary reports from scheduling software. RESULTS: In 2020, significant reductions in clinical service, revenue, and productivity were observed in the UBC GDP relative to 2019. The number of GDP appointments for June-December 2020 was lower by 68%. The clinical productivity reduced by 67% for the same period. Expenses were slightly reduced. The overall number of LTC clinical rotations for students were only slightly lower for undergraduate students in 2020 than in 2019, and it increased for graduate students. CONCLUSION: The COVID-19 pandemic and associated public health restrictions had a negative impact on the clinical service and productivity of the UBC GDP in 2020 relative to 2019. However, clinical educational rotations to LTC were slightly increased in 2020 relative to 2019. Dental care for LTC residents can be provided if rigorous administrative controls, engineering controls and personal protective equipment are employed.

Undergraduate Dental Education in Gerodontology in Germany between 2004 and 2019-A case for compulsory teaching?

INTRODUCTION: The study surveys the present state of undergraduate dental education in gerodontology in Germany and highlights changes between 2004 and 2019. MATERIALS AND METHODS: In 2019, questionnaires were emailed to the department heads of all German dental schools. Data were analysed descriptively and compared to existing data from 2004, 2009 and 2014. RESULTS: Thirty-nine (86.7%) out of forty-five responding department heads stated to teach aspects of gerodontology in traditional core subject lecture series. Overall, 15 (55.6%) out of 27 responding dental university schools are offering special education in gerodontology (dedicated lecture series and/or practical training). A stronger focus on non-dental topics has been observed over the years. DISCUSSION: The 15-year observation period in Germany shows that teaching gerodontology should be mandatory. There is a lack of specialists in gerodontology at the dental schools, although specialisation has been possible for many years in the German professional association. Students should be sure that, as in other subjects, they are well trained for the very heterogeneous patient group of seniors. The financial and personnel prerequisites for the universities need to be established. CONCLUSION: Inclusion of gerodontology in the national syllabus is a decisive factor for the integration of the subject into undergraduate courses. The recommendations of the European College of Gerodontology (2009) and of the German Association of Gerodontology (DGAZ) regarding didactical and practical teaching should be implemented in the respective compulsory syllabus to prepare current undergraduate dental students for the demographic challenges of tomorrow.

COVID-19: Impacts on oral healthcare delivery in dependent older adults.

OBJECTIVES: To evaluate the impacts of restrictions to the provision of dental services for dependent older patients due to the COVID-19 pandemic. METHODS: Data were gathered on the number of dependent older patients treated, emergency treatment provided and the revenues generated by a specialised clinic for geriatric dentistry during the current pandemic period and compared with the recorded clinical activity from the preceding year. Hypothetical projections were generated for the remainder of the current year based on the assumption that restrictions due to COVID-19 would remain. RESULTS: A significant decrease in the total number of dependent older patients treated was recorded during the periods of January-March 2020 (P = .026) and April-May 2020 (P = .001) when compared to 2019. According to projections, by December 2020 the clinic will be providing 81.14% less clinical activity compared to 2019 (P < .0001), including a complete cessation of domiciliary services. Despite decreases in expenditure, revenues generated by the clinic have decreased significantly due to reduced clinical activity during January-March 2020 (P = .268) and April-May 2020 (P = .010) compared to 2019, and would decline further by 899.61% by December 2020. CONCLUSIONS: The restrictions implemented to prevent the spread of COVID-19 have resulted in a significant reduction in oral healthcare provision for dependent older adults. Within this clinic, dedicated to dependent older adults, clinical activity is projected to reduce by 81% by the end of 2020 with associated reductions in revenue generation. Given the importance of oral healthcare delivery for this patient group, this may have significant and lasting impacts.

The provision of mobile dental services to dependent elderly people in Switzerland.

OBJECTIVE: This work aimed at describing mobile dental services provided by both the private sector and the universities in Switzerland to dependent elderly people. It also aimed at presenting the views of both sectors on the current status of these services. BACKGROUND: As people age and become more care-dependent, their oral health requirements increase, as access to dental care decreases. METHOD: A survey was sent to practitioners who potentially provided a mobile dental service (n = 253). Five interviews were conducted with six individuals who have a leading role in Geriatric dentistry in the four universities in Switzerland that provide dental training. RESULTS: The private sector provides a mobile dental service to the elderly mainly through the use of portable equipment, while university services are provided by different models. The interviewees discussed the reasons as to why these services were set up. They discussed the challenges associated with treating dependent elderly patients, which often makes work in this field hard and unattractive. Both sectors see the need for better collaboration with other professionals. CONCLUSION: The private sector in Switzerland provides a mobile dental service to elderly people mostly through the use of portable equipment, while university services are provided in a variable configuration of models. Better collaboration is required to improve dental care and service delivery to dependent elders. There is a potential for improvement of these services, in order to meet the demand of an ageing population, catering for both the institutionalised elders and those living at home.

Current status of gerodontology curriculum in India and other parts of the world: A narrative review.

BACKGROUND: The current rise in the world's geriatric population has placed additional demands on dental professionals, as the management of geriatric patients requires distinct competencies. AIM: To review and perform a content analysis of the gerodontology undergraduate curriculum worldwide. DATA SOURCES: A search was carried out in PubMed, Web of Science, ERIC and EMBASE databases for the period-July 2008 till May 2019, using MeSH terms. A search for websites of Indian universities was also done, and undergraduate curricula were screened. STUDY ELIGIBILITY CRITERIA: The study included articles related to the undergraduate curriculum, which contained training in geriatric dentistry. Articles in foreign languages and those related to dental hygienists were excluded. RESULTS: A total of 218 articles were obtained, of which 19 met the inclusion criteria. A total of 301 colleges taught gerodontology. Amongst them, 50 colleges had a gerodontology department. Clinical training and outreach experience were provided in 175 and 73 colleges, respectively. There are no reports on the status of gerodontology in Asian countries (excluding Japan). In India, gerodontology is not taught as a separate subject. However, few gerodontology-related topics are covered in clinical subjects. CONCLUSIONS: There seems to be a wide variation in the content of gerodontology curriculum taught worldwide. Other than the European and American regions, gerodontology is yet to develop in other parts of the world. In India, a robust training programme is required to address the lack of dental care providers for the geriatric population using guidelines established by ECG and ADEA.

Self-reported oral health problems and the ability to organize dental care of community-dwelling elderly aged ≥75 years.

BACKGROUND: It is unclear how many community-dwelling elderly (≥75 years) experience oral health problems (e.g. pain, dry mouth, chewing problems) and how they manage their dental care needs. This study aimed to assess self-reported oral health problems in elderly who are frail or have complex care needs, and their ability to organize dental care when reporting oral pain. METHODS: Three thousand five hundred thirty-three community-dwelling elderly participating in the "Embrace" project were asked to complete questionnaires regarding oral status and oral health problems. Frailty was assessed with the Groningen Frailty Indicator (GFI). Intermed for Elderly Self-Assessment (IM-E-SA) was used to determine complexity of care needs. Next, elderly who reported oral pain were interviewed about their oral pain complaints, their need for dental care, and their ability to organize and receive dental care. For statistical analyses Chi2-tests and the one-way ANOVA were used. RESULTS: One thousand six hundred twenty-two elderly (45.9%) completed the questionnaires. Dry mouth (11.7%) and oral pain (6.2%) were most frequently reported. Among the elderly reporting oral pain, most were registered at a local dentist and could go there when needed (84.3%). Robust elderly visited the dentist independently (87%), frail (55.6%) and complex (26.9%) elderly more often required assistance from caregivers. CONCLUSIONS: Dry mouth and oral pain are most reported oral health problems among community-dwelling elderly. Elderly with complex care needs report most oral health problems. In case an elderly seeks dental treatment to alleviate an oral pain complaint, most elderly in this study were able to organize dental care and transport to the dentist. Frail and complex elderly often need assistance from caregivers to visit the dentist. Therefore caretakers should keep in mind that when frailty progresses, visiting a dentist may become more and more difficult and the risk for poor oral health increases.

Orofacial pain and its potential oral causes in older people with mild cognitive impairment or dementia.

BACKGROUND: The number of people with dementia and natural dentition is growing. As dementia progresses, the degree of self-care decreases and the risk of oral health problems and orofacial pain increases. OBJECTIVES: To examine and compare the presence of orofacial pain and its potential causes in older people with Mild Cognitive Impairment (MCI) or dementia. METHODS: In this cross-sectional observational study, the presence of orofacial pain and its potential causes was studied in 348 participants with MCI or dementia with all levels of cognitive impairment in two outpatient memory clinics and ten nursing homes. RESULTS: Orofacial pain was reported by 25.7% of the 179 participants who were considered to present a reliable pain self-report (Mini-Mental State Examination score ≥14 points), while it could not be determined in people with more severe cognitive impairment. The oral health examination of the 348 participants indicated that potential painful conditions, such as coronal caries, root caries, tooth root remnants or ulcers were present in 50.3%. There was a significant correlation between the level of cognitive impairment and the number of teeth, r = 0.185, P = 0.003, teeth with coronal caries, r = -0.238, P < 0.001, and the number of tooth root remnants, r = -0.229, P = 0.004, after adjusting for age. CONCLUSIONS: This study indicated that orofacial pain and its potential causes were frequently present in participants with MCI or dementia. Therefore, a regular oral examination by (oral) healthcare providers in people with MCI or dementia remains imperative, even if no pain is reported.

Teaching undergraduate geriatric dentistry in five South America countries.

OBJECTIVE: This study aimed to qualitatively analyse undergraduate geriatric dentistry (GD) teaching characteristics identified by geriatric dentistry teachers and senior students in five South American countries. BACKGROUND: GD involves the knowledge and skills required to provide oral health care for older people. METHODS: Exploratory-descriptive research with a qualitative approach developed in the undergraduate context of public universities in Chile, Argentina, Brazil, Colombia and Peru. Nine dental schools were intentionally selected. The participants were GD module teachers (20) and their senior students (30). Data were collected through open interviews via Skype® conducted between May and August 2015 and were analysed using a content analysis technique with ATLAS.ti® software, resulting in four categories. RESULTS: GD modules are theoretical or a theoretical-practical mix. Most teachers are prosthodontists without specific training in GD. Their motivations to teach GD are related to personal, family, professional and social reasons. Humanity, sensitivity and knowledge of older people are considered fundamental characteristics of a GD teacher. CONCLUSIONS: Students' first contact with an older person usually occurs during clinical activities. The participants mentioned insufficient hours for GD modules in the curricula and exclusively theoretical modules that do not allow students to learn typical specificities of older people. In the context of this study, the undergraduate GD teaching-learning process presented some weaknesses regarding educational methods, professor training and the interaction between older people and students. Diversification of learning scenarios and GD professor training are highly recommended.

Curriculum content in geriatric dentistry in USA dental schools.

OBJECTIVES: The aim of this study was to re-examine the teaching of geriatric dentistry in the USA dental schools, to identify curriculum content and compare the findings to previous reports. METHODS: All dental schools in the United States were contacted via email with a questionnaire to assess the teaching of geriatric dentistry. Non-responding schools were sent a minimum of three reminder emails to complete the survey. A statistical analysis was performed. Descriptive statistics were conducted to profile the variables of interest. Bivariate analysis was performed to explore if any of the variables were related using Fisher's exact test, non-parametric Wilcoxon rank-sum test and the Kruskal-Wallis test. RESULTS: Fifty-six of the 67 dental schools completed the questionnaire. Geriatric dentistry was taught in all dental schools; for 92.8%, the course was compulsory. We found that 62.5% were teaching it as an independent course, 25% as an organised series of lectures and 8.9% as occasional lectures in parts of other courses. Clinically, 84.2% have some form of compulsory education in geriatric dentistry. Public schools were marginally associated with an increased interest in expanding the geriatric dentistry curriculum (P = .078). No differences were found between these variables and school location. CONCLUSIONS: Geriatric dentistry is now required in 92.8% of dental schools. The teaching of traditional topics has not changed much; however, the number of gerontological topics has increased. Clinical teaching needs to be expanded, as in only 57.1% of schools was it a requirement. The ageing imperative will require research to determine the impact of teaching on services to the geriatric community.

Oral health and dental care of older persons-A systematic map of systematic reviews.

OBJECTIVES: To examine the current knowledge on oral health status and dental care of older persons through a systematic mapping of systematic reviews of low or moderate risk of bias. BACKGROUND: Geriatric dentistry covers all aspects of oral health and oral care of older persons. Oral health is part of general health and contributes to a person's physical, psychological and social wellbeing. METHODS: A literature search was performed in three different databases (PubMed, The Cochrane Library and Cinahl) within 12 domains: Dental caries, periodontitis, Orofacial pain and temporomandibular joint (TMJ) pain, mucosal lesions, oral motor function, dry mouth, halitosis, interaction between oral status and other medical conditions, ability to interrelate and communicate, quality of life, ethics and organisation of dental care for older persons. Systematic reviews were identified and scrutinised, highlighting scientific knowledge and knowledge gaps. RESULTS: We included 32 systematic reviews of which 14 were judged to be of low/moderate risk of bias. Most of the domains lack systematic reviews with low or moderate risk of bias. In two of the domains evidence was identified; in institutionalised people aged 65 or older, effective oral hygiene can prevent pneumonia. Furthermore, there is an evidence of a relationship between malnutrition (protein energy-related malnutrition, PEM) and poor appetite and edentulousness. CONCLUSIONS: There is an urgent need for further research and evidence-based knowledge within most domains in geriatric dentistry and in other fields related to oral health and dental care for older persons striving for multi-disciplinary research programmes.

Oral hypofunction in the older population: Position paper of the Japanese Society of Gerodontology in 2016.

BACKGROUND: There is growing international interest in identifying the effects of ageing on oral health and on appropriate strategies for managing oral disorders. The Japanese Society of Gerodontology (JSG), as the official representative of researchers and clinicians interested in geriatric dentistry in Japan, makes several recommendations on the concept of "oral hypofunction." AIMS: This study proposes diagnostic criteria and management strategies to reduce the risk of oral hypofunction among older people. CONCEPTUAL FRAMEWORK: We define oral hypofunction as a presentation of 7 oral signs or symptoms: oral uncleanness; oral dryness; decline in occlusal force; decline in motor function of tongue and lips; decline in tongue pressure; decline in chewing function; and decline in swallowing function. The criteria of each symptom were determined based on the data of previous studies, and oral hypofunction was diagnosed if the criteria for 3 or more signs or symptoms were met. CONCLUSIONS: We recommend that more evidence should be gathered from clinical studies and trials to clarify our diagnostic criteria and management strategies.

Development of undergraduate gerodontology courses in Austria, Germany and Switzerland 2004-2014.

PURPOSE/OBJECTIVES: In view of the demographic shift, undergraduate dental students should be prepared for growing numbers of older people and their specific needs. The study examines changes in undergraduate dental teaching in Austria, Germany and Switzerland between 2004 and 2014. METHODS: Questionnaires were mailed in 2004, 2009 and 2014 to all deans and all department heads of Austrian (n = 4), German (n = 30) and Swiss (n = 4) dental schools. RESULTS: Response rates were 51% for deans and 47% for heads of department. Gerodontology was taught in 5 German universities, all 3 Swiss and 1 Austrian dental school. Aspects of gerodontology were included in traditional core subjects; however, in a large number of German (88%) and Austrian (50%) universities, dedicated lecture series and seminars are lacking. Changes over time indicate firmly established teaching in Switzerland, minor fluctuations in Austria and reduced dedicated teaching activities in Germany. CONCLUSIONS: Inclusion of gerodontology in the national syllabus is a decisive factor for the integration of the subject into undergraduate courses. The recommendations of the European College of Gerodontology (2009) regarding didactical and practical teaching should be implemented in the respective compulsory syllabus to prepare current undergraduate dental students for the challenges of tomorrow.

Undergraduate students' evaluation and reflections on a gerodontology programme.

INTRODUCTION: Many societies have observed a steady increase of many older adults living longer due to advancements in health and standard of living. The dental team requires specialised training in gerodontology to better prepare for the future needs of the elderly patients. It is the aim of this study to report the undergraduate students' activities and perspectives on their work experience in a geriatric residence. MATERIALS AND METHODS: An anonymous online questionnaire on the theoretical and practical aspects of training was sent to students in dentistry and dental hygiene (DH) undergraduate courses. Students were also invited to discuss their experiences. Data of clinical treatment performed by the students were collected. The number of clinical hours of student exposure to patients was measured. RESULTS: Completion of the questionnaire was high (90%). Both DH and dentistry students have in excess of 100 hours/y of clinical practice. Overall students rate their experience as a positive one that enriches patients' well-being. However they identify barriers to oral health and experience challenges related to their clinical work and level of competence (Kruskal-Wallis Test P < .05). CONCLUSIONS: study participants were strongly motivated towards the management of frail older adults and cognisant of the barriers and constraints of achieving a reasonable level of oral health. Gerodontology programmes should be adaptable in order to create the appropriate environment and address socio-emotional challenges experienced by students.

Oral health and orofacial pain in older people with dementia: a systematic review with focus on dental hard tissues.

OBJECTIVE: The aim of this review was to provide a systematic overview including a quality assessment of studies about oral health and orofacial pain in older people with dementia, compared to older people without dementia. METHODS: A systematic literature search was performed in PubMed, CINAHL, and the Cochrane Library. The following search terms were used: dementia and oral health or stomatognathic disease. The quality assessment of the included articles was performed using the Newcastle-Ottawa Scale (NOS). RESULTS: The search yielded 527 articles, of which 37 were included for the quality assessment and quantitative overview. The median NOS score of the included studies was 5, and the mean was 4.9 (SD 2.2). The heterogeneity between the studies was considered too large to perform a meta-analysis. An equivalent prevalence of orofacial pain, number of teeth present, decayed missing filled teeth index, edentulousness percentage, and denture use was found for both groups. However, the presence of caries and retained roots was higher in older people with dementia than in those without. CONCLUSIONS: Older people with dementia have worse oral health, with more retained roots and coronal and root caries, when compared to older people without dementia. Little research focused on orofacial pain in older people with dementia. CLINICAL RELEVANCE: The current state of oral health in older people with dementia could be improved with oral care education of caretakers and regular professional dental care.

Higher education in Gerodontology in European Universities.

BACKGROUND: The rapid aging of the European population and the subsequent increase in the oral care needs in older adults necessitates adequate training of dental professionals in Gerodontology (Geriatric Dentistry). This study was designed to investigate the current status of Gerodontology teaching amongst European dental schools at the undergraduate, postgraduate and continuing education levels. METHODS: An electronic questionnaire was developed by a panel of experts and emailed to the Deans or other contact persons of 216 dental schools across 39 European countries. The questionnaire recorded activity levels, contents and methodology of Gerodontology teaching as part of dental education programs. Repeated e-mail reminders and telephone calls were used to encourage non-responders to complete the questionnaire. RESULTS: A total of 123 responses from 29 countries were received (response rate: 56.9%). Gerodontology was taught in 86.2% of schools at the undergraduate level, in 30.9% at the postgraduate level and in 30.1% at the continuing education level. A total of 43.9% of the responding schools had a dedicated Gerodontology program director. Gerodontology was taught as an independent subject in 37.4% of the respondent schools. Medical problems in old age, salivary impairment and prosthodontic management were the most commonly covered topics in Gerodontology teaching. Clinical teaching took place in 64.2% of the respondent schools, with 26.8% offering clinical training in outreach facilities. CONCLUSIONS: The vast majority of European dental schools currently teach Gerodontology at the undergraduate level. More training opportunities in oral care of frail elders should be offered, and more emphasis should be placed on interdisciplinary and interprofessional training, educational collaborations, and the use of modern technologies. Dedicated postgraduate Gerodontology courses need to be developed to create a significant number of specialized dentists and trained academics.

[A PhD completed. Oral health care and oral health-related quality of life of frail and care-dependent older people]. / Serie: Hora est. Mondzorg en mondgezondheidgerelateerde levenskwaliteit van kwetsbare en zorgafhankelijke ouderen.

When older people become frail, they often give up making dental visits, while their oral health care and oral health deteriorate. Open interviews and questionnaires were used to explore why frail older people change their oral health care behaviour and which (frailty-related) factors contribute to this change. These are mainly motivation-related factors. There seems to be a turning point where frail older people discontinue their oral health care routines and stop caring whether or not they loose teeth, because the perceived efforts no longer outweigh the perceived benefits of making dental visits and upkeep of oral hygiene. The use of standard questionnaires such as the validated Geriatric Oral Health Assessment Index-NL to measure oral health-related quality of life is limited, because they do not provide personal context required to interpret the outcomes. From a pre-frail stage (oral) care providers should monitor specific factors that might negatively affect oral health and oral health care behaviour, like chronic pain or diminished mobility, dexterity, cognition, will to live, energy and social support.

The Public Health Reach of High Fluoride Vehicles: Examples of Innovative Approaches.

Fluorides and sealants have been shown to reduce caries in populations, making fluoride interventions a large part of the dental public health effort. Although public health programs have traditionally focused on fluoride vehicles delivering less than 1,000 ppm of fluoride, more recent efforts have shifted toward the use of high fluoride vehicles such as varnishes and prescription toothpastes. In the USA, states are developing innovative strategies to increase access to dental services by using primary care medical providers to deliver early preventive services as part of well-child care visits. Currently, Medicaid programs in 43 states reimburse medical providers for preventive services including varnish application. Still, there is uncertainty about the cost-effectiveness of such interventions. In many resource-strained environments, with shortages of dental health care providers, lack of fluoridated water and lower dental awareness, it is necessary to develop sustainable programs utilizing already established programs, like primary school education, where caries prevention may be set as a priority. Dental caries among the elderly is an ongoing complex problem. The 5,000-ppm F toothpaste may be a reasonable approach for developing public health programs where root caries control is the main concern. Fluoride varnish and high concentration fluoride toothpaste are attractive because they can easily be incorporated into well-child visits and community-based geriatric programs. Additional research on the effectiveness and costs associated with population-based programs of this nature for high risk groups is needed, especially in areas where a community-based fluoride delivery program is not available.