Clinical Oral Disorders in Adults Screening Protocol (CODA-SP) from the 2019 Vancouver IADR Consensus Symposium.

BACKGROUND: The Clinical Oral Disorder in Elders (CODE) index was proposed in 1999 to assess the oral health status and treatment needs of older people who typically were edentate or had few natural teeth. Since then, more people are retaining natural teeth into old age and have oral disorders similar to younger adults. In addition, there has been further guidance on screening for disease that includes changes to the clinical indicators of several oral disorders and greater sensitivity to people's concerns about their oral health and care needs. METHODS: Experts in dental geriatrics assembled at a satellite symposium of the International Association of Dental Research in June 2019 to revise the objectives and content of the CODE index. Before the symposium, 139 registrants were asked for comments on the CODE index, and 11 content experts summarised current evidence and assembled reference lists of relevant information on each indicator. The reference lists provided the base for a narrative review of relevant evidence supplemented by reference tracking and direct searches of selected literature for additional evidence. RESULTS: Analysis of the evidence by consensus of the experts produced the Clinical Oral Disorders in Adults Screening Protocol (CODA-SP). CONCLUSIONS: The CODA-SP encompasses multiple domains of physical and subjective indicators with weighted severity scores. Field tests are required now to validate its effectiveness and utility in oral healthcare services, outcomes and infrastructure.

A metatheory explaining how patients manage tooth loss.

OBJECTIVES: To explore how a metatheory composed of five dominant psychosocial theories of communication, developmental regulation, emotions, resources and social cognition, explains the beliefs, concerns and experiences, of people experiencing tooth loss. BACKGROUND: Complete tooth loss is the leading cause of disability associated with oral conditions in 19 of 21 global regions, and it is among the most difficult treatment challenges in dentistry. METHODS: Interviews with 18 participants were analysed inductively using interpretive description and qualitative synthesis to explain their beliefs and experiences relating to tooth loss. RESULTS: Theoretical constructs from the five dominant theories constituting the metatheory explained the beliefs, concerns and experiences of the participants. For example, both before and after tooth loss they engaged in adaptive behaviours according to developmental regulation theory; implemented management strategies according to emotion theory, social cognitive theory, and resource theory; sought help from friends and dental professionals according to communication theory; and modified their physical and social activities according to social cognitive theory. CONCLUSION: A metatheory synthesised from five dominant theories addressing communication, personal background, emotions, resources and social awareness, offers a comprehensive and plausible explanation of how people respond psychologically and socially to the loss of their teeth, and expands the scope of information needed to help manage their loss and subsequent treatment.

A typology of systematic reviews for synthesising evidence on health care.

OBJECTIVES: The objectives of this paper are to (a) Review published references to systematic reviews; (b) offer a typology of systematic reviews for synthesising evidence on health care; and (c) summarise the guides for designing, reporting and appraising the reviews. BACKGROUND: Systematic reviews play a role in finding, synthesising, transferring and implementing evidence for healthcare policy, practice guidelines and allocation of health resources. They have been particularly successful in confirming or synthesising evidence for health care by meta-analysing aggregated data from multiple randomised controlled trials. However, concerns about the limitations of evidence from controlled trials have prompted interest in other review methods capable of locating and appraising evidence from more diverse, and possibly more realistic, healthcare situations. METHODS: An iterative citation-tracking process with Google Search and grey literature identified 204 papers on previous typologies and methods of systematic reviews. RESULTS AND CONCLUSIONS: There are six types of systematic reviews: narrative; meta-analysis; scoping; qualitative; umbrella; and realist. Each type has distinct objectives, characteristics and attributes, but with much overlapping of methods and guides. Sensitivity to the need for qualitative evidence on complex human responses to ill-health and health care has broadened the objectives and methods of health-related systematic reviews to find, appraise and synthesis useful evidence for practice guidelines, healthcare policy and allocation of health resources.

Developmental regulation of lifelong dental experiences and beliefs in Guangzhou and Hong Kong.

AIMS: The aim of this study was to explain through the life-course and life-span perspectives of developmental regulation theory the controls on dental experiences and beliefs throughout the lives of older people in Guangzhou and Hong Kong. BACKGROUND: Dental diseases and disabilities among older people are serious public health concerns in China. METHODS: A facilitator conducted eight focus groups, three in Hong Kong and five in Guangzhou, involving a total of 51 participants. She encouraged discussions about lifetime events to explain dental experiences and beliefs. Transcripts were coded and analysed using a constant comparative approach to identify themes that explained the regulators of dental experiences throughout the participants' lives. RESULTS: Participants explained the influence of culture and history through critical events, and how external and internal factors regulated their current oral health status and beliefs. They emphasised the role of Traditional Chinese Medicine and family, and the stress of social upheaval compounded by a scarcity of dental services. They revealed also how current choice of dental services and health promotional programs, helped by personal food choice, self-reliance, and scepticism, helped them to adjust and cope with dental diseases and disabilities and the commercialisation of dental services. CONCLUSIONS: Dental experiences and beliefs of older people living in Guangzhou and Hong Kong were regulated strongly during personal development by culture and history during critical events, and by various controlling factors, such as health promotion and choice of services supplemented by food choice, nutritional balance, self-reliance, scepticism and social adjustments.

A Model Pathway to Oral Health Care for Homeless People.

OBJECTIVES: This study aimed at developing a model pathway to use of oral health care by homeless people based on their own perceptions and experiences with oral health care and related services in Vancouver. METHODS: We applied Gelberg-Andresen's behavioural model for vulnerable populations to predict health care use and interviewed 25 homeless adults (18 men and 7 women; age range 25-64 years) to develop a model pathway of care. Data collection and thematic analysis were carried out concurrently and iteratively to construct the pathway, which aimed at mutual decision-making and organization of the care process. RESULTS: Thematic analysis identified 4 main themes: government-sponsored oral health programs, homeless support, oral health outreach initiatives and professional education. CONCLUSIONS: The model pathway helps to explain the factors that enable homeless people to access oral health care. It may also help dental teams foster positive care-seeking behaviour relevant to this vulnerable population so that oral disorders can be managed more sympathetically and effectively.

Panoramic radiographs made before complete removable dental prostheses fabrication: A retrospective study of clinical significance.

STATEMENT OF PROBLEM: The value of digital panoramic radiographs to screen for problems before fabricating conventional complete dentures is unclear. PURPOSE: The purpose of this retrospective study was to examine the influence of pretreatment digital panoramic radiographs on the clinical management of patients receiving complete removable dental prostheses. MATERIAL AND METHODS: The clinical records, including panoramic radiographs, of 169 patients seeking new complete removable dental prostheses over a 6-year period were interpreted independently by both a prosthodontist and an oral and maxillofacial radiologist to identify radiographic findings that influenced clinical patient management. A 95% confidence interval and an observed proportion of agreement were used to interpret the results. RESULTS: Sixty percent of the 169 radiographs examined had 1 or more abnormal or positive radiographic findings; however, only 6 (<4%) of 165 abnormalities detected influenced patient management, and 3 of them were identified during the clinical examination. CONCLUSIONS: Pretreatment digital panoramic radiographs revealed very few abnormalities that influenced the treatment of patients requiring complete removable dental prostheses. Furthermore, the digital images in this study revealed positive findings at a rate similar to those found in studies assessing analog radiographs, reinforcing current guidelines that recommend against radiographic screening of patients who seek new complete removable dental prostheses.

Oral health and the frailty syndrome.

The frailty syndrome is an ever-growing area of study among older adults because of its association with an increased risk of falls, hospitalization, institutionalization, dependency and mortality. Frailty is neither a disease nor a disability but is better understood as a medical syndrome of multisystem dysregulation that results in a diminished ability to overcome everyday stressors. The prevalence of frailty in any given population can vary widely, in part because of the way in which it is defined and measured, but in general it is higher among women and in those with advanced age and declining health. Whilst it is largely understood that older adults will differ biologically, psychologically and socially, and that each of these domains can impact oral health, we are only beginning to investigate how the mouth is affected in frailty. Given that both hard and soft structures contribute to oral health and disease status among older adults with varying degrees of impairment and disability, frailty adds yet another dimension to be considered. This paper will discuss how frailty can influence and be influenced by oral disorders, as well as the potential relationship to oral neglect and the resultant consequences among this vulnerable population.

The impact of oral health on body image and social interactions among elders in long-term care.

OBJECTIVE: The objective of this study was to explore how social interactions and body image are influenced by perceived oral health among older people who live in long-term care facilities. BACKGROUND: Social interactions among frail elders in long-term care (LTC) facilities are limited, but to what extent body image and oral health influence their social relations is poorly understood. A positive body image and the perception of adequate oral health are linked to increased social contacts, as well as improved health and well-being irrespective of age. However, as frailty increases, it is unclear whether appearance and oral health priorities remain stable. MATERIALS AND METHODS: Open-ended interviews were conducted with a purposefully selected group of cognitively intact, older men and women who exhibited varying degrees of frailty, social engagement and oral health conditions and lived in one of seven long-term care facilities. The interviews were analysed using a constant comparative technique, and a second interview with participants checked the trustworthiness of the analysis. RESULTS: Three major categories were expressed by the participants: (1) My mouth is fine; (2) It depends; and (3) Not that important. Within each category, there were several contributing and influencing factors. CONCLUSIONS: Social interactions among residents in LTC may be negatively impacted by poor oral health, but only if other personal and social issues are less bothersome than conditions with the mouth.

The use of Subject Matter Experts in Validating an Oral Health-Related Quality of Life measure in Korean.

OBJECTIVES: This paper aimed to employ subject matter experts (SMEs) to assess the extent to which the Korean version of the short-form of the OHIP (OHIP-14 K) is culturally valid and equivalent in Korean. METHODS: We approached 17 bilingual Korean SMEs from which 10 independently rated the clarity, relevance, and cultural equivalence of the OHIP-14 K. SME's varied between 10 and 41 years of clinical experience and were mostly males (# 7). We used Item-level Content Validity Index (I-CVI) to gauge the proportion of SMEs who considered the content of OHIP items (e.g., instruction, response format, etc.) to be culturally valid. We also performed additional analysis to determine the level of agreement between the SMEs. RESULTS: The experts rated most of the items to be clear (S-CVI = 0.93) while having difficulties in assigning relevance of the questions to the expected domains (S-CVI = 0.42). Moreover, considerable disagreement existed among the experts in regard to the relevance (Kfree = 0.19 to 1.00) and the cultural equivalence indexes (ADM = 0.36 to 0.96). The content of the OHIP-14 K for the most part clearly reproduced the language of the original OHIP-14. However, experts disagreed on the relevance and conceptual equivalence of the OHIP-14 K for a Korean population. CONCLUSIONS: Patient-oriented outcome measures such as the OHIP can be used across cultures once there are indeed assessing the same domains and constructs of interest. The CVI technique seems to be an alternative tool for evaluating content validity and equivalency of an OHQoL measure. A more refined, culturally relevant version of OHIP-14 K was proposed although there is no available data yet to support a better score validity, reliability and responsiveness of this proposed version.

Thirty years of portraying oral health through models: what have we accomplished in oral health-related quality of life research?

OBJECTIVES: This paper critically examines the different models of oral health aimed at representing oral health-related quality of life (OHRQoL) and explores the extent to which such models changed conceptually to accommodate current theories and empirical knowledge of oral function, impairment and disability. METHODS: A critical synthesis of the existing literature based on a comprehensive yet non-systematic review using Ovid-MEDLINE was performed. Full text of manuscripts available on models of oral health and OHRQoL published in English between 1 January 1950 and 30 June 2013 were identified. RESULTS: Nineteen manuscripts were identified presenting and discussing various models of oral health and OHRQoL that are predominantly negative and linear. These models are mostly based on sick role-related theories and do not readily accommodate the biopsychosocial theories of oral health. Alternative portrayals have emerged to include positive behaviours and adaptive strategies dynamically, but have yet to influence patient care and the development of subjective OHRQoL indicators. CONCLUSION: Despite the multitude of graphical representations of concepts, dental research has remained somewhat 'linear' in portraying the consequences of oral diseases as a one-way street. Although the conceptualization of oral health has evolved in the past 30 years, dental research still refers to it as the absence of disease in more than half a dozen models of OHRQoL focused mostly on dysfunction and disability.

Inequity in oral health care for elderly Canadians: part 2. Causes and ethical considerations.

The Canadian Health Measures Survey, conducted between March 2007 and February 2009, revealed unmet dental needs among older adults in Canada. This article, the second of a 3-part series, explains that the inequity in oral care faced by elderly Canadians is due largely to the current fee-for-service dental service system. However, the inequity has arisen because of financial, behavioural and physical barriers, and both the community at large and the dental profession have a social responsibility to reduce this unfairness and provide equitable access to oral care for older people.

Confronting dental uncertainty in old age.

OBJECTIVE: To provide an overview of the literature about uncertainty in health care and how it relates to the oral health care of older people. BACKGROUND: The medical literature describes uncertainty in health care from the initial informed-consent to its impact on a patient's ability to cope with undesirable outcomes. METHODS: A narrative review of the medical, dental and psychological literature was conducted to identify pertinent information on the theory and implications of uncertainty in healthcare. The findings are infused into a case-report illustrating the recurrence of uncertainty experienced by an older woman who had multiple treatments over several years to restore her dentition damaged severely by dental caries. RESULTS: Uncertainty originates from inadequate understanding, incomplete information and undifferentiated alternatives leading to unnecessary diagnostic tests and healthcare costs. A conceptual taxonomy clarifies the characteristics of uncertainty in the context of scientific, practical or personal sources and offers management possibilities through effective communications to identify choices and probabilities that help patients to adapt and cope with adverse events. CONCLUSIONS: Uncertainty pervades healthcare. It can lead patients to self-blame, anger and withdrawal from care unless it is communicated effectively so that they can adapt and cope with the disappointment of adversity and continue with alternative approaches to care.

The Seattle Care Pathway for securing oral health in older patients.

There is a need for a structured, evidence based approach to care for older dental patients. The following article describes the development of the Seattle Care Pathway based upon a workshop held in 2013. An overview is provided on the key issues of older persons dental care including the demography shift, the concept of frailty, the need for effective prevention and treatment to be linked to levels of dependency and the need for a varied and well educated work force. The pathway is presented in tabular form and further illustrated by the examples in the form of clinical scenarios. The pathway is an evidence based, pragmatic approach to care designed to be globally applicable but flexible enough to be adapted for local needs and circumstances. Research will be required to evaluate the pathways application to this important group of patients.

Inequity in oral health care for elderly Canadians: part 1. Oral health status.

Oral health is a contributory factor to general well-being and quality of life. The Canadian Health Measures Survey between March 2007 and February 2009, documented the oral problems that elderly people experience. This age group faces inequity in oral health care (especially in a fee-for-service system) and the aging of the Canadian population will exacerbate the problem of inequity. This article, the first of a 3-part series, discusses the impact of poor oral health on elderly people. The second article will consider inequity in terms of the financial, behavioural and physical barriers within the Canadian health care system, as well as ethical considerations related to this inequity, and the third will provide suggestions to overcome the barriers.

The influence of culture on the oral health-related beliefs and behaviours of elderly chinese immigrants: a meta-synthesis of the literature.

Neglect of the mouth can lead to impairment, disability, and discomfort; as a result, it can have a negative impact on quality of life in old age. Some minority groups in North America shoulder a disproportionate burden of dental impairment compared to people of European origins, possibly because of different cultural beliefs and a distrust of Western oral healthcare. This paper explores these factors in elderly Chinese immigrants through a meta-synthesis of selected literature that reveals a dynamic interplay of traditional Chinese beliefs about oral health, immigration, and structural factors mediating access to Western dentistry. It also identifies several conceptual issues and gaps in knowledge, offers avenues of research including the cross-cultural application of two recent models of oral health, and discusses various strategies for improving access to dental services for minority populations.

Access to dental care for low-income adults: perceptions of affordability, availability and acceptability.

The objective of this study was to explore access to dental care for low-income communities from the perspectives of low-income people, dentists and related health and social service-providers. The case study included 60 interviews involving, low-income adults (N = 41), dentists (N = 6) and health and social service-providers (N = 13). The analysis explores perceptions of need, evidence of unmet needs, and three dimensions of access--affordability, availability and acceptability. The study describes the sometimes poor fit between private dental practice and the public oral health needs of low-income individuals. Dentists and low-income patients alike explained how the current model of private dental practice and fee-for-service payments do not work well because of patients' concerns about the cost of dentistry, dentists' reluctance to treat this population, and the cultural incompatibility of most private practices to the needs of low-income communities. There is a poor fit between private practice dentistry, public dental benefits and the oral health needs of low-income communities, and other responses are needed to address the multiple dimensions of access to dentistry, including community dental clinics sensitive to the special needs of low-income people.

Social interactions, body image and oral health among institutionalised frail elders: an unexplored relationship.

OBJECTIVES: This paper draws on theories of ageing, body image and disfigurement, to explore the potential for relationships between oral health, body image and social interactions between institutionalised elders. BACKGROUND: Social relationships are important at all stages of life. A positive body image increases confidence in social interactions, which contributes substantially to health, well-being and quality of life. Body image can be negatively impacted by oral conditions, particularly those that are appearance related and do not meet cultural ideals. RESULTS: Typically, the oral health of frail elders in long-term care facilities is poor, but to what extent poor oral health and dysfunction influence body image, and social behaviours is unclear. CONCLUSIONS: We conclude that there is the potential for poor oral health conditions to contribute negatively to the social well-being in this population, but suggest that it requires further investigation.

A scoping review and research synthesis on financing and regulating oral care in long-term care facilities.

BACKGROUND: Oral health care for frail elders is grossly inadequate almost everywhere, and our knowledge of regulating and financing oral care in this context is unclear. OBJECTIVE: This scoping study examined and summarised the published literature available and the gaps in knowledge about regulating and financing oral care in long-term care (LTC) facilities. METHODS: We limited the electronic search to reports on regulating and financing oral care, including reports, commentaries, reviews and policy statements on financing and regulating oral health-related services. RESULTS: The broad electronic search identified 1168 citations, which produced 42 references, including 26 pieces of grey literature for a total of 68 papers. Specific information was found on public and private funding of care and on difficulties regulating care because of professional segregation, difficulties assessing need for care, uncertainty on appropriateness of treatments and issues around scope of professional practice. A wide range of information along with 19 implications and 18 specific gaps in knowledge emerged relevant to financing and regulating oral healthcare services in LTC facilities. CONCLUSIONS: Effort has been given to enhancing oral care for frail elders, but there is little agreement on how the care should be regulated or financed within the LTC sector.

Discussions on oral health care among elderly Chinese immigrants in Melbourne and Vancouver.

BACKGROUND: This study explored how elderly Chinese immigrants value and relate to how acculturation influences oral health and subsequent service use. METHODS: Elders who had immigrated to Melbourne and Vancouver within the previous 15 years were recruited from local community centres and assigned to focus groups of 5-7 participants in Vancouver (4 groups) or Melbourne (5 groups). RESULTS: Following an iterative process of thematic analysis, the discussions revealed that immigrants care about the comfort and appearance of their teeth, and they value Western dentistry as a supplement to traditional remedies, but they have difficulty getting culturally sensitive information about oral health care. Accessing dentistry, they explained, is distressing because of language problems and financial costs that impose on their children. Consequently, many immigrants obtain dental treatment in China when they return for occasional visits. They felt that separation of dentistry from national health care programmes in Canada and Australia disregards natural links between oral health and general health. CONCLUSIONS: The similarity of concerns in both cities suggests that dissemination of information and availability of services are the important themes influencing oral health, and that, beliefs developed over a lifetime play an important role in interpreting oral health in the host country.

Magnet-retained implant-supported overdentures: review and 1-year clinical report.

Open-field aluminum-nickle-cobalt magnets have been used in prosthodontics for many years, but success has been limited because these magnets are susceptible to corrosion by the saliva and because their retentive force is weak relative to the initial retention offered by mechanical attachments. More recently, magnets have been made from alloys of the rare earth elements samarium and neodymium, which provide stronger magnetic force per unit size. In addition, a new generation of laser-welded containers has improved protection from salivary corrosion. The current resurgence of interest in this type of attachment appears justified because, unlike mechanical attachments, magnets have potential for unlimited durability and might therefore be superior to mechanical ball or bar attachments for the retention of removable prostheses on implants. To date, no long-term prospective trials have been conducted to confirm the clinical durability of this new generation of magnets for retaining dentures on either teeth or implants. The aim of this study was to document initial clinical experiences and levels of satisfaction among edentulous patients treated with mandibular implant-supported overdentures retained using a new generation of rare-earth magnetic attachments. At the outset, all but one of the 17 patients had had several years of experience with implant-supported overdentures. During the first year, the mean overall satisfaction among these 17 patients increased from less than 70 to over 90 out of 100 (standardized visual analogue scale). No unusual difficulties were encountered in rendering the treatment or maintaining the attachments. This report offers preliminary evidence of the excellent potential of these magnets for retaining mandibular implant-supported overdentures.