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.

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.

Perception of dry mouth in a sample of community-dwelling older adults in Japan.

The purpose of this study was to examine the prevalence of perceived dry mouth among a group of independently-living elderly persons in Japan, and to determine its association with general disease, medication, and dental status, as well as its effect on oral function. The study population consisted of participants of the Senior Citizens' College. The subjective sensations of oral dryness on waking and while eating a meal were measured by a questionnaire. The number of usable questionnaires was 1003 or 77.9%. The mean age of the subjects was 66.3 +/- 4.2 years, and 53.0% were male. More than one-third (37.8%) of the subjects reported oral dryness on waking. Only 9.1% of them noticed a subjective feeling of dry mouth during eating. Persons who had at least one of these symptoms made up 41.0%. A multiple stepwise logistic regression analysis indicated the following results: Perception of dry mouth on waking was more frequent among males (p < 0.001), persons who had a low BMI (p < 0.05), and those taking two or more prescribed drugs (p < 0.01). Sensation of dry mouth when eating was more frequent among subjects with a low BMI (p < 0.001) and those who wore a denture in the maxillary arch (p < 0.05). Perception of dry mouth when eating was associated with self-assessed chewing ability (p < 0.01) and dissatisfaction with speaking clearly (p < 0.05), as well as dental status. However, dissatisfaction with tasting a meal had a significant relationship with the reports of mouth dryness on waking (p < 0.01). Our findings suggest that a substantially higher percentage of persons have the perception of dry mouth on waking than when eating, which was associated with medications, being male, and having a low BMI. This perception may influence oral function, especially the reported dissatisfaction with tasting foods.

In vitro evaluation of fluoride-releasing restorative materials for sealing the root canals of overdenture abutments.

PURPOSE: The purpose of this study was to evaluate the ability of newer fluoride-releasing restorative materials to protect the root surface from acid attack. MATERIALS AND METHODS: The materials used were glass-ionomer cement (GIC), resin-modified glass-ionomer cement (RM-GIC), and a compomer (Comp). A composite resin (CR) was used as the control. The restored teeth were stored in deionized, distilled water for 14 days and subjected to 300 thermocycles (55 degrees C and 5 degrees C). The teeth were cycled in a demineralizing solution (pH 5.0 or 4.0) for 6 hours and in a remineralizing solution (pH 7.0) for 17 hours for 10 days. The depths of lesions created by acid challenge were measured at the interface of the tooth and the restorative material and then at a distance of 50, 100, and 300 microns from the tooth-restoration margin using polarized light microscopy and contact microradiography. RESULTS: At pH 4.0, there was significant difference in the depth at the interface between the tooth and the restorative material (P < .001). The GIC and RM-GIC were protective, and the lesion depths were significantly shallower than for Comp or CR. The protective effect varied depending on the distance from the interface of the tooth and the restorative material. At pH 5.0, the GIC and RM-GIC had no lesions at the interface, while the Comp and the CR had lesions (P < .001). CONCLUSION: Fluoride-releasing glass-ionomer cement seems to be an appropriate material to seal the root canals of overdenture abutments, because it has an inhibiting effect on demineralization at the cavity wall in vitro.

Nursing directors' perceptions of the dental components of the Minimum Data Set (MDS) in nursing homes.

The Directors of Nursing (DON's) of all 428 nursing homes in the state of Iowa were sent a pre-tested questionnaire. The aim of the study was to examine the perceptions by nursing directors on the utility of a dental component of the Minimum Data Set (MDS) in identifying residents with dental problems in their facility. The return rate was 55.1% from the DON's. It was reported that 66.4% of the homes had a training program for the MDS and that in 38.0% of the homes there was only one person doing the assessments. The majority (76.0%) of the DON's stated that the MDS was useful in tracking residents and that it did help them to identify dental problems. When asked how often it was useful in the identification of dental needs, only 9% stated that it was often useful. Also, regarding frequency of dental appointments for the residents, a mean of 51.0% of residents were estimated to have received some dental care during the previous year (means of 33.2% at the facility, 22.4% at a dental office, and 0.4% in a hospital). If change is to occur, the dental profession must try to get the nursing home assessors to convince the nursing homes to use the oral/nutritional/dental sections of the MDS as they were intended under the OBRA regulations.

Reflections on changes in geriatric dentistry.

The development of geriatric dental education programs in the United States and at the University of Iowa over the last twenty years is reviewed. The program at Iowa evolved from a didactic elective program taught by a single faculty person to required didactic and clinical programs that include a special care clinic in the dental school and a mobile unit with portable equipment serving ten area nursing homes with comprehensive care. Factors influencing the curriculum development are identified and discussed, and as no dental schools are the same, some general applications are suggested from the Iowa experience.

Patient management and decision making in complete denture fabrication using a duplicate denture procedure: a clinical report.

A patient may have difficulty adapting to a new prosthesis for either physical or psychological reasons. This article describes a procedure for duplicating an existing denture and gives the practitioner an alternative to the traditional denture fabrication techniques. The duplicated denture fabrication technique minimizes the changes to the new denture, making it easier for the patient to adapt to new dentures. However, in-depth communication with the patient is necessary for successful denture therapy.

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.

The future of dental care for the elderly population.

The U.S. population is aging, and the elderly are maintaining many of their natural teeth. Studies have shown that if older people have teeth, they tend to utilize dental services to a similar extent as younger cohorts. Geriatric dental care is the diagnosis, treatment, and prevention of dental and oral diseases for all older adults. A functional categorization of the aging population is more useful in dentistry than a chronological one, and 70 percent of this population, or 23.2 million people, is able to visit a dentist in his or her office. The oral health care of older adults has become more challenging because they will no longer accept extraction and dentures as a solution to complex restorative needs. This paper discusses these issues and looks at the future of geriatric dental care.

Changing dietary patterns with changing dentition: how do people cope?

Food plays a significant and essential role in the survival of all people. There has been a suggestion that there is a strong association between changes in dental status such as loss of teeth and denture wearing and low intake of essential nutrients. This paper explores the relationship between diet and nutrition and a change from (A) an old complete denture to an implant-supported denture, from (B) the dentate status to an immediate complete denture, and from (C) an old complete denture to a functionally corrected new complete denture. A summary of the findings is that loss of teeth influences masticatory efficiency and function and that a replacement prosthesis may improve function but does not significantly change dietary intake.

An in vitro evaluation of the integrity of stainless steel crown margins cemented with different luting agents.

The elderly population is retaining more teeth which require extensive restorations. The purpose of this study was to identify a luting agent which had the least marginal breakdown when used with stainless steel crowns. Thirty-six caries-free molars were selected, prepared for stainless steel crowns, and embedded in acrylic to support the crown and tooth. The crowns (Unitek/3M) were cemented with 4 different luting agents: (A) Fleck's Cement, (B) Ketac-Cem, (C) All-Bond C & B Cement, and (D) Panavia EX Cement. All the restored teeth were thermocycled and divided into 3 experimental groups. Twelve teeth were stained. The remaining teeth were occlusally loaded and stained. The remaining 12 teeth were thermocycled and stained again. The stainless steel crowns were then sectioned and photographed at 7.5x mag. The dye penetration was evaluated by measurement of the percentage of dye penetration from the crown margin to the cusp tip on each side. Statistical analysis found that the least dye penetration was with All-Bond C & B Cement (p = 0.0001). The most extensive penetration was observed in Ketac-Cem Occlusal loading was a significant factor (p = 0.0001) increasing the dye penetration, but the crown-tooth gap was not.

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.

In vitro evaluation of topical fluorides for overdenture abutments.

STATEMENT OF PROBLEM: Topical fluorides are effective, yet none have been developed specifically for root or dentin surfaces. PURPOSE: This study evaluated the ability of several commercial topical fluorides to protect overdenture abutments from in vitro acid demineralization. MATERIAL AND METHODS: Twenty extracted teeth from persons aged 50 to 70 years were prepared for overdenture abutments. The teeth were sectioned to provide 40 buccal and lingual halves, covered with nail varnish except for windows on the occlusal and root surfaces, and randomly divided into 4 groups of 10 specimens, which were cycled for 6 hours in acid demineralization, washed, and then held 17 hours in a remineralizing solution for 18 days. Before each cycle, the specimens were treated with either Karigel, Karigel-N, or a NaF solution. The control group was treated with fluoride-free solution. RESULTS: The depth of the artificial lesions on the root surfaces showed a statistically significant dose response. On the occlusal, there were no differences in lesion depth between the various topical fluorides and the control group. But there was a dose response when the remineralized band was subtracted from the lesion depth. Remineralization bands in the occlusal lesions were not evident in the control group, but were present in the fluoride groups. CONCLUSION: This study suggests that higher concentrations of NaF are more protective for overdenture abutments.

Challenges in geriatric oral health research methodology concerning caregivers of cognitively impaired elderly adults.

Little is known about oral health care behaviors of community-dwelling, cognitively impaired elderly (CIE) persons. Few studies have been conducted regarding the actual provision of oral care for CIE persons or the attitudes and concerns about oral health among their caregivers. The CIE person's ability to perform self-care decreases over time, and the role of the caregiver in daily oral care becomes increasingly important. The purpose of this pilot study was to explore the attitudes toward oral health and identify related concerns among caregivers who care for community-dwelling CIE persons. Caregivers were surveyed by means of a self-administered, mailed questionnaire. To maintain confidentiality, an intermediary was used for recruitment and data collection. Overall, 148 caregivers were invited by an intermediary to participate in the survey; only 21 (14%) consented to participate and returned the questionnaire. This paper discusses some of the numerous methodological challenges identified when an attempt was made to survey care-givers' attitudes toward and barriers to providing oral care for a dependent CIE.

Denture treatment needs of an overdenture population.

Cross-sectional and longitudinal studies have identified that persons wearing overdentures require regular care and maintenance of their dentures and their remaining dentition. This paper reports on a longitudinal study of the denture treatment needs of 284 dentures placed in 254 patients seen over a period of 12 years. At placement of the overdentures, baseline measurements and photographs were made by a single examiner. These measurements included evaluation of the restorations, abutment height above the gingival margin, periodontal probing depths, and oral hygiene. Denture status was evaluated by examining stability, retention, the integrity of the denture bases, and the relationship of the teeth in centric occlusion. Denture hygiene was also assessed. Based upon this examination, the subjects' denture treatment needs were determined. The majority of overdentures were well tolerated, and in general the patients were satisfied with their dentures. The most common denture treatment need was cleaning, followed by adjustment of the denture bases. Relining was a more common problem in the mandibular arch than in the maxillae. The need for occlusal adjustment did not seem to be a problem after the fifth year, but this might have been because of replacement of worn teeth or dentures. The majority of denture repairs were necessitated before the sixth year. Patients who received immediate dentures did not have greater treatment needs. Looseness of the dentures was the primary complaint, followed by sore teeth and denture-bearing tissues. In spite of their complaints, the great majority of the patients were satisfied with their overdentures.

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.

Radiographic findings, ridge resorption, and subjective complaints of complete denture patients.

To evaluate the relationship between the complaints of complete denture wearers and alveolar bone resorption as well as the location of mental foramina, 96 patients were interviewed. All subjects had received new dentures at the University of Iowa between August 1985 and July 1990. Panoramic radiographs had been made for all the subjects before dentures were fabricated. The amount of estimated ridge resorption correlated significantly with the number of years females had been edentulous, but no correlation was found in males. The location of the mental foramen in relationship to the crest of residual ridge correlated negatively with the number of years both genders were edentulous. Subjective need for dental treatment, as expressed by "sore gums" or poor or fair chewing ability, were the most frequent complaints among the subjects. These complaints were more often recorded with the subjects who had lost more than 50% of their estimated original ridge height than with those with less than 50% resorption, but this difference was not significant.