Providing Oral Healthcare to Older Patients-Do We Have What It Takes?

Over the past decades, there has been an increase in the number of natural teeth that are maintained into older age, and this has represented an increase in the need for more complex dental treatment for this population. A trained workforce is needed in order to provide dental care to the different groups of elderly. Currently, the undergraduate training in gerodontology offered by dental schools seems to be limited, with great variation among dental schools worldwide. Given the heterogeneity of elderly groups, it is unlikely that new graduates from dental schools can be deemed competent to deal with the different groups of elderly. In this article, barriers to oral healthcare's provision to older adults are discussed, including the lack of appropriately trained dental professionals. Training pathways are discussed, including the preparation of undergraduate education to provide a suitable foundation to be developed further in postgraduate education. It is also proposed that older adults are classified according to their dependency level and each level is managed by properly trained dental professionals. In order to upskill general dental practitioners to care for these patients, postgraduate certification programmes could be structured to provide additional training. Furthermore, the development of geriatric oral health educational programmes for non-dental healthcare workers is recommended.

Physiological and yield responses of contrasting upland rice genotypes towards induced drought.

Drought alters rice morphophysiology and reduces grain yield. This study hypothesized that the combined analysis of morphophysiological and agronomic traits enables a systemic approach to responses to water deficit, allowing the selection of resistance markers to upland rice. The objectives were to evaluate the effects of water deficit applied at the reproductive stage in plant water status, leaf gas exchanges, leaf non-structural carbohydrate contents, and agronomic traits in upland rice genotypes; and to verify if the analyzed variables may be applied to group the genotypes according to their tolerance level. Water deficit was induced by irrigation suppression in eight genotypes at R2-R3. Physiological and biochemical traits were evaluated at the end of the water deficit period, thenceforth irrigation was restored until grain maturation for the analysis of the agronomic traits. Water deficit reduced: Ψw (63.64%, average); gs (28-90%); transpiration rate (40.63-65.45%); RWC from Serra Dourada to Esmeralda (43.36-61.48%); net CO2 assimilation from Serra Dourada to Primavera (70.04-99.91%); iWUE from Esmeralda to Primavera (83.98-99.85%); iCE in Esmeralda (99.92%); 100-grain weight in CIRAD and Soberana (13.65-20.63%); and grain yield from Primavera to IAC 164 (34.60-78.85%). Water deficit increased Ci from Cambará to Early mutant (79.64-215.23%), and did not affect the tiller number, shoot dry biomass, fructose, and sucrose contents. The alterations in the variables distinguished groups according to the water regime. RWC, Ψw, leaf gas exchanges, and iCE were valuable traits to distinguish the water regime treatments, but not to group the genotypes according to the drought tolerance level. Supplementary Information: The online version contains supplementary material available at 10.1007/s12298-023-01287-8.

Response rates to questionnaire-based studies in the contemporary dental literature: A systematic review.

OBJECTIVES: This systematic review aimed to investigate what is a reasonable response rate for dental questionnaire-based studies in recent literature and to assess the factors that affect the response rates. METHODS: We used MEDLINE/PubMed to search the dental literature of 2021 (January-October). Two reviewers independently assessed studies eligibility and extracted data using standardized electronic extraction form. RESULTS: One hundred and seventy-two studies were eligible, of these a total of 149 response rates were reported from 133 studies, whereas the remaining 39 studies were excluded as they did not report response rates. The median response rate across the included studies was 77% (mean = 70.8%). We found significant negative correlation between the response rate and the actual number of distributed questionnaires (sample size) (r = -0.4127; P < 0.001). We also found an association between the response rate and the area of distribution, e.g., national or international (P = 0.0012). However, a wide variation was observed in the quality of information reported within this review and we did not find clear evidence of association between the response rate and other variables such as questionnaire piloting, number of questions in the questionnaire and the journal impact factor. CONCLUSIONS: The findings of this systematic review confirm the association between the response rate and the sample size, where the response rate increases when the sample size less than 300 participants. In addition, a higher response rate could be achieved when the study conducted within the same institution (e.g., university). SIGNIFICANCE: Questionnaire-based research can provide answers to several questions that could not be answered by other types of research related to the field of dentistry, dental health practitioners and students' attitudes and behaviours and more. Questionnaire-based publications can effectively contribute to dental research; thus, dental journals should consider development of a minimum set of guidelines in the reporting of questionnaire-based manuscripts.

Undergraduate teaching and assessment methods in prosthodontics curriculum: An international Delphi survey.

OBJECTIVES: To achieve consensus amongst an expert panel of prosthodontics/restorative dentistry academics on the best undergraduate teaching and assessments, and to develop recommendations regarding teaching and assessment of undergraduate prosthodontics. METHODS: Semi-structured electronic questionnaires were used to collect data from senior clinical academics involved in the teaching of prosthodontics on three consecutive occasions (Delphi method). The questionnaires asked the experts' opinion on best teaching and assessment methods in the undergraduate prosthodontics curriculum. Invitation emails, with a hyperlink to the Round 1 questionnaire, were sent to 36 international dental academic experts. In later rounds, panellists were invited to consider their previous responses in light of the overall group response in attempt to bring the panel to a consensus. The group response was summarized using simple descriptive statistics, and the target level of consensus for each question was set at ≥ 70%. A response rate of at least 70% between rounds was deemed appropriate to maintain rigour. RESULTS: Twenty-three senior academic experts from eleven countries agreed to participate. Eighteen (representing nine different countries) completed the questionnaires in its entirety (response rate 78.3%). The number of statements that attained consensus agreement was much higher than the number of non-consensus statements-92.6%, 175 statements out of 189 over three iterative rounds. Only 14 statements did not obtain a consensus during this Delphi study. CONCLUSIONS: A total of 175 consensus statements represent the agreement expert views of participated senior academics in prosthodontics from nine different countries and across four continents. These consensus statements could be considered detailed guidelines and recommendations to improve future undergraduates' curriculum in prosthodontics. CLINICAL SIGNIFICANCE: This Delphi study achieved a high consensus among a panel of senior academics in the teaching and assessment of undergraduate prosthodontics. This consensus could help minimise the current international and national divergence in dental schools' prosthodontics curricula, which could benefit future dentists and, subsequently, the patients.

COVID-19 pandemic and its impact on dental students: A multi-institutional survey.

PURPOSE/OBJECTIVES: To investigate dental students' perceptions and concerns regarding the COVID-19 pandemic, their coping strategies and support resources, and their perceived stress levels. METHODS: A customized 19-item survey and the perceived stress scale (PSS) were applied to undergraduate dental students from the US, Spain, Ireland, Chile, India, and Brazil between April 10 and July 5, 2020. Linear modeling and mediation analysis were used to explore the relationships among demographics, stressors, coping mechanisms, social support, and stress RESULTS: A total of 4475 students responded to the survey. The majority (72.4%) were women, and 52.3% had no COVID-19 training at the time of the survey. The students reported that they had to accommodate to changes in patient care (96.6%) and didactic learning (95.2%) activities, while 88.5% of the respondents indicated at least one of their courses moved online. Transition to online courses went "smoothly with some troubles" for 51.8% of the respondents, and 48.3% perceived the faculty as prepared for the online transition; however, 45.9% reported feeling extremely concerned about the impact of COVID-19 on their education. The average PSS score was 21.9 of 40 (moderate stress). Multivariate models were built for participants with full data (n = 3899). Being male, having completed more dental coursework, and perceiving a smoother transition were associated with lower PSS scores; more concern about academic progress was associated with higher PSS. Faculty support mediated the relationship between a smoothness of transition and concern about academic progress and PSS scores CONCLUSION: Stress caused by the pandemic may be alleviated by smoother transition and good faculty support.

Contemporary Challenges and Management of Dental Caries in the Older Population.

The prevalence of caries is set to increase in the coming years as a result of a growing ageing population and a concomitant reduction in levels of edentulousness. Evidence for management of caries in older adults is scarce compared to that for the child population, however, similar principles of risk assessment, prevention and minimal intervention should be applied by dental health professionals. Early identification of high-risk older adults facilitates the implementation of risk reduction strategies, such as topical fluoride regimes. When operative intervention cannot be avoided, Atraumatic Restorative Technique (ART) may allow for conservative cavity preparation and has the advantage of being suitable for the domiciliary setting.

Atraumatic vs conventional restorative treatment for root caries lesions in older patients: Meta- and trial sequential analysis.

OBJECTIVES: We aimed to appraise the comparative clinical efficacy of atraumatic restorative treatment (ART) versus conventional restorative treatment (CT) using a meta-analysis, and assessed the robustness of evidence by trial sequential analysis (TSA). BACKGROUND: Due to its simplified clinical approach, ART may be advantageous over CT for restoration of root caries lesions in institutionalised older patients. METHODS: Three electronic databases (PubMed, Embase and Cochrane CENTRAL) were screened, and hand searches and cross-referencing performed to identify randomised controlled trials reporting on survival of ART vs CT for restoration of root caries in older patients. Trial selection, data extraction and risk of bias assessment were performed by two independent reviewers. ART and CT were compared using fixed- or random-effects pairwise meta-analysis for per-protocol (PP), intention-to-treat (ITT) and best-case scenarios. TSA was used to control for risk of random errors. RESULTS: A total of 235 studies were identified, and three trials involving 130 patients (463 restorations) were included. Risk of bias was high or moderate in all but one trial. ART was associated with a significantly increased risk of failure (OR [95% CI] 2.06 [1.06/4.00]) in PP- but not in ITT analysis (1.36 [0.92/2.02]). Analyses for best-case scenarios found great uncertainty introduced by attrition. No firm evidence was reached according to TSA. CONCLUSIONS: For restoration of root caries, there is insufficient data to clearly rule out whether differences between ART and CT exist. Limited available data indicate there might be an increased risk of failure for ART.

Minimal intervention dentistry for partially dentate older adults.

BACKGROUND: Chronic dental and oral diseases, such as dental caries and periodontal disease, continue to be a significant health problem among older adults. Given the rapidly changing profile of the ageing population, and their complex health needs, there is a need to develop new evidence-based approaches to oral health care. Recently, care philosophies have been developed that take a minimally invasive, functionally oriented, approach to oral health care with a focus on providing a reduced, but healthy, natural dentition which can be maintained with support of better oral hygiene. METHOD: A review of the literature concerning use of minimal intervention dentistry (MID) to manage caries and toothloss in partially dentate older adults was undertaken. RESULTS: A variety of chemotherapeutic agents are available to prevent development of root caries and/or arrest root caries lesions, with professionally applied solutions (ie 22 500 NaF, 38% SDF or 40% CHX) every 3 to 6 months demonstrating best outcomes. Application of 38% SDF annually in high-risk, institutionalised older adults is effective in arresting root caries. Atraumatic restorative treatment can be used successfully to manage active carious lesions and limit the removal of natural tooth tissue. Finally, functionally oriented treatment planning to manage partial toothloss is successful in terms of quality of life impact and cost-effectiveness. CONCLUSION: Available evidence is somewhat limited and more long-term studies are need. However, currently available evidence suggests that minimal intervention dentistry can be predictable and cost-effective in older adults.

The relationship between oral-health-related quality of life and general health in an elderly population: A cross-sectional study.

OBJECTIVE: To assess the oral-health-related quality of life (OHRQoL) in a cohort of Irish older patients and explore associations with overall health status. BACKGROUND: The impact of oral health conditions on older individuals' quality of life may be influenced by patients' general health status. MATERIALS AND METHODS: This paper reports a cross-sectional study, which analysed baseline data from patients aged over 60 years. Patients were recruited from two different environments, namely Cork University Dental Hospital and St. Finbarr's Hospital, to take part in two research studies. All patients completed the Oral Health Impact Profile (OHIP-14) and EuroQol-5D (EQ-5D) questionnaires. All patients provided a comprehensive overview of their general medical status. Data from the Quality of Life questionnaires were analysed to check for differences between healthy and frail elders and explore associations between OHRQoL and general health. RESULTS: The patient sample comprised 146 (44.6%) male and 181 (55.4%) female participants, with a mean (SD) age of 73.96 (6.9). Frail patients reported a higher mean OHIP-14 score compared to non-frail patients (P < 0.001). Pearson's correlation analysis showed a negative association between OHIP-14 and EQ-5D scores. Regression analysis showed that among frail individuals, better general health corresponded to poorer OHRQoL. In the non-frail cohort, better general health was related to better OHRQoL, although these results were not statistically significant. CONCLUSIONS: General health was not significantly associated with the way that patients perceive their oral health within this patient cohort. However, factors such as objective oral health, denture wear and patient's expectations may play a role in this association.

How do we incorporate patient views into the design of healthcare services for older people: a discussion paper.

BACKGROUND: Across the European Union costs for the treatment of oral disease is expected to rise to €93 Billion by 2020 and be higher than those for stroke and dementia combined. A significant proportion of these costs will relate to the provision of care for older people. Dental caries severity and experience is now a major public health issue in older people and periodontal disease disproportionately affects older adults. Poor oral health impacts on older people's quality of life, their self-esteem, general health and diet. Oral health care service provision for older people is often unavailable or poor, as is the standard of knowledge amongst formal and informal carers. The aim of this discussion paper is to explore some of the approaches that could be taken to improve the level of co-production in the design of healthcare services for older people. MAIN TEXT: People's emotional and practical response to challenges in health and well-being and the responsiveness of systems to their needs is crucial to improve the quality of service provision. This is a particularly important aspect of care for older people as felt, expressed and normative needs may be fundamentally different and vary as they become increasingly dependent. Co-production shifts the design process away from the traditional 'top-down' medical model, where needs assessments are undertaken by someone external to a community and strategies are devised that encourage these communities to become passive recipients of services. Instead, an inductive paradigm of partnership working and shared leadership is actively encouraged to set priorities and ultimately helps improve the translational gap between research, health policy and health-service provision. DISCUSSION: The four methodological approaches discussed in this paper (Priority Setting Partnerships, Discrete Choice Experiments, Core Outcome Sets and Experience Based Co-Design) represent an approach that seeks to better engage with older people and ensure an inductive, co-produced process to the research and design of healthcare services of the future. These methods facilitate partnerships between researchers, healthcare professionals and patients to produce more responsive and appropriate public services for older people.

Risk indicators associated with root caries in independently living older adults.

OBJECTIVE: To determine the risk indicators associated with root caries experience in a cohort of independently living older adults in Ireland. METHODS: The data reported in the present study were obtained from a prospective longitudinal study conducted in a cohort of independently living older adults (n=334). Each subject underwent an oral examination, performed by a single calibrated examiner, to determine the root caries index and other clinical variables. Questionnaires were used to collect data on oral hygiene habits, diet, smoking and alcohol habits and education level. A regression analysis with the outcome variable of root caries experience (no/yes) was conducted. RESULTS: A total of 334 older dentate adults with a mean age of 69.1 years were examined. 53.3% had at least one filled or decayed root surface. The median root caries index was 3.13 (IQR 0.00, 13.92). The results from the multivariate regression analysis indicated that individuals with poor plaque control (OR 9.59, 95% CI 3.84-24.00), xerostomia (OR 18.49, 95% CI 2.00-172.80), two or more teeth with coronal decay (OR 4.50, 95% CI 2.02-10.02) and 37 or more exposed root surfaces (OR 5.48, 95% CI 2.49-12.01) were more likely to have been affected by root caries. CONCLUSIONS: The prevalence of root caries was high in this cohort. This study suggests a correlation between root caries and the variables poor plaque control, xerostomia, coronal decay (≥2 teeth affected) and exposed root surfaces (≥37). The significance of these risk indicators and the resulting prediction model should be further evaluated in a prospective study of root caries incidence. CLINICAL SIGNIFICANCE: Identification of risk indicators for root caries in independently living older adults would facilitate dental practitioners to identify those who would benefit most from interventions aimed at prevention.

Two-year survival of ART restorations placed in elderly patients: A randomised controlled clinical trial.

OBJECTIVES: Older dentate adults are a high caries risk group who could potentially benefit from the use of the atraumatic restorative treatment (ART). This study aimed to compare the survival of ART and a conventional restorative technique (CT) using rotary instruments and a resin-modified glass-ionomer for restoring carious lesions as part of a preventive and restorative programme for older adults after 2 years. METHODS: In this randomised controlled clinical trial, 99 independently living adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations. The survival of restorations was assessed by an independent and blinded examiner 6 months, 1 year and 2 years after restoration placement. RESULTS: Ninety-six (67.6%) and 121 (76.6%) restorations were assessed in the ART and CT groups, respectively, after 2 years. The cumulative restoration survival percentages after 2 years were 85.4% in the ART and 90.9% in the CT group. No statistically significant between group differences were detected (p=0.2050, logistic regression analysis). CONCLUSIONS: In terms of restoration survival, ART was as effective as a conventional restorative approach to treat older adults after 2 years. This technique could be a useful tool to provide dental care for older adults particularly in the non-clinical setting. ( TRIAL REGISTRATION NUMBER: ISRCTN 76299321). CLINICAL SIGNIFICANCE: The results of this study show that ART presented survival rates similar to conventional restorations in older adults. ART appears to be a cost-effective way to provide dental care to elderly patients, particularly in out of surgery facilities, such as nursing homes.

Subjective impact of minimally invasive dentistry in the oral health of older patients.

OBJECTIVES: The aim of this study was to investigate if a minimally invasive oral health package with the use of atraumatic restorative treatment (ART) or a conventional restorative technique (CT) would result in any perceived benefit from the patients' perspective and if there would be any difference between the two treatment groups. MATERIALS AND METHODS: In this randomised clinical trial, 99 independently living older adults (65-90 years) with carious lesions were randomly allocated to receive either ART or conventional restorations using minimally invasive/intervention dentistry (MID) principles. Patients completed an Oral Health Impact Profile (OHIP)-14 questionnaire before and 2 months after treatment. They were also asked to complete a global transition question about their oral health after treatment. RESULTS: At baseline, the mean OHIP-14 scores recorded were 7.34 (ART) and 7.44 (CT). Two months after treatment intervention, 90 patients answered the OHIP-14 and the mean scores were 7.23 (not significant (n.s.)) and 10.38 (n.s.) for the ART and CT groups, respectively. Overall, 75.5 % of patients stated that their oral health was better compared to the beginning of treatment. CONCLUSIONS: Although not shown by the OHIP-14, patients perceived an improvement in their overall oral status after treatment, as demonstrated by the global transition ratings in both groups. CLINICAL RELEVANCE: Dental treatment using minimally invasive techniques might be a good alternative to treat older individuals, and it can improve their oral health both objectively and subjectively.

Minimal intervention dentistry and older patients part 2: minimally invasive operative interventions.

UNLABELLED: As described in the first paper of this two part series, the expansion of our older population and the concomitant reduction in levels of edentulism will result in an increase in the number of patients presenting in general practice with complex restorative challenges. The application of the concepts of minimal intervention dentistry and minimally invasive operative techniques may offer a powerful armamentarium to the general dentist to provide ethical and conservative treatment to older patients. CLINICAL RELEVANCE: When it is unavoidable, operative intervention should be as minimally invasive as practicable in older patients to preserve the longevity of their natural dentition.

Minimal intervention dentistry and older patients. Part 1: Risk assessment and caries prevention.

Ten million people in the UK today are aged over 65. The latest projections estimate that there will be 5 1/2 million more people aged 65 and older in the next 20 years. This projected pattern of population ageing will have profound consequences for dentistry. Minimal intervention dentistry (MID) is a modern evidence-based approach to caries management in dentate patients that uses the 'medical model' whereby disease is controlled by the 'oral physician'. This approach offers considerable benefits over conventional dentistry for older patients. It encourages patients to be responsible for their oral health through the provision of both knowledge and motivation. MID encompasses risk assessment for dental disease, early detection and control of disease processes, and minimally invasive treatment. Clinical Relevance: Risk assessment tools can aid the general dental practitioner and the patient to develop a suitable caries prevention programme for that individual and reduce the need for future operative intervention.

Cost-effectiveness of ART restorations in elderly adults: a randomized clinical trial.

BACKGROUND: As the world population ages, the requirement for cost-effective methods of treating chronic disease conditions increases. In terms of oral health, there is a rapidly increasing number of dentate elderly with a high burden of maintenance. Population surveys indicate that older individuals are keeping their teeth for longer and are a higher caries risk group. Atraumatic Restorative Treatment (ART) could be suitable for patients in nursing homes or house-bound elderly, but very little research has been done on its use in adults. OBJECTIVES: To compare the cost-effectiveness of ART and a conventional technique (CT) for restoring carious lesions as part of a preventive and restorative programme for older adults. METHODS: In this randomized clinical trial, 82 patients with carious lesions were randomly allocated to receive either ART or conventional restorations. Treatment costs were measured based on treatment time, materials and labour. For the ART group, the cost of care provided by a dentist was also compared to the cost of having a hygienist to provide treatment. Effectiveness was measured using percentage of restorations that survived after a year. RESULTS: Eighty-two patients received 260 restorations, that is, 128 ART and 132 conventional restorations. 91.1% of the restorations were on one surface only. After a year, 252 restorations were assessed in 80 patients. The average cost for ART and conventional restorations was €16.86 and €28.71 respectively; the restoration survival percentages were 91.1% and 97.7%, respectively. This resulted in a cost-effectiveness ratio of 0.18 (ART) and 0.29 (CT). When the cost of a hygienist to provide ART was inserted in the analysis, the resulting ratio was 0.14. CONCLUSIONS: Atraumatic restorative treatment was found to be a more cost-effective alternative to treat older adults after 1 year, compared to conventional restorations, especially in out of surgery facilities and using alternative workforce such as hygienists. Atraumatic restorative treatment can be a useful tool to provide dental care for frail and fearful individuals who might not access dental treatment routinely.