Evaluation of the Oral Hygiene Ability Instrument (OHAI): Test of reliability.

OBJECTIVES: To evaluate the reliability of the new Oral Hygiene Ability Instrument (OHAI) developed to assess the cause of any inability for older adults to manage oral hygiene self-care. Oral hygiene is an important part of oral health. The inability to manage oral hygiene, combined with other risk factors, often results in poor oral health and impaired quality of life. A reliable OHAI could benefit preventive oral health care. METHODS: The preliminary OHAI uses 33 items in three parts: (I) interview, (II) clinical examination and (III) observation of oral hygiene activities. A total of 37 older adults participated in a test-retest study of Part I. Inclusion criteria were age ≥ 65 years, have at least one tooth and be able to oral hygiene self-care. The intra- and inter-rater reliability of parts II and III used films and photographs of OHAI assessments of 15 different individuals. These films/photographs were assessed twice by four dental professionals who had participated in the OHAI data collection. For statistical analyses of the reliability, per cent agreement, Krippendorff's alpha and E. Svensson's method were used. RESULTS: The test-retest for Part I items showed acceptable-to-good agreement and no systematic disagreement. In Part II, two items showed somewhat limited reliability. Part III showed good intra- and inter-rater reliability. CONCLUSION: The OHAI items seem stable and reliable for the intended sample, and the instrument may be a valuable tool to identify older adults at risk of impaired oral health. However, two items may need to be reformulated.

Development of an instrument to assess oral hygiene ability in older adults: The oral hygiene ability instrument.

OBJECTIVES: To describe the development process of an instrument to assess the ability to manage daily oral hygiene and the cause of impaired oral hygiene. The instrument is initially aimed for use by the dental team in the ageing population. BACKGROUND: Oral hygiene is an important component of oral health. Inability to manage oral hygiene combined with other risk factors often results in poor oral health and impaired quality of life. METHODS: A guideline for instrument development was used during the construction of the instrument. The method included three phases: I. planning: the purpose and target group of the instrument were determined, and a literature review and qualitative focus-group study were conducted; II. construction: objectives were formulated, and a pool of items was built; and III. evaluation and validation, which included two pilot studies, interviews, item analyses and revision of the instrument. RESULTS: The planning and construction phases resulted in an instrument with 47 items comprising three parts: (a) interview, (b) clinical examination and (c) observation of activities of daily living (oral hygiene). After two pilot studies, the instrument was found to have good content validity. Analyses of qualitative and quantitative data resulted in a reduction in the number of items to 33. CONCLUSION: OHAI can be a valuable tool as a preventive method to identify older adults at risk of impaired oral health. However, the instrument needs further evaluation before wider use.

Swedish Quality Registry for Caries and Periodontal Diseases - a framework for quality development in dentistry.

OBJECTIVES: There is a need for monitoring dental health and healthcare, as support for quality development, allocation of resources and long-term planning of dental care. The aim of this paper is to describe the concept and implementation of the Swedish Quality Registry for Caries and Periodontal Diseases (SKaPa). MATERIALS AND METHODS: The SKaPa receives information by automatic transfer of data daily from electronic patient dental records via secure connections from affiliated dental care organisations (DCOs). The registry stores information about DCOs, dental professionals and patients. Information on a patient level includes personal identifier, gender, age, living area, dental status, risk assessments for caries and periodontitis, and dental care provided. In addition, data generated from a global question on patient-perceived oral health are uploaded. In total, more than 400 variables are transferred to the registry and updated daily. RESULTS: In 2018, all of the 21 public DCOs and the largest private DCO in Sweden were affiliated to SKaPa, representing a total of 1,089 public and 234 private dental clinics. The accumulated amount of information on dental healthcare covers 6.9 million individuals out of the total Swedish population of 10 million. SKaPa produces reports on de-identified data, both cross-sectional and longitudinal. CONCLUSION: As a nationwide registry based on automatic retrieval of data directly from patient records, SKaPa offers the basis for a new era of systematic evaluation of oral health and quality of dental care. The registry supports clinical and epidemiological research, data mining and external validation of results from randomised controlled trials.

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.

Discontinued dental attendance among elderly people in Sweden.

AIM: Our objective was to study the loss of dental attendance and a possible age trend among patients aged ≥65 years in Sweden. Regular dental check-ups are considered to be an important factor in maintaining oral health. Approximately 80% of the adult population in Sweden are enrolled in a regular check-up system; however, dental practitioners often find that older patients attend fewer check-ups. Old people may naturally lose contact with dental services as they move to special housing or die. In this systematic study, these factors were investigated and used as exclusion criteria. MATERIALS AND METHODS: Data were collected for all patients (n = 4759) aged 65 or older from the electronic journal system in 3 large public dental clinics in 3 communities. Their dental records for the years 2004-2009 were studied longitudinally by 1 person at each clinic; 1111 patients were excluded (patients died during study period, wanted emergency care only, obtained special dental care allowance, moved from the community or moved to special housing, or left the clinic for another caregiver). The statistical analyses were performed using the Statistical Package for the Social Sciences version 21 (IBM). RESULTS: Of the 3648 patients (1690 men and 1958 women) included in the study, 13% lost contact with their dental service over the course of the study (10% of those were aged 65-79 and 21% ≥80). The decrease in regular dental contact had a statistically significant association with increasing age (P < 0.001). CONCLUSION: A considerable number of older people living independently or with moderate supportive care in their own homes lost contact with dental service despite enrolment in a recall system.

Can costs of screening for hypertension and diabetes in dental care and follow-up in primary health care be predicted?

AIM: The purpose was to assess the direct costs of screening for high blood pressure and blood glucose in dental care and of follow-up in primary health care and, based on these data, arrive at a prediction function. Study population. All subjects coming for routine check-ups at three dental health clinics were invited to have blood pressure or blood glucose measurements; 1,623 agreed to participate. Subjects screening positive were referred to their primary health care centres for follow-up. METHODS: Information on individual screening time was registered during the screening process, and information on accountable time, costs for the screening staff, overhead costs, and analysis costs for the screening was obtained from the participating dental clinics. The corresponding items in primary care, i.e. consultation time, number of follow-up appointments, accountable time, costs for the follow-up staff, overhead costs, and analysis costs during follow-up were obtained from the primary health care centres. RESULTS: The total screening costs per screened subject ranged from €7.4 to €9.2 depending on subgroups, corresponding to 16.7-42.7 staff minutes. The corresponding follow-up costs were €57-€91. The total resource used for screening and follow-up per diagnosis was 563-3,137 staff minutes. There was a strong relationship between resource use and numbers needed to screen (NNS) to find one diagnosis (P < 0.0001, degree of explanation 99%). CONCLUSIONS: Screening and follow-up costs were moderate and appear to be lower for combined screening of blood pressure and blood glucose than for separate screening. There was a strong relationship between resource use and NNS.

Efficacy of screening for high blood pressure in dental health care.

BACKGROUND: There is consensus on the importance of early detection and treatment of high blood pressure. Dental care is one of few medical services to which a considerable proportion of the general population comes for regular check-ups. We tested the effects of blood pressure screening in dental care centres with subsequent work-up of subjects screening positive in primary health care (PHCC). METHODS: Altogether 1,149 subjects 40-65 years old or 20-39 years old with body mass index >25, and with no previously known hypertension, who came for a dental examination had their blood pressure measured with an Omron M4® automatic blood pressure reading device. Subjects with systolic blood pressure readings above 160 mmHg or diastolic above 90 mmHg were referred to their PHCC for a check up. Outcome data were obtained by scrutiny of PHCC and hospital patient records for hypertension diagnoses during the three years following screening. RESULTS: 237 (20.6%) subjects screened positive. Of these, 230 (97.1%) came to their PHCC within the 3-year follow-up period, as compared with 695 (76.2%) of those who screened negative (p < 0.0001). Of those who screened positive, 76 (32.1%) received a diagnosis of hypertension, as compared with 26 (2.9%) of those who screened negative. Sensitivity was 79.1%, specificity 84.8% and positive predictive value 30.1%. The number of subjects needed to screen to find one case of hypertension was 18. CONCLUSIONS: Co-operation between dental and primary care for blood pressure screening and work-up appears to be an effective way of detecting previously unknown hypertension.

Clinicians' preventive strategies for children and adolescents identified as at high risk of developing caries.

BACKGROUND: Clinicians handle diagnosis and treatment planning of caries in different ways, and the underlying factors leading to management of risk and choice of treatment strategies are poorly understood. AIM: The aim of this study was to investigate dentists' and dental hygienists' choices of preventive strategies for children and adolescents identified as at high risk of developing caries. DESIGN: A sample of dental records from 432 of a total of 3372 children in a Swedish county identified as at high risk of developing caries, aged 3-19 years, was randomly selected for analysis in the study. Information of importance for the therapists' choice of caries management strategies were obtained from the dental records. RESULTS: The results showed that therapists considered tooth brushing instruction and fluoride treatment at the clinic to be of primary importance as treatment given in 60% of the cases, respectively. Fluoride treatment at home and diet counselling were both chosen in half of the cases. Fissure sealant therapy was used in 21% of the cases, and 15% of the patients did not receive any preventive treatment at all. The results also showed that girls more often received fluoride treatment, tooth brushing instruction and oral hygiene information than boys. CONCLUSIONS: In the majority of the children and adolescents, several preventive measures were given. The more background factors included in the risk assessment, the more preventive measures were given. The differences between the treatments given to girls and the boys need to be further investigated.

Strategies for caries risk assessment in children and adolescents at public dental clinics in a Swedish county.

BACKGROUND: Since caries prevalence has decreased and become polarized, high-risk preventive strategies have been widely adopted. The underlying factors leading to assessment and management of caries risk are poorly understood. AIM: The aim of this study was to identify the factors forming the basis for dentist's caries risk assessment in dental care for children and adolescents. DESIGN: From all 3372 children in a Swedish county identified as at high risk for developing caries, a sample of dental records from 432 children, aged 3-19 years, were randomly selected to be analysed in the study. Information about medical and social history, dental status, dietary habits, oral hygiene, and salivary data was obtained from the records. RESULTS: The results show that the only data registered in the majority of the dental records were dental status from the clinical examination and bitewing radiographs. In approximately half of the dental records, medical history and data concerning oral hygiene were registered. Dental history and dietary habits were noted in approximately 25% of the dental records, whereas other risk factors/indicators were occasionally registered. CONCLUSIONS: Dentists mainly base their caries risk assessments on past caries experience, a reliable risk indicator for assessing the risk of being affected by caries again. In children with no experience of caries, knowledge of other risk factors/indicators needs to be available to perform a caries risk assessment. In this study, documentation of such knowledge was strongly limited.

Association between high blood pressure and deep periodontal pockets: a nested case-referent study.

A hypertension screening project was performed jointly at a dental clinic and a primary health care centre. In this report the hypothesis that there is an association between high diastolic blood pressure and deep periodontal pockets was tested. A total of 1,239 consecutive patients aged 35-65 years had their blood pressure measured before the dental examination or had a known hypertension. Information on medical history and tobacco use was obtained by interview and dental status was recorded. Fifty-four subjects had known hypertension and 141 had previously unknown diastolic blood pressure >90 mmHg (cases). For each case an age, sex and tobacco-use matched referent was chosen from those with diastolic blood pressure < or =90 mmHg. Significantly more cases than referents had periodontal pockets > or = 5 millimeters deep. In multivariate analyses the prevalence of deep periodontal pockets was associated with blood pressure status also after adjustment for the small differences between the groups in age, sex, tobacco use and number of teeth. In conclusion there was an association between diastolic blood pressure and prevalent deep periodontal pockets. Whether the relationship is a causal one remains to be explored. Screening for high blood pressure at regularly visits at the dental clinic may give the dental care a new important role in the public health field.

A 20-year study of dentists' and dental hygienists' assessment of dental caries lesions in bite-wing radiographs.

Epidemiological data reveal that the prevalence of dental caries in western countries has decreased in recent decades. The aim of this study was to investigate how dentists and dental hygienists assess dental caries lesions in bite-wing radiographs between 1983 and 2003. All dentists and dental hygienists in Public Dental Health in Uppsala County were offered to take part in the study. The participants assessed manifest and initial caries lesions in eight bite-wing radiographs from three patients individually. An X-ray viewer and binoculars were used. The assessments were repeated in the same radiographs every five years, a total of five times, between 1983 and 2003. In the different test occasions 80-103 dentists and 11-48 dental hygienists participated. The registration of dental caries changed between 1983 and 2003. The number of manifest lesions registered by dentists decreased between 1983 and 1988, but were stable after 1988. Dental hygienists showed no changes in the registration of manifest lesions during the study. Initial lesions registered by dentists and dental hygienists increased between 1988 and 1998. Assessments of initial caries lesions displayed a wider range than manifest lesions. Increasing age and more years in the profession resulted in fewer registered initial caries lesions. Dental hygienists had a tendency to register less caries than dentists. In conclusion, the result of the study indicate that inclusion of initial caries lesions in epidemiological reports should lead to a reduction in reliability. The changes in assessments of manifest caries lesions that took place in the 19805s should be considered when epidemiological data are evaluated.

High mercury emissions from dental clinics despite amalgam separators.

Mercury (Hg) as amalgam has been used as a dental filling material for more than 150 years. Thereby, dentists and their patients have been directly exposed to Hg, and the public and the environment indirectly exposed via Hg emissions from incinerators and Hg in waste water from households and dental clinics. Due to the toxic properties of Hg and bioaccumulation in biota of Hg emitted via dental clinic waste water, amalgam separators were introduced in Sweden in the 1980s. Although these amalgam separators in the certification process are required to remove at least 95% of incoming Hg in a standardized laboratory test, their efficiency in practical use has not been properly investigated. Here we present actual Hg emissions via waste water from 12 dental clinics equipped with the same type of amalgam separator based on sedimentation. All waste water was collected for four consecutive working days, initially at ordinary operating conditions and a second time after a thorough revision and cleaning of the discharge system. The results indicate that mercury emissions from dental clinics can be reduced by an improved design of the discharge system, a sensible use of high pressure water cleaning, and regular maintenance, including replacement of amalgam separators and filters at certain intervals. The study also indicates that banning Hg in dentistry is the one long-term way to stop Hg emissions from dental amalgam.

Mercury recovery in situ of four different dental amalgam separators.

Amalgam separators are used to physically remove dental amalgam from waste water in dental clinics. They are thereby supposed to reduce mercury (Hg) emissions to the municipal waste water system to acceptable levels. We here present results from a comparative study in situ of three amalgam separators available on the market, all with a claimed efficiency of 99% according to Danish and ISO protocols, and using sedimentation as the principle of separation. We also present corresponding data for an investigational prototype of an improved separator. The obtained efficiency of the three commercial separators is far below what is stated by the manufacturer and by authorities assumed to be the efficiency in clinical conditions. They reduced Hg emissions by 79 - 91%, leaving an average Hg content in outgoing waste water of 1.5 mg L(-1). However, the prototype separator participating in this study retained 99.9% of the waste water Hg emissions, leaving an average Hg content in outgoing waste water of 0.004 mg L(-1). Physical restrictions prohibit sedimentary type separators to recover the Hg fractions causing the largest damages in wastewater treatment plants. This fraction is not considered in the ISO protocol for testing amalgam separators, which therefore needs to be revised. Abolishing the use of dental amalgam and cleaning the tubing systems is the most efficient long-term solution to reduce Hg emissions from dental clinics. Until then, Hg emissions originating from placing, polishing or removing existing amalgam fillings, should be counteracted by the use of low-emission amalgam separators, already on the market or presently being developed for use alone or together with sedimentary type amalgam separators.

Oral retention of fluoride from a mucosa adhesive paste (Orabase) supplemented with NaF--a pilot study.

PURPOSE: Individuals with cognitive impairments have an increased caries risk. Methods to prevent caries based on home care use of fluorides (F) presuppose a person's ability to cooperate and follow instructions. The aim of the present investigation was therefore to develop and evaluate an F-containing mucosa adhesive paste, which can be applied in home care by nursing staff. MATERIALS AND METHODS: A cross-over, double-blind study design was used. The F concentrations were studied in whole saliva and interproximal fluid samples after application of a paste with 0.1% F based on the mucosa adhesive Orabase. A placebo product without F was used as control. In six healthy adults the paste was applied before sleep in the vestibulum in the region of the first molar in each quadrant. The application was repeated during four nights. RESULTS: Six hours after the application of the F paste the F concentrations in the interproximal areas and whole saliva had increased by 12-160 times compared to samples collected before the applications. The lower increase of the interproximal F concentrations was observed in the front region. CONCLUSIONS: The results suggest that an F-containing mucosa adhesive paste may be a promising vehicle for caries prevention in subjects unable to follow traditional home care recommendations.

Move of adults with intellectual disability from institutions to community-based living: changes of food arrangements and oral health.

The policy of deinstitutionalisation, integration and increased independence for individuals with intellectual disability has been accepted in the western part of the world. The aim of the present study was to evaluate the changes in oral health and eating arrangements when intellectually disabled persons move from an institution to integrated living. In 55 subjects the incidence of caries and tooth mortality was compared 4.7 years before and after the change in living arrangements. In addition, changes in oral hygiene routines, eating arrangements and weight were registered. The incidence of caries and tooth mortality was low among individuals with severe and moderate intellectual disability during 4.7 years before as well as after de-institutionalisation, and no differences could be observed between the periods. After 4.7 years of integrated living, 40% of the subjects were estimated to have gained weight. Among those subjects with an estimated decreased weight (13%), the caries incidence was higher compared to other subjects with intellectual disability. Participation in grocery shopping and cooking increased in the integrated living. The increase in weight suggests an impact on general health after almost 5 years of integrated living. No indications of a corresponding influence on oral health in individuals with severe or moderate intellectual disability could be observed after deinstitutionalisation. However, oral health in weight-losing subjects need further investigations.