Dental caries prevalence and dental care utilization among the very old.

BACKGROUND: This article reports on coronal and root caries prevalence and dental care utilization patterns of elderly Iowans aged 79 years or older. METHODS: The sample for this study was 449 people who were surviving members of the Iowa 65+ Rural Health Study cohort originally recruited in 1981. The authors focused their analyses on the 342 of these who were dentate. Examinations were conducted in subjects' homes by trained and calibrated examiners, using a halogen headlight, a mouth mirror, a color-coded periodontal probe and a no. 23 explorer. RESULTS: The mean age of subjects was 85.1 years (range 79-101 years), and they had a mean of 19.4 remaining teeth. Nearly all subjects (96 percent) had coronal decay experience, while 23 percent of the subjects had untreated coronal decay, about one-fourth of which was recurrent. Nearly two-thirds (64 percent) of the sample had root caries experience, with 23 percent having untreated root caries. Utilization of dental services was high among the dentate elderly, with nearly three-quarters reporting having visited a dentist within the past year. Nearly all reported that they paid for dental care themselves with no third-party coverage. CONCLUSIONS: The findings from this study of the very old suggest that coronal and root caries remain prevalent, with high levels of dental care utilization among those who have retained natural teeth. CLINICAL IMPLICATIONS: As the U.S. population ages, and more teeth are retained, demand for dental services in the population of the oldest elderly people is likely to increase.

Comparison of three salivary flow rate assessment methods in an elderly population.

Measuring salivary flow rates among the frail elderly is a challenge. The currently used spit collection method requires levels of time and cooperation that often may exclude the frail elderly who are at high risk for salivary compromise. A measurement method that is not only valid and reliable, but also feasible and acceptable is needed for use in population studies of compromised adults. This study compared two salivary flow rate assessment methods using a suction machine against the currently accepted spit collection method in an elderly population aged 75 and older. Three methods of flow rate (g/min) assessment were compared at three time periods among 16 elders (mean age 86.6 years). Flow rates using the 2-min open suction method compared well with the 10-min spit method (r=0.778) but the 2-min closed suction method did not (r=0.158). Reliability evaluation of the open suction method and the spit method was assessed using a test/retest with a 1-week interval. Both methods demonstrated good comparable reliability (spit method r=0.566, P=0.01); open suction method, (r= 0.861, P<0.01). Based on a short survey questionnaire about the three methods, 11 of the 16 elderly subjects preferred the use of the suction machine to the spit method. These results indicate that the 2-min open suction method technique is a valid and reliable means of measuring salivary flow. The lower level of patient cooperation needed, the shorter time period required, and this preliminary report of its acceptability support the use of this method in future population studies of frail elders.

Factors related to decisions to extract or retain at-risk teeth.

OBJECTIVES: Decisions to extract a tooth may be among the most critical in dentistry. The aim of this study was to prospectively investigate both clinical and nonclinical factors related to decisions to extract or retain teeth in private general dental practice. METHODS: A convenience sample of 196 Iowa dentists in private general dental practice reported on 549 cases where decisions were made to extract or retain teeth as they occurred in their practices during a one-month period in May 1997. Bivariate and multivariate analyses were used to identify factors that differentiated between cases where a tooth (or teeth) was extracted and cases where an at-risk tooth was retained. RESULTS: Of the 549 cases, 67 percent involved extraction, while the remainder involved alternatives to extraction. In comparing extraction cases to alternative treatment cases, we excluded 150 extraction cases because dentists reported that no alternative to extraction was available. Using Generalized Estimating Equations (GEE), we identified cost of treatment, presence of tooth mobility, poor prognosis of alternative treatment, and presence of gross caries as significant factors associated with extraction, while previous treatment of the tooth and concerns with patients' health were significantly associated with alternatives to extraction. CONCLUSIONS: For teeth at risk for extraction, cost, substantial periodontal disease, and several clinical factors were predictive of extraction.

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.

The accuracy of tooth loss data collected by nurses.

This paper reports on the accuracy of tooth counts conducted in 22 subjects by 10 trained nurses as part of a large longitudinal study of a pharmacological agent. These nurses participated in a training course consisting of seminars, discussion, demonstrations, and practice examinations. Each of the nurses then counted the teeth of 22 subjects and recorded their findings independently. The counts of the nurses were compared with those of the dentists to assess the accuracy of the nurses' counts. We found that nurses and dentists were in perfect agreement for 86% of the patient counts conducted. Individual nurses' levels of agreement with dentists ranged from 73% to 100%, with pairwise kappa statistic values ranging from 0.70 to 1.00. In addition, both Pearson correlation and interclass correlation measures exceeded 0.98 for every comparison of dentist and nurse counts. The results of this study suggest that training nondental health care workers may be an accurate and low-cost way of obtaining tooth loss data and other oral health measures, particularly when oral health data are collected as part of larger, multi-disciplinary studies.

Dental treatment outcomes among dentate nursing facility residents: an initial study.

This investigation used retrospective methodology to examine the outcomes of previous dental treatment and the incidence of developing restorative and extraction needs, including dental caries, among nursing facility residents. Data were taken from treatment records of 48 dentate residents in 10 nursing facilities who received comprehensive dental treatment delivered through the Geriatric Mobile Unit (GMU) program operated by the University of Iowa College of Dentistry and were examined an average of 2.9 years after initial examination. Residents had a mean age of 84 years at the second exam, and 90% were female. About 18% of all previously placed restorations needed to be replaced, and an additional 11% of teeth that received a restoration needed to be extracted at follow-up. At follow-up, nearly 70% (33/48) of residents needed restorative care, while 44% (21/48) needed extractions. The mean incidence of teeth developing new treatment needs between the two visits was 2.7 teeth/person (14.9% of teeth) for restorative need and 1.1 teeth/person (6.6% of teeth) for extraction need. Results suggest that successful treatment outcomes can be achieved for nursing facility residents, but that dental disease and treatment needs develop at a high rate among these residents.

Medical conditions associated with missing teeth and edentulism in the institutionalized elderly.

Several studies have reported the prevalence of medical conditions or investigated the relationships between the oral health status and general health conditions in the elderly. However, the relationship between medical conditions and oral health among the elderly is not well-described. Previous studies have not clearly identified a consistent association between medical conditions and oral health, specifically edentulism and tooth loss. The purpose of this study was to investigate the relationships between medical conditions and oral health, as assessed by edentulism and missing teeth, in an institutionalized elderly population. A systematic sample (n = 175), stratified by age and sex, was drawn from nursing home patients treated by the University of low' as Geriatric Mobile Unit (GMU) team. Data were extracted from GMU dental records, regarding history of medical conditions, medications, dental history, dentate status, and tooth-by-tooth conditions. Mean numbers of missing teeth were significantly higher among those who had a history of atherosclerotic vascular disease, heart failure, ischemic heart disease, and joint disease. Subjects who had a history of atherosclerotic vascular disease, heart failure, ischemic heart disease, and joint disease were more likely to be edentulous than subjects who did not have a history of those diseases. The biological basis for these relationships between dentate status and systemic medical conditions is unclear and warrants further study.

Geriatric patient simulations for dental hygiene.

The rapidly increasing number of this country's elderly requires that dental hygiene students practice the clinical problem-solving skills of information gathering, assessment, and treatment applied to geriatric patients. Computer-based simulations are purported to provide this experience, but little research has been completed with simulations in the education of dental hygienists. This paper summarizes the process used to design, develop, and evaluate a series of eighteen computer-based geriatric simulated patients. It contains a brief description of the simulations and a description of the design, validation, authoring, and formative evaluation phases. The paper also describes the summative evaluation, provides implementation suggestions, and summarizes future directions. The summative evaluation, conducted at four institutions, suggests that computer-based simulations are an effective instructional method as measured by pre/post-tests. The results suggest that simulations can provide a standardized set of geriatric patient experiences. These simulations may prove especially valuable at institutions that are unable to provide clinical geriatric experiences or lack the expertise to conduct a didactic course in geriatrics.

First-molar caries experience among Taiwanese first-grade children.

Evidence suggests that dental caries levels may have risen dramatically among Taiwanese children during the past twenty years. Accurate and consistent methods of assessing the dental caries in Taiwanese children, however, have not been widely employed. This project assessed, in detail, the caries status of 333 first grade children attending four schools in Taiwan. Mean DMFS and DMFT computed solely from first-molar data for these children were 1.46 and 1.19, respectively. Mean DMFS for females was 1.57, while for males it was 1.35. Overall, 48 percent of the children were caries-free in their permanent first molars. Nearly 90 percent of DMF was "decayed," while the remainder was "filled." Children from families in lower socioeconomic status (SES) categories had significantly higher mean DMFS than did higher SES children. Results suggest that caries prevention and dental treatment programs should be developed or enhanced to reduce the caries problem among Taiwanese children, particularly those at high risk.

Medical and functional status changes among nursing facility residents: implications for dentistry.

This paper reports the results of a study that investigated changes in the medical and functional status of nursing facility residents over a 2.9 year period. Sixty-seven residents from 10 nursing facilities were included in the study, which demonstrated that the resident's medical and functional status deteriorated during this period. These changes adversely affected the residents' ability to receive recommended dental treatment, suggesting that early, definitive, and often aggressive treatment approaches be used in providing services to these individuals.

Factors influencing the future need for treatment of root surfaces.

This paper discusses the current status of root surface caries in the elderly population and the need for treatment of this condition in the future. Although root surface exposure and root caries have been reported for adults at all ages, the people at greatest risk for these conditions are the elderly. In the United States, life expectancy and the population aged 65 years and older has increased substantially, and the proportion of the elderly population who are dentate has increased and is projected to increase further. Utilization of dental services by the elderly is similar to that of employed adults. Interpretation of studies of the prevalence and incidence of root surface caries are difficult due to differences in sampling, definition of lesions, and reporting conventions. Root surface caries prevalence is related to age and continues to be a significant problem for this population as they age. Factors that may affect the future need for treatment are explored.

Factors related to acceptance of dental treatment services in a nursing home population.

This study reports on factors related to acceptance of restorative, oral surgery, and prosthodontic dental treatment services by a population of nursing home residents. Lower cost treatment plans and eligibility for Medicaid benefits were associated with acceptance of all treatment, and for the categories of oral surgery and prosthodontic services. Acceptance of routine restorative procedures was more strongly associated with female residents. It is concluded that financial concerns appear to pose the greatest barrier in providing dental treatment services to nursing home residents.

Family member and guardian acceptance of dental services for nursing home residents.

The decision to utilize dental treatment often rests with a nursing home resident's family member or guardian, and factors associated with family member/guardian acceptance of dental services for residents have not been identified. This paper reports the results of a study which found that nearly 66% of nursing home residents' next of kin identified themselves as being primarily responsible for making health care decisions for the residents. Among these 109 resident/next of kin pairs, utilization of dental services by the residents was associated with younger next of kin, next of kin with higher levels of education, and next of kin who perceived dental need for the resident. In addition, residents who were female, physically mobile, not mentally alert, dentate, and had fewer years of education had dental services accepted for them at a higher rate than did residents who were male, physically immobile, alert, edentulous, or had more years of education. Findings suggest that more effort should be directed at educating the next of kin of nursing home residents in the value of dental care among the elderly.

Five-year incidence of tooth loss in Iowans aged 65 and older.

The prevalence of missing teeth has been described for US adults, but little is known about the incidence of tooth loss in any segment of the population. This study investigated the 5-yr incidence of tooth loss in a random sample of Iowans aged 65 yr and older residing in two rural counties. These people had an average of 20 teeth at baseline and approximately 40% lost at least one tooth in the subsequent 5 yr. The incidence of tooth loss was highest for mandibular molars and lowest for mandibular canines. Men were more likely than women to lose teeth. Although we were able to identify a number of statistically significant potential risk factors for tooth loss, the multivariate models that incorporated all these factors were not good predictors of which people were at highest risk for tooth loss.

Incidence of tooth loss among elderly Iowans.

This study investigated the 18-month incidence of tooth loss in a random sample of 451 dentate noninstitutionalized Iowans aged 65 and older residing in two rural counties. They had a mean of 19.0 teeth at baseline and lost an average of 0.4 teeth during the subsequent 18 months. Twenty-one per cent of the population lost at least one tooth. Four people had all their teeth extracted. Of the teeth present at baseline, 1.9 per cent subsequently were extracted. The highest incidence of tooth loss occurred among mandibular molars (3.7 per cent), followed by maxillary premolars and canines (3.1 per cent each). The best predictors of tooth loss were previous coronal and root caries.

Incidence of coronal and root caries in an older adult population.

Incidence rates for new root caries and new coronal caries in noninstitutionalized older adults are unknown. In this study, a representative sample of 451 elderly Iowans received dental examinations at the start of the study and again after 18 months. This dentate cohort had a mean of 0.87 new surfaces of coronal decay per person per year and a mean of 0.57 new surfaces of root decay per person per year. Coronal caries occurred at an annual rate of 1.4 surfaces per 100 susceptible coronal surfaces. Root caries occurred at an annual rate of 2.6 surfaces per 100 susceptible root surfaces. This study shows that both coronal and root caries were active in this older population, indicating a need for emphasis on the prevention and treatment of dental caries in older adults.