Observational study of selective screening for prediabetes and diabetes in a real-world setting: an interprofessional collaboration method between public dental services and primary health care in Sweden.

OBJECTIVE: Describe a method in a real-world setting to identify persons with undiagnosed prediabetes and type 2 diabetes through an interprofessional collaboration between Public Dental Services and Primary Health Care in Regions Stockholm. DESIGN: A descriptive observational study. SETTING: The study was conducted at seven sites in the region of Stockholm, Sweden. Each collaborating site consisted of a primary health clinic and dental clinic. SUBJECTS: Study participants included adults over 18 years of age who visited the Public Dental Services and did not have a medical history of prediabetes or type 2 diabetes. MAIN OUTCOME MEASURES: Selective screening is conducted in accordance with a risk assessment protocol at the Public Dental Services. In the investigated method, DentDi (Dental and Diabetes), adults diagnosed with caries and/or periodontitis over a cut-off value are referred to the Primary Health Care clinic for screening of prediabetes and type 2 diabetes. RESULTS: DentDi, introduced at seven sites, between the years 2017 and 2020, all of which continue to use the method today. A total of 863 participants from the Public Dental Services were referred to the Primary Health Care. Of those 396 accepted the invitation to undergo screening at the primary health care centre. Twenty-four individuals did not meet the inclusion criteria, resulting in a total of 372 persons being included in the study. Among the 372 participants, 27% (101) had elevated glucose levels, of which 12 were diagnosed with type 2 diabetes and 89 with prediabetes according to the study classification. CONCLUSIONS: DentDi is a feasible method of interprofessional collaboration where each profession contributes with the competence included in everyday clinical practice for early identification of persons with prediabetes and type 2 diabetes with a complete chain of care. The goal is to disseminate this method throughout Stockholm County and even other regions in Sweden.

Type 2 diabetes and poor oral health have a bidirectional association. The number of persons with undetected prediabetes and type 2 diabetes is high and rising globally.Through collaboration between Public Dental Services and Primary Health Care we have developed a feasible and novel method of selectively screening for prediabetes and type 2 diabetes in a real-world setting.By utilizing everyday practice within each discipline, this method has been implemented at seven sites in Region Stockholm.From the original number of 863 participants referred from the Public Dental Services to Primary Health Care 396 attended the medical screening. After excluding 24 participants, a total of 372 participants underwent screening for prediabetes and type 2 diabetes.The results of this study showed that almost 30% who were screened for prediabetes and type 2 diabetes had elevated blood glucose levels.

Orofacial dysfunction after stroke-A multidisciplinary approach.

OBJECTIVE: This paper describes the study protocol in an ongoing clinical trial evaluating oral screen training as part of a post-stroke rehabilitation programme. Baseline data were related to four domains: dysphagia, lip function, masticatory performance and patient-related outcome measures (PROM). BACKGROUND: Stroke is one of the most common causes of disability-adjusted life years, and dysphagia is a common remaining problem after stroke. Rehabilitation using oral screen training has been suggested to improve swallowing, but evidence is still insufficient. MATERIALS AND METHODS: Patients diagnosed with stroke with persisting objective and/or subjective swallowing dysfunction after primary rehabilitation were assessed for eligibility. In total, 25 patients were included. Objective function was assessed by swallowing capacity test (SCT), lip force and masticatory performance, subjective function by EAT-10 and NOT-S and PROM by LiSat-11 and ESAS. RESULTS: Baseline data presented a heterogeneous pattern with no significant association between objective and subjective dysfunction. Most of the participants (20/25) showed impaired swallowing capacity in SCT, and 23/24 revealed orofacial dysfunction according to NOT-S. The most common subjective item reported was chewing and swallowing problems (19/24). CONCLUSION: The heterogenous findings in the included tests and the lack of correlations emphasise the importance of multidisciplinary approaches to identify objective and subjective orofacial post-stroke dysfunction in clinical practice to be able to offer evidence-based individualised care. The included participants were representative of stroke patients with dysphagia, which supports proceeding with the planned intervention.

White matter abnormalities mediate the association between masticatory dysfunction and cognition among older adults.

BACKGROUND: Masticatory parameters, such as reduced number of teeth and posterior contacts, have been shown to be associated with reduced cognitive status. The underlying mechanisms that affect these associations, are however, not well understood. OBJECTIVES: The study aims to investigate the association between masticatory dysfunction and cognition and explore the mediating effect of brain structure. METHODS: In this cross-sectional study, 45 older adults with subjective masticatory dysfunction (mean age 72.3 ± 4.0 years) were included. Mini-Mental State Examination score <25, brain trauma, neurological disease, neurodegenerative disorders, depression or poor Swedish language skills were criteria for exclusion. Cognitive functions (executive function and episodic memory) and masticatory dysfunction defined by functional occluding status (FOS; the number of occluding units and number of remaining teeth) were analysed with partial correlation models. Structural magnetic resonance imaging was performed on 28 feasible participants. Multiple regression analyses were performed to evaluate the predictive value of brain structure and white matter hypointensities (WM-hypo) on cognitive functions. A mediation analysis was applied to assess significant predictor/s of the association between FOS and cognition. RESULTS: Both episodic memory and executive functions were positively correlated with FOS. WM-hypo predicted cognitive status (executive function, p ≤ .01). WM-hypo mediated 66.6% (p = 0.06) of the association between FOS and executive functions. CONCLUSION: Associations between FOS and cognitive functions are reported, where FOS, a potential modifiable risk factor, was related to both episodic memory and executive functions. The mediating effect of WM-hypo on the association between FOS and executive functions highlights the impact of the vascularisation of the brain on the link between mastication and cognition. The present study provides increased knowledge that bridges the gap between masticatory dysfunction and cognition.

Patients' thoughts about assessment of fracture risk in a dental setting using FRAX-a qualitative interview study.

FRAX is a tool based on questions that identifies persons at risk of fragility fractures. We interviewed patients about their thoughts on doing FRAX in a dental setting. They were generally positive but had some concerns that need to be considered before introducing FRAX in a dental setting. PURPOSE: To investigate patients' thoughts about assessing the risk of fragility fractures using the FRAX tool in a dental setting. Sweden has a high incidence of fragility fractures, but many of these are preventable. The most common method for identifying persons with a high risk of sustaining fragility fractures is FRAX, a validated instrument for assessing the risk of suffering fragility fractures within 10 years. In the Nordic countries, most of the adult population has regular contact with their dentist, which could be useful in identifying high-risk individuals. METHODS: A qualitative inductive approach to content analysis, with individual semi-structured interviews, was used. Seven women and three men, aged 65-75 years, were interviewed and assessed with FRAX. RESULTS: An overarching theme was that patients considered a FRAX assessment in the dental setting a good service but doubted that the dentists would have the interest, time, and knowledge to do it. The patients had little knowledge and experience of osteoporosis and fragility fractures. They were positive towards assessing the fracture risk with the FRAX instrument. If they were found to have a high fracture risk, they expected the dentist to send a referral for further investigation and to collaborate in the risk assessment with their family physician. They thought risk assessment in a dental context would be a good service if the fee was the same as that in primary care. CONCLUSION: Most participants were positive about having FRAX and other health assessments done in the dental clinic, but this study shows that patients have concerns that need to be addressed before introducing FRAX in this context.

The Effect of Domiciliary Professional Oral Care on Root Caries Progression in Care-Dependent Older Adults: A Systematic Review.

With care dependency, untreated root caries lesions (RCLs) and irregular dental visits are common. RCLs, if left untreated, could lead to pain, tooth loss, difficulties eating, and impact on general health. Therefore, there is a need for prevention and effective treatment for RCLs, and especially in those with care dependency. The aim of this systematic review was to investigate the effect of domiciliary professional oral care on root caries development and progression, in comparison with self-performed or nurse-assisted oral care. A literature search was conducted in four databases in November 2022. Two authors independently screened the literature throughout the review process. Five of the identified studies were found to be relevant. Four of these were assessed as having moderate risk of bias and were included in the review, while one study had high risk of bias and was excluded from further analyses. Due to heterogenicity of the included studies (and of the interventions and outcomes), no meta-analysis or synthesis without meta-analysis (SWiM) was performed. The participation of dental personnel performing mechanical plaque removal and fluoride, or chlorhexidine application seems beneficial for care-dependent older adults with risk of RCLs development and progression. However, future studies are needed.

Dental health of patients with X-linked hypophosphatemia: A controlled study.

Objective: The present study compared the dental health of patients with X-linked hypophosphatemia (XLH) with healthy age- and gender-matched controls to increase our knowledge of the impact of XLH on oral health. Materials and methods: Twenty-two adult patients with XLH in the Stockholm region of Sweden were referred to the Department of Orofacial Medicine at Karolinska Institutet for an extended clinical and radiological examination. Pre-existing radiologic examinations of 44 healthy age- and gender-matched controls were retrieved from the Department of Oral Radiology, at Karolinska Institutet. Results: The 22 patients with XLH (15 females, median age 38 years, range 20-71; 7 males, median age 49 years, range 24-67) had a significantly higher number of root-filled teeth compared to healthy controls (p = .001). In the XLH group, females had significantly better oral health than males, especially concerning endodontic and cariological status (p's = .01 and .02, respectively). Periodontal status differed non-significantly between the XLH and control groups. Conclusion: Patients with XLH had a significantly lower oral health status compared to a healthy population especially concerning endodontic conditions. Male patients with XLH had a higher risk of poor oral health compared to female patients with XLH.

Long term association of hip fractures by questions of physical health in a cohort of men and women.

We do not know if fracture predicting factors are constant throughout life, if they can be assessed earlier in life, and for how long. The aim was to study the association between questions about health status and mobility and fragility fractures in a cohort during a 35-year follow-up. A cohort of 16,536 men and women in two age groups, 26-45 and 46-65 years old, who answered five questions of their physical health status in postal surveys in 1969-1970. We obtained data on hip fractures from 1970 to the end of 2016. We found most significant results when restricting the follow-up to age 60-85 years, 35 for the younger age group and 20 years for the older. Men of both age groups considered "at risk" according to their answers had a 2.69 (CI 1.85-3.90)- 3.30 (CI 1.51-7.23) increased risk of having a hip fracture during a follow-up. Women in the younger age group had a 2.69 (CI 1.85-3.90) increased risk, but there was no elevated risk for women in the older age group. This study shows that questions/index of physical health status may be associated with hip fractures that occur many years later in life, and that there is a time span when the predictive value of the questions can be used, before other, age-related, factors dominate. Our interpretation of the results is that we are studying the most vulnerable, who have hip fractures relatively early in life, and that hip fractures are so common among older women that the questions in the survey lose their predictive value.

Prevalence of ongoing or previous SARS-CoV-2 infection among dental personnel - the Swedish experience.

CONCLUSIONS: The seroprevalence of SARS-CoV-2 infection was approximately similar to that in healthcare personnel, and approximately equal compared to that in the general population. MATERIALS AND METHODS: We carried out an observational cohort study from March to June 2020, including 341 employees randomly selected from Public Dental Service in the County of Stockholm. The primary outcome variable was the prevalence of SARS-CoV-2 RNA and/or antibodies against SARS-CoV-2. Throat samples were analysed for SARS-CoV-2 RNA. Venous blood was collected to detect antibodies against SARS-CoV-2 using the Luminex analysis tool (immunoassay) and ELISA. Logistic regression analysis was used to compare the independent groups and calculate the unadjusted odds ratio. OBJECTIVE: To investigate whether personnel in a public dental clinic had a higher frequency of ongoing or previous severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection than hospital healthcare workers or the general public in Stockholm during weeks 23-25 in 2020. RESULTS: The mean age of the participants was 50.1 years, and 11.7% were male. The prevalence of SARS-CoV-2 RNA and/or antibodies against SARS-CoV-2 was 12.0% (95% confidence interval 8.8-16.0). Among them, 82.5% reported symptoms and 85.4% were on sick-leave between March and June 2020.

Cognitive changes and neural correlates after oral rehabilitation procedures in older adults: a protocol for an interventional study.

BACKGROUND: Epidemiological studies show an association between masticatory function and cognitive impairment. This has further strengthened the notion that tooth loss and impaired masticatory function may be risk factors for dementia and cognitive decline. Animal experiments have indicated a causal relationship and several possible mechanisms have been discussed. This evidence is, however, lacking in humans. Therefore, in the current interventional study, we aim to investigate the effect of rehabilitation of masticatory function on cognition in older adults. METHODS: Eighty patients indicated for prosthodontic rehabilitation will be randomly assigned to an experimental or a control group. Participants will conduct neuropsychological assessments, masticatory performance tests, saliva tests, optional magnetic resonance imaging, and answer questionnaires on oral health impact profiles and hospital anxiety and depression scale before, 3 months, and 1 year after oral rehabilitation. The difference between the two groups is that the control group will be tested an additional time, (at an interval of about 3 months) before the onset of the oral rehabilitation procedure. The primary outcome is a change in measures of episodic memory performance. DISCUSSION: Although tooth loss and masticatory function are widespread in older people, it is still an underexplored modifiable risk factor potentially contributing to the development of cognitive impairment. If rehabilitation of masticatory function shows positive effects on the neurocognitive function, this will have great implications on future health care for patients with impaired masticatory status. The present project may provide a new avenue for the prevention of cognitive decline in older individuals. TRIAL REGISTRATION: The protocol for the study was retrospectively registered in ClinicalTrials.gov Identifier: NCT04458207, dated 02-07-2020.

Two methods of evaluating mandibular trabecular pattern in intraoral radiographs and the association to fragility fractures during a 47-year follow up.

In this longitudinal cohort study, we explored the association of fragility fractures to sparse trabecular bone pattern in intraoral radiographs using two methods, a visual and a semi-automated. Our aim was to study both sexes and to include younger age-groups, during a follow-up time of 47 years. The cohort consisted of 837 men and women aged 18-65 years, with intraoral radiographs from 1970-1971. The trabecular pattern was assessed in the mandibular premolar region with a visual and a semi-automated method. Data on fragility fractures were acquired from the Swedish National Patient Register for 47 years of follow-up time. Sparse trabecular pattern was found in 2.2% of the cohort using the visual method, and 18% were deemed at 'risk of osteoporosis' using the semi-automated method. A total of 132 individuals suffered at least one fragility fracture during the follow-up period. We found no significant association between fractures and sparse trabecular pattern using either method. This study shows that visual assessment, as a predictor of future fractures, may not be a suitable method for individuals of all ages and sexes. As for the semi-automated method, there is still very limited evidence for its fracture predictive ability.

Discontinued dental care attendance among people with dementia: A register-based longitudinal study.

OBJECTIVE: To investigate the factors that increase the risk of discontinuing dental care utilisation after dementia is diagnosed in a population in Stockholm County, Sweden. BACKGROUND: As the progression of dementia results in a deteriorating ability to maintain good oral health, it is important to identify people at risk of discontinued dental care after being diagnosed with dementia. MATERIALS AND METHODS: This study is a register-based longitudinal study. Data were extracted from the Swedish Dementia Registry (SveDem), the Swedish National Patient Register, the Dental Health Register and the Municipal Dental Care Register (Stockholm County Council). The data included people using both general public dental services and care-dependent individuals. Dental visits three years before and after dementia had been diagnosed were analysed. RESULTS: In total, 10 444 people were included in the analysis, of which 19% did not have dental visits recorded after they were diagnosed with dementia. A logistic regression model, adjusted for relevant factors, showed that the factors associated with a greater risk for discontinued dental attendance were fewer remaining teeth (OR = 0.96, 95% CI = 0.95, 0.97) and living alone compared to living with another adult (OR = 1.23, 95% CI = 1.05, 1.43). People with Parkinson's disease dementia had a lower risk (OR = 0.40, 95% CI = 0.19, 0.84) than people with Alzheimer's disease. CONCLUSION: Patients, dental and healthcare personnel, and family members should all be aware of these risk factors so that appropriate support and oral care for people with dementia can be delivered.

Effects of Domiciliary Professional Oral Care for Care-Dependent Elderly in Nursing Homes - Oral Hygiene, Gingival Bleeding, Root Caries and Nursing Staff's Oral Health Knowledge and Attitudes.

PURPOSE: The primary aim was to describe the effects for nursing home residents of monthly professional cleaning and individual oral hygiene instruction provided by registered dental hygienists (RDHs), in comparison with daily oral care as usual. The secondary aim was to study the knowledge and attitudes among nursing staff regarding oral health care and needs. PATIENTS AND METHODS: In this randomised controlled trial (RCT), 146 residents were recruited from nine nursing homes in Regions of Stockholm and Sörmland and were randomly assigned (on nursing home level) to either intervention group (I; n=72) or control group (C; n=74). Group I received monthly professional cleaning, individual oral hygiene instructions and information given by an RDH. Group C proceeded with daily oral care as usual (self-performed or nursing staff-assisted). Oral health-related data was registered with the mucosal-plaque score index (MPS), the modified sulcus bleeding index (MSB), and root caries. The nursing staff's attitudes and knowledge were analysed at baseline and at six-month follow-up. Statistical analysis was performed by Fisher's exact test and two-way variance analysis (ANOVA). RESULTS: Improvements were seen in both Group I and Group C concerning MPS, MSB and active root caries. The nursing staff working with participants in Group I showed significant improvements regarding the Nursing Dental Coping Beliefs Scale (DCBS) in two of four dimensions, oral health care beliefs (p=0.0331) and external locus of control (p=0.0017) compared with those working with Group C. The knowledge-based questionnaire showed improvement (p=0.05) in Group I compared with Group C. CONCLUSION: Monthly professional oral care, combined with individual oral health care instructions, seems to improve oral hygiene and may reduce root caries among nursing home residents. This may also contribute to a more positive attitude regarding oral hygiene measures among nursing home staff, as compared with daily oral care as usual.

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.

Serum immunoglobulin A (IgA)-mediated immunity in human immunodeficiency virus type 2 (HIV-2) infection.

In the present study, we sought to define the importance of serum IgA (sIgA)-mediated immunity in HIV-2 infection. Serum samples from a total of 29 HIV-2-infected patients from Guinea-Bissau (n = 20) and Portugal (n = 9) were studied. Samples from seronegative individuals were used as controls. Antibody reactivity to native and recombinant envelope glycoproteins as well as peptides representing various regions of the envelope glycoproteins was investigated. Furthermore, the capacity of purified IgA to neutralize the HIV-2(SBL6669) strain was tested. All serum samples showed IgA reactivity against whole HIV-2 antigen. Twenty-eight out of 29 IgA samples (96%) reacted with native HIV-2 gp125, 26/29 (90%) with recombinant gp105, and 29/29 (100%) with recombinant gp36. When using peptides, the most prominent IgA reactivity was seen against the peptide representing aa 644-658 of the transmembranous protein gp36, to which 72% of the sera reacted. Purified sIgA antibodies showed neutralizing effects against HIV-2(SBL6669) in 17/29 cases (59%). This work describes the HIV-2-specific sIgA antigenic response. Moreover, our findings show, for the first time, that sIgA may play a role in the in vitro neutralization of HIV-2.