Care-resistant behaviour during oral examination in Dutch nursing home residents with dementia.

OBJECTIVE: To assess the occurrence and associations of verbal and non-verbal care-resistant behaviour (CRB) during oral examination by a dental hygienist in nursing home residents with dementia. BACKGROUND: CRB is a barrier to providing professional oral care and daily oral hygiene care. Understanding the predictors of CRB might help care professionals in learning to anticipate this behaviour. METHODS: In this multicentre cross-sectional study signs of verbal and non-verbal CRB were reported during the oral examination. Data collection occurred in the psychogeriatrics wards of 14 different nursing homes in the Netherlands (N = 367). RESULTS: A total of 367 residents were included. CRB was evident in 82 residents (22.3%), of whom 45 (55%) showed verbal and 37 (45%) non-verbal CRB. Associated with CRB were age >85 years, duration of residential stay longer than 2 years, and having Korsakov dementia. Other factors associated with CRB were duration of residential stay (categories ">2 and ≤4 years" or ">4 years") and having a natural dentition (P = .043-.005, OR = 1.20-1.33, 95% CI = 1.00-8.48). Significant associations for verbal and non-verbal CRB were age between 76 and 85 years, vascular dementia and Korsakov dementia (P = .031-.006, OR = .020-1.49, 95% CI = 0.43-2.15). CONCLUSION: The occurrence of CRB was 22.3% and was associated with older age and longer duration of residential stay, Vascular and Korsakov dementia and natural dentition.

Oral health care services for community-dwelling older people with dementia: A scoping review.

OBJECTIVE: To assess whether, and if so, which oral health care services for community-dwelling older people with dementia are available. BACKGROUND: Oral health in people with dementia is poor compared with people without dementia. Although multiple oral health care interventions have previously been studied for older people living in nursing homes, little is known about interventions or services for community-dwelling older people with dementia. MATERIALS AND METHODS: A literature search was performed in the databases Pubmed, Embase and CINAHL. The following search terms were used: "Dementia", "Oral health", "Dental health services" and "Older person". The term "dental health services" was intended to be an as broad as possible construct because limited search results were expected. RESULTS: The search generated 1624 unique references, of which seven studies were eligible for inclusion (four cohort studies, one cross-sectional study, and two qualitative studies). The included studies described two actual oral health care services: a telephone help line on oral health and dementia, and a mobile geriatric dental programme in adult day health centres. A need was found for services and strategies specific to community-dwelling older people with dementia. One identified solution was an intervention with individually tailored daily oral hygiene self-care supported by the informal caregiver. Furthermore, increasing accessibility of oral health care professionals with treatment at other locations than their own practices, better collaboration between health care professionals and preventive oral health care are highly necessary. CONCLUSION: There is limited evidence on the availability of oral health care services for community-dwelling older people with dementia, while a need was found for oral health care services that focus on good accessibility, oral hygiene self-care, preventive strategies and collaboration among health care professionals.

Exploring associations between multidimensional frailty and oral health in community-dwelling older people. A pilot study.

OBJECTIVE: To determine the associations between four validated multidimensional self-report frailty scales and nine indices of oral health in community-dwelling older persons. MATERIALS AND METHODS: This pilot study was conducted in a sample of 208 older persons aged 70 years and older who visited two dental practices in the Netherlands. Frailty status was measured by four different self-report frailty questionnaires: Tilburg Frailty Indicator (TFI), Groningen Frailty Indicator (GFI), Sunfrail Checklist (SC), and the Sherbrooke Postal Questionnaire (SPQ). Oral health was assessed by two calibrated examiners. RESULTS: The prevalence of frailty according to the four frailty measures TFI, GFI, SC, and SPQ was 32.8%, 31.5%, 24.5%, and 49.7%, respectively. The SC correlated with four oral health variables (DMFT, number of teeth, percentage of occlusal contacts, Plaque Index), the TFI with three (number of teeth, percentage of occlusal contacts, Plaque Index), the GFI only with DPSI, and the SPQ with the number of teeth and the number of occlusal contacts. CONCLUSION: Of the studied multidimensional frailty scales, the SC and TFI were correlated with most oral health variables (four and three, respectively). However, it should be noticed that these correlations were small. CLINICAL RELEVANCE: The SC and TFI might help to identify older people with risk of poor oral health so that preventive care can be used to ensure deterioration of oral health and maintenance of quality of life. Vice versa early detection of frailty by oral care professionals could contribute to interprofessional management of frailty.

Oral bisphosphonates: Adverse effects on the oral mucosa not related to the jaw bones. A scoping review.

BACKGROUND: Oral bisphosphonates are widely used in the treatment of bone resorptive diseases. There is an evidence that oral bisphosphonates can exert adverse effects on the oral mucosa independently of their effects on the jaw bones. OBJECTIVE: To systematically map the literature on adverse effects of oral bisphosphonates on the oral mucosa of adults with bone resorptive diseases. DESIGN: Scoping review of the literature, including different study designs. METHODS: Systematic searches of the PubMed, LILACS, Google Scholar and EMBASE databases were conducted. Two independent reviewers screened titles and abstracts according to predetermined criteria. RESULTS: The search retrieved 26 unique articles, comprising 22 case reports, one case series and three reviews describing a total of 56 cases of oral adverse events related to oral bisphosphonates. 88% of the reported cases were female suffering from comorbidities other than metabolic bone diseases. The improper use of the oral bisphosphonate was the most suspected cause of the adverse effect on the oral mucosa. Its management mainly involved withdrawal of the medication. CONCLUSION: Adverse effects on the oral mucosa can develop from using oral bisphosphonates. Standardised registration of these adverse effects in university clinics and private practises could provide additional information about their occurrence and severity.

Oral Health of Older Patients in Dental Practice: An Exploratory Study.

BACKGROUND: Some older people stop visiting the dentist when they get older. This study aims to identify the characteristics and oral health status of older people who do visit community dental practices. METHODS: In this exploratory cross-sectional study, the oral health of Dutch community-dwelling older people was assessed. A random sample of general dental practitioners and older people who visit the dental practice was drawn. The dentists were asked to prospectively select one older patient and describe this patient using a specially developed registration form; the patient was requested to complete a questionnaire. Data were described for 3 distinct groups of older people. Statistical measures for distribution and dispersion were used to describe the oral health of community-dwelling older patients in relation to the age. RESULTS: A total of 373 (40.4%) dentist registration forms and 372 (40.3%) patient questionnaires were returned. Data were available for 364 (39.4%) dentist-patient couples. Amongst the patients, 52.8% were female and most had a high socioeconomic status. About 65.7% had one or more problems related to general health, and 75.2% used medication. Regarding the overall oral health status, the average number of teeth was 20, 3.5% were edentulous. Oral health problems were more common in the older patient group (aged 75+), in whom frailty was also most common. CONCLUSIONS: Older people who visit community dental practices are still relatively healthy, non-frail, and highly educated.  Even in this group, there is a turning point in both general and oral health from the age of 75.

Provision of Oral Health Care by Dentists to Community-Dwelling Older Patients.

BACKGROUND: Research into oral health care for older people has shown that dental care in general decreases with increasing age and frailty and, therefore, oral health care provision may be complex. The aim of this study is to identify the oral health care dentists provide to community-dwelling older people and which barriers they experience in doing this. METHODS: In this cross-sectional study, a representative sample of dentists in the Netherlands was asked to prospectively select one older patient and describe this patient using a specially developed registration form; the patient was requested to fill out a questionnaire. The relationship between experienced barriers in providing oral health care to older patients and characteristics of the dentists and the patients was studied by means univariate and multivariate logistic regression analysis. RESULTS: In total, 923 dentists were asked to participate in the study. Data were available for 39.4% dentist-patient pairs. In most cases (87.4%), oral health care was focussed on conservation of the dentition. In all, 14.0% of the dentists experienced barriers in providing oral health care for older people. Some patient factors increase the risk of experiencing barriers, eg, the more difficult behaviour of older patients and the greater disease burden. CONCLUSIONS: Oral health care was mostly focussed on conservation of the dentition, and dentists especially experience barriers in oral health provision to older patients if they are already frail.

Oral Health Assessment Tool (OHAT) deputized to informal caregivers: Go or no go?

OBJECTIVE: Investigating the usability of the Dutch version of the Oral Health Assessment Tool (OHAT-NL) with informal caregivers of community-dwelling older people with suspected dementia, without specific training. MATERIALS AND METHODS: In accordance with guidelines for establishing the cultural equivalency of instruments, the OHAT was translated into Dutch. Fifteen informal caregivers of community-dwelling older people with suspected dementia and, as a reference standard, a dentist assessed the oral health of the older people using the OHAT-NL. The caregivers' scores were compared with the dentist's scores. The usability of the OHAT-NL was rated on a 10-point scale (0 = incomprehensible, and 10 = very user friendly) and investigated further through short structured interviews. RESULTS: There were differences between the dentist's and caregivers' assessments of the individual categories of the OHAT-NL. The specificity of the need to visit an oral health care professional was 100.0%, while the sensitivity was 78.6%. The informal caregivers concluded that the tool made them more aware of different aspects of oral health. The tool was rated with a mean score of 7.7 (SD 1.7). CONCLUSION: The OHAT-NL could be a useful tool for informal caregivers without specific training to indicate whether the person they care for should visit an oral health care professional.

Assessed and perceived oral health of older people who visit the dental practice, an exploratory cross-sectional study.

OBJECTIVES: To assess the oral health of older people who visit the community dental practice from both the dentists' and the patients' perspective. MATERIALS AND METHODS: In this exploratory cross-sectional study the oral health of Dutch community dwelling older people was assessed. A representative sample of general dental practitioners was asked to randomly and prospectively select one older patient and describe this patient using a specially-developed registration form; in addition the patient was requested to complete a questionnaire. The oral health of older people was described from the perspective of the dentists and the perspective of the older people themselves based on the definition of oral health from the World Dental Federation (FDI]. Relations between oral health of older people and dentist and older patient characteristics were analysed using Spearman's rank correlation coefficient (rho) and an ordinal regression model. RESULTS: In total, 923 dentists were asked to participate in the study; data was available for 39.4% dentist-patient pairs. Dentists assessed the oral health of older patients as good or acceptable in 51.4% of the cases while this was the case in 76.2% of older patients themselves. The assessment of the dentist gets more negative with high treatment intensity and with older patients having certain diseases and more medication, while the assessment is more positive for older patients who visit the dentist on a regular basis. Older people's assessment of their oral health gets more negative by being female and with high treatment intensity, having certain diseases and higher use of medication. CONCLUSIONS AND CLINICAL RELEVANCE: Chronically illness as expressed by the number of diseases and the use of medication, seems to be a risk factor for poor oral health. Older patients themselves assess their oral health differently, mostly more positive, than their dentist.

Self-reported oral health in the Dutch 100-plus Study of cognitively healthy centenarians: an observational cohort study.

BACKGROUND: Due to improved healthcare, more people reach extreme ages. Oral health in the oldest-old has thus far been poorly described. Here, we investigated self-reported oral health factors, use of professional oral health care, and associations with clinical measures in centenarians considered cognitively healthy. METHODS: In this observational cohort study, we included 162 (74% female) centenarians from the Dutch 100-plus Study cohort who self-reported to be cognitively healthy, as confirmed by a proxy. Centenarians were questioned about their physical well-being including medication use and their cognitive functioning was evaluated using the Mini-Mental State Examination. Questions regarding oral health included preservation of teeth, oral pain or discomfort, chewing ability, xerostomia, and time since last visit to an oral health care provider. Associations between oral health and clinical measures were investigated with ordinal logistic or linear regression analyses, adjusted for gender, age, and education. RESULTS: The majority of the centenarians indicated to have good oral health: 76% felt no oral pain/discomfort, 65% indicated to chew well; while only 18% had symptoms of xerostomia. Of all centenarians, 83% were edentulous and were wearing removable complete maxillary and mandibular dental prostheses, 1% was edentulous with no dental prosthesis, while 16% was dentate with or without removable partial dental prostheses (10 and 6% respectively). Dentate and edentulous centenarians experienced similar levels of oral pain and/or discomfort, chewing ability, xerostomia, and their cognitive functioning was similar. No relationship between cognitive functioning and chewing ability was found. Xerostomia was associated with medication use (p = .001), which mostly regarded medications for cardiovascular diseases, diuretics, anti-coagulants, and antacids. Only 18% of the centenarians visited an oral health care provider during the year prior to the interview, of whom 48% were dentate centenarians. Notably, 49% of the centenarians had not visited an oral health care provider for ≥10 years. CONCLUSIONS: Most centenarians were edentulous and did not report oral complaints. Less than one-fifth of the centenarians continued to seek regular professional oral health care. Since the proportion of dentates in the oldest-old will increase in the near future, a proactive attitude toward this group is necessary.

Mind your teeth-The relationship between mastication and cognition.

This article explores the multifactorial relationship between mastication and cognition, with a focus on dementia. Older persons, especially those with dementia, are at great risk of suffering from oral health problems such as orofacial pain and loss of natural teeth. A possible explanation could be that the cognitive and motor impairments resulting from dementia cause a decrease in self-care and as such, a worsening of oral health. An alternative explanation is that cognition and oral health influence each other. Animal studies show that a decrease in masticatory activity, for example, due to a soft diet or loss of teeth, causes memory loss and neuronal degeneration. The relationship between mastication and cognition has also been researched in human studies, but a cause-effect relationship has not been proven. It is likely that multiple factors play a role in this relationship, such as self-care, nutrition, stress and pain.

The effect of a daily application of a 0.05% chlorhexidine oral rinse solution on the incidence of aspiration pneumonia in nursing home residents: a multicenter study.

BACKGROUND: Dysphagia and potential respiratory pathogens in the oral biofilm are risk factors for aspiration pneumonia in nursing home residents. The aim of the study was to examine if the daily application of 0.05% chlorhexidine oral rinse solution is effective in reducing the incidence of aspiration pneumonia in nursing home residents with dysphagia. Associations between background variables (age, gender, dysphagia severity, care dependency, medication use, number of medical diagnoses, teeth and dental implants, and wearing removable dentures) and the incidence of aspiration pneumonia were also examined. METHODS: This study is a multicenter study in which for 1 year participants with dysphagia in the intervention group received the usual oral hygiene care with the addition of a 0.05% chlorhexidine oral rinse solution, whereas participants in the control group received only oral hygiene care. RESULTS: Data of 103 participants in 17 nursing homes were analyzed. Survival analysis showed no significant difference in the incidence of pneumonia between both groups (Cox regression, HR = 0.800; 95% CI [0.368-1.737], p = 0.572). Cox regression analysis for Functional Oral Intake Scale (FOIS)-level showed a significant risk of the incidence of pneumonia (HR = 0.804; 95% CI [0.656-0.986], p = 0.036). After adjustment for Group and FOIS-level, Cox multivariate proportional hazard regression analysis showed that the variables age, gender, Care-dependency Scale-score (CDS) number of diseases, medication use, number of teeth, and the presence of dental implants or removable dentures were not significantly associated with the incidence of pneumonia. CONCLUSIONS: Chlorhexidine oral rinse solution 0.05% as an adjunctive intervention in daily oral hygiene care was not found to reduce incidence of aspiration pneumonia. The requested number of participants to achieve sufficient power was not established and high drop-out rate and non-structural compliance was present. The power was considered to be sufficient to analyze the associations between the background variables and the incidence of pneumonia in the included nursing home residents with dysphagia. Dysphagia was found to be a risk factor for aspiration pneumonia. TRIAL REGISTRATION: Registration in The Netherlands National Trial Register: TC = 3515. Approval for the study was obtained from the Medical Ethical Committee of the Radboud University Medical Center (NL. nr:41,990.091.12).

Nursing home-acquired pneumonia, dysphagia and associated diseases in nursing home residents: A retrospective, cross-sectional study.

BACKGROUND: Nursing home-acquired pneumonia (NHAP) is a common infection among nursing home residents. There is also a high prevalence of dysphagia in nursing home residents and they suffer more often from comorbidity and multimorbidity. This puts nursing home residents at higher risk of (mortality from) NHAP. Therefore it is important to gain more insight into the incidence of NHAP and the associated medical conditions in nursing home residents with dysphagia. OBJECTIVE: To investigate possible associations between NHAP and dysphagia in nursing home residents and to search for a medical risk profile for NHAP. DESIGN: A retrospective cross-sectional study. SETTING: Three nursing homes in The Netherlands. PARTICIPANTS: 416 electronic medical files of nursing home residents aged 65 or older living in 3 nursing homes. METHODS: Data about age, gender, diagnosis of dysphagia and/or pneumonia, medical diagnosis and possible cause of death of the nursing home residents were extracted from electronic medical files. RESULTS: The data of 373 electronic medical files were analyzed. A significant difference in the prevalence of dysphagia was found between the nursing homes (p < 0.001). The incidence of NHAP was 5-12% in the participating nursing homes. Statistically significant higher incidence of NHAP was found in residents with dysphagia (p = 0.046). Residents with dysphagia had statistically significantly more diseases compared to residents without dysphagia (p = 0.001). Logistic regression analyses revealed no statistically significant associations between NHAP and the number of diseases and the ICD-10 diseases. CONCLUSIONS: Dysphagia was found to be a risk factor for NHAP. Awareness of the signs of dysphagia by nurses and other care providers is important for early recognition and management of dysphagia and prevention of NHAP.

Risks, consequences, and prevention of falls of older people in oral healthcare centers.

One-third of community-dwelling people older than 65 years of age fall each year, and half of them fall at least twice a year. Older care home residents are approximately three times more likely to fall when compared to community-dwelling older people. Risk indicators for falls are related to the older people's body, environment, behavior, and activities. An important health risk indicator is (orthostatic or postprandial) hypotension, which may induce cerebral hypoperfusion. Although the majority of falls remain without major consequences, 10% to 25% of falls in care homes result in bodily trauma. Prevalent fall-related injuries are brain injury, lower extremity fracture including hip fracture and forearm/wrist fracture, facial fracture, humeral fracture, and rib/scapular fracture. As fall accidents by older people can have severe consequences, prevention of falls is of paramount importance. Healthcare providers, including oral healthcare providers, should inform older people on risks of falling and draw attention to potentially hazardous arrangements.

Risk of aspiration in care home residents and associated factors.

Pneumonia is a prevalent cause of death in care home residents. Dysphagia is a significant risk factor of aspiration pneumonia. The purpose of the current study was to screen for risk of aspiration in care home residents in the Netherlands and assess potential risk factors of aspiration. Five experienced speech-language therapists assessed 203 care home residents (115 primarily physically disabled, 88 primarily cognitively impaired) 60 and older in the first week after admission to a care home. In 43 (21.2%) residents, speech-language therapists assessed risk of aspiration and found no significant difference between physically disabled (26.1%) and cognitively impaired (14.8%) residents. After multivariate logistic regression analysis, the final prediction model for risk of aspiration showed Parkinson's disease as a significant factor (odds ratio = 5.11; 95% confidence interval [1.49, 17.52]) . The authors therefore conclude that risk of aspiration is a relevant care problem among Dutch care home residents and requires further assessment.

Subjective dysphagia in older care home residents: a cross-sectional, multi-centre point prevalence measurement.

BACKGROUND: Dysphagia has been found to be strongly associated with aspiration pneumonia in frail older people. Aspiration pneumonia is causing high hospitalization rates, morbidity, and often death. Better insight in the prevalence of (subjective) dysphagia in frail older people may improve its early recognition and treatment. OBJECTIVE: First, to assess the prevalence of subjective dysphagia in care home residents in the Netherlands. Second, to assess the associations of subjective dysphagia with potential risk factors of dysphagia. DESIGN: Retrospective data-analysis of a cross-sectional, multi-centre point prevalence measurement. SETTING: 119 care homes in the Netherlands. PARTICIPANTS: Data of 8119 care home residents aged 65 years or older were included and analyzed. METHODS: Subjective dysphagia was assessed by a resident's response to a dichotomous question with regard to experiencing swallowing problems. If a resident was not able to respond (e.g. residents with dementia or aphasia), the question was answered by the ward care provider, or the resident's file was consulted for registered swallowing complaints and/or dysphagia. Several residents' data were collected: gender, age, (number of) diseases, the presence of malnutrition, the Care Dependency Scale score, and the body mass index. RESULTS: Subjective dysphagia was found in 751 (9%) residents. A final model for subjective dysphagia after multivariate backward stepwise regression analysis revealed eight significant variables: age (B -0.022), Care Dependency Scale score (B -0.985), 'malnutrition' (OR 1.58; 95% CI 1.31-1.90), 'comorbidity' (OR 1.07; 95% CI 1.01-1.14), and the disease clusters 'dementia' (OR 0.55; 95% CI 0.45-0.66), 'nervous system disorder' (OR 1.55; 95% CI 1.20-1.99), 'cardiovascular disease' (OR 0.81; 95% CI 0.67-0.99) and 'cerebrovascular disease/hemiparesis' (OR 1.74; 95% CI 1.45-2.10). CONCLUSION: It seems justified to conclude that subjective dysphagia is a relevant care problem in older care home residents in the Netherlands. Care Dependency Scale score, 'malnutrition', and the disease clusters 'dementia', 'nervous system disorder', and 'cerebrovascular disease/hemiparesis' were associated with the presence of subjective dysphagia in this study. Age, 'comorbidity' and 'cardiovascular disease' showed very small influence.

Oral health care and aspiration pneumonia in frail older people: a systematic literature review.

OBJECTIVE: To systematically review the literature on oral health care interventions in frail older people and the effect on the incidence of aspiration pneumonia. BACKGROUND: Oral health care seems to play an important role in the prevention of aspiration pneumonia in frail older people. METHODS: Pubmed, Web of Science, Cochrane Library, EMBASE and CINAHL were searched for eligible intervention studies. Only publications with regard to hospitalized or institutionalized older people, who were not dependent on mechanical ventilation were eligible. Two authors independently assessed the publications for their methodological quality. RESULTS: Five publications were included and reviewed. Two studies showed that improvement of oral health care diminished the risk of developing aspiration pneumonia and the risk of dying from aspiration pneumonia directly. The three studies remaining showed that adequate oral health care decreased the amount of potential respiratory pathogens and suggested a reduction in the risk of aspiration pneumonia by improving the swallowing reflex and cough reflex sensitivity. CONCLUSIONS: According to the results of the current systematic literature review oral health care, consisting of tooth brushing after each meal, cleaning dentures once a day, and professional oral health care once a week, seems the best intervention to reduce the incidence of aspiration pneumonia.

Risk factors for aspiration pneumonia in frail older people: a systematic literature review.

OBJECTIVE: To systematically review the risks for aspiration pneumonia in frail older people and the contribution of bad oral health among the risk factors. DESIGN: Systematic literature review. SETTING: PubMed (Medline), Web of Science, Cochrane Library, EMBASE, and CINAHL were searched for eligible studies, published in English in the period January 2000 to April 2009. PARTICIPANTS: Frail older people. MEASUREMENTS: Only publications with regard to hospitalized, institutionalized, or frail home-dwelling people of 60 years and older were eligible. Two authors independently assessed the publications for their methodological quality. Unadjusted and adjusted odds ratios and their corresponding 95% confidence intervals for respective risk factors related to aspiration pneumonia were extracted. The results were evaluated according to the levels of evidence of the Oxford Centre for Evidence-based Medicine. RESULTS: A total of 21 publications fulfilled the quality criteria. Evidence level 2a (systematic review with homogeneity of cohort studies) was found for a positive relationship between aspiration pneumonia and age, male gender, lung diseases, dysphagia, and diabetes mellitus; 2b (individual cohort study) for severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, and bad oral health; 3a (systematic review with homogeneity of case-control studies) for malnutrition; 3b (individual case-control study) for Parkinson's disease and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health among the risk factors seems limited. CONCLUSION: Thirteen significant risk factors were identified: age, male gender, lung diseases, dysphagia, diabetes mellitus, severe dementia, angiotensin I-converting enzyme deletion/deletion genotype, bad oral health, malnutrition, Parkinson's disease, and the use of antipsychotic drugs, proton pump inhibitors, and angiotensin-converting enzyme inhibitors. The contribution of bad oral health seems limited.