In this issue
In a systematic review, researchers examined the effect of silver diamine fluoride (SDF) in preventing and arresting caries in exposed root surfaces of adults. The study was published in the August issue of The Journal of the American Dental Association.
Root caries among adults peaks at about 70 years of age. Untreated caries can lead to pain, social dysfunction, and possibly handicap. The development of root caries begins with repeated bouts of demineralization and remineralization on exposed root surfaces, but it is the degradation of the organic components of dentin and cementum that plays a crucial role in its progression. It is reasonable to postulate that topical application of products that inhibit proteolysis might be used to manage root caries.
SDF has primarily been used to treat coronal caries in pediatric patients. SDF inhibits the proliferation of cariogenic microbes and stimulates remineralization of enamel and dentin while also preventing dentinal collagen breakdown. In 2016, the U.S. Food and Drug Administration approved SDF as a medicament to desensitize hypersensitive teeth, and dentists have also been using it off-label to manage caries. SDF is easy to apply, painless, noninvasive, and cost-effective. It is thought that SDF might prove to be a valuable tool for inhibiting and arresting caries in older adults with mobility and oral self-care challenges.
The purpose of this systematic review was to conduct a methodologically sound qualitative and quantitative synthesis of the existing evidence on the use of SDF to prevent and arrest root caries in adults. Inclusion criteria were adult patients with exposed root surfaces; topical SDF applied by a health care professional; comparison of no intervention, placebo, cariostatic agent, or dental restorative material; and development of new root caries or root caries arrest at least 12 months after product application. Studies were retrieved from multiple databases, clinical trial registries, and the Brazilian database of theses and dissertations. The risk of bias was evaluated by using the Cochrane Risk of Bias Tool. For caries prevention, the difference in mean caries increment as weighted mean differences of decayed or filled root surfaces (DFRS), prevented fractions, and confidence intervals were calculated. For cares arrest, the difference in mean number of arrested lesions between SDF and control groups was determined.
This meta-analysis demonstrated that yearly applications of topical SDF in older adults lowered the incidence of new root caries by at least 50%, with even higher rates shown for increased duration of treatment. Owing to the methodological precision and pooled date used in this meta-analysis, the authors considered their estimate of SDF efficacy to be precise. Because the studies were grouped by duration of treatment, it was apparent that the preventive effect of SDF increased with longer duration of intervention. The authors concluded that further research is needed to verify the findings and gain additional information about the optimal frequency of SDF treatment.
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Using the Dental Activities Test to measure dental function in patients with cognitive impairments
Cognitive impairment is a frequent affliction among geriatric adults and often affects dental-related function (DRF), which can seriously compromise oral and systemic health. In an article published in the March 2017 issue of Journal of the American Geriatric Society, the authors described developing the Dental Activities Test (DAT) to assess DRF in geriatric patients with cognitive impairment.
Ninety older adults with normal to severely impaired cognition were recruited from 3 assisted living facilities in North Carolina. Inclusion criteria included being 50 years or older, not being blind or deaf or having a severe physical disability, and speaking English. Exclusion criteria were patients who required antibiotic prophylaxis before dental care or the need for an emergency dental referral. A geriatric dentist and a dental hygienist performed oral examinations on the patients. A research staff member with no dental background administered the DAT and the St. Louis University Mental Status (SLUMS) examination to patients and interviewed residential staff about activities of daily living of the study patients. The DAT and SLUMS examination were administered twice in 3 days to a subset of 43 patients to test for interrater reliability. The DT was readministered to a different subset of 43 patients 2 weeks after the first test to evaluate the test-retest reliability assessment.
Mean (standard deviation) age of the participants was 83.7 (8.9 years), 79% were women, 68% were white, and 30% black. A total of 37.4% were classified as being cognitively intact or mildly impaired, while 25.3% were moderately impaired, 25.3% severely impaired, and 12.1% very severely impaired. The mean (standard deviation) SLUMS examination score was 8.21 (7.81), and 88.9% of patients received a diagnosis of dementia.
Internal consistency of the DAT was impressive (α = 0.90) with an excellent interrater (r = 0.90) and test-retest reliability (r = 0.84). Participants who had higher scores on the Instrumental Activities of Daily Living scale performed better on the DAT. Patients with better cognitive function, as indicated by challenging the SLUMS examination assessment performed better on the DAT assessment. Significantly different (P < .001) cognitive and functional scores existed across 4 functional categories of dental care: 0-2 full care, 3-5 needs assistance, 6-8 needs supervision, and 9 independent. One item was identified as a prescreening question to identify patients who might benefit from taking the DAT: understanding a medication schedule. This item had 97% sensitivity and 100% specificity with an excellent positive predictive value (1.00) and negative (0.88) predictive value.
Because cognitive impairment alone does not predict DRF of individual patients, geriatric dentists need a simple tool to evaluate DRF in cognitively impaired patients. As an independent measure, the DAT demonstrated excellent consistency, interrater reliability, test-retest reliability, and construct and concurrent validity. This test enables dental health care workers to reliably assess DRF and develop customized strategies to improve patients’ oral health depending on their dental skills cognitive impairment levels.
The DAT measures global DRF using a summative score. Staff observations of individual dental tasks may help refine customized dental plans for patients with cognitive impairment. The DAT is a simple, straightforward tool that allows dental assessment by people without formal training in cognitive and functional assessment. Investigators caution that the DAT assesses a patient’s capacity but not their skill to perform oral health–related activities. The authors conclude that the DAT is a simple tool to measure DRF and provides utilitarian data to help health care professionals customize oral health care for patients with cognitive impairment.
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The existence of multiple diseases and disorders in the geriatric population, compounded by the increase in the number of medications older patients must take, represents a significant public health problem. Polypharmacy involves the concomitant use of 5 or more medications.
In a cross-sectional study published online July 9 in Clinical Interventions in Aging, researchers identified medication behaviors of geriatric patients living in provinces in Eastern Turkey and Central Anatolia. Of 310 people older that 60 years living in nursing homes in Elazig, Malatya, and Kaseri provinces in Turkey, the final study population included 255 participants. Exclusion criteria included declining to be interviewed, failure to cooperate, and visual or auditory dysfunction complicating communication. The mean (standard deviation [SD]) age of the participants was 72.70 (8.26) years overall, with 72.99 (9.31) years for men, and 72.55 (7.65) years for women. A total of 64.7% of the study population were men, 38.5% had graduated from an educational institution, and 36.5% lacked any social security. The most frequently used medications among the participants were antihypertensive agents (52.2%), analgesic and anti-inflammatory agents (43.1%), pharmacologic agents to treat gastrointestinal disorders (20.8%), and cardiovascular system agents (14.9%).
A total of 87.8% of participants were treated with polypharmacy, with 98.4% reporting the physician had recommended the medications. A total of 95.3% were not familiar with adverse effects of their medication, 93.7% indicated they had not read the package inserts of their medications, and, of those, 41.2% felt it was not necessary to do so. A total of 82.7% of participants indicated their drugs produced no adverse effects. A total of 70.2% reported a health care professional had not given them any information regarding their medicines. Of those who indicated they had been informed about the drugs they were taking, that information came from the nurse in 55.3% of cases, and from the physician in 44.7% of cases. A total of 51.3% of participants indicated being informed about the length of drug use, 30.3% about the intended purpose of the medication, 7.9% about drug dose, and 6.6% on adverse effects of the pharmaceutical.
Prior studies also reported that antihypertensive agents were the most frequently used medications by the elderly, followed by analgesics and anti-inflammatory medications. Previous studies also found similar rates of polypharmacy among nursing home residents, and that the average patient took 5 drugs. Because participants were under the supervision of physicians and nurses, the high proportion of patients taking medications under a physician’s orders, on time, and at the correct dose was expected in the nursing home population; therefore, these findings may not hold true for elderly people living at home.
The findings that such a high proportion of nursing home residents were unfamiliar with potential adverse effects of their drugs and had not read the drug package inserts are worrisome. The authors conclude that drug package inserts should be worded in plain, simple language that is easy for laypeople to understand. They also advise that package inserts and labels on the medication bottles be printed in large font to assist readability by the geriatric population.
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Given that poor oral health—in particular periodontal disease—is associated with systemic diseases such as diabetes and cardiovascular disease, the question of whether treating periodontal disease might improve systemic health rises to the foreground. In an article published in the August issue of The Journal of the American Dental Association, researchers conducted a systematic review to analyze whether improved dental care would reduce overall health care costs for patients with chronic medical ailments and for pregnant women.
Studies were retrieved from multiple databases. The studies examined expenses incurred for treatment of periodontal disease, health care during pregnancy, and health care in patients with chronic systemic conditions. Inclusion criteria were original empirical studies, studies that examined the association of periodontal disease treatment with overall health expenditures, and studies that examined chronic inflammatory systemic disorders or pregnant patients.
Of the 982 studies identified using the search strategy described in the article, 305 were duplicates, resulting in retention of 677 articles. Title and abstract screening reduced this number to 7 potential articles. After the full-text articles were read and inclusion criteria were applied, 3 articles remained to form the basis of this analysis. Medical and dental insurance claims data covering the years 2001 through 2011 were analyzed.
All 3 studies reported on patients with diabetes mellitus. Two studies also examined patients with cerebrovascular and coronary artery disease. The third study also examined members with rheumatoid arthritis and pregnancy. The American Dental Association’s Code on Dental Procedures and Nomenclature (CDT) was used to delineate patients in each study into either a treatment or control group. Patients who received periodontal therapy were entered in the treatment group, and patients who were provided “other dental services” were entered in the control group.
Total health care costs served as the outcome measure in each study. To compare total health care costs for patients with diabetes across the 3 studies, the per member per month (PMPM) costs were calculated. One study found a PMPM reduction of $236.67, a second a reduction of $74.96, and the third an increase of $19.15.
This systematic literature review culled only 3 articles assessing the impact of oral health care on systemic health care costs for people with chronic medical conditions. These 3 studies examined treatment for periodontal disease exclusively, and this is the dental condition for which we have the strongest oral-systemic association. Two studies demonstrated a decrease in PMPM health care costs, while the third showed an increase.
Dental care is coded by procedure performed, whereas medical services are coded by diagnosis. This makes it difficult to analyze outcomes comparing the dental and medical systems. Since most dental insurers operate on a fee-for-service basis, there is little incentive to change coding practices. Adoption of outcome-based payment programs, as has been gaining popularity in medicine, would require an extensive overhaul in the diagnostic coding schema for dentistry.
The authors discuss advantages of integrated dental-medical health care systems in which dentists and physicians share skills and interoperable electronic health records and pool risk. An example would be the provision of topical fluoride varnish to pediatric patients during well-child appointments billed to medical insurance, which could help increase access to care for at-risk populations. Continued research on the relationships between the oral condition and various chronic systemic maladies will play a role in determining the nature of dental care and access to it, along with determining the structure of health care systems and reimbursement strategies. The authors concluded that the small number of studies, differences in codes to identify treatment and control groups, and the mixed outcomes reviewed in this study point to the need for high-quality studies to continue exploring the impact of periodontal treatment and systemic health care costs.
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ADA 2018 courses can help treat aging patients
Menopause affects 163 million women in the U.S. daily. ADA 2018 offers courses on how to identify and address the hormonal changes that affect many bodily systems, including gums and dentition. Martinis and Menopause: Implications for Women’s Health is a course that shows health care professionals their role in understanding, supporting, and educating patients on what they need to do to take care of themselves as they get older. Help patients identify the hormonal changes they are experiencing, and the risk factors and prevention strategies for oral, heart, and bone health. Earn 1.5 CE hours for this course.
Visit ADA CE Online to learn about dental conditions associated with aging and what to expect as the number of senior aged patients continues to grow. Hear from our Science Institute experts and The Journal of the American Dental Association on the how to treat this aging population.
Webinar: Treatment Planning for the Geriatric Patient
If you would like to learn more about the ins and outs of dental care for geriatric patients, make sure to attend this webinar on Sept. 19. ADA member Dr. Gregory Folse, who serves on the Association’s National Elder Care Advisory Committee, will share some of the insight he’s gained after working exclusively in nursing homes. He will discuss:
• How to develop treatment appropriate treatment plans for geriatric patients in all stages of life.
• When to provide dental treatment, maintain oral disease, or do nothing at all.
• Potentially adverse dental, medical, pharmacological, and psychological issues that guide the decision making process.
Participants are eligible for one hour of continuing education credit. Register today!
In this issue
Using the Dental Activities Test to measure dental function in patients with cognitive impairments residents >>
The consulting editor for JADA+ Scan — Healthy Aging is Linda C. Niessen, DMD, MPH; Dean and Professor; Nova Southeastern University College of Dental Medicine.