What's in this issue?
Strategies for customization of dental caries management for frail older adults and those with special needs >>
Better oral health helps improve general health among the US geriatric populationPeriodontitis and edentulism can lead to problems with mastication, taste, swallowing, and the desire and ability to eat. This can lead to malnourishment, which may compromise systemic health. There is a dearth of empirical evidence for this on a national level. The aim of a study published online in the July/August 2019 issue of Special Care in Dentistry was to explore the importance of oral health on systemic health in older Americans.
The authors used data for people 65 years or older from the 2015-2016 cycle of the National Health and Nutrition Examination Survey (NHANES). The demographic variables they examined were age, sex, educational level, race, marital status, military service, and annual family income. The primary outcome variable was self-perception of oral health. This was measured by responding to “Rate the health of your teeth and gums,” with 1 of 5 choices ranging from poor to excellent. The cadre of variables under the overall health and well-being umbrella included general health, depression (mental health), work restriction (physical function), energy levels (well-being), appetite (well-being), and systemic diseases. Ten individual systemic diseases were of interest: hypertension, diabetes, asthma, arthritis, coronary heart disease, congestive heart disease, thyroid disease, chronic bronchitis, liver disease, and cancer.
The complex sampling design, weighting, and poststratification to US Census Bureau population estimates of the NHANES data yielded prevalence estimates and findings that can be generalized to the US population. Statistical software (R, Version 3.4.1) was used for descriptive and inferential statistics, with significance set at a less than .05 at 2-tailed. Mean, standard deviation, and percentage were used to calculate weighted prevalence estimates for demographics, oral health, well-being, and systemic diseases. The association of oral health with physical, mental, and overall health and systemic diseases was conducted using χ2 tests and logistic regressions. The responses “excellent” or “very good” for the oral health outcome variable were recoded as “positive,” and the responses “fair” or “poor” were recoded as “negative.” Logistic regressions used to predict the positive or negative outcome from the overall health and well-being variables were run, followed by computation of the odds ratio (OR) and 95% confidence interval.
The elderly population examined represented 47.8 million US adults 65 years or older. Most were female (56.3%), 56.6% were married, and 83.2% had high school diplomas or higher. Race and ethnicity was classified as Mexican American (4.3%), other Hispanic (3.4%), white (76.4%), black (7.7%), and Asian (4.4%). Statistically significant relationships were found between oral health and general health (χ2, 200; P < .05), energy levels (χ2, 60; P < .05), work limitation (χ2, 50; P < .05), depression (χ2, 80; P < .05), and appetite (χ2, 70; P < .05). Positive oral health was associated with better general health (OR, .480; P < .05), better mental health (OR, .613; P < .05), higher energy levels (OR, .613; P < .05), and better appetite (OR, .559; P < .05). Six systemic diseases were associated with oral health outcome. Elderly patients with poor oral health also had diabetes (χ2, 17.489; P < .05), coronary heart disease (χ2, 21.459; P < .05), congestive heart failure (χ2, 12.077; P < .05), hypertension (χ2, 9.3185; P < .05), asthma (χ2, 2.8009; P < .05), and liver disorders (χ2 = 9.0851; P < .05).
The authors note that this is a sentinel study using a large national dataset to demonstrate the positive relationship between oral health and overall health and well-being in seniors. It appears that overall health has a complex relationship with oral health and that the roles of confounding factors need to be teased out.
The authors point out several limitations of this study. First, because oral and overall health variables were self-reported, there is a possibility of participant self-bias, either positive or negative. Further studies adding clinical measures are recommended. A second limitation is the use of a single self-reported response to assess oral health status. The authors conclude that, as this study reveals the direct relationship between oral health and overall health, it serves as a call to action to the US health care system, the culture of health care organizations, policy makers, and dental education curricula developers to value oral health for seniors and improve oral health care access and delivery systems for the geriatric population.
Projected oropharyngeal carcinoma incidence among middle-aged US adults
The incidence of oropharyngeal cancer (OPC) has been on the rise since the 1990s, especially among younger white men. It has been determined that human papillomavirus (HPV) subtype 16 is a causal agent for OPC. Younger white men have a high prevalence of oral HPV infection as well as a rising incidence of OPC that is associated with sexual practice changes that began with the birth cohort from the 1950s. Owing to the continuous increase in incidence of OPC in the United States, the authors of a study published in the September issue of Head & Neck conducted a study to project the health burden of HPV-related OPC through the year 2045, which will be critical for planning cancer control.
The authors retrieved OPC incidence data for the years 2000-2015 from the Surveillance, Epidemiology, and End Results 18 Registries program, which covers about 28% of the US population. Age-standardized and age-specific rates were determined by sex, age, race, ethnicity, and age at diagnosis. The US Census Bureau was mined for population projections from 2016 through 2045. Projections of cancer incidence were generated using a combination of population projections from 2016 through 2045 and the average annual percentage change of cancer-specific incidence rates. To calculate the average annual percentage change, age-standardized cancer incidence rates per year were applied to the Joinpoint regression model using Joinpoint trend analysis software (National Cancer Institute). When the annual percentage change was statistically significant, the terms “increase” or “decrease” were applied. In all other cases, the term “stable” was used.
OPC incidence increased 1.94% (95% confidence interval [CI], 1.65% to 2.23%) per year, and non-Hispanic white men constituted most of OPC cases. The age-standardized incidence of OPC was 4.5-fold higher in men than in women in 2015. The annual percentage change was highest in non-Hispanic whites (2.88% per year, 95% CI, 2.59% to 3.17%) and remained significant in Hispanic, Asian, and American Indian/Alaska Native groups.
The number of OPC cases was projected to increase by 130% from 2016 through 2045 in the US population, with men comprising most the increase (91.46%). People aged 55 through 69 years were projected to have the highest incidence and greatest number of cases by 2045. Among US women, OPC was forecast to increase gradually during this period, whereas in US men, the number of cases increased dramatically, reaching 43,023 (157% increase) by 2045. It is estimated that OPC incidence will reach 22.30 per 100,000 men by 2045. In non-Hispanic white men aged 55 through 69 years, OPC ranked ninth in the number of new cancer cases in 2016. By 2045, OPC will rank as the third most common cancer in non-Hispanic white men aged 55 through 69 years, after surpassing prostate cancer.
The authors noted that several limitations exist in their projections. They did not account for changes in the assumptions made in the model and assumed that recent trends in cancer incidence will remain steady longitudinally. However, they are aware that continued development of novel prevention and screening strategies will lead to future alterations in incidence trends. They advocate for conducting such projections regularly to capture up-to-date temporal trends and using different modeling approaches.
If current trends continue, OPC will become the third most common cancer in middle-aged US men. Health care providers will be challenged to conduct risk stratification of patients who have OPC, as it is considered a heterogeneous disease with distinct clinical outcomes necessitating varied treatment approaches. The authors conclude that the projections advocate for strengthening HPV vaccination campaign efforts in adolescents to reduce future OPC burden. This projection may prove utilitarian for policy makers who must prioritize cancer prevention resources in the future.
Life partner influence on use of preventive health services
Use of preventive health services is a first-order tool for reducing the risk of illness, possible hospitalization, and health care expenditures. However, the level of receipt of such services remains low. Novel approaches to motivate at-risk populations are needed to promote regular use of preventive services. The aim of a study published online February 22 in Journal of Aging and Health was to examine partner concordance on preventive health services receipt through the impact of the partner’s previous preventive behaviors, sex, and subgroup effects across birth cohorts and income class.
The authors examined data from the 2008 and 2012 waves of the Health and Retirement Study at the University of Michigan, a nationally representative sample of people born from 1931 through 1941, and their life partners. These data permitted inquiry into whether a person’s decision to receive a preventive service (flu vaccine) was a function of their partner’s previous usage history and sex. The final study population was comprised of 2,680 respondents from 4 age cohorts: HRS (born between 1931 and 1941), WB (war baby, 1942-1947), EBB (early baby boomer, 1948-1953), and MBB (middle baby boomer, 1954-1959).
The dependent variable was whether a respondent received flu vaccine in the current year given that he or she did not receive one in the previous year. Four service use indicators of a life partner were constructed: Nonuse, Stopper, Continuous, and Starter. These indicators were used to predict the respondent’s likelihood of receiving a flu vaccine in the current year. The first 2 indicators were deemed to be negative partner behaviors, and the latter 2 were to be positive partner behaviors.
The study controlled for a number of variables, including demographics, socioeconomic variables, health conditions, new disease diagnoses, and life events.
A logistic regression model was used to predict the conditional probability of a respondent’s receiving a flu vaccine in the current year given that it was not received in the previous year. The statistical significance and magnitude of β estimators indicated the existence and relative strength of partner impact. It was assumed that the first 2 should be positive (encouraging) and the latter 2 negative (discouraging). It is possible that individual decision making and partner concordance vary across a person’s life span and socioeconomic status. Therefore, the analyses were also run by dividing the study sample into groups: younger or older than 65 years and above or below median household income to evaluate trends.
Of the 2,680 people in the study, 1,363 were men and 1,317 were women. Flu vaccines were received by 32.5% in 2012. Partner vaccination history was found to be 44.7% Nonuser, 4.1% Stopper, 29.6% Continuous, and 17.1% Starter. The average age of respondents was 66.6 years, 12.7% indicated being black or Hispanic, and the median household income was $53, 639.
Couples generally tended to use or not use preventive services in the same year; however, partner concordance was shown to have differentiated effects. Having a Nonuser partner significantly reduced a person’s likelihood of receiving a flu vaccine (odds ratio [OR], 0.543 for men, 0.633 for women), while having a Continuous or Starter partner significantly elevated the likelihood of receiving a flu vaccine (OR, 2.17 and 2.86 for men, 1.99 and 3.32 for women). Women were more sensitive to the encouraging effects and less responsive to the discouraging effects than men. This indicates that strategies to promote flu shot receipt should target women. Sex differences were larger in the middle-aged birth cohorts than in the early- and late-aged cohorts and among those with lower than median incomes. The authors conclude that the results provide direction for the design of interventions on preventive behavior promotion.
Strategies for customization of dental caries management for frail older adults and those with special needs
Caries has been shown to be an active disease in older adults (> 65 years), and its burden is further elevated among frail older adults and those with special needs. As the sequelae of caries impact systemic health and quality of life, it is important to prevent and control coronal and root caries in this population. An article published in the October issue of Dental Clinics of North America describes a systematic approach to educating dental students about how to assess the risk of rapid oral health deterioration (ROHD).
The overarching premise of the ROHD risk assessment is that only a complete understanding of all the risk factors affecting the patient will enable the clinician to improve the patient’s caries risk, improve caries prevention, and select appropriate treatment(s) for the individual patient. The first step is to gather all information concerning ROHD risk factors for the patient. These risk factors are culled from the patient and caregiver interview, health history forms, medication lists, oral examination, radiographic interpretation, and caries risk assessment. ROHD risk factors fall into 1 of 3 categories: general health, social support, and oral conditions.
In terms of general health, multiple diseases may diminish the patient’s ability to maintain good oral hygiene, including congenital and acquired physical deficits, cognitive afflictions, sensory impairments, and compromised manual dexterity. ROHD risk factors affecting the patient’s social support may play a critical role in facilitating or impairing a patient’s access to oral health care, maintaining daily oral hygiene, and adhering to the recommended treatment plan. Discretionary finances for oral health care, patient’s dependency on caregivers, community-based factors such as water fluoridation, availability of healthy foods, and ageism are social support-related risk factors. Xerostomia (most frequently caused by the use of multiple medications) and salivary gland hypofunction are oral conditions that can increase the risk of experiencing ROHD.
The second step in the ROHD risk assessment is the prioritization of the gathered information. When developing the treatment plan, the clinician needs to examine all the general health conditions, social support factors, and oral health conditions affecting the patient and determine which are most likely to contribute to ROHD progression.
In the third step, the clinician categorizes the patient’s current ROHD stage to predict the patient’s future oral health if no dental treatment is rendered or whether an active treatment protocol should be instituted. This step lets the dentist visualize and manage the patient’s condition as a continuum. ROHD is classified into 4 categories based on risk factor severity and disease progression:
- Risk factors are not present, no ROHD is occurring;
- Risk factors are present, ROHD is not currently occurring;
- Risk factors are present, ROHD is currently occurring;
- Risk factors are present, ROHD has already occurred.
This classification helps clinicians determine the preventive and restorative approaches to the treatment plan that was constructed based on the patient’s risk factors.
The fourth step involves selecting treatment alternatives and choosing a specific intervention backed by a rationale. A communication plan is developed for presentation to the patient’s caregivers and the health care team. In working to prevent ROHD, managing dry mouth is critical. Maintaining adequate hydration, relief from xerostomia symptoms, and medication reconciliation are key. Use of saliva stimulants or substitutes as indicated, reduction in spices or acidic foods in the diet, and use of remineralizing products, prescription fluoridated toothpastes or gels, fluoride varnishes, and silver diamine fluoride should be considered and customized to the individual patient’s situation. For patients with manual dexterity concerns, a variety of aids to assist toothbrushing and flossing are available. For some patients, dietary changes may reduce caries risk. When treatment is necessary, the dentist may consider incomplete caries removal or atraumatic restorative treatment options.
The authors conclude that a methodical, systematic ROHD risk assessment requires identifying and examining all risk factors for an individual patient, identifying priority and critical factors, developing action plans for preventive and restorative strategies, and communicating treatment and maintenance plans to caregivers. This holistic approach is thought to offer a better option for caries management in frail older adults and those with special needs than a narrow, tooth-focused perspective.Read the original article here or contact the ADA Library & Archives for further assistance.
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Learn how to treat your aging patients’ special needs
With advances in medicine and better lifestyles, your patients 65 and older are becoming a larger part of your practice. Although they may be healthier, this demographic still faces particular issues that aging unfortunately brings, such as dry mouth, increased sensitivity to drugs, comorbid conditions, as well as more root and coronal caries. These three CE courses will help you understand these concerns and develop appropriate treatment plans for your aging patients.
- Today’s Top Restorative Tips
- Oral Health Topics: Aging and Dental Health
- Prophylactic Antibiotic Use in Dental Patients with Prosthetic Joins: What is the Evidence?
Visit ADACEOnline.org to find out more information about these and other healthy aging courses.
What's in this issue?
Strategies for customization of dental caries management for
The consulting editor for JADA+ Scan — Healthy Aging is Linda C. Niessen, DMD, MPH; Professor; Nova Southeastern University College of Dental Medicine.