Oral hygiene and colonization of Candida species in denture wearers without mucosal inflammation
Oral Candida albicans is commensal in approximately one-half of healthy people, but the prevalence increases in people who wear removable dentures owing to the porous potential of the surface biofilm that can harbor fungal microorganisms. The objective of this study was to determine whether a relationship exists between oral hygiene and proliferation of yeasts in patients lacking mucosal inflammation. In addition, the study sought to determine whether mycological examination was needed in denture wearers without mucosal inflammation. Results of this study were reported online July 17 in Clinical Interventions in Aging.
This retrospective study was carried out on a group of 289 full or partial denture wearers seeking a new prosthesis and who had undergone clinical mucosal examination for mucosal inflammation, hygiene, or both and a mycological examination. Inclusion criterion was absence of oral mucosal inflammation. Exclusion criteria included patients with postoperative or framework denture, xerostomia, medications, smoking, immunosuppression, hormonal disorder, or lack of necessary data. The final study population was consisted of 91 patients, of whom 29 (31%) were men and 62 (69%) were women, with an average age of 66 years. Most of the patients (62) wore complete dentures, and 29 wore partial denture appliances. A number of statistical analyses were performed using program R, Version 3.5.1., R Core Team (developed at Bell Laboratories; formerly AT&T, now Lucent Technologies). A value of P < .05 was considered significant.
C. albicans was the predominant yeast in 33 patients. On mycological culture, 60 patients had 0 through 20 yeast colonies, 20 patients had 21 through 50 colonies, and 11 had 51 to over 100 colonies. Antifungal treatment is not required when culture reveals up to 20 yeast colonies. In the study group, yeast growth exceeding 20 colonies occurred in 31 patients. Despite lack of mucosal inflammation, all patients whose cultures exceeded 20 yeast colonies required antifungal treatment. Seventy-seven people (84.6%) were found to have good or satisfactory oral hygiene, and 14 (15.3%) had bad oral hygiene. In 22 patients with good hygiene, Candida species were present in 59%, and 10% of these harbored more than 20 colonies.
The authors conclude that no significant relationship was found between oral hygiene and colonization of Candida species in denture wearers without mucosal inflammation (P = .332). This is of concern as oral Candida species may colonize the upper gastrointestinal tract and lead to septicemia with potentially dangerous sequelae. The authors propose mycological examination of patients who wear dentures and have no clinical signs or symptoms of stomatitis. The authors further propose future research to expand the sample size to investigate the association of the presence of oral Candida species in denture wearers with the risk of Candida infection.
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Does toothbrushing with 0.2% chlorhexidine gel improve oral health and pneumonia incidence among neurodisabled adults?
Providing dental care to patients who are functionally neurodisabled can be complex and difficult. Enhanced calculus buildup occurs in patients who are fed via percutaneous endoscopic gastrostomy (PEG). The specific aim of this study was to assess the impact of an oral care program on oral hygiene and pneumonia incidence in patients who are neurodisabled and are PEG fed or PEG and orally fed. Results were published in the September issue of Special Care in Dentistry.
Long-term care hospital-based patients on PEG or PEG and oral feeding regimens were eligible for this study. Inclusion criteria included 18 years or older and being dentate. Exclusion criteria included edentulism, allergy to chlorhexidine, and use of chlorhexidine in the year before the study. The oral health care regime consisted of provision of twice daily toothbrushing performed by a trained assistant, using 0.2% chlorhexidine gel in the morning and fluoridated toothpaste in the evening daily for 12 months. At baseline and every 6 weeks subsequently, dental plaque was measured using the Simplified Debris Index and periodontal pocketing was assessed via the Basic Periodontal Examination. For the year before the study and for the year of the study, data on the rates of pneumonia, number of chest radiographs obtained, number of courses of antibiotics taken, and hospitalization rates were extracted from medical records.
Oral health was assessed using Friedman (dental plaque) and Cochran Q tests (periodontal pocketing) to ascertain whether there were differences in mean values of dental plaque and proportion of patients with pockets greater than 3.5 millimeters over time. Post-hoc analysis of significant values was conducted with Wilcoxon signed rank tests (dental plaque) and McNemar tests (periodontal pocketing) with Bonferroni correction. Wilcoxon signed rank tests were applied to examine data extracted from medical records before and after the onset of the study. Significance level for all tests was set at 0.05, except for those analyzing multiple pairs of data, for which significance was set at P = .001. Data were analyzed using SPSS Statistics 23 software (IBM).
The final study group comprised 49 patients, with a mean age of 53 years. There were 28 women and 21 men. Forty-two patients (86%) were PEG fed only, and 7 (14%) were PEG and orally fed. Statistical analysis demonstrated a significant improvement in dental plaque levels (χ28 = 113.318, P < .001) and a significant decrease in the number of patients with periodontal pockets greater than 3.5 mm (χ28 = 33.770, P < .001) during the study period. There was a reduction in all clinical outcomes between the 12-month period before the study and the 12-month period during which chlorhexidine was used; however, none of these were statistically significant.
The authors conclude that daily toothbrushing with 0.2% chlorhexidine gel can significantly improve dental plaque scores and periodontal health, and that these improvements are sustainable over time. Although the incidence of pneumonia was reduced in the year during which chlorhexidine toothbrushing was used, that reduction was not statistically significant. The authors point out several study limitations. It is difficult to determine whether the improved oral health during the study year was due to the chlorhexidine, the improved technique of the staff after training, or both. The relatively small study sample size reflected both the nature of the patient population and the difficulty of obtaining informed consent from next of kin.
Although the number of instances of pneumonia, rounds of antibiotics used, chest radiographs obtained, and hospital admissions was reduced during the study period, none of these factors was statistically significant. However, the authors concluded that the trend in reduction of these clinical outcomes, coupled with improved oral health, may be associated with a reduction in oral bacterial carriage. The authors propose that future research using a randomized control trial with a larger sample size through a multicenter study may provide robust evidence of the effect of improved oral health on respiratory conditions.
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Access to dental care service may improve cognitive health among older adults
An estimated 46.8 million people worldwide had dementia in 2015. A number of studies have demonstrated an association between edentulism and cognitive decline, cognitive impairment not dementia, and dementia. The authors of a study published online May 29 in Journal of Aging and Health designed a prospective longitudinal cohort study with people lacking cognitive impairment at baseline to ask 3 research questions: Is edentulism associated with cognitive decline?, Is dental care service utilization associated with cognitive decline? and Is the association between edentulism and cognitive decline moderated by dental care service use?
Longitudinal data from the Health and Retirement Study (2006-2014) were used to analyze people 51 years and older who were identified as having normal cognition at baseline, as measured using a modified Telephone Interview for Cognitive Status (m-TICS). The study sample included 12,405 participants, with data gathered at baseline and every 2 years thereafter for a total of 5 waves of data collection. Self-reported edentulism at baseline was used as the marker of oral health. Self-reported dental visits at each wave served as a measure of dental care services utilization. A set of time-invariant covariates and time-varying covariates that could confound the association among oral health, dental care service utilization, and cognitive functioning were included in the data analysis.
Sample characteristics at baseline were examined, including differences between dentate and edentate participants. Participants’ cognitive functioning and dental visits at each wave, stratified by edentulism status at baseline, were evaluated. Research questions were addressed using multilevel (2-level) linear regression models. A within-between random-effects model was used to deconstruct information in each time-varying variable. A parameterization approach was used to capture longitudinal changes in cognitive functioning while accounting for cross-sectional differences among participants of different ages at baseline. Statistical analyses of the models were performed using the MIXED procedure in Stata (Version 15.1) (StataCorp LLC).
Of the 12,405 study participants, 1,910 (15%) self-identified as edentulous. At baseline, dentate participants had higher cognitive functioning than edentate participants (P < .001). At baseline, more than three-quarters of dentate participants reported having a dental visit within the past 2 years, and less than one-quarter of edentate participants did so. Controlling for other study variables, there was no statistically significant correlation with cognitive functioning and edentulism (b , –0.06, P = .397). However, both within person and between people components of dental service utilization were associated with cognitive functioning (within person effect b, 0.09, P < .031). Participants who had dental visits more consistently during the duration of the study had higher levels of cognitive functioning (between people effect b, 0.42, P < .001) than did their counterparts who reported less frequent dental visits. Edentate participants had a more rapid decline in cognitive function than their dentate counterparts, with a significant interaction term between edentulism and linear time (b, –0.28, P = .003) (first research question). Participants who reported more dental visits showed slower cognitive decline than their counterparts who did not have dental visits (second research question). More frequent use of dental care services was not protective against cognitive decline for edentate participants, but the combination of being dentate at baseline and consistent dental visits over time was needed to attenuate cognitive decline (third research question).
This study found a statistically significant association between edentulism and cognitive decline in a large national sample of people 51 years and older. The authors conclude that for dentate participants, having dental visits during the study period was linked to a reduction in cognitive decline. For dentate participants who had dental visits infrequently and for all edentate participants, cognitive decline was more rapid.
One limitation of this study was that the identification of cognitive function was based on modified Telephone Interview for Cognitive Status, which is a screening tool for cognitive function, rather than neuropsychological examination. Also, the observational nature of this study did not permit the identification of causal relationships. The authors suggest that future research be conducted to determine whether increased use of dental care services may provide improvement in cognitive function in older patients.
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Quality of life in older adults improves with making dental care affordable
Although oral health is a critical element of overall health and quality of life, dental care remains the largest unmet health need owing to affordability. The specific aim of a study published online July 1 in Journal of Aging and Health was to evaluate the association between self-reported ability to afford dental care and quality of life among older adults.
This study used cross-sectional data from the 2008 National Health Interview Survey (NHIS) and its adult oral health supplement. This survey included information on health status as well as health care access and utilization for 11,760 adults 45 years and older. The core NHIS queried whether there was any time in the prior 12 months during which the participant needed dental care but could not afford it. Other core NHIS questions covered age, sex, race or ethnicity, education level, presence of chronic health conditions including heart disease and diabetes, smoking status, family income, and insurance status. In the oral health supplement, dentate participants (9,647) were asked about bleeding gingivae, broken or missing restorations or teeth, and toothache or sensitive teeth during the previous 6 months.
The Global Burden of Disease project provides case and disability definitions and disability weights for a variety of conditions. NHIS oral disease questions were mapped to Global Burden of Disease disability definitions. Multivariate logistic regression models were used to examine the increased probability of identifying an oral condition attributable to inability to afford dental care. These were performed for every combination of conditions under base, conservative, and generous assumptions. Disability-adjusted life-years (DALYs) attributed to inability to afford dental care were calculated by multiplying the increased probability of reporting each dental condition by its disability weight. A χ2 test was used to assess the differences in the composition of study participants who reported they could not afford dental care. A logistic regression model was used to evaluate the association between reporting inability to afford dental care and predictors of dental service utilization. A determination of whether the probability of reported inability to afford dental care varied for the independent variables was determined using t tests. All analyses were conducted using SUDAAN (Release 11.0, Research Triangle Institute) to address survey weighting and to adjust variance for the multistage, clustered research design. Significance was set at P < .05.
The prevalence of self-reported inability to afford dental care in the prior 12 months was 11.9%. Younger age, female sex, non-Hispanic Black or Hispanic race, lower level of education, poor, uninsured or enrolled in Medicaid, current smoker, and having heart disease or diabetes were factors associated with inability to afford dental care. In the multivariate regression model, inability to afford dental care was still strongly correlated with income, private insurance, age, edentulousness, smoking status, heart disease, and sex after controlling for covariates. The prevalence of eating problems was 8.5%, bad breath or bleeding gingivae 14.3%, and toothache or sensitive teeth 37.7%, all self-reported. For the base-case assumption, inability to afford dental care varied by age for severe tooth loss problems (P = .037), for an increase of 0.017 DALYs per person per year. For generous assumptions, the increase in DALYs was 0.020 per person per year.
The authors note that this study did not take into account treatment costs that could be avoided owing to increased utilization of preventive dental care services if dental care could be made more affordable. One limitation of this study is that the most recent NHIS to include an oral health supplement was 2008. The authors note, however, that few policy changes have occurred since that time that would have affected adult dental insurance coverage. The authors conclude that making dental care affordable for adults 45 years and older could significantly improve their quality of life at a reasonable cost.
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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.
The consulting editor for JADA+ Scan — Healthy Aging is Linda C. Niessen, DMD, MPH; Professor; Nova Southeastern University College of Dental Medicine. |
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