Measuring dental-related function in patients with history of stroke
The influence of cognitive decline on oral health is mediated by impaired dental-related function. Existence of a valid and reliable measure of a person’s ability to perform oral self-care would set the stage for implementation of customized dental care interventions, as needed. The specific aim of this study was to examine in an outpatient setting the reliability, convergent validity, and structural validity of the dental activities test (DAT) among patients with a history of stroke. Results were published in the January/February issue of Special Care in Dentistry.
The sample consisted of 207 patients with a history of stroke attending neurology clinics in 3 hospitals in Beijing, China, from September 2016 through October 2017. Inclusion criteria were having a history of stroke, having 6 or more teeth, being able to communicate in Mandarin, and being able to provide informed consent. Patients provided sociodemographic data and stroke history by means of a structured interview. Cognitive function was assessed using the Beijing version of the Montreal Cognitive Assessment (MoCA-BJ). Assessment of physical function was conducted using the modified Rankin Scale to allow stratification into 1 of 4 groups: functionally independent, mildly impaired, moderately impaired, and severely impaired. Ability to perform activities of daily living (ADL) were assessed using Katz Index of Independence in Activities of Daily Living, and the Lawton Instrumental Activities of Daily Living Scale (IADL). Dental-related function was assessed using the DAT scale consisting of 9 tasks as directed and scored. Higher scores on the DAT scale (range, 1-9) indicated higher overall dental-related function. Patients were divided into 4 groups based on DAT score: functionally independent (9), supervision needed (6-8), assistance needed (3-5), and full care needed (0-2).
Participant characteristics were delineated using descriptive statistics with SPSS 25.0 (SPSS). Internal consistency of the DAT was evaluated with Kuder Richardson-20. The item-to-total correlation of the DAT items was assessed using Spearman correlation coefficient. Convergent validity was evaluated using Spearman correlation coefficient between DAT scores and physical function, and cognitive evaluations (ADL, IADL, MoCA-BJ scores).
Confirmatory factor analysis (CFA) using Mplus Version 7.1 examined structural validity of the DAT. The object of the CFA was to evaluate whether a 1-factor model (of the 9-item DAT) could account for the pattern of correlation among the 9 items. Multiple model fit indexes were used to determine how well the 1-factor model fit the data.
Of the 207 study participants, 57.5% were male. The average age was 69.5 years, and most participants were urban dwellers and holders of pensions and health insurance. A total of 81.2% of participants had a history of a single stroke, mostly ischemic. The average cognition level was moderate as measured by MoCA-BJ at 18.57 (range, 0-30). Mild cognitive impairment was found in 50.2% of participants. As evaluated by the modified Rankin Scale, 50.2% of participants were functionally independent, 17.9% had mild impairment, 15.5% moderate impairment, and 16.4% severe impairment. Participants had high levels of dental-related function, as measured by DAT (mean, 7.95; range, 0-9). One-half the patients were independent in regard to dental-related function. Of the other one-half, 42% required only supervision, but 4.3% required assistance and 3.9% total care.
The distribution of performance levels across the 9 dental-related activities in the DAT indicated that the activities in 6 items were much easier to accomplish than in the other 3. Specifically, the item on determining a medication schedule following instructions was the most challenging to accomplish successfully. There was good internal consistency in the DAT (Kuder Richardson-20, 0.85; 95% confidence interval, 0.82 to 0.88), so the 9 items together represent 1 construct. Participants who scored higher on the DAT likewise performed better in cognitive and physical function evaluations, reflecting good convergent validity of the DAT. The 1-factor CFA model yielded strong positive model fit results.
Overall, the results demonstrate that the DAT is a useful 1-factor model as reflected by internal consistency, convergent validity, and structural validity. The DAT was designed with items at various levels of difficulty to identify people who have impaired function developing along the continuum of cognitive impairment. Some cognitive functions are lost at early stages in the dementia spectrum, and others are lost much later. The authors conclude that this study showed the reliability and validity of DAT as a 1-factor construct in evaluating the ability of patients with a history of stroke to perform dental-related functions. The authors observed that there is a possible redundancy of items with lower degrees of difficulty in dental-related functions and a paucity of items reflecting impairment at moderate and high levels of difficulty. The authors propose a refinement of the DAT at the item level to reflect the full continuum of dental-related function, thereby improving the test as a psychometric tool.
Read the original article here or contact the ADA Library & Archives for further assistance.
Editor’s note: This study demonstrates that the DAT can be a useful measure of identifying the ability of a patient with a history of stroke to perform oral hygiene skills. This test may also be a useful tool in measuring a patient’s oral hygiene ability if the patient has serious medically complex conditions.
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Oral health in patients with head and neck cancer
Although radiation therapy is efficacious in the treatment of head and neck cancer (HaNC), there is a dearth of information regarding patients’ knowledge about the side effects of such treatment both in the immediate postradiotherapy period and in the long term. The specific aim of this prospective observational study was to assess patients’ oral health knowledge, oral health–related quality of life (OHRQoL), oral health status in the immediate postradiotherapy period, and adherence to recommended oral health behaviors after treatment. Results of this study were published in the November/December issue of Special Care in Dentistry.
Fifty-three consecutive patients scheduled to attend a dental 5-month postradiation therapy review at a hospital in London, United Kingdom, in January 2017 before being discharged to primary dental care were invited to participate in the study. Inclusion criteria consisted of being older than 18 years and willing to participate, having mental capacity to understand and provide informed consent, having completed radiotherapy for HaNC, and attending the postradiotherapy review.
At time 1 (T1), study participants completed a questionnaire evaluating oral health knowledge and OHRQoL (as measured by Oral Health Impact Profile–14). A postradiotherapy dental review was conducted to assess oral and dental health, assess adherence to postradiotherapy dental treatment advice, and identify dental problems (caries, oral dryness, osteoradionecrosis, trismus). Before being discharged to primary dental care, participants were advised orally about diet, management of xerostomia, oral hygiene, and recommended dental visits.
At time 2 (T2), 4 weeks after discharge, participants were contacted by e-mail, text, or phone to complete a questionnaire assessing their adherence to postradiotherapy advice. The questionnaire inquired as to whether the patient had or intended to visit a primary care dentist, whether they used the prescribed high-fluoride toothpaste, how frequently they used the high-fluoride toothpaste, and the reason for not using the high-fluoride toothpaste, in such cases.
The study population comprised 30 patients with a mean age of 58.9 years. Twenty-three (77%) were men, 17 (57%) had oral cancer, and 13 had other types of HaNC. All patients were treated with chemotherapy and hyperfractionation intensity-modulated radiation therapy. One-half of the participants rated their overall health as fair, 27% as good, and 7% as very good. A total of 67% rated their oral health as fair or worse, 27% as good, and 7% as very good. At T1, 45% of participants reported not having received information about potential side effects of radiation therapy, and 69% denied receiving information about the need for oral hygiene before and during radiotherapy. In the evaluation of OHRQoL, the mean OHIP-14 score was 8.6 (SD 5.3), indicating that each person experienced a mean of 8 problems. The most frequently reported problems were pain, discomfort on chewing, the need to interrupt meals, an unsatisfactory diet, and xerostomia. All but 1 brushed his or her teeth, and all but 1 of those used toothpaste. A total of 77% reported having a general dentist of record, with 43% attending regularly.
Sixteen patients (53%) had active caries in more than 2 teeth, 83% experienced xerostomia, and 40% displayed trismus, while 5 established and 2 new cases of ORN were identified. At T2, 70% were contacted by phone, and 30% were contacted by text or e-mail, as requested in their contact preferences. A total of 93% had a general dentist of record, and 100% reported using high fluoride toothpaste.
Thirteen patients (45%) claimed they received no information about potential side effects of radiotherapy, and 69% claimed to have not been given information about long-term effects of radiotherapy or how to ameliorate them. The authors found this surprising, as presentation of this information is a component of the care protocol. They hypothesize that the information was delivered but that the patients were not able to retain it owing to fear, anxiety, competing information, or the shock of receiving the diagnosis. Also, patients have different preferences for receiving information and processing it. The authors propose the development of multimodal presentation formats for this critical information, from written and visual materials to face-to-face presentations. The authors were encouraged by the increase in participants having a general dentist of record from 77% at T1 to 93% at T2. However, they caution that participants may have given socially acceptable responses during the T2 interview. Other limitations of the study were small sample size, lack of control groups, and low overall response rate. In conclusion, the authors advocate development of stronger and varied communication strategies to enhance patient preparation for radiotherapy and addressing side effects, as needed.
Read the original article here or contact the ADA Library & Archives for further assistance.
Editor’s note: Even when patients are given preoperative health information before treatment, they may not retain it owing to competing information. Make preoperative health information a standard part of your practice and document it in the patient’s record when possible.
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Restorative therapies for root caries in older people
As the number of functionally dependent, frail older adults residing in assisted living facilities rises, it is anticipated that root caries will become an increasingly prevalent problem. Owing to reduced access to, and diminished capacity to receive, dental care, combined with moisture control and bonding difficulties with the restorations themselves, alternative approaches to the treatment of root caries are needed. Atraumatic restorative treatment (ART) involves removal of grossly carious tissue using hand instruments only, followed by placement of a viscous agent, such as high-viscosity glass-ionomer cement. The specific aim of this systematic review was to compare the clinical efficacy of ART with that of conventional therapy (CT) for restoring root caries in older adults using a meta-analysis and to assess the robustness of the synthesized evidence using a trial sequential analysis (TSA). Results of this study were published in the September issue of Gerodontology.
Three electronic databases (Embase via Ovid, MEDLINE via PubMed, and CENTRAL) were searched for randomized controlled trials (RCTs) reporting on survival of ART and CT restorations placed in older adults to treat root caries. PICO (Patient or Population Problem, Intervention, Comparison or Control, and Outcome) criteria followed included adults older than 60 years with restorable root caries (Population), restoration of root caries using ART (Intervention), restoration of root caries using CT (Control), and restoration failure inclusive of reason for failure (Outcomes). RCT selection, data extraction, and risk of bias assessment were conducted by 2 independent, calibrated reviewers. Meta-analysis was conducted for the outcome using Review Manager (RevMan) Version 5.3 (The Cochrane Collaboration). This included comparison of ART and CT using fixed- or random-effects pairwise meta-analysis for per-protocol (PP), intention-to-treat (ITT), and best-case scenarios. Odds ratios (OR) and 95% confidence intervals (CI) were calculated. Trial Sequential Analysis Viewer 0.9.5.10 Beta (Copenhagen Trial Unit, Centre for Clinical Intervention Research, 2016) was used to perform the TSA to control for risk of random errors.
The literature review yielded 332 studies, of which 11 were examined as full-text manuscripts. Three RCTs were included in this study. Within these studies, a total of 463 restorations were placed in 130 patients. Follow-up time ranged from 6 through 24 months. Participants’ ages ranged in age from 60 through 101 years in 1 RCT and 65 through 90 years in a second trial, and a mean age of 78.6 years was listed for the third trial. Nursing homes were the setting for 2 RCTs, and the third study took place in a geriatric day hospital and dental university hospital. Marginal defects and retention loss were the main causes for failure of restorations.
In the PP analysis, a significantly increased risk of experiencing failure in ART restorations compared with CT restorations was found (OR, 2.06 95% CI, 1.06 to 4.00]). In the ITT analysis, no significant differences emerged in risk of experiencing failure between the 2 treatments (OR, 1.36 [95% CI, 0.92 to 2.02]). The extreme scenario analysis indicated great uncertainty introduced by attrition. No firm evidence on ART versus CT was produced by the TSA regardless of whether PP or ITT scenario analyses were evaluated. The risk of bias was found to be low in 1 RCT, moderate in a second, and high in the third. The certainty of the evidence was deemed to be low.
Although ART may theoretically be more appealing for treating root caries in a dependent older population, limited data in this systematic review and meta-analysis revealed that ART may be associated with higher failure rates than CT. TSA demonstrated that a clear conclusion could not be reached. The validity of the findings of this study were further weakened by high attrition rates in the trials. Higher failure rates with ART restorations may be due to reduced adhesion associated with this method of restoration. Marginal defects were a main cause of failure. Increased cariogenicity in the area of the ART restorations owing to the press finger technique and lack of polishing may contribute to failures. The authors suggest that future trials should investigate whether finishing ART restorations may enhance their survival.
The authors noted several additional limitations to their study. Only 3 RCTs were included, and there was a heterogeneity in technique and restorative materials used. The participants’ age range was wide, which possibly introduced a heterogeneity of risk factors. All included studies had high attrition rates, and the authors advise that future trials take this into account in power calculations. Failure rates for both ART and CT restorations were high, calling into question whether a noninvasive approach such as silver diamine fluoride might be effective in managing root caries in this population. The authors conclude that further RCTs be conducted to reach firm conclusions on the efficacy of ART versus CT.
Read the original article here or contact the ADA Library & Archives for further assistance.
Impact of nonendodontic factors on success of nonsurgical root canal therapy in older people
It has been well-established that primary endodontic factors, including preoperative endodontic periapical lesions, poor technical root canal filling, poor quality of coronal restoration, and retreatment, negatively affect the success of nonsurgical root canal treatment (NSRCT). However, there is a paucity of information regarding whether secondary nonendodontic factors affect the success of NSRCT. The specific aim of this study was to determine the impact of nonendodontic factors, such as periodontal disease and use of age-related chronic disease medications (CDM), on the failure rate of NSRCT in patients 60 years and older. Results of this study were published in the September issue of Gerodontology.
The initial study population was 177 patients with a total of 212 NSRCTs performed from 2010 through 2013 in a dental school in Würzburg, Germany. Inclusion criteria included being 60 years or older, having complete radiographic data (preoperative, working length, and postoperative radiographs), using rotary nickel-titanium files for shaping, and using matching-taper–single cone filling. In cases of patients with multiple NSRCTs, only 1 tooth per participant was chosen randomly. Cases with radiographic exposure or positioning errors were excluded.
Three raters assessed radiographs independently at baseline and again after 2 months for endodontic factors. The length and density of root canal fillings were measured at the cervical, middle, and apical one-thirds of the roots. Coronal restorations were evaluated both clinically and radiographically. Treated teeth with a periodontal index score of 1 or 2 were deemed to be periapically healthy, while those with a periodontal index score of 3 through 5 were considered diseased.
All participants were also evaluated for secondary nonendodontic factors, which may have affected outcome of NSRCT. Participants were screened using the periodontal screening index and assumed to have periodontitis in cases with a probing depth equal to or greater than 5.5 millimeters. Periodontal probing depth (in mm) and tooth mobility (0-3) were recorded.
Data were collected on participants’ use of antidiabetic agents, antihypertensive agents, anticoagulant agents, statins, uricostatics, immunosuppressants, and bisphosphonates. Statistical analyses were performed using SPSS software. χ2 tests with Yates continuity correlation was used to test for association with endodontic outcome, and Pearson χ2 tests were used to assess differences with a significance level of α = 0.05. Logistic regression rendered odds ratios to predict endodontic outcome. Cohen κ coefficient measured the corresponding effect size.
The final study sample consisted of 93 patients. Fifty-two were aged 60 through 69 years, 35 were 70 through 79 years, and 6 were 80 through 89 years. The average (standard deviation) recall period after NSRCT was 38.93 (10.09) months (range, 19.8-58.2 months). Eighty-one of 93 NSRCT teeth were deemed healed, for a success rate of 87.1%. Preoperative periapical status revealed a significant association with endodontic outcome (χ2 [1, n = 93]) = 9.810; P = .002; phi = 0.357), a medium effect. The other primary factors showed no significant association with NSRCT outcome as P values were all greater than .05.
In the analysis of secondary nonendodontic factors, Pearson χ2 tests revealed no significant association between NSRCT outcome and periodontitis, and no effect. In addition, the χ2 test for independence with Yates continuity correlation identified no significant association between NSRCT outcome and use of CDM, and no effect. Only chronic intake of anticoagulant agents showed a significant association with endodontic outcome (χ2 [1, n = 93] = 6.470; P = .011; phi = 0.297), a small effect.
In this study, patients who regularly used CDMs, especially antidiabetic and antihypertensive agents, did not show lower success rates of NSRCT than patients who did not take such pharmaceuticals. The authors offered no insight into why the number of treatment failures should be higher in patients taking anticoagulant agents (9 of 35; P= .01), but they suggested that this association should be further investigated. Limitations of this study included a small sample size, the fact that dose and reliability of taking medications were not evaluated, the adequacy of the response of the patient to the drug, and that the effect of other unidentified systemic illnesses were not addressed. The authors concluded that neither periodontitis nor CDM use represented clinically relevant factors in the outcome of NSRCT in older patients in this study, and that further research to elucidate the impact of anticoagulants is needed.
Read the original article here or contact the ADA Library & Archives for further assistance.
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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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