Effect of Receiving Dental Treatment on mortality among nursing facility residents.

AIM: To assess the association between receipt of different types of dental procedures and mortality among nursing home residents. METHODS AND RESULTS: Between June 2006 and March 2008, 535 nursing home residents received a health screening assessment and were offered comprehensive dental care. Death certificate data were obtained in September 2013 and multivariable regression models were generated to assess the effect of dental procedures delivered after the screening assessment on mortality, adjusting for demographic and health-related covariates. Residents had a mean age of 85.2 years at baseline and approximately 30% were edentulous. About two-thirds received at least one dental procedure, and about 88% had died, between the screening date and the end of follow-up. Among dentate residents, after adjustment for relevant covariates, for each one-unit increase in the number of intervals during which they received at least one preventive dental procedure there was a 13% decrease in mortality (HR = 0.87, 95% CI = 0.78-0.98) at any given time, while for prosthetic dental procedures there was a 16% decrease in mortality (HR = 0.84, 95% CI = 0.72-0.97). Among edentulous residents, only prosthetic procedures were analyzed, and they were not significantly associated with mortality. CONCLUSION: Among dentate institutionalized elderly, receipt of preventive or prosthetic dental procedures was associated with decreased mortality.

Dental Care in Programs of All-Inclusive Care for the Elderly: Organizational Structures and Protocols.

OBJECTIVES: This study uses a national model of community-based long-term services and supports, the Program of All-inclusive Care for the Elderly (PACE), to identify organizational structures and protocols that can facilitate the delivery of dental examinations. DESIGN: We developed an online survey instrument and conceptual model for this study representing 10 domains believed to characterize a quality PACE dental program. SETTING AND PARTICIPANTS: The Qualtrics survey was distributed nationally to all 124 PACE programs in the 31 states PACE was available. Respondents in this study represented 35 programs (program response rate = 28.2%) in 23 states (state response rate = 74.2%). METHODS: Selected independent variables from each of the 10 domains were tested against the reported delivery of dental examinations variable using the Kendall τ and χ2. Twenty-nine programs were included in the final analysis. RESULTS: Most programs mandated a dental examination within 31-60 days of enrollment (63.6%). Few programs had a dental manual (15.6%) or any quality assurance for dental care (32.3%). A majority of programs (58.8%) stated that they had a protocol for enrollees to receive a cleaning every 6-12 months. Having a system for quality assurance for dental care, protocol for a cleaning every 6-12 months, mandating a comprehensive dental examination and providing preventive dental services onsite with built-in equipment, were all statistically associated with a higher reported delivery of dental examinations. CONCLUSION AND IMPLICATIONS: Organizations providing long-term services and supports, including PACE, can use these identified domains to develop minimal standards to ensure dental care is part of innovative models of community-based long-term services and supports. Implementing these domains can facilitate effective delivery of dental examinations that have the potential to support positive oral health and general health outcomes.

Cluster randomized control trial of nursing home residents' oral hygiene following the Mouth Care Matters education program for certified nursing assistants.

AIMS: The purpose of this study was to determine if the number of certified nursing assistants (CNAs) trained with the Mouth Care Matters (MCM) oral health educational program had an impact on nursing facility (NF) resident oral health. MATERIALS AND METHODS: Three NFs participated in a cluster randomized control trial. In NF-A: all CNAs were offered the MCM program, NF-B: 3 CNAs were offered the MCM program, and NF-C: Control (no CNAs were offered the MCM program). Demographic information, systemic health data, and oral health data at baseline, 3-month, and 6-month intervals were collected and analyzed using Kruskal-Wallis, Wilcoxon signed-rank and Wilcoxon rank-sum tests. A total of 24 dentate residents participated in this study. Plaque control record scores for NF-A were significantly reduced compared to NF-B and NF-C (P < .001 and P = .002 respectively) and gingival bleeding index for NF-A were significantly reduced compared to NF-B and NF-C (P = .002 and P < .001 respectively). CONCLUSION: Increasing the number of CNA's trained in the Mouth Care Matters educational program positively impacted NF residents' oral hygiene.

Teaching rapid oral health deterioration risk assessment: A 5-year report.

PURPOSE/OBJECTIVES: The purpose of this study was to present a 5-year report about the outcomes of using a teaching tool that guides dental students through the thought process of the expert about how to assess the risk of rapid oral health deterioration (ROHD) among older adults and provide viable treatment alternatives. METHODS: A teaching tool was previously developed using ROHD risk factors identified in the literature and the steps that experts apply in their treatment decision making, summarized in 10 questions. During 5 years, 188 senior dental students were introduced to the teaching tool and asked to use the 10-question set to present a case they have treated during their Geriatric and Special Needs Program. Two evaluators were asked to grade the students on each question. Students were graded "G" if they answered the question and grasped the principles behind it, "A" if they only answered the question, or "M" if they missed the question. Additionally, the students were given a form to grade the importance of and comment on the exercise. RESULTS: More than 75% of the students had an A or G for most questions, agreement between the 2 evaluators was above 85%, and students' performances improved during the 5-year period. Additionally, 94.4% of the students considered the teaching tool as important or very important for the general dentist. CONCLUSION: The vast majority of the students had an A or G grade, examiner agreement was high, and the students appreciated the importance of this teaching tool for the general dentist.

Setting the PACE for frail older adults in the community: An underused opportunity for furthering medical-dental integration.

BACKGROUND: The integration of dentistry into comprehensive and long-term care has occurred infrequently and with limited success. The authors aim to describe how the Program of All-Inclusive Care for the Elderly (PACE) has the potential for such incorporation for the growing population of nursing home-appropriate older adults preferring to age in place. METHODS: The authors used a 56-item online survey to explore aspects of oral health care within PACE, including organizational structure, availability and provision of care, preventive protocols, and provider reimbursement. The survey was distributed to all 124 programs nationally. Data analyses included descriptive statistics for each of the variables of interest. RESULTS: Thirty-five programs completed the survey (28%) in 23 states (74%) where PACE is available. Most programs covered comprehensive dental services and predominantly provided care off-site. Most programs reimbursed dentists at Medicaid fee-for-service rates and some at commercial rates. Dentistry was most frequently ranked the second-highest specialty focus behind mental health. CONCLUSIONS: PACE is a comprehensive interdisciplinary model of care and an underused opportunity for furthering medical-dental integration. It uses local dental resources in order to accommodate the oral health care needs of the growing population of older adults preferring to age in place. PRACTICAL IMPLICATIONS: PACE is an opportunity for the dental profession to further medical-dental integration and ensure that newer models of long-term care include comprehensive and coordinated oral health care programs. It is also an opportunity to promote an integrated model of care with policy makers to support integrated oral health care for the nursing home-eligible population.

Systemic Health Characteristics and Self-Reported Xerostomia among Nursing Facility Residents in Iowa-US and Sao Paulo-Brazil / Saúde Sistêmica e Xerostomia Auto-Reporada entre Residentes em Instituições de Longa Permanência em Iowa-EUA e São Paulo-Brasil

Objective: To describe and compare potential differences in systemic health characteristics and xerostomia among residents in American and Brazilian nursing facilities (NF). Material and Methods: This secondary analysis used data from a study in NF located in Iowa-USA (n=81) and Sao Paulo (SP)-Brazil (n=119). Recorded data included demographics, medications, comorbid conditions, and self-reported xerostomia. Results: The Iowa group mean age was 82.1 years (±12.9), 60.5% were females, and 100% were white, whereas the SP group mean age was 76.4 years (±8.7), 47.9% females, most participants identified as either white (42.0%) or as more than one race (45.4%). The median number of comorbid conditions and medications in the Iowa were 9 and 12, respectively, as compared to 2 and 6 in SP. Most common comorbidities in Iowa were hypertension, dementia (including Alzheimer), and depression. In SP, they were hypertension, unspecified diabetes mellitus (including type 2), and Parkinson. Most common prescription medications in Iowa were acetaminophen, acetylsalicylic acid, and magnesium hydroxide, while in SP, they were omeprazole, acetylsalicylic acid, and losartan. Xerostomia was reported by 32.1% (Iowa) and 59.7% (SP) of the participants. There was no association between age and dry mouth sensation in either Iowa (p=0.480) or SP (p=0.130) samples. However, there was an association between total medications and dry mouth sensation in Iowa (p=0.040), but not in SP (p=0.075) Conclusions: Iowans presented with higher numbers of comorbidities and prescription medications, however xerostomia was reported in a greater percentage in SP. Xerostomia was associated to higher number of medications in Iowa, but not in SP.(AU)

Objetivo: Descrever e comparar possíveis diferenças nas características de saúde sistêmica e xerostomia entre residentes em instituições de longa permanência (ILP) americanas e brasileiras. Materiais e Métodos: Esta análise utilizou dados de um estudo em ILPs localizadas em Iowa/EUA (n = 81) e São Paulo/Brasil (n = 119). Os dados avaliados incluíram dados demográficos, medicamentos, comorbidades e xerostomia autoreportada. Resultados: A idade média do grupo de Iowa foi de 82,1 anos (± 12,9), 60,5% eram do sexo feminino e 100% eram brancos, enquanto a idade média do grupo SP foi de 76,4 anos (± 8,7), 47,9% do sexo feminino, a maioria dos participantes identificados como brancos ( 42,0%) ou como mais de uma raça (45,4%). A média do número de comorbidades e medicamentos em Iowa foi de 9 e 12, respectivamente, em comparação com 2 e 6 em SP. Comorbidades mais comuns em Iowa foram hipertensão, demência (incluindo Alzheimer) e depressão. Em SP, foram hipertensão, diabetes mellitus (incluindo o tipo 2) e Parkinson. Os medicamentos de prescrição mais comuns em Iowa eram acetaminofeno, ácido acetilsalicílico e hidróxido de magnésio, enquanto em SP, foram omeprazol, ácido acetilsalicílico e losartana. A xerostomia foi reportada por 32,1% dos participantes em Iowa e 59,7% em SP. Não houve associação entre idade e sensação de boca seca nas amostras de Iowa (p = 0,480) ou SP (p = 0,130). No entanto, houve associação entre o total de medicamentos e a sensação de boca seca em Iowa (p= 0,040), mas não em SP (p = 0,075). Conclusões: Os residentes de Iowa apresentaram maior número de comorbidades e prescrição de medicamentos, porém a xerostomia foi relatada em maior percentual em SP. A xerostomia foi associada ao maior número de medicamentos em Iowa, mas não em SP.(AU)

Iowa nursing facility oral hygiene (INFOH) intervention: A clinical and microbiological pilot randomized trial.

PURPOSE/AIM: The aim of this pilot study was to evaluate feasibility and gather initial data for a definitive study to test the clinical and microbiological effectiveness of a nursing facility (NF) customized oral hygiene protocol, intended to be delivered by dental hygienists and NF personnel. MATERIALS AND METHODS: A convenience sample of 8 Eastern Iowa NFs was recruited, and each NF was assigned to one of three intervention groups: (1) control (current oral hygiene practice), (2) educational program only, and (3) educational program plus 1% chlorhexidine varnish monthly application. Demographic information, systemic health data, patient centered data, oral health data, and microbiology samples were collected at baseline and after 6 months. RESULTS: Recruitment response rates were 21% for NFs and 23% for residents. A total of 81 residents were examined at baseline and of those, 49 were examined at 6 months (39.5% attrition). There were no statistically or clinically significant differences among the intervention groups at 6 months for any of the recorded clinical or microbiological outcomes. CONCLUSIONS: Recruitment and retention posed a significant challenge to this trial, even with a relatively short observation period. Results from this pilot study did not encourage further investigation of this customized oral hygiene protocol.

Anterior restoration longevity among nursing facility residents: a 30-year retrospective study.

AIM: To assess factors influencing anterior dental restoration longevity among the institutionalized elderly. METHODS: Among a sample of Eastern Iowa nursing facility dental patients, one anterior restoration placed from 1985 to 2014 was selected at random from each subject. Kaplan-Meier survival curves were generated, with restoration failures defined as subsequent restorative codes involving the same surface; endodontic procedures; or extractions. Bivariate and multivariable Cox proportional hazards modeling were performed. RESULTS: In multivariable analyses, the 1985 to 1999 cohort (n = 496) had longer restoration survival in in females < 75 years old versus males < 75 years old (P = 0.016), males ≥75 years old (P = 0.026) and females ≥75 years old (P = 0.030); one- versus three-surface restorations (P < 0.001); and restorations placed by faculty/residents versus pre-doctoral students (P = 0.009). The 2000 to 2014 cohort (n = 521) had longer restoration survival in females < 75 years old versus males ≥75 years old (P = 0.012) and females ≥75 years old (P = 0.019); residents who paid out-of-pocket versus those on Medicaid (P = 0.019); and composite resin versus glass ionomer cement restorations (P < 0.001). CONCLUSIONS: Knowing how long restorations last, and what factors affect their longevity, could improve treatment planning, informed consent, and communication with residents and caregivers, and also help inform practice guidelines for restorative care among the institutionalized elderly.

Preventive dental care among Medicaid-enrolled senior adults: from community to nursing facility residence.

OBJECTIVE: The primary objective of this study was to determine whether the utilization rate of preventive oral health care services while senior adults were community-dwelling differed from the rate after those same senior adults were admitted to nursing facilities. A secondary objective was to evaluate other significant predictors of receipt of preventive oral health procedures after nursing facility entry. METHODS: Iowa Medicaid claims from 2007-2014 were accessed for adults who were 68+ years upon entry to a nursing facility and continuously enrolled in Medicaid for at least three years before and at least two years after admission (n = 874). Univariate, bivariate and multivariable analyses were conducted. RESULTS: During the five years that subjects were followed, 52.8% never received a dental exam and 75.9% never received a dental hygiene procedure. More Medicaid-enrolled senior adults received ≥1 preventive dental procedure in the two years while residing in a nursing facility compared to the three years before entry. In multivariable analyses, the strongest predictor of preventive oral health care utilization after entry was the receipt of preventive oral health services before entry (p < 0.01). CONCLUSIONS: The strongest predictor of receipt of dental procedures in the two years after nursing facility entry was the receipt of dental procedures in the three years before entry while community-dwelling. This underscores the importance of the senior adult establishing a source of dental care while community-dwelling.

A Teaching Tool for Establishing Risk of Oral Health Deterioration in Elderly Patients: Development, Implementation, and Evaluation at a U.S. Dental School.

The aim of this study was to develop and evaluate a learning strategy using critical thinking to teach dental students how to assess the risk of rapid oral health deterioration (ROHD) among elderly patients. A learning guide was developed using risk factors identified in the literature and the steps that expert faculty members apply in their clinical decision making, summarized in a set of ten steps. A new system of labeling risk was developed for the elderly population, which correlates the level of risk with the amount of disease. Participants in the study were all 91 fourth-year dental students in two subsequent classes who took part in a five-week Geriatrics and Special Needs Clinic rotation in the spring of 2015 and 2016. The students were introduced to the ROHD concept and asked to use the guide in a presentation during their rotation. The students were graded on an A, G, or M scale (Applied concept, Grasped and applied concept, or Missed application of concept). Students were also asked to assess their learning experience, and their answers were thematically grouped and analyzed. For eight of the ten steps, at least 93% of the students were graded A or G. The exceptions were the steps about developing a communications plan, which was missed by 23.1%, and self-assessment, which was missed by 30.8%. Interexaminer agreement on students' applying (A + G grades) versus missing the step was moderate or high on six of ten items. Nearly all the students (98.7%) considered assessing the risk of ROHD an important or very important skill. In this study, a learning strategy to teach dental students how to assess the risk of ROHD among elderly patients was developed and successfully implemented.

Critical Thinking Theory to Practice: Using the Expert's Thought Process as Guide for Learning and Assessment.

Critical thinking skills are essential for the successful dentist, yet few explicit skillsets in critical thinking have been developed and published in peer-reviewed literature. The aims of this article are to 1) offer an assessable critical thinking teaching model with the expert's thought process as the outcome, learning guide, and assessment instrument and 2) offer three critical thinking skillsets following this model: for geriatric risk assessment, technology decision making, and situation analysis/reflections. For the objective component, the student demonstrates delivery of each step in the thought process. For the subjective component, the student is judged to have grasped the principles as applied to the patient or case. This article describes the framework and the results of pilot tests in which students in one year at this school used the model in the three areas, earning scores of 90% or above on the assessments. The model was thus judged to be successful for students to demonstrate critical thinking skillsets in the course settings. Students consistently delivered each step of the thought process and were nearly as consistent in grasping the principles behind each step. As more critical thinking skillsets are implemented, a reinforcing network develops.

Dental status as a predictor of mortality among nursing facility residents in eastern Iowa.

OBJECTIVE: This study aimed to evaluate dental status (ie, number of teeth and presence of removable dental prostheses) as a predictor of all-cause mortality among nursing facility residents. BACKGROUND: Edentulism has been associated with poorer health outcomes in geriatric populations. MATERIALS AND METHODS: Between March 2006 and June 2008, oral health screening examinations were completed for 584 residents of 10 nursing facilities in four eastern Iowa counties. In September 2013, demographic, general and oral health information was obtained from the screening forms and linked with Iowa state death certificate data. The study outcome (time to death) was defined as the number of days between the screening examination and death. Univariate and bivariate distributions were assessed, and multivariable Cox proportional hazards regression models were generated to arrive at factors associated with time to death. RESULTS: A total of 535 residents were eligible for data analysis. Age at screening ranged from 60-103 years (mean=85.2), 70% were female, and 33% were edentulous. By September 2013, 468 (87.5%) had died, with a median time to death among these individuals of 2.0 years. The final multivariable Cox model included data from 393 (73.4%) of the residents; statistically significant relationships were observed between time to death and dental status, age, sex, cooperativeness with care providers and renal disease. CONCLUSIONS: Dental status remained strongly associated with time to death even after controlling for other important demographic and health-related factors.

Health trends in a geriatric and special needs clinic patient population.

PURPOSE: To quantify differences and recent changes in health status among patients attending the Geriatric and Special Needs Dentistry (GSND) and Family Dentistry (FAMD) clinics at the University of Iowa College of Dentistry. METHODS: A total of 388 randomly selected records from patients attending the GSND or FAMD clinics from 1996-2000 or from 2006-2010 were reviewed. Univariate and bivariate analyses were conducted, followed by multivariable logistic regression analyses to compare characteristics of patients across clinics. RESULTS: Between the two GSND cohorts, the mean number of medications reported increased from 4.0 to 6.5 (p < 0.001).  Within both cohorts, mental health conditions were significantly more prevalent among patients attending the GSND than FAMD clinic (p < 0.001). CONCLUSIONS: Within cohorts, patients seen in the GSND clinic tended to have more medical problems than patients attending the FAMD clinic, particularly mental health conditions; and medication use was more common in the recent cohort in both GSND and FAMD clinics.

Factors related to receipt of dental care in Eastern Iowa nursing facilities.

OBJECTIVE: To assess factors related to nursing facility residents' receipt of dental treatment when it was offered on site. METHODS: Screening forms that included demographic, general, and dental health information were obtained from residents of 10 nursing facilities in Eastern Iowa, and their dental procedure history for up to 7 years after screening was recorded. Residents were grouped as having received either no procedures; diagnostic procedures only; or nondiagnostic procedures. RESULTS: Of the 586 residents, the mean age was 83.8 years at screening and 31.3% were edentulous. The odds of receiving nondiagnostic procedures were lower among residents who were older (OR = 0.98, 95%CI 0.96-0.99) or edentulous (OR = 0.31, 95%CI 0.20-0.46), compared to those who received no dental procedures. CONCLUSIONS: Those who were older or edentulous had lower odds of receiving nondiagnostic dental procedures. Well-designed prospective cohort studies are needed to better evaluate barriers to receipt of dental treatment among the institutionalized elderly.

Iowa dentists' involvement in care for patients who are homebound.

This study investigated the frequency of Iowa dentists' provision of in-office and out-of-office dental care for people who are homebound, as well as comparing the practice and educational characteristics among dentists who did and did not provide care for patients who were homebound. The authors mailed a survey form to all licensed dentists on the Iowa State Health Professional license database (n = 1,168), excluding pediatric dentists and orthodontists. A second mailing was sent to all nonrespondents four months later, resulting in 638 returned forms for a 54.6% response rate. The questionnaire included two outcome responses associated with the treatment in the dentist's office or in the patient's home for patients who are homebound. About 40% of Iowa dentists reported providing care in the office to patients who are homebound, but care outside of the office was provided by fewer dentists (6%) who had more years of practice experience. These results suggest an increased sense of professional or community responsibility among these older Iowa dentists. Education efforts may increase homebound care and more involvement of younger dentists.

The involvement of Iowa dentists in hospice care.

The relationships between dentist characteristics and professional education with involvement of Iowa dentists in hospice care were investigated. Using the 1999 Iowa Health Professional database, a survey requesting information regarding involvement in and training for care of hospice patients was mailed to all licensed dentists (N = 1,210). Two mailings yielded a 54.6% response rate. Of the 638 dentist respondents, the mean age was 47, 86% were male, 88% general dentists, and 295 (46%) reported providing some treatment for hospice patients. At least one dentist reported providing hospice patient care in 72 of Iowa's 99 counties. About 90% of dentists treating hospice patients were general practitioners. Males were more likely to provide treatment (p < 0.0313). Neither dentist age nor years in practice were significant predictors. Dentists were more likely to treat hospice patients in the office (IO, 40%). The most prevalent treatments were denture relines (31% IO; 71% OO), examinations (16% IO; 68% OO), and emergency treatment (12.5% IO; 53% OO). More than 86% of surveyed dentists indicated that their professional education did not adequately train them to meet the clinical, psychosocial, communication, or spiritual needs of hospice patients.

The prevalence of periodontal disease measures in elderly adults, aged 79 and older.

From 1996-98, we examined 449 adults (mean age 85 years) from the 1982 Iowa 65+ Rural Health Study, in the field using headlight, mirror, and periodontal probe. Ninety-six of the 342 dentate subjects were excluded from the follow-up examination due to contraindications to probing, and 10 could not be assessed due to refusals, fatigue or other reasons. For all remaining subjects (n=236), attachment loss, defined as recession plus probing depth, was determined at four sites per tooth. Ninety-one percent of the subjects had at least one site with 4+ mm of attachment loss, 45% had one or more sites with attachment loss of 6+ mm, and 15% had 8+ mm of attachment loss. Moderate periodontal disease is prevalent among very old dentate adults while advanced periodontal disease is much less prevalent, suggesting that most periodontal treatment needed by this age group can be provided by general dentists and dental hygienists rather than periodontists.

Elder mistreatment: dental assessment and intervention.

Elder mistreatment has increasingly been recognized as a serious and complex health issue affecting large numbers of elders each year. Dependent elder populations are often at heightened risk for mistreatment by those individuals and institutions that care for them. Health professionals have been found to lack knowledge regarding assessment, diagnosis, intervention, and reporting criteria of elder mistreatment. This article reviews the types and prevalence of elder mistreatment, risk factors, signs and symptoms, preventive interventions, and ethical considerations.

Tooth loss in the very old: 13-15-year incidence among elderly Iowans.

OBJECTIVES: Very few studies have reported tooth loss incidence over a period of 10 years or more, and fewer have reported tooth loss occurrence in subjects aged 80 and older, so that the long-term pattern of tooth loss in the very old is largely unknown. This study assessed 13-15-year tooth loss incidence among a cohort of Iowans, aged 65 and older at baseline. METHODS: Oral examinations were conducted on 520 subjects beginning in 1983, and periodically until 1988, with another round of examinations conducted on surviving members of the initial cohort during 1996-98. RESULTS: Of the 73 remaining subjects, 45 subjects lost a total of 153 teeth during the period (mean=2.1 teeth lost), with a maximum of 17 teeth lost. Molars were the most commonly lost teeth, while canines and maxillary incisors were the least commonly lost. Bivariate analyses found that tooth loss was associated with untreated decay at baseline and level of periodontal attachment loss at earlier examinations. Logistic regression identified only greater severity of attachment loss as a significant risk factor for tooth loss (Adjusted odds ratio=2.4, P=0.006). The impact of tooth loss on subjects' lives was assessed using OHIP and other questions. The occurrence of tooth loss over the study period had little impact, but the number of remaining teeth significantly impacted subjects' ability to eat or chew food, swallow, or their willingness to smile. CONCLUSIONS: These results suggest that tooth loss continues in the very old, that periodontal attachment loss is associated with tooth loss in this age group, and that loss of teeth over one's lifetime does affect certain quality-of-life measures.