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.

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.

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.

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.

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.