Appropriate use of antibiotics for oral/dental conditions in older adults: a narrative review.

OBJECTIVES: Considering the high rates in the use of antibiotics for oral/dental conditions in older patients and the rise in antimicrobial resistance, appropriate antibiotic prescription is important. This narrative review aimed to discuss the challenges and special considerations when prescribing antibiotics to older patients for oral/dental conditions. METHODS: PubMed/MEDLINE, Scopus, Web of Science, and articles' reference lists were searched for antibiotics use for oral conditions by older patients. Moreover, scientific and professional organisations' official websites were searched for guidelines on antibiotic use in dentistry. RESULTS: Despite several guidelines about the use of antibiotics in dentistry, specific information on their administration to older patients is missing. Relevant challenges include age-related changes in pharmacokinetics and pharmacodynamics, comorbidities and polypharmacy associated with low adherence, contraindications, adverse reactions, and drug-drug interactions. In unfit and frail older patients some antibiotics should be avoided, or doses should be adjusted, according to medical conditions or medications received. Amoxicillin, with doses adapted to renal function, is one of the safest options, while other antibiotics should be chosen with caution upon indications and individual patient characteristics. CONCLUSIONS: Healthcare providers should prescribe antibiotics to unfit and frail older adults with caution, given the multitude of comorbidities and potential interactions with medications received. Further research is needed on the safe and effective use of antibiotics in older patients.

Towards an operational definition of oral frailty: A e-Delphi study.

OBJECTIVES: Building upon our recently developed conceptual definition of oral frailty (the age-related functional decline of orofacial structures), this e-Delphi study aims to develop an operational definition of oral frailty by identifying its components. METHODS: We used a modified e-Delphi study to reach a consensus among international experts on the components of oral frailty. Twelve out of fifteen invited experts in the field of gerodontology participated. Experts responded to three rounds of an online 5-point scale questionnaire of components to be included or excluded from the operational definition of oral frailty. After each round, scores and rationales were shared with all experts, after which they could revise their position. A consensus was reached when at least 70% of the experts agreed on whether or not a component should be included in the operational definition of oral frailty. RESULTS: The experts achieved a high level of agreement (80 - 100%) on including eight components of oral frailty and excluding nineteen. The operational definition of oral frailty should include the following components: 1) difficulty eating hard or tough foods, 2) inability to chew all types of foods, 3) decreased ability to swallow solid foods, 4) decreased ability to swallow liquids, 5) overall poor swallowing function, 6) impaired tongue movement, 7) speech or phonatory disorders, and 8) hyposalivation or xerostomia. CONCLUSION: This e-Delphi study provided eight components that make up the operational definition of oral frailty. These components are the foundation for the next stage, which involves developing an oral frailty assessment tool.

Clinical and Subjective Oral Health Status of Care Home Residents in Europe: A Systematic Review.

OBJECTIVE: Several studies demonstrated the poor oral health of care home residents in Europe but there is no systematic overview of the relevant literature. The objective of this study was to systematically review the evidence on the clinical and subjective oral health outcomes of care home residents in Europe. DESIGN: The study design is a systematic review. METHODS AND PARTICIPANTS: All included publications presented data on clinical and/or subjective oral health outcomes in care home residents in Europe with no restrictions for language or study design. MEDLINE, Embase, and CINAHL were searched, including publications from January 2010 onward. Data extraction and quality assessment (Qualsyst tool) was performed by 2 researchers independently. Findings were synthesized narratively, lack in data homogeneity restricted the relevance of a meta-analysis. RESULTS: Eighty-three papers from 18 countries were included in the systematic review, with a sample size ranging from 39 to 92,827 participants. Their mean age was older than 80 years. The residents had few natural teeth, with fewer than a third a functional natural dentition. Removable dentures were present in half to 80% of residents. A high prevalence of dental caries was reported. Oral hygiene was insufficient, for both natural teeth and removable dentures. Few residents had a healthy periodontium. Clinical treatment needs were found in most residents. Perceived treatment needs were high with at least one-third of care home residents reporting a need for care due to poor oral health. A fifth to half of the residents reported negative impacts of their oral condition on their everyday lives. CONCLUSION AND IMPLICATIONS: This systematic review clearly highlights the poor oral health and high burden of oral conditions among care home residents across Europe, irrespective of country or health care system. There is need for substantial policy actions to improve oral health in care homes.

Frailty as a determinant of dental attendance among community-dwelling older adults.

OBJECTIVES: The aim of this study was to assess the association between different levels of frailty and dental attendance among home-dwelling older adults, in Belgium. BACKGROUND: While many determinants of dental attendance among older adults have been identified, no study has focused on the role of frailty. MATERIALS AND METHODS: This was a cross-sectional study on a random sample of home-dwelling adults aged 60 and over from two Belgian cities. Data were collected with a structured questionnaire through a participatory peer-research method. Time since the last dental attendance was the dependent variable. The independent variable was frailty, assessed with the Comprehensive Frailty Assessment Instrument, including physical, psychological, social, and environmental subdomains. Covariates were age, gender, having a partner, educational level, and household income, as well as self-perceived oral health. Data analysis included descriptive, bivariate (Chi-Square, ANOVA, and Kruskal-Wallis), and binomial logistic regression analyses. RESULTS: The sample consisted of 1329 older adults with a mean age of 72.5 years (SD 8.9, range 60-103). In the low frailty group, 73% attended the dentist in the previous 12 months, while it was 62% and 54% in the medium and high frailty groups, respectively. In the fully adjusted model, the initial gradient in the relationship between overall frailty and dental attendance remained; those in the medium and the high frailty groups were respectively 1.46 (95% CI: 1.09, 1.95) and 1.67 (95% CI: 1.15, 2.43) times more likely to report no dental attendance in the previous year than the low frailty group. Similar associations could be seen in the physical and environmental frailty subdomains. CONCLUSION: Frailty is consistently associated with less favourable dental attendance, independent from age, gender, socioeconomic factors, family composition, and self-perceived oral health. Once frailty has been detected, good interprofessional communication and care are needed to avoid the drop-out of older adults from the oral healthcare system.

Oral healthcare delivery in institutionalised older people: A health-economic evaluation.

OBJECTIVES: This health-economic evaluation aimed to assess the cost-effectiveness of a number of alternatives for preventive and curative oral health care in institutionalised older people in Flanders. METHODS: A six-state Markov model was used to compare expected costs and healthy oral years (HOYs) of four alternatives: (1) usual care; (2) on-site preventive care; (3) on-site preventive care + curative care in the community; and (4) on-site preventive care + on-site curative care. A healthcare payer perspective was adopted, and the time horizon was 10 years. Deterministic and probabilistic sensitivity analyses were performed. RESULTS: Incremental cost-effectiveness ratios (ICERs) of alternatives 2, 3 and 4 (all compared to alternative 1) were as follows: (2) 7944 €/HOY gained; (3) 1576 €/HOY gained; and (4) 1132 €/HOY gained. Hence, alternatives 2 and 3 were not cost-effective compared to alternative 4. The probability that oral care interventions are more effective and cost-saving than usual care was <3% for all three interventions. CONCLUSIONS: For institutionalised older people, on-site solutions for preventive and curative oral health care might be the most cost-effective alternative. It should be kept in mind that on-site solutions require large initial investment and that the advanced age of the population and the high costs of oral health care make it unlikely that these interventions would become cost-saving, even in the long term.

Assessment of oral health in older adults by non-dental professional caregivers-development and validation of a photograph-supported oral health-related section for the interRAI suite of instruments.

OBJECTIVES: An optimized oral health-related section and a video training were developed and validated for the interRAI suite of instruments. The latter is completed by professional non-dental caregivers and used in more than 40 countries to assess care needs of older adults. METHODS: The optimized oral health-related section (ohr-interRAI) consists of nine items and a video training that were developed in consecutive phases. To evaluate psychometric properties, a study was conducted in 260 long-term care residents. Each resident was assessed by a dentist and by four caregivers (two who received the video training, two who did not). RESULTS: Mean kappa values and percent agreement between caregivers and dentist ranged between κ = 0.60 (80.2%) for dry mouth and κ = 0.13 (54.0%) for oral hygiene. The highest inter-caregiver agreement was found for dry mouth with κ = 0.63 [95% CI: 0.56-0.70] (81.6%), while for the item palate/lips/cheeks only κ = 0.27 [95% CI: 0.18-0.36] (76.7%) was achieved. Intra-caregiver agreement ranged between κ = 0.93 [95% CI: 0.79-1.00] (96.4%) for dry mouth and κ = 0.45 [95% CI: 0.06-0.84] (82.8%) for gums. Logistic regression analysis showed only small differences between caregivers who watched the video training and those who did not. CONCLUSIONS: Psychometric properties of the optimized ohr-interRAI section were improved compared to previous versions. Nevertheless, particularly the items based on inspection of the mouth require further refinement and caregiver training needs to be improved. CLINICAL RELEVANCE: Valid assessment of oral health by professional caregivers is essential due to the impaired accessibility of regular dental care for care-dependent older adults.

Xerostomia and polypharmacy among dependent older New Zealanders: a national survey.

BACKGROUND: Medication-induced xerostomia is common in older people. We investigated medication use and xerostomia in dependent older New Zealanders. METHODS: Medication and xerostomia data analysed from a nationally representative survey of dependent older people. Automatic interaction detection analysis identified medications combinations most strongly associated with xerostomia, and then xerostomia was modelled. RESULTS: Just over half were taking five to nine different medications; one in five was taking 10+. Xerostomia prevalence (29.4%; 95% confidence interval 26.5, 32.5) was higher among the latter and lowest in psychogeriatric patients. After controlling for age and sex, it was higher among people taking any antidepressant, and higher still with a tricyclic antidepressant and either a steroid or an anticholinergic, or among people taking a bronchodilator without prophylactic aspirin. CONCLUSIONS: Health practitioners should work together to ensure that those with xerostomia are managed in a timely and appropriate manner. Medication review is an important component of that.

Micronutrients encapsulation in enhanced nanoliposomal carriers by a novel preparative technology.

Micronutrients administration by fortification of staple and complementary foods is a followed strategy to fight malnutrition and micronutrient deficiencies and related pathologies. There is a great industrial interest in preparation of formulations for joint administration of vitamin D3 and vitamin K2 for providing bone support, promoting heart health and helping boost immunity. To respond to this topic, in this work, uncoated nanoliposomes loaded with vitamin D3 and K2 were successfully prepared, by using a novel, high-yield and semi continuous technique based on simil-microfluidic principles. By the same technique, to promote and to enhance mucoadhesiveness and stability of the produced liposomal structures, chitosan was tested as covering material. By this way polymer-lipid hybrid nanoparticles, encapsulating vitamin D3 and vitamin K2, with improved features in terms of stability, loading and mucoadhesiveness were produced for potential nutraceutical and pharmaceutical applications.

Practical Guidelines for Physicians in Promoting Oral Health in Frail Older Adults.

Good oral health in old age is particularly important for maintaining adequate oral function, preventing pain and discomfort, controlling localized or systemic inflammation, sustaining social interaction, and preserving quality of life. Given that oral health is an integral part of general health and well-being, and that major chronic systemic and oral diseases share common risk factors, oral health prevention and promotion should be embedded within routine medical assessment and care provision. The role of medical physicians, particularly primary care physicians, geriatricians, and elderly care physicians, in community and long-term care facilities in assessing and promoting oral health in frail older adults is critical and has been emphasized in recent European recommendations. All physicians should appreciate the importance of oral health and incorporate an initial oral health screening into routine medical assessment and care. A short interview with patients and carers on current oral health practices may help to assess the risk for rapid oral health deterioration. The interview should be followed by an oral health assessment, using validated tools, for nondental health care providers. Based on these findings, the physician should decide on necessary follow-up procedures, which may include oral health counseling and/or dental referral. Oral health counseling should include advice on daily oral, mucosal, and denture hygiene; denture maintenance; dietary advice; smoking cessation; limitation of harmful alcohol consumption; management of xerostomia; and frequent dental review. To enable physicians to perform the tasks recommended in this publication, appropriate teaching at both undergraduate and postgraduate levels must be delivered in addition to provision of appropriate continuing education courses.

The impact of a preventive and curative oral healthcare program on the prevalence and incidence of oral health problems in nursing home residents.

AIMS: To assess the impact of an oral healthcare program in nursing homes on the initial treatment backlog and residents' oral health stability. MATERIALS AND METHODS: The study is a longitudinal cohort study in nursing home residents in Flanders, Belgium, to evaluate the oral healthcare programme Gerodent. The program consisted of: (1) the introduction of an oral healthcare team, (2) oral health education, (3) the implementation of oral health guidelines and protocols, and (4) regular visits of a mobile dental team. Data were extracted from the oral health records of 381 residents from 21 nursing homes who received treatments from the mobile dental team between October 2010 and March 2014 (mean follow-up period of 22.5 months). Oral health and treatment need between baseline and follow-up were compared. RESULTS: The mean age at baseline was 82.4 years and the mean number of consultations per resident was 3.61 during the follow-up period. The proportion of residents with an oral treatment need was reduced from 65.9% to 31.3%. Among residents with natural teeth, there was significantly lower prevalence of caries (from 70.5% at baseline to 36.5% at follow-up; p<0.001), residual roots (from 54.2% to 25.1%; p<0.001), and need for fillings (from 31.9% to 17.1%; p<0.001) or extractions (from 64.3% to 31.6%; p<0.001). In the group with partial or full dentures (n = 223), 38.1% needed a repair, rebasing or renewal of their existing dentures at baseline and the respective figure at follow-up was 9.0% (p<0.001). In terms of oral health stability, 53% of the residents had no incident restorative and prosthetic treatment need throughout the follow-up period. A lower number of natural teeth at baseline (p<0.001) and a shorter follow-up period (p = 0.002) were associated with higher chances of oral health stability. CONCLUSION: The oral healthcare program Gerodent significantly reduced the treatment backlog and contributed to a considerable proportion of residents being stable in terms of oral health without any incident treatment needs.

Medication Use and Its Potential Impact on the Oral Health Status of Nursing Home Residents in Flanders (Belgium).

BACKGROUND: Polypharmacy is considered the most important etiologic factor of hyposalivation, which in turn can initiate oral health problems. OBJECTIVES: To describe the medication use of nursing home residents, to identify the medications related to hyposalivation and to find possible associations between the different classes of medication, the number of medications, and the oral health status of the residents. DESIGN: A cross-sectional study. PARTICIPANTS: The study population consisted of the residents of a nonrandom sample of 23 nursing homes from 2 Belgian provinces, belonging to the oral health care network Gerodent. All residents of the sample visited the Gerodent mobile dental clinic between October 2010 and April 2012. MEASUREMENTS: For each resident, oral health data, demographic data, and an overview of the total medication intake were collected. RESULTS: The study sample consisted of 1226 nursing home residents with a mean age of 83.9 years [standard deviation (SD) 8.5]. The mean number of medications per person was 9.0 (SD 3.6, range 0-23, median 9.0). Of all prescribed medication, 49.6% had a potential hyposalivatory effect with a mean number per person of 4.5 (SD 2.2, range 0-15, median 4.0). In the bivariate analyses, associations were found between medication use and oral health of residents with natural teeth: the higher the number of medications (with risk of dry mouth) and the overall risk of medication-related dry mouth, the lower the number of natural teeth (P = .022, P = .005, and P = .017, respectively). In contrast, the total treatment need tended to decrease with rising medication intake, resulting in a clear increase of the treatment index with rising medication intake (P = .003, P < .001 and P = .002). The logistic regression model analysis confirmed that the proportion of carious teeth diminished and the treatment index increased in case of rising medication intake, especially when considering the number of medications with a risk of dry mouth and the overall risk of medication-related dry mouth. A possible explanation for this trend might be the finding that in the group with a high medication use, the teeth most sensitive to caries and plaque retention could already have been extracted at the moment of screening for the study, because of a lifelong history of caries pathology. CONCLUSIONS: This study shows a high level of medication use, including the substantial intake of medication with a possible hyposalivatory effect. Moreover, clear associations were found between the medication intake and the oral status of the residents.

An oral health survey of vulnerable older people in Belgium.

OBJECTIVES: The aim of this study was to gain insight in the oral health of persons aged 65 years or more. MATERIALS AND METHODS: Data were obtained from 652 vulnerable older persons (≥65) by means of a clinical oral examination. Additional demographic data were gathered including age, gender, residence, and care dependency. RESULTS: The mean age of the total study sample was 83 (7.7) years and 71 % was female. Nearly 33 % of the sample was living at home with support, and 67 % was residing in nursing homes. The number of occluding pairs was low and the proportion of edentulous people was highest among persons with the highest care dependency. The mean Decay-missing-filled teeth index (DMFT) was 20.3 (9.0). A prosthetic treatment need and inadequate oral hygiene levels were observed in 40 % and more than 60 % of the subjects, respectively. The highest treatment need was observed in the oldest age group and the highest mean dental plaque in older persons with the highest care dependency. CONCLUSIONS: The oral health in frail older people in Belgium is poor. The restorative and prosthetic treatment need is high and oral hygiene levels are problematic. Age, residence, and care dependency seemed to have some influence on oral health parameters. CLINICAL SIGNIFICANCE: In the long term, the most important future challenge of oral health care policies is to identify older adults before they begin to manifest such oral health deterioration. Regular dental visits should be strongly promoted by all (oral) health care workers during the lifespan of all persons including older adults.

Effect of an oral healthcare protocol in nursing homes on care staffs' knowledge and attitude towards oral health care: a cluster-randomised controlled trial.

OBJECTIVE: To explore the impact of a supervised implementation of an oral healthcare protocol, in addition to education, on nurses' and nurses' aides' oral health-related knowledge and attitude. MATERIALS AND METHODS: A random sample of 12 nursing homes, accommodating a total of 120-150 residents, was obtained using stratified cluster sampling with replacement. The intervention included the implementation of an oral healthcare protocol and three different educational stages. One of the investigators supervised the implementation process, supported by a dental hygienist. A 34-item questionnaire was developed and validated to evaluate the knowledge and attitude of nurses and nurses' aides at baseline and 6 months after the start of the intervention. Linear mixed-model analyses were performed to explore differences in knowledge and attitude at 6 months after implementation. RESULTS: At baseline, no significant differences were observed between the intervention and the control group for both knowledge (p = 0.42) and attitude (p = 0.37). Six months after the start of the intervention, significant differences were found between the intervention and the control group for the variable knowledge in favour of the intervention group (p < 0.0001) but not for the variable attitude (p = 0.78). Out of the mixed model with attitude as the dependent variable, it can be concluded that age (p = 0.031), educational level (p = 0.009) and ward type (p = 0.014) have a significant effect. The mixed model with knowledge as the dependent variable resulted in a significant effect of the intervention (p = 0.001) and the educational level (p = 0.009). CONCLUSION: The supervised implementation of an oral healthcare protocol significantly increased the knowledge of nurses and nurses' aides. In contrast, no significant improvements could be demonstrated in attitude.