Experience of dental care, knowledge and attitudes of older immigrants in Sweden-A qualitative study.

OBJECTIVES: Knowledge about the oral health and dental care habits of older immigrants is limited. The aim of this study was to explore dental service utilization, oral care habits, and attitudes to and knowledge about oral diseases and their prevention among older immigrants in Sweden. METHODS: A qualitative research method was used, and data were collected in individual interviews to gain a deeper understanding of the immigrants' views. Thirteen immigrants, seven women and six men, recruited from meeting places for older immigrants, participated, all aged between 59 and 88 (median 72 years). Interviews were tape-recorded and transcribed verbatim. Eight interviews were carried out with the help of an authorized interpreter. RESULTS: In the analytical process, performed using the content analysis method, meaning units were identified and condensed into codes which were labelled and grouped into subcategories and categories. The interview analysis resulted in four categories: Experiences of dental care, Attitudes, Barriers and Prevention of oral diseases. The elderly immigrants described a mix of regular and acute dental care and were often not satisfied with the outcome of the treatments. They stated that oral health was important and that they were responsible for their own teeth. Barriers to dental care were costs, language problems and lack of confidence in dental services. Daily oral hygiene routines were performed using a traditional chewing stick and/or regular toothbrush. CONCLUSION: The participants stated that, despite the barriers to treatment described above, they valued good oral health and visited dental services when they needed to.

Dental attendance patterns among older people: a retrospective review of records in public and private dental care in Sweden.

OBJECTIVES: Nowadays, older people retain their natural teeth more frequently and so are at increased risk of oral disease. At the same time, discontinued contacts with dental services prevent access to preventive care and increase the risk of undetected disease. This study aims to evaluate how often older people discontinue regular dental visits and to establish the reasons. METHODS: This study is a retrospective review of records of patients aged ≥75 years from seven Swedish clinics, three in the public dental service (PuDS) and four in the private (PrDS). All patients were examined in 2010, and their dental attendance records from 2010 to 2014 studied. Data included gender, dental insurance system, last performed planned examination, emergency visits, registrations in the recall system, cause of discontinued care and number of teeth and implants. RESULTS: In total, 993 records were studied, 303 in PuDS and 690 in PrDS. In both groups, 10% of patients had no complete dental examinations between 2010 and 2014 after baseline examination in 2010. One-quarter were not registered in the recall system after their last examinations, and this was more common in PrDS than PuDS. In many cases, no reason for discontinued regular visits were described in the records. The mean number of natural teeth was 19.0 in both groups, but there were more implants in the PrDS group. CONCLUSIONS: A large proportion of the participants risked losing regular contact with dental services. Dental services appeared to lack strategies for maintaining regular dental care for elderly patients.

Older people's description of factors that facilitate and impede regular dental care - a qualitative interview study.

OBJECTIVES: The aim of this study was to achieve an understanding of older people's view of the benefits of regular dental care and investigate factors that facilitate and impede regular dental care. METHODS: A qualitative research method was used. To gain a deeper understanding of the elderly people's views, individual interviews were conducted. Fifteen respondents, eleven women and four men aged between 65 and 95, participated, all recruited from senior social centres. All interviews were tape-recorded and transcribed verbatim, and the content analysis method was then used. Meaning units were identified and condensed into codes which were labelled and grouped into categories and subcategories. RESULTS: Findings were grouped into three categories: experiences of dental care, obstacles and facilitators to dental care and about oral health and responsibility. The elderly had experience of both regular and irregular dental care. Obstacles to visiting dental services included high costs and complicated dental insurance, other practical obstacles, lack of confidence in dentistry and seeing no benefits of dental care at their age. Views of the importance of oral health varied, and some people thought poor teeth were shameful. Some expressed that oral health was your own responsibility, while others thought that oral health was the responsibility of the dental services. CONCLUSIONS: Several factors which hamper regular dental care have been identified, and taken together, these obstacles often became unsurmountable. However, individuals taking their own responsibility for their dental status and dental services making certain adaptations, both encourage people to seek regular dental care.

'I take for granted that patients know' - oral health professionals' strategies, considerations and methods when teaching patients how to use fluoride toothpaste.

OBJECTIVES: The aim of this study was to explore the oral health professionals' (OHPs') perspectives regarding their strategies, considerations and methods when teaching their patients the most effective way of toothbrushing with fluoride (F) toothpaste. METHODS: A qualitative research method was used to collect data. To stimulate interactivity among the participants, interviews were performed in focus groups. Five groups of OHPs, including dentists, dental hygienists and dental nurses, were interviewed a total of 23 individuals. The interviews were analysed using manifest and latent qualitative content analysis. Data were systematically condensed and coded to the relevant phrases that identified their content. RESULTS: Three categories were identified in the manifest and latent content analysis: (i) strategies and intentions, (ii) providing oral hygiene information and instruction and (iii) barriers to optimal oral healthcare education. Health promotion and seeing to the patients' best interest were driving forces among the OHPs as well as personal success in their preventive work. They focused on toothbrushing techniques more than on how to use F toothpaste. Barriers to oral health information were cost to the patients and, to some extent, the opinion of the OHPs that some patients were impossible to motivate or that patients already know what to do. CONCLUSION: The OHPs described toothbrushing with F toothpaste as very important, although the plaque removal perspective dominated. They did not focus on how to use F toothpaste, because they believed that knowledge about and appropriate behaviour concerning F toothpaste were already familiar to their patients.

Laser in caries treatment--patients' experiences and opinions.

OBJECTIVES: The aim of this study was to obtain a deeper understanding of patient's experiences and perspectives after dental caries treatment with Er:YAG laser technology. METHODS: Twelve patients aged 15-30 years who had undergone at least one laser caries excavation agreed to participate in an interview study. All the interviews were tape recorded and transcribed by a transcription agency. The transcribed texts were analysed using manifest and latent qualitative content analysis. RESULTS: The categories in this study were identified as choosing laser, understanding laser, encouraging dental care and my oral health. The motivation for laser treatment was described as dental fear in general, specific fear of needles or discomfort with the drill. The informants described the dentist's role as initiators of treatment and willing or unwilling facilitators. Laser treatment was described as safer and more carefully considered treatment. They felt generally safe with laser and were able to relax during the treatment. All interviewers described a positive impression of the laser, and words like 'up to date' and 'future-oriented' were used to describe laser. Laser treatment was considered less painful. CONCLUSIONS: The results indicate that patients find laser a feasible and convenient treatment option.

Adolescents' experiences of a two-year oral health intervention programme in two Swedish secondary schools.

OBJECTIVES: To describe adolescents' experiences of participating in a school-based oral health intervention programme for 2 years containing education about oral health and fluoride varnish treatment at the school clinic. METHODS: Sixteen adolescents aged 13-16 were interviewed in three focus group sessions. A phenomenographic approach was used for analysis. RESULTS: The results are presented as three themes and seven descriptive categories. The three themes were 'Seeing the dental hygienist', 'Treatments at the dental hygiene clinic' and 'Education about oral health in class'. The results demonstrate satisfaction with the intervention, such as accessibility, time gain and expanding knowledge. On the other hand, feelings of vulnerability in the treatment sessions were expressed. The fluoride varnish treatment was given both positive and negative reviews. The contact between the participants and the dental hygienist was important, and the opportunity to ask questions about oral health issues was emphasized. CONCLUSIONS: Both positive and negative experiences of the programme were found. Adolescence is a transitional period of life, and for this reason, it is important to create a good working alliance between students and the dental hygienist in future school-based oral health interventions.

Oral health education for schoolchildren: a qualitative study of dental care professionals' view of knowledge and learning.

AIM: The aim of the study was to describe and interpret dental professionals' view of knowledge, learning, health promotion and their expectations of and attitudes to the response from schoolchildren. METHODS: A qualitative study design was used with discourse method. Nine dental hygienists and dental nurses, who have practised oral health education among schoolchildren, described their work in tape-recorded, semi-structured interviews. The discourse method stresses the variation and distinctions in the statements, and to understand the content of the text, its contextual dependence must be taken into account. RESULTS: The preventive discourse could be found in all interviews, but it was concentrated on disease prevention and less on maintaining health. The biomedical view of knowledge dominated. Children's and parent's own responsibility for healthy habits was stressed, but no reflection of ethical considerations associated with influencing people's life-style was found. The text revealed discrepancy between the informants, and even within the same individual, showing ambivalence towards oral health education. Some individuals suggested lessons guided by communication with the children, while others wanted to maintain methods based on information about oral diseases to a greater extent. CONCLUSIONS: Different perspectives were found. The expression 'oral health promotion' was frequently used and supported by all the interviewed informants, but the statements did not reveal the informant's definition of the concept. Several educators focused on signs of diseases and less on the individual's view of their own health. In the future, oral health education programme needs to focus on quality of life, behavioural variables and indicators of empowerment rather than just disease outcomes.

Fluoride retention of a mucosa adhesive paste compared with other home-care fluoride products.

Home-care use of fluoride (F) requires a motivated individual and several F products rely on a person's ability to follow instructions and to cooperate with the treatment. The aim of this crossover study was to investigate concentrations, distribution in the oral cavity and duration of the elevated F concentrations after using four F products: (1) a mucosa adhesive paste with 0.1% F, (2) a mouth rinsing solution with 0.2% NaF, (3) toothpaste containing 0.5% F and (4) a tablet with 0.75 mg F. Fourteen subjects used the four products in randomized order either during the daytime or just before going to bed. The F concentration was measured both in saliva and at interproximal sites. After 6 h of sleep, the F concentration after using the mucosa adhesive paste and the mouth rinse solution was high in saliva. In the interproximal area, the adhesive paste showed the highest values. During daytime use, all the products increased the F concentration, but only the mucosa adhesive paste and the rinsing solution elevated F in saliva for up to 2 h. In the interproximal area, the paste increased the F concentration most. In conclusion, this study showed that the mucosa adhesive paste and the mouth rinse solution led to higher F concentrations and for a longer time than tablets and toothpaste. For patients who are unable to comply with traditional F treatment, an F-containing adhesive paste therefore has the potential to be a useful vehicle. For individuals who are able to cooperate, a mouth rinse with an F solution is a simple, efficient and well-known method for preventing dental caries.

Oral sugar clearance in individuals with oral motor dysfunctions.

Feeding problems due to impaired oral motor functions resulting in prolonged meals are common among persons with brain damage. The aim of the present investigation was to study the oral sugar clearance in 16 individuals with oral motor dysfunction (OMD) and 16 individuals with normal oral functions (control group). Repeated saliva samples were collected on filter paper discs at two locations before and during 30 min after intake of a glucose tablet. The individuals with OMD had significantly higher initial glucose concentrations in saliva and longer glucose elimination time compared to the control group. For some of the subjects with OMD, sugar clearance was extremely slow. The sugar clearance time was positively related to the severity of drooling problems, but not to the degree of dysphagia. The results from this study indicate that individuals with OMD have an increased risk of dental caries.

Move of adults with mental retardation from institutions to community-based living: changes in the oral microbiological flora.

In the Western world, the policy of deinstitutionalization and integration of individuals with mental retardation is generally accepted. We tested the hypothesis that de-institutionalization may lead to changes of habits with a potential to influence oral health. When 57 adults with mental retardation moved from an institution to community-based living, their oral hygiene habits, gingival bleeding, and a three-day food record were registered one month before and 9 and 21 months after the move. Mutans streptococci and lactobacilli in saliva, P. intermedia/P. nigrescens, P. gingivalis, and A. actinomycetemcomitans in supragingival plaque, and C. albicans on mucous membranes were analyzed. After 21 months of community-based living, fewer persons showed high classes of mutans streptococci, growth of P. intermedia/P. nigrescens, and high frequency of sucrose intake, and more subjects showed growth of C. albicans. In a short perspective, the indicators of oral diseases suggest an unchanged or lower risk of oral diseases after the de-institutionalization of individuals with moderate or severe mental retardation.

Longitudinal study of dental caries, tooth mortality and interproximal bone loss in adults with intellectual disability.

The investigation focused on longitudinal changes of oral health in a group of adults with intellectual disability. A number of 124 individuals, aged 21-40 yr in 1990, were followed during 8.5 yr. The incidence and prevalence of caries, incidence of tooth mortality, and interproximal bone loss were registered from clinical examinations and bite-wing radiographs. The subjects visited the dental clinic for preventive dental care on average every third month during the period. The caries incidence was low, on average 0.51 new lesions per yr. Persons with mild intellectual disability experienced more caries than other subjects. During the 8.5 yr, the subjects had lost on average 1.82 teeth, with periodontitis dominating as the reason for tooth mortality. Individuals who cooperated poorly with dental treatment had lost the most teeth. The average annual bone loss in all subjects was 0.03 mm. Subjects with Down syndrome had a higher bone loss compared to those with other diagnoses of intellectual disability. Thus, the major part of the persons with intellectual disability showed satisfactory oral health. However, subjects with poor ability to cooperate with dental treatment and subjects with Down syndrome showed an increased risk for impaired oral health.

Studies on oral health in mentally retarded adults.

UNLABELLED: During the last decades, a new policy involving normalisation, integration, equality and deinstitutionalisation of mentally retarded (MR) individuals has been accepted in Sweden. Consequently, many institutions have been closed and an increased number of people with MR are now integrated into the Swedish community. The general aim of this thesis was to investigate if a greater degree of independence for MR adults influenced the prevalence of oral diseases. MATERIAL AND METHODS: The caries incidence and prevalence, number of remaining teeth, incidence of tooth mortality and interproximal bone loss were investigated in a group of MR adults, aged 21-40 years, all with protracted, regular preventive dental care. The studied variables were related to living arrangements and degree of MR, and were followed during 8.5 years (Papers I, II and VI). Incidence and reasons for tooth mortality were studied during 10 years in institutionalised MR individuals (Paper III). In connection with the closing-down of an institution for MR adults, the changes of oral hygiene habits, sucrose intake and oral microbiological flora were studied in the new integrated living (Papers IV and V). RESULTS: Less restrictive living arrangements and mild forms of MR were correlated to a high caries prevalence in persons with MR. After 8.5 years, the caries incidence had decreased in all subjects, but persons with mild MR and those who lived integrated still had a higher caries prevalence than other MR adults. With the exception of subjects with Down syndrome, the interproximal bone loss during 8.5 years was similar or lower compared to normal Swedish populations. Institutionalised MR subjects had lost an average of 3.72 teeth during 10 years. Periodontitis was the main reason for tooth mortality. Persons who cooperated well with dental treatment and those who used neuroleptics lost fewer teeth during the 10-year period compared to other MR individuals. The proportion of subjects with high levels of mutans streptococci and subjects who showed growth of P. intermedia/P. nigrescens decreased after deinstitutionalisation, and less subjects consumed sucrose frequently. The oral hygiene routines, and the levels of lactobacilli, P. gingivalis and A. actinomycetemcomitans were not influenced by the change in living arrangements. A simplified saliva sampling method, involving licking directly on the bacteria culture, was developed to count lactobacilli in saliva when delivering whole saliva was impossible. CONCLUSIONS: Less restrictive living and a mild degree of MR were correlated to a high caries prevalence. Subjects with poor ability to cooperate with dental treatment and those with Down syndrome have an obvious risk of deteriorated oral health. However, compared to normal Swedish populations, the MR subjects studied in this thesis had, after several years of regular dental care, satisfactory oral health.

Simplified sampling methods for estimating levels of lactobacilli in saliva in dental clinical practice.

The aim of the present study was to evaluate whether estimation of lactobacilli was possible with simplified saliva sampling methods. Dentocult LB (Orion Diagnostica AB, Trosa, Sweden) was used to estimate the number of lactobacilli in saliva sampled by 3 different methods from 96 individuals: (i) Collecting and pouring stimulated saliva over a Dentocult dip-slide; (ii) direct licking of the Dentocult LB dip-slide; (iii) contaminating a wooden spatula with saliva and pressing against the Dentocult dip-slide. The first method was in accordance with the manufacturer's instructions and selected as the 'gold standard'; the other 2 methods were compared with this result. The 2 simplified methods for estimating levels of lactobacilli in saliva showed good reliability and specificity. Sensitivity, defined as the ability to detect individuals with a high number of lactabacilli in saliva, was sufficient for the licking method (85%), but significantly reduced for the wooden spatula method (52%).

Incidence of, and reasons for, tooth mortality among mentally retarded adults during a 10-year period.

The aim of the study was to investigate the reasons for, and incidence of, tooth mortality over a 10-year period in mentally retarded adults receiving regular dental care. The number of teeth present in 115 individuals (mean age in 1984 was 41.0, range 19-83 years) was registered in 1984 and 1994. The reasons for tooth mortality, medication utilization, frequency of dental care visits and cooperation during dental treatment were registered and related to tooth loss. The average incidence of tooth mortality was 3.72 teeth during the 10-year period. The mean number of dental care visits per year was 6.6. Most of the 428 teeth (58%) were lost due to periodontal disease. The preventive dental care given was not sufficient to arrest oral diseases. The data indicate, however, that achievement of cooperation in dental care situations not only makes dental treatment possible, but also leads to a decreased incidence of tooth mortality.

Inter-relationship among degree of mental retardation, living arrangements, and dental health in adults with mental retardation.

The aim of the present investigation was to study the inter-relationship among the degree of mental retardation, the way of living, and dental health in adults with mental retardation. One hundred and thirty-two adults between the ages of 21 and 40 years who were mentally retarded were examined on two occasions, one year apart. All subjects had had regular dental care for at least 10 years. The clinical examinations included bite-wing radiographs and were made by the same dentist. The degree of mental retardation was assessed by a professional psychologist. The results show that the degree of mental retardation as well as living arrangements are factors influencing the dental health of persons with mental retardation. Subjects who were mildly retarded had higher caries incidence and caries prevalence compared with subjects with moderate or severe mental retardation. From a preventive dental health perspective, special attention should be focused on subjects with mild mental retardation who are not living in institutions.

Dental health status of mentally retarded adults with various living arrangements.

During the last few years in Sweden, there has been a change in the way of living for the mentally retarded. There has been a gradual movement away from institutions toward a more integrated life within society. The aim of the present study was to examine the dental health of mentally retarded adults with different ways of living. Forty-two subjects lived in an institution, 50 lived in integrated units, and 40 stayed in their own apartments or with their parents. All subjects had had regular dental care for at least ten years. The clinical examination was made by one dentist. The use of fluoride and chlorhexidine was recorded in addition to a microbiological examination. The results showed a higher caries prevalence and incidence in subjects with integrated living. Compared with other studies where the mentally retarded had had no regular dental care, the caries incidence and prevalence were lower in this study, and the number of missing teeth was lower. The prevalence of mutans streptococci was related to caries prevalence and incidence. High scores of mutans streptococci could be observed, even among subjects with a frequent use of chlorhexidine gel. The loss of alveolar bone was more pronounced for individuals living in the institution compared with that in individuals with other ways of living.

Interrelationship between vitamin A, iodine and iron status in schoolchildren in Shoa Region, central Ethiopia.

A total of 14,740 schoolchildren in seven provinces of Shoa Administrative Region in Central Ethiopia were surveyed for the prevalence of goitre, xerophthalmia and anaemia. Haemoglobin and packed cell volume were assessed in 966 children in one province while an in-depth study was conducted on 344 children in the same province and two others. Goitre, xerophthalmia (Bitot's spots) and clinical anaemia were observed in 34.2, 0.91 and 18.6% respectively of the children. Most biochemical variables were within the normal range while those of haemoglobin (Hb), mean corpuscular Hb concentration (MCHC) and urinary I excretion were lower, and mean corpuscular volume, mean corpuscular Hb (MCH), and immunoglobulins G and M were higher. Hb was strongly correlated with retinol, ferritin, MCHC, MCH, packed cell volume and erythrocyte count while retinol formed a triad with transthyretin (TTR) and retinol-binding protein (RBP) which were all correlated with one another. Total and free thyroxin and total and free triiodothyronine were positively correlated as were the concentrations of the total and free hormones. Thyrotropin (TSH) was negatively correlated with total and free thyroxin and positively correlated with free triiodothyronine. Thyroxin and triiodothyronine in both free and combined forms were all correlated with thyroxin-binding globulin which in turn was negatively correlated with the triad retinol, RBP and TTR. The triad was also negatively correlated with C-reactive protein. Urinary I excretion was positively associated with total thyroxin and negatively associated with TSH. The anaemia found was not nutritional in origin but due to the effect of infestation with intestinal parasites and malaria.