Pattern of tooth loss in older adults with dementia under current model of care
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Pattern of Tooth loss in Older Adults with Dementia Under Current Model of Care . Xi Chen, DDS, PhD Assistant Professor Department of Dental Ecology. Introduction. Oral health is a serious concern for Older Adults with Dementia (OAD) Oral health is associated with systemic health Pain

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Pattern of tooth loss in older adults with dementia under current model of care l.jpg

Pattern of Tooth loss in Older Adults with Dementia Under Current Model of Care

Xi Chen, DDS, PhD

Assistant Professor

Department of Dental Ecology

Xi Chen, UNC School of Dentistry


Introduction l.jpg
Introduction Current Model of Care

  • Oral health is a serious concern for Older Adults with Dementia (OAD)

    • Oral health is associated with systemic health

      • Pain

      • Uncontrolled diabetes

      • Respiratory infection

      • Cardiovascular disease

    • Oral health is poor in patients with dementia

Xi Chen, UNC School of Dentistry


Oral health issues in older adults with dementia l.jpg
Oral Health Issues in Current Model of Care Older Adults with Dementia

  • Poor oral hygiene

    • Altered oral hygiene habits

    • Poor oral hygiene

      • Higher accumulation of dental plaque and calculus

      • Increased sites with gingival bleeding

Xi Chen, UNC School of Dentistry


Oral health issues in older adults with dementia4 l.jpg
Oral Health Issues in Current Model of Care Older Adults with Dementia

  • Increased risk of dental caries

    • High prevalence of coronal and root caries

    • High coronal and root caries increments

      • Coronal caries: 3.0 surfaces/year (dementia) vs. 1.5 surfaces/year (no dementia)*

      • Root caries: 1.5 surfaces/year (dementia) vs. 0.8 surface/year (no dementia)*

        * Source: Chalmers JM, Carter KD, Spencer AJ. Caries incidence and increments in community-living older adults with and without dementia. Gerodontology 19:73-88, 2002 .

Xi Chen, UNC School of Dentistry


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Oral Health Issues in Current Model of Care Older Adults with Dementia

  • Increased prevalence of edentulism

Xi Chen, UNC School of Dentistry


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Oral Health Issues in Current Model of Care Older Adults with Dementia

  • Decreased use of dentures over time

  • Increased denture- related soft tissue problems

Xi Chen, UNC School of Dentistry


Oral health issues in older adults with dementia7 l.jpg
Oral Health Issues in Current Model of Care Older Adults with Dementia

  • Increased prevalence of soft tissue lesions

Xi Chen, UNC School of Dentistry


Introduction8 l.jpg
Introduction Current Model of Care

  • How dementia impairs dentition integrity and progressively affect oral function has not been well studied

  • Clinicians speculate OAD may have increased risk of tooth loss

Xi Chen, UNC School of Dentistry


Introduction9 l.jpg
Introduction Current Model of Care

  • Hypothesis

    • Tooth loss does not differ in patients with and without dementia

  • Objective

    • Study the association between dementia and tooth loss

    • Detail tooth loss pattern of OAD under the current model of care

Xi Chen, UNC School of Dentistry


Methods l.jpg
Methods Current Model of Care

  • Retrospective design

    • Study subjects were brought to a state of oral health before enrollment

    • Dental care was equally provided to all the subjects during follow-up

  • Clinical setting

    • Community-based geriatric dental clinic in Minnesota

  • Study period: 10/1999 – 12/2006

  • Outcome of interest

    • Tooth loss, defined as complete loss of natural tooth

      • Tooth loss under current care model vs. natural history of tooth loss

  • Study population

    • 1626 elderly patients

    • 491 study subjects, including 119 OAD

Xi Chen, UNC School of Dentistry


Methods11 l.jpg
Methods Current Model of Care

  • Sample selection

    • Selection criteria

      • Presented as new patient and finished initial treatment plan and returned for care at least once thereafter

      • Dentate after finished initial treatment plan

    • Identifying patients with dementia

      • With ICD-9 code

        • 290.x, 294.1 or 331.2

      • Without ICD-9 code

        • Dementia (all types)

        • Alzheimer’s disease

        • Chronic Brain Syndrome (CBS)

    • Sampling process

      • Two study groups

      • Propensity Score Matching (PSM)

Xi Chen, UNC School of Dentistry


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Methods Current Model of Care

  • Determination of enrollment period

Xi Chen, UNC School of Dentistry


Methods13 l.jpg
Methods Current Model of Care

  • Data collection

    • Two sources

      • Dental office management system

      • Dental records

    • 27 variables were identified and used as predictors

      • Demographics

      • Baseline medical assessment

      • Baseline cognitive and functional assessment

      • Baseline oral assessment

Xi Chen, UNC School of Dentistry


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Methods Current Model of Care

  • Assessing burdens of comorbidity and anticholinergic effect of medications

    • Comorbidity -- Charlson Comorbidity Index (Charlson et al., 1987)

      • 19 categories -- each with an associated weight

      • Overall comorbidity score reflects the cumulative increased likelihood of mortality

      • The higher the score, the more severe the burden of comorbidity

    • Anticholinergic burdens of medications -- Anticholinergic Drug Scale (Carnahan et al., 2006)

      • Associated with serum anticholinergic activity

      • 4-level scale

      • Total score reflects the burden of these medications

Xi Chen, UNC School of Dentistry


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Methods Current Model of Care

  • Addressing potential confounders

    • Age

    • Residential status

    • Anticholinergic effect of medication

    • Physical mobility etc.

Dementia

Age

Tooth Loss

Xi Chen, UNC School of Dentistry


Methods16 l.jpg
Methods Current Model of Care

  • Addressing potential confounders

    • Propensity Score Matching

Xi Chen, UNC School of Dentistry


Methods17 l.jpg
Methods Current Model of Care

  • Statistical analysis models

    • Tooth survival

      • Cox proportional hazard model

    • Rate of tooth loss events per patient year

      • Poisson regression

    • Number of teeth lost per patient per year

      • Negative Binomial regression

Xi Chen, UNC School of Dentistry


Results l.jpg
Results Current Model of Care

Demographic characteristics of study subjects

Xi Chen, UNC School of Dentistry


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Results Current Model of Care

Dental assessment at first arrival

Xi Chen, UNC School of Dentistry


Results20 l.jpg
Results Current Model of Care

Medical assessment

* ADS – Anticholinergic Drug Scale

Xi Chen, UNC School of Dentistry


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Results Current Model of Care

Cognitive and functional assessment

Xi Chen, UNC School of Dentistry


Results22 l.jpg
Results Current Model of Care

Characteristics of tooth loss between demented group and non-demented group

Xi Chen, UNC School of Dentistry


Results23 l.jpg
Results Current Model of Care

Tooth survival

P = 0.50;Hazard Ratio = 0.92 for demented vs. non-demented subjects with 95% confidence interval (0.59, 1.63)

Xi Chen, UNC School of Dentistry


Results24 l.jpg
Results Current Model of Care

Rate of tooth loss events per patient year

Ratio of tooth loss events for demented and non-demented subjects = 0.93, with 95% confidence interval (0.62, 1.39)

Xi Chen, UNC School of Dentistry


Results25 l.jpg
Results Current Model of Care

Number of teeth lost per patient per 5 years

Ratio of rate of teeth lost per patient per 5 years for demented and non-demented subjects = 1.05, with confidence interval (0.55, 1.98)

Xi Chen, UNC School of Dentistry


Discussion l.jpg
Discussion Current Model of Care

  • Clinical characteristics of older adults with dementia

    • More chronic medical conditions

    • High anticholinergic burden of medications

    • Impaired physical mobility

    • 74% unable to efficiently manage oral hygiene

    • More caries or retained roots at first arrival

    • Percentage of the remaining teeth that were decayed or broken was also higher

  • Clinical indications

    • Increased risk of oral disease

    • Adequate preventive care

    • Care-giver education and training

Xi Chen, UNC School of Dentistry


Discussion27 l.jpg
Discussion Current Model of Care

  • Patterns of tooth loss

    • 27% lost at least one tooth when dental care was provided during the follow up

    • 11% had tooth loss events occurring in one year

    • >20% lost at least one tooth at the end of 24 months

  • Clinical indications

    • High risk and rapid rate of tooth loss in a group of the elderly population

    • Strong need to identify patients with high risk

    • Individualize treatment plan – preventive and prosthetic

Xi Chen, UNC School of Dentistry


Discussion28 l.jpg
Discussion Current Model of Care

  • Association between dementia and tooth survival

    • Insignificant in this study

    • Statistical power was adequate

  • Possible explanations

    • High anticholinergic burden of medications

      • 66% took medications with anticholinergic side effect

      • 30+% took medications with total anticholinergic burden equal to or greater than 3

    • Tooth loss under current model of care

      • Not solely due to oral disease

      • Dentist’s decision to extract ( Johnson, 1993)

        • non-restorability (53.8%)

        • dental caries (45.6%)

        • periodontal disease (40.3%)

        • prosthetic considerations (45.6%)

        • non-dental factors (13-17%)

Xi Chen, UNC School of Dentistry


Discussion29 l.jpg
Discussion Current Model of Care

  • Limitations

    • Unable to precisely measure association between severity of cognitive impairment and risk of tooth loss

    • Exact causes of tooth loss could not be identified

    • Issue of generalizability

Xi Chen, UNC School of Dentistry


Conclusion l.jpg
Conclusion Current Model of Care

  • Oral health was poor in OAD

    • High risk and rapid rate of tooth loss in a group of the elderly subjects

    • Dementia alone had no statistically significant impact on tooth survival under the current model of care

    • Demented elders could obtain good treatment outcome and maintain their dentition and oral function as well as those without dementia

Xi Chen, UNC School of Dentistry


Acknowledgement l.jpg
Acknowledgement Current Model of Care

  • University of Minnesota Doctoral Dissertation Fellowship program

  • Amherst H. Wilder Foundation

  • The Oral Health Services for Older Adults program (OHSOA) at the University of Minnesota

Xi Chen, UNC School of Dentistry


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